Unemployment, measured and perceived decline of economic resources: Contrasting three measures of recessionary hardships and their implications for adopting negative health behaviors

The effect of social exclusion on the cognitive health of middle-aged and older adults: A systematic review

This systematic review aimed to evaluate the independent and joint effects of social exclusion in three specific domains-economic, social relations, and civic participation-on the cognitive health of middle-aged and older adults. Longitudinal studies from January 2000 to October 2023 were identified via Web of Science, Scopus, and PubMed, with sixty-five studies meeting inclusion criteria. The quality of the studies was assessed with Newcastle-Otawa Scale. Analysis revealed a strong association between economic exclusion and cognitive decline, with most studies indicating a significant negative impact. Ten studies found a positive link between volunteering and cognitive health for civic participation, while eight did not, showing mixed evidence. In social relations, most studies connected loneliness, social isolation, smaller social networks, reduced contact with family and friends, lower engagement in activities, and negative social interactions with cognitive decline. Notably, one study found that older adults experiencing social exclusion in multiple domains simultaneously face even greater cognitive decline. In summary, this review shows that social exclusion in economic, social relations, and civic participation and all together domains is associated with greater cognitive decline in older adults.

Economic recession, illicit drug use and the young population: a systematic literature review and meta-analysis

AIMS

Economic recessions impact on drug use through different channels, with potential conflicting outcomes. Previous studies have reached mixed outcomes, and a clear and comprehensive picture is difficult to depict.

METHODS

We use a systematic review of literature - conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines - and a hierarchical mixed-effects meta-analysis to provide a comprehensive quantitative assessment of the relationship between business cycle and the use of drugs by young populations. The heterogeneity of studies was assessed by the I2 statistic, and the publication bias was evaluated with contour-enhanced funnel plots.

RESULTS

We identify 25 studies, published over the period 2008-2020. These articles carried out an empirical analysis of the impact of the business cycle on illegal drug consumption in Organisation for Economic Co-operation Development (OECD) countries. Most of the studies (17 studies) covered the 2007 financial crisis. Among the outcomes, 9 studies traced a countercyclical relationship between economic recessions and drug use, 3 showed a procyclical relationship and 13 studies found mixed results. Unemployment was the most widely used variable to assess macroeconomic conditions in most of the studies (21 studies). The meta-analysis shows a partial correlation of .03 (95% confidence interval (CI): .0147-.0453) between the unemployment rate and drug use among young individuals. Therefore, we conclude that, on average, recessions tend to boost drug use. This impact is more marked with cannabis use than it is with cocaine, opioids or other drugs.

CONCLUSION

This study provides robust evidence that in periods of economic downturns, the young populations tend to increase the use of illegal drugs, with cannabis as their main preference. Therefore, in periods of economic severity, society may particularly benefit from implementing widely reaching public prevention programmes and demand reduction interventions, targeting this subgroup of the population.

Association of cigarette smoking with changes in macroeconomic conditions

This study uses data from the 1987-2022 Behavioral Risk Factor Surveillance System and state-level employment rates from the US Bureau of Labor Statistics to estimate the association between macroeconomic conditions and cigarette smoking. Our finding suggests a positive association, which constantly declined with time after the 2001 recession. We find that a one percentage point increase in the employment rate is associated with a 1.4% higher likelihood of smoking cigarettes in the overall sample but declined to 0.4% among cohorts surveyed from 2011 to 2022. We also find strong positive and heterogeneous associations among sociodemographic groups, except among Blacks and persons aged 65 years and older, among whom there is no association; however, the positive associations consistently decreased among these sociodemographic groups. Consequently, the strong positive association disappeared in several sociodemographic groups in cohorts surveyed over the last decade.

Partner incarceration, maternal substance use, and the mediating role of social support: A longitudinal analysis using the future of families and child wellbeing study

INTRODUCTION

The United States is responsible for the highest incarceration rate globally. This study aimed to explore the impact of partner incarceration on maternal substance use and whether social support mediates the relationship between partner incarceration and maternal substance use.

METHODS

Using data from the Future of Families and Child Wellbeing Study, a longitudinal cohort following new parents and children, this analysis quantifies the relationship between paternal incarceration and maternal substance use (N = 2823). We analyzed maternal responses in years 3 (2001-2003), 5 (2003-2006), 9 (2007-2010), and 15 (2014-2017). We explored the role of financial support and emergency social support as potential mediators. Confirmatory factor analysis (CFA) was employed to construct support-related mediators. We modeled the impact of partner incarceration and maternal substance use using generalized estimating equations (GEE) to account for repeated measures, adjusting for appropriate confounders (age of mother at child's birth, race, education, employment, and history of intimate partner violence).

RESULTS

Nearly half (44.2%, N = 1247) of participants reported partner incarceration. Among mothers who experienced partner incarceration, the odds of reporting substance use were 110% greater than those who reported no partner incarceration (adjusted Odds Ratio [aOR]: 2.10; 95% Confidence Interval (CI):1.67-2.63). Financial support at year 5 accounted for 19.5% (95% CI: 6.03-33.06%) of the association between partner incarceration at year 3 and substance use at year 9; emergency social support at year 5 accounted for 6.4% (95% CI: 0.51-12.25%) of the association between partner incarceration and substance use at year 9. Neither financial nor emergency social support at year 9 were significant mediators between partner incarceration at year 3 and substance use at year 15.

CONCLUSIONS

These findings demonstrate that partner incarceration impacts maternal substance use. Financial and emergency support may partially mediate this relationship in the short term, which has important implications for families disrupted by mass incarceration.

Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults

Importance

As a financial hardship, negative wealth shock has been implicated in some adverse health outcomes. However, associations between negative wealth shock and cognitive decline and dementia have not been examined.

Objective

To investigate whether negative wealth shock was associated with cognitive decline and incident dementia among middle-aged and older US adults.

Design, Setting, and Participants

The Health and Retirement Study (HRS) is a prospective cohort study conducted biennially among US adults older than 50 years. Data from the HRS from calendar years 1996 to 2020 were analyzed from July 1 to 31, 2023. The final sample included 8082 participants with complete data of interest.

Exposures

Wealth status was quantified with questionnaires. Negative wealth shock was defined as a loss of 75% or more in total wealth over a 2-year period. Asset poverty was defined as zero or less total net wealth.

Main Outcomes and Measures

Cognitive function was assessed with the modified Telephone Interview for Cognitive Status (TICS-m). Dementia status was determined with TICS-m scores and proxy assessment.

Results

Among 8082 participants included (mean [SD] age, 63.7 [5.7] years; 4179 women [51.7%] and 3903 men [48.3%]; 1111 Black [13.7%], 6689 White [82.7%], and 282 other [3.5%]), 1441 developed incident dementia over a median follow-up time of 14 (IQR, 7-20) years. Compared with participants who had positive wealth without shock, those with negative wealth shock had accelerated cognitive decline (β coefficient, -0.014 [95% CI, -0.027 to -0.001]; P = .03) and increased risks of dementia (hazard ratio [HR], 1.27 [95% CI, 1.11-1.46]; P < .001). Higher dementia risks were also found in participants with asset poverty at baseline (HR, 1.61 [95% CI, 1.30-2.00]; P < .001). Associations were found in White participants (HR, 1.34 [95% CI, 1.14-1.58]; P < .001) and participants younger than 65 years (HR, 1.38 [95% CI, 1.13-1.68]; P = .001) but not in other races and ethnicities or those 65 years or older.

Conclusions and Relevance

In this cohort study, negative wealth shock was associated with accelerated cognitive decline and elevated risks of dementia among middle-aged and older US adults, with modifications by age and ethnicity. These findings should be confirmed by further prospective and interventional studies.

Association of Sustained Low or High Income and Income Changes With Risk of Incident Type 2 Diabetes Among Individuals Aged 30 to 64 Years

Importance

Evidence of the association between income fluctuation and risk of type 2 diabetes (T2D) is scarce.

Objective

To investigate whether sustained low or high income and income changes are associated with incidence of T2D.

Design, Setting, and Participants

In this population-based cohort study, more than 7.8 million adults without T2D aged 30 to 64 years from a nationally representative sample from the Korean Health Insurance Service database were enrolled in 2012 and followed up to 2019 (median follow-up, 6.3 years [IQR, 6.1-6.6 years]).

Exposures

Twenty quantiles of monthly health insurance premiums determined income levels. Income quartiles were annually analyzed from 2008 to 2012. Beneficiaries of the Medical Aid Program were regarded as those with very low income. A decrease in income was indicated as a reduction of 25% or more in income compared with income in the previous year.

Main Outcomes and Measures

The primary outcome was incident T2D based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes E11 to E14, 1 or more claims of antidiabetic medication, or a fasting glucose level of 126 mg/dL or higher. Multivariable Cox proportional hazards models were used to assess the association of low- or high-income status and income changes with incidence of T2D.

Results

Of 7 821 227 participants (mean [SD] age, 46.4 [9.3] years; 54.9% men), 359 931 (4.6%) developed T2D at least 1 year after enrollment. Individuals who repeatedly experienced low and very low income for 5 years showed 22% (hazard ratio [HR], 1.22 [95% CI, 1.21-1.23]) and 57% (1.57 [95% CI, 1.53-1.62]) higher T2D risk compared with those who never experienced low and very low income, respectively. In contrast, individuals who were repeatedly in high-income quartiles showed lower T2D risk compared with those who never experienced high income (HR, 0.86 [95% CI, 0.85-0.86]). The number of income decreases was associated with elevated T2D risk (≥2 vs 0 income decreases: HR, 1.08 [95% CI, 1.06-1.11]; P < .001 for trend). When income quartile status was compared between 2008 and 2012, individuals who experienced an income increase had lowered T2D risk, while those who experienced an income decrease had elevated T2D risk in each income quartile group.

Conclusions and Relevance

This cohort study found that individuals who experienced sustained low-income status or an income decrease had elevated T2D risk, while those who had sustained high-income status or an income increase had lowered T2D risk.

COVID-19-Related Shifts in Polysubstance Use

Background: Big Events, such as economic crises and natural disasters, affect drug use patterns (e.g. Friedman & Rossi, 2015). The COVID-19 pandemic is a Big Event that led to lockdowns, travel restrictions, protocols on businesses, and rules for social engagements across the globe. Studies primarily in Europe and Oceania show that the pandemic impacted the type and amount of substances used (e.g. Winstock et al., 2020). Objectives: This study examines the impact of COVID-19 on substance use using a sample of 257 individuals across 36 states, who engage in polysubstance use. Results: The sample was recruited via DanceSafe, Inc.'s social media to complete an online survey (April-October 2020) about drug use during the pandemic. The mostly White, heterosexual sample used an average of seven different substances in the past 12 months. Slightly less than half reported increasing use since the onset of the COVID-19 pandemic, with young adults and lesbian, gay, bisexual, pansexual, or queer (LGBPQ) identifying individuals significantly more likely to do so. Relative to other substances, benzodiazepine use increased, and 3,4- methylenedioxymethamphetamine (MDMA) and psychedelic use decreased, while alcohol use stayed the same. Conclusions: The COVID-19 pandemic disproportionately affected those who are young adults, LGBPQ, and use drugs. Their unique needs during the pandemic warrant attention. The swap from leisure (e.g. MDMA) to anti-anxiety (e.g. Xanax) drugs is not surprising. Yet, the rise in novel benzodiazepines (Laing et al., 2021) is a point of concern that suggests drug checking and educational efforts can best reduce potential risks.

Associations between relative deprivation with opioid use among working-age adults during the great recession

Recessions, poverty, and unemployment have been associated with opioid use. However, these measures of financial hardship may be imprecise, limiting our ability to understand this relationship. We tested associations between relative deprivation and non-medical prescription opioid use (NMPOU) and heroin use among working-age adults (ages 18-64) during the Great Recession. Our sample included working-age adults in the 2005-2013 United States National Survey of Drug Use and Health (n = 320,186). Relative deprivation compared the lowest limit of participants' income category to the national 25th percentile individual income for people with similar socio-demographic characteristics (race and ethnicity, gender, year). We distinguished the period before (1/2005-11/2007), during (12/2007-06/2009), and after (07/2007-12/2013) the Great Recession. We estimated odds of past-year NMPOU and heroin use for each past-year exposure (i.e., relative deprivation, poverty, unemployment) using separate logistic regressions adjusting for individual-level covariates (gender, age, race/ethnicity, marital status, and education) and national-level annual Gini coefficient. Our results show that NMPOU was higher among people experiencing relative deprivation (aOR = 1.13, 95% CI = 1.06-1.20), poverty (aOR = 1.22, 95% CI = 1.16-1.29), and unemployment (aOR = 1.42, 95% CI = 1.32-1.53) between 2005 and 2013, as was heroin use (aORs = 2.54, 2.09, 3.55, respectively). The association between relative deprivation and NMPOU was modified by recession timing, and was significantly higher after the Recession (aOR = 1.21, 95% CI = 1.11-1.33). Relative deprivation was associated with higher odds of NMPOU and heroin use, and higher odds of NMPOU after the Great Recession. Our findings suggest contextual-level factors may modify the relationship between relative deprivation and opioid use, and support the need for new measures of financial hardship.

The association between student loan debt and perceived socioeconomic status and problematic drinking and mental health symptoms: A preliminary investigation

U.S. young adults face the largest student loan burden in history, rising income inequality, and economic uncertainty. Personal debt and other financial stressors have been associated with problematic drinking and mental health symptoms. In this paper, we investigated whether student loan debt was more strongly linked to problem drinking and mental health symptoms among those in lower positions of socioeconomic status (SES) and those who perceived greater [in]stability in their SES (SES-instability). Using data from a larger study of college graduates, we investigated SES, SES-instability, student debt, and their 2-way interactions on problematic drinking and mental health symptoms. College graduates (N = 331), who were two years post-graduation, completed measures assessing student debt, perceived SES, SES-instability, problematic drinking, and mental health symptoms (depression, anxiety, and stress). The hypotheses and data analysis plan were registered prior to conducting analyses. The expected unique, positive associations of SES-instability with problematic drinking and mental health symptoms were supported. SES was uniquely linked with problematic drinking only and in the opposite direction as predicted. Student debt was uniquely and positively linked to stress only. The expected interactions were largely supported for SES-instability and student debt-i.e., the associations of student debt with problematic drinking, anxiety, and stress were stronger (more positive) for those with greater SES-instability. The expected interactions for SES and student debt were null. Though data are cross-sectional and come from an educationally-privileged group, study findings provide preliminary evidence of links between young adult student loan debt, greater SES-instability, and their drinking/mental health.

The impact of an unemployment insurance reform on incidence rates of hospitalisation due to alcohol-related disorders: a quasi-experimental study of heterogeneous effects across ethnic background, educational level, employment status, and sex in Sweden

Background

Many Western countries have scaled back social and health expenditure, including decreases in the generosity and coverage of unemployment insurance, resulting in negative effects on general health and well-being at the aggregate level. Yet, research has not sufficiently looked into heterogeneity of such effects across different subgroups of the population. In Sweden, the 2006 unemployment insurance reform, implemented on the 1^st of January 2007, encompassed a drastic increase of insurance fund membership fees, reduced benefit levels, and stricter eligibility requirements. As this particularly affected already socioeconomically disadvantaged groups in society, such as foreign-born and low-educated individuals, the current study hypothesise that the reform would also have a greater impact on health outcomes in these groups.

Methods

Based on register data for the total population, we utilise a quasi-experimental approach to investigate heterogeneous health effects of the reform across ethnic background, educational level, employment status, and sex. Due to behaviourally caused diseases having a relatively shorter lag time from exposure, hospitalisation due to alcohol-related disorders serves as the health outcome. A series of regression discontinuity models are used to analyse monthly incidence rates of hospitalisation due to alcohol-related disorders among individuals aged 30–60 during the study period (2001–2012), with the threshold set to the 1^st of January 2007.

Results

The results suggest that, in general, there was no adverse effect of the reform on incidence rates of hospitalisation due to alcohol-related disorders. A significant increase is nonetheless detected among the unemployed, largely driven by Swedish-born individuals with Swedish-born or foreign-born parents, low-educated individuals, and men.

Conclusions

We conclude that the Swedish 2006 unemployment insurance reform generally resulted in increasing incidence rates of hospitalisation due to alcohol-related disorders among unemployed population subgroups known to have higher levels of alcohol consumption.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14209-2.

The Life Course of Unemployment and Midlife Health

Objectives: We estimate associations between unemployment trajectories from ages 27-49 and physical and mental health at age 50. Methods: Data are from the U.S. National Longitudinal Survey of Youth, 1979 (N=6434). Group-based trajectory models are used to identify unemployment trajectories. Generalized linear models with a modified Bolck, Croon, and Hagenaars (BCH) correction are used to regress health on unemployment trajectory groups. Results: We identified "Consistently Low (70%)," "Decreasing Mid-Career (18%)," and "Persistently High (12%)" unemployment trajectories. Experiencing Decreasing Mid-Career or Persistently High trajectories was associated with worse physical and mental health at age 50 than Consistently Low trajectories. Experiencing a Persistently High trajectory was associated with worse physical and mental health than a Decreasing Mid-Career trajectory. Discussion: Timing and likelihood of unemployment are associated with midlife health. Mid-Career unemployment is associated with worse physical and mental health at age 50, but not to the same degree as Persistently High unemployment.

Angina Outcomes in Nonsmokers Exposed to Secondhand Smoke: Results from the National Health and Nutrition Examination Survey 2007–2018

Objective  The aim of the study is to examine the relationship between secondhand smoke (SHS) and angina using the National Health and Nutrition Examination Survey database over a 12-year period.

Methods  Self-reported smoking status and cotinine levels were used to identify exposure groups (smokers, nonsmokers, and secondhand smokers), and medical history of angina was also collected via a self-report survey. The association between exposure to SHS and angina was analyzed using odd ratios with 95% confidence intervals calculated using two logistic regression models.

Results  The study found that when aggregating data from all 12 years, secondhand smokers are 42.9% significantly more likely to report having experienced angina, while smokers were 97.7% significantly more likely to report having angina compared with nonsmokers.

Conclusions  This study is the first of its kind to examine data from a national database over a 12-year period to determine an association between SHS and angina outcomes, thus highlighting the importance of reducing SHS exposure to improve cardiovascular health.

Smoking and alcohol use in unemployed populations: a systematic review and meta-analysis

Unemployment is an economic and social phenomenon that has economic, social, personal, and health consequences. This study aimed to investigate the relationship between unemployment and alcohol use and smoking as a systematic review and meta-analysis. The two databases PubMed and Scopus were selected for the search and using a set of keywords, these two sources of scientific information were searched from 2004 to June 2021 and 1996 until June 2021, respectively. To meta-analyze the relationship between unemployment and smoking and alcohol use, odds ratio and confidence interval were calculated for this relationship. The meta-analysis was performed based on a random-effects. Subgroups were also performed for men and women. Heterogeneity in studies as well as publication bias were also examined. A total of 52 cross-sectional and cohort studies were included in the meta-analysis. In the relationship between unemployment and alcohol use, the odds ratio was 1.25 and the confidence interval was between 1.12 and 1.41. In the relationship between unemployment and smoking, the odds ratio was 1.43 and the confidence interval was between 1.13 and 1.81. According to the results, it can be said that unemployment increases the likelihood of alcohol use and smoking. Therefore, policymakers must pay more attention to the health consequences of economic problems, especially unemployment.

Understanding How and Why Alcohol Interventions Prevent and Reduce Problematic Alcohol Consumption among Older Adults: A Systematic Review

Problematic alcohol use has been increasing in older adults (55+) in recent decades. Many of the effective interventions that are available to prevent or reduce the negative effects of alcohol consumption are aimed at adults in general. It is unclear whether these interventions also work for older adults. The objective of this review was to understand how (i.e., which elements), in which context, and why (which mechanisms) interventions are successful in preventing or reducing (problematic) alcohol consumption among older adults. A systematic review of articles published between 2000 and 2022 was performed using PubMed, PsycINFO, Web of Science and CHINAHL. Realist evaluation was used to analyze the data. We found 61 studies on interventions aimed at preventing or reducing problematic alcohol use. Most of the interventions were not specifically designed for older adults but also included older adults. The findings of the current study highlight three major effective elements of interventions: (1) providing information on the consequences of alcohol consumption; (2) being in contact with others and communicating with them about (alcohol) problems; and (3) personalized feedback about drinking behavior. Two of these elements were also used in the interventions especially designed for older adults. Being in contact with others and communicating with them about (alcohol) problems is an important element to pay attention to for developers of alcohol interventions for older adults because loneliness is a problem for this age group and there is a relationship between the use of alcohol and loneliness.

Non-physical factors that impact return to work in individuals with upper extremity injuries: A scoping review

BACKGROUND

Upper extremity injuries may prevent adults from returning to work, impacting productivity, and engagement in meaningful employment.

OBJECTIVE

The scoping review identified various non-physical factors that impact return to work (RTW) after an upper extremity injury.

METHODS

Database searches included: CINAHL, PsycINFO, PubMed, and the Cochrane Database of Systematic Reviews. The authors further hand searched the journals Work and The Journal of Hand Therapy. Inclusion criteria included articles published in English, published from 2000-2020, and addressed the following topics: upper extremity injury, the client's psychosocial perceptions of the injury, and return to work.

RESULTS

After title and abstract review, 9 studies were identified for full-text review that examined various patterns related to non-physical factors that impact RTW. Three themes emerged from the full-text reviews including client self-efficacy, social determinants of health, and the need for holistic intervention approaches.

CONCLUSIONS

Practitioners involved in the rehabilitation of working age clients with upper extremity injuries should remain cognizant of the non-physical factors that can impact return to work and incorporate holistic approaches like monitoring and addressing self-efficacy, psychosocial well-being, and social determinants of health into clinical practice.

Employment status, unemployment duration, and health-related metrics among US adults of prime working age: Behavioral Risk Factor Surveillance System, 2018-2019

BACKGROUND

While unemployment has been associated with poor health, few recent studies in the United States have comprehensively assessed associations between employment status (including duration unemployed) and healthcare access, health-related behaviors, and specific health outcomes.

METHODS

We assessed health-related metrics by employment status in 2018-2019 Behavioral Risk Factor Surveillance System respondents ages 25-54. We calculated the unadjusted prevalence and adjusted prevalence ratios to compare employed workers to respondents who were self-employed, short-term (<12 months) unemployed, long-term unemployed, and unable to work.

RESULTS

Adverse health outcomes increased with unemployment duration and were highest for those unable to work. Non-Hispanic Blacks were most likely to be unemployed or unable to work. Short-term unemployment and self-employment were associated with poor healthcare access. Health behaviors and outcomes declined with increasing duration of unemployment and were worst for those unable to work.

CONCLUSIONS

In the United States, access to affordable healthcare is problematic for both the self-employed and the short-term unemployed. Short-term unemployment is a particularly important locus for intervention and provision of resources to prevent health declines that may hinder re-employment.

The Great Recession, behavioral health, and self-rated health: An examination of racial/ethnic differences in the US

The Great Recession has been associated with racial/ethnic disparities in economic loss, alcohol-related problems and mental health in the US. In this study, we examine its effect on overall health, the role of heavy drinking and mental health, and whether these relationships vary by race/ethnicity. Using US National Alcohol Survey data collected from White, African American and Latino individuals between June 2009 and March 2010 (N = 4656), we conducted gender-stratified simultaneous path modeling to test racial/ethnic differences in hypothesized paths from recession-related hardships to overall self-rated health through current depressive symptoms and heavy drinking. Recession impacts were measured using an index of job-related, financial and housing hardships. Models accounted for demographic characteristics and heavy drinking, health conditions and alcohol-related health harms occurring prior to the Great Recession. We found that in men and women of each racial/ethnic group, more accumulated recession hardships were associated with greater depressive symptoms and more frequent heavy drinking, and depressive symptoms were associated with poorer self-rated health. Further, heavy drinking was related to poorer self-rated health in Black men and depressive symptoms in Latino men, and for Black and Latina women, prior heavy drinking was associated with current depressive symptoms. Findings highlight adverse, behavioral and overall health consequences of a severe recession for men and women of diverse racial/ethnic groups, as well as unique risks for Black and Latino men and women. Findings suggest the need for behavioral health interventions alongside multisector strategies to bolster the labor market and social safety net during severe economic downturns.

Midlife Wealth Mobility and Long-term Cardiovascular Health

Importance

The association of socioeconomic status and cardiovascular outcomes has been well described, but little is known about whether longitudinal changes in wealth are associated with cardiovascular health status.

Objective

To evaluate the association between midlife wealth mobility and risk of cardiovascular events.

Design, Setting, and Participants

This longitudinal, retrospective cohort study included US adults 50 years or older who participated in the Health and Retirement Study. Participants in the primary analysis had no history of cardiovascular disease and had observations in at least two of three 5-year age intervals (50-54, 55-59, and 60-64 years) and follow-up after 65 years of age. Data were collected from January 1, 1992, to December 31, 2016, and analyzed from November 10, 2020, to April 26, 2021.

Exposures

Quintiles of wealth (reflecting total nonhousing assets) were defined within each of 4 birth cohorts (1931-1935, 1936-1940, 1941-1945, and 1946-1950). Wealth mobility was defined as an increase or a decrease of 1 or more wealth quintiles and was compared with wealth stability (same quintile over time) using covariate-adjusted Cox proportional hazards regression models.

Main Outcomes and Measures

Composite outcome of nonfatal cardiovascular event (myocardial infarction, heart failure, cardiac arrhythmia, or stroke) or cardiovascular death.

Results

A total of 5579 participants were included in the primary analysis (mean [SD] age, 54.2 [2.6] years; 3078 women [55.2%]). During a mean (SD) follow-up of 16.9 (5.8) years, 1336 participants (24.0%) experienced a primary end point of nonfatal cardiovascular event or cardiovascular death (14.4 [95% CI, 13.6-15.2] per 1000 patient-years). Higher initial wealth (per quintile) was associated with lower cardiovascular risk (adjusted hazard ratio [aHR] per quintile, 0.89 [95% CI, 0.84-0.95]; P = .001). When compared with stable wealth, participants who experienced upward wealth mobility (by at least 1 quintile) had independently lower hazards of a subsequent nonfatal cardiovascular event or cardiovascular death (aHR, 0.84 [95% CI, 0.73-0.97]; P = .02), and participants who experienced downward wealth mobility had higher risks (aHR, 1.15 [95% CI, 1.00-1.32]; P = .046).

Conclusions and Relevance

These findings suggest that upward wealth mobility relative to peers in late middle age is associated with lower risks of cardiovascular events or death after 65 years of age.

Unemployment and mortality in a large Italian cohort

BACKGROUND

Aim of this study was to examine the association between unemployment and mortality, taking into account potential confounders of this association. A secondary objective was to assess whether the association between unemployment and mortality was modified by lack of household economic resources.

METHODS

Prospective cohort composed of a representative sample of Italian subjects 30-55 years who participated in the Italian National Health Survey 1999-2000, followed up for mortality up to 2012 (15 656 men and 11 463 women). Data were analyzed using Cox regression models, stratified by gender and adjusted for health status, behavioral risk factors, socioeconomic position and position in the household. The modifying effect of the lack of economic resources was assessed by testing its interaction with unemployment on mortality.

RESULTS

Among women, unemployment was not associated with mortality, whereas among men, higher mortality was found from all causes (HR = 1.82), which was not modified by lack of economic resources, and from neoplasms (HR = 1.59), cardiovascular diseases (HR = 2.58) and suicides (HR = 5.01).

CONCLUSIONS

Results for men were robust to the adjustment for main potential confounders, suggesting a causal relationship between unemployment and mortality. The lack of effect modification by economic resources supports the relevance of the loss of non-material benefits of work on mortality.

New evidence on the impact of the Great Recession on health-compromising behaviours

Using data from the English Longitudinal Study of Ageing over the period 2004-2017, this paper explores the effects of the Great Recession and its aftermath upon health-compromising behaviours in adults aged 50 and over. We introduce new techniques into this area of research, namely dynamic random-effects logit estimators which control for initial conditions and correlated individual effects. We observe a lack of crisis effect upon the probabilities of smoking and being physically inactive, as well as of transitioning in and out of these behaviours. In line with other recent literature, this suggests that the relationship between economic recessions and smoking and physical inactivity may have broken down. Alternatively, the over 50s may have been protected from the crisis and subsequent austerity measures. Nonetheless, both the crisis and post-crisis period were associated with a lower probability of drinking frequently.

Use of Health Information Varies by Region Among Older Adults in the U.S

Objective: To examine geographic variations in health information use among older adults in the United States. Methods: We compared 15,531 adults (age 45 and older) across four U.S. regions. Descriptive analyses were conducted to assess health information seeking and use by year. The relationship between health information seeking or use and regional changes were assessed using binomial logistic regression. Binomial models were adjusted by socio-demographics, chronic conditions, and health information sources. Magnitude and direction of relationships were assessed using adjusted odds ratios (aORs), 95% confidence intervals (CIs), and p-values. Results: Only the Northeast region showed increases in health information seeking (3.8%) and use (4.5%) among older adults. However adjusted models showed those living in the Northeast were 28% less likely to use health information to maintain their health and 32% less likely to use health information to treat illness. Conclusion: As a result of the current pandemic, older adults are facing a growing burden from health care expenses. Inability to gather and use health information for personal safety or self care can potentially increase inequalities in health, especially for older adults without personal health care providers.

Alcohol Use and COVID-19: Can we Predict the Impact of the Pandemic on Alcohol Use Based on the Previous Crises in the 21st Century? A Brief Review

The enormous health and economic challenges precipitated by the 2019 coronavirus disease (COVID-19) pandemic are comparable or even greater than those associated with previous historical world crises. Alcohol use, especially drinking to cope with stress, is a concern, as an increase in its sales has been reported in some countries during the quarantine. This study aims to provide a better understanding of what to expect in terms of alcohol consumption, risk factors for excessive use, and its potential consequences during this pandemic based on previous experiences. We investigated how traumatic events related to alcohol consumption. Studies on mass traumatic events (i.e., terrorism as 9/11), epidemic outbreaks (i.e., severe acute respiratory syndrome [SARS] in 2003), economic crises (such as 2008's Great Recession), and COVID-19 were selected. The main keywords used to select the studies were alcohol use, drinking patterns, alcohol use disorders, and alcohol-related consequences. Previous studies reported increases in alcohol use associated with those events mediated, at least partially, by anxiety and depressive symptoms, and posttraumatic stress disorder (PTSD). Being male, young, and single also seems to be associated with a higher vulnerability to develop risky drinking behavior after those tragic events. The discussion of previous risk and protective factors can contribute to elaborate more specific public health policies to mitigate the impact of the current pandemic on people's mental health, especially alcohol-related problems.

Cross-country and historical variation in alcohol consumption among older men and women: Leveraging recently harmonized survey data in 21 countries

BACKGROUND

Alcohol consumption causes greater harm in older than younger adults. As the population ages, understanding cross-country and time-varying drinking patterns of older adults is of critical importance. Available evidence relies primarily on ecological data.

METHODS

We harmonized survey data for 179,881 adults age 50+ observed repeatedly between 1998 and 2016 in 21 countries. Next, we estimated historical variation in consumption across countries (overall and stratified by gender and age group 50-64/65+).

RESULTS

On average, 51.95 % of older adults consumed any alcohol over the observed period. For 13 countries, the proportion of older adults who drink increased (mean annual increase: 0.76 percent points). Heavy drinking (men drinks/day>3 or binge>5, women drinks/day>2 or binge>4) peaked at 23.54 % for England in 2010 and lifetime abstainers at 69.65 % for China in 2011. Across countries and among drinkers, consumption frequency was 2.57 days/week, the number of standard drink units when drinking was 2.57, and the average number of drinks/day over a week was 1.12. Consumption patterns varied substantially across countries and historical time. Overall probability and frequency of consumption were higher in men than women, with the largest gaps observed in 2011 for China, but gender gaps decreased (even reversed) in the young old and varied across country and time.

CONCLUSIONS

Wide variation in older adults' alcohol consumption across countries and time suggests that broad scale prevention and intervention efforts can be harnessed for potential population-level health benefits. Further variation by gender and age reflect physiological and social factors simultaneously shaping alcohol consumption.

Socioeconomic determinants of depression amid the anti-extradition bill protests in Hong Kong: the mediating role of daily routine disruptions

BACKGROUND

Previous research has suggested a socioeconomic gradient of mental health in the face of potentially traumatic events. Nevertheless, few studies examined the intermediary mechanisms of this gradient. This study tested a hypothesised mediating effect of disruptions to daily routines (eg, eating/sleeping habits) between socioeconomic status (SES) and depression among participants and non-participants of the anti-extradition bill protests in summer 2019 in Hong Kong.

METHODS

A territory-wide telephone survey was conducted during the movement in the first 3 weeks of July 2019 to collect self-report data from 1112 Cantonese-speaking Hong Kong citizens. Stratified by participation in the anti-extradition bill protests, logistic regression was conducted to examine the inverse relationship between SES and depression. Subsequently, path analysis was conducted to test the hypothesised indirect effect through daily routine disruptions.

RESULTS

In total, 581 (52.2%) respondents participated in the anti-extradition bill protests. Logistic regression showed that higher educational attainment was protective of depression among both participants and non-participants, while the protective effect of household income level HK$40 000-HK$79 999 (compared with <HK$20 000) was only observed among participants. Path analysis showed that 50.3% of the socioeconomic gradient was explained by daily routine disruptions among participants, compared with 8.3% among non-participants.

CONCLUSIONS

Daily routine disruptions partially explain the association between low SES and depression, especially among participants of the anti-extradition bill protests. To improve population mental health, such disruptions should be mitigated.

Association of negative financial shocks during the Great Recession with depressive symptoms and substance use in the USA: the CARDIA study

BACKGROUND

The Great Recession of 2008 was marked by large increases in unemployment and decreases in the household wealth of many Americans. In the 21st century, there have also been increases in depressive symptoms, alcohol use and drug use among some groups in the USA. The objective of this analysis is to evaluate the influence of negative financial shocks incurred during the Great Recession on depressive symptoms, alcohol and drug use.

METHODS

We employed a quasi-experimental fixed-effects design, using data from adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Our financial shock predictors were within-person change in employment status, income and debt to asset ratio between 2005 and 2010. Our outcomes were within-person change in depressive symptoms score, alcohol use and past 30-day drug use.

RESULTS

In adjusted models, we found that becoming unemployed and experiencing a drop in income and were associated with an increase in depressive symptoms. Incurring more debts than assets was also associated with an increase in depressive symptoms and a slight decrease in daily alcohol consumption (mL).

CONCLUSION

Our findings suggest that multiple types of financial shocks incurred during an economic recession negatively influence depressive symptoms among black and white adults in the USA, and highlight the need for future research on how economic recessions are associated with health.

Ageing and Alcohol: Drinking Typologies among Older Adults

Objectives: Alcohol consumption and harms among older people are increasing. We examined different demographic characteristics and drinking patterns among an older population. Methods: Secondary analyses of nationally representative Australian data; subjects aged 50+ years (N = 10,856). Two-step cluster analysis was performed to identify demographic groups and alcohol consumption behaviours. Results: Three groups were identified: Group 1 (older, unmarried, and lived alone): >65 years, moderate drinkers, poorest health, psychological distress, social disadvantage, smokers, illicit drug users, and more frequent previous alcohol treatment. Group 3 (older married): >65 years, good health, low psychological distress, less likely to drink at risky levels, and one in five drank daily. Group 2 (younger married): 50-64 years, mostly employed, highest proportion of risky drinkers and of 5+ standard drinks per session, and liberal drinking attitudes with most concern from others about their drinking. Discussion: These demographic typologies can inform targeted prevention efforts for an estimated 1.3 million adults older than 50 years drinking at risky levels.

Unemployment, employment precarity, and inflammation

Unemployment has been associated with poorer health, but few studies have examined the biological mechanisms that confer these health decrements. Further, no studies to date have examined differences across employment groups to consider whether employment (in whatever means) is preferential in terms of health. The present study utilised secondary data from Understanding Society: The Household Longitudinal Survey during the aftermath of the recent global recession. Two markers of peripheral inflammation: C-reactive protein (CRP) and fibrinogen were assessed across employment groups (unemployed; permanent, temporary, and self-employed), controlling for individual, socio-demographic and health variables to give greater context to our understanding of how employment status influences health. After controlling for relevant confounds, unemployment was associated with higher levels of fibrinogen but not CRP. Subsequent analyses of employment subgroup revealed the temporary employed have similar levels of fibrinogen to the unemployed, and may therefore be at a similar health disadvantage. The findings confirm that unemployment is associated with increases in one marker of peripheral inflammation, but that this health protection is not conferred to those in precarious employment.

Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States

Importance

Health insurance is effective in preventing financial hardship from unexpected major health care events. However, it is also essential to assess whether vulnerable patients, particularly those from low-income families, are adequately protected from longitudinal health care costs for common chronic conditions such as atherosclerotic cardiovascular disease (ASCVD).

Objective

To examine the annual burden of total out-of-pocket health expenses among low-income families that included a member with ASCVD.

Design, Setting, and Participants

In this cross-sectional study of the Medical Expenditure Panel Survey from January 2006 through December 2015, all families with 1 or more members with ASCVD were identified. Families were classified as low income if they had an income under 200% of the federal poverty limit. Analyses began December 2017.

Main Outcomes and Measures

Total annual inflation-adjusted out-of-pocket expenses, inclusive of insurance premiums, for all patients with ASCVD. We compared these expenses against annual family incomes. Out-of-pocket expenses of more than 20% and more than 40% of family income defined high and catastrophic financial burden, respectively.

Results

We identified 22 521 adults with ASCVD, represented in 20 600 families in the Medical Expenditure Panel Survey. They correspond to an annual estimated 23 million or 9.9% of US adults with a mean (SE) age of 65 (0.2) years and included 10.9 million women (47.1%). They were represented in 21 million or 15% of US families. Of these, 8.2 million families (39%) were low income. The mean annual family income was $57 143 (95% CI, $55 377-$58 909), and the mean out-of-pocket expense was $4415 (95% CI, $3735-$3976). While financial burden from health expenses decreased throughout the study, even in 2014 and 2015, low-income families had 3-fold higher odds than mid/high-income families of high financial burden (21.4% vs 7.6%; OR, 3.31; 95% CI, 2.55-4.31) and 9-fold higher odds of catastrophic financial burden (9.8% vs 1.2%; OR, 9.35; 95% CI, 5.39-16.20), representing nearly 2 million low-income families nationally. Further, even among the insured, 1.6 million low-income families (21.8%) experienced high financial burden and 721 000 low-income families (9.8%) experienced catastrophic out-of-pocket health care expenses in 2014 and 2015.

Conclusions and Relevance

One in 4 low-income families with a member with ASCVD, including those with insurance coverage, experience a high financial burden, and 1 in 10 experience a catastrophic financial burden due to cumulative out-of-pocket health care expenses. To alleviate economic disparities, policy interventions must extend focus to improving not only access, but also quality of coverage, particularly for low-income families.

Drug and Alcohol Abuse: the Role of Economic Insecurity

Objectives: We evaluate the extent to which subjective and objective measures of economic distress account for differences in substance abuse between the mid-1990s and early-2010s. Methods: We use cross-sectional survey data for national samples of Americans aged 25-74 in 1995-96 (N = 3034) and 2011-14 (N = 2598). Using a logit model, we regress dichotomous indicators of drug and alcohol abuse on economic distress. Results: After adjusting for sociodemographic characteristics, the odds of drug abuse in the early-2010s among older individuals (aged 50+) were 2.9 times (95%CI 1.9-4.2) those of the mid-1990s, but there was no statistically significant period difference in drug abuse among younger individuals. Measures of model performance demonstrate that subjective measures of economic distress are better predictors of drug abuse than objective measures. The subjective measures also account for a larger share (26%) of the increase in drug abuse at ages 50+ than the objective measures (6%). We cannot draw clear conclusions regarding alcohol abuse because results are sensitive to specification. Conclusions: The rise in drug abuse among midlife Americans may relate to perceived economic distress that is not captured by standard economic measures.

Men's Income Trajectories and Physical and Mental Health at Midlife

Using time-varying, prospectively measured income in a nationally representative sample of Baby-Boomer men (the National Longitudinal Survey of Youth - 1979 [NLSY79]), we identify eight group-based trajectories of income between ages 25-49 and use multinomial treatment models to describe the associations between group-based income trajectories and mental and physical health at midlife. We find remarkable rigidity in income trajectories: less than 25% of our sample experiences significant upward or downward mobility between the ages of 25 to 49 and most who move remain or move into poverty. Men's physical and mental health at age fifty is strongly associated with their income trajectories, and some upwardly mobile men achieve the same physical and mental health as the highest earning men after adjusting for selection. The worse physical and mental health of men on other income trajectories is largely attributable to their early life disadvantages, health behaviors, and cumulative work experiences.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

Medical marijuana laws and adolescent marijuana use in the United States: a systematic review and meta-analysis

AIMS

To conduct a systematic review and meta-analysis of studies in order to estimate the effect of US medical marijuana laws (MMLs) on past-month marijuana use prevalence among adolescents.

METHODS

A total of 2999 papers from 17 literature sources were screened systematically. Eleven studies, developed from four ongoing large national surveys, were meta-analyzed. Estimates of MML effects on any past-month marijuana use prevalence from included studies were obtained from comparisons of pre-post MML changes in MML states to changes in non-MML states over comparable time-periods. These estimates were standardized and entered into a meta-analysis model with fixed-effects for each study. Heterogeneity among the study estimates by national data survey was tested with an omnibus F-test. Estimates of effects on additional marijuana outcomes, of MML provisions (e.g. dispensaries) and among demographic subgroups were abstracted and summarized. Key methodological and modeling characteristics were also described. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

None of the 11 studies found significant estimates of pre-post MML changes compared with contemporaneous changes in non-MML states for marijuana use prevalence among adolescents. The meta-analysis yielded a non-significant pooled estimate (standardized mean difference) of -0.003 (95% confidence interval = -0.012, +0.007). Four studies compared MML with non-MML states on pre-MML differences and all found higher rates of past-month marijuana use in MML states pre-MML passage. Additional tests of specific MML provisions, of MML effects on additional marijuana outcomes and among subgroups generally yielded non-significant results, although limited heterogeneity may warrant further study.

CONCLUSIONS

Synthesis of the current evidence does not support the hypothesis that US medical marijuana laws (MMLs) until 2014 have led to increases in adolescent marijuana use prevalence. Limited heterogeneity exists among estimates of effects of MMLs on other patterns of marijuana use, of effects within particular population subgroups and of effects of specific MML provisions.

Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States

Importance

A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective

To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants

The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures

Experiencing a negative wealth shock, defined as a loss of 75% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures

Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results

There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance

Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

Work disability in the United States, 1968-2015: Prevalence, duration, recovery, and trends

The United States workforce is aging. At the same time more people have chronic conditions, for longer periods. Given these trends the importance of work disability, physical or nervous problems that limit a person's type or amount of work, is increasing. No research has examined transitions among multiple levels of work disability, recovery from work disability, or trends. Limited research has focused on work disability among African Americans and Hispanics, or separately for women and men. We examined these areas using data from 30,563 adults in the 1968-2015 Panel Study of Income Dynamics. We estimated annual probabilities of work disability, recovery, and death with multinomial logistic Markov models. Microsimulations accounting for age and education estimated outcomes for African American, Hispanic, and non-Hispanic white women and men. Results from these nationally representative data suggested that the majority of Americans experience work disability during working life. Most spells ended with recovery or reduced severity. Among women, African Americans and Hispanics had less moderate and severe work disability than whites. Among men, African Americans became severely work disabled more often than whites, recovered from severe spells more often and had shorter severe spells, yet had more severe work disability at age 65. Hispanic men were more likely to report at least one spell of severe work disability than whites; they also had substantially more recovery from severe work disability, and a lower percentage of working years with work disability. Among African Americans and Hispanics, men were considerably more likely than women to have severe work disability at age 65. Work disability declined significantly across the study period for all groups. Although work disability has declined over several decades, it remains common. Results suggest that the majority of work disability spells end with recovery, underscoring the importance of rehabilitation and workplace accommodation.

Impact of the financial crisis on COPD burden: Greece as a case study

Poverty and low socioeconomic status have been associated with chronic obstructive pulmonary disease (COPD). The current financial crisis has forced millions back into poverty. Greece is one of the countries hit the hardest, and is in the middle of a deep ongoing collapse. There have been early reports stating the apparent effects of the Greek downturn on respiratory health. This review summarises the overall impact of the financial crisis on COPD burden throughout the period of economic downturn by analysing the case study of Greece. In all levels of the healthcare system, current economic restrictions have reduced the capacity to prevent, diagnose and treat COPD in parallel with current higher detection rates of COPD. Remarkably, expenditure on healthcare has been reduced by >25%, resulting in major healthcare equipment shortages. Lower wages (by up to 20%) and higher co-payments of up to 25% of a drug's purchase price have led to patients struggling to afford inhaled medications. Treatment nonadherence has been reported, resulting in 11.5% more exacerbations and 14.1% more hospitalisations annually, while the mean cost per severe COPD exacerbation has been approximated as €2600. Greece is a noteworthy example illustrating how COPD burden, quality of care and patients' outcome can be affected by economic crisis.

Individual and regional factors affecting stress and problem alcohol use: A representative nationwide study of China

OBJECTIVES

The objective of this study was to examine the association between individual and environmental stressors and problem alcohol use among Chinese university students.

METHODS

Participants were 11,942 students, who were identified through a multistage survey sampling process that included 50 universities. Individual information, including feelings of stress and perceptions of problem alcohol use, was obtained by self report. Urban and regional variables were retrieved from the National Bureau of Statistics database. Both unadjusted and adjusted methods were considered in the analyses.

RESULTS

Almost one third (32.6%) of the students suffered from some form of severe stress while problem alcohol use prevalence was 7.3%, (95% CI: 4.1-10.4%). The multilevel logistic regression model found that uncertainty stress, gender, father's occupation and monthly expenses were associated with problem alcohol use. Of the contextual factors home region and the university city GDP and unemployment rate were important. When interactions were considered, the relationship between monthly expenses and financial uncertainty and problem drinking was most evident in high level universities. By contrast, the effects of uncertainty stress on problem drinking were most evident in middle and low level universities.

CONCLUSIONS

The findings underscore that efforts to control problem alcohol use among students in China should pay greater attention to environmental determinants of stress and particularly to improvements in stress management in university settings.

Young Finnish Unemployed Men's Experiences of Having Participated in a Specific Active Labor Market Program

The purpose of the present study was to describe young Finnish unemployed men's experiences of having participated in a specific active labor market program, intended to fight unemployment and offered at a resource center. Fifteen young unemployed Finnish men in the age range 18 to 27 years were interviewed face-to-face. Purposive sampling was used to increase the variation among informants. The interview texts were analyzed using both manifest and latent qualitative content analysis. The present results reported that the young men felt that they, thanks to the program at the resource center, had acquired daily routines and could ultimately believe in the future. The young men described how they now had a structure, economic support, and that they could return to their daily life. The informants also described how they could see new possibilities and believe in oneself. There is a lack of empirical studies assessing the possible impact of active labor market programs on the unemployed based on participants' own experiences. Further research is needed to describe and elucidate in more detail the effects of targeted support measures and the needs of unemployed men of different ages and living in different contexts.

Changes in alcohol consumption in the 50- to 64-year-old European economically active population during an economic crisis

Background

The aim was to compare alcohol drinking patterns in economically active people aged 50-64 years before the last economic crisis (2006) and during the crisis (2013).

Methods

Cross-sectional study with data from 25 479 economically active people aged 50-64 years resident in 11 European countries who participated in wave 2 or wave 5 of the SHARE project (2006 and 2013). The outcome variables were hazardous drinking, abstention in previous 3 months and the weekly average number of drinks per drinker. The prevalence ratios of hazardous drinking and abstention, comparing the prevalence in 2013 vs. 2006, were estimated with Poisson regression models with robust variance, and the changes in the number of drinks per week with Poisson regression models.

Results

The prevalence of hazardous drinking decreased among both men (PR = 0.75; 95%CI = 0.63-0.92) and women (PR = 0.91; 95%CI = 0.72-1.15), although the latter decrease was smaller and not statistically significant. The proportion of abstainers increased among both men (PR = 1.11; 95%CI = 0.99-1.29) and women (PR = 1.18; 95%CI = 1.07-1.30), although the former increase was smaller and not statistically significant. The weekly average number of drinks per drinker decreased in men and women. The decreases in consumption were larger in Italy and Spain.

Conclusion

From 2006 to 2013, the amount of alcohol consumed by late working age drinkers decreased in Europe, with more pronounced declines in the countries hardest hit by the economic crisis.

US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991-1992 to 2012-2013

Importance

Over the last 25 years, illicit cannabis use and cannabis use disorders have increased among US adults, and 28 states have passed medical marijuana laws (MML). Little is known about MML and adult illicit cannabis use or cannabis use disorders considered over time.

Objective

To present national data on state MML and degree of change in the prevalence of cannabis use and disorders.

Design, Participants, and Setting

Differences in the degree of change between those living in MML states and other states were examined using 3 cross-sectional US adult surveys: the National Longitudinal Alcohol Epidemiologic Survey (NLAES; 1991-1992), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002), and the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; 2012-2013). Early-MML states passed MML between NLAES and NESARC ("earlier period"). Late-MML states passed MML between NESARC and NESARC-III ("later period").

Main Outcomes and Measures

Past-year illicit cannabis use and DSM-IV cannabis use disorder.

Results

Overall, from 1991-1992 to 2012-2013, illicit cannabis use increased significantly more in states that passed MML than in other states (1.4-percentage point more; SE, 0.5; P = .004), as did cannabis use disorders (0.7-percentage point more; SE, 0.3; P = .03). In the earlier period, illicit cannabis use and disorders decreased similarly in non-MML states and in California (where prevalence was much higher to start with). In contrast, in remaining early-MML states, the prevalence of use and disorders increased. Remaining early-MML and non-MML states differed significantly for use (by 2.5 percentage points; SE, 0.9; P = .004) and disorder (1.1 percentage points; SE, 0.5; P = .02). In the later period, illicit use increased by the following percentage points: never-MML states, 3.5 (SE, 0.5); California, 5.3 (SE, 1.0); Colorado, 7.0 (SE, 1.6); other early-MML states, 2.6 (SE, 0.9); and late-MML states, 5.1 (SE, 0.8). Compared with never-MML states, increases in use were significantly greater in late-MML states (1.6-percentage point more; SE, 0.6; P = .01), California (1.8-percentage point more; SE, 0.9; P = .04), and Colorado (3.5-percentage point more; SE, 1.5; P = .03). Increases in cannabis use disorder, which was less prevalent, were smaller but followed similar patterns descriptively, with change greater than never-MML states in California (1.0-percentage point more; SE, 0.5; P = .06) and Colorado (1.6-percentage point more; SE, 0.8; P = .04).

Conclusions and Relevance

Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders. State-specific policy changes may also have played a role. While medical marijuana may help some, cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public.

The Effects of the Global Economic Recession and a Reduced Alcohol Tax on Hospitalizations Due to Alcohol-Attributed Diseases in Taiwan

This study is to assess the effects of the 2008 economic crisis and a 2009 alcohol tax reduction on alcohol-related morbidity for men of different socioeconomic statuses in Taiwan. Admissions data for the period from 2007 to 2012 for men aged 24–59 years in 2007 was retrieved from the National Health Insurance Research Database. With stratification over three income levels, an interrupted time-series analysis examining the effects of the crisis and taxation reduction on incidence rates of hospitalization for alcohol-attributed diseases (AADs) was employed. The low income group showed a significant (p < 0.05) change in the rate of AAD-related hospitalizations in July 2008; specifically, an abrupt 7.11% increase that was then sustained for several months thereafter. In contrast, while the middle income group exhibited a significant 22.9% decline in the rate of AAD-related hospitalizations over the course of the crisis, that downward trend was gradual. The reduction of the alcohol tax resulted in increased rates of AADs among both the low and high income groups. The economic recession and the reduction of the alcohol tax resulted in an increased rate of AAD among low income men.

Harmful drinking after job loss: a stronger association during the post-2008 economic crisis?

OBJECTIVES

This study investigated, among the Dutch working population, whether job loss during the post-2008 economic crisis is associated with harmful drinking and whether this association is stronger than before the crisis.

METHODS

Repeated cross-sectional data from the Dutch Health Interview Survey 2004-2013 were used to define episodic drinking (≥6 glasses on 1 day ≥1/week) and chronic drinking (≥14 glasses/week for women and ≥21 for men). These data were linked to longitudinal data from tax registries, to measure the experience and duration of job loss during a 5-year working history.

RESULTS

Before the crisis, job loss experience and duration were not associated with harmful drinking. During the crisis, job loss for more than 6 months was associated with episodic drinking [OR 1.40 (95% CI 1.01; 1.94)], while current job loss was associated with chronic drinking [OR 1.43 (95% CI 1.03; 1.98)]. These associations were most clear in men and different between the pre-crisis and crisis period (p interaction = 0.023 and 0.035, respectively).

CONCLUSIONS

The results suggest that economic crises strengthen the potential impact of job loss on harmful drinking, predominately among men.

Recent declines in cancer incidence: related to the Great Recession?

PURPOSE

In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions.

METHODS

Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression.

RESULTS

Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index.

CONCLUSIONS

Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

Unemployment as a chronic stressor: A systematic review of cortisol studies

OBJECTIVE

Unemployment is a type of chronic stressor that impacts human health. The reasons for how the stress of unemployment affect health is still a matter of discussion. One of the pathways from chronic stress to ill health is mediated by cortisol, and so we set out to compile extant data on how its secretion is affected by unemployment.

DESIGN

A systematic literature search was conducted to establish the cortisol dysregulatory effects of this stressor.

MAIN OUTCOME MEASURES

Only studies that specifically examined the effects of unemployment on cortisol excretion, and were written in English were included.

RESULTS

Ten reports were obtained and synthesised to determine the severity and complexity of the effect of unemployment on cortisol secretion. The resulting combined evidence is mixed in terms of degree or dynamic of relationship.

CONCLUSIONS

The differences between the cumulate findings of the studies can be understood in the context of the lack of both standardised methodology and an absence of consensus on unemployment definition. We propose existing methodologies may be strengthened by acknowledging and accounting for the individual characteristics that may be relevant to the stress experience of unemployment.

Health inequalities after austerity in Greece

Since the beginning of economic crisis, Greece has been experiencing unprecedented levels of unemployment and profound cuts to public budgets. Health and welfare sectors were subject to severe austerity measures, which have endangered provision of as well as access to services, potentially widening health inequality gap. European Union Statistics on Income and Living Conditions data show that the proportion of individuals on low incomes reporting unmet medical need due to cost doubled from 7 % in 2008 to 13.9 % in 2013, while the relative gap in access to care between the richest and poorest population groups increased almost ten-fold. In addition, austerity cuts have affected other vulnerable groups, such as undocumented migrants and injecting drug users. Steps have been taken in attempt to mitigate the impact of the austerity, however addressing the growing health inequality gap will require persistent effort of the country’s leadership for years to come.

Effects of the Global Financial Crisis on Health in High-Income Oecd Countries

A growing body of evidence documents how economic crises impact aspects of health across countries and over time. We performed a systematic narrative review of the health effects of the latest economic crisis based on studies of high-income countries. Papers published between January 2009 and July 2015 were selected based on review of titles and abstracts, followed by a full text review conducted by two independent reviewers. Ultimately, 122 studies were selected and their findings summarized. The review finds that the 2008 financial crisis had negative effects on mental health, including suicide, and to a varying extent on some non-communicable and communicable diseases and access to care. Although unhealthy behaviors such as hazardous drinking and tobacco use appeared to decline during the crisis, there have been increases in some groups, typically those already at greatest risk. The health impact was greatest in countries that suffered the largest economic impact of the crisis or prolonged austerity. The Great Recessions in high-income countries have had mixed impacts on health. They tend to be worse when economic impacts are more severe, prolonged austerity measures are implemented, and there are pre-existing problems of substance use among vulnerable groups.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.