Long-Term Effects of the Communities That Care Trial on Substance Use, Antisocial Behavior, and Violence Through Age 21 Years

Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review

BACKGROUND

Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts.

METHODS

This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory.

FINDINGS

We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired.

CONCLUSIONS

For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020205342.

Integrated Theory-Based Health and Development Interventions for Young People: A Global Scoping Review

BACKGROUND

Most health and developmental issues affecting young people are interrelated. However, few interventions address multiple behavioral domains simultaneously or are based on theories that encompass a holistic perspective of youth development.

AIM

The purpose of this scoping review was to identify and describe the range of theory-based, multibehavioral health interventions aimed at improving two or more of the following behavioral youth outcomes: (1) sexual and reproductive health; (2) education and employment; (3) violence; and (4) substance use.

METHODS

Interventions conducted worldwide and published in English or Spanish between January 2000 and July 2020 were identified using four databases: PubMed, PsycINFO, LILACS, and SciELO.

RESULTS

A total of 11,084 articles were identified, of which 477 were retrieved and assessed for eligibility. Twenty-three articles (evaluating 21 interventions) ultimately met the inclusion criteria. Most interventions were conducted in the United States and addressed two behavioral domains of interest, although seven interventions incorporated three domains, and one incorporated all four. Substance use was the most common domain (16 interventions) but only in the United States/Canada, followed by sexual and reproductive health (14 interventions). All produced significant improvement in at least one outcome or for at least one subgroup of youth. The most common theoretical foundations were positive youth development and social learning theory.

CONCLUSION

Integrated interventions that are theory based and evidence informed can support positive development and empower youth to make healthy decisions. Further efforts are needed to address structural and policy issues that affect young people's developmental opportunities and health outcomes.

The association of alcohol use and heavy drinking with subsequent handgun carrying among youth from rural areas

PURPOSE

Alcohol use and handgun carrying are more prevalent among youth in rural than urban areas and their association may be stronger among rural adolescents. Alcohol use may be modifiable with implications for reducing handgun carrying and firearm-related harm. We examined the association between lagged alcohol use and subsequent handgun carrying in rural areas and examined variation in the association by developmental stages, hypothesizing that it would be stronger among adolescents than youth adults.

METHODS

We used a longitudinal sample of 2,002 adolescents from ages 12 to 26 growing up in 12 rural communities in 7 states with surveys collected from 2004 to 2019. We estimated the association of lagged past-month alcohol use on handgun carrying in the subsequent 12 months using population-average generalized estimating equations with logistic regression on multiply imputed data.

FINDINGS

During adolescence (ages 12-18), those who drank heavily had 1.43 times the odds (95% CI = [1.01, 2.03]) of subsequent handgun carrying compared to those who did not drink alcohol, and those who consumed alcohol but did not drink heavily had 1.30 times the odds of subsequent handgun carrying compared to those who did not drink (95% CI = [0.98, 1.71]). During young adulthood (ages 19-26), associations of alcohol use (OR = 1.28; 95% CI = [0.94, 1.63]) and heavy drinking (OR = 1.38; 95% CI = [1.08, 1.68]) were similar to adolescence.

CONCLUSIONS

Alcohol use and subsequent handgun carrying were positively associated during adolescence and young adulthood among individuals who grew up in rural areas, similar to findings in urban areas. Reducing alcohol use may be an important strategy to prevent handgun carrying and firearm-related harm among young people in rural areas.

Establishing a Protocol for Determining the Costs of an Integrated Set of Evidence-based Practices Aimed at Reducing Opioid Overdose Deaths

OBJECTIVES

In the midst of the opioid overdose crisis, local jurisdictions face a choice of public health interventions. A significant barrier when considering evidence-based practices (EBPs) is the lack of information regarding their implementation cost. This protocol paper provides the methodological foundation for the economic cost evaluations of community-wide strategies on the scale of a national study. It can serve as a resource for other communities, local policymakers, and stakeholders as they consider implementing possible public health strategies in their unique settings.

METHODS

We present a protocol that details (1) the process of identifying, reviewing, and analyzing individual strategies for study-funded and non-study-funded costs; (2) prospective costing tool designation, and; (3) data collection. To do this, we set up working groups with community stakeholders, reviewed financial invoices, and surveyed individuals with detailed knowledge of their community implementation.

DISCUSSION

There were 3 main challenges/limitations. The first was the lack of a standard structure for documenting nonfunded costs associated with each strategy. The second was the need for timely implementation of cost data. The third was generalizability because our study designed its strategies for selected communities due to their high opioid overdose mortality rates. Future steps include more tailored questions to ask during the categorization/filter process and establishing realistic expectations for organizations regarding documenting.

CONCLUSIONS

Data collected will provide a critical methodological foundation for costing large community-based EBP strategies and provide clarity for stakeholders on the cost of implementing EBP strategies to reduce opioid overdose deaths.

Contextual effects of community capacity as a predictor for adolescent alcohol, tobacco, and illicit drug use: A multi-level analysis

Adolescent substance use is a major public health issue that can result in enduring physical, psychological, and social consequences. This study seeks to examine the relationship between community capacity for prevention and the 4-week prevalence rate of substance use, including tobacco, alcohol, other drugs, and binge-drinking, among students in Germany ranging from grades 5 to 11. This study employed a cross-sectional design and used baseline data from 28 communities participating in the CTC-EFF study. The sample consisted of 7210 students who were surveyed about their substance use behavior. Additionally, 158 local key informants were surveyed on ten capacity domains, which included commitment, knowledge and skills, resources, leadership, inclusiveness, prevention collaboration, sectoral-collaboration, cohesion, problem-solving skills, and needs orientation. Furthermore, a total capacity score was calculated as the mean of the ten capacity domains. To examine the associations between community capacity and substance use behavior, logistic multi-level models were utilized. The analysis shows a negative association between community capacity (total score) and any substance use (OR = 0.28, 95% CI 0.12-0.56). Specifically, higher levels of total community capacity are associated with lower odds of alcohol use (OR = 0.30, 95% CI 0.13-0.80), tobacco use (OR = 0.09, 95% CI 0.01-0.60), and binge-drinking (OR = 0.67, 95% CI (0.46-0.99). Further analyses of distinct community capacity domains indicate that higher levels of sectoral-collaboration (OR = 0.62, 95% CI 0.37-0.97), knowledge and skills (OR = 0.74, 95% CI 0.40-0.79), resources (OR = 0.52, 95% CI 0.36-0.76), and problem-solving skills (OR = 0.71, 95% CI 0.36-0.89) are associated with lower odds of any substance use. The study findings suggest that community capacity is associated with substance use behavior, emphasizing the importance of capacity building in interventions targeting the reduction of substance use among adolescents.

Opioid Use Disorder Community Education Events: Rural Public Health Implications

The opioid overdose epidemic continues to disproportionately impact underserved rural areas throughout the nation, with many of these rural areas experiencing greater opioid-related mortality rates than their urban counterparts. With limited treatment infrastructure and resources, two rural communities in Southeast Utah utilized community-based participatory research collaboration principles to develop, implement, and evaluate a series of evidence-based community opioid education events. This practical and quantitative study surveying 123 participants describes the collaborative efforts of two rural communities in addressing the devastating impacts of the opioid overdose epidemic and reflects on the success of the events via descriptive analysis of summary data. These events increased participants' reported perceptions of and knowledge in four main education areas: stigma reduction, prevention and treatment awareness, naloxone education and use, and resource location awareness. Post-event surveys further supported these results, revealing improved learning in each of these four areas, indicating increased knowledge toward opioid use disorder treatments and stigma reduction. In addition, participants identified key takeaways such as local resource awareness and dismantling stigma as effective strategies to reduce the negative effects of the opioid overdose epidemic. This model for rural community education supports previous research and serves as an effective strategy of public health practice to address the opioid overdose epidemic on a local level.

Kailo: a systemic approach to addressing the social determinants of young people's mental health and wellbeing at the local level

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people's mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people's mental health and wellbeing at the local level.

Patterns of alcohol use among middle school students in rural communities: Associations with community violence exposure

Stress-coping theory posits that exposure to stressors, such as community violence, increases risk for early alcohol initiation. The current study identified patterns of alcohol use in an ethnically diverse sample of early adolescents in rural communities, and examined relations between different forms of exposure to community violence and severity of adolescents' alcohol use patterns. Participants were 5011 middle school students (46.4% non-Hispanic White, 25.5% Latinx, and 13.4% Black; 50% female) living in rural communities in the southeastern United States. Latent class analysis identified subgroups that differed in their patterns of lifetime and past 30-day alcohol use, and subgroup differences in exposure to community violence. Five subgroups were identified: abstainers (56.5%), initiators of wine and beer (12.5%); moderately frequent wine and beer users (10.3%); moderately frequent wine, beer, and liquor users who got drunk (12.0%); and highly frequent wine, beer, and liquor users who got drunk (8.6%). Subgroups differed across sex, grade, and racial-ethnic background. Subgroups characterized by severe alcohol use reported more frequent exposure to community violence and physical victimization, while controlling for nonviolent stressors. Consistent with stress-coping theory, the results indicate that experiencing physical victimization and witnessing community violence robustly relate to adolescents' high-risk alcohol use.

Understanding community- and system-capacity change over time: A close look at changing social capital in Evidence2Success communities

Evidence in majority White and low-population areas suggest that community prevention systems can create social capital that is needed to support high-quality implementation and sustainability of evidence-based programs. This study expands prior work by asking the question: How does community social capital change during the implementation of a community prevention system in low-income, highly populated communities of color? Data were collected from Community Board members and Key Leaders in five communities. Linear mixed effect models analyzed data on reports of social capital over time, first as reported by Community Board members then by Key Leaders. Community Board members reported social capital improved significantly over time during the implementation of the Evidence2Success framework. Key Leader reports did not change significantly over time. These findings suggest that community prevention systems implemented in historically marginalized communities may help communities build social capital that is likely to support the dissemination and sustainability of evidence-based programs.

A Qualitative Study of Health Equity's Role in Community Coalition Development

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)-a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity.

Gone Too Soon: priorities for action to prevent premature mortality associated with mental illness and mental distress

Globally, too many people die prematurely from suicide and the physical comorbidities associated with mental illness and mental distress. The purpose of this Review is to mobilise the translation of evidence into prioritised actions that reduce this inequity. The mental health research charity, MQ Mental Health Research, convened an international panel that used roadmapping methods and review evidence to identify key factors, mechanisms, and solutions for premature mortality across the social-ecological system. We identified 12 key overarching risk factors and mechanisms, with more commonalities than differences across the suicide and physical comorbidities domains. We also identified 18 actionable solutions across three organising principles: the integration of mental and physical health care; the prioritisation of prevention while strengthening treatment; and the optimisation of intervention synergies across social-ecological levels and the intervention cycle. These solutions included accessible, integrated high-quality primary care; early life, workplace, and community-based interventions co-designed by the people they should serve; decriminalisation of suicide and restriction of access to lethal means; stigma reduction; reduction of income, gender, and racial inequality; and increased investment. The time to act is now, to rebuild health-care systems, leverage changes in funding landscapes, and address the effects of stigma, discrimination, marginalisation, gender violence, and victimisation.

School Handgun Carrying Among Youth Growing Up in Rural Communities

PURPOSE

To characterize school handgun carrying and violence risk factors among rural youth.

METHODS

Using a sample of rural youth (n = 1995), we quantified the proportion who carried a handgun to school, carried but not to school, and did not carry across grades 7-12 and endorsed risk factors for violence in individual, peer, school, and community domains.

RESULTS

Overall, 3% (95% confidence interval [CI]: 2%-4%) of youth ever carried to school; 15% (95% CI: 14%-16%) carried but not to school; and 82% (95% CI: 80%-84%) never carried. Violence risk factors (e.g., attacking someone) were more commonly endorsed by youth who carried to school (84%; 95% CI: 73%-95%) than those who carried but not to school (51%; 95% CI: 44%-58%) and did not carry (23%; 95% CI: 20%-26%).

DISCUSSION

Carrying a handgun to school in rural areas is not common; however, it is associated with risk factors for violence. Understanding violence risk factors among youth who carry handguns to school could inform violence prevention programs in rural areas.

Adolescent risk and protection profiles for violence perpetration: Insights for family- and community-based prevention

Youth violence continues to be a major developmental and health concern. Preventative resources at individual, family, and community levels may reduce risk, yet the extent to which youth violence perpetration differs by patterns of risk and protective factors remains unknown. Using data from the Florida Youth Substance Abuse Survey (N = 4630; 49% female; M_age  = 14.69), we conducted person-centered, latent profile analyses to identify four patterns for risk of violence perpetration among middle and high school youth. Youth in the Low Risk-High Protection profile (37%) had low likelihood of violence perpetration. Youth in the Low Risk-Low Protection profile (4%) were characterized by poor family functioning, low school belonging, and low community protection. These youth had similar odds of violence perpetration as youth in the Moderate Risk-Moderate Protection profile (44%), which were elevated compared to the Low Risk-High Protection profile. Youth in the High Risk-Low Protection profile (15%), which had the highest levels of risk factors and lowest levels of protective factors, had the highest likelihood of violence perpetration. The High Risk-Low Protection profile was expected based on past research, but the emergence of the Low Risk-Low Protection profile is a unique contribution to the research. Findings contribute to the literature by going beyond a cumulative risk model, identifying subgroups with various patterns of risk and protection in the population, and highlighting the importance of selected prevention for subgroups of youth with high risk or challenging family and community environments.

Antisocial Behavior and Attitudes Towards Antisocial Behavior after a Five-Year Municipal Youth and Family Master Plan in Pomona, California, USA

Within an integrated conceptual framework made up of social cognitive theory, theory of fundamental causes, and the risk and protective factor approach, we assess reported antisocial behavior and favorable attitudes toward antisocial behavior among youths and parents in a high-school sample after the implementation of a Youth and Family Master Plan in Pomona, California, USA from 2005 to 2009. We perform z tests for same students (8th grade 2005 and 12th grade 2009), same grade (8th,10th, and 12th grade), inter-grade, same year, and overall, 2005 to 2009 comparisons for Pomona, Los Angeles, and US national samples. It was hypothesized that after five years of implementation, Pomona Youth and Family Master Plan (PYFMP) activities will reduce antisocial behavior and favorable parental and youth attitudes toward antisocial behavior. Within a p-value of 05, z-test results show a decline in youth antisocial behavior among youths in the Pomona sample. Patterns in youth antisocial behavior were not consistent with youth favorable attitudes toward antisocial behavior but were consistent with perceived parental favorable attitudes toward antisocial behavior. Though youth favorable attitudes toward antisocial behavior were generally rising within the Pomona data, when compared to the rates of change in Los Angeles and US, Pomona rates of change were lower. Intra and inter jurisdictional patterns above could be attributed to the community multicomponent interventions of the PYFMP. They also align with assumptions and explanations offered in the integrated conceptual framework, which suggest a mediating role for environmental factors.

Substance-Specific Risk Factors among Young Adults: Potential Prevention Targets across Cannabis-Permissive Environments

PURPOSE

This study examined levels of substance-specific risk factors such as perception of harm from substance use among young adults in a range of cannabis-permissive environments. The main objective was to inform future preventive interventions aimed at reducing cannabis use in the context of increasingly permissive environments.

METHODS

Data came from the Community Youth Development Study (CYDS) collected in 2016 when participants were about 23 years old (n = 1,722 participants residing in 46 U.S. states). Young adults self-reported their perceptions about the harms related to cannabis, alcohol, and cigarette use; attitudes about and ease of access to cannabis and other substances; and perceived wrongfulness and social acceptability of cannabis, alcohol, and cigarette use and of selling of cannabis and other illegal drugs.

RESULTS

Young adults in more permissive cannabis contexts reported higher levels of all cannabis-specific risk factors (e.g., greater access to and more favorable attitudes about cannabis use), except for perception of harm from regular cannabis use. However, permissiveness of the cannabis environment was not associated with heightened levels of risk factors for other substance use (such as alcohol, cigarettes, and opioids).

CONCLUSIONS

Future preventive interventions for young adults living in more permissive cannabis contexts may need to focus on cannabis-specific risk factors in particular and go beyond considerations of harm from regular use. Future studies should replicate these findings with other samples.

Protocol for community-driven selection of strategies to implement evidence-based practices to reduce opioid overdoses in the HEALing Communities Study: a trial to evaluate a community-engaged intervention in Kentucky, Massachusetts, New York and Ohio

INTRODUCTION

Opioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally.

METHODS AND ANALYSIS

The CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation.

ETHICS AND DISSEMINATION

The HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders.

TRIAL REGISTRATION NUMBER

NCT04111939.

Effectiveness of the Promising Neighbourhoods community program in 0-to 12-year-olds A difference-in-difference analysis

Objective

The purpose of this study was to evaluate a collaborative community-based program that aims to a) increase the health, safety and talent development of youth, and b) contribute to the reduction of socioeconomic inequalities.

Methods

A difference-in difference design with two separate cross-sectional samples in 2018 (n = 984) and 2021 (n = 413) among 0- to 12-year-olds with an intervention and comparator condition was used. The program, called Promising Neighbourhoods, consists of collaboration with community stakeholders, data-based priority setting, knowledge-and theory-based policies, and evidence-based interventions. The program was implemented in three neighbourhoods which were compared with three similar comparator neighbourhoods in which the program was not implemented. Logistic difference-in-difference regression was used to test effectiveness of the intervention on informal parenting support, outdoor-play, sport club membership, general health and risk of emotional and behavioural difficulties and to examine differences in intervention effects between children with a lower or higher socioeconomic status.

Results

A significant intervention effect of the Promising Neighbourhoods program after two-years was found for outdoor-play (OR 0.61; 95%CI 0.37, 0.99). No other significant intervention effects were found for other outcomes. No different interventions effects were found for children with a lower or higher socioeconomic status on outcomes.

Conclusion

The findings of this study indicate a positive intervention effect for one of the outcomes in 0- to 12-year-olds. Further mixed-methods evaluation research and using longer follow-up periods are needed to examine the value of these type of programs. Further development of Promising Neighbourhoods seems warranted.

Trial registration

This study was prospectively registered in the Netherlands National Trial Register (Number: NL7279) on 26 September 2018.

•

A collaborative neighbourhood program involving stakeholders was evaluated.

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The program included joint priority setting to promote child health/well-being.

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A positive intervention effect was found for one outcome in 0- to 12-year-olds.

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No reduction in socioeconomic inequalities was found in 0- to 12-year-olds.

Young adult opioid misuse indicates a general tendency toward substance use and is strongly predicted by general substance use risk

OBJECTIVE

To examine whether young adult opioid misuse reflects a general tendency toward substance use and is influenced by general substance use risk or whether it is a different phenomenon from other drug use.

METHODS

At ages 23 (2016) and 26 (2019), a panel of young adults (n = 3794 to 3833) in the United States self-reported their past-month substance use (opioid misuse, heavy drinking, cigarettes, cannabis) and substance-specific risk factors (perceptions of harm; approval of use; and use of each substance by friends and romantic partners). Structural equation models examined non-opioid and opioid-specific associations between latent risk and substance use factors.

RESULTS

Opioid misuse and opioid-specific risk factors shared significant variance with latent substance use and latent substance use risk, respectively, which were strongly associated. A statistically significant residual correlation between opioid-specific risk and opioid misuse remained.

CONCLUSION

Young adult opioid misuse reflects a general tendency toward substance use and is strongly predicted by risk for substance use. Opioid-specific risk factors play only a small independent role. Existing evidence-based substance use interventions may be effective in preventing opioid misuse among young adults.

Long-term Effects of Adolescent Substance Use Prevention on Participants, Partners, and their Children: Resiliency and Outcomes 15 Years Later During the COVID-19 Pandemic

We examined whether participation in adolescent substance use prevention programming can enhance long-term resilience into adulthood such that individuals were better able to cope with adversities during the initial months of the COVID-19 pandemic, yielding benefits for the individuals, their partners/spouses, and children; 197 adults (28-30 years old) who entered the PROSPER randomized trial of substance use prevention programming as 6th graders and subsequently had become parents-and 128 of their partners-participated in two waves of long-term follow-up data collection. Respondents completed questionnaires on substance use, adjustment, parenting quality, and children's mood and behavior problems 15 years after baseline, and again via an online survey in the first three months of the COVID-19 pandemic. Results were mixed, with some indications of better adjustment of PROSPER intervention compared to control participants during the early phase of the pandemic (less increase in alcohol use and less decrease in parenting warmth) and their children (lower levels of externalizing and internalizing problems) but several null results as well (no differences in other substance use behaviors, other parenting measures, or parent depression). Adolescent substance use prevention programs can foster long-term individual and interpersonal resilience factors that allow participants-as well as their children-to adapt and cope with unforeseen periods of acute stress and adversity with less deterioration in health and well-being.

Applying the PROSPER prevention delivery system with middle schools: Emerging adulthood effects on substance misuse and conduct problem behaviors through 14 years past baseline

This study evaluated emerging adult effects of the PROmoting School‐Community‐University Partnerships to Enhance Resilience (PROSPER) universal prevention delivery system implemented in middle schools. Twenty‐eight rural school districts were randomized to intervention and control conditions, with 1985 nineteen‐year‐old participants (90.6% White, 54.1% female) evaluated through age 25. Intent‐to‐treat, multi‐level, point‐in‐time analyses of covariance and growth analyses were conducted. Outcomes were assessed with self‐report measures of substance misuse (lifetime, current, frequency) and conduct problem behaviors. Analyses showed very limited point‐in‐time effects; there were growth pattern effects on measures of illicit drugs, non‐prescribed drugs, cigarettes, and drug problems. When risk moderation was observed, it favored higher‐risk participants. These emerging adult effects concerning slower growth of lifetime misuse combine with more robust adolescent stage findings to support PROSPER’s public health value.

Cigarette Pack Price and Its Within-Person Association With Smoking Initiation, Smoking Progression, and Disparities among Young Adults

BACKGROUND

There is a dearth of research on within-person relationships between tobacco price and cigarette smoking initiation and progression in young adulthood. This project examines the within-person association between cigarette pack price and smoking initiation and progression between age 18 and 21/22, focusing on differences across subgroups.

METHODS

Data came from the longitudinal Monitoring the Future (MTF) project. MTF examines drug use behaviors with nationally representative samples of 12th graders annually. Subsamples of 12th graders are annually selected and followed longitudinally. Among 12th graders from baseline years 2000-2014, we examined past 30-day cigarette smoking initiation among baseline never smokers (N = 15 280) and progression to daily smoking among youth who were not daily smokers at baseline (N = 26 998). We used hierarchical logistic regression and interaction terms to assess differences across sex, race/ethnicity, and parental education.

RESULTS

The within-person relationship between pack price and smoking indicated that a one-dollar increase in pack price corresponded with a 72% decrease in the odds of initiation (AOR = 0.28, 95% CI = 0.18, 0.44) and 70% decrease in the odds of progression to daily smoking (AOR = 0.30, 95% CI = 0.21, 0.44). There was a linear age trend for both smoking initiation and progression. There were no statistically significant interactions between price and demographics, making it difficult to disentangle differences across subgroups.

CONCLUSIONS

Exposure to increased cigarette prices during young adulthood was associated with lower odds of cigarette smoking initiation and progression. Additional policies and programs beyond cigarettes prices could help reduce tobacco-related disparities in smoking initiation and progression among young adults.

IMPLICATIONS

There is a strong, within-person relationship between cigarette prices and smoking initiation and progression during the transition to young adulthood: higher prices are associated with decreased odds of both initiation and progression. Cigarette taxation can help to prevent smoking initiation and progression among youth, but it is less clear how taxes are associated with disparities in smoking experienced by certain subgroups. We could not draw definitive conclusions about the impact of cigarette prices on tobacco-related disparities. Tobacco taxes should be increased on a regular basis to ensure young adults experience within-person increases in prices, and complementary programs geared toward reducing tobacco-related disparities among young adults should be promoted.

Valuing the cross-sector benefits from improving youth health to drive investment in place-based preventive interventions in the US: A simulation modeling study

Healthcare payment reform has not produced incentives for investing in place-based, or population-level, upstream preventive interventions. This article uses economic modeling to estimate the long-term benefits to different sectors associated with improvements in population health indicators in childhood. This information can motivate policymakers to invest in prevention and provide guidance for cross-sector contracting to align incentives for implementing place-based preventive interventions. A benefit-cost model developed by the Washington State Institute for Public Policy was used to estimate total and sector-specific benefits expected from improvements to nine different population health indicators at ages 17 and 18. The magnitudes of improvement used in the model were comparable to those that could be achieved by high-quality implementation of evidence-based population-level preventive interventions. Benefits accruing throughout the lifecycle and over a ten-year time horizon were modelled. Intervention effect sizes of 0.10 and 0.20 demonstrated substantial long-term benefits for eight of the nine outcomes measured. At an effect size of 0.10, the median lifecycle benefit per participant across the ten indicators was $3080 (ranged: $93 to $14,220). The median over a 10-year time horizon was $242 (range: $14 to $1357). Benefits at effect sizes of 0.20 were approximately double. Policymakers may be able to build will for additional investment based on these cross-sector returns and communities may be able to capture these cross-sector benefits through contracting to better align incentives for implementing and sustaining place-based preventive interventions.

Protective Factors for Nicotine and Marijuana Vaping Among U.S. Adolescents

INTRODUCTION

Nicotine and marijuana vaping among U.S. adolescents are public health priorities. Research has assessed the demographic and risk factors related to vaping, but there is a dearth of research on protective factors for vaping. On the basis of the healthy youth development perspective, the developmental assets framework is used to assess cumulative protective factors and vaping in a national sample of adolescents.

METHODS

Data came from the nationally representative Monitoring the Future study, consisting of 12th graders (n=6,982) from the 48 contiguous U.S. states (2017-2019). Past 30-day nicotine and marijuana vaping and developmental assets (low, medium, or high) were examined. Covariates included demographics and other substance use. Weighted descriptive statistics, logistic regression, postestimation analyses, and multiple imputation were used.

RESULTS

Students with higher assets were less likely to vape nicotine and marijuana, even after adjusting for covariates. The odds of nicotine vaping were lower for students with medium assets (AOR=0.65, 95% CI=0.54, 0.78) and high assets (AOR=0.22, 95% CI=0.16, 0.29) than for students with low assets. Similarly, the odds of marijuana vaping were lower for youth with medium assets (AOR=0.54, 95% CI=0.42, 0.69) and high assets (AOR=0.09, 95% CI=0.05, 0.18) than for those with low assets. Social competence and positive peer norms were strongly protective against both forms of vaping.

CONCLUSIONS

The healthy youth development perspective applies to the critical issues of nicotine and marijuana vaping among adolescents. Promoting cumulative assets may help to prevent vaping among U.S. adolescents, and increasing the specific assets of social competence and positive peer norms could be particularly fruitful.

The Intersection of Depressive Symptoms, Adverse Childhood Experiences, and Protective Factors Among Adolescents: Epidemiological Evidence from Minnesota, 2016 and 2019

Prevalence of mental health problems among US youth has increased in recent years, and there is a dearth of epidemiological research at the state level that integrates risk and protective factors into population-based surveillance. We utilized the developmental assets framework to measure protective factors; we assessed (1) prevalence of depressive symptoms, high adverse childhood experiences (ACEs; ≥ 4 ACEs), and few developmental assets (≤ 2 assets) over time, and (2) associations among these three phenomena. Using 2016 and 2019 Minnesota Student Survey data, we utilized descriptive statistics, multivariable logistic regression, and post-estimation analyses (adjusting for school clustering and demographics). Using pooled data, we examined how high ACEs and few assets predicted depressive symptoms and we tested three-way interactions for high ACEs, few assets, and survey year. There were statistically significant increases in prevalence of depressive symptoms, high ACEs, and few assets between 2016 and 2019. High ACEs (AOR = 2.74; 95% CI = 2.61, 2.89) and few assets (AOR = 3.13; 95% CI = 3.00, 3.26) were positively related to depressive symptoms; interactions were statistically significant. Additive interactions showed that, compared to their counterparts, adolescents with high ACEs and few assets had the highest prevalence of depressive symptoms, and this group exhibited the largest increase in prevalence between 2016 and 2019. Depressive symptoms are highest among adolescents with high risk and few protective factors, and recent increases in the prevalence of depressive symptoms appear to have disproportionately occurred among these adolescents. We offer a potential roadmap for following the Centers for Disease Control and Prevention recommendations to integrate ACEs and protective factors into local public health efforts.

Study protocol for a cluster randomized trial of a school, family, and community intervention for preventing drug misuse among older adolescents in the Cherokee Nation

BACKGROUND

The national opioid crisis has disproportionately burdened rural White populations and American Indian/Alaska Native (AI/AN) populations. Therefore, Cherokee Nation and Emory University public health scientists have designed an opioid prevention trial to be conducted in rural communities in the Cherokee Nation (northeast Oklahoma) with AI and other (mostly White) adolescents and young adults. Our goal is to implement and evaluate a theory-based, integrated multi-level community intervention designed to prevent the onset and escalation of opioid and other drug misuse. Two distinct intervention approaches-community organizing, as implemented in our established Communities Mobilizing for Change and Action (CMCA) intervention protocol, and universal school-based brief intervention and referral, as implemented in our established Connect intervention protocol-will be integrated with skill-based training for adults to strengthen social support for youth and also with strategic media. Furthermore, we will test systems for sustained implementation within existing organizational structures of the Cherokee Nation and local schools and communities. This study protocol describes the cluster randomized trial, designed to measure implementation and evaluate the effectiveness on primary and secondary outcomes.

METHODS

Using a cluster randomized controlled design and constrained randomization, this trial will allocate 20 high schools and surrounding communities to either an intervention or delayed-intervention comparison condition. With a proposed sample of 20 high schools, all enrolled 10th grade students in fall 2021 (ages 15 to 17) will be eligible for participation. During the trial, we will (1) implement interventions through the Cherokee Nation and measure implementation processes and fidelity, (2) measure opioid and other drug use and secondary outcomes every 6 months among a cohort of high school students followed over 3 years through their transition out of high school, (3) test via a cluster randomized trial the effect of the integrated CMCA-Connect intervention, and (4) analyze implementation costs. Primary outcomes include the number of days during the past 30 days of (1) any alcohol use, (2) heavy alcohol use (defined as having at least four, among young women, or five, among young men, standard alcoholic drinks within a couple of hours), (3) any marijuana use, and (4) prescription opioid misuse (defined as "without a doctor's prescription or differently than how a doctor or medical provider told you to use it").

DISCUSSION

This trial will expand upon previous research advancing the scientific evidence regarding prevention of opioid and other drug misuse during the critical developmental period of late adolescent transition to young adulthood among a sample of American Indian and other youth living within the Cherokee Nation reservation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04839978 . Registered on April 9, 2021. Version 4, January 26, 2022.

Improving Sexual Health in U.S. Rural Communities: Reducing the Impact of Stigma

Sexually transmitted infections (STI), including HIV, are among the most reported diseases in the U.S. and represent some of America’s most significant health disparities. The growing scarcity of health care services in rural settings limits STI prevention and treatment for rural Americans. Local health departments are the primary source for STI care in rural communities; however, these providers experience two main challenges, also known as a double disparity: (1) inadequate capacity and (2) poor health in rural populations. Moreover, in rural communities the interaction of rural status and key determinants of health increase STI disparities. These key determinants can include structural, behavioral, and interpersonal factors, one of which is stigma. Engaging the expertise and involvement of affected community members in decisions regarding the needs, barriers, and opportunities for better sexual health is an asset and offers a gateway to sustainable, successful, and non-stigmatizing STI prevention programs.

Community Change Programs for Children and Youth At-Risk: A Review of Lessons Learned

The significant role of the community in the lives of children and youth at-risk has become increasingly clear to social work academics and professionals over the last three decades. Alongside the more traditional individual and family responses, community interventions have been designed to catalyze change in the environment of children and youth at-risk and supply holistic and sustainable responses to their needs. Ten such community intervention programs were identified from the United States, Australia, Canada, and Israel. Most employed the community development model, focused on developing leadership and social capital (improving community networking) and advancing coordination between the organizations and sectors in the field of risk among children and youth. The diverse programs reviewed focused both on at-risk children and youth in general or specifically on child abuse and neglect. The programs originated from different health, education, and welfare disciplines and sponsoring authorities. The majority were funded originally by private foundations; however, government involvement was significant, particularly in the adoption and support of initiatives after their development. The current analysis of the programs refers to core issues that arose from the review: professional orientation, main target unit, main initiator, and research and evaluation. Analysis of program characteristics enables identifying relevant aspects of these programs for use by policy, governmental, and nonprofit sector stakeholders seeking to develop similar programs. Conclusions and recommendations to advance the field are suggested considering the current context of government cuts in welfare funds.

Simultaneous use of marijuana and alcohol: Potential prevention targets among young adults who use alcohol

Simultaneous alcohol and marijuana use (SAM) such that their effects overlap has emerged as a behavior that is riskier than using either substance separately. It has been associated with high-risk binge drinking and driving while intoxicated during young adulthood, and it has been demonstrated to cause greater physical and mental impairment than use of alcohol or marijuana separately. To identify intervention and prevention targets specific to SAM, we examined the relationships between alcohol- and marijuana-specific beliefs and attitudes (risk factors) and self-reported SAM compared to non-simultaneous co-use (CAM) and alcohol use only in the past 30 days in a sample of young adults (n = 1,023, mean age = 23.17; SD = 0.43). Of those who reported drinking alcohol in the past 30 days, 20.7% reported SAM, 12.6% reported CAM, and 66.6% reported using only alcohol. Results from multinomial logistic regression analyses indicated that some marijuana-specific risk factors (e.g., belief that it is not at all wrong for someone their age to use marijuana) differentiated SAM or CAM from alcohol use only, but alcohol-specific risk factors generally did not. However, the perceptions that parents approved of their using marijuana or frequently drinking heavily were associated with a greater likelihood of SAM compared to CAM (OR ranged from 2.25 to 3.53). Findings point to the salience of individuals' attitudes and beliefs around marijuana use and their perception of parental approval of heavy drinking and marijuana use as potential targets for prevention programs targeting risk reduction among young adults.

Social and Relational Health Risks and Common Mental Health Problems Among US Children: The Mitigating Role of Family Resilience and Connection to Promote Positive Socioemotional and School-Related Outcomes

Nearly 70% (67.6%) of US children with mental, emotional, and behavioral problems (MEB) experienced significant social health risks (SHR) and/or relational health risks (RHR). Shifts are needed in child mental health promotion, prevention, diagnosis, and treatment to address both RHR and SHR. Public health approaches are needed that engage families, youth, and the range of child-serving professionals in collaborative efforts to prevent and mitigate RHR and SHR and promote positive mental health at a community level. Building strong family resilience and connection may improve SR and, in turn, academic and social outcomes among all US children with or without MEB.

A scoping review of whole-of-community interventions on six modifiable cancer prevention risk factors in youth: A systems typology

Whole-of-community interventions delivered across entire geospatial areas show promise for improving population health for youth cancer prevention. The aims of this scoping review were to synthesize the whole-of-community intervention literature on six modifiable risk factors in youth for cancer prevention (alcohol use, diet, obesity, physical activity, sun exposure, tobacco use) and to develop and apply a typology describing the inclusion of fundamental control system functional characteristics. A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus for studies published to the end of 2019. Eligible studies included a geospatially defined whole-of-community intervention; youth 0-18 years; and at least one of the six cancer risk factor outcomes. An iterative process was undertaken to create a typology describing the functions for whole-of-community interventions guided by systems theory, and the typology was used to code the included interventions. A total of 41 interventions were included. Most interventions (43.9%) assessed multiple cancer risk factors. Few interventions provided fundamental functions necessary for community system coordination: sensor, controller, effector. Although communities are a patchwork quilt of microsystems where individuals interact in geographically bounded places nested within larger whole systems of influence, a control systems approach has not been used to frame the literature. Whole-of-community interventions can be characterized by the fundamental system functions necessary for coordinating population health improvement. Future whole-of-community intervention efforts should draw on fundamental knowledge of how systems operate and test whether adoption of the key functions is necessary for whole-of-community population health improvement.

The Dismal State of Federal Funding for Experimental Evaluations of Interventions to Reduce Greenhouse Gas Emissions

The threats of climate change to human well-being are well-documented and are growing in number and intensity. Despite the international community investing heavily in technological innovation and policy initiatives to solve the problem, emissions continue to rise. Experts are recognizing that eliminating emissions cannot be achieved without modifying the human behavior of which emissions are a function. However, little attention has been allocated to expanding the use of strategies developed by the behavioral-science community to reduce emissions on large scales. One possible reason is that federal funding has not been arranged to select such research. Therefore, we conducted an analysis of six sources of information about federal funding to fight climate change (the Government Accountability Office, the National Science Foundation, the Environmental Protection Agency, the Department of Energy, the National Institutes of Health, and the Center for Disease Control) and examined the extent to which they are funding behavioral science research to reduce emissions. Our results show an appalling lack of funding for behavioral science research to reduce emissions, especially experimental evaluations of strategies for reducing them. Implications and recommendations for funding of future research are discussed.

State of the Art in Substance Use Prevention and Early Intervention: Applications to Pediatric Primary Care Settings

With changes to drug-related policies and increased availability of many drugs, we currently face a public health crisis related to substance use and associated health consequences. Substance use and substance use disorders (SU/SUDs) are complex developmental disorders with etiologies that emerge through the intergenerational transmission of biological, familial, and environmental factors. The family ecosystem both influences and is influenced by SU/SUDs, particularly in children and adolescents. Family dynamics and parent functioning and behaviors can represent either risk or protective factors for the development of SU/SUDs in children. Primary care providers who provide care for children, adolescents, and families are in an ideal position to deliver prevention messages and to intervene early in the development of substance misuse and SUD among their patients. Despite recommendations from the American Academy of Pediatrics, few pediatric primary care providers provide anticipatory guidance to prevent or screen for substance misuse. Many barriers to those practices can be overcome through the integration and application of findings from the field of prevention science and the many lessons learned from the implementation of evidence-based interventions. Consideration of the implications of prevention science findings would help clarify the relevant roles and responsibilities of the primary care clinician, and the benefit of referral to and consultation from addiction specialists. Additionally, the past decade has seen the development and validation of a continuum of evidence-based prevention and early SU/SUD intervention activities that can be adapted for use in primary care settings making wide-spread implementation of prevention feasible. We propose a paradigm shift away from a model based on diagnosis and pathology to one upstream, that of family-focused prevention and early intervention. Adapting and scaling out empirically based prevention and early SU/SUD interventions to primary care settings and removing barriers to collaborative care across primary care, addiction medicine, and mental health providers offer the potential to meaningfully impact intergenerational transmission of SU/SUD — addressing a leading health problem facing our nation.

Unintentional injury deaths in children and youth, 2010-2019

BACKGROUND

Unintentional injuries are the leading cause of death for children and youth aged 1-19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0-19 years have changed during 2010-2019.

METHOD

CDC analyzed 2010-2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0-19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state.

RESULTS

From 2010-2011 to 2018-2019, unintentional injury death rates decreased 11% overall-representing over 1,100 fewer annual deaths. However, rates increased among some groups-including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018-2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged < 1 and 15-19 years (31.9 and 16.8 per 100,000) than other age groups, among American Indian or Alaska Native (AIAN) and Blacks than Whites (19.4 and 12.4 vs. 9.0 per 100,000), motor-vehicle traffic (MVT) than other causes of injury (4.0 per 100,000), and rates increased as rurality increased (6.8 most urban [large central metro] vs. 17.8 most rural [non-core/non-metro] per 100,000). From 2010-2011 to 2018-2019, 49 states plus DC had stable or decreasing unintentional injury death rates; death rates increased only in California (8%)-driven by poisoning deaths. Conclusion and Practical Application: While the overall injury death rates improved, certain subgroups and their caregivers can benefit from focused prevention strategies, including infants and Black, Hispanic, and AIAN children. Focusing effective strategies to reduce suffocation, MVT, and poisoning deaths among those at disproportionate risk could further reduce unintentional injury deaths among children and youth in the next decade.

Life-course predictors of homelessness from adolescence into adulthood: A population-based cohort study

INTRODUCTION

Internationally, the prevalence of young adult homelessness is concerning. Few data on life-course predictors from longitudinal studies exist, limiting our capacity to inform prevention strategies at the population-level.

METHODS

Data were drawn from a state representative population-based sample of young adults from Victoria, Australia participating in the International Youth Development Study (IYDS; N = 927, 54% female). Participants were recruited in state-representative secondary school samples at Grade 7 (age 13, 2002), with follow-up in Grades 9 (age 15) and 11 (age 17) and at ages 21, 23 and 25. Using longitudinal path modelling, we conducted a series of analyses testing life-course predictors of young adult homelessness across multiple socializing contexts, and the interrelationships among them.

RESULTS

The rate of young adult homelessness was 5.5%. Path modelling showed higher levels of family conflict at ages 13 and 15 uniquely predicted homelessness by age 25. This effect remained after accounting for other risk factors in peer-group (e.g., interactions with antisocial peers), school (e.g., low academic performance), and community contexts (e.g., low neighborhood attachment). Peer drug use and interaction with antisocial peers at age 15 mediated the association between family conflict at age 13 and homelessness by age 25.

CONCLUSIONS

Findings point to the vulnerability of early adolescents to family conflict. This vulnerability heightens risk for young adult homelessness. Findings strengthen the case for both primary prevention programs that build healthy relationships between family members from early on in adolescence and for investment in homelessness prevention at key developmental periods.

Community utilization of risk and protective factor data for prevention planning in Chile and Colombia

Many effective community health service delivery systems implemented in the USA assess risk and protective factors (RPFs) for youth problem behaviors in a community, and report these data back to local coalitions for prevention planning. This study examined whether community prevention coalitions in Chile and Colombia perceived these reports of RPFs-based on the results of the Communities That Care Youth Survey-to be understandable, valid, useful, and worth disseminating. Thematic content analysis was used to analyze qualitative data collected from 7 focus groups with 75 coalition members. Results indicated heterogeneity between and within coalitions in terms of participants' understanding of RPFs. However, most participants found reports of RPFs to be easy to understand, thorough, 'true' to their communities, and useful for diagnosing and prioritizing needs, action planning, and mobilizing others in their communities. Findings suggest the viability of preventive systems that rely on community-level RPF data, for use in Latin America.

E-cigarette use is associated with subsequent cigarette use among young adult non-smokers, over and above a range of antecedent risk factors: a propensity score analysis

BACKGROUND AND AIMS

There is a public health concern that the use of e-cigarettes among non-smoking young adults could be associated with transition to combustible cigarette use. The current study is a quasi-experimental test of the relationship between e-cigarette use and subsequent combustible cigarette use among young adult non-smokers, accounting for a wide range of common risk factors.

DESIGN

Logistic regression was used to predict combustible cigarette use on three or more occasions at age 23 years based on age 21 e-cigarette use. Inverse probability weighting (IPW) was used to account for confounding variables.

SETTING

Data were drawn from the Community Youth Development Study (CYDS), a cohort study of youth recruited in 2003 in 24 rural communities in seven US. states PARTICIPANTS: Youth in the CYDS study (n = 4407) were surveyed annually from ages 11 to 16, and at ages 18, 19, 21 and 23 years (in 2016). The sample was gender balanced (50% female) and ethnically diverse (20% Hispanic, 64% white, 3% black and 12% other race or ethnicity). The current study was limited to participants who had never used combustible cigarettes by age 21 (n = 1825).

MEASUREMENTS

Age 21 use of e-cigarettes and age 23 use of combustible cigarettes (three or more occasions) were included in the regression analysis. Age 11-19 measures of 22 common predictors of both e-cigarette and combustible cigarette use (e.g. pro-cigarette attitudes, peer smoking, family monitoring) were used to create IPWs.

FINDINGS

After applying IPW, e-cigarette use at age 21 was associated with a twofold increase in odds of combustible cigarette use on three or more occasions 2 years later (odds ratio = 2.16, confidence interval 1.23, 3.79).

CONCLUSIONS

Among previously never-smoking US young adults, e-cigarette use appears to be strongly associated with subsequent combustible cigarette smoking, over and above measured preexisting risk factors.

Long-term Impacts and Benefit-Cost Analysis of the Communities That Care Prevention System at Age 23, 12 Years After Baseline

This study estimated sustained impacts and long-term benefits and costs of the Communities That Care (CTC) prevention system, implemented and evaluated in a longitudinal cluster-randomized trial involving 24 communities in seven states. Analyses utilized reports from a longitudinal panel of 4407 participants, followed since the study's baseline in grade 5, with most recent follow-up 12 years later at age 23. Impacts on lifetime abstinence from primary outcomes of substance use and antisocial behavior were estimated using generalized linear mixed Poisson regression analysis, adjusted for individual and community-level covariates. Possible cascading effects on 4-year college completion, major depressive disorder, and generalized anxiety disorder through age 23 were evaluated as secondary outcomes. CTC had a statistically significant global effect on primary outcomes and also on combined primary and secondary outcomes. Among primary outcomes, point estimates suggested absolute improvements in lifetime abstinence of 3.5 to 6.1% in the intervention arm and relative improvements of 13 to 55%; 95% confidence intervals revealed some uncertainty in estimates. Among secondary outcomes, 4-year college completion was 1.9% greater among young adults from intervention communities, a 20% relative improvement. Mental health outcomes were approximately the same across trial arms. Although CTC had small sustained effects through age 23, benefit-cost analyses indicated CTC was reliably cost beneficial, with a net present value of $7152 (95% credible interval: $1253 to $15,268) per participant from primary impacts and $17,919 ($306 to $39,186) when secondary impacts were also included. It remained cost beneficial even when impacts were adjusted downward due to the involvement of CTC's developer in the trial. Findings suggest that broader dissemination of CTC could improve public health and individual lives in the long term and generate positive net benefits to society.

Tobacco Taxation and Its Prospective Impact on Disparities in Smoking Initiation and Progression Among Young Adults

PURPOSE

Limited research exists on tobacco taxes and cigarette smoking initiation and progression, particularly across different sociodemographic groups in young adulthood. This project examines how cigarette pack price in late adolescence prospectively relates to smoking initiation and progression by 21 years of age, focusing on differences across demographics.

METHODS

Data are from the longitudinal Monitoring the Future project (2001-2017). Monitoring the Future examines drug use behaviors with nationally representative samples of 12th graders annually. Subsamples of 12th graders are followed up longitudinally. We examined past 30-day cigarette smoking among baseline never smokers (N = 9,232) and daily smoking among youths who were not daily cigarette smokers at baseline (N = 15,141). Using logistic regression, we examined state-level cigarette pack price at a modal age of 18 years and smoking at follow-up ages 19-20 years; we used interaction terms to assess differences across sociodemographic groups (by gender, race/ethnicity, and parental education).

RESULTS

For each dollar increase in price at baseline, the odds of initiation by age 19-20 years were reduced by 12% (adjusted odds ratio = .88; 95% confidence interval = .78, .99) and the odds of progression to daily smoking were reduced by 16% (adjusted odds ratio = .84; 95% confidence interval = .76, .92). After adjusting for multiple testing, for both outcomes there were no statistically significant interactions between price and demographics.

CONCLUSIONS

Cigarette prices in late adolescence were associated with a prospective reduction in cigarette smoking initiation and progression among young adults, with limited differences across sociodemographic characteristics. Higher cigarette prices can prevent smoking initiation and progression; however, complementary interventions are needed to reduce initiation and progression among subgroups disproportionately affected by tobacco.

Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

BACKGROUND AND OBJECTIVES

During the current drug overdose crisis, the United States is experiencing a significant number of overdose deaths, hospitalizations, and emergency department visits. Given the vulnerability of young persons to substance use, it is important to assess how this crisis affects the nation's youth. In this study, we investigate trends in suspected nonfatal drug-related overdoses (all-drugs, opioids, heroin, and stimulants) among youth using syndromic surveillance data from 2016 to 2019.

METHODS

A retrospective analysis of emergency department syndromic surveillance data were used to detect quarterly trends in suspected drug overdoses from April 2016 through September 2019 among youth aged 0 to 10, 11 to 14, and 15 to 24 years. Syndrome definitions were developed using chief complaint free-text and discharge diagnosis codes to identify overdoses involving all-drugs, opioids, heroin, and stimulants. Pearson χ² tests detected quarter-to-quarter changes, and joinpoint regression analysis assessed trends over time.

RESULTS

On average, there was a 2.0% increase for youth aged 0 to 10 years and a 2.3% increase for youth aged 11 to 14 years for suspected all-drug overdoses. Suspected heroin overdoses decreased by an average of 3.3% per quarter for youth aged 15 to 24 years. Among all age groups, suspected stimulant overdoses increased across the study period, 3.3% for 0 to 10-year-olds, 4.0% for 11- to 14-year-olds, and 2.3% for 15- to 24-year-olds.

CONCLUSIONS

Suspected stimulant-involved drug overdoses appear to be rising among youth. These findings could inform targeted interventions, such as stimulant-focused prevention, and comprehensive approaches, including school-based prevention and other strategies to lower morbidity and mortality.

Community engagement to implement evidence-based practices in the HEALing communities study

BACKGROUND

The implementation of evidence-based practices to reduce opioid overdose deaths within communities remains suboptimal. Community engagement can improve the uptake and sustainability of evidence-based practices. The HEALing Communities Study (HCS) aims to reduce opioid overdose deaths through the Communities That HEAL (CTH) intervention, a community-engaged, data-driven planning process that will be implemented in 67 communities across four states.

METHODS

An iterative process was used in the development of the community engagement component of the CTH. The resulting community engagement process uses phased planning steeped in the principles of community based participatory research. Phases include: 0) Preparation, 1) Getting Started, 2) Getting Organized, 3) Community Profiles and Data Dashboards, 4) Community Action Planning, 5) Implementation and Monitoring, and 6) Sustainability Planning.

DISCUSSION

The CTH protocol provides a common structure across the four states for the community-engaged intervention and allows for tailored approaches that meet the unique needs or sociocultural context of each community. Challenges inherent to community engagement work emerged early in the process are discussed.

CONCLUSION

HCS will show how community engagement can support the implementation of evidence-based practices for addressing the opioid crisis in highly impacted communities. Findings from this study have the potential to provide communities across the country with an evidence-based approach to address their local opioid crisis; advance community engaged research; and contribute to the implementation, sustainability, and adoption of evidence-based practices.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04111939).

The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BACKGROUND

Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths.

METHODS

The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined.

DISCUSSION

The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Health economic design for cost, cost-effectiveness and simulation analyses in the HEALing Communities Study

BACKGROUND

The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings.

METHODS

The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list-controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention.

DISCUSSION

The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.

Model and approach for assessing implementation context and fidelity in the HEALing Communities Study

BACKGROUND

In response to the U.S. opioid epidemic, the HEALing (Helping to End Addiction Long-term^SM) Communities Study (HCS) is a multisite, wait-listed, community-level cluster-randomized trial that aims to test the novel Communities That HEAL (CTH) intervention, in 67 communities. CTH will expand an integrated set of evidence-based practices (EBPs) across health care, behavioral health, justice, and other community-based settings to reduce opioid overdose deaths. We present the rationale for and adaptation of the RE-AIM/PRISM framework and methodological approach used to capture the CTH implementation context and to evaluate implementation fidelity.

METHODS

HCS measures key domains of the internal and external CTH implementation context with repeated annual surveys and qualitative interviews with community coalition members and key stakeholders. Core constructs of fidelity include dosage, adherence, quality, and program differentiation-the adaptation of the CTH intervention to fit each community's needs. Fidelity measures include a monthly CTH checklist, collation of artifacts produced during CTH activities, coalition and workgroup attendance, and coalition meeting minutes. Training and technical assistance delivered by the research sites to the communities are tracked monthly.

DISCUSSION

To help attenuate the nation's opioid epidemic, the adoption of EBPs must be increased in communities. The HCS represents one of the largest and most complex implementation research experiments yet conducted. Our systematic examination of implementation context and fidelity will significantly advance understanding of how to best evaluate community-level implementation of EBPs and assess relations among implementation context, fidelity, and intervention impact.

Going the Distance: Technical Assistance to Community Prevention Coalitions and its impact on Prevention Coalitions Over Time

Prevention Coordinators are the linking agents providing technical assistance between universities and communities in the PROSPER model to support the implementation and sustainability of youth and family programs that have reduced substance abuse in prior research. This study examines the outcomes and trajectory of the frequency of contact of technical assistance (i.e. dosage) with community collaborative prevention coalitions across the three stages of coalition development. After communities were randomized, members of PROSPER coalitions (n=12) provided information about the quality of their operations at five time points across four and one-half years; prevention coordinators reported on the frequency of contact with their community coalitions at 14 intervals across the same period of time. This study only utilizes the intervention communities. Results from correlational models show that levels of dosage relate to the quality of internal coalition processes over time, but that the direction of the relationship changes over time: high frequency of contact early on relates to lower coalition-rated functioning initially. In contrast, early frequency of contact relates to higher levels of coalition functioning at later time points. Furthermore, longitudinal mixed models show that levels of dosage were consistent over time. These results provide empirical support of the importance of a proactive technical assistance model and add further evidence that important distinctions exist among different coalition developmental phases.

Scaling up and scaling out: Consilience and the evolution of more nurturing societies

This paper argues that diverse disciplines within the human sciences have converged in identifying the conditions that human beings need to thrive and the programs, policies, and practices that are needed to foster well-being. In the interest of promoting this view, we suggest that this convergence might usefully be labeled "The Nurture Consilience." We review evidence from evolutionary biology, developmental, clinical, and social psychology, as well as public health and prevention science indicating that, for evolutionary reasons, coercive environments promote a "fast" life strategy that favors limited self-regulation, immediate gratification, and early childbearing. However, this trajectory can be prevented through programs, practices, and policies that (a) minimize toxic social and biological conditions, (b) limit opportunities and influences for problem behavior, (c) richly reinforce prosocial behavior, and (d) promote psychological flexibility. The recognition of these facts has prompted research on the adoption, implementation, and maintenance of evidence-based interventions. To fully realize the fruits of this consilience, it is necessary to reform every sector of society. We review evidence that free-market advocacy has promoted the view that if individuals simply pursue their own economic well-being it will benefit everyone, and trace how that view led business, health care, education, criminal justice, and government to adopt practices that have benefited a small segment of the population but harmed the majority. We argue that the first step in reforming each sector of society would be to promote the value of ensuring everyone's well-being. The second step will be to create contingencies that select beneficial practices and minimizes harmful ones.

Prescription Opioid Misuse and Use of Alcohol and Other Substances Among High School Students - Youth Risk Behavior Survey, United States, 2019

Adolescence is an important period of risk for substance use initiation and substance use-related adverse outcomes. To examine youth substance use trends and patterns, CDC analyzed data from the 2009-2019 Youth Risk Behavior Survey. This report presents estimated prevalence of current (i.e., previous 30-days) marijuana use, prescription opioid misuse, alcohol use, and binge drinking and lifetime prevalence of marijuana, synthetic marijuana, cocaine, methamphetamine, heroin, injection drug use, and prescription opioid misuse among U.S. high school students. Logistic regression and Joinpoint analyses were used to assess 2009-2019 trends. Prevalence of current and lifetime substance use by demographics, frequency of use, and prevalence of co-occurrence of selected substances among students reporting current prescription opioid misuse are estimated using 2019 data. Multivariable logistic regression analysis was used to determine demographic and substance use correlates of current prescription opioid misuse. Current alcohol, lifetime cocaine, methamphetamine, heroin, and injection drug use decreased during 2009-2019. Lifetime use of synthetic marijuana (also called synthetic cannabinoids) decreased during 2015-2019. Lifetime marijuana use increased during 2009-2013 and then decreased during 2013-2019. In 2019, 29.2% reported current alcohol use, 21.7% current marijuana use, 13.7% current binge drinking, and 7.2% current prescription opioid misuse. Substance use varied by sex, race/ethnicity, grade, and sexual minority status (lesbian, gay, or bisexual). Use of other substances, particularly current use of alcohol (59.4%) and marijuana (43.5%), was common among students currently misusing prescription opioids. Findings highlight opportunities for expanding evidence-based prevention policies, programs, and practices that aim to reduce risk factors and strengthen protective factors related to youth substance use, in conjunction with ongoing initiatives for combating the opioid crisis.

Piloting of the Just Say Know prevention program: a psychoeducational approach to translating the neuroscience of addiction to youth

BACKGROUND

Substance use during adolescence can have a number of negative consequences and interfere with normal brain development. Given limited time and resources, brief group- and school-based prevention programs are an efficient strategy for educating youth about the effects of substance use on health outcomes.

OBJECTIVES

To determine if a science-based, interactive substance prevention program could improve student knowledge and influence students' attitudes toward future substance use behaviors.

METHODS

The Just Say Know program was given to 1,594 middle and high school students. The facilitator engaged students in an interactive, hour-long session covering brain basics and effects of substance use. Students completed an eight-item pre- and post-knowledge-based test to measure learning outcomes along with feedback questions about youths' attitudes toward substance use and the program.

RESULTS

After the program, 94% of students reported that it provided helpful information; 92% reported it may influence their approach to substance use, with 76% specifying that they would delay or cut back on substance use. Knowledge-based test performance increased by 78%, with high schoolers displaying significantly higher scores than middle schoolers, but both showing similar improvements in scores. Students who reported higher levels of friends' substance use had smaller improvements from pre- to posttest.

CONCLUSION

Results suggest Just Say Know, a scientifically-based prevention program, is effective in increasing adolescents' program based-knowledge, has the potential to affect youths' attitudes toward substance use, and is well-received. These findings provide preliminary evidence that a cost-effective, neuroscience-informed group prevention program might reduce or delay adolescents' future substance use.

Public Health Benefits 16 Years After a Statewide Policy Change: Communities That Care in Pennsylvania

Communities That Care (CTC), an evidence-based prevention system, has been installed outside of a research context in over 500 communities worldwide. Yet, its effectiveness in a non-research context is unknown. Using a repeated cross-sectional design with propensity score weighting at the school district-level, the purpose of this study was to examine the effect of widespread diffusion of CTC across Pennsylvania on adolescent substance use, delinquency, and depression. Anonymous youth survey data were collected from 6th, 8th, 10th, and 12th grade students every other year from 2001 to 2011. Three-hundred eighty-eight school districts participated in one to six waves of data collection during that time, resulting in a total of 470,798 student-reported observations. The intervention school districts received programming provided by CTC coalitions. Outcome measures were lifetime and past 30-day alcohol, tobacco, marijuana, and other drug use. Lifetime and past year participation in delinquency and current depressive symptoms were also analyzed. Analyses revealed that CTC school districts had significantly lower levels of adolescent substance use, delinquency, and depression. This effect was small to moderate, depending on the particular outcome studied. Overall effects became stronger after accounting for use of evidence-based programs; there are likely differences in implementation quality and other factors that contribute to the observed overall small effect size. Future research needs to unpack these factors.

Initiation Age, Cumulative Prevalence, and Longitudinal Patterns of Handgun Carrying Among Rural Adolescents: A Multistate Study

PURPOSE

Adolescent handgun carrying is a behavioral marker for youth interpersonal conflicts and an intervention point for violence prevention. Our knowledge about the epidemiology of adolescent handgun carrying mainly pertains to urban settings. Evidence on the initiation age, cumulative prevalence, and longitudinal patterns of this behavior and on handgun-related norms and peer behavior among male and female rural adolescents is scant.

METHODS

We used data from the control arm of the Community Youth Development Study, a community-randomized controlled trial of the Communities That Care prevention system. Annually, 1,039 males and 963 females were surveyed from Grade 6 (2005) to age 19 years (2012) in 12 rural towns across seven U.S. states.

RESULTS

In Grade 6, 11.5% of males and 2.8% of females reported past-year handgun carrying. Between Grade 6 and age 19 years, 33.7% of males and 9.6% of females reported handgun carrying at least once. Among participants who ever reported handgun carrying, 34.0% of males and 29.3% of females did so for the first time in Grade 6. Among participants who ever reported handgun carrying, 54.6% of males and 71.7% of females did so only one time over the seven study assessments. Greater proportions of participants who reported handgun carrying than those who did not do so endorsed prohandgun norms and had a peer who carried among both males (Grade 10: prevalence difference = 57%; 95% CI: 46%-67%) and females (Grade 10: prevalence difference = 45%; 95% CI: 12%-78%).

CONCLUSIONS

Rural adolescent handgun carrying is not uncommon and warrants etiologic research for developing culturally appropriate and setting-specific prevention programs.