Tobacco Use among Foster Youth: Evidence of Health Disparities

Cardiovascular Disease Events in Adults with a History of State Care in Childhood: Pooling of Unpublished Results from 9 Cohort Studies

Background

Individuals who were separated from their biological family and placed into the care of the state during childhood (out-of-home care) are more prone to developing selected physical and mental health problems in adulthood, however, their risk of cardiovascular disease (CVD) is uncertain. Accordingly, we pooled published and unpublished results from cohort studies of childhood care and adult CVD.

Methods

We used two approaches to identifying relevant data on childhood care and adult CVD (PROSPERO registration CRD42021254665). First, to locate published studies, we searched PubMed (Medline) until November 2023. Second, with the aim of identifying unpublished studies with the potential to address the present research question, we scrutinised retrieved reviews of the impact of childhood state care on related adult health outcomes. All included studies were required to have prospective measurement of state care in childhood and a follow-up of CVD events in adulthood as the primary outcome (incident coronary heart disease and/or stroke). Collaborating investigators provided study-specific estimates which were aggregated using random-effects meta-analysis. The Newcastle-Ottawa Scale was used to assess individual study quality.

Findings

Thirteen studies (2 published, 11 unpublished) met the inclusion criteria, and investigators from nine provided viable results, including updated analyses of the published studies. Studies comprised 611,601 individuals (301,129 women) from the US, UK, Sweden, Finland, and Australia. Relative to the unexposed, individuals with a care placement during childhood had a 50% greater risk of CVD in adulthood (summary rate ratio after basic adjustment [95% confidence interval]: 1.50 [1.22, 1.84]); range of study-specific estimates: 1.28 to 2.06; I2 = 69%, p = 0.001). This association was attenuated but persisted after multivariable adjustment for socioeconomic status in childhood (8 studies; 1.41 [1.15, 1.72]) and adulthood (9 studies, 1.28 [1.10, 1.50]). There was a suggestion of a stronger state care-CVD association in women.

Interpretation

Our findings show that individuals with experience of state care in childhood have a moderately raised risk of CVD in adulthood. For timely prevention, clinicians and policy makers should be aware that people with a care history may need additional attention in risk factor management.

Cardiovascular Disease and Risk Factors in Individuals With a History of Out-of-home Care

BACKGROUND

Exposure to childhood out-of-home care (foster family and residential care) is associated with an increased risk of ill-health and disability in adulthood, but the risk for cardiovascular disease has not previously been studied longitudinally.

METHODS

This was a national cohort study generated from linkage of a range of population-based registers, resulting in a national cohort of 881 731 of whom 26 310 (3.0%) had a history of out-of-home care. The study population, born 1972 to 1981, was followed from age 18 to age 39 to 48 years for hospitalizations and death.

RESULTS

After adjusting for year of birth and maternal education, individuals with a history of childhood out-of-home-care experienced a doubling of the risk for coronary disease (hazard ratio; 95% confidence interval: 2.05; 1.74-2.41) and stroke (hazard ratio 1.85; 1.59-2.15), compared with the general population, with similar estimates for men and women. Women with a history of out-of-home care had a more than doubled risk for cigarette smoking in early pregnancy, with a relative risk of 2.26; (2.18-2.34) and a moderately increased risk for gestational diabetes relative risk 1.49 (1.19-1.86). There was marked attenuation (40% to 90%) in effect estimates for disease and risk factors after further control for cohort members educational achievement at age 15-16 years.

CONCLUSIONS

A history of childhood out-of-home care was associated with a doubled risk of early cardiovascular disease events. Cigarette smoking and educational underachievement were the main identified risk factors.

WITHDRAWN: Cardiovascular disease in individuals with a history of out-of-home care: a Swedish national cohort study

The authors have withdrawn their manuscript owing to errors apparent in the results. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.

Housing status as a social determinant of disparities in adolescent smoking, vaping, and dual use of cigarettes and e-cigarettes

Little is known about how various housing situations among adolescents may be associated with differential patterns of smoking and vaping-information with practical relevance for tobacco prevention and control efforts. We analyzed disparities by housing status in past 30-day smoking, vaping, and dual use of cigarettes and e-cigarettes/vape products among adolescents participating in the population-based California Healthy Kids Survey (N = 931,355; 2017-2019). Generalized linear mixed models for a categorical outcome quantified differences in prevalence and adjusted odds ratios (AORs) of smoking only, vaping only, and dual use among adolescents in various housing situations relative to their peers living in a home with one or more parents/guardians or other relatives. Our findings suggest adolescents living in a friend's home; adolescents living in a hotel, motel, shelter, car, campground, or other transitional or temporary housing; and adolescents living in a foster home, group care, or waiting placement evidenced pronounced disparities in past 30-day smoking only (AORs: 3.16-3.40, ps < 0.0001) and dual use of cigarettes and e-cigarettes/other nicotine vape products (AOR: 3.73-5.83, ps < 0.0001) relative to their peers living in a home with one or more parents/guardians or other relatives. Vaping only disparities, although significant, were relatively smaller (AORs: 1.53-1.88, ps < 0.0001). These findings emphasize housing as a social determinant of smoking, vaping, and dual use disparities among adolescents and have implications for multilevel preventive intervention development.

Technology-Based Smoking Cessation for Youth Exiting Foster Care: A Pilot Randomized Trial

Despite high rates of cigarette use, little attention has been paid to screening and cessation services for youth in foster care. Study aims were to test the feasibility, acceptability, and preliminary efficacy of a technology-based smoking cessation intervention. Study enrollment, satisfaction, and engagement were high in the intervention arm, where readiness to change also significantly increased over time. Intervention and control participants significantly reduced cigarette use at 6-month follow up, though groups did not differ. Technology-based interventions appear to be attractive and offer a potentially scalable link to health care that this vulnerable population may not otherwise seek.

Using machine learning to determine the shared and unique risk factors for marijuana use among child-welfare versus community adolescents

OBJECTIVE

This study used machine learning (ML) to test an empirically derived set of risk factors for marijuana use. Models were built separately for child welfare (CW) and non-CW adolescents in order to compare the variables selected as important features/risk factors.

METHOD

Data were from a Time 4 (Mage = 18.22) of longitudinal study of the effects of maltreatment on adolescent development (n = 350; CW = 222; non-CW = 128; 56%male). Marijuana use in the past 12 months (none versus any) was obtained from a single item self-report. Risk factors entered into the model included mental health, parent/family social support, peer risk behavior, self-reported risk behavior, self-esteem, and self-reported adversities (e.g., abuse, neglect, witnessing family violence or community violence).

RESULTS

The ML approaches indicated 80% accuracy in predicting marijuana use in the CW group and 85% accuracy in the non-CW group. In addition, the top features differed for the CW and non-CW groups with peer marijuana use emerging as the most important risk factor for CW youth, whereas externalizing behavior was the most important for the non-CW group. The most important common risk factor between group was gender, with males having higher risk.

CONCLUSIONS

This is the first study to examine the shared and unique risk factors for marijuana use for CW and non-CW youth using a machine learning approach. The results support our assertion that there may be similar risk factors for both groups, but there are also risks unique to each population. Therefore, risk factors derived from normative populations may not have the same importance when used for CW youth. These differences should be considered in clinical practice when assessing risk for substance use among adolescents.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Smoking in Teenagers from the Social Protection System-What Do We Know about It?

Background and Objectives: The impact of smoking on the young population is an extremely important issue for the public health system. As the prevalence of smoking is considerably increasing amongst the pubescent and adolescent population, the prevention of smoking at this age should be considered of high priority. The primary aim of this observational study was to assess tobacco use in teenagers included in the social protection system. Materials and Methods: 275 foster care teenagers (155 from the Professional Maternal Assistance System (AMP) and 120 from the residential system) from two different counties were enrolled. After a brief interactive session focused on the main consequences of smoking, a self-administered questionnaire was anonymously completed. Results: The mean age of the study group was 14 years, with a significant difference between the residential system and AMP (p = 0.001). Smoking status was significantly higher in participants from family-type houses (36.7%) than in those from the AMP (11.7%) (p < 0.001). The presence of smokers in the family (78.3%) and passive smoking (64.7%) were significantly higher in children from the residential system than in those from the AMP (32.9% and 31.8%, respectively) (p < 0.001). The number of cigarettes consumed daily was associated with the age of the participants (p = 0.01, rho 0.42). In total, 82.3% were cigarette users and 19.4% were e-cigarette users. Smokers bought the majority of their cigarettes from the store (63.2%) or asked a friend (19.3%) or an adult to buy them on their behalf (12.3%). Conclusions: The null hypothesis, according to which children who are abandoned but raised and cared for by professional nursing assistants are predisposed to earlier tobacco activity compared to children raised in a normal familiar environment, is supported. Future education and prevention campaigns conveying the benefits of a healthy long-term lifestyle to this population category are needed.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.

Tobacco Use as a Health Disparity: What Can Pediatric Clinicians Do?

Tobacco use is a global health crisis, and has a tremendous and negative impact on health and wellbeing. Tobacco use disproportionately affects members of vulnerable populations, and by acting on multiple socioecological levels, serves to perpetuate and reinforce cycles of poverty. Members of the pediatric medical community can play a key role in interrupting cycles of tobacco use. Providers can serve as powerful allies to vulnerable communities by treating tobacco use in caregivers, counseling youth against using tobacco products, protecting children from the impact of secondhand smoke exposure, and advocating for economic, social, and health policies to disrupt intergenerational smoking.

Combustible Cigarette Smoking and Alternative Tobacco Use in a Sample of Youth Transitioning from Foster Care

Among the struggles faced by youth currently in or recently exiting foster care, tobacco use remains a low priority for practitioners and researchers, alike. Indeed, despite the dramatically altered landscape of tobacco products on the market, there have been no studies evaluating the use of alternative tobacco products among this vulnerable population. The current study aimed to determine the prevalence of lifetime and current combustible and non-combustible tobacco use among youth exiting foster care, and report on the prevalence of nicotine dependence, motivation to quit, and preferred methods of tobacco cessation. Youth aged 18-24 (M = 20.13, SD = 1.16) who were transitioning from foster care (N = 154) completed a survey of tobacco product use adapted from the Population Assessment of Tobacco and Health Baseline Survey. Most participants (76%) reported lifetime use of combustible cigarettes, while almost half (42%) were current combustible cigarette smokers. Current use of electronic cigarettes was comparable to general population rates. Many participants (76%) reported interest in quitting and willingness to try through patches/gum (56%) and technology-based (61%) approaches. Youth exiting foster care are at high risk for smoking and other tobacco product use, as well as dependence, yet are rarely screened for use or advised to quit. As tobacco use remains among the most preventable causes of mortality and morbidity, future work should involve implementation of screening within child welfare and tailoring interventions to the unique needs of this population. The current results underscore a missed opportunity to promote public health in a vulnerable population.

Smoking Behaviors Among Adolescents in Foster Care: A Gender-Based Analysis

BACKGROUND AND OBJECTIVES

Adolescents in foster care are at high risk for cigarette smoking. However, it is not clear how their smoking behaviors vary by gender. The present study examined lifetime and current smoking among males and females, and explored gender-specific risk factors for engagement in smoking behaviors.

METHOD

Data from the Multi Site Evaluation of Foster Youth Programs was used to evaluate patterns of smoking among adolescents aged 12-18 years (N = 1121; 489 males, 632 females).

RESULTS

Males and females did not differ significantly in rates of lifetime and current smoking, or in the age of smoking initiation and number of cigarettes smoked on a typical day. Gender-based analyses revealed that older age and placement in group homes or residential treatment facilities were associated with heightened risk of smoking among males. In contrast, sexual minority status (i.e., nonheterosexual orientation) and increased childhood victimization were associated with heightened risk of smoking among females. A history of running away was linked to smoking in both genders.

CONCLUSION

Gender should be considered when designing intervention programs to address cigarette smoking among foster youth, as the stressors associated with smoking may differ for males and females.

The role of adverse childhood experiences as determinants of non-suicidal self-injury among children and adolescents referred to community and inpatient mental health settings

The objectives of this study were to examine the prevalence of, and determine the effect of adverse childhood experiences on non-suicidal self-injury among children and adolescents referred to community and inpatient mental health settings. Data for this study were obtained from the interRAI Child and Youth Mental Health dataset. A total of 2038 children and adolescents aged 8-18 years (M=12.49; SD=2.88, 61.1% males) were analyzed. Binary logistic regression was fitted to identify predictors of non-suicidal self-injury as a function of adverse childhood experiences, depression, and social support while simultaneously controlling for age, gender, type of patient, legal guardianship, marital status of parents/caregivers, history of foster family placement, and mental health diagnoses. Of the 2038 children and adolescents examined, 592 (29%) of this clinical sample engaged in non-suicidal self-injury. In the multivariate logistic regression model, children and adolescents who were physically abused had 49% higher odds of engaging in non-suicidal self-injury and children and adolescents who were sexually abused had 60% higher odds of engaging in non-suicidal self-injury, when compared to their non-abused counterparts. Other predictors of non-suicidal self-injury include: older age, female gender, inpatient status, depression, attention deficit-hyperactivity disorder, disruptive behavior disorder, and mood disorders. Children and adolescents who had some form of social support had a 26% decrease in the odds of engaging in non-suicidal self-injury. Assessment procedures for indicators of mental health, particularly among children and adolescents with a history of adverse childhood experiences, should also take into account non-suicidal self-injury. In addition to bolstering social support networks, addressing depression and related emotion regulation skills in childhood may help prevent future non-suicidal self-injury behaviors.