CDC Report Highlights Risky Health Behaviors in High School Students

The 2013 Youth Risk Behavior Survey released yesterday by the CDC highlights continued challenges and progresses in US high school students' risky health behaviors. Image:

The 2013 Youth Risk Behavior Survey released yesterday by the CDC highlights continued challenges and progresses in reducing risky health behaviors among US high school students. Image: ©iStock.com/A-Digit

Certain risky health behaviors of high school students such as marijuana use and distracted driving continue to pose a public health challenge, according to a report released yesterday by the US Centers for Disease Control and Prevention (CDC). However, improvements are being seen in other areas, such as cigarette smoking and alcohol use.

The findings are from the CDC’s 2013 Youth Risk Behavior Survey, a nationwide school-based survey of more than 13 000 high school students in 42 states conducted every 2 years since 1991. The survey focuses on 6 categories of risky health behaviors among youth and young adults: behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and drug use, unsafe sex behaviors, unhealthy dietary behaviors, and physical inactivity.

Examples of risky behaviors that remain an ongoing concern include the following:

  • Marijuana use remains high, with 40.7% of students reporting ever having used marijuana and almost a quarter of students (23%) reporting using marijuana at least once in past 30 days. These numbers are unchanged since 2011 but reflect a significant increase since the CDC began the annual survey in 1991.
  • Texting or emailing while driving also remains common, with 41% of students claiming to have done so within the past 30 days.
  • Wearing bicycle helmets remains uncommon, with 87.9% of students reporting “never or rarely” using a helmet. This percentage has been slowly but steadily climbing since 2005.
  • Although the percentage of students reporting being sexually active has remained unchanged at 34% since 2003, the percentage of those using condoms decreased from 63% in 2003 to 59% in 2013.

Examples of areas of progress include the following:

  • Cigarette smoking among high school students is at an all-time low since 1991, with 5.6% of students reporting frequent smoking (≥20 days in the last 30 days), and 15.7% of students reporting current smoking (≥1 day in the last 30 days). In 1991, these numbers were 12.7% for frequent smoking and 27.5% for current smoking. In fact, this 15.7% already meets the CDC’s Healthy People 2020 goals for reducing adolescent cigarette use to 16% or less. However, when expanded to all tobacco products, current reported use was 22.4%. Furthermore, e-cigarettes, which recent evidence suggests is a growing concern, were not specifically mentioned in the survey.
  • Alcohol use continues to decrease, with 34.9% of high school students reporting current alcohol use (≥1 day in the last 30 days). This again represents the lowest rate since 1991, when 50.8% of students reported current alcohol use.
  • Electronic bullying decreased slightly since 2011 (the first year it was included in the survey), from 16.2% to 14.8%.

Fact sheets with more information and summaries of trends since 1991 can be found here on the CDC website.

JAMA Forum: Is Keeping Firearms Out of the Hands of Mentally Ill People the Answer to Gun Violence?

Lawrence Gostin, JD

Lawrence Gostin, JD

The cultural divide over firearms in the United States is cavernous and appears unbridgeable. There seems to be no common ground, but increasingly there is one shared position: improving identification of mentally ill individuals while restricting their access to firearms.

The public overwhelmingly supports limiting firearm access to persons with mental illness, which is consistent with the National Rifle Association’s position that “guns don’t kill people; people kill people.” The problem is that focusing solely or primarily on persons with mental illness will not quell firearm violence. (In the case of suicide attempts—a major factor in gun injuries and deaths—the link with mental illness, particularly depression, is stronger. But even here firearm restrictions have a powerful effect in reducing harms to vulnerable individuals [see box on Guns, Suicides and Mental Illness].)

The Gun Control Act of 1968 prohibits selling firearms to individuals involuntarily committed to a mental institution. The National Instant Criminal Background Check System (NICS), however, is badly flawed because states never enter many prohibited persons into the database. Obama Administration initiatives—a grant program and rule changes—seek to make it easier for states to enter information into the database, but this hasn’t resulted in significant improvements.Meanwhile, those who are in the system can easily avoid background checks, such as by purchasing firearms at a gun show—a notorious loophole. States can also issue “Brady permits,” allowing licensed sellers to waive background checks.

In the wake of the Isla Vista shootings on May 23 and other mass killings, Congress and state legislatures circulated bills designed to keep firearms out of the hands of severely mentally ill individuals. House Democrats, for example, proposed on May 6 a major expansion of the number of mentally ill patients who would be barred from purchasing firearms. A bipartisan proposal last December powerfully incentivizes states to reform their standards for committing severely mentally ill persons to hospitals or outpatient treatment, while also authorizing court-ordered therapy and medication. California lawmakers are proposing a “gun violence restraining order” that would allow families to petition a court to bar a mentally unstable person from possessing firearms.

Historically, society has stereotyped persons with mental illness as dangerous, believing that restraining their liberty or rights would solve social problems. But the evidence does not support this position. Focusing on persons with mental illness allows politicians to claim they are acting in response to firearm violence, while neglecting the principal reason the United States has vastly greater gun deaths than any other developed country. The singular difference between the United States and the rest of the world is simply the number of firearms circulating in society.

What has long been understood in public health is that changing behavior is notoriously difficult. What is far more effective is to change the environment. In this case, limiting access to firearms would prevent many gun injuries and deaths—not just in mass shootings but also, more importantly, on the streets in every major city in the United States. (Mass killings account for only about 0.15% of all homicides but are given disproportionate attention in the media).

Although most mass killers are mentally ill, only a small minority of persons with mental illness is violent. Overall, only about 4% to 5% of overall violent crime can be attributed to persons with mental illness. At the same time, it is exceedingly difficult to predict violence based on a psychiatric diagnosis: psychiatrists’ predictions of violence are no better than chance. It is true that mental illness can be a risk factor for violence, but often only with comorbidities, such as alcohol or drug abuse. The latter are far more powerful predictors of violence than the diagnosis of mental illness. Still more powerful is a history of violence, particularly threatening or using a lethal weapon such as a firearm.

These data suggest that the legislative response to the Isla Vista murders deals with the problem of gun violence only at the margins. At the same time, the response reinforces deep and historical stereotypes of persons with mental illness as irrational and dangerous. At present, federal law restricts firearm access to persons involuntarily committed to a mental institution. This makes most sense, as civil commitment standards incorporate danger to self or others. Widening the net to voluntary admission or to outpatient treatment would not only be overinclusive but also would discourage persons with emotional problems to seek diagnosis and treatment. This would be the wrong result for individuals, their families, and society as a whole.

It is unlikely that it will be possible to stop all or most mass killings; there are too many isolated and angry people and too much access to the means of death. However, there are evidence-based courses of action fully available if the political will could be summoned.

First, and most simply, Congress could fix the badly broken system of reporting to the NICS, giving states more powerful incentives to comply. That would at least offer mental health and law enforcement professionals a reliable method of restricting gun access to those who are civilly committed. Closing the gun show loophole is also essential because legal norms should not be so easily skirted. It is only common sense that if lawmakers create a rule—in this case, banning gun access to civilly committed individuals—it should be enforced fairly and consistently.

Second, Congress could require national background checks for all firearm purchases, an approach that has overwhelming public support. It appears reasonable to make sure that everyone who buys a firearm should be checked to ensure he or she is fit to use the weapon responsibly. This does not interfere with the right of responsible individuals to bear firearms.

Third, restricting firearm access should focus on conduct demonstrating an elevated risk of dangerousness. This would include a history of violence, especially using a firearm. For example, individuals convicted of misdemeanors involving violence should be included within the category of those unable to own a firearm. This behavioral criterion is the best predictor of violent behavior and does not stereotype individuals or drive mentally ill persons underground.

There is a certain simplistic comfort to conflating guns, violence, and mental illness. However, although it may make policy makers feel better, it is unlikely to get to the core of the problem. The only way to meaningfully reduce violence is to prevent truly dangerous people from purchasing firearms and to enact reasonable limits on the means needed for lethal behavior.

 ***

About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

As Prescription Drug Use Rises, so Do Child Poisonings

As more adults take prescription medications, more children are being harmed by accidental or intentional exposure to such medications. Image: Julie Fairman/iStockphoto.com

As more adults take prescription medications, more children are being harmed by accidental or intentional exposure to such medications. Image: Julie Fairman/iStockphoto.com

Growing numbers of children and adolescents are ending up in the hospital for drug-related poisonings, as the use of prescription medications by adults to treat hypertension and other cardiac problems, diabetes, high cholesterol, and pain increases, according to an analysis published in the journal Pediatrics today.

Efforts to reduce the risk of accidental medication exposure among children, such as using child-proof packaging and educating patients about safe medication storage, have helped reduce drug-related poisoning deaths among children. But rates of drug poisonings among youth are high and continue to rise. Each year, more than 70000 children are seen in emergency departments for such poisonings and at least 12% of them are hospitalized.

To assess how trends in adult prescription medication use are affecting drug poisoning rates among children, a team of researchers analyzed data from 2000-2009 on child drug exposures and related health visits from the National Poison Data System and adult prescription drug information from the National Ambulatory Medical Care Survey. The researchers found that increasing numbers of adult prescriptions were associated with growing numbers of youth poisonings, especially among children between birth and 5 years of age.

The relationship between increasing adult prescription drug use and youth poisonings was particularly strong for opioid medications. Youth exposure to opioids was associated with higher proportions of serious injury (26.8%) and hospitalization (35.2%), as was exposure to hypoglycemics (19.5% and 49.4%, respectively). Hypoglycemic drugs, prescribed for patients with diabetes, and b-blockers, prescribed for patients with cardiac conditions, were associated with the highest rates of emergency department visits.

The authors conclude that renewed efforts are needed to protect children from exposure to adults’ prescription medications, with specific measures targeting age-specific risks. For example, very young children are often inadvertently exposed to drugs they encounter while exploring, but adolescents often intentionally consume medications to get high or to harm themselves.

JAMA Forum: Public Health Regulation as a Public Process

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

Media coverage of new public health regulations often seems to follow a template:

The [regulatory agency]’s plan to implement [public health regulation] is causing controversy among [businesses affected] and [individuals who object]. While public health officials say the plan is needed in order to address the [public health problem] that affects [statistics], opponents believe the plan to be an example of government interfering too much in [topic area].

These news stories carry the implication that all sides of the issue are frozen into position and that policy making is little more than a power struggle.

But there’s another way to think about how policy is developed to improve health: as a dynamic process open to a range of policy alternatives. Besides adopting binding regulations, agencies can take a range of other steps, such as educating about a health threat, asking for public reporting of data, and encouraging voluntary efforts by key parties.

The process of deciding which tools to use can have a big effect on the eventual outcome. After defining a public health issue with data, agencies can seek broad input on solutions, including feedback on specific ideas. I have seen public engagement around problems generate interest and momentum, while altering the initial positions of regulators, industry, and others.

Where there is no consensus, an agency may decide that steps short of regulation can accomplish the intended goal. Or the agency may opt to press forward. In my experience, contested regulatory action has a greater chance of success when the process leading up to the decision effectively engaged the public.

Here are 3 examples:

  • When I served as health commissioner in Baltimore, the US Centers for Disease Control and Prevention (CDC) reported the case in 2006 of the death of young child who swallowed a piece of decorative metal that came with a sneaker. Our health department collected data and found high lead levels in children’s jewelry for sale in the city. We released these findings, leading to wide media coverage of the potential risk. When we pursued whether retailers would be interested in a voluntary agreement not to sell such products, this turned out not to be possible. We then proposed and later implemented a regulation banning the sale of children’s jewelry with high lead levels. Our staff later testified before Congress on our efforts, contributing to federal legislation that established a strict standard across the country.
  • More recently, Maryland’s Department of Health and Mental Hygiene has explored the issue of crib bumper pads, which have been associated with infant deaths. We held 2 public advisory committee meetings in May and July of 2011 and several public comment periods on how to address the issue. After internal and external discussion, we recognized that there existed not only scientific justification, but also support from the local editorial boards, injury experts, physician organizations, and many others to take action. We made some adjustments to the proposal based on public input and then moved forward. The ban on sale of baby bumper pads, the first at a state level in the country, takes effect next month.

In each of these cases, there was extensive public dialogue on the problem before there was a decision to pursue regulatory action. By the time we moved forward, there was considerable understanding of what our agency was doing and why.

So when regulations are needed, this is the kind of coverage I hope to see:

The [regulatory agency] is implementing [public health regulation] in order to address [problem]. The action, which is supported by [key group No. 1], [key group No. 2], and [key group No. 3], comes [time period] after it was first proposed.

In taking this step, the [regulatory agency] heard from [opponents] concerned about [objections]. In hearing these concerns, the agency modified its original proposal by [modifications] and determined that [other alternatives] were not going to be effective. A smooth transition is expected.

***

About the author: Joshua M. Sharfstein, MD, is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Firearm Injuries Pose Greater Risks to Youth Than Other Types of Injuries

Angela Sauaia, MD, PhD, of the University of Colorado, and colleagues found that gun injuries are more likely than other types of injuries among youth to require intensive care or result in death. (Image: Gordon Bernhardt)

Angela Sauaia, MD, PhD, of the University of Colorado, and colleagues found that gun injuries are more likely than other types of injuries among youth to require intensive care or result in death. (Image: Gordon Bernhardt)

Children and adolescents who are injured by firearms are more likely than youth who have injuries resulting from other causes to require intensive care and to die, according to an analysis published in JAMA today.

As state and federal legislators debate the merits of new legislation to curb gun violence, public health leaders have lamented the lack of research available to guide policy makers to the most effective means to reduce gun-related injuries. As Arthur L. Kellermann, MD, MPH, and Fredrick Rivara, MD, MPH, recently noted in a JAMA Commentary, public health research has helped substantially reduce deaths from car crashes, drowning, and fires, but a 17-year moratorium on federal funding for firearms research has stymied investigation of gun violence and how to best prevent it.

The new study provides some insights on gun-related trauma among children and adolescents between the ages of 4 and 17 years who were treated at 2 level 1 trauma centers in Colorado between 2000 and 2008. The researchers found that firearms were involved in 1.9% of the 6920 youth injuries they analyzed over that period. These young patients with firearm-related injuries were more likely to require intensive care (50.4%) compared with individuals with other causes of injury (19.3%); they also were more likely to die (13.2%) as a result of their injuries than those with other types of trauma (1.7%). Youths with firearm-related injuries were more likely than those with other types of injuries to be adolescent males and to have self-inflicted wounds.

Angela Sauaia, MD, PhD, associate professor of public health and surgery at the University of Colorado, discussed the findings with news@JAMA.

news@JAMA: Why did you decide to do the study?

Dr Sauaia: We initially decided to do a study on playground injuries, but we realized as we coded injuries [in the trauma registries] that there was a morbid pattern of violence among youth specifically with firearms.

news@JAMA: How do your findings compare with previous studies?

Dr Sauaia: There are few studies on pediatric injuries; most are just a snapshot in time, 1 year or 1 center. This is one of the few studies looking at temporal trends.

news@JAMA: What do you think your findings tell us about the role of firearms in injuries among youth?

Dr Sauaia: Firearm injuries in children are not isolated tragedies; they are part of the routine of ER physicians and trauma surgeons.

news@JAMA: How are these gun-related injuries different from other types of injuries?

Dr Sauaia: They are more severe, they demand more health care, and they claim more lives.

news@JAMA: Do you think the findings would likely be different in other regions?

Dr Sauaia: Possibly. I’m not optimistic that results would be much different.

news@JAMA: What further research is needed?

Dr Sauaia: So much more research is needed to understand better how we can prevent firearm injuries. One obvious place to start, regardless of where you stand on gun possession, is that a number of these adolescents who were injured had access to an unsecured and loaded firearm. And that is something we can all agree to work on.

news@JAMA: What do you think is the main take-home message?

Dr Sauaia: The main message is gun injuries among youth are not an isolated tragedy. Firearm injuries kill more than any other types of injury, many are self-inflicted, and many can be prevented by not allowing youth access to unlocked and loaded guns.

Mobile Device Users: Keep Your Eyes on the Road, Your Hands Upon the Wheel

A survey found 69% of motorists in the United States said they had talked on a cell phone while driving at least once in the previous 30 days. (Image: Michael Krinke/iStockphoto.com)

A survey found 69% of motorists in the United States said they had talked on a cell phone while driving at least once in the previous 30 days. (Image: Michael Krinke/iStockphoto.com)

More US motorists increase their risk of being in a car crash by talking, texting, and emailing on cell phones than drivers in 7 European countries, according to federal health officials.

Worldwide, road traffic crashes contribute to an estimated 1.3 million deaths annually. Experts know that risk factors for crashes include speed and alcohol, but recent evidence suggests that using mobile devices while driving quadruples the risk of being in a crash. Continue reading

Author Insights: Signs of Brain Changes Linked to Mental Difficulties Found in Retired Football Players

 John Hart Jr, MD, of the Center for BrainHealth at the University of Texas at Dallas, and his colleagues found evidence of brain changes in former professional football players who had cognitive or mood problems later in life compared with former players without such problems and nonplayers. Image: The Center for BrainHealth at the University of Texas at Dallas

John Hart Jr, MD, of the Center for BrainHealth at the University of Texas at Dallas, and his colleagues found evidence of brain changes in former professional football players who had cognitive or mood problems later in life compared with former players without such problems and nonplayers. Image: The Center for BrainHealth

Changes in the brain’s white matter may help explain why some former professional football players develop cognitive dysfunction and depression later in life, according to a study published in JAMA Neurology today.

High-profile suicides of former National Football League (NFL) players who developed cognitive deficits and depression later in life have sparked debate about whether the frequent concussions suffered by some of these athletes may contribute to lasting neurological damage. A 2009 study found brain degeneration in former athletes who had experienced brain trauma. In addition, a 2009 survey of former NFL players suggested an elevated rate of depression or memory problems among former players compared with men in the general population. Continue reading