The association between alcohol use and health behaviors related to the risk of cardiovascular disease: the South Carolina Cardiovascular Disease Prevention Project

Association of Substance Use With Behavioral Adherence to Centers for Disease Control and Prevention Guidelines for COVID-19 Mitigation: Cross-sectional Web-Based Survey

BACKGROUND

Substance use is a risk factor for COVID-19 infection and adverse outcomes. However, reasons for elevated risk for COVID-19 in substance users are not well understood.

OBJECTIVE

The aim of this study was to evaluate whether alcohol or other drug use is associated with adherence to Centers for Disease Control and Prevention (CDC) guidelines for COVID-19 mitigation. Preregistered analyses tested the hypothesis that greater use of alcohol and other drugs would be associated with lower CDC guideline adherence. A secondary objective was to determine whether substance use was associated with the likelihood of COVID-19 testing or outcome.

METHODS

A cross-sectional web-based survey was administered to a convenience sample recruited through Amazon's Mechanical Turk platform from June 18 to July 19, 2020. Individuals aged 18 years or older and residing in Connecticut, Massachusetts, New Jersey, New York, or Rhode Island were eligible to participate. The exposure of interest was past 7-day use of alcohol, cigarettes, electronic cigarettes, cannabis, stimulants, and nonmedical opioids. The primary outcome was CDC guideline adherence measured using a scale developed from behaviors advised to reduce the spread of COVID-19. Secondary outcomes were likelihood of COVID-19 testing and a positive COVID-19 test result. All analyses accounted for the sociodemographic characteristics.

RESULTS

The sample consisted of 1084 individuals (mean age 40.9 [SD 13.4] years): 529 (48.8%) men, 543 (50.1%) women, 12 (1.1%) other gender identity, 742 (68.5%) White individuals, 267 (24.6%) Black individuals, and 276 (25.5%) Hispanic individuals. Daily opioid users reported lower CDC guideline adherence than nondaily users (B=-0.24, 95% CI -0.44 to -0.05) and nonusers (B=-0.57, 95% CI -0.76 to -0.38). Daily alcohol drinkers reported lower adherence than nondaily drinkers (B=-0.16, 95% CI -0.30 to -0.02). Nondaily alcohol drinkers reported higher adherence than nondrinkers (B=0.10, 95% CI 0.02-0.17). Daily opioid use was related to greater odds of COVID-19 testing, and daily stimulant use was related to greater odds of a positive COVID-19 test.

CONCLUSIONS

In a regionally-specific, racially, and ethnically diverse convenience sample, adults who engaged in daily alcohol or opioid use reported lower CDC guideline adherence for COVID-19 mitigation. Any opioid use was associated with greater odds of COVID-19 testing, and daily stimulant use was associated with greater odds of COVID-19 infection. Cigarettes, electronic cigarettes, cannabis, or stimulant use were not statistically associated with CDC guideline adherence, after accounting for sociodemographic covariates and other substance use variables. Findings support further investigation into whether COVID-19 testing and vaccination should be expanded among individuals with substance-related risk factors.

Prevalence of personal weight control attempts in adults: a systematic review and meta-analysis

The purpose of this systematic review and meta-analysis was to estimate the prevalence of personal weight control attempts (weight loss and/or maintenance) worldwide and to identify correlates, personal strategies used and the underlying motives. We included epidemiological/observational studies of adults (≥18 years) reporting prevalence of weight control attempts in the past-year. Seventy-two studies (n = 1,184,942) met eligibility criteria. Results from high quality studies showed that 42% of adults from general populations and 44% of adults from ethnic-minority populations reported trying to lose weight, and 23% of adults from general populations reported trying to maintain weight annually. In general population studies, higher prevalence of weight loss attempts was observed in the decade of 2000-2009 (48.2%), in Europe/Central Asia (61.3%) and in overweight/obese individuals and in women (p < 0.01). Of the 37 strategies (grouped in 10 domains of the Oxford Food and Activity Behaviours Taxonomy) and 12 motives reported for trying to control weight, exercising and dieting (within the energy compensation and restraint domains, respectively) and wellbeing and long-term health were the most prevalent. To our knowledge, this is the first systematic review to investigate weight control attempts worldwide. Key strategies and motives were identified which have implications for future public health initiatives on weight control.

The period prevalence of risk behavior co-occurrence among Canadians

INTRODUCTION

While the benefits of complying with health recommendations is well documented, a considerable proportion of Canadians engage in multiple modifiable risk behaviors. The purpose of this multi-wave longitudinal study was to identify the individual period prevalence and co-occurrence of multiple modifiable risk behaviors, particularly excessive alcohol consumption, physical inactivity, and tobacco use, within a nationally representative sample of Canadians.

METHODS

Secondary data analysis was conducted on the first seven cycles of the National Population Health Survey. This longitudinal sample included 15,167 Canadians aged 12years of age or older. Gender-specific criteria were employed to define excessive alcohol consumption. Individuals expending <3.0kcal/kg/day during their leisure-time and smoking cigarettes (daily or occasionally) met the criteria for physical inactivity and tobacco use, respectively.

RESULTS

The period prevalence of the Canadian general population that participated in multiple risk behaviors was 21.5% in cycle 7. The most common pairwise combination of co-occurring risk behaviors was physical inactivity and smoking. The proportion of Canadians reporting the co-occurrence of all three risk behaviors in cycle 7 was 2.6%.

CONCLUSIONS

Understanding patterns of modifiable risk behaviors is an initial step in developing and implementing public health interventions. The co-occurrence of these three risk behaviors is a viable concern for one in five Canadians. For these individuals, the likelihood of encountering premature morbidity and mortality is escalated. As the majority of Canadians reported being physically inactive, allocating limited resources towards enhancing leisure-time physical activity levels could have significant population-level implications for improving the health of Canadians.

Relationship of moderate alcohol intake and type of beverage with health behaviors and quality of life in elderly subjects

PURPOSE

This work was aimed to study the relationships of moderate alcohol intake and the type of beverages consumed with health behaviors and quality of life in elderly people.

METHODS

In this observational study, 231 subjects (55-85 years) voluntarily answering to advertisements were enrolled and divided in three study groups: abstainers and occasional consumers (ABS; n = 98), moderate drinkers of beer (BEER; n = 63) and moderate drinkers of all sorts of alcoholic beverages (MIXED; n = 70). Variables assessed included physical activity, activities of daily living, Mediterranean diet-adherence score, tobacco consumption, quality of sleep, body composition, medication and perception of health through the SF-36 questionnaire. Their relationship with alcohol consumption was assessed through general linear models including confounding variables (age, sex, chronic disease prevalence and socioeconomic status). ABS were also compared to moderate drinkers (MOD = BEER + MIXED).

RESULTS

The mean daily alcohol consumption in each group was (mean ± SD): ABS: 0.7 ± 1.1; BEER: 12.7 ± 8.1; MIXED: 13.9 ± 10.2 g/day. MOD and MIXED showed significantly higher physical activity (metabolic standard units; METs) than ABS (p = 0.023 and p = 0.004, respectively). MOD spent significantly less time doing housework activities than ABS (p = 0.032). Daily grams of alcohol consumption were significantly associated with METs (B = 21.727, p = 0.023). Specifically, wine consumption (g/day) was associated with METs (B = 46.196, p = <0.001) and showed borderline significant relationships with mental health (B = 0.245, p = 0.062) and vitality perception (B = 0.266, p = 0.054).

CONCLUSION

Moderate alcohol consumption, and in particular wine consumption, is associated with a more active lifestyle and better perception of own health in the Spanish elderly subjects studied.

Physical activity and risk of alcohol use disorders: results from a prospective cohort study

AIMS

To examine the effect of physical activity on risk of developing alcohol use disorders in a large prospective cohort study with focus on leisure-time physical activity.

METHODS

Data came from the four examinations of the Copenhagen City Heart Study (CCHS), performed in 1976-1978, 1981-1983, 1991-1994 and 2001-2003. Information on physical activity (classified as Moderate/high, low or sedentary) and covariates was obtained through self-administered questionnaires, and information on alcohol use disorders was obtained from the Danish Hospital Discharge Register, the Danish Psychiatric Central Research Register and the Winalco database. In total, 18,359 people participated in the study, a mean follow-up time of 20.9 years. Cox proportional hazards model with delayed entry was used. Models were adjusted for available covariates (age, smoking habits, alcohol intake, education, income and cohabitation status) including updated time-dependent variables whenever possible.

RESULTS

A low or moderate/high leisure-time physical activity was associated with almost half the risk of developing alcohol use disorder compared with a sedentary leisure-time physical activity. This translates into a 1.5- to 2-fold increased risk of developing alcohol use disorder (Hazard ratios for men 1.64; 95% CI 1.29-2.10 and women 1.45; 1.01-2.09) in individuals with a sedentary leisure-time physical activity, compared with a moderate to high level. However, when stratifying by presence of other psychiatric disorders, no association was observed in women with psychiatric comorbidity. Residual confounding may have been present in this study, especially according to rough measures of income and education.

CONCLUSIONS

In both men and women, being sedentary in leisure time was a risk factor for developing an alcohol use disorder.

A longitudinal examination of the interrelationship of multiple health behaviors

BACKGROUND

Evaluating the interrelationship of health behaviors could assist in the development of effective public health interventions. Furthermore, the ability to identify cognitive mediators that may influence multiple behavioral changes requires evaluation.

PURPOSE

To evaluate covariation among health behaviors, specifically alcohol consumption, leisure-time physical activity, and smoking, and examine whether mastery acts as a mediating social-cognitive mechanism that facilitates multiple health behavior change in a longitudinal analysis.

METHODS

In 2010, secondary data analysis was conducted on the first seven cycles of the Canadian National Population Health Survey. Data collection began in 1994-1995 and has continued biennially. At the time of this analysis, only seven cycles of data (2006-2007) were available. Parallel process growth curve models were used to analyze covariation between health behaviors and the potential mediating effects of perceived mastery.

RESULTS

Increases in leisure-time physical activity were associated with reductions in tobacco use, whereas declines in alcohol consumption were associated with decreases in tobacco use. Covariation between alcohol consumption and leisure-time physical activity did not reach statistical significance. For the most part, mastery was unsuccessful in mediating the interrelationship of multiple behavioral changes.

CONCLUSIONS

Health behaviors are not independent but rather interrelated. In order to optimize limited prevention resources, these results suggest that population-level intervention efforts targeting multiple modifiable behavioral risk factors may not need to occur simultaneously.

Association between alcohol use and cardiovascular self-care behaviors among male hypertensive Veterans Affairs outpatients: a cross-sectional study

BACKGROUND

Alcohol use is associated with health behaviors that impact cardiovascular outcomes in patients with hypertension, including avoiding salt, exercising, weight management, and not smoking. This study examined associations between varying levels of alcohol use and self-reported cardiovascular health behaviors among hypertensive Veterans Affairs (VA) outpatients.

METHODS

Male outpatients with self-reported hypertension from 7 VA sites who returned mailed questionnaires (N = 11,927) were divided into 5 levels of alcohol use: nondrinking, low-level use, and mild, moderate, and severe alcohol misuse based on AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) scores (0, 1-3, 4-5, 6-7, and 8-12, respectively). For each category, adjusted logistic regression models estimated the prevalence of patients who self-reported avoiding salt, exercising, controlling weight, or not smoking, and the composite of all four.

RESULTS

Increasing level of alcohol use was associated with decreasing prevalence of avoiding salt, controlling weight, not smoking, and the combination of all 4 behaviors (P values all <.001). A linear trend was not observed for exercise (P =.83), which was most common among patients with mild alcohol misuse (P =.01 relative to nondrinking).

CONCLUSIONS

Alcohol consumption is inversely associated with adherence to cardiovascular self-care behaviors among hypertensive VA outpatients. Clinicians should be especially aware of alcohol use level among hypertensive patients.

Behavioral mechanisms, elevated depressive symptoms, and the risk for myocardial infarction or death in individuals with coronary heart disease: the REGARDS (Reason for Geographic and Racial Differences in Stroke) study

OBJECTIVES

The aim of this study was to determine whether behavioral mechanisms explain the association between depressive symptoms and myocardial infarction (MI) or death in individuals with coronary heart disease (CHD).

BACKGROUND

Depressive symptoms are associated with increased morbidity and mortality in individuals with CHD, but it is unclear how much behavioral mechanisms contribute to this association.

METHODS

The study included 4,676 participants with a history of CHD. Elevated depressive symptoms were defined as scores ≥4 on the Center for Epidemiologic Studies Depression 4-item Scale. The primary outcome was definite/probable MI or death from any cause. Incremental proportional hazards models were constructed by adding demographic data, comorbidities, and medications and then 4 behavioral mechanisms (alcohol use, smoking, physical inactivity, and medication non-adherence).

RESULTS

At baseline, 638 (13.6%) participants had elevated depressive symptoms. Over a median 3.8 years of follow up, 125 of 638 (19.6%) participants with and 657 of 4,038 (16.3%) without elevated depressive symptoms had events. Higher risk of MI or death was observed for elevated depressive symptoms after adjusting for demographic data (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.15 to 1.72) but was no longer significant after adjusting for behavioral mechanisms (HR: 1.14, 95% CI: 0.93 to 1.40). The 4 behavioral mechanisms together significantly attenuated the risk for MI or death conveyed by elevated depressive symptoms (-36.9%, 95% CI: -18.9 to -119.1%), with smoking (-17.6%, 95% CI: -6.5% to -56.0%) and physical inactivity (-21.0%, 95% CI: -9.7% to -61.1%) having the biggest explanatory roles.

CONCLUSIONS

Our findings suggest potential roles for behavioral interventions targeting smoking and physical inactivity in patients with CHD and comorbid depression.

Dimensions of health-related lifestyle in young adulthood: results from a national population survey

AIM

This study assessed the underlying structure of health-related behaviours among young adults in Iceland. A number of individual behaviours were considered, including both positive and negative health-related behaviours. A central question was whether distinct underlying health-related lifestyles can be identified in this age group.

METHOD

The study was based on the data from a national health survey entitled 'Health and Living Conditions in Iceland'. The original survey comprised a random sample of 18-75 year olds drawn from the National Register (response rate 69%). The current study used a subsample from the survey, consisting of young adults, age: 18-24 (N = 348). A total of 37 variables pertaining to health-related behaviour were analysed. The 37 variables were factor-analysed using principal component (PC) factor analysis.

RESULTS

The PC analysis yielded four underlying health lifestyle dimensions: (i) physical activity; (ii) unhealthy diet; (iii) substance use; and (iv) healthy diet. The four factors explained 35.3% of the total item variance. The mean Cronbach's alpha for the four factors was 0.69. Correlations between factors were generally weak.

CONCLUSION

Distinct health-related lifestyle dimensions underlie the numerous health-related behaviours that young adults engage in. The analysis of positive and negative lifestyle dimensions helps identify vulnerable young adults disproportionally involved in unfavourable patterns of health-related behaviour. Weak factor correlations and high unexplained item variance suggests that individual health-related behaviours need consideration, albeit within a larger framework acknowledging interconnected and sometimes inconsistent behaviours.

Co-occurrence of problem behaviors in South Korean adolescents: findings from Korea Youth Panel Survey

Study findings showed problem behaviors can be observed in clusters in South Korean adolescents. Prevention programs targeting problem behavior clusters may have a greater impact on adolescents at risk for more than one problem behavior than programs targeting only a portion of the cluster.

The use of preventive healthcare by Canadian women who drink alcohol

BACKGROUND

Despite established links among heavy alcohol consumption, other poor health behaviors, and poor health status, no Canadian study has specifically addressed the relationship between drinking and the use of preventive healthcare services. This study examines the relationship between drinking and female-specific preventive health service use through a secondary analysis of the 1996-1997 NPHS.

METHODS

Recent use of Pap smears and mammograms was examined in relation to current alcohol consumption, using multivariate logistic regression (weighted n = 25,095).

RESULTS

In general, there was a trend toward greater odds of recent service use among light and moderate drinkers than among heavy drinkers and lifetime abstainers. However, only moderate drinkers were significantly (P < 0.01) more likely than abstainers to have recently had a Pap smear.

CONCLUSIONS

The trend toward lower use of preventive services by heavy drinkers is concerning considering the established harmful effects of prolonged alcohol consumption on health and the tendency for multiple risk behaviors to cluster together in the same individuals. Early detection of departures from good health may alleviate the elevated use of healthcare services among those diagnosed with alcohol use disorders.

Behavioral risk factors among members of a health maintenance organization

BACKGROUND

Co-occurrence of risk behaviors (RBs) substantially increases the risk of disease. This study examines the co-occurrence of four health risk behaviors (i.e., smoking, high-fat diet, sedentariness, and high-risk drinking) and demographic and psychosocial variables associated with number of RBs in a sample of members of a health maintenance organization who participated in the Seasonal Variation in Cholesterol (Seasons) study.

METHODS

Seasons study baseline data were used. Subjects completed a self-administered questionnaire packet containing questions on demographics, smoking history, and leisure-time physical activity, a 7-day dietary recall instrument, and various psychosocial measures. Results presented here are based on 496 subjects with complete data on all RBs.

RESULTS

Forty-three percent of participants had > or = two RBs. The most prevalent RB combination was high-fat diet/sedentariness, with 30% of subjects reporting both RBs. Associations between RBs were observed. A greater number of RBs were observed among younger and less-educated subjects, those with higher depression scores, and subjects who perceived their health as poor.

CONCLUSIONS

Findings highlight the importance of designing and evaluating primary care-based screening programs and interventions for multiple RBs.

Characteristics of inactive primary care patients: baseline data from the activity counseling trial. For the Activity Counseling Trial Research Group

BACKGROUND

Although many primary care patients are inactive, being able to classify even small amounts and intensities of activity and factors associated with these activity levels could be helpful for physicians who are trying to motivate their patients to become more physically active.

METHODS

Sociodemographics, physical activity, fitness, other cardiovascular risk factors, and psychosocial measures were measured at baseline in the 874 patients in the Activity Counseling Trial. Patients were categorized into three groups: (1) no moderate-to-vigorous physical activity (MVPA), (2) some moderate but no vigorous activity, and (3) some vigorous activity. Multiple logistic regression was used to determine factors cross-sectionally associated with activity intensity.

RESULTS

One or more cardiovascular risk factors in addition to physical inactivity were present in 84% of participants. Maximal oxygen uptake averaged 25.2 ml/kg/min; 85% had poor to fair aerobic fitness. Physical activity averaged 32.7 kcal/kg/day, with 13.5 min of MVPA/day; 26% engaged in some vigorous activity, 11% engaged in no MVPA. In unadjusted analyses, gender, age, race, education, income, employment, smoking, alcohol use, and exercise self-efficacy were associated with activity intensity (P = 0.05-0.001). A greater percentage engaged in moderate than in vigorous activity in all subgroups. In multiple logistic regression analyses, odds ratios (95% confidence intervals) for engaging in vigorous activity were 0. 39 (0.28, 0.56) for women, 0.38 (0.19, 0.75) for 65+ compared with 35- to 44-year-olds, and 1.14 (1.06, 1.22) for 10-unit increases in performance self-efficacy score.

CONCLUSIONS

Most primary care patients who are physically inactive have additional cardiovascular risk factors, particularly overweight and obesity. All subgroups pursue moderate-intensity activity more often than vigorous activity. Women, older persons, and those with lower exercise self-efficacy are less likely to engage in vigorous activity.

Psychosocial, behavioral, and biometric characteristics of stages of exercise adoption

This study incorporates the Stages of Change model to examine the relationship between the stages of exercise adoption and indicators of health and fitness. Subjects were 198 United States Forest Service (USFS) workers recruited from 8 USFS ranger stations in the Pacific Northwest. Analysis indicated that those subjects in Action and Maintenance stages of exercise adoption differed significantly from those in Preparation and Precontemplation/Contemplation stages on a variety of indicators of both health and fitness. Also, interesting differences were noted among the physically inactive stages, e.g., Preparation stage subjects showed lower triglycerides, systolic blood pressure, and higher HDL cholesterol compared with subjects in the Precontemplation/Contemplation stage. Progressing to the Preparation stage, where the individual remains inactive but is aware of the problem and has begun to make small changes, is associated with a differing (more positive) health profile in this study compared to those in the Precontemplation/Contemplation stage. These results imply that simply advancing in stage can have a variety of health benefits.

Prevalence and co-occurrence of health risk behaviors among high-risk drinkers in a primary care population

BACKGROUND

Approximately 10% of patients seen in the primary care setting meet criteria for high-risk (HR) drinking. Little data are available about the co-occurrence of other risk behaviors (RBs) in this population. This study examines the co-occurrence of smoking, poor diet, and sedentariness, and several change-related variables, among 479 HR drinkers participating in Project Health, a NIAAA-funded study testing the effectiveness of a provider-delivered intervention to reduce HR drinking.

METHOD

Data were collected at study entry via standardized interview and questionnaire.

RESULTS

The prevalence of additional RBs among HR drinkers was smoking, 35%; poor diet, 28%; and sedentariness, 44%. In addition to HR drinking, 67% of participants had at least one RB, and 61% reported smoking, sedentariness, or both. Perception of drinking as a problem was generally low (20%), as was intention to change drinking. Seventy-two percent of participants with multiple RBs perceived at least one of these RBs as a problem. Younger, unmarried, less-educated, blue-collar, and non-working participants were more likely to have multiple RBs than white-collar workers.

CONCLUSION

Additional RBs are common among HR drinkers and may increase their already elevated health risks. Implications of these findings for interventions integrating multiple RBs into primary care settings are discussed.

Alcohol usage in sport and exercise

In this review we consider some of the acute and chronic effects of alcohol on human exercise and sport performance. The 1982 position stand of the American College of Sport Medicine on the use of alcohol in sport emphasized that there was little benefit for an athlete. Subsequent literature continues to demonstrate that there are adverse effects on performance. However, the literature is often confusing and disparate. We will attempt to explain the effects and speculate on the possible mechanisms. We divide the review into acute and chronic metabolic and physiological effects of alcohol on exercise performance, primarily in humans. We also review the epidemiological evidence of the associations between alcohol use and problem alcohol behaviors in various athletic groups. Finally, we review the limited data on the effectiveness of exercise therapy in the treatment of alcohol dependent patients. In spite of scientific evidence that alcohol use is, in general, detrimental (or of no benefit) to sport (exercise) performance, alcohol continues to be used by athletes both on a chronic basis and even immediately prior to sports participation. There is some encouraging but limited evidence that student-athlete alcohol use is decreasing and exercise can be effective as part of alcohol rehabilitation.

Cigarette smoking, alcohol consumption, and screening mammography among women ages 50 and older

BACKGROUND

The associations among cigarette smoking and alcohol consumption with recent screening mammograms were evaluated among women ages 50 years and older.

METHODS

The sample included 946 white and African-American women ages 50 years and older from the 1995 Maryland Behavioral Risk Factor Survey. Bivariate and logistic regression analyses were performed to evaluate the associations between current cigarette smoking and alcohol consumption in the past month (none, 1-7 drinks, >7 drinks) with obtaining a screening mammogram in the past 2 years (recent mammogram), controlling for sociodemographic and health variables.

RESULTS

Seventy-eight percent of respondents had recent mammograms, 15% smoked cigarettes, 18% reported 1-7 drinks, and 12% reported >7 drinks in the past month. Smokers had lower mammography rates than nonsmokers (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.30-0.75). Women who drank alcoholic beverages had higher mammography rates than nondrinkers (OR = 1.37, 95% CI = 1.03-1.83). Smokers had the lowest mammography rates, regardless of their consumption of alcohol. An interaction was observed among white but not African-American women: nonsmokers who consumed moderate amounts of alcohol (1-7 drinks) had the highest mammography rates in this subgroup.

CONCLUSIONS

To reduce breast cancer mortality, it is important to increase screening mammography among all women over age 50 and especially among smokers and the oldest women.

Clustering of health-related behaviors among 18-year-old Australians

BACKGROUND

Few studies among young adults have examined clustering of health behaviors affecting risk for lifestyle diseases.

METHODS

Smoking, alcohol consumption, physical activity, and diet were examined among Australian 18-year-olds (301 males, 282 females) initially recruited at the age of 9 years from 26 schools. Association analysis was used to recognize behavior clustering.

RESULTS

Fat intake was greater among male smokers than nonsmokers (36% energy vs 34% energy). Women smokers ate less fiber (14.1 g/day) than did nonsmokers (17.8 g/day). Smoking was significantly related, among males, to unsafe drinking (odds ratio 2.38) and higher fat intake (odds ratio 1.06) and, among females, to unsafe drinking (odds ratio 1.59), lower dietary fiber (odds ratio 0.93), and less physical activity (odds ratio 0.36). Cluster analysis defined separate behavior clusters for men and women with smoking status identifying further subgroups. Smoking, drinking alcohol to excess, and adverse dietary choices clustered among men and women, with physical inactivity also clustering among women.

CONCLUSION

Smoking among adolescents is an important indicator of behaviors influencing risk for later cardiovascular disease and other medical disorders. Multimodal approaches allowing for gender differences in health-related behaviors are likely to be more successful than targeting a single behavior in this age group.