Did a workplace sugar-sweetened beverage sales ban reduce anxiety-related SSB consumption during the COVID-19 pandemic?

OBJECTIVE

Workplace sugar-sweetened beverage (SSB) sales bans can reduce SSB consumption. Because stress and anxiety can promote sugar consumption, we examined whether anxiety among hospital employees during the COVID-19 pandemic was associated with changes in SSB consumption and explored whether this relationship varied by exposure to a workplace SSB sales ban.

DESIGN

In a prospective, controlled trial of workplace SSB sales bans, we examined self-reported anxiety (Generalized Anxiety Disorder-7; GAD-7) and self-reported SSB consumption (fluid ounces/day) before (July 2019) and during (May 2020) the COVID-19 pandemic.

SETTING

Hospital sites in two conditions (4 with SSB sales bans, 3 without sales bans) in Northern California.

PARTICIPANTS

We sampled 580 participants (hospital employees) from a larger trial of sales bans; all were regular consumers of SSBs (minimum 3/week at main trial enrollment). This subsample was chosen based on having appropriately timed data for our study questions.

RESULTS

Across conditions, participants reduced SSB consumption over the study period. However, participants with higher pandemic-era anxiety scores experienced smaller reductions in SSB consumption after 9 months compared to those with lower anxiety scores (β = 0.65, p<.05). When the sample was disaggregated by sales ban condition, this relationship held for participants in the control group (access to SSBs at work, β = 0.82, p<.05), but not for those exposed to an SSB sales ban (β = 0.42, p=.25).

CONCLUSIONS

SSB sales bans likely reduce SSB consumption through multiple pathways; buffering stress-related consumption may be one mechanism.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

[How the infant food industry processes scientific research]

For the minority of health claims on infant formula marketing materials that cited scientific studies, the vast majority had a high risk of bias and was sponsored by formula manufacturers. This is consistent with prior research revealing a 'cycle of bias' in nutrition research. The food industry biases what is being investigated in the first place. It encourages a focus on exercise and specific nutrients that legitimize health claims for specific products - a situation that is exacerbated by chronic government disinvestment in research on dietary patterns. Industry-funded studies more often report findings favourable to their sponsor, possibly because scientists are mostly influenced by their funders on an unconscious level. Investigating such effects is complicated because funding sources are not always reported clearly. Industry-funded studies should be assessed critically on what was and on what was not investigated. Governments should increase funding for nutritional research for a more level playing field.

Controlled trial of a workplace sales ban on sugar-sweetened beverages

OBJECTIVE

To examine the effectiveness of a workplace sugar-sweetened beverage (SSB) sales ban on reducing SSB consumption in employees, including those with cardiometabolic disease risk factors.

DESIGN

A controlled trial of ethnically diverse, full-time employees who consumed SSB heavily (sales ban n 315; control n 342). Outcomes included standardised measures of change in SSB consumption in the workplace (primary) and at home between baseline and 6 months post-sales ban.

SETTING

Sutter Health, a large non-profit healthcare delivery system in Northern California.

PARTICIPANTS

Full-time employees at Sutter Health screened for heavy SSB consumption.

RESULTS

Participants were 66·1 % non-White. On average, participants consumed 34·7 ounces (about 1 litre) of SSB per d, and the majority had an elevated baseline BMI (mean = 29·5). In adjusted regression analyses, those exposed to a workplace SSB sales ban for 6 months consumed 2·7 (95 % CI -4·9, -0·5) fewer ounces of SSB per d while at work, and 4·3 (95 % CI -8·4, -0·2) fewer total ounces per d, compared to controls. Sales ban participants with an elevated BMI or waist circumference had greater post-intervention reductions in workplace SSB consumption.

CONCLUSIONS

Workplace sales bans can reduce SSB consumption in ethnically diverse employee populations, including those at higher risk for cardiometabolic disease.

Using an Online Panel to Crosswalk Alternative Measures of Alcohol Use As Fielded in Two National Samples

Introduction

Accurate estimation of the health effects of drinking is hampered by inconsistent phrasing of questions about alcohol use in commonly-used health surveys (e.g., HRS, NYLS79), and measurement error in brief self-reports of drinking. We fielded an online survey to a diverse pool of respondents, assessing two versions of alcohol use questions. We used the measurement survey responses to evaluate correspondence across question versions and create a crosswalk between versions of alcohol questions from two different nationally representative studies of middle-aged adults. The measurement model can also be used to incorporate measurement error correction.

Methods

Respondents to two measurement survey platforms (Centiment and Qualtrics) were asked drinking frequency and quantity questions as phrased in the Health and Retirement Study (HRS: average days per week drank in the last 3 months; quantity consumed on days drank in the last 3 months) and differently phrased questions from the National Longitudinal Survey of Youth 1979 (NLSY79: days drank in last 30 days, average quantity consumed on days drank). The order in which respondents encountered different versions of the questions was randomized. From these questions, we derived measures of average weekly alcohol consumption. In the online panel data, we regressed responses to the HRS question on responses to the NLSY question and vice versa to create imputation models. HRS (n=14,639) and NLSY79 (n=7,069) participants aged 50-59 self-rated their overall health (range 0-4, 0=excellent and 4=poor). NLSY79 or HRS participants' responses to the alcohol question from the other survey were multiply imputed (k=30) using the measurement model from the measurement survey participant data (k=30). We regressed self-rated health on each alcohol measure and estimated covariate-adjusted coefficients from observed and imputed versions of the questions.

Results

The measurement survey (n=2,070) included respondents aged 50+; 64.8% female; 21.4% Hispanic, 23.95% Black, 27.1% White, and 27.6% another ("Other") self-reported racial/ethnic identity. Associations of observed alcohol question responses with self-reported health were slightly smaller than associations of imputed responses for frequency of alcohol use and consumption on days when alcohol was used. For example, using the HRS version of the frequency of alcohol use (days per week), the estimate for the observed question in HRS respondents was ꞵ =-0.045 [-0.055,-0.036]; and the estimate for the imputed version of the HRS question in NLSY79 respondents was ꞵ=-0.051 [-0.065,-0.037]. The estimated effect of average drinks per week was substantially larger for the imputed version of the measure (ꞵ for the observed question in HRS=-0.002 [-0.004,0.001], ꞵ for the imputed version of the HRS measure in NLSY79 respondents=-0.02 [-0.027,-0.012]). Patterns were similar when using the NLSY79 versions of questions as reported in NLSY79 and imputed for HRS respondents. For example, the estimated effect of average drinks per week was substantially larger for the imputed version of the NLSY79 question (ꞵ for the observed question in NLSY79=-0.006 [-0.01,-0.002], ꞵ for the imputed version of the HRS question in NLSY79 respondents=-0.019 [-0.027,-0.01]).

Conclusions

Measurement inconsistencies and imperfect reliability are major challenges in estimating effects of alcohol use on health. Collecting additional data using online panels is a feasible and flexible approach to quantifying measurement differences. This approach may enable measurement error corrections, improve meta-analyses, and promote evidence triangulation.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention

BACKGROUND AND OBJECTIVE

Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight.

METHODS

Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019.

RESULTS

Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence.

CONCLUSIONS

Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

Alignment in local approaches to alcohol and cannabis control policy: A case study of California cities and counties

BACKGROUND

Public health experts have urged governments around the world to regulate newly legalized cannabis as they do alcohol to effectively and efficiently protect health. However, research evaluating the alignment of alcohol and cannabis policies is sparse. We assessed similarities and differences in local alcohol and cannabis control policies across California, and characterized localities adopting distinct policy approaches.

METHODS

Using standard legal epidemiologic techniques, we collected and coded local alcohol and cannabis control policies relevant to public health for 12 California counties and all incorporated cities within them (N=241). We assessed whether localities were equally stringent on alcohol and cannabis policies by comparing overall restrictiveness (summed policy scores) and 9 specific provisions that applied to both substances. We captured distinct local alcohol-cannabis policy approaches using latent class analysis, and examined this classification in relation to local demographic, socioeconomic, political, and retail market characteristics.

RESULTS

All 241 localities permitted alcohol sales, while 71% banned cannabis sales. Among those that did not ban cannabis sales, more stringent alcohol policy scores were associated with more stringent cannabis policy scores (linear regression coefficient: 0.16 [95% CI: 0.07, 0.25]). Local governments rarely adopted the same provisions for alcohol and cannabis (e.g., limits on hours of sale, advertising restrictions), and only two regulated the co-location of cannabis and alcohol outlets. Localities that were restrictive on alcohol yet permissive on cannabis (12%) were more urban, politically progressive, and had more low-income and racial/ethnic minority residents. Localities that were more permissive on alcohol and restrictive on cannabis (51%) were more socioeconomically advantaged.

CONCLUSION

We found few similarities between local alcohol and cannabis control policies. California's experience suggests that, as governments around the world legalize cannabis, lessons learned from regulating alcohol are not routinely applied to cannabis, particularly in communities distinguished by high social and economic advantages.

Drink Tap: A Multisector Program to Promote Water Access and Intake in San Francisco Parks

Taxes on sugar-sweetened beverages (SSBs), or drinks with added sugars, show promise in decreasing purchases and consumption of SSBs. Some have called for coupling such taxes with improvements in access to safe drinking water as a strategy for reducing inequities in SSB intake, yet no studies have examined such an approach. Drink Tap is a San Francisco-based program in which public tap water stations were installed in parks and public spaces (winter 2017) and promotional efforts (fall and winter 2018) encouraged water intake. At the same time, San Francisco and surrounding communities were also implementing SSB taxes. We conducted a quasi-experimental study to examine whether water access and promotion combined with SSB taxes affected beverage intake habits more than SSB taxes alone. We conducted 1-hour observations (N = 960) at 10 intervention parks (Drink Tap plus SSB taxes) and 20 comparison parks (SSB taxes only) in San Francisco Bay Area cities before (July-September 2016) and after (June-August 2019) implementation of Drink Tap. We found significant adjusted percentage increases in drinking water among visitors to intervention parks, compared with comparison parks: water from park water sources (+80%, P < .001) and water from reusable bottles (+40%, P = .02). We found no significant reductions in visitors observed drinking bottled water, juices, or SSBs. The Drink Tap intervention led to increases in water intake from park sources and reusable bottles across parks that surpassed increases achieved through SSB taxes alone. Jurisdictions should consider coupling tap water access and promotion with policies for reducing intake of SSBs.

Pathways from climate change to emotional wellbeing: A qualitative study of Kenyan smallholder farmers living with HIV

Climate change is associated with adverse mental and emotional health outcomes. Social and economic factors are well-known drivers of mental health, yet comparatively few studies examine the social and economic pathways through which climate change affects mental health. There is additionally a lack of research on climate change and mental health in sub-Saharan Africa. This qualitative study aimed to identify potential social and economic pathways through which climate change impacts mental and emotional wellbeing, focusing on a vulnerable population of Kenyan smallholder farmers living with HIV. We conducted in-depth, semi-structured interviews with forty participants to explore their experience of climate change. We used a thematic analytical approach. We find that among our study population of Kenyan smallholder farmers living with HIV, climate change is significantly affecting mental and emotional wellbeing. Respondents universally report some level of climate impact on emotional health including high degrees of stress; fear and concern about the future; and sadness, worry, and anxiety from losing one's home, farm, occupation, or ability to support their family. Climate-related economic insecurity is a main driver of emotional distress. Widespread economic insecurity disrupts systems of communal and family support, which is an additional driver of worsening mental and emotional health. Our study finds that individual adaptive strategies used by farmers in the face of economic and social volatility can deepen economic insecurity and are likely insufficient to protect mental health. Finally, we find that agricultural policies can worsen economic insecurity and other mental health risk factors. Our proposed conceptual model of economic and social pathways relevant for mental health can inform future studies of vulnerable populations and inform health system and policy responses to protect health in a changing climate.

Using Online Crowdsourced Data to Measure the Availability of Cannabis Home Delivery: A Pilot Study

OBJECTIVE

The growing availability of cannabis products through home delivery services may affect cannabis-related health outcomes. However, research is impeded by a lack of data measuring the scale of home delivery. Prior research demonstrated that crowdsourced websites can be used to validly enumerate brick-and-mortar cannabis outlets. We piloted an extension of this method to explore the feasibility of measuring availability of cannabis home delivery.

METHOD

We tested implementation of an automated algorithm designed to webscrape data from Weedmaps, the largest crowdsourced website for cannabis retail, to count the number of legal cannabis retailers offering home delivery to the geographic centroid of each Census block group in California. We compared these estimates to the number of brick-and-mortar outlets within each block group. To assess data quality, we conducted follow-up telephone interviews with a subsample of cannabis delivery retailers.

RESULTS

We successfully implemented the webscraping. Of the 23,212 block groups assessed, 22,542 (97%) were served by at least one cannabis delivery business. Only 461 block groups (2%) contained one or more brick-and-mortar outlets. In interviews, availability varied dynamically as a function of staffing levels, order sizes, time of day, competition, and demand.

CONCLUSIONS

Webscraping crowdsourced websites could be a viable method for quantifying rapidly evolving availability of cannabis home delivery. However, key practical and conceptual challenges must be overcome to conduct a full-scale validation and develop methodological standards. Acknowledging data limitations, cannabis home delivery appears to be nearly universal in California, whereas availability of brick-and-mortar outlets is limited, underscoring the need for research on home delivery.

Intellectual functioning in survivors of extremely low birthweight: Cognitive outcomes in childhood and adolescence

BACKGROUND

Infants born at extremely low birthweight (ELBW: ≤1000 g) are vulnerable to intellectual disabilities, but the factors that may distinguish between ELBW survivors with and without these impairments are not well understood. In this study, prospective associations between neonatal factors and functional outcomes in childhood and adolescence were compared in ELBW survivors with and without borderline intellectual functioning (BIF).

METHODS

Borderline intellectual functioning was defined by IQ < 85, assessed at 8 years. Among 146 ELBW survivors, 48 (33%) had IQ scores under 85, and 98 (67%) had scores equal to or over 85. Group differences in demographic and risk factors were assessed via t-test, chi-squared analysis or non-parametric tests. Neonatal factors that differed between ELBW groups were tested for association with adaptive behaviour assessed at age 5 years, and reading and arithmetic skills assessed at ages 8 and 15 years, using hierarchical regression models.

RESULTS

Extremely low birthweight survivors with BIF had significantly lower birthweights than ELBW survivors without BIF (790 vs. 855 g, P < 0.01) and were more likely to be born to mothers with lower socioeconomic status (SES) (78% vs. 48%, P < 0.01). These ELBW survivors also were more likely to be diagnosed with significant neurosensory impairment (NSI; 35% vs. 19%, P < 0.04), experienced more bronchopulmonary dysplasia (56% vs. 38%, P < 0.04), received more days of respiratory support (median 33 vs. 14 days, P < 0.01) and remained in hospital for longer periods (median 81 vs. 63 days, P < 0.03). Birthweight, familial SES, NSI and duration of respiratory support were significant predictors for one or more outcomes. Across groups, lower familial SES was associated with lower academic scores (Ps < 0.05), and NSI predicted lower adaptive functioning (Ps < 0.001). Other associations were moderated by group: among ELBW survivors with BIF, heavier birthweights predicted better arithmetic skills, the presence of NSI was associated with poorer arithmetic skills and more ventilation days predicted poorer reading skills.

CONCLUSIONS

At birth, ELBW survivors with BIF faced more physiological and social disadvantages and required more medical intervention than their ELBW peers without BIF. Smaller birth size, NSI burden and prolonged neonatal ventilatory support displayed gradients of risk for childhood and adolescent academic outcomes across groups. Whereas academic performance in ELBW survivors with BIF was sensitive to variation in birth size, NSI or ventilation days, ELBW survivors without BIF attained thresholds of intellectual ability that were sufficient to support higher levels of academic performance at both ages, regardless of their status on these factors. The findings are discussed in relation to Zigler's developmental theory of intellectual disability.

Water Security Experiences and Water Intake Among Elementary Students at Low-Income Schools: A Cross-Sectional Study

OBJECTIVE

To examine students' experiences of water security at school and how experiences relate to intake of water from different sources of water at school.

DESIGN/METHODS

In this cross-sectional study, 651 students in grades 3 to 5 in 12 low-income public elementary schools in the San Francisco area completed surveys about their daily intake of water from different sources of water at school, experiences of water security including safety, cleanliness, and taste of water at school, and their demographics. Multivariable linear regressions examined associations between students' water security experiences at school and reported intake from different sources of water at school.

RESULTS

Approximately half of students were Latino (56.1%) and had overweight/obesity (50.4%). Most (74.5%) had some negative water security experience at school. Students drank from the school fountain or water bottle filling station a mean of 1.2 times/day (standard deviation [SD] = 1.4), sinks 0.2 times/day (SD = 0.7), tap water dispensers 0.2 times/day (SD = 0.6), and bottled water 0.5 times/day (SD = 1.0). In multivariable linear regression, students with more negative experiences of school water security drank less frequently from fountains (-0.5 times/day, P value < .001), but more frequently from tap water dispensers (0.1 times/day, P value = .040) and sinks (0.1 times/day, P value = .043), compared to students with no negative perceptions.

CONCLUSIONS

On average, students had negative school water security experiences, which decreased their consumption of water from tap water sources. However, relationships between negative water security experiences and reported water intake appeared to be mitigated by water source. Schools should consider installing more appealing water sources to promote water intake.

Equity in Coverage of Local Cannabis Control Policies in California, 2020‒2021

Objectives. To assess whether cannabis control policies that may protect public health were adopted evenly across California localities with differing sociodemographic compositions. Methods. From November 2020 to January 2021, we measured cannabis control policies for 241 localities across California and linked them to data on the characteristics of the communities affected by these policies. We evaluated whether disadvantaged communities were more likely to allow cannabis businesses and less likely to be covered by policies designed to protect public health. Results. Localities with all-out bans on cannabis businesses (65% of localities) were disproportionately high-education (55.8% vs 50.5% with any college) and low-poverty (24.3% vs 34.2%), with fewer Black (4.4% vs 6.9%) and Latinx (45.6% vs 50.3%) residents. Among localities that allowed retail cannabis businesses (28%), there were more cannabis control policies in localities with more high-income and Black residents, although the specific policies varied. Conclusions. Cannabis control policies are unequally distributed across California localities. If these policies protect health, inequities may be exacerbated. Public Health Implications. Uniform adoption of recommended cannabis control policies may help limit any inequitable health impacts of cannabis legalization. (Am J Public Health. 2022;112(11):1640-1650. https://doi.org/10.2105/AJPH.2022.307041).

Buprenorphine Treatment: Advanced Practice Nurses Add Capacity

During the COVID-19 pandemic, there was slower growth in the number of new waivers authorizing clinicians to provide buprenorphine treatment for opioid use disorder. However, treatment capacity grew at a stable rate as a result of already authorized clinicians obtaining waivers for larger patient panels. Advanced practice nurses accounted for the largest portion of capacity growth during the pandemic.

A Spatiotemporal Analysis of the Association of California City and County Cannabis Policies with Cannabis Outlet Densities

BACKGROUND

Cannabis outlets may affect health and health disparities. Local governments can regulate outlets, but little is known about the effectiveness of local policies in limiting outlet densities and discouraging disproportionate placement of outlets in vulnerable neighborhoods.

METHODS

For 241 localities in California, we measured seven policies pertaining to density or location of recreational cannabis outlets. We geocoded outlets using web-scraped data from the online finder Weedmaps between 2018 and 2020. We applied Bayesian spatiotemporal models to evaluate associations of local cannabis policies with Census block group-level outlet counts, accounting for confounders and spatial autocorrelation. We assessed whether associations differed by block group median income or racial-ethnic composition.

RESULTS

Seventy-six percent of localities banned recreational cannabis outlets. Bans were associated with fewer outlets, particularly in block groups with higher median income, fewer Hispanic residents, and more White and Asian residents. Outlets were disproportionately located in block groups with lower median income [posterior RR (95% credible interval): 0.76 (0.70, 0.82) per $10,000], more Hispanic residents [1.05 (1.02, 1.09) per 5%], and fewer Black residents [0.91 (0.83, 0.98) per 5%]. For the six policies in jurisdictions permitting outlets, two policies were associated with fewer outlets and two with more; two policy associations were uninformative. For these policies, we observed no consistent heterogeneity in associations by median income or racial-ethnic composition.

CONCLUSIONS

Some local cannabis policies in California are associated with lower cannabis outlet densities, but are unlikely to deter disproportionate placement of outlets in racial-ethnic minority and low-income neighborhoods.

Indirect COVID-19 health effects and potential mitigating interventions: Cost-effectiveness framework

Background

The COVID-19 pandemic led to important indirect health and social harms in addition to deaths and morbidity due to SARS-CoV-2 infection. These indirect impacts, such as increased depression and substance abuse, can have persistent effects over the life course. Estimated health and cost outcomes of such conditions and mitigation strategies may guide public health responses.

Methods

We developed a cost-effectiveness framework to evaluate societal costs and quality-adjusted life years (QALYs) lost due to six health-related indirect effects of COVID-19 in California. Short- and long-term outcomes were evaluated for the adult population. We identified one evidence-based mitigation strategy for each condition and estimated QALYs gained, intervention costs, and savings from averted health-related harms. Model data were derived from literature review, public data, and expert opinion.

Results

Pandemic-associated increases in prevalence across these six conditions were estimated to lead to over 192,000 QALYs lost and to approach $7 billion in societal costs per million population over the life course of adults. The greatest costs and QALYs lost per million adults were due to adult depression. All mitigation strategies assessed saved both QALYs and costs, with five strategies achieving savings within one year. The greatest net savings over 10 years would be achieved by addressing depression ($242 million) and excessive alcohol use ($107 million).

Discussion

The COVID-19 pandemic is leading to significant human suffering and societal costs due to its indirect effects. Policymakers have an opportunity to reduce societal costs and health harms by implementing mitigation strategies.

Food and beverage industry interference in science and policy: efforts to block soda tax implementation in Mexico and prevent international diffusion

Mexico is the largest soft drink market in the world, with high rates of obesity and type 2 diabetes. Due to strains on the nation’s productivity and healthcare spending, Mexican lawmakers implemented one of the world’s first public health taxes on sugar-sweetened beverages (SSBs) in 2014. Because Mexico’s tax was designed to reduce SSB consumption, it faced strong opposition from transnational food and beverage corporations. We analysed previously secret internal industry documents from major corporations in the University of California San Francisco’s Food Industry Documents Archive that shed light on the industry response to the Mexican soda tax. We also reviewed all available studies of the Mexican soda tax’s effectiveness, contrasting the results of industry-funded and non-industry-funded studies. We found that food and beverage industry trade organisations and front groups paid scientists to produce research suggesting that the tax failed to achieve health benefits while harming the economy. These results were disseminated before non-industry-funded studies could be finalized in peer review. Mexico still provided a real-world context for the first independent peer-reviewed studies documenting the effectiveness of soda taxation—studies that were ultimately promoted by the global health community. We conclude that the case of the Mexican soda tax shows that industry resistance can persist well after new policies have become law as vested interests seek to roll back legislation, and to stall or prevent policy diffusion. It also underscores the decisive role that conflict-of-interest-free, peer-reviewed research can play in implementing health policy innovations.

Longer Leukocyte Telomere Length Predicts Stronger Response to a Workplace Sugar-Sweetened Beverage Sales Ban: An Exploratory Study

BACKGROUND

Shorter leukocyte telomere length (LTL) is associated with increased risk of a number of metabolic diseases including insulin resistance and the development of type 2 diabetes mellitus. Shorter LTL is also associated with stress reactivity suggestive of a possible role for LTL to predict response to behavioral interventions. However, few studies have evaluated how interventions, such as weight loss or dietary changes, are associated with LTL changes or whether LTL can predict behavioral responses to interventions.

OBJECTIVES

We evaluated metabolic changes in relation to LTL changes and LTL at baseline in a cohort of at-risk adults in response to a 10-mo workplace-based sugar-sweetened beverage (SSB) intervention.

METHODS

At baseline, metabolic health and LTL measurements were assessed through standard blood draws on 212 participants. Multivariable linear regression models were used to assess changes in anthropometrics, SSB consumption, and 13 blood-based metabolic risk factors, in relation to LTL at baseline and changes in LTL.

RESULTS

Longer LTL at baseline was associated with decreases in SSB consumption over the 6-mo follow-up period (B = -29.67; P = 0.04). Slower LTL attrition rates were associated with decreases in waist circumference (B = -0.27; P  = 0.03), HDL cholesterol (B = -0.20; P  = 0.05), and apoA1 (B = -0.09; P = 0.01).

CONCLUSIONS

Longer LTL at baseline predicted a favorable overall response to a behavioral intervention: decreases in SSB consumption. Abdominal adiposity losses paralleled slower declines in LTL suggestive of overall health benefits, but we found differences in the relations between metabolic changes and LTL at baseline compared with LTL attrition rates. Longer LTL may be a proxy marker of a positive behavioral response.This trial was registered at clinicaltrials.gov as NCT02585336.

Missed Opportunities: The Need to Promote Public Knowledge and Awareness of Sugar-Sweetened Beverage Taxes

Despite a growing body of evidence showing that sugar-sweetened beverage (SSB) taxes nudge consumers away from SSBs, we lack an understanding of people's awareness and perceptions of SSB taxes and whether tax awareness and perceptions differ based on sociodemographic characteristics. We used serial cross-sectional study intercept surveys (n = 2715) in demographically diverse neighborhoods of Berkeley and Oakland in 2015 and 2017, and San Francisco and Richmond in 2017. In the year following successful SSB tax ballot measures, 45% of respondents correctly recalled that an SSB tax had passed in their city. In untaxed cities, 14% of respondents incorrectly thought that a tax had passed. Perceived benefits of SSB taxes to the community and to children's health were moderate and, like correct recall of an SSB tax, were higher among respondents with higher education levels. Awareness of SSB taxes was low overall, and perceptions about taxes' benefits varied by educational attainment, reflecting a missed opportunity to educate citizens about how SSB taxes work and their importance. Public health efforts should invest in campaigns that explain the benefits of SSB taxes and provide information about how tax revenues will be invested, both before and after a tax proposal has passed.

A cluster-randomized controlled trial of an elementary school drinking water access and promotion intervention: Rationale, study design, and protocol

INTRODUCTION

Promoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions.

METHODS

Informed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7 months and 15 months after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms.

DISCUSSION

This paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.

Preemption in Tobacco Control: A Framework for Other Areas of Public Health

Preemption-when a higher level of government limits the authority of a lower level to enact new policies-has been devastating to tobacco control. We developed a preemption framework based on this experience for anticipating and responding to the possibility of preemption in other public health areas. We analyzed peer-reviewed literature, reports, and government documents pertaining to tobacco control preemption. We triangulated data and thematically analyzed them.Since the 1980s, tobacco companies have attempted to secure state preemption through front groups, lobbying key policymakers, inserting preemption into other legislation, and issuing legal threats and challenges. The tobacco control community responded by creating awareness of preemption through media advocacy, educating policymakers, mobilizing national collaborations, and expanding networks with the legal community. Ten of the 25 state smoke-free preemption laws have been fully repealed. Repeal, however, took an average of 11 years.State preemption has been detrimental to tobacco control by dividing the health community, weakening local authority, chilling public education and debate, and slowing local policy diffusion. Health scholars, advocates, and policymakers should use the framework to anticipate and prevent industry use of preemption in other public health areas.

Transferring Racial/Ethnic Marketing Strategies From Tobacco to Food Corporations: Philip Morris and Kraft General Foods

Objectives. To investigate the transfer of marketing knowledge and infrastructure for targeting racial/ethnic minorities from the tobacco to the food and beverage industry in the United States.Methods. We analyzed internal industry documents between April 2018 and April 2019 from the University of California San Francisco Truth Tobacco Industry Documents Library, triangulated with other sources.Results. In the 1980s, Philip Morris Companies purchased General Foods and Kraft Foods and created Kraft General Foods. Through centralized marketing initiatives, Philip Morris Companies directly transferred expertise, personnel, and resources from its tobacco to its food subsidiaries, creating a racial/ethnic minority-targeted food and beverage marketing program modeled on its successful cigarette program. When Philip Morris Companies sold Kraft General Foods in 2007, Kraft General Foods had a "fully integrated" minority marketing program that combined target marketing with racial/ethnic events promotion, racial/ethnic media outreach, and corporate donations to racial/ethnic leadership groups, making it a food industry leader.Conclusions. The tobacco industry directly transferred racial/ethnic minority marketing knowledge and infrastructure to food and beverage companies. Given the substantial growth of food and beverage corporations, their targeting of vulnerable populations, and obesity-related disparities, public policy and community action is needed to address corporate target marketing.

Association of a Workplace Sales Ban on Sugar-Sweetened Beverages With Employee Consumption of Sugar-Sweetened Beverages and Health

IMPORTANCE

Reductions in sugar-sweetened beverage (SSB) intake can improve health, but are difficult for individuals to achieve on their own.

OBJECTIVES

To evaluate whether a workplace SSB sales ban was associated with SSB intake and cardiometabolic health among employees and whether a brief motivational intervention provides added benefits to the sales ban.

DESIGN, SETTING, AND PARTICIPANTS

This before-after study and additional randomized trial conducted from July 28, 2015, to October 16, 2016, at a Northern California university and hospital assessed SSB intake, anthropometrics, and cardiometabolic biomarkers among 214 full-time English-speaking employees who were frequent SSB consumers (≥360 mL [≥12 fl oz] per day) before and 10 months after implementation of an SSB sales ban in a large workplace, with half the employees randomized to receive a brief motivational intervention targeting SSB reduction.

INTERVENTIONS

The employer stopped selling SSBs in all workplace venues, and half the sample was randomized to receive a brief motivational intervention and the other half was a control group that did not receive the intervention. This intervention was modeled on standard brief motivational interventions for alcohol used in the workplace that promote health knowledge and goal setting.

MAIN OUTCOMES AND MEASURES

Outcomes included changes in SSB intake, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and measures of abdominal adiposity. The primary associations tested were the correlation between changes in SSB intake and changes in HOMA-IR.

RESULTS

Among the 214 study participants, 124 (57.9%) were women, with a mean (SD) age of 41.2 (11.0) years and a baseline mean (SD) body mass index of 29.4 (6.5). They reported a mean daily intake of 1050 mL (35 fl oz) of SSBs at baseline and 540 mL (18 fl oz) at follow-up-a 510-mL (17-fl oz) (48.6%) decrease (P < .001). Reductions in SSB intake correlated with improvements in HOMA-IR (r = 0.16; P = .03). Those not randomized to receive the brief intervention reduced their SSB intake by a mean (SD) of 246.0 (84.0) mL (8.2 [2.8] fl oz), while those also receiving the brief intervention reduced SSB intake by 762.0 (84.0) mL (25.4 [2.8] fl oz). From baseline to follow-up, there were significant reductions in mean (SE) waist circumference (2.1 [2.8] cm; P < .001).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that the workplace sales ban was associated with a reduction in SSB intake and a significant reduction in waist circumference among employees within 10 months. The randomized clinical trial portion of this study found that targeting those at high risk with a brief motivational intervention led to additional improvements. Workplace sales bans may offer a promising new private-sector strategy for reducing the health harms of SSB intake.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02585336.

Impacts of Medical Marijuana Laws on Young Americans Across the Developmental Spectrum

Introduction State legalization of marijuana for medical purposes could increase illicit marijuana use among young people. Medical marijuana laws may boost the availability of marijuana and reduce perceptions of its harmfulness, leading more young people to try it. Prior studies report little evidence that these laws are impacting marijuana consumption by young Americans, and none have systematically compared developmentally distinct age groups. Methods We performed multilevel, serial cross-sectional analyses on ten annual waves of U.S. National Survey on Drug Use and Health, from 2004 to 2013, comparing young people in states with and without medical marijuana laws. Disaggregated analyses compared multiple measures of marijuana use across approximately 450,300 individuals in early adolescence (12-14 years), late adolescence (15-17 years) and young adulthood (18-25 years). Results Dwelling in a state that had legalized medical marijuana was not associated with marijuana consumption in the past month among early adolescents, late adolescents or young adults. However, young adults living in medical marijuana states were significantly more likely to have initiated first use in the past year. Conclusions Medical marijuana laws increase the likelihood that young adults will start using marijuana but do not affect more vulnerable developmental groups in early and late adolescence. Delaying the age of first use into young adulthood can reduce the risk of a drug use disorder later in life. Young adults are in the peak years of engagement with illicit drugs and state medical marijuana laws appear to be leading larger numbers to try the drug.

Social and Political Factors Associated With State-Level Legalization of Cannabis in the United States

Thirty-three U.S. states and the District of Columbia (DC) have legalized the use of marijuana for medicinal purposes and 10 states and DC have legalized marijuana for adult recreational use. This mirrors an international trend toward relaxing restrictions on marijuana. This paper analyzes patterns in marijuana laws across U.S. states to shed light on the social and political forces behind the liberalization of marijuana policy following a long era of conservatism. Data on U.S. state-level demographics, economic conditions, and cultural and political characteristics are analyzed, as well as establishment of and levels of support for other drug and social policies, to determine whether there are patterns between states that have liberalized marijuana policy versus those that have not. Laws decriminalizing marijuana possession, as well as those authorizing its sale for medical and recreational use, follow the same pattern of diffusion. The analysis points to underlying patterns of demographic, cultural, economic, and political variation linked to marijuana policy liberalization in the U.S. context, which deserve further examination internationally.

Tobacco industry involvement in children's sugary drinks market

Kim H Nguyen and colleagues examine how tobacco companies applied their knowledge of flavours, colours, and child focused marketing to develop leading children’s sugar sweetened drink brands. These techniques continue to be used by drinks companies despite industry agreement not to promote unhealthy products in this way

A Professional Development Educator Primer on Dual Admission Academic Progression

The Institute of Medicine's Future of Nursing report recommends an increasingly higher educated RN workforce. Community colleges play a critical role in educating entry-level nurses to meet the needs of underserved regions in the United States. The National Education Progression in Nursing is introduced as a champion for academic progression, and the dual admission/concurrent enrollment model is highlighted. [J Contin Educ Nurs. 2019;50(1):9-11.].

Pathways and mechanisms linking dietary components to cardiometabolic disease: thinking beyond calories

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference 'Diet and Cardiometabolic Health - Beyond Calories', and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential 'beyond calories' mechanisms may lead to new strategies for attenuating the obesity crisis.

Achieving Health Equity Through Community Engagement in Translating Evidence to Policy: The San Francisco Health Improvement Partnership, 2010-2016

BACKGROUND

The San Francisco Health Improvement Partnership (SFHIP) promotes health equity by using a novel collective impact model that blends community engagement with evidence-to-policy translational science. The model involves diverse stakeholders, including ethnic-based community health equity coalitions, the local public health department, hospitals and health systems, a health sciences university, a school district, the faith community, and others sectors.

COMMUNITY CONTEXT

We report on 3 SFHIP prevention initiatives: reducing consumption of sugar sweetened beverages (SSBs), regulating retail alcohol sales, and eliminating disparities in children's oral health.

METHODS

SFHIP is governed by a steering committee. Partnership working groups for each initiative collaborate to 1) develop and implement action plans emphasizing feasible, scalable, translational-science-informed interventions and 2) consider sustainability early in the planning process by including policy and structural interventions.

OUTCOME

Through SFHIP's efforts, San Francisco enacted ordinances regulating sale and advertising of SSBs and a ballot measure establishing a soda tax. Most San Francisco hospitals implemented or committed to implementing healthy-beverage policies that prohibited serving or selling SSBs. SFHIP helped prevent Starbucks and Taco Bell from receiving alcohol licenses in San Francisco and helped prevent state authorization of sale of powdered alcohol. SFHIP increased the number of primary care clinics providing fluoride varnish at routine well-child visits from 3 to 14 and acquired a state waiver to allow dental clinics to be paid for dental services delivered in schools.

INTERPRETATION

The SFHIP model of collective impact emphasizing community engagement and policy change accomplished many of its intermediate goals to create an environment promoting health and health equity.

Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents

Early warning signals of the coronary heart disease (CHD) risk of sugar (sucrose) emerged in the 1950s. We examined Sugar Research Foundation (SRF) internal documents, historical reports, and statements relevant to early debates about the dietary causes of CHD and assembled findings chronologically into a narrative case study. The SRF sponsored its first CHD research project in 1965, a literature review published in the New England Journal of Medicine, which singled out fat and cholesterol as the dietary causes of CHD and downplayed evidence that sucrose consumption was also a risk factor. The SRF set the review's objective, contributed articles for inclusion, and received drafts. The SRF's funding and role was not disclosed. Together with other recent analyses of sugar industry documents, our findings suggest the industry sponsored a research program in the 1960s and 1970s that successfully cast doubt about the hazards of sucrose while promoting fat as the dietary culprit in CHD. Policymaking committees should consider giving less weight to food industry-funded studies and include mechanistic and animal studies as well as studies appraising the effect of added sugars on multiple CHD biomarkers and disease development.

Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans

There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.

Capturing Heterogeneity in Medical Marijuana Policies: A Taxonomy of Regulatory Regimes Across the United States

BACKGROUND

There is considerable movement in the U.S. to legalize use of cannabis for medicinal purposes. Twenty-three U.S. states and the District of Columbia have laws that decriminalize use of marijuana for medicinal purposes. Most prior studies of state medical marijuana laws and their association with overall marijuana use, adolescent use, crime rates, and alcohol traffic fatalities have used a binary coding of whether the state had a medical marijuana law or not. Mixed results from these studies raise the question of whether this method for measuring policy characteristics is adequate.

OBJECTIVES

Our objective was to develop a validated taxonomy of medical marijuana laws that will allow researchers to measure variation in aspects of medical marijuana statutes as well as their overall restrictiveness.

METHODS/RESULTS

We used a modified Delphi technique using detailed and validated data about each state's medical marijuana law. Three senior researchers coded elements of the state laws in initiation of use, quantity allowed, regulations around distribution, and overall restrictiveness. We used 2013 data from the U.S. National Survey on Drug Use and Health to assess validity of the taxonomy. Results indicate substantial state-level variation in medical marijuana policies. Validation analysis supported the taxonomy's validity for all four dimensions with the largest effect sizes for the quantity allowed in the state's medical marijuana policy.

CONCLUSIONS/IMPORTANCE

This analysis demonstrates the potential importance of nondichotomous measurement of medical marijuana laws in studies of their impact. These findings may also be useful to states that are considering medical marijuana laws, to understand the potential impact of characteristics of those laws.

Young People's More Permissive Views About Marijuana: Local Impact of State Laws or National Trend?

OBJECTIVES

To determine whether state medical marijuana laws "send the wrong message," that is, have a local influence on the views of young people about the risks of using marijuana.

METHODS

We performed multilevel, serial, cross-sectional analyses on 10 annual waves of the US National Survey on Drug Use and Health (2004-2013) nationally and for states with marijuana laws using individual- and state-level controls.

RESULTS

Living in medical marijuana states was associated with more permissive views regarding marijuana across 5 different measures. However, these associations became non-statistically significant after we adjusted for state-level differences. By contrast, there was a consistent and significant national time trend toward more permissive attitudes, which was less pronounced among children of middle school age than it was among their older counterparts.

CONCLUSIONS

Passing medical marijuana laws does not seem to directly affect the views of young people in medical marijuana states. However, there is a national trend toward young people taking more permissive views about marijuana independent of any effects within states.

Recent Developments in Alcohol Services Research on Access to Care

In the United States, only about 10 percent of people with an alcohol or drug use disorder receive care for the condition, pointing to a large treatment gap. Several personal characteristics influence whether a person will receive treatment; additionally, many people with an alcohol use disorder do not perceive the need for treatment. The extent of the treatment gap differs somewhat across different population subgroups, such as those based on gender, age, or race and ethnicity. Recent health care reforms, such as implementation of the Patient Protection and Affordable Care Act of 2010, likely will improve access to substance abuse treatment. In addition, new treatment approaches, service delivery systems, and payment innovations may facilitate access to substance abuse services. Nevertheless, efforts to bridge the treatment gap will continue to be needed to ensure that all people who need alcohol and drug abuse treatment can actually receive it.

Sugar industry influence on the scientific agenda of the National Institute of Dental Research's 1971 National Caries Program: a historical analysis of internal documents

BACKGROUND

In 1966, the National Institute of Dental Research (NIDR) began planning a targeted research program to identify interventions for widespread application to eradicate dental caries (tooth decay) within a decade. In 1971, the NIDR launched the National Caries Program (NCP). The objective of this paper is to explore the sugar industry's interaction with the NIDR to alter the research priorities of the NIDR NCP.

METHODS AND FINDINGS

We used internal cane and beet sugar industry documents from 1959 to 1971 to analyze industry actions related to setting research priorities for the NCP. The sugar industry could not deny the role of sucrose in dental caries given the scientific evidence. They therefore adopted a strategy to deflect attention to public health interventions that would reduce the harms of sugar consumption rather than restricting intake. Industry tactics included the following: funding research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay with questionable potential for widespread application, cultivation of relationships with the NIDR leadership, consulting of members on an NIDR expert panel, and submission of a report to the NIDR that became the foundation of the first request for proposals issued for the NCP. Seventy-eight percent of the sugar industry submission was incorporated into the NIDR's call for research applications. Research that could have been harmful to sugar industry interests was omitted from priorities identified at the launch of the NCP. Limitations are that this analysis relies on one source of sugar industry documents and that we could not interview key actors.

CONCLUSIONS

The NCP was a missed opportunity to develop a scientific understanding of how to restrict sugar consumption to prevent tooth decay. A key factor was the alignment of research agendas between the NIDR and the sugar industry. This historical example illustrates how industry protects itself from potentially damaging research, which can inform policy makers today. Industry opposition to current policy proposals-including a World Health Organization guideline on sugars proposed in 2014 and changes to the nutrition facts panel on packaged food in the US proposed in 2014 by the US Food and Drug Administration-should be carefully scrutinized to ensure that industry interests do not supersede public health goals.

How do integrated health care systems address racial and ethnic disparities in colon cancer?

PURPOSE

Colorectal cancer (CRC) disparities have persisted over the last two decades. CRC is a complex disease requiring multidisciplinary care from specialists who may be geographically separated. Few studies have assessed the association between integrated health care system (IHS) CRC care quality, survival, and disparities. The purpose of this study was to determine if exposure to an IHS positively affects quality of care, risk of mortality, and disparities.

PATIENTS AND METHODS

This retrospective secondary-data analysis study, using the California Cancer Registry linked to state discharge abstracts of patients treated for colon cancer (2001 to 2006), compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, the hazard of mortality, and racial/ethnic disparities in an IHS versus other settings.

RESULTS

More than 30,000 patient records were evaluated. The IHS had overall higher rates of adherence to NCCN guidelines. Propensity score-matched Cox models showed an independent and protective association between care in the IHS and survival (hazard ratio [HR], 0.87; 95% CI, 0.85 to 0.90). This advantage persisted across stage groups. Black race was associated with increased hazard of mortality in all other settings (HR, 1.15; 95% CI, 1.04 to 1.27); however, there was no disparity within the IHS for any minority group (P > .11 for all groups) when compared with white race.

CONCLUSION

The IHS delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the IHS. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health care reform.

The equal right to drink

The starting place for this essay is Knupfer and Room's insight that more restrictive norms around drinking and intoxication tend to be selectively applied to the economically dependent segments of society, such as women. However, since these authors wrote in 1964, women in the US and many other societies around the globe have experienced rising economic independence. The essay considers how the moral categories of acceptable drinking and drunkenness may have shifted alongside women's rising economic independence, and looks at evidence on the potential consequences for women's health and wellbeing. I argue that, as women have gained economic independence, changes in drinking norms have produced two different kinds of negative unintended consequences for women at high and low extremes of economic spectrum. As liberated women of the middle and upper classes have become more economically equal to men, they have enjoyed the right to drink with less restraint. For them, alongside the equal right to drink has come greater equality in exposure to alcohol-attributable harms, abuse and dependence. I further suggest that, as societies become more liberated, the economic dependency of low-income women is brought into greater question. Under such conditions, women in poverty-particularly those economically dependent on the state, such as welfare mothers-have become subject to more restrictive norms around drinking and intoxication, and more punitive social controls.