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OBJECTIVES: We assessed self-reported frequency of purchase of medications and medical care services in Mexico by southern New Mexico (United States, [U.S.]) residents in relation to their medical insurance coverage. METHODS: We analyzed data obtained in 1998 and 1999 from a health interview survey of residents in a six-county region of southern New Mexico, using prevalence and logistic regression methods for complex survey data. RESULTS: About 22% of southern New Mexico residents had purchased medications and 11% had sought medical care in Mexico at least once during the year preceding the survey. When we adjusted for the effects of other variables, persons able to pay for services out of pocket and those who were uninsured were more likely than persons who were fully covered to purchase medications or medical care in Mexico. CONCLUSIONS: Large numbers of people residing near the border in New Mexico traveled south to Mexico to purchase medications and medical care. Lack of medical insurance was associated with higher frequencies of these purchases. There seems to be a need to establish relationships between U.S. private and public care plans and Mexican medical care providers to identify appropriate mechanisms for U.S. residents to purchase medical care in Mexico.

OBJECTIVES: We assessed self-reported frequency of purchase of medications and medical care services in Mexico by southern New Mexico (United States, [U.S.]) residents in relation to their medical insurance coverage. METHODS: We analyzed data obtained in 1998 and 1999 from a health interview survey of residents in a six-county region of southern New Mexico, using prevalence and logistic regression methods for complex survey data. RESULTS: About 22% of southern New Mexico residents had purchased medications and 11% had sought medical care in Mexico at least once during the year preceding the survey. When we adjusted for the effects of other variables, persons able to pay for services out of pocket and those who were uninsured were more likely than persons who were fully covered to purchase medications or medical care in Mexico. CONCLUSIONS: Large numbers of people residing near the border in New Mexico traveled south to Mexico to purchase medications and medical care. Lack of medical insurance was associated with higher frequencies of these purchases. There seems to be a need to establish relationships between U.S. private and public care plans and Mexican medical care providers to identify appropriate mechanisms for U.S. residents to purchase medical care in Mexico.OBJETIVOS: Evaluamos la frecuencia con que habitantes del sur del estado de Nuevo México, Estados Unidos, autoinformaron de la frecuencia con que compraban medicamentos y servicios médicos en México y examinamos dicha frecuencia a la luz de su cobertura con un seguro médico. MÉTODOS: Analizamos los datos obtenidos en 1998 y 1999 mediante una entrevista de salud de residentes de una región de seis condados en Nuevo México, usando métodos de prevalencia y regresión logística para datos de encuesta complejos. RESULTADOS: Cerca de 22% de los residentes de la parte sur del estado de Nuevo México habían comprado medicinas y 11% habían buscado atención médica en México por lo menos una vez en el transcurso del año que precedió a la encuesta. Cuando se hicieron ajustes en función de los efectos de otras variables, las personas que podían pagar los servicios de su propio bolsillo y las que no tenían seguro eran más propensas a comprar medicinas o atención médica en México que las que tenían cobertura médica completa. CONCLUSIONES: Muchas personas que habitan cerca de la frontera en el estado de Nuevo México viajaban hacia el sur hasta México para comprar medicinas y atención médica. La falta de seguro médico estuvo asociada con una compra más frecuente de ambas cosas. Parece haber una necesidad de establecer relaciones entre los planes de seguro médico estadounidenses privados y públicos y los proveedores de servicios médicos mexicanos con el fin de identificar mecanismos apropiados para que los residentes de Estados Unidos puedan comprar atención médica en México.

This study used an ecologic design based on data from 1990 to 1994 gathered from forensic, vital statistic, census, law enforcement and liquor licensing agencies to assess the relationship between liquor outlet density and alcohol-related health outcomes in New Mexico. Linear regression models show that suicide, alcohol-related crash, and alcohol-related crash fatality (adjusted for age, sex, and minority status) are significantly associated with liquor outlet density. Data also show that, compared with the first tertile, suicide and alcohol-related crash rates increase about 50% and the alcohol-related crash fatality rate two-fold with the third tertile of liquor outlet density. Greater availability of liquor outlets is associated with higher rates of suicide, alcohol-related crash, and alcohol-related crash fatality.

Background: We sought to assess prevalence of behavioral risk factors and evaluate the usefulness of survey data gathered by telephone in the New Mexico border region. Methods: This study compared behavioral risk factor data gathered from two probability sample surveys administered in 1998–1999, one by means of a telephone interview and the second face to face. Prevalence estimates for medical care access, injury, and chronic disease risk factors were compared by survey mode, overall, and stratified by income level. Results: Risk factor prevalence estimates based on telephone interviews resemble estimates obtained from face-to-face interviews. Although risk factor prevalence estimated from face-to-face interviews were in general slightly greater than those from telephone interviews, none of these differences reached statistical significance. When data for each respective survey were examined by income level, prevalence estimates for comparable income groups in both surveys were in general agreement and estimates within survey increased with declining income. Conclusion: In the New Mexico border region, telephone survey data appear to be reasonably valid and offer opportunities for population-based health research.

Objective: Data on the health impact of breast and cervical cancer screening programs for low-income women are limited. We sought to determine whether a statewide program to provide breast and cervical cancer screening services influenced trends in disease incidence and stage. Methods: We assessed trend data regarding breast and cervical cancer incidence and stage gathered by the New Mexico Tumor Registry and the Surveillance, Epidemiology, and End Results Program before (1975 through 1990) and during (1991 through 1998) implementation of the New Mexico Breast and Cervical Cancer Screening Program. Results: The incidence of cervical carcinoma in-situ increased rapidly in 1991. The incidence per 100,000 population for in-situ breast cancer (2.9 in 1975–1982, 8.5 in 1983–1990, and 16.8 in 1991–1998) and local breast cancer (39.9 in 1975–1982, 46.5 in 1983–1990, and 61.3 in 1991–1998) also increased during the program operation. Notably, a significant increase in incidence per 100,000 population for regional and distant breast cancer from 1975–1982 (31.5) to 1983–1990 (36.0) declined during the 1991–1998 (33.2) period of program operation. Conclusions: The statewide screening program improved detection of breast and cervical cancer and helped reduce the incidence of advanced stages of breast cancer in a relatively short time period.

The authors explored two methodological issues in the estimation of smoking-attributable mortality for the United States. First, age-specific and age-adjusted relative risk, attributable fraction, and smoking-attributable mortality estimates obtained using data from the American Cancer Society's second Cancer Prevention Study (CPS II), a cohort study of 1.2 million participants (1982-1988), were compared with those obtained using a combination of data from the National Mortality Follow-back Survey (NMFS), a representative sample of US decedents in which information was collected from informants (1986), and the National Health Interview Survey (NHIS), a nationally representative household survey (1987). Second, the potential for residual confounding of the disease-specific age-adjusted smoking-attributable mortality estimates was addressed with a model-based approach. The estimated smoking-attributable mortality based on the CPS II for the four most common smoking-related diseases-lung cancer, chronic obstructive pulmonary disease, coronary heart disease, and cerebrovascular disease-was 19% larger than the estimated smoking-attributable mortality based on the NMFS/NHIS, yet the two data sources yielded essentially the same smoking-attributable mortality estimate for lung cancer alone. Further adjustment of smoking-attributable mortality for disease-appropriate confounding factors (education, alcohol intake, hypertension status, and diabetes status) indicated little residual confounding once age was taken into account.

Tuberculosis (TB) and its co-morbid conditions have become a burden on global health economies. It is well understood that susceptibility of the host to TB infection/disease is influenced by both genetic and environmental factors and their interactions. The aims of this pilot case-control study are to characterize the sociodemographic and environmental factors related to active TB disease (TB/case) and latent TB infection (LTBI/control) status, and to identify risk factors associated with progression from LTBI to TB. We recruited 75 cases with TB (mean age=46.3y; females=41%) and 75 controls with LTBI (mean age=39.0y; females=37%), from the Mestizo population of Cuidad Juarez, Mexico. In addition to the determination of case/control status, information on environmental variables was collected (e.g., socioeconomic status, smoking, alcohol consumption, substance abuse, nutritional status, household demographics, medical histories and presence of type 2 diabetes [T2DM]). The data were analyzed to identify the environmental correlates of TB and LTBI using univariate and multivariate statistical approaches. Following multivariate logistic regression analysis, TB was associated with poor nutrition, T2DM, family history of TB, and non-Chihuahua state of birth. These preliminary findings have relevance to TB control at the Mexico-United States border, and contribute to our future genetic study of TB in Mexicans.

Retrospective examination of a national probability sample revealed that young women, particularly those who dropped out of high school, have reached smoking rates as high or higher than subgroups of young men. These results suggest that surveillance, research, and public health programs are needed to address the rapid increase in smoking among young women.

We assessed risk factors for sudden coronary death among persons without a history of coronary heart disease (unexpected sudden coronary death) and persons with a history of coronary heart disease (sudden coronary heart disease death). We analyzed national data to calculate death rates and odds ratios for both types of sudden coronary death. Among modifiable factors that we examined, only cigarette smoking increased risk for unexpected sudden coronary death [odds ratio (OR) = 1.8; 95% confidence interval (CI) = 1.2-2.7]. Diabetes mellitus (OR = 3.8; 95% CI = 2.5-5.8 for women), cigarette smoking (OR = 1.5; 95% CI = 1.0-2.1), and hypertension (OR = 1.4; 95% CI = 1.1-1.9) increased the risk for sudden coronary heart disease death. Etiologic factors for sudden death appear to differ depending on the presence or absence of coronary disease. With preexisting coronary disease, factors associated with chronic coronary disease may elevate sudden death risk; without coronary disease, factors that provoke ventricular arrhythmias may trigger sudden death.

Introduction Data to assess factors associated with differences in coronary heart disease mortality between Caucasians and African Americans are limited. We assessed risks for sudden, nonsudden, and other coronary death between Caucasians and African Americans in relation to known risk factors for coronary disease and socioeconomic status. Methods We analyzed data from the 1986 National Mortality Followback Survey, the 1985 National Health Interview Survey, and the U.S. Bureau of the Census. Logistic regression methods were used to create multivariate models to assess the relationship of socioeconomic status and other known modifiable risk factors to death from each of the three coronary diseases for Caucasians and African Americans separately. Results In an age- and gender-adjusted analysis of data on men 25-44 years old and women 25-54 years old, African Americans had about twice the risk for sudden, nonsudden, or other coronary death as did Caucasians. Adjusted risks for coronary death for Caucasians associated with modifiable risk factors (cigarette smoking, body weight, diabetes, and hypertension) either resembled or were slightly greater than those for African Americans. Half or more of all excess risks for African Americans in multivariate models could be explained by socioeconomic status. About 18% of excess sudden coronary death risk could be further explained by known modifiable coronary heart disease risk factors. Conclusions Broad public health efforts are needed to address these causes of excess mortality.

Physical activity is inversely associated with depressive symptoms, and cigarette smoking is positively associated with depressive symptoms. Data from the first National Health and Nutrition Examination Survey (NHANES I) and the NHANES I Epidemiologic Follow-up study were analyzed to determine whether the relationship between physical activity and self-reported distress (depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale) was different for cigarette smokers and nonsmokers. Logistic regression was used to calculate odds ratios (adjusted for age, race, sex, education, alcohol use, and perceived health status) for depressive symptoms (> or = 16) associated with physical activity and smoking status among 2,054 respondents. At baseline, the odds ratio for depressive symptoms was about 2 times higher for moderately active smokers and nonsmokers, and 3 times higher for low active smokers and nonsmokers, compared with highly active nonsmokers. For 1,132 persons with a low number of depressive symptoms (< 16) at baseline, the incidence of depressive symptoms after 7-9 yr of follow-up was about 2 times higher for low/moderately active smokers and nonsmokers than for highly active nonsmokers. The association between physical activity and the prevalence and incidence of depressive symptoms is not significantly modified by smoking status.

We assessed the relationship between depression and smoking initiation among people of Mexican, Puerto Rican and Cuban ancestry residing in specific geographic areas of the United States. Survey data were examined to calculate incidence of smoking initiation and prevalences and odds ratios for ever smoking by presence of depressed mood, a history of major depression or both conditions. Depressed mood, a history of major depression or both conditions were associated with smoking initiation risks during childhood, adolescence and young adulthood. These findings suggest that the relationship between depressive states and smoking initiation is established early in life. More definitive studies are needed to confirm these findings.

Objective. This study examined the relationships between anabolic-steroid use and the use of other drugs, sports participation, strength training, and school performance among a nationally representative sample of US high school students. Design. Randomized survey data from the 1991 Centers for Disease Control and Prevention Youth Risk Behavior Survey. Setting. Public and private schools in the 50 United States and District of Columbia. Patients. A total of 12 272 9th through 12th grade students. Main Outcome Measured. Prevalence of anabolicsteroid use. Results. The frequency of anabolic-steroid use was significantly associated with the frequency of use of cocaine, the use of other drugs such as amphetamines and heroin, tobacco smoking, and alcohol use. The weighted prevalences of anabolic-steroid use were higher among male (4.08%) than female students (1.2%). Students living in the South (3.46%) reported higher prevalences than students in the Midwest (3.0%), West (2.02%), or Northeast (1.71%). Students with self-perceived below-average academic performances (5.10%) and students reporting injected drug use also reported higher anabolic-steroid use (51.57%). Based on a multiple logistic regression, the following variables were found to be significant predictors of anabolic-steroid use: injectable drug use (odds ratio [OR], 17.86), use of other drugs (OR, 4.19), male gender (OR, 2.79), alcohol use (OR, 1.38), and strength training (OR, 1.73). The variables that were significantly associated with anabolic-steroid use varied by gender and by region of the country. Conclusion. These data suggest that adolescent anabolic-steroid users in this country are more likely to engage in strength training, injected drug use, and the use of multiple drugs, even after controlling for sports participation and poorer academic performance. These data confirm previous findings of an association between multiple drug use and anabolic-steroid use. Also, engaging in strength-training exercises continued to be associated with anabolic-steroid use after controlling for drug use and other predictors.

Knowledge of the epidemiology of tobacco use and dependence can be used to guide research initiatives, intervention programs, and policy decisions. Both the reduction in the prevalence of smoking among US adults and black adolescents and the decline in per capita consumption are encouraging. These changes have probably been influenced by factors operating at the individual (e.g., school-based prevention programs and cessation programs) and environmental (e.g., mass media educational strategies, the presence of smoke-free laws and policies, and the price of tobacco products) levels (for a discussion of these factors, see, e.g., refs. 2, 48, 52, 183, and 184). The lack of progress among adolescents, especially whites and males, and the high risk for experimenters of developing tobacco dependence present cause for great concern (48, 183-186). In addition to those discussed above, several areas of research can be recommended. 1. Better understanding of the clustering of tobacco use with the use of other drugs, other risk behaviors, and other psychiatric disorders could better illuminate the causal processes involved, as well as the special features of the interventions needed to prevent and treat tobacco dependence. 2. To better understand population needs, trend analyses of prevalence, initiation, and cessation should, whenever possible, incorporate standardized measures of these other risk factors. Future research should compare the effect of socioeconomic status variables on measures of smoking behavior among racial/ethnic groups in the United States. 3. For reasons that may be genetic, environmental, or both, some persons do not progress beyond initial experimentation with tobacco use (2, 48, 183, 187-192), but about one-third to one-half of those who experiment with cigarettes become regular users (48, 193, 194). Factors, both individual and environmental, that can influence the susceptibility of individuals to tobacco dependence need further attention. 4. To estimate their sensitivity and specificity, comparisons of the National Household Survey on Drug Abuse indicators of dependence with DSM-based criteria are needed. Public health action continues to be warranted to reduce the substantial morbidity and mortality caused by tobacco use (195). A paradigm for such action has been recommended and involves preventing the onset of use, treating tobacco dependence, protecting non-smokers from exposure to secondhand smoke, promoting nonsmoking messages while limiting the effect of tobacco advertising and promotion on young people, increasing the real (inflation-adjusted) price of tobacco products, and regulating tobacco products (186).

After almost two decades of decline, cigarette smoking is on the rise among adolescents in the United States. Although in recent years both AfricanAmerican and white adolescents have experienced increases in cigarette smoking, the prevalence of smoking among African-American adolescents has been consistently lower than that of whites (DPrevious studies (2,3) have not been able to explain why the race differential in adolescent cigarette smoking occurs. However, these studies have been crosssectional in nature and primarily examined only the contribution of sociodemographic and behavioral factors. In response, a prospective cohort study was conducted among AfricanAmerican and white adolescents who participated in both the first (1989) and the second (1993) waves of the Teenage Attitudes and Practices Survey (TAPS). The purpose of this study was to determine whether the race differential in the incidence of cigarette smoking is attributed to differences in sociodemographic, environmental, personal, or behavioral factors. TAPS was designed to provide national household-based smoking data on teenagers who were 11-18 years of age. The first TAPS (TAPS I) was conducted in 1989. The primary method of data collection was computer-assisted telephone interviewing. Teenagers who were not available by telephone were sent a mailed questionnaire. The eligible population included 12 097 adolescents. Of that number, 9965 interviews were completed either by telephone or by mail, with a resulting survey response rate of 82% (4,5). For TAPS II, interviews were conducted in 1993. Of the 9965 TAPS I respondents, 9135 were eligible (those completing a telephone interview) and 7960 (87%) teenagers participated in TAPS II (6). Given the 7960 participants, analyses were restricted to African-American and white adolescents (ages 11-17 years) who had never tried cigarettes at base line (n = 3531). Forty-seven (1.3%) respondents were excluded because of missing data on at least one study variable. Thus, the final study population consisted of 3484 adolescents for whom information was complete. Race was the exposure variable, and smoking status was the outcome variable. Based on two questions concerning main racial background and Hispanic origin, respondents described themselves as either non-Hispanic AfricanAmerican or non-Hispanic white. With respect to smoking status, respondents were asked the following questions: 1) Have you ever smoked a cigarette? 2) Have you ever tried or experimented with cigarette smoking, even a few puffs? Those who answered "no" to both questions were considered never smokers. Those who answered "yes" to either question were considered trial smokers. Control variables were categorized as sociodemographic (sex, age, and parental education), environmental (household smoking and number of same-sex friends who smoke), personal (five items on perceived benefits of smoking), or behavioral (intention to smoke, organized physical activity, and school performance). Weighted percentages were used to estimate the cumulative incidence of trial smoking for each population subgroup. Then, logistic regression analysis (7) was used to estimate the odds ratio (OR) of trial smoking for whites (compared with African-Americans) before and after adjustment for confounding factors. Logistic regression-model estimates were calculated with the use of SUDAAN, a procedure for analyzing complex sample survey data (8). After 4 years of follow-up, 30.0% of African-American adolescents became trial smokers compared with 43.1% of whites. The crude OR was 1.6 (95% confidence interval [CI] = 1.3-2.0). In Table 1, the crude OR was adjusted for multiple confounding factors. The adjusted OR of 1.8 (95% CI = 1.5-2.3) was virtually the same as the crude OR. Other predictors of trial smoking included household smoking, the number of same-sex friends who smoke, intention to smoke, and school performance. These data suggest that selected sociodemographic, environmental, personal, and behavioral factors do not account for the race differential in the incidence of adolescent cigarette smoking. The present findings are consistent with those of previous studies (2,3). One limitation of this analysis is a possible differential misclassification. African-American adolescents may be more likely to underreport their smoking habits than white adolescents (9,10), resulting in an overestimation of effect. Differential misclassification, however, is not likely to explain the race-smoking association. Investigators (9) have found that the race differential in adolescent smoking persists, even when biochemical measures of cigarette smoking are used. These findings underscore the need for more research on contributors to the race differential in teen smoking. African-American adolescents may be less likely to smoke than whites because of stronger actions against teen smoking by African-American parents (11-13), the belief among African-Americans that tobacco products are being marketed specifically to them (75), or a lower likelihood among African

We sought to assess trends in prostate cancer incidence, treatment and mortality in African American men by means of analysis of prostate cancer data from three states, Connecticut, Iowa and New Mexico, all participants in the Surveillance, Epidemiology, and End Results (SEER) Program. Compared with levels before prostate specific antigen (PSA) testing, prostate cancer incidence increased in all three states after widespread testing. For men diagnosed with localized or regional prostate cancer, the respective increases in radical prostatectomy in Connecticut, Iowa, and New Mexico were 3.2, 2.3, and 4.9 times pre-test levels. Age-standardized mortality in Connecticut and Iowa increased slightly; in New Mexico the 104.7 deaths per 100,000 in 1979-1986, 62.1 in 1987-1990, dropped to 47.6 in 1991-1998, an amount of decline that was statistically significant. Introduction of PSA testing influenced early detection and treatment of prostate cancer in all three states. Although decline in prostate cancer mortality in New Mexico over time may be linked with use of the PSA test and definitive therapy, the relationship among these factors, and thus the proper treatment for the early stages of this condition, is unclear on the basis of these data.

New Mexico leads the nation in poisoning mortality, which has increased during the 1990s in New Mexico and the United States. Most of this increase has been due to unintentional deaths from illicit drug overdoses. Medical examiner and/or vital statistics data have been used to track poisoning deaths. In this study, the authors linked medical examiner and vital statistics records on underlying cause of death, coded using the International Classification of Diseases, Ninth Revision, to assess the extent to which these data sources agreed with respect to poisoning deaths. The authors used multiple-cause files, which are files with several causes listed for each death, to further assess poisoning deaths involving more than one drug. Using vital statistics or medical examiner records, 94.7% of poisoning deaths were captured by each source alone. For unintentional illicit drug and heroin overdose deaths, each data source alone captured smaller percentages of deaths. Deaths coded as E858.8 (unintentional poisoning due to other drugs) require linkage with medical examiner or multiple-cause records, because this code identifies a significant percentage of illicit drug overdose deaths but obscures the specific drug(s) involved. Surveillance of poisoning death should include the use of medical examiner records and underlying- and multiple-cause vital statistics records.

Data on the health impact of breast and cervical cancer screening programs for low-income women are limited. We sought to determine whether a statewide program to provide breast and cervical cancer screening services influenced trends in disease incidence and stage.We assessed trend data regarding breast and cervical cancer incidence and stage gathered by the New Mexico Tumor Registry and the Surveillance, Epidemiology, and End Results Program before (1975 through 1990) and during (1991 through 1998) implementation of the New Mexico Breast and Cervical Cancer Screening Program.The incidence of cervical carcinoma in-situ increased rapidly in 1991. The incidence per 100,000 population for in-situ breast cancer (2.9 in 1975-1982, 8.5 in 1983-1990, and 16.8 in 1991-1998) and local breast cancer (39.9 in 1975-1982, 46.5 in 1983-1990, and 61.3 in 1991-1998) also increased during the program operation. Notably, a significant increase in incidence per 100,000 population for regional and distant breast cancer from 1975-1982 (31.5) to 1983-1990 (36.0) declined during the 1991-1998 (33.2) period of program operation.The statewide screening program improved detection of breast and cervical cancer and helped reduce the incidence of advanced stages of breast cancer in a relatively short time period.

Objective: To examine whether sociodemographic factors and health risk and problem behaviors explain the prevalence of cigarette smoking among US adolescents. Design: Probability survey. Participants: A nationally representative sample of US adolescents. Main Outcome Measures: Weighted prevalence, adjusted odds ratio (OR), and 95% confidence intervals (CIs) for current smoking status by health risk and problem behaviors. Results: The prevalence of smoking was highest among adolescents who were white, older, and who had a high school education or lived in the Northeast. When we adjusted for sociodemographic factors and health risk and problem behaviors, smoking was associated with marijuana use (OR, 3.7; 95%CI, 2.7-5.1), binge drinking (OR, 2.1; 95% CI, 1.6-2.8), and fighting (OR, 1.4; 95% CI, 1.1-1.7) among white adolescent males. Similar associations between each of these 3 behaviors and cigarette smoking were found among white adolescent females and African American and Hispanic adolescent males and females. Cigarette smoking was also associated with using smokeless tobacco, having multiple sexual partners, and not using bicycle helmets among white adolescent males and females, having multiple sexual partners among Hispanic adolescent females, and carrying weapons among Hispanic adolescent males. Conclusions: Marijuana use, binge drinking, and fighting are correlates of cigarette smoking among US adolescents. These associations, which vary by sex and race or ethnicity, suggest clustering to form a risk behavior syndrome. Arch Pediatr Adolesc Med. 1997;151:66-71

Background The present study was designed to compare risk factor prevalences in coronary heart disease deaths in persons dying within 1 hour of onset of cardiovascular symptoms (sudden coronary death), those dying without such sudden symptoms (nonsudden coronary death), and those with unknown duration of symptoms before death (other coronary death). Methods and Results Data from the 1986 National Mortality Followback Survey and the US Bureau of the Census were examined to assess death rates for sudden, nonsudden, and other coronary deaths. Multivariate logistic regression methods were used to calculate the odds ratio (OR), compared with nonsudden and other coronary deaths, for sudden coronary death associated with socioeconomic status variables, the person’s location at death, and coronary heart disease risk factors. Mortality rates for all coronary deaths increased with age, were higher for men than women, and increased with decreasing years of schooling. The rate of sudden coronary death was highest for Hispanics. In 1986, an estimated 251 000 sudden coronary deaths (95% CI=238 000 to 263 000) occurred in the United States. Sudden coronary deaths were less likely than nonsudden coronary deaths to occur at home (OR=0.5, 95% CI=0.4 to 0.6), but individuals who died of sudden coronary death were more likely to have been current cigarette smokers (OR=1.3, 95% CI=1.0 to 1.8). No other modifiable risk factors for coronary heart disease distinguished sudden coronary deaths from nonsudden coronary deaths. Conclusions Contrary to the commonly held view, coronary deaths in the home are more likely to be nonsudden than sudden. Cigarette smoking more likely results in sudden than nonsudden coronary death, perhaps because of nicotine-induced ventricular arrhythmias.

We assessed rates and trends in safety belt use by presence and type of safety belt law using data from states participating in the 1984-1989 Behavioral Risk Factor Surveillance System. State(s) with a safety belt law allowing law enforcement officers to stop vehicles for occupants' failure to use safety belts (primary enforcement law) had greater and more rapid increases in safety belt use rates than did states with laws requiring that vehicles must first be stopped for some other violation before a citation or fine for occupants' failure to use safety belts could be imposed (secondary enforcement law). Larger and sustained increases in safety belt use occurred when safety belt laws became effective or when fines were imposed for violations than when laws were first enacted. These data suggest that primary enforcement laws result in greater and more rapid increases in safety belt use than do secondary enforcement laws, and that initial increases in safety belt use following implementation of laws are sustained.

Background: Lower rates of invasive cardiac procedures have been reported for blacks and women than for white men. However, few studies have adjusted for differences in the type of hospital of admission, insurance status, and disease severity. Setting, Design, and Participants: Data from the National Hospital Discharge Survey were used to investigate race and sex differences in rates of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery among 10 348 persons hospitalized for acute myocardial infarction. Results: White men consistently had the highest procedure rates, followed by white women, black men, and black women. After matching for the hospital of admission and adjusting for age, in-hospital mortality, health insurance, and hospital transfer rates (with white men as the referent), the odds ratios for cardiac catheterization were 0.67 (95% confidence interval [CI],0.51 to 0.87) for black men, 0.72 (95% CI, 0.63 to 0.83) for white women, and 0.50 (95% CI, 0.37 to 0.68) for black women. Similar race-sex differences were noted for percutaneous transluminal coronary angioplasty and coronary artery bypass surgery. Conclusions: Race and sex differentials in the rates of invasive cardiac procedures remained despite matching for the hospital of admission and controlling for other factors that influence procedure rates, suggesting that the race and sex of the patient influence the use of these procedures. (Arch Intern Med. 1995;155:318-324)

Prevalence and Odds Ratios for Regular and Heavy Smoking, by Physical Activity Variables, 1990 Youth Risk Behavior Survey Physical Activity Variable Regular Smoking Among Ever Smokers Heavy Smoking Among Current Smokers Sample Size Prevalence, % Odds Ratio (95% CI)* Sample Size Prevalence, % Odds Ratio (95% CI)* Physical education None 6143 Referent 1769 38 Referent No activity 1126 24 1.3(0.9-1.7) 325 36 1.2 (0.9-1.6) Activity 3707 0.9 (0.8-1.1) 970 29 0.8 (0.7-1.0) Unknown 85 21 Community programs, d/mo None 7393 23 Referent 2129 37 Referent 2267 18 0.9 (0.7-1.0) 1.0 (0.7-1.3) 1388 15 0.9 (0.7-1.1) 332 25 0.8 (0.5-1.1) Unknown 13 Vigorous activity, d/mo None 2249 24 Referent 624 Referent 1-2 2329 23 0.9 (0.8-1.0) 687 0.9 (0.7-1.1) 3-5 2428 1.0 (0.8-1.1) 694 34 0.7 (0.5-0.9) 6-8 1290 19 0.8 (0.6-1.0) 0.5 (0.4-0.7) 2742 0.8 (0.6-1.0)† 703 29 0.7 (0.5-0.9)† Unknown 23 *Odds ratios are adjusted for age, race/ethnicity, sex, perceived school

Objective. —To examine smoking patterns, smoking initiation, and the relationship of sports participation and age at smoking initiation to regular and heavy smoking among adolescents. Design. —Survey. Participants. —A nationally representative sample of US high school students. Outcome Measures. —Prevalences of smoking patterns, prevalence and incidence of smoking initiation, and prevalences and odds of regular and heavy smoking in relation to sports participation and age at smoking initiation. Results. —Seventy-two percent of students reported experimenting with, formerly, or ever smoking cigarettes, and 32% reported smoking in the past 30 days. Students who had participated in interscholastic sports were less likely to be regular and heavy smokers than were others who had not participated. Smoking initiation rates increased rapidly after age 10 years and peaked at age 13 to 14 years. Students who began smoking at age 12 years or younger were more likely to be regular and heavy smokers than were students who began smoking at older ages. Conclusions. —These data suggest that smoking initiation at a young age can increase the risk of nicotine addiction during adolescence and that sports participation may influence smoking behavior. Interventions to prevent smoking should be available before age 12 years to help combat the smoking epidemic among youth. ( JAMA . 1993;269:1391-1395)

Background.— Although many physicians and laypersons believe that stress plays a role in the occurrence of peptic ulcer disease, the importance of stress in the pathogenesis of peptic ulcers remains controversial. Methods.— To investigate the relationship between perceived stress and peptic ulcer disease we used data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study—a nationally representative cohort study of US adults. This analysis included 4511 persons who had not previously been diagnosed with peptic ulcer disease. Results.— At baseline, 68% of the cohort perceived themselves as stressed. During 13 years of follow-up, 208 persons developed ulcers; the cumulative incidence of ulcers was 7.2% for persons who were stressed and 4.0% for persons who were not. After we adjusted for age, sex, education, smoking status, and regular aspirin use, persons who perceived themselves as stressed were 1.8 times more likely to develop ulcers than those who did not (95% confidence interval, 1.3 to 2.5). We also found a graded relationship between the perceived amount of stress and the incidence of peptic ulcers; relative to nonstressed persons, the relative risk of developing an ulcer was 1.4,1.9,2.3,2.4, and 2.9 at five increasing levels of stress. Conclusions.— These findings suggest that persons who perceive their lives as stressful may be at increased risk for the development of peptic ulcer disease. ( Arch Intern Med. 1992;152:829-833)

Data from previous studies suggest that infertility is a risk factor for endometrial cancer. We used data from the Cancer and Steroid Hormone Study to further characterize this relationship. The subject group comprised 399 women ages 20-54 with newly diagnosed epithelial endometrial cancer ascertained through six cancer registries. The control group comprised 3040 women in the same age range selected by random-digit telephone dialing from the same geographic areas where cancer patients resided. Compared with women who reported no fertility problem, women with physician-diagnosed infertility who had reported at least 2 years of infertility had an odds ratio for endometrial cancer, adjusted for age, of 1.7 (95% confidence interval 1.1-2.6). Women who reported infertility resulting from ovarian factors had an adjusted odds ratio of 4.2 (95% confidence interval 1.7-10.4). These results suggest that factors such as anovulation may explain much of the increased risk of endometrial cancer found among subgroups of infertile women.

In Reply.— We commend Dr Phillips' view that physicians should play an active role in the battle against cigarette smoking. If counseling and education are our greatest weapons against smoking, then physicians must indeed volunteer as foot soldiers in trench warfare. How can physicians be more effective in their efforts? Drs Marks and Fisher 1 recommend that when counseling adolescents about cigarette smoking, physicians should emphasize short-term effects, such as coughing, phlegm production, wheezing, respiratory infections, bad breath, reduced sports performance, and shortness of breath, in addition to discussing long-term effects. Other suggestions include using questionnaires as "icebreakers" 1 ; adopting desirable interviewing techniques that create trust, show concern, avoid judgmental attitudes, and maintain objectivity 2 ; using computer-assisted health education materials 3 ; and developing reminder aids that can be used for follow-up. 4 In particular, special attention should be provided to children and young adolescents with behavioral difficulties or parents who

Data from multiple studies suggest that depression plays a role in cigarette smoking. To obtain a national perspective on the role of depression in the dynamics of smoking, we analyzed data from the first National Health and Nutrition Examination Survey and the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. We used the Center for Epidemiologic Studies Depression Scale to assess symptoms of depression and used the standard cutoff (score, ≥16) for defining persons as depressed. The cross-sectional analysis of the first National Health and Nutrition Examination Survey showed that the prevalence of current smokers increased as the Center for Epidemiologic Studies Depression Scale score increased, whereas the quit ratio (former smokers/ever smokers) decreased as the Center for Epidemiologic Studies Depression Scale score increased. Among the cohort of smokers in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, the estimated incidence of quitting after 9 years of follow-up was 9.9% for depressed smokers and 17.7% for nondepressed smokers. When we adjusted for amount smoked, sex, age, and educational attainment by means of a Cox proportional hazards model, we found that depressed smokers were 40% less likely to have quit compared with nondepressed smokers (relative risk, 0.6). These findings suggest that depression plays an important role in the dynamics of cigarette smoking in the United States. ( JAMA . 1990;264:1541-1545)

Cigarette smoking initiation greatly influences smoking prevalence in the United States. To understand better the initiation of cigarette smoking, we estimated the age-specific incidence of cigarette smoking initiation in relation to race/ethnicity, sex, and educational attainment, using the reported age at smoking onset for 18- to 35-year-old respondents in the 1987 National Health Interview Survey (N = 14 764) and the Hispanic Health and Nutrition Examination Survey (N = 3123) conducted during 1982 to 1984. Among white, black, and Hispanic respondents the incidence of smoking initiation increased rapidly after 11 years of age, reaching a peak in groups 17 to 19 years of age, rapidly declining in groups through age 25 years, and gradually declining thereafter. Age-specific smoking initiation rates were generally lower among black than white respondents, similar between white and Hispanic respondents, and appreciably higher among black and Hispanic men than women. Compared with persons who graduated from high school, persons with less than high school education were consistently more likely to start smoking cigarettes during childhood and adolescence. These data indicate that age and educational attainment are the factors most consistently associated with cigarette smoking initiation among all race/ethnic groups in the United States. These data also emphasize the need for smoking-prevention education beginning at an early age, particularly among persons of low socioeconomic status. ( JAMA . 1990;264:1550-1555)

• Although multiple studies support a causal relationship between smoking and peptic ulcers in men, data for women are limited. Therefore, we used data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, a nationally representative prospective study of US adults, to evaluate the impact of smoking on the incidence of peptic ulcers in women. The study cohort included 2851 women who had not been diagnosed as having a peptic ulcer prior to the baseline interview. Among these women, 140 (4.9%) developed peptic ulcer disease. During 12.5 years of follow-up, the estimated cumulative incidence of ulcers was 10.0% for current smokers, 6.4% for former smokers, and 5.4% for never smokers. After adjusting for age, education, regular aspirin use, coffee consumption, and use of alcohol, current smokers were 1.8 times more likely to develop ulcers than never smokers (95% confidence interval, 1.2 to 2.6); the risk of peptic ulcer increased as the amount smoked increased. During the time of this study, we estimate that approximately 20% of incident peptic ulcer cases among US women were attributable to cigarette smoking. (Arch Intern Med. 1990;150:1437-1441)

To investigate trends in the prevalence of cigarette smoking among different age groups of Mexican-Americans, Cuban-Americans, and Puerto Rican-Americans, the smoking histories of 8,286 adults and adolescents from the 1982-83 Hispanic Health and Nutrition Examination Survey (HHANES) were evaluated. Age-specific prevalence rate curves were constructed by using the estimated smoking rates among 8-, 18-, 28-, 38-, 48-, and 58-year-olds from 1923 to 1983. Age-specific rates were higher for men than for women. However, rates declined over time among all age groups of Mexican-American men, and among Cuban-American and Puerto Rican-American men older than 18 years. In contrast, rates for Mexican-American women did not change appreciably over time, but they increased markedly for 28- and 38-year-old Cuban-American women and most age groups of Puerto Rican-American women. These results suggest that rates of cigarette smoking among Hispanic women are beginning to converge with those of Hispanic men, and that rates of smoking initiation among Cuban-American boys and Puerto Rican-American boys and girls have either remained unchanged or increased markedly over time.

To update a 1977 to 1978 case-fatality estimate for tubal sterilization in U.S. hospitals, we reviewed the medical records of women reported by the Commission on Professional and Hospital Activities to have died after tubal sterilization procedures in 1979 or 1980. We project that the most reasonable case-fatality rate estimate is slightly greater than 9 per 100,000 sterilizations if all deaths associated with the procedure are considered. Rate estimates that assume minimum and maximum numbers of all associated deaths in our sample are approximately 6 per 100,000 and 10 per 100,000 sterilizations, respectively. However, when only deaths that can be attributed to sterilization per se are considered, the most reasonable case-fatality rate is estimated at between 1 and 2 per 100,000 procedures, a lower rate than previously reported. Rate estimates that assume minimum and maximum numbers of attributable deaths in our sample are approximately 1 per 100,000 and 5 per 100,000 sterilizations, respectively. These results further indicate that death attributable to tubal sterilization is rare.The medical records of women reported by the US Commission on Professional and Hospital Activities to have died after tubal sterilization procedures in 1979-80 were reviewed to obtain current case-fatality estimates. The previous estimate, which used data from 1977 and 1978, was 3.6/100,000 procedures. The Commission identified 53 women who had tubal sterilization and who died during hospitalization; however, permission to review medical records was obtained for only 37 of these women. Of these 37 deaths, 28 were associated with sterilization and 9 involved coding errors. Of the 28 sterilization-associated deaths, 17 were attributable to concurrent cesarean section and 7 were attributable to other concurrent procedures. Of the 3 women whose deaths were clearly related to the sterilization procedure, 2 had no underlying illnesses and 1 had severe congenital heart disease (which may have contributed to her death). In the 4th case, the probable cause of death was intracranial hemorrhage caused by pregnancy-induced hypertension. The 28 sterilization-associated deaths occurred among a total population of 433,744 women who received tubal sterilizations in US hospitals in 1979 and 1980. Since 28 of the 37 deaths reviewed were associated with sterilization, it was assumed that 76% of the unreviewed deaths were sterilization-associated. This assumption results in a total number of 40 deaths and a case-fatality rate of 9.2/100,000 procedures. Use of the same procedure suggests a sterilization-attributable case-fatality rate of 1.5/100,000. In view of the small number of deaths involved, the decline in sterilization-attributable deaths from 1977-78 and 1979-80 should not be interpreted as a trend over time. However, these results confirm the belief that death attributable to tubal sterilization is a rare event.

To investigate historical trends of cigarette smoking among Mexican-Americans, Cuban-Americans, and Puerto Rican—Americans, we conducted a birth cohort analysis of smoking prevalence by using smoking histories of 8286 adults and adolescents from the 1982-1983 Hispanic Health and Nutrition Examination Survey. We constructed smoking prevalence curves for men and women among successive ten-year birth cohorts. Birth cohort—specific prevalence rates were higher for men than for women. Rates, however, decreased among successive cohorts of men. Conversely, rates increased among successive cohorts of Cuban-American and Puerto Rican—American women. For example, peak rates among the 1911 through 1920 cohorts were 26% (Cuban-American women) and 25% (Puerto Rican—American women) compared with peak rates of 43% and 52%, respectively, among comparable groups from 1951 through 1960. These results demonstrate that despite a reduction of cigarette smoking among successive cohorts of Hispanic men, Hispanic women have made little progress or have actually increased their cigarette smoking. ( JAMA 1989;261:66-69)