California Behavioral Risk Factor Surveillance Research Articles

Importance of accounting for regional differences in modifiable risk factors for Alzheimer’s disease and related dementias: The case for tailored interventions in California

AbstractBackgroundWe previously estimated that 37% of Alzheimer’s disease and related dementias (ADRD) cases in the U.S. may be attributable to modifiable risk factors, and that the most important risk factors differ based on race/ethnicity, but it’s not known whether national estimates generalize to specific states or regions. The aim of the present study was to (1) compare the proportion of ADRD cases that are potentially attributable to modifiable risk factors in California, to the U.S., overall and by sex and race/ethnicity, and (2) to estimate how many cases are potentially preventable by reducing the prevalence of key modifiable risk factors by 25%.MethodParticipants included adults ≥18 years from the California (n = 9,836) and the U.S. (n = 378,615). We calculated population attributable risks (PARs) using prevalence data from the national and California Behavioral Risk Factor Surveillance Survey (BRFSS) and relative risks from recent meta‐analyses. We estimated individual and combined PARs for ADRD in California and compared them to our U.S. estimates.ResultsIn California, overall, 29% of ADRD cases were potentially attributable to the combination of 8 modifiable risk factors evaluated in this study, compared to 37% in the U.S. The top 3 ADRD risk factors were the same in California and the U.S., but their relative importance differed (low education [CA:15%; U.S.:12%], midlife obesity [CA:15%; U.S.:17.7%], and physical inactivity (CA:10%; U.S.:12%). The combined PAR was lower in California compared to the U.S. in men (CA:28%; U.S.:36%) and Blacks (CA: 30%; U.S.:40%), but was similar in women and other race/ethnic groups. This was primarily due to lower risk factor prevalence within these groups. Low education was especially important in the Hispanic population (CA:30%; U.S.:26%). The total number of ADRD cases currently attributable to combined risk factors was 199,246 in California and 2,287,683 in the U.S. If the combined risk factors were reduced by 25%, we could potentially prevent approximately 40,665 cases in California and 445,737 in the U.S.ConclusionThe potential impact of modifiable ADRD risk factors differed in California and the U.S., overall and within sex and race/ethnic groups, highlighting the importance of tailoring dementia risk reduction campaigns.

Complete home smoking ban survey analysis: an opportunity to improve health equity among sexual minority adults in California, USA

BackgroundIncreasing the proportion of adults living in smoke-free homes is a US Healthy People 2020 objective. Complete home smoking bans are associated with higher odds of smoking cessation attempts and cessation duration. Sexual minority adults have disproportionality higher rates of smoking. This study investigates correlates of having a complete home smoking ban among sexual minority adults in California.MethodsSecondary data analyses of the California Behavioral Risk Factor Surveillance System (CA BRFSS), 2014–2016. The CA BRFSS telephone survey of adults was conducted in English and Spanish and used random digit dial for landline and cell numbers. Weighted descriptives were stratified by sexual orientation and biological sex. Weighted bivariate and multivariable logistic regression analyses included only sexual minorities (i.e., lesbian, gay, bisexual) and were analyzed as a group and separately by biological sex to account for intragroup variances. The final weighted total of sexual minority adults (N = 359,236) included sexual minority adult females (N = 163,490) and sexual minority adult males (N = 195,746).ResultsSexual minority adults in California had a lower prevalence of complete home smoking bans (Female 76.2%; Male 75.7%), higher prevalence of current cigarette smoking (Female 23.3%; Male 17.4%) and of e-cigarette use (Female 5.8%; Male 6.4%) than their straight counterparts. Sexual minorities that smoke everyday (Female Adjusted Odds Ratio (AOR) 0.26, 95% Confidence Interval (CI) 0.11–0.63; Male AOR 0.24, 95% CI 0.01–0.56) or some days (Female AOR 0.28, 95% CI 0.09–0.90) had lower adjusted odds of having a complete home smoking ban compared to those who never smoked.ConclusionsSmoking everyday was the only consistent predictor of not having a complete home smoking ban among sexual minority adults. Focused efforts to increase prevalence of complete home smoking bans should address smoking status to improve health equity among sexual minority adults.

Accounting for lack of representation in dementia research: Generalizing KHANDLE study findings on the prevalence of cognitive impairment to the California older population.

Most dementia studies are not population-representative; statistical tools can be applied to samples to obtain critically-needed population-representative estimates, but are not yet widely used. We pooled data from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study and the California Behavioral Risk Factor Surveillance System (CA-BRFSS), a population-representative study. Using weights accounting for sociodemographic/health differences between KHANDLE and CA-BRFSS, we estimated cognitive impairment prevalence and age- and sex-adjusted racial/ethnic inequalities in California adults 65+ without prior dementia diagnosis. After weighting KHANDLE, the estimated cognitive impairment prevalence in California was 20.3% (95% confidence interval 17.8-23.0); unweighted prevalence was 24.8% (23.1%-26.6%). Inequalities (larger prevalences) were observed among Black and Asian groups versus whites. We used a novel statistical approach to estimate population-representative cognitive impairment prevalence and inequalities. Such statistical tools can help obtain population-representative estimates from existing studies and inform efforts to reduce racial/ethnic disparities.

Public health interventions to reduce Alzheimer’s risk: Need for tailored approaches

AbstractBackgroundWe have previously estimated that 30% of Alzheimer’s disease in the U.S. may be attributable to modifiable risk factors, and that the most important risk factors to target are physical inactivity, depression, and smoking. However, estimates in the U.S. population as a whole may not be ideal for guiding public health messaging about Alzheimer's risk reduction because they do not take into consideration the unique risk factor profiles of different regions. In this study, we estimate the proportion of Alzheimer’s disease cases that are potentially attributable to modifiable risk factors in California, which has the largest and most diverse population in the U.S.MethodWe calculated individual and combined population attributable risks (PARs) for Alzheimer’s disease in California for eight modifiable risk factors: physical inactivity, smoking, depression, low education, diabetes, midlife obesity, midlife hypertension, and hearing loss. Relative risks for each risk factor were extracted from recent meta‐analyses. Risk factor prevalence and communality were determined using data from the 2017 and 2018 California Behavioral Risk Factor Surveillance Survey, a population‐based survey weighted to provide representative estimates. To account for non‐independence of the risk factors, we estimated the communality and uniqueness of each risk factor via principal component analysis and applied them to Levin’s formula.ResultsIn California, the estimated PARs (95% confidence intervals) for modifiable risk factors were as follows: low education: 14.0% (13.3%, 14.8%), midlife obesity: 13.4% (12.9%, 13.9%), physical inactivity: 10.3% (9.8%, 10.8%), midlife hypertension: 7.4% (7.2%, 7.7%), depression: 7.4% (7.0%, 7.7%), diabetes: 6.7% (6.2%, 7.2%), smoking: 4.5% (4.2%, 4.8%), and hearing loss: 1.9% (1.7%, 2.1%). The combined PAR estimate was 29.4% (28.1%, 30.7%) incorporating the correlations between risk factors.ConclusionConsistent with our previous U.S. estimates, we found that about a third of Alzheimer’s disease cases in California might be attributable to modifiable risk factors. However, the most important risk factors differed, with low education, midlife obesity and physical inactivity contributing to the largest proportion of cases. Public health interventions to reduce dementia risk may be more effective if tailored to address the most important risk factors in the region.

The Association of California's Proposition 56 Tobacco Tax Increase With Smoking Behavior Across Racial and Ethnic Groups and by Income.

On April 1, 2017, California Proposition 56 (Prop 56) was implemented, increasing the excise tax on cigarettes by $2/pack. This study compares the association of Prop 56 with smoking prevalence and smoking intensity across racial/ethnic groups, further examining distinctions across income subgroups within each racial/ethnic group. The study used pooled cross-sectional data from the 2012-2018 California Behavioral Risk Factor Surveillance System. We examined two outcomes: current smoking prevalence and smoking intensity conditional on current smoking. A two-part econometric model was used to estimate the association of Prop 56 with smoking prevalence and intensity using multiple logistic regression and multiple linear regression, respectively. The two-part model was run separately for all adults (full sample) and each racial/ethnic group. Within each racial/ethnic group, we ran stratified analyses by income subgroups. The results indicated that Prop 56 was negatively associated with smoking prevalence among full sample, Hispanic, White, and African American adults and negatively associated with smoking intensity among full sample and White smokers. Stratified analyses by race/ethnicity and income showed that Prop 56 was negatively associated with smoking prevalence among low-income full sample and White adults and among middle-income smokers in the full, Hispanic, White, African American, and Asian samples. Prop 56 was negatively associated with smoking intensity among middle-income Hispanic and high-income White smokers. The association between Prop 56 and smoking intensity was positive among high-income African American smokers. Prop 56 was associated with a reduction in smoking prevalence across multiple racial/ethnic groups, particularly within the low- and middle-income subgroups. Our findings indicate that the reduction in smoking prevalence immediately following the implementation of Prop 56 tobacco tax increase was significant across a variety racial/ethnic groups, particularly low- and middle-income subgroups. We found differential responses in smoking prevalence across income groups among Whites but not among racial/ethnic minorities. We found no evidence of any significance association between Proposition 56 and smoking intensity among minorities and economically vulnerable populations, except for middle-income Hispanics. Researchers, policy makers, and advocates should consider the additional merits of targeted, community-based, noneconomic tobacco control interventions in reaching low- and middle-income groups within racial/ethnic minorities.

Effects of a minimum floor Price law on cigarette use in Oakland, California: A static microsimulation model

Tobacco minimum floor price laws (MFPLs) are a non-tax price policy that set a price below which tobacco products cannot be sold, thereby raising prices. Despite their growing interest among policy makers, little is known about the effects of local MFPLs on smoking prevalence or smoking intensity. We aimed to project the impact of a local tobacco MFPL on cigarette smoking prevalence and cigarette smoking intensity in Oakland, California, including detailed analysis of several important subpopulations. We used data collected between April 2017 and December 2019 from the California Behavioral Risk Factor Surveillance System and the National Youth Tobacco Survey to construct a static microsimulation model representative of Oakland. We projected the impact of MFPLs ranging from $8.00 to $13.00 per pack. All analyses were conducted between 2019 and 2020. With the introduction of an MFPL and assuming 15% policy evasion, mean price paid per pack was projected to increase by $1.05 to $4.69, cigarette smoking prevalence was projected to drop by 0.3% to 0.8%, and smoking intensity was projected to drop by 0.7% to 2.0% among continuing smokers. Total number of cigarettes smoked per month was projected to drop by 246,000 to 734,000 cigarettes, a 3.0% to 9.0% reduction from the current level (8.2 million cigarettes). The greatest reductions in cigarette smoking prevalence were among those aged 12 to 24-years-old, of non-Hispanic black or other race/ethnicity, and living below the federal poverty level. An MFPL in Oakland may substantially reduce cigarette use and target several important subpopulations.

Valley Fever (Coccidioidomycosis) Awareness - California, 2016-2017.

Valley fever (coccidioidomycosis) is endemic in the southwestern United States and caused by inhalation of Coccidioides spp. fungal spores from soil or dust; 97% of U.S. Valley fever cases are reported from Arizona and California (1). In California, Valley fever incidence increased 213% from 2014 to 2018 (2). In 2016, the California Department of Public Health (CDPH) added three questions to the adult California Behavioral Risk Factor Surveillance System (BRFSS) survey to better understand whether Californians had heard of Valley fever, knew the environmental risk where they live, and knew who is at risk for severe disease. A total of 2,893 BRFSS respondents aged ≥18 years answered at least one Valley fever question. Using the weighted California population, 42.4% of respondents reported general awareness of Valley fever; awareness was lowest among adults aged 18-44 years (32.9%) and Hispanic persons (26.4%). In addition, despite higher percentages reporting awareness of Valley fever, only 25.0% of persons living in a high-incidence region and 3.0% of persons living in a moderate-incidence region were aware that they lived in areas where Coccidioides spp. exist. Among persons with one or more risk factors for severe disease, 50.8% reported having heard about Valley fever, but only 3.5% knew they were at increased risk for severe disease. The findings from this survey helped to inform a statewide Valley fever awareness campaign implemented during 2019-2020 and to guide outreach to persons living in high- and moderate-incidence regions in California and potentially other southwestern states or who are at risk for severe disease.

Abstract IA12: Border Health Consortium of the Californias

Abstract San Diego County is a minority-majority region, in which non-Hispanic whites are not the majority population (46%). Hispanics comprise 33.5% of the population and Asian Pacific Islanders (APIs) make up 12.8%. For risk factor burden, data based on California Health Interview Survey and Behavioral Risk Factor Surveillance System show that Hispanics in San Diego County have the lowest colorectal, breast, and cervix cancer screening rates, the highest obesity prevalence, and the highest proportion of no physical activity. The mission of the Border Health Consortium of the Californias-Binational Cancer Work Group is to promote cancer-free lives and erase borders in our region. We will identify and characterize priority cancer topics for our border region, organize along the cancer control continuum, identify key border region cancer activities and resources (binational), and identify key border region cancer needs (binational). To reach our objectives we will optimize collaboration, coordination, and cooperation. Citation Format: Prisci Quijada. Border Health Consortium of the Californias [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr IA12.

Smoking Behavior in Low- and High-Income Adults Immediately Following California Proposition 56 Tobacco Tax Increase.

Objectives. To compare the association of California Proposition 56 (Prop 56), which increased the cigarette tax by $2 per pack beginning on April 1, 2017, with smoking behavior among low- and high-income adults.Methods. Drawing on a sample of 17 206 low-income and 21 324 high-income adults aged 21 years or older from the 2012 to 2018 California Behavioral Risk Factor Surveillance System data, we explored 2 outcomes: current smoking prevalence and smoking intensity (average number of cigarettes per day among current smokers). For each income group, we estimated a multivariable logistic regression to analyze the association of Prop 56 with smoking prevalence and a multivariable linear regression to analyze the association of Prop 56 with smoking intensity.Results. Although we observed no association between smoking intensity and Prop 56, we found a statistically significant decline in smoking prevalence among low-income adults following Prop 56. No such association was found among the high-income group.Conclusions. Given that low-income Californians smoke cigarettes at greater rates than those with higher incomes, our results provide evidence that Prop 56 is likely to reduce income disparities in cigarette smoking in California.

Relationships Between Adverse Childhood Experiences and Health Status in Systemic Lupus Erythematosus.

Adverse childhood experiences (ACEs) are associated with poor adult health and immune dysregulation. The impact of ACEs on patients with autoimmune disease is unknown. The present study was undertaken to compare the prevalence of ACEs in patients with systemic lupus erythematosus (SLE) to a population-based survey estimate and to investigate relationships between ACEs and SLE outcomes. Data derived from the California Lupus Epidemiology Study (CLUES), a sample of adult patients with SLE. Participants completed a 10-item ACE questionnaire covering 3 domains (abuse, neglect, household challenges). We estimated ACE prevalence in 269 CLUES participants compared to geographically matched respondents from the 2015 California Behavioral Risk Factor Surveillance System (BRFSS), which was standardized to CLUES participant characteristics (age, sex, race/ethnicity). We examined associations of patient-reported and physician-assessed health status measures with overall ACE levels and domains using multivariable linear regression, controlling for sociodemographics, nephritis, and juvenile-onset SLE. Although specific domains varied, overall ACE levels were similar for CLUES and BRFSS respondents. Among SLE patients, 63.2% had ≥1 ACE, and 19.3% had ≥4. ACEs were more prevalent in those who were older, women, Latino or African American, and without college degrees, but not in those with lupus nephritis. In adjusted models, higher ACE levels and ACE domains were associated with worse patient-reported SLE activity, depression, and health status but were not significantly associated with physician-assessed SLE activity, damage, or severity. Given the association between ACE levels and important patient-reported outcomes in SLE, our study reinforces the need for prevention of ACEs in childhood and for clinical interventions to promote resilience among adults who have experienced ACEs.

Simulating the Impact of a Cigarette Minimum Floor Price Law on Adult Smoking Prevalence in California.

Minimum floor price laws (MFPLs) are an emerging tobacco control policy that sets a minimum price below which a specific tobacco product cannot be sold. MFPLs target cheaper products and may disproportionately impact consumers choosing low price brands or using discounts to reduce prices. We developed a static microsimulation model for California, United States to project short-term effects of different MFPL options for a 20-stick pack of cigarettes on adult smoking behaviors. We simulated 300 000 individuals defined by race and ethnicity, sex, age, and poverty status. Smoking behaviors and cigarette prices were assigned based on demographic distributions in the 2014-2016 California Behavioral Risk Factor Surveillance System. We drew 100 random samples (n = 30 000), weighted to state-level California demographic characteristics. We simulated six MFPL options and modeled impacts on smoking prevalence and cigarette consumption, in general, and separately for those in households below or above 250% of the federal poverty level, assuming a price elasticity of -0.4. Predicted changes in prices, prevalence, and consumption increased exponentially as the floor price increased from $7.00 to $9.50. Assuming 15% policy avoidance, projected increases in average cigarette prices ranged from $0.19 to $1.61. Decreases in smoking prevalence ranged from 0.05 to 0.43 percentage points, and decreases in average monthly cigarette consumption ranged from 1.4 to 12.3 cigarettes. Projected prices increased, and prevalence and consumption decreased, more among individuals in households below 250% federal poverty level. MFPLs are a promising tobacco control strategy with the potential to reduce socioeconomic disparities in cigarette smoking prevalence and consumption. Despite reductions in adult smoking prevalence, significant socioeconomic disparities remain, with lower-income groups smoking at substantially higher levels than higher-income groups. Policies that set a floor price below which a tobacco product cannot be sold could reduce socioeconomic disparities in smoking, depending on variation in prices paid by smokers prepolicy. By using a microsimulation model to predict changes in smoking for different population groups in California under several floor price scenarios, this study demonstrates that MFPLs have the potential to reduce adult smoking prevalence overall, and especially for lower-income tobacco users.

Adult health burden and costs in California during 2013 associated with prior adverse childhood experiences.

ObjectivesTo estimate the adult health burden and costs in California during 2013 associated with adults’ prior Adverse Childhood Experiences (ACEs).MethodsWe analyzed five ACEs-linked conditions (asthma, arthritis, COPD, depression, and cardiovascular disease) and three health risk factors (lifetime smoking, heavy drinking, and obesity). We estimated ACEs-associated fractions of disease risk for people aged 18+ for these conditions by ACEs exposure using inputs from a companion study of California Behavioral Risk Factor Surveillance System data for 2008–2009, 2011, and 2013. We combined these estimates with published estimates of personal healthcare spending and Disability-Adjusted-Life-Years (DALYs) in the United States by condition during 2013. DALYs captured both the years of healthy life lost to disability and the years of life lost to deaths during 2013. We applied a published estimate of cost per DALY.ResultsAmong adults in California, 61% reported ACEs. Those ACEs were associated with $10.5 billion in excess personal healthcare spending during 2013, and 434,000 DALYs valued at approximately $102 billion dollars. During 2013, the estimated health burden per exposed adult included $589 in personal healthcare expenses and 0.0224 DALYs valued at $5,769.ConclusionsEstimates of the costs of childhood adversity are far greater than previously understood and provide a fiscal rationale for prevention efforts.

Demographic Moderators of the Relationship Between Adverse Childhood Experiences and Cigarette Smoking

Background: Research suggests that there is a dose–response relationship between Adverse Childhood Experiences (ACEs) and cigarette smoking, such that as ACE score increases, so do the odds of smoking behavior, but little is known about what factors moderate this relationship. Objectives: The goal of this study was to examine demographic characteristics as potential moderators of relationship between ACE score and cigarette smoking. Methods: A secondary data analysis was conducted using the 2013 California Behavioral Risk Factor Surveillance System data. The sample included 2,604 U.S. adults (54.8% female; Age: M = 53.3, SD = 8.10). We used multinomial logistic regression to test sex, race, income, and education as moderators of the relationship between ACE score and smoking. Results: ACEs were not significantly associated with smoking behavior. No interactions between ACE score and sex, race, education, or income significantly predicted smoking outcomes. Sex, race, education, and income were significantly and independently associated with smoking outcomes. Men, individuals with lower income and education, and certain ethnic/racial groups reported greater odds of smoking. Conclusions/Importance: Results suggest that there may not be a relationship between ACEs and smoking later in life. Additionally, the relationship between ACEs and smoking in adulthood may not depend on basic demographic features. Knowing which populations are more vulnerable to smoking can help clinicians better assess and tailor interventions to meet the needs of their patients by using culturally sensitive interventions and obtaining resources to help improve treatment access, motivation, and success.

Perceived neighborhood disorder, racial-ethnic discrimination and leading risk factors for chronic disease among women: California Behavioral Risk Factor Surveillance System, 2013

Social environmental factors are theoretically identified as influential drivers of health behaviors – tobacco smoking, alcohol consumption, and physical activity – related to chronic disease disparities. Empirical studies investigating relationships involving social environmental factors have found that either greater interpersonal racial-ethnic discrimination or perceived neighborhood disorder were associated with adverse health behaviors, with potentially larger effects among women. We simultaneously tested whether measures of perceived racial-ethnic discrimination and perceived neighborhood disorder were associated with physical activity, alcohol consumption and tobacco smoking; lifestyle risk factors of major chronic disease among women. Data were from the 2013 California Behavioral Risk Factor Surveillance System. In addition to demographic and socioeconomic factors, women self-reported experiences with racial-ethnic discrimination and perception of neighborhood disorder (i.e., crime safety, traffic safety, and aesthetics/physical disorder). Survey-, and inverse probability of censoring-weighted regression models of each chronic disease risk factor were used to investigate associations involving racial-ethnic discrimination and neighborhood disorder, controlling for potential confounders. Perceiving racial-ethnic discrimination and greater neighborhood disorder were associated with a greater tobacco smoking prevalence. Experiences of racial-ethnic discrimination were associated with greater alcohol consumption among African American and Latino women, but not White women. Similarly, African American women reporting experiences with racial-ethnic discrimination report engaging in physical activity about half as much time as women reporting no racial-ethnic discrimination. Increases in perceived neighborhood disorder were associated with increases in alcohol consumption. All associations with social environmental factors were adjusted for potential confounders and each other. Neighborhood disorder and racial-ethnic discrimination may be important, independent contributors to chronic disease risk through relationships with tobacco smoking, alcohol consumption, and physical activity.

Age, period, and cohort effects in adult lifetime asthma prevalence in California: an application of hierarchical age-period-cohort analysis

PurposeUsing 27 years of survey data, the contributions of age, period, and cohort effects on the increase in adult lifetime asthma prevalence in California were examined. MethodsLifetime asthma diagnosis for adults was assessed in 1984–1992 and 1995–2011 through the California Behavioral Risk Factor Surveillance System, an annual, cross-sectional, population-based survey (n = 144,100). Using date of survey and date of birth, we classified 18,305 adult respondents with lifetime asthma into 7 age groups, 6 periods, and 17 cohorts. Using hierarchical, cross-classified random effects models, birth cohort, period, and age patterns in adult lifetime asthma prevalence were analyzed. ResultsAfter adjusting for sex, ethnicity, education, and smoking, age effects peak in young adulthood, flatten from 40 to 60 years old, and then decrease in older adulthood. A significant positive trend in asthma prevalence was observed in the two earliest survey periods (1984–1993; P value < .0001). Survey period trends appear to flatten beginning in 2004. Although the overall birth cohort effect was statistically significant, the magnitude of the effect for each birth cohort category was small (P value = .0005). ConclusionsWe observed that strong age and period effects have been driving the increase in lifetime asthma prevalence in California over the past 3 decades.

Prevalence of medical marijuana use in California, 2012.

The US Drug Enforcement Agency classifies marijuana as an illegal substance, yet in 22 states marijuana is legal for medicinal use. In 1996, California legalised the use of marijuana for medicinal purposes, but population-based data describing medical marijuana users in the state has not been available. Our aim was to examine the demographic differences between users and non-users of medical marijuana in California utilising population-based data. We used data from the California Behavioral Risk Factor Surveillance System 2012, an annual, random-digit-dial state-wide telephone survey that collects health data from a representative adult sample (n = 7525). Age-adjusted prevalence rates were estimated. Five percent of adults in California reported ever using medical marijuana, and most users believed that medical marijuana helped alleviate symptoms or treat a serious medical condition. Prevalence was similar when compared by gender, education and region. Prevalence of ever using medical marijuana was highest among white adults and younger adults ages 18-24 years, although use was reported by every racial/ethnic and age group examined in our study and ranged from 2% to 9%. Our study's results lend support to the idea that medical marijuana is used equally by many groups of people and is not exclusively used by any one specific group. As more states approve marijuana use for medical purposes, it is important to track medical marijuana use as a health-related behaviour and risk factor.

Chronic disease burden among cancer survivors in the California Behavioral Risk Factor Surveillance System, 2009–2010

The California Behavioral Risk Factor Surveillance System estimates that 56.6 % of cancer survivors report ever being diagnosed with a chronic disease. Few studies have assessed potential variability in comorbidity by cancer type. We used data collected from a representative sample of adult participants in the 2009 and 2010 California Behavioral Risk Factor Surveillance System (n = 18,807). Chronic diseases were examined with cancer survivorship in case/non-case and case/case analyses. Prevalence ratios (PR) and corresponding 95 % confidence intervals (95 % CI) were estimated using Cox proportional hazards models, with adjustment on race, sex, age, education, smoking, and drinking. Obesity was associated with gynecological cancers (PR 1.74; 95 % CI 1.26-2.41), and being overweight was associated with gynecological (PR 1.40; 95 % CI 1.05-1.86) and urinary (PR 2.19; 95 % CI 1.21-3.95) cancers. Arthritis was associated with infection-related (PR 1.78; 95 % CI 1.12-2.83) and hormone-related (PR 1.20; 95 % CI 1.01-1.42) cancers. Asthma was associated with infection- (PR 2.26; 95 % CI 1.49-3.43), hormone- (PR 1.46; 95 % CI 1.21-1.77), and tobacco- (PR 1.86; 95 % CI 1.25-2.77) related cancers. Chronic obstructive pulmonary disease (COPD) was associated with infection- (PR 2.16; 95 % CI 1.22-3.83) and tobacco-related (PR 2.24; 95 % CI 1.37-3.66) cancers and with gynecological cancers (PR 1.60; 95 % 1.00-2.56). This is the first study to examine chronic disease burden among cancer survivors in California. Our findings suggest that the chronic disease burden varies by cancer etiology. A clear need has emerged for future biological and epidemiological studies of the interaction between chronic disease and cancer etiology in survivors.

Role of the Gender-Linked Norm of Toughness in the Decision to Engage in Treatment for Depression

Given their prevalence and persuasive power in our culture, gender norms--commonly described as socially reinforced, learned expectations of what it means to be a man or a woman--likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment ("wait-and-see" approach). Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions. Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=-.70, p<.01). Men's greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.03). Men's greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women's treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services.

Role of the Gender-Linked Norm of Toughness in the Decision to Engage in Treatment for Depression

Given their prevalence and persuasive power in our culture, gender norms--commonly described as socially reinforced, learned expectations of what it means to be a man or a woman--likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment ("wait-and-see" approach).Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions.Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=-.70, p<.01). Men's greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.03).Men's greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women's treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services.

Poverty, Sprawl, and Restaurant Types Influence Body Mass Index of Residents in California Counties

This article examines the relationships between structural poverty (the proportion of people in a county living at < or =130% of the federal poverty level [FPL]), urban sprawl, and three types of restaurants (grouped as fast food, chain full service, and independent full service) in explaining body mass index (BMI) of individuals. Relationships were tested with two-tiered hierarchical models. Individual-level data, including the outcome variable of calculated BMI, were from the 2005, 2006, and 2007 California Behavioral Risk Factor Surveillance Survey (n = 14,205). County-level data (n = 33) were compiled from three sources. The 2000 U.S. Census provided the proportion of county residents living at < or = 130% of FPL and county demographic descriptors. The sprawl index used came from the Smart Growth America Project. Fast-food, full-service chain, and full-service independently owned restaurants as proportions of the total retail food environment were constructed from a commercially available market research database from 2004. In the analysis, county-level demographic characteristics lost significance and poverty had a consistent, robust association on BMI (p < 0.001). Sprawl demonstrated an additional, complementary association to county poverty (p < 0.001). Independent restaurants had a large, negative association to BMI (p < 0.001). The coefficients for chain and fast-food restaurants were large and positive (p < or = 0.001), indicating that as the proportion of these restaurants in a county increases, so does BMI. This study demonstrates the important role of county poverty and urban sprawl toward understanding environmental influences on BMI. Using three categories of restaurants demonstrates different associations of full-service chain and independent restaurants, which are often combined in other research.