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This study examines associations between self-reported drinking and driving or being a passenger of a drinking driver and risk and protective factors in a general population of adolescents.We used a two-staged sampling procedure to survey 2,955 students in Washington State public schools in Grades 9-12. Students were asked if they were a passenger of, or had been, a drinking driver in the previous month. They were also asked about individual, parent, school and community risk and protective factors. Comparisons were made using hierarchical polychotomous logistic regression, entering age and gender and parent, school and community protective factors at the first step and individual risk factors at the second step.Driving after drinking in the previous month was reported by 12.1% of respondents and riding with a drinking driver was reported by an additional 17.6% of respondents. At the first step, driving after drinking was more likely and riding with a drinking driver was less likely among youth who were age 16 or older, and male students were more likely than female students to report driving after drinking. Parent, school and community support were each significantly associated with less driving after drinking, and school support was significantly associated with less riding with drinking drivers. At the second step, higher quantity and frequency of drinking, more smoking cigarettes and drug use and less seat belt use were each associated with both drinking and driving and riding with drinking drivers. Gun carrying was also associated with driving after drinking.Drinking and driving behaviors were associated with risk and protective factors in the community, school, family and individual. Pilot prevention programs should test the effectiveness of reducing drinking and driving involvement by addressing such factors.

Background There is growing evidence for associations between generations in family violence and between family violence in both childhood and adulthood and women’s health. Most studies focus on a subset of family violence (child abuse, witnessing intimate partner violence [IPV] as a child, and/or adult IPV), and few examine possible differences associated with the nature of abusive experiences, such as physical versus sexual abuse. Methods A population-based telephone survey, the 1999 and 2001 Washington State Behavioral Risk Factor Surveillance System, asked a representative sample of 3527 English-speaking, non-institutionalized adult women whether they had been physically or sexually assaulted or witnessed interparental violence in childhood, and whether they had experienced physical assault or emotional abuse from an intimate partner in the past year. The survey also asked about current general health and mental distress in the past month. Results The risks associated with childhood family violence experiences varied depending on the nature of those experiences. Women reporting childhood physical abuse or witnessing interparental violence were at a four- to six-fold increase in risk of physical IPV, and women reporting any of the experiences measured were at three- to four-fold increase in risk of partner emotional abuse. In contrast, women reporting childhood sexual abuse only were not at increased risk of physical IPV. Women reporting childhood physical abuse were at increased risk of poor physical health, and women reporting any type of childhood family violence were at increased risk of frequent mental distress. Approximately one third of women reporting poor general health and half of women reporting frequent mental distress also reported at least one of the childhood experiences measured. Conclusions These findings underscore the role of childhood experiences of abuse and of witnessing family violence in women’s current risk for IPV, poor physical health, and frequent mental distress.

Residential clusters of non-communicable diseases are a source of enduring public concern, and at times, controversy. Many clusters reported to public health agencies by concerned citizens are accompanied by expectations that investigations will uncover a cause of disease. While goals, methods and conclusions of cluster studies are debated in the scientific literature and popular press, investigations of reported residential clusters rarely provide definitive answers about disease etiology. Further, it is inherently difficult to study a cluster for diseases with complex etiology and long latency (e.g., most cancers). Regardless, cluster investigations remain an important function of local, state and federal public health agencies. Challenges limiting the ability of cluster investigations to uncover causes for disease include the need to consider long latency, low statistical power of most analyses, uncertain definitions of cluster boundaries and population of interest, and in- and out-migration. A multi-disciplinary Workshop was held to discuss innovative and/or under-explored approaches to investigate cancer clusters. Several potentially fruitful paths forward are described, including modern methods of reconstructing residential history, improved approaches to analyzing spatial data, improved utilization of electronic data sources, advances using biomarkers of carcinogenesis, novel concepts for grouping cases, investigations of infectious etiology of cancer, and “omics” approaches.

Measuring the extent to which individuals meet the 5 A Day dietary recommendation for fruits and vegetables can provide information on the effectiveness of public health efforts to increase consumption of these foods. However, dietary measurement is complicated by the issue of serving size. We compared two methods of measuring fruit and vegetable consumption using a random-digit-dialed telephone survey of 917 Washington state adults. The survey included two sets of questions about fruit and vegetable consumption, one providing and the other not providing standard definitions of serving size. The specific wording of questions had a large effect on the conclusions about levels of fruit and vegetable consumption. Although only 26% of respondents met the 5 A Day recommendations without serving size information, 50% met these recommendations when using a measure that included a definition of serving size.

Introduction Obesity, hypertension, and high cholesterol are risk factors for cardiovascular disease, which accounts for approximately 20% of deaths in Washington State. For most states, self-reports from the Behavioral Risk Factor Surveillance System (BRFSS) provide the primary source of information on these risk factors. The objective of this study was to compare prevalence estimates of self-reported obesity, hypertension, and high cholesterol with examination-based measures of obesity, hypertension, and high-risk lipid profiles. Methods During 2006–2007, the Washington Adult Health Survey (WAHS) included self-reported and examination-based measures of a random sample of 672 Washington State residents aged 25 years or older. We compared WAHS examination-based measures with self-reported measures from WAHS and the 2007 Washington BRFSS (WA-BRFSS). Results The estimated prevalence of obesity from WA-BRFSS (27.1%; 95% confidence interval [CI], 26.3%–27.8%) was lower than estimates derived from WAHS physical measurements (39.2%; 95% CI, 33.6%–45.1%) (P < .001). Prevalence estimates of hypertension based on self-reports from WA-BRFSS (28.1%; 95% CI, 27.4%–28.8%) and WAHS (33.4%; 95% CI, 29.4%–37.7%) were similar to the examination-based estimate (29.4%; 95% CI, 25.8%–33.4%). Prevalence estimates of high cholesterol based on self-reports from WA-BRFSS (38.3%; 95% CI, 37.5%–39.2%) and WAHS (41.8%; 95% CI, 35.8%–48.1%) were similar; both were lower than the examination-based WAHS estimate of high-risk lipid profiles (59.2%; 95% CI, 54.2%–64.2%) (P < .001). Conclusion Self-reported heights and weights underestimate the prevalence of obesity. The prevalence of self-reported high cholesterol is significantly lower than the prevalence of high-risk lipid profiles. Periodic examination-based measurement provides perspective on routinely collected self-reports.

Concern about violent video games has been widely expressed [1–3]. A professor of military science has asserted that some games are “very definitely enabling violence” in a way analogous to training programs used by the military and police agencies [4, p. 315]. Also, violent video games have been suggested as a contributing factor in recent school shootings by adolescent males who played violent games [5]. However, population-level evidence suggests that between 1991 and 1997, there was a linear decrease in adolescent weapon-carrying and physical fighting [6], and this downward trend continued in 1999 [7]. Also, between 1993 and 1998 (the most recent year available), national homicide rates dropped from 2.5 to 1.5 per 100,000 for 10to 14-year-olds and from 20.5 to 11.7 per 100,000 for 15to 19-year-olds. During this period, video games were ubiquitous, and most games contained violence [8,9], calling into question the notion that video games have a largescale harmful effect on youth violence. We reviewed the scientific literature to determine whether the evidence supports a public health concern that violent video games contribute to real-life aggression. Youth violence and delinquency have been consistently associated with family factors such as child abuse and neglect, parental rejection of the child, and parental criminality and alcoholism [10]. Individual factors such as poor performance in school and on standardized tests, truancy, gang membership, and attention–deficit-hyperactivity and conduct disorders are also consistent predictors of youth violence and delinquency, although these factors may be early manifestations or “markers” rather than causes of later problem behavior. Violent video games may be considered in the context of war play and other forms of aggressive play by youth. Societal attitudes toward aggressive play differ among adults [11]. Aggressive play differs from real aggression by the fact that it does not include an attempt to injure someone. Although opponents of aggressive play argue that such play fosters real-life violence, proponents argue that it is a natural, even inevitable, aspect of boys’ play and provides an opportunity to try to come to terms with war, violence, and death [11]. Several psychological theories are relevant to the possible role of video game violence in youth aggression. J. L. Sherry [personal communication, October 25, 1999] identified six theories used to predict either increased or decreased aggression after violent video game play. First, social learning theory [12,13] suggests that at least some aggression is learned by observing, and then by imitating, a model who acts aggressively. Aggressive video game characters might serve as models for aggressive behavior. Further, rewards such as higher points and longer playing times within the game and increased status From the Office of Epidemiology, Washington State Department of Health, Olympia, Washington. Address correspondence and reprint requests to: Lillian Bensley, Ph.D., Non-Infectious Conditions Epidemiology, Washington State Department of Health, P.O. Box 47812, Olympia, Washington 98504-7812. E-mail: Lillian.Bensley@doh.wa.gov. Manuscript accepted March 1, 2001. JOURNAL OF ADOLESCENT HEALTH 2001;29:244–257

CONTEXT: Although studies of clinical samples have identified links between childhood abuse, especially sexual abuse, and adult health-risk behaviors, the generalizability of these findings to the population and the relative importance of different types of abuse in men and women are not known. OBJECTIVE: To estimate the risk of self-reported adult HIV-risk behaviors and heavy drinking that is associated with self-reported childhood histories of physical and/or sexual abuse for men and women in a general-population sample, after controlling for age and education. A second objective is to determine whether, among women, early and chronic sexual abuse is associated with heightened risk compared to later or less extensive abuse. DESIGN: A population-based telephone survey, the 1997 Washington State Behavioral Risk Factor Surveillance System (BRFSS), asked a representative sample of adults whether they had ever been physically or sexually abused in childhood, and if so, the age at first occurrence and number of occurrences. The survey also asked about levels of alcohol use and, for those under 50 years, about HIV-risk behaviors. PARTICIPANTS: Three thousand four hundred seventy-three English-speaking non-institutionalized civilian adults in Washington State. MAIN OUTCOME MEASURES: Self-reported HIV-risk behaviors in the past year and heavy drinking in the past month. RESULTS: We identified associations between reported abuse history and each health-risk behavior that we examined. For women, early and chronic sexual abuse (occurring without nonsexual physical abuse) was associated with more than a 7-fold increase in HIV-risk behaviors (odds ratio O., 7.4; 95% confidence intervals C. 2.4 to 23.5); and any sexual abuse, combined with physical abuse, was associated with a 5-fold increase in these risk behaviors (OR, 5.0; 95% CI, 2.2 to 11.5). For women, only combined sexual and physical abuse was associated with heavy drinking (OR, 6.2; 95% CI, 2.2 to 16.9). Physical abuse alone was not associated with either health-risk behavior for women. For men, any sexual abuse was associated with an 8-fold increase in HIV-risk behaviors (OR, 7.9; 95% CI, 1.8 to 35.1). Physical abuse alone was associated with a 3-fold increase in risk of HIV-risk behaviors (OR, 3.2; 95% CI, 1.3 to 7.9) and a similar increase in risk of heavy drinking (OR, 3.2; 95% CI, 1.8 to 5.5). Although only 29% of the women and 19% of the men who were asked about HIV-risk behaviors reported any history of childhood abuse, these accounted for 51% and 50% of those reporting HIV-risk behaviors, respectively. For heavy drinking the corresponding figures were 25% of the women and 23% of the men reporting any abuse, who accounted for 45% and 33% of those reporting heavy drinking, respectively. CONCLUSIONS: Efforts to prevent or remediate adult health-risk behaviors should consider the possibility of a history of childhood abuse, as one third to one half of those reporting HIV-risk behaviors or heavy drinking in a general-population survey also reported childhood abuse. Language: en

Purpose: We examined the associations of self-reported abuse and sexual molestation with self-reported alcohol and drug use in a general population of adolescents. Methods: We used a stratified cluster sampling procedure with replacement to sample 4790 students in Washington State public schools in Grades 8, 10, and 12. Students were asked whether they had ever been abused by an adult and whether they had ever been sexually molested. They were also asked about their levels of alcohol and drug use and about early initiation of substance use. We conducted polytomous logistic regressions, controlling for gender and grade, using Software for the Statistical Analysis of Correlated Data (SUDAAN). Results: We identified associations between reported abuse history and alcohol and drug use in adolescence and early initiation of substance use. The associations between reported abuse history and alcohol use were stronger at younger ages. The strongest association was between combined abuse and molestation, and relatively severe (heavy) drinking by eighth graders (odds ratio, 7.9; 95% confidence interval, 2.6–17.4). For drug use, the associations with reported abuse history were slightly stronger at higher levels of severity and for combined abuse and molestation compared to nonsexual abuse. For early initiation, the associations with abuse history were stronger for combined abuse and molestation than for nonsexual abuse or molestation alone, and stronger for marijuana use/regular drinking than for alcohol/cigarette experimentation. For example, adjusted odds ratios and 95% confidence intervals (in parentheses) for combined abuse and molestation were 3.5 (2.8–4.5) for alcohol/cigarette experimentation and 12.2 (6.3–23.6) for marijuana use/regular drinking by age 10. For abuse alone, these figures were 2.5 (2.0–3.1) and 4.7 (3.0–7.3), respectively. Conclusion: Efforts to reduce substance use and abuse in adolescence, particularly heavy use and use early in adolescence, should consider the possible role of a history of maltreatment.

Purpose: To examine the associations of self-reported abuse and sexual molestation with self-reported antisocial behavior and suicidal ideation/behavior in a general population of adolescents. Methods: We used a stratified cluster sampling procedure with replacement to sample 4790 students in Washington State public schools in Grades 8, 10, and 12. Students were asked in a self-administered questionnaire whether they had ever been abused by an adult and whether they had ever been sexually molested. They were also asked about antisocial behavior and suicidal ideation and behavior in the past year. We conducted polytomous logistic regressions, controlling for gender and grade, using Software for the Statistical Analysis of Correlated Data (SUDAAN). Results: Reported abuse history was associated with antisocial behavior and with suicidal ideation and behavior. The associations were stronger for abuse and molestation than for nonsexual abuse or molestation alone, and stronger at higher levels of severity (e.g., suicide attempts vs. suicidal thoughts). For example, adjusted odds ratios and 95% confidence intervals (in parentheses) for abuse and molestation were 4.4 (3.1–6.2) for suicidal thoughts, 6.8 (4.4–10.4) for suicide plan, 12.0 (7.9–18.4) for noninjurious suicide attempt, and 47.1 (23.3–95.3) for injurious suicide attempt. For abuse alone, these figures were 2.3 (1.7–3.2), 3.1 (2.1–4.6), 5.1 (3.3–7.8), and 11.8 (4.4–31.9), respectively. Conclusions: Efforts to reduce antisocial behavior and suicidal ideation/behavior in adolescence, particularly early or severe manifestations of the behaviors, should consider the possible role of a history of maltreatment, especially the possibility of sexual abuse.