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Fingesi TS, Kimaru LJ, Okusanya BO, Ehiri JE, Rosales C. Nicotine and Alcohol Use as Predictors of Recreational Cannabis Use in Adolescence: A Systematic Review and Narrative Synthesis. Subst Use Misuse 2024; 59:1367-1382. [PMID: 38658323 DOI: 10.1080/10826084.2024.2342008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background: The prevalence of recreational cannabis use among adolescents is a growing public health concern due to its link to short- and long-term adverse effects on adolescents' wellbeing, physical health, mental health, and interpersonal behaviors. Method: Five databases were searched from inception to March 17, 2023, for exposure (nicotine product, alcohol) and outcome (recreational cannabis) in adolescents (persons aged 10-19 years). The studies were screened independently by two reviewers, and the quality of the studies was assessed with Newcastle Ottawa and AXIS tool. PRISMA guidelines were employed in this review. Result: Twenty-one (21) studies involving 2,778,406 adolescents were included in the appraisal and heterogeneity was found among these studies. Ascertainment bias was commonly detected in thirteen (13) of the included studies. Among the substances examined as potential exposures, nicotine-product use emerged as a significant factor associated with future cannabis use among adolescents, particularly in mid-adolescence and in places where recreational cannabis use has been legalized. Conclusion: Current evidence suggests an association between nicotine-product use and subsequent recreational cannabis use among adolescents. However, further research is needed to establish causality between exposure to nicotine substances and the use of recreational cannabis within this age demographic. Additionally, there is a need for the development of prevention programs and targeted policies that continuously inform and update this vulnerable sub-population about the risks associated with cannabis use for leisure.
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Affiliation(s)
- T S Fingesi
- Community Environment and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Phoenix, Arizona, USA
| | - L J Kimaru
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - B O Okusanya
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - J E Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - C Rosales
- Division of Public Health Practice and Translational Research, Mel and Enid Zuckerman College of Public Health, University of Arizona, Phoenix, Arizona, USA
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Hamann SL, Kungskulniti N, Charoenca N, Kasemsup V, Ruangkanchanasetr S, Jongkhajornpong P. Electronic Cigarette Harms: Aggregate Evidence Shows Damage to Biological Systems. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6808. [PMID: 37835078 PMCID: PMC10572885 DOI: 10.3390/ijerph20196808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023]
Abstract
Evidence of the harms of e-cigarettes has been unfolding slowly and has been documented in many reviews and reports worldwide. A narrative review of new evidence is presented since, as research has continued, newly aggregated evidence of the dangers of electronic cigarettes on the brain, heart, and lungs is vital to inform decisions on restricting the use of e-cigarettes. Several biomedical research databases were searched for electronic cigarette health effects, emphasizing reviews, systematic reviews, and meta-analyses. Over 50 review studies, primarily in 2022 and 2023, illustrate some of the latest information on e-cigarette harms. Results show studies of respiratory, neurological, and cardiovascular effects. Researchers call for expanding studies through new methods to elaborate on initial findings of multiple harms emerging in clinical investigations. Since the use of electronic cigarettes for adult cessation is not sanctioned in most countries, it is clear that health authorities see significant costs to the health of the general population if the promotion and use of electronic cigarettes occur worldwide. Regulatory action to control electronic cigarettes should consider the substantial evidence of electronic cigarette harm.
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Affiliation(s)
- Stephen L. Hamann
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Nipapun Kungskulniti
- Faculty of Public Health, Mahidol University, Bangkok 10400, Thailand;
- Thailand Health Promotion Institute, Bangkok 10330, Thailand
| | - Naowarut Charoenca
- Faculty of Public Health, Mahidol University, Bangkok 10400, Thailand;
- Thailand Health Promotion Institute, Bangkok 10330, Thailand
| | - Vijj Kasemsup
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Suwanna Ruangkanchanasetr
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Passara Jongkhajornpong
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Duan Z, Kasson E, Ruchelli S, Rajamahanty A, Williams R, Sridharan P, Sapra T, Dopke C, Pannell A, Nakshatri S, Berg CJ, Cavazos-Rehg PA. Assessment of Online Marketing and Sales Practices Among Recreational Cannabis Retailers in Five U.S. Cities. Cannabis Cannabinoid Res 2023. [PMID: 37699251 DOI: 10.1089/can.2022.0334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background: With more states legalizing recreational cannabis, examining cannabis retail and marketing is crucial, as it may influence consumers' perceptions and behaviors. Particularly understudied is online cannabis retail. Methods: In Spring 2022, coders collected and analyzed data regarding retailer characteristics, age verification, and marketing strategies (e.g., product availability, health-related content, promotions, website imagery) among 195 cannabis retail websites in five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive analyses characterized the websites overall and across cities. Results: Overall, 80.5% verified age for website entry, and 92.8% offered online purchases (92.3% of retailers in Seattle, where prohibited). Of these, 82.9% required age verification for purchases, and 30.9% offered delivery. Almost all (>92%) offered flower/bud, concentrates, edibles, vaping devices, topicals, and tinctures. Health warnings were displayed on 38.3% of websites. Although all five states required health warnings regarding use during pregnancy, only 10.3% had these warnings. In addition, 59.0% posted some unsubstantiated health claims, most often indicating physical and mental health benefits (44.6%). Although Colorado, Washington, and Oregon prohibit health claims, 51.2-53.8% of these retailers posted them. Discounts, samples, or promotions were present on 90.8% of websites; 63.6% had subscription/membership programs. Subpopulations represented in website content included the following: 27.2% teens/young adults, 26.2% veterans, 7.2% sexual/gender minorities, and 5.6% racial/ethnic minorities. Imagery also targeted young people (e.g., 29.7% party/cool/popularity, 18.5% celebrity/influencer endorsement). Conclusions: Regulatory efforts are needed to better monitor promotional strategies and regulatory compliance (e.g., health claims, youth-oriented content, underage access) among online cannabis retailers.
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Affiliation(s)
- Zongshuan Duan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sabrina Ruchelli
- Center for Public Health Law Research, Temple University Beasley School of Law, Philadelphia, Pennsylvania, USA
| | - Aishwarya Rajamahanty
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - River Williams
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Priyanka Sridharan
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Tanvi Sapra
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Campbell Dopke
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Alexandria Pannell
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Sapna Nakshatri
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
- George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Patricia A Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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Sun R, Mendez D, Warner KE. The Association Between Cannabis Use and Subsequent Nicotine Electronic Cigarette Use Among US Adolescents. J Adolesc Health 2023; 73:133-140. [PMID: 37031094 DOI: 10.1016/j.jadohealth.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/01/2023] [Accepted: 02/06/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE The current study assessed the association between cannabis use among youth never e-cigarette users and subsequent e-cigarette use. METHODS The Population Assessment of Tobacco and Health Study is a nationally representative cohort study. Participants aged 12 years and older were selected using a 4-stage, stratified probability sample design from the US civilian, noninstitutionalized population. We included adolescents who participated in both wave 4.5 (2017-2018) and wave 5 (2018-2019) of Population Assessment of Tobacco and Health, and were never e-cigarette users at baseline (N = 9,925). Through multivariable logistic regressions, we examined the prospective association between cannabis use and subsequent e-cigarette use. RESULTS E-cigarette use at wave five was significantly more common among youth cannabis users at wave 4.5. The adjusted relative risks between ever cannabis use and subsequent past 12-month, past 30-day, and frequent e-cigarette use (≥20 days per month) were 1.53 (95% CI, 1.26-1.81), 1.70 (95% CI, 1.25-2.15), and 2.10 (95% CI, 1.17-3.03), respectively. The adjusted relative risks between past 30-day cannabis use and subsequent past 12-month, past 30-day, and frequent e-cigarette use were 1.54 (95% CI, 1.04-2.28), 2.01 (95% CI, 1.23-3.29), and 2.87 (95% CI, 1.44-5.71), respectively. We also found significant associations between ever cannabis vaping with subsequent e-cigarette use. DISCUSSION While previous research associates e-cigarette use with subsequent onset of cannabis use, we identify a reverse directional effect, where adolescent cannabis use is associated with increased likelihood of future e-cigarette use.
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Affiliation(s)
- Ruoyan Sun
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama.
| | - David Mendez
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Kenneth E Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Williams RJ, Wills TA, Choi K, Pagano I. Associations for subgroups of E-cigarette, cigarette, and cannabis use with asthma in a population sample of California adolescents. Addict Behav 2023; 145:107777. [PMID: 37336095 DOI: 10.1016/j.addbeh.2023.107777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/12/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023]
Abstract
Knowledge about the respiratory health consequences of adolescents' use of tobacco products with cannabis remains limited. We studied whether e-cigarettes, combustible cigarettes, and cannabis were independently associated with asthma in a population-based sample of 150,634 public high school students (10th and 12th graders), drawn in a two-stage design to be representative of the state of California in 2019-2020. Measures were obtained for use of e-cigarettes, combustible cigarettes, and cannabis; motives for use (three substances); method of use (for cannabis); ever being diagnosed with asthma; and having an asthma attack in past 12 months. Cross-classification indicated Nonuse for 64% of the sample; 15% Dual E-cigarette/Cannabis Use; 10% Exclusive Cannabis Use; 5% Exclusive E-cigarette Use; and 5% Triple Use. Multinomial logistic regression with a three-level criterion variable, controlling for age, sex, parental education, race/ethnicity, and three types of household use showed that compared with Nonuse, odds of Lifetime Asthma (vs. Never Had) was elevated for Triple Use (AOR = 1.14, CI 1.06-1.24), Dual E-cigarette/Cannabis Use (1.17, 1.12-1.23), Exclusive Cannabis Use (1.17, 1.11-1.23), and Exclusive E-cigarette Use (1.10, 1.02-1.18). Similar results were noted for Recent Asthma. Among persons who had used cannabis, 88% of the Triple group and 74% of the Dual E-cigarette/Cannabis group reported both smoking and vaping cannabis. Thus, co-occurrence of e-cigarette and cannabis use was a common pattern among adolescents in this study, and subgroups of cannabis and e-cigarette use showed similar associations with asthma. Preventive approaches should highlight the health implications of exclusive or combined e-cigarette and cannabis use.
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Affiliation(s)
- Rebecca J Williams
- California Department of Public Health, California Tobacco Control Program, Sacramento, CA, United States.
| | - Thomas A Wills
- Cancer Prevention in the Pacific Program, University of Hawaii Cancer Center, Honolulu, HI, United States
| | - Kelvin Choi
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, MD, United States
| | - Ian Pagano
- Cancer Prevention in the Pacific Program, University of Hawaii Cancer Center, Honolulu, HI, United States
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Sharma P, Mathews DB, Nguyen QA, Rossmann GL, A Patten C, Hammond CJ. Old Dog, New Tricks: A Review of Identifying and Addressing Youth Cannabis Vaping in the Pediatric Clinical Setting. Clin Med Insights Pediatr 2023; 17:11795565231162297. [PMID: 36993933 PMCID: PMC10041590 DOI: 10.1177/11795565231162297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
Cannabis vaping has emerged as a predominant mode of cannabis use among United States (US) adolescents and young adults (AYA) primarily due to the popularity of modifiable designs of vaping devices coupled with changes in cannabis policies and increased availability of cannabinoid products. New methods for cannabis vaping by e-liquid/oil vaping, dry plant vaping, and cannabis concentrate vaping (ie, dabbing) have had high uptake among American youth with unclear long-term health implications. Issues with contamination, mislabeling, and expansion of the vaped cannabis market to include not only delta-9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) but also delta-9-THC analogs (eg, delta-8 and delta-10) sold as hemp-derived "legal highs" further complicated this healthcare space. Recent research suggests that cannabis/THC vaping carries distinct and overlapping risks when compared to cannabis smoking and may be associated with greater risk for acute lung injuries, seizures, and acute psychiatric symptoms. Primary care clinicians providing care for AYA are in an ideal position to identify cannabis misuse and intervene early to address cannabis vaping. To improve public health outcomes, a need exists for pediatric clinicians to be educated about different ways/methods that youth are vaping cannabinoid products and associated risks related to cannabinoid vaping. Further, pediatric clinicians need to be trained how to effectively screen for and discuss cannabis vaping with their youth patients. In the current article, we present a clinically focused review of cannabis vaping among young people with 3 main aims to: (1) identify and describe the cannabis vaping products commonly used by American youth; (2) review the health correlates of youth cannabis vaping; and (3) discuss clinical considerations related to identifying and treating youth who vape cannabis.
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Affiliation(s)
- Pravesh Sharma
- Behavioral Health Research Program, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry, Mayo Clinic Health System, Eau Claire, WI, USA
- Pravesh Sharma, Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry, Mayo Clinic Health System, 1221 Whipple St., Eau Claire, WI 54703, USA.
| | | | - Quang Anh Nguyen
- Behavioral Health Research Program, Mayo Clinic, Rochester, MN, USA
| | | | - Christi A Patten
- Behavioral Health Research Program, Mayo Clinic, Rochester, MN, USA
| | - Christopher J Hammond
- Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Duan Z, Wang Y, Romm KF, Henriksen L, Schleicher NC, Berg CJ. State T21, Restrictions on Flavored E-Cigarette Products, and Non-Medical Cannabis Sales Legalization in Relation to Young Adult Reports of Vape Shop Age Verification and Product Offerings: A Multilevel Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15079. [PMID: 36429798 PMCID: PMC9690108 DOI: 10.3390/ijerph192215079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 06/16/2023]
Abstract
Vape shop practices related to age verification and product offerings (e.g., other tobacco, cannabis), which may affect young-adult tobacco/substance use, are likely impacted by state-level policies (i.e., Tobacco 21 [T21], flavored e-cigarette restrictions, non-medical cannabis legalization). Using data from young adults (18-34 years) in 6 US states representing variability in whether/when they implemented the aforementioned policies, this study focused on past 6-month e-cigarette users who visited vape shops (Wave 1 [W1]: September-December 2018, n = 1127; W2: September-December 2019, n = 702; W3: September-December 2020, n = 549). Multilevel modeling examined T21 in relation to participants' reports of age verification at last vape shop visit (among those < 27), and flavor restrictions and cannabis legalization in relation to noticing other tobacco or cannabis products at last visit. At W1-W3, 69.7%, 78.7%, and 75.8% of participants < 27 reported age verification, and participants increasingly noticed other tobacco (W2: 36.9%; W3: 48.6%) and cannabis products (W1: 25.8%; W2: 41.3%; W3: 58.3%). State T21 was unrelated to age verification (aOR = 1.19, 95%CI = 0.80-1.79); flavored e-cigarette restrictions correlated with noticing other tobacco products (aOR = 1.96, 95%CI = 1.10-3.51); flavored e-cigarette restrictions (aOR = 2.26, 95%CI = 1.57-3.24) and cannabis legalization (aOR = 2.84, 95%CI = 1.78-4.51) correlated with noticing cannabis products. Regulatory efforts must be informed by ongoing surveillance of such policies and their impact.
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Affiliation(s)
- Zongshuan Duan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Yan Wang
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Katelyn F. Romm
- TSET Health Promotion Research Center, Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Lisa Henriksen
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Nina C. Schleicher
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Carla J. Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
- George Washington Cancer Center, George Washington University, Washington, DC 20052, USA
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Sun R, Mendez D, Warner KE. Use of Electronic Cigarettes Among Cannabis-Naive Adolescents and Its Association With Future Cannabis Use. JAMA Netw Open 2022; 5:e2223277. [PMID: 35867059 PMCID: PMC9308048 DOI: 10.1001/jamanetworkopen.2022.23277] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Electronic cigarette (e-cigarette) use has been reported to increase the likelihood of future cigarette smoking among adolescents. The prospective association between e-cigarette use and cannabis use has been less clear, especially in recent years. OBJECTIVE To examine the association between e-cigarette use among cannabis-naive adolescents and cannabis use 1 year later. DESIGN, SETTING, AND PARTICIPANTS The Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study, uses a 4-stage, stratified probability sample design to select participants aged 12 years or older from the US civilian, noninstitutionalized population. This study sample included 9828 cannabis-naive adolescents at the baseline survey who participated in both wave 4.5 (2017-2018) and wave 5 (2018-2019) of PATH. EXPOSURES e-Cigarette use, assessed by ever use, past 12-month use, and past 30-day use. MAIN OUTCOMES AND MEASURES Cannabis use in wave 5, assessed by past 12-month and past 30-day use. Multivariable logistic regressions assessed the association between e-cigarette use and cannabis use 1 year later. Results were weighted to produce nationally representative findings. RESULTS Of the 9828 adolescents included in the analysis, 5361 (57.3%) were aged 12 to 14 years, 5056 (50.7%) were male, and 4481 (53.0%) were non-Hispanic White. After adjustment for sociodemographic characteristics, environmental factors, other substance use, and sensation seeking, e-cigarette use among cannabis-naive adolescents was associated with increased likelihoods of both self-reported past 12-month and past 30-day cannabis use 1 year later. The adjusted relative risks (aRRs) of subsequent past 12-month cannabis use with ever use of e-cigarettes was 2.57 (95% CI, 2.04-3.09), with past 12-month use of e-cigarettes was 2.62 (95% CI, 2.10-3.15), and with past 30-day use of e-cigarettes was 2.18 (95% CI, 1.50-2.85). The aRRs of subsequent past 30-day cannabis use with ever use of e-cigarettes was 3.20 (95% CI, 2.10-4.31), with past 12-month use of e-cigarettes was 3.40 (95% CI, 2.17-4.63), and with past 30-day use of e-cigarettes was 2.96 (95% CI, 1.52-4.40). CONCLUSIONS AND RELEVANCE This cohort study's findings suggest a strong association between adolescent e-cigarette use and subsequent cannabis use. However, despite the strong association at the individual level, e-cigarette use seems to have had a minimal association with the prevalence of youth cannabis use at the population level.
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Affiliation(s)
- Ruoyan Sun
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham
| | - David Mendez
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Kenneth E. Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
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