Good news and bad news on what youth are smoking and drinking

Our friends to the south are very more diligent in collecting information on the health and wellbeing of their population.   Canada has much to learn and emulate.   A report released last week is based on an ongoing youth risk behaviour surveillance study.  The study comprises work from the national surveillance program, 43 state surveys and 21 large urban school area surveys  US behaviour youth survey.  Are you envious yet?   The down side, is the report rarely puts data into a temporal context.   Just like with patients, it is measuring changes that are critical to management of the population’s health.

The study and the Canadian comparators are rich information and worth using as a benchmark for surveys in provinces and regions. 

Work in both countries confirms something most would have suspected.  Regular tobacco use behaviour in US youth has reached a relative low at 10.2% daily use in the last 30 days with any tobacco smoking use at 18.1%.  This is good news.  On the other hand, marijuana use in the last 30 days was at 23.1%.   Officially, marijuana use has become more prevalent than tobacco. 

Lest we forget the third of the major psychoactive substances, alcohol.   Consumption being illegal for youth under 21 in the US with provinces at either 18 or 19 years of age. US youth use of alcohol in the previous 30 days was the highest of the three substances at 38.7%. Alcohol consumption by youth seems to be decreasing amongst this US population .

Within Canada we have the Youth smoking survey 2010-2011 Youth smoking survey 2010-2011 which shows tobacco use at  10% use in past 30.  This survey also asks about alcohol and drug use with rates reported at 45% use of alcohol in the last year, and this is also appears to be decreasing.  Past year cannabis use reported at 21% and also supposedly decreasing.   Note that question format and time frames make comparison to the US survey difficult but suggestive that youth in both countries have similar risk profiles.

The Canadian drug and Alcohol Use Monitoring Survey provides some information on youth (ages 15-24) CDAUMS  but does not provide directly comparable statistics to the US youth behavioural survey .   Cannabis consumption in the past year – 25.1%.   Alcohol consumption in past 30 days – 52.3%.   Noting that these numbers would at least appear consistent with the youth survey data given a slightly different age group.

Here rests the public health dilemma.   We have different approaches to efforts to control and regulate tobacco, alcohol and marijuana, the former being legal, the later still considered a criminal offense to have possession of. Alcohol supposed not legal for consumption for youth.    Relative success has occurring through concerted efforts to reduce tobacco and alcohol, yet efforts to control marijuana use are limited by lack of information, lack of legitimacy and significant illicit profit compared to regulated substances like tobacco and alcohol.  

While marijuana may not have the same health risks associated with its use, it is not something to be promoted or encouraged – but controlled.  

Dietary modification to improve the public's health. New news to chew on.

Mayor Bloomberg’s pronouncement that he hopes to ban large sized soft drinks has caused a flurry of diet related activity. No reference here to the mayor’s comments as the blogosphere is filled with opinions on the relative value, morals and expected impacts of such a ban.  Our only comment is it was NYC’s 2006 ban on unsaturated fats that led the wave across the country and resulted in considerable benefit in reduced unhealthy fat consumption.

Let us begin by reiterating that there is no clearly demonstrated effective long term cure for overweight and obesity.   The consistently most effective intervention is bariatric surgical intervention which is unlikely to be widely endorsed for other than the morbidly obese. 

So the issue of obesity gives great fodder to fill lay magazines, morning talk shows and fuel for weight loss schemes – all of which are thriving.   This blog is no less guilty than others of trying to weigh into the fray.  healthy environments and obesity,  losing weight  low sodium diets,  Motivational interviewing for obesity,   obesity and political ramifications . 

Three more items to expand the discussion.  To reinforce what we all know is a study demonstrating that Americans know it as well.  Losing weight is tough, and tougher than completing their taxes.  The original article at Science daily on losing weight.  The executive original work can be found at food information council survey and with the encouragement that primary review of such reports is good practice.  Lost in the press release headlines about how difficult it is to lose weight, are some good tidbits of information on the current state of American health on food intake, obesity and physical activity. It is challenging on the site to actually determine the methodology other than an on-line survey which may contribute to certain biases.

A review that confirms that there is up to a 14% benefit in cardiovascular events in men only in modifying dietary fat that resulted in lower triglycerides and LDL.   There was no benefit noted in all cause or cardiovascular mortality.   The full review (a 2011 update of the 2001 review) is available within the Cochrane database – the abstract at Dietary modification for cardiovascular events.

Lastly is a piece on the reduced risk of childhood obesity amongst infants born vaginally compared to Caesarean  section.   Biologically this is being promoted by changes in GI tract flora.  An interesting avenue for additional research.   Is anyone aware of a good retrospective study looking at adult weights at birth type?   C-section and childhood obesity.

Diabetes and endocrine disorders continue to be some of the few causes of death and disability that are increasing, and obesity is a significant risk factor to the development of these conditions.  The solution is prevention, but in working towards prevention, we need also grapple with early intervention and in intervention when manifest problems are developing.  

Harm Reduction and the politics of language.

Anyone who interfaces with the federal government will have noted its pathological phobia with the term “harm reduction”.  That generic set of two words that inferences that as humans we sometimes chose to engage in activities that have a higher risk for hurting or potentially even killing ourselves, and that we can reduce the likelihood of harm by invoking any variety of activities.  Helmets for cyclists and boarders, barrier and contraceptive protection for sexual intimacy, seat belts in cars, wearing sunscreen, donning a parka during the winter – the list can go on and something each of us engages in constantly in our lives without a second thought.

The more specific definition that has caused angst suggests harm reduction is an activity limited to persons who suffer from addictions, often but not exclusively associated with illicit drugs. This blog has spoken to many types such as supervised injection sites, cannabis decriminalization, needle exchange/distribution, methadone distribution programs, safer alcohol consumption guidelines, alcohol distribution in some homeless housing initiatives.   Some of these you may be comfortable with, others might cause some to raise their shackles as a stretch of their moral frameworks.

Health is a science and should be driven by evidence.  From a health perspective, many of the listed harm reduction for addictions result in a demonstrable benefit for individual and societal health.  Most have a net cost reduction to the taxpayer through deferred health and social services.  So they should be an easy sell. Differing perceptions of morality, religion and politics are often barriers to doing the right thing.   So how has the current government influenced the discussion on harm reduction.

So lets do an experiment and obtain some evidence.   Go to a government home page – we tried Health Canada and PHAC.  Take a search on the term “harm reduction.   Respectively the searchers returned 668 and 340 document references. Now try to learn about where public government documents reference harm reduction.  Most of the material is related to pesticide and product regulation so finding relevant materials is not as straightforward.   If you expand the search by collection on the right hand menu and pick “health concerns”, most of the addictions materials are listed, some 177 documents.   The PHAC site is more generic and most of the material returned is related to addiction concerns. Presented as a linear time trend as below:

As a reminder,  Harper was elected in 2006, reelected in 2008 and obtained a majority government in 2011. Minister Aglukkaq was first elected in 2008 and immediately began her long standing term as Minister of Health.   PHAC supposedly operates at arms length from the government, but is somewhat handcuffed by federal political structures.  

So, in a world where governments have long used manipulation of language and words to meet their own purposes – here is clear evidence of political ideology affecting the science of health and the operations of Health Canada.  And clear evidence of the social impact that governments can have by imposing views and curtailing dialogue – reminiscent of dictatorial regimes.  

Coffee, Tea or ??

Products that are widely consumed are excellent targets for health claims, but the very nature of consumption patterns make epidemiological investigation challenging, and if absolute associations are weak, then identification of potential benefit or risks can be a lifelong career.  The identification of the health effects of tea and coffee are prime examples.  

Since the mid-1970’s numerous publications have sought the definitive relationship, and many of these studies were published in no less an esteemed journal as the New England Journal of Medicine.  The wonderful series of publications makes an excellent course in critical appraisal of health publications as conflicting results appear to arise from similarly executed investigations. The major challenge being the association between stimulate consumption and certain other behaviours such as smoking, caloric intake, alcohol consumption and socioeconomic status. 

The latest in the series of hundreds of North American and European coffee studies is also published in this esteemed journal and looks at some 5 million person-years of follow-up and death events in 33,000 men and 19,000 women.   NEJM study on coffee and mortality

Tea drinkers fear not, the literature is just as rife with more interest from predominately tea drinking countries.  The subject received a rigorous review that explored some 40 studies also covering a few million person-years of exposure and a variety of epidemiological study methods.  The analysis was more specifically focused on cardiovascular disease and diabetes outcomes  tea and health outcomes review article.  

So the results, or at least what is available and comparable.

	Coffee - male	Coffee - female	Tea (black)
Unadjusted relationship	>3 cups associated with up to 60% increase in mortality	Similar to males with up to 50% increase in high consumption
Adjustment for identified associated variables (confounders)	Up to a 10% reduction in mortality noted at 2 or more cups per day	More benefit up to 16% and also in groups of >2 cups/day
Cancer adjusted for confounders	Slight increase of 4 and 8% respectively for 4-5 cups and >6 cups	Non-statistical differences.
Heart disease	Reduction of 7-14% with greatest benefit at 2-3 cups per day	Greater benefit of up to 28%	Several studies showing up to 40% reductions in cardiovascular death.  Benefit to women also seems slightly greater
Respiratory disease	Dose response relationship with up to 19% reduction at >6 cups	Similar positive benefit of up to 35%
Stroke	A notable reduction of up to 30% in all consumption ranges except for unadjusted >6 cups per day	Benefit only noted at >2 cups per day	Numerous studies reporting benefit of up to 40% reduction with greater benefit for women
Diabetes	An apparent benefit for all consumption groups, adjusted and unadjusted	Similar broad benefits of up to 43% noted	Benefits in the range of up to 40% noted.

Perhaps even more reflective of the great debate globally, no study mentions adjusting for consumption the other common beverage.  The assumption that both coffee and tea drinkers are exclusive in their habits is reflective of the biases within the literature.  Also notable is the extensive discussion of what constituents of tea are perceived as beneficial, with the absence of such debate in the coffee literature. 

Such investigations will continue to populate the medical literature for decades to come until someone convinces a naive group of youth to be randomly allocated to cohorts of coffee, tea or neither and subject them to decades without allowing for their choice of stimulant.  Stated otherwise, the question and the subject will continue to percolate and simmer. 

Public health in the June news: Overdiagnositis, poverty, tobacco, health system, UV and Hep B

It is only through your readership that this blog can continue.  The diversity of readers has shifted with less than half being the target from Canada for which the blog is written.  Please provide feedback at drphealth@gmail.com follow on twitter @drphealth.  You can also follow by email by linking at the lower left hand corner however statistics are not collected and may skew away from actual readership.  Better, join the followers on the link at the lower right hand corner.   Comments are encouraged and feedback very welcomed.

The monthly popular review of what’s hot in public health.  

Overdiagnositis   DrPHealth was one of numerous commenters on the risks of overscreening DrPHealth May 14 in relation to the release of prostate cancer screening recommendations that clearly identified unintended risks as a point of concern.   BMJ continued the barrage and expanded the conversation to the whole issue of overdiagnosis.  The well written commentary clearly puts the risks of the health care system as a significant cause of avoidable mortality and morbidity.  BMJ overdiagnosis    You are referenced specifically to the estimated overdiagnosis rates noted in Table 1.  Follow this debate over the next few years.  Those who work in the system are likely very familiar with both the problem, and the avoidance behaviour demonstrated by professionals who see errors of omission as more problematic than errors of the system. “Better to have tried and failed than to not have tried at all” (often paraphrased from Tennyson)

Poverty report card  From Ontario is a report card on progress towards implementing the provincial poverty reduction action plan.  Long on baseline data and short on evidence of progress – the report card at least is an attempt to keep the issues alive and on the public agenda.   Timing is everything as the baseline data are prerecession, and the evidence shows as much the impact of the recession as efforts to ameliorate poverty.  Keep it up. Ontario poverty report card

Tobacco control report card   Out of BC and with a regional bias, hidden in the report card are some great provincial comparisons.  Jump to the appendices and see how provinces and territories stack up.  While BC is the basis, it is very useful information on performance against best practices.   The relative arbitrary grading detracts from the value of the report card as the gradings are based on rank ordering rather than progress towards the best practices. Tobacco control report card

Health Council of Canada 2012 report card: This is only included here as an example of how what gets measured gets managed.  The HCC has failed to record the unintended consequences of focusing on a limited number of doable actions - one of which has been the erosion of public health in order to shift resources to the fields flagged in by the Council.  The document is filled with political platitudes and lacks depth amongst the verbosity (including the jurisdiction analysis which do not provide for comparability between provinces.  Time to step to the plate and provide a true report card on the state of health in Canada.  Health Council of Canada 2012 report 

Effectiveness of UV index  Canadian weather risk communication was the subject of a disappointingly underread series in DrPHealth in January  Weather that kills  and Community health and weather risks.  Disappointing as these are likely definitive synthesis of the subjects that are not available anywhere else.   Many tools for communicating weather risks are substantially Canadian or Canada has played a major role including Wind chill factor, Humidex index, the Air Quality Health Index and the Ultraviolet Index.  A substantive question is on the relative benefit of such tools which are the mainstay of weather forecasters and TV weatherpeople.  The entry is a review out of Germany of the known effectiveness of the UV index and suggesting relatively low awareness and behaviour change impact.  Not surprising as what other indices show is that they don’t seem to affect decisions today, but the cumulative messaging can result in substantive behaviour changes and long term risk reduction – clearly an area for lots of study.  Review of UV Index

Prevention of perinatal Hepatitis B transmission:  Just to slip in something is a potential practice change.  The traditional approach to babies born to mothers known to be Hepatitis B antigen positive has been the provision of Hepatitis B Immunoglobulin.  A proposed alternative approach is the provision of lamuvidine (antiviral) during late pregnancy and showing good results, comparable or better than HBIG provision. Warning the review article is not the easiest to read  Lamuvidine vs HBIG for perinatal Hep B transmission . 

CPHA – Time to support our organization.

With the CPHA meeting just a week away, a reminder to all Canadian public health workers of the need to support the organization.   At a 102 years of age, its longevity exceeds most of the other health organizations in the country.  CPHA is feeling the pressure of both federal cuts and a long standing dependency on coordination of international projects which began to be eroded over a decade ago, and as with many organizations was slow to respond to the impending fiscal reality.  It is however still the preeminent public health organization in the country and all public health workers should consider actively being involved.  To this should be added the benefits to align the professional specific organizations under the umbrella – the Public Health Physicians of Canada have attempted to do this for the past 4-5 years with some success, it is time for groups like CIPHI (Public health inspectors) and CHNAC (public health nurses) to lay down professional jealousies and come together in defence of the organization from which they were originally conceived. 

For our international colleagues, while this post relates to a short term domestic issue, CPHA has been a major driver behind the World Federation of Public Health Associations whose current president Jim Chauvin is a long standing director of policy with the CPHA head office. He is not the first Canadian to chair this relatively young group either.   WFPHA home page 

Some of the great work that Canadian public health workers depend upon that requires our support, more of which can be found just by suffering the CPHA website at CPHA home page

Canadian Coalition for Public Health in the 21^st Century – a network of 35 health organizations that stand together in advocating for health in Canada.  The organization has been in place for 9 years

Canadian Coalition for Immunization Awareness and Promotion – headed from the CPHA offices, this is the group that keeps promoting immunization awareness and providing the great resources that most public health workers depend on daily.

CPHA used to house the Canadian Aids/HIV clearinghouse until funding was eliminated a couple of years back – it still maintains a portal to many on-line resources.

Canadian Journal of Public Health – a foundational document that remains one of the few resources for public health professionals focused predominately on Canadian public health practice.

Annual conference – an enjoyable location where academics, policy makers, senior officials, front line staff can come together as equals and discuss the issues of public health in Canada.

And many more, including numerous portals, services, sales and advocacy activities.  

CEO Deb Lynkowski has done a marvellous job over the past few years in opening transparency of the organization and attempting to bring an approach to fiscal sustainability in a resource compromised environment.  The retirement of assistant CEO Janet McLaren who quietly in the background made things happen within the organization was a significant loss but with well wishes for her retirement.  Other key office staff who have weathered the years and remain dedicated to the mission of CPHA include the directors Greg Penny (knowledge), Ian Culbert (communications) and Karen Craven (CJPH assistant editor). These are the unsung heroes of the Canadian public health system.

If you are a member – thank you.  If not, it is not a huge financial commitment but one that reaps benefits for all Canadian public health workers and through them, to all Canadians.  Not in Canada – support your national public health association, it is the backbone for public health work globally. 

DrPHealth blog evaluation

As the site passes approaches 7500 views, some statistics for dedicated readers.

	Month of May	All-time (11 months)
Posts	15	172
Views	624 (20.1 views per day)	7416 (22.1 views per day)
Canadian viewer proportion	28.7%	62.8%
Other top viewing countries	US – 33.0% Russia – 11.5% Other European – 6% Other - ~21%	US – 17.5% Russia – 7% Other European – 5% Other ~ 8%
Top Posts viewed	Health and Built Environment 3 Health social services May 3  – 41 views Telehealth (Apr 3) – 32 views in May Bill C-31 May 7 – 32 views Opposition to Bill C-31 May 16 -22 views	Cost of poverty Jan12 – 121 views Telehealth Apr 3 – 106 views Smart meters Feb 3 -  69 views Social injustice Dec 5 – 56 views Determinants Jan 9  – 51 views
Referring sites	Google – 66 Facebook - 3	Google – 189 Twitter – 106 Domar – 70 Linked In – 56 CHNet – 34 Facebook - 32

What conclusions can you draw?  Here are ours:

Canadian readership has either dropped or moved to direct email for which no tracking is available

Issues of social justice seem to have the greatest popularity

Niche topics can be either very successful (Telehealth and healthy built environment), or very disappointing (weather and health series).  (Posting specific information is available for total views)

Canadian specific content which is the focus of the blog is not attracting the attention that was the messaging intent

Twitter and Link-in posting are not nearly as effective as they were

A small handful of 4 or 5 dedicated viewers have provided most of the 26 published comments and dialogue on the drphealth@gmail.com site. 

Your comments, thoughts and suggestions are welcome by posting a comment or sending privately to drphealth@gmail.com. 

Thank you for your continued readership.