Faculty Bibliography

BACKGROUND:While emerging studies suggest that the COVID-19 pandemic caused disruptions in routine healthcare utilization, the full impact of the pandemic on healthcare utilization among diverse group of patients with type 2 diabetes is unclear. The purpose of this study is to examine trends in healthcare utilization, including in-person and telehealth visits, among U.S. veterans with type 2 diabetes before, during and after the onset of the COVID-19 pandemic, by demographics, pre-pandemic glycemic control, and geographic region. METHODS:We longitudinally examined healthcare utilization in a large national cohort of veterans with new diabetes diagnoses between January 1, 2008 and December 31, 2018. The analytic sample was 733,006 veterans with recently-diagnosed diabetes, at least 1 encounter with veterans administration between March 2018-2020, and followed through March 2021. Monthly rates of glycohemoglobin (HbA1c) measurements, in-person and telehealth outpatient visits, and prescription fills for diabetes and hypertension medications were compared before and after March 2020 using interrupted time-series design. Log-linear regression model was used for statistical analysis. Secular trends were modeled with penalized cubic splines. RESULTS:In the initial 3 months after the pandemic onset, we observed large reductions in monthly rates of HbA1c measurements, from 130 (95%CI,110-140) to 50 (95%CI,30-80) per 1000 veterans, and in-person outpatient visits, from 1830 (95%CI,1640-2040) to 810 (95%CI,710-930) per 1000 veterans. However, monthly rates of telehealth visits doubled between March 2020-2021 from 330 (95%CI,310-350) to 770 (95%CI,720-820) per 1000 veterans. This pattern of increases in telehealth utilization varied by community type, with lowest increase in rural areas, and by race/ethnicity, with highest increase among non-hispanic Black veterans. Combined in-person and telehealth outpatient visits rebounded to pre-pandemic levels after 3 months. Despite notable changes in HbA1c measurements and visits during that initial window, we observed no changes in prescription fills rates. CONCLUSIONS:Healthcare utilization among veterans with diabetes was substantially disrupted at the onset of the pandemic, but rebounded after 3 months. There was disparity in uptake of telehealth visits by geography and race/ethnicity.

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke (SHS) exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory infections (LRIs), and upper respiratory infections (URIs) in the early post-policy period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to policy) to children living in lots with other subsidized housing (unexposed to policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015 and December 31, 2019 (policy introduction was July 30, 2018). We also examined effect modification by baseline age group (0-2, 3-6, 7-15). In NYC, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early post-policy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient URI claims (IRR=1.05, 95% CI=1.01, 1.08), a result most pronounced among children ages 3-6. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

Exposure to indoor environmental risk factors is associated with patterns of asthma morbidity. In this study, we assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). We used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma ("ever asthma") and experiencing a past-year asthma attack. We further examined whether associations were modified by smoking status (among adults), smoking within the home (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.35, 2.84), and past-year asthma attack (OR = 2.24; 95% CI 1.21,4.18). Living in rental assistance housing was also significantly associated with ever asthma (OR = 1.75; 95% CI 1.16, 2.66). Associations between public or rental assistance housing and ever asthma were marginally non-significant among children. Associations between living in public or rental assistance housing and ever asthma were more pronounced among ever smokers than among never smokers. Housing environments remain important predictors of both pediatric and adult asthma morbidity. Associations between living in subsidized housing and asthma outcomes among adults are most apparent among ever smokers.

The goal of our study is to understand the impact of Tobacco 21 (T21) laws on youth smoking and health equity. We conducted modified Poisson regression models using 2014-2019 Monitoring the Future data to measure the impact of attending school in a county 100% covered by a T21 law versus counties with <100% T21 coverage on past 30-day smoking participation (n = 262,632), first cigarette smoking initiation (n = 189,698), and daily smoking initiation among 8th, 10th, and 12th graders (n = 214,496), separately. Additive interactions were tested between T21 coverage and sex, race/ethnicity, parental education, and college plans. T21 coverage was associated with a lower likelihood of smoking participation among 12th graders. T21 coverage was most strongly associated with a lower likelihood of smoking participation among: Hispanic and NH (Non-Hispanic) Other/Multiracial individuals; respondents with parents who had less than a college education; and respondents who were not definitely planning on attending college. T21 laws were associated with a lower likelihood of smoking participation among 12th graders. T21 policies were most impactful for individuals disproportionately impacted by tobacco, indicating T21 laws might help reduce tobacco-related health disparities.

Research on whether sexual orientation discrimination is associated with multiple tobacco product use among sexual minority (SM) adults is limited. Thus, we explored the associations between sexual orientation discrimination and exclusive, dual, and polyuse among a subset of SM adults (18+) (n = 3453) using the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. We evaluated six indicators of prior-to-past-year sexual orientation discrimination separately and as a summary scale and defined past-year exclusive, dual, and polyuse based on cigarette, electronic nicotine delivery systems, other combustible (cigars and traditional pipe), and smokeless tobacco products. Using multinomial logistic regression, we estimated adjusted associations between sexual orientation discrimination and exclusive, dual, and polyuse. Experiencing discrimination in public places, being called names, and being bullied, assaulted, or threatened were associated with dual use, while experiencing discrimination when obtaining health care or insurance and when receiving health care were associated with polyuse. Each one-unit increase in the sexual orientation discrimination summary scale was associated with 5% and 10% higher odds of dual (95% CI: 1.01-1.10) and polyuse (95% CI: 1.02-1.18), respectively. To conclude, we advise health professionals to consider the salience of discrimination against SM adults and how these experiences lead to dual/polyuse.

INTRODUCTION/BACKGROUND:To analyze the impact of Truth and state-sponsored anti-tobacco media campaigns on youth smoking in the U.S., and their potential to reduce tobacco-related health disparities. METHODS:Our study included data from the 2000-2015 Monitoring the Future study, an annual nationally representative survey of youth in 8 th (n=201,913), 10 th (n=194,468), and 12 th grades (n=178,379). Our primary exposure was Gross Ratings Points (GRPS) of Truth or state-sponsored anti-tobacco advertisements, from Nielsen Media Research. Modified Poisson regression was used to assess the impact of a respondent's GRPs on smoking intentions, past 30-day smoking participation, and first and daily smoking initiation. Additive interactions with sex, parental education, college plans, and race/ethnicity were used to test for differential effects of campaign exposure on each outcome. RESULTS:Greater campaign exposure (80 th vs. 20 th GRP percentile) was associated with lower probabilities of smoking intentions among 8 th graders, smoking participation among 8 th and 12 th graders, and initiation among 8 th graders. Greater exposure was associated with a greater reduction in the likelihood of smoking participation among 10 th and 12 th grade males than females; 10 th and 12 th graders with parents of lower education versus those with a college degree; and 12 th graders who did not definitely plan to go to college relative to those who did. CONCLUSIONS:Media campaign exposure was associated with a lower likelihood of youth smoking behaviors. Associations were more pronounced for groups disproportionately affected by smoking, including youth of lower socioeconomic status. Media campaigns may be useful in reducing smoking disparities and improving health equity. IMPLICATIONS/CONCLUSIONS:Few recent studies have investigated the impact of anti-tobacco media campaigns on youth smoking and their potential to reduce tobacco-related health disparities in the U.S. We found media campaigns - specifically state-sponsored media campaigns - reduced the likelihood of several smoking outcomes among youth, with some evidence that they mitigate disparities for disproportionately affected groups.

BACKGROUND AND AIMS/OBJECTIVE:Tobacco control policies may differentially impact smoking initiation among socio-demographic groups. We measured longitudinal associations between exposure to smoke-free laws in grade 12 (modal age 18 years) and patterns of smoking initiation in the United States. DESIGN/METHODS:Prospective longitudinal analysis. SETTING AND PARTICIPANTS/METHODS:We used data on US young adults sampled at modal age 18 years from the Monitoring the Future Survey. Baseline data were collected between 2000 and 2017, with the last year of follow-up in 2018. The sample number varied by outcome and time-point, ranging from 7314 to 17 702. MEASUREMENTS/METHODS:Smoke-free law coverage in work-places and hospitality venues (restaurants/bars) was measured as the percentage of the county population covered by each type of law. We examined associations with any past 30-day smoking initiation and daily smoking initiation at modal ages 19/20, 21/22 and 23/24, using Poisson regression and calculating average marginal effects. We explored effect modification by sex, race/ethnicity and parental education by testing the significance of interaction terms. FINDINGS/RESULTS:Work-place law coverage at modal age 18 was associated with a lower probability of daily smoking initiation at modal ages 21/22 [-2.4 percentage points (p.p.); 95% confidence interval (CI) = -3.9, -0.9] and 23/24 (-2.0 p.p.; 95% CI = -3.9, -0.2). Hospitality law coverage was associated with a lower probability of daily smoking initiation at modal ages 19/20 (-1.6 p.p.; 95% CI = -2.8, -0.4), 21/22 (-2.3 p.p.; 95% CI = -3.7, -0.9) and 23/24 (-1.8 p.p.; 95% CI = -3.6, -0.0). Findings were inconclusive with regard to associations with any past 30-day smoking initiation and with regard to effect modification, after adjusting for multiple testing. CONCLUSIONS:Exposure to smoke-free laws at age 18 appears to be prospectively associated with reduced daily smoking initiation 1-6 years later.

BACKGROUND:Emerging evidence suggests many people have persistent symptoms after acute COVID-19 illness. Our objective was to estimate the prevalence and correlates of post-acute sequelae of SARS-CoV-2 infection (PASC). METHODS:We employed a population-based probability survey of adults with COVID-19 in Michigan. Living non-institutionalized adults aged 18+ in the Michigan Disease Surveillance System with COVID-19 onset through mid-April 2020 were eligible for selection (n=28,000). Among 2,000 selected, 629 completed the survey between June - December 2020. We estimated PASC prevalence, defined as persistent symptoms 30+ (30-day COVID-19) or 60+ days (60-day COVID-19) post COVID-19 onset, overall and by sociodemographic and clinical factors, including self-reported symptom severity and hospitalization status. We used modified Poisson regression to produce adjusted prevalence ratios (aPR) for potential risk factors. RESULTS:The analytic sample (n=593) was predominantly female (56.1%), aged 45 and older (68.2%), and Non-Hispanic White (46.3%) or Black (34.8%). 30- and 60-day COVID-19 were highly prevalent (52.5% and 35.0%), even among non-hospitalized respondents (43.7% and 26.9%) and respondents reporting mild symptoms (29.2% and 24.5%). Respondents reporting very severe (vs. mild) symptoms had 2.25 times higher prevalence of 30-day COVID-19 ([aPR] 2.25, 95% CI 1.46-3.46) and 1.71 times higher prevalence of 60-day COVID-19 (aPR 1.71, 95% 1.02-2.88). Hospitalized (vs. non-hospitalized) respondents had about 40% higher prevalence of both 30-day (aPR 1.37, 95% CI 1.12-1.69) and 60-day COVID-19 (aPR 1.40, 95% CI 1.02-1.93). CONCLUSIONS:PASC is highly prevalent among cases reporting severe initial symptoms, and, to a lesser extent, cases reporting mild and moderate symptoms.

BACKGROUND:Sexual minority (SM) (gay, lesbian and bisexual) adults are at higher risk of smoking compared with heterosexual individuals, yet little is known about how the tobacco control policy landscape interacts with sexual orientation smoking disparities. METHODS:We conducted a descriptive analysis to explore differential exposure to smoke-free laws and televised anti-tobacco media using two sources of national data from the United States: Census data on same-sex couple households/all households and data on SM adults/all adults from the National Health Interview Survey (NHIS). We combined this information with variables representing the proportion of individuals in each county covered by smoke-free laws (2013-2017), and average county-level exposure to televised anti-tobacco media campaigns (2013-2015). We compared average coverage levels for SM populations to average coverage levels for the broader US population. RESULTS:Between 2013 and 2017, same-sex couple households/SM adults lived in counties with higher levels of smoke-free law coverage compared with all US households/adults for workplaces (Census: 71.3% vs 68.0%; NHIS: 70.7% vs 67.9%) and hospitality venues (Census: 82.3% vs 77.0%; NHIS: 80.5% vs 77.2%). There were no consistent differences in exposures to anti-tobacco media campaigns across datasets. CONCLUSIONS:SM adults may be more likely to live in areas with smoke-free laws, compared with the general population. Findings point to the need to examine other potential drivers of smoking in SM populations.