OBJECTIVES: This manuscript describes traumatic brain injury (TBI)-related mortality in the United States during 2021, by geography, sociodemographic characteristics, mechanism of injury, and injury intent. METHOD: Multivariable modeling of TBI mortality was performed to assess the simultaneous effect of multiple factors (geographic region, sex, race and ethnicity, and age) included in the model. Authors analyzed multiple-cause-of-death data from the National Vital Statistics System and included records when an International Classification of Diseases, Tenth Revision (ICD-10) underlying cause of death injury code, and a TBI-related ICD-10 diagnosis code were both listed. RESULTS: During 2021, there were 69,473 TBI-related deaths. Rates were highest among older adults, males, and non-Hispanic American Indian/Alaska Native persons. A large proportion of all TBI-related deaths were attributed to unintentional falls and suicides. Model-based rates of TBI mortality revealed a divergent pattern with increasing rates by age group, while rate ratios simultaneously declined with age among specific racial/ethnic groups when compared with non-Hispanic White persons. CONCLUSION: Findings indicate unintentional falls and suicides remain a common cause of fatal TBI and specific groups are disproportionally affected by such injuries. Health care providers can play a role by assessing patients at increased risk for TBI and providing referrals for care and culturally tailored interventions when warranted.

Suicide, including firearm suicide, remains a substantial public health concern in the United States. During the previous 2 decades, overall suicide rates and firearm suicide rates have risen by approximately one third, approaching 50,000 overall suicides during 2022, including approximately 27,000 firearm suicides (1). Firearm suicides account for approximately one half of all suicides, and this proportion has been increasing (2,3). This analysis includes national firearm suicide data from 2019 through the end of 2022, categorized by race and ethnicity, presented both annually and by month (or quarterly) to track subannual changes.

The rate of firearm homicide in the United States rose sharply from 2019 through 2020, reaching a level not seen in more than 2 decades, with ongoing and widening racial and ethnic disparities (1). During 2020–2021, the rate increased again (2). This report provides provisional firearm homicide data for 2022, stratified by race and ethnicity, presented both annually and by month (or quarter) to document subannual changes.

The firearm homicide rate in the United States increased nearly 35% from 2019 to 2020, coinciding with the emergence of the COVID-19 pandemic (1). This increase affected all ages and most population groups, but not equally: existing disparities, including racial and ethnic disparities, widened. The firearm suicide rate was higher than the firearm homicide rate in 2020 and remained consistent with recent years overall; however, increases were observed in some groups (1). To assess potential increases from 2020 to 2021, final 2020 and provisional 2021, National Vital Statistics System mortality data and U.S. Census Bureau population estimates were used to examine all-cause homicide and suicide rates; firearm homicide and suicide rates overall and by sex, age,* race and ethnicity; and the percentage of homicides and suicides from firearm injuries.† This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§

INTRODUCTION: Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies. METHODS: Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018. RESULTS: Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning. CONCLUSIONS: Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region.

INTRODUCTION: The majority of homicides (79%) and suicides (53%) in the United States involved a firearm in 2020. High firearm homicide and suicide rates and corresponding inequities by race and ethnicity and poverty level represent important public health concerns. This study examined changes in firearm homicide and firearm suicide rates coinciding with the emergence of the COVID-19 pandemic in 2020. METHODS: National vital statistics and population data were integrated with urbanization and poverty measures at the county level. Population-based firearm homicide and suicide rates were examined by age, sex, race and ethnicity, geographic area, level of urbanization, and level of poverty. RESULTS: From 2019 to 2020, the overall firearm homicide rate increased 34.6%, from 4.6 to 6.1 per 100,000 persons. The largest increases occurred among non-Hispanic Black or African American males aged 10-44 years and non-Hispanic American Indian or Alaska Native (AI/AN) males aged 25-44 years. Rates of firearm homicide were lowest and increased least at the lowest poverty level and were higher and showed larger increases at higher poverty levels. The overall firearm suicide rate remained relatively unchanged from 2019 to 2020 (7.9 to 8.1); however, in some populations, including AI/AN males aged 10-44 years, rates did increase. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: During the COVID-19 pandemic, the firearm homicide rate in the United States reached its highest level since 1994, with substantial increases among several population subgroups. These increases have widened disparities in rates by race and ethnicity and poverty level. Several increases in firearm suicide rates were also observed. Implementation of comprehensive strategies employing proven approaches that address underlying economic, physical, and social conditions contributing to the risks for violence and suicide is urgently needed to reduce these rates and disparities.

Firearm homicides and suicides represent an ongoing public health concern in the United States. During 2018-2019, a total of 28,372 firearm homicides (including 3,612 [13%] among youths and young adults aged 10-19 years [youths]) and 48,372 firearm suicides (including 2,463 [5%] among youths) occurred among U.S. residents (1). This report is the fourth in a series* that provides statistics on firearm homicides and suicides in major metropolitan areas. As with earlier reports, this report provides a special focus on youth violence, including suicide, recognizing the magnitude of the problem and the importance of early prevention efforts. Firearm homicide and suicide rates were calculated for the 50 most populous U.S. metropolitan statistical areas (MSAs)(†) for the periods 2015-2016 and 2018-2019, separated by a transition year (2017), using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. Following a period of decreased firearm homicide rates among persons of all ages after 2006-2007 in large metropolitan areas collectively and nationally, by 2015-2016 rates had returned to levels comparable to those observed a decade earlier and remained nearly unchanged as of 2018-2019. Firearm suicide rates among persons aged ≥10 years have continued to increase in large MSAs collectively as well as nationally. Although the youth firearm suicide rate remained much lower than the overall rate, the youth rate nationally also continued to increase, most notably outside of large MSAs. The findings in this report underscore a continued and urgent need for a comprehensive approach to prevention. This includes efforts to prevent firearm homicide and suicide in the first place and support individual persons and communities at increased risk, as well as lessening harms after firearm homicide and suicide have occurred.

This study examined the population-based incidence of firearm homicide in the United States to identify geographic concentrations and to determine whether such concentrations have changed over time. It further examined the simultaneous associations of urbanization, poverty, and ethnicity/race with firearm homicide incidence. Using county-level data from the National Vital Statistics System and the U.S. Census Bureau for the years 2004-2018, the findings show geographic patterns not commonly recognized, including several lengthy and continuous corridors with a high incidence of firearm homicide, traversing both metro and non-metro areas. While the data clearly show a strongly disproportionate concentration of firearm homicide incidence in a subset of the population defined by geography, they do not suggest increasing concentration over time. The study findings also generally indicate increasing firearm homicide incidence with increasing levels of surrounding poverty, a phenomenon observed for both metro and non-metro areas.

Objectives. To document the increasing influence of firearm suicide on the incidence of traumatic brain injury (TBI)-related death in the United States.Methods. We used national vital statistics data from 2008 to 2017 to identify TBI-related deaths, overall and by cause, among US residents. National counts stratified by year, sex, and age group (to facilitate age adjustment) were merged with corresponding population estimates to calculate incidence rates.Results. During the 10-year period beginning in 2008, when it became the leading cause of TBI-related death in the United States, firearm suicide accounted for nearly half (48.3%) of the increase in the absolute incidence of TBI-related death when combining all injury categories showing absolute increases. Rates of TBI-related firearm suicide increased among both males and females.Conclusions. Safe storage of firearms among people at risk and training of health care providers and community members to identify and support people who may be thinking of suicide are part of a comprehensive public health approach to suicide prevention.Public Health Implications. States, communities, and health care systems can save lives by prioritizing comprehensive suicide prevention. (Am J Public Health. Published online ahead of print April 16, 2020: e1-e3. doi:10.2105/AJPH.2020.305622).

One in 10 U.S. residents aged >/=18 years reports falling each year (1). Among all age groups, falls can cause serious injury and are the second leading cause of traumatic brain injury (TBI)-related deaths (2). TBI is a head injury caused by a bump, blow, or jolt to the head or body or a penetrating head injury that results in disruption of normal brain function.* CDC estimated national and state-specific rates and trends for TBI-related deaths (TBI deaths) caused by unintentional falls (fall-related TBI deaths) among U.S. residents during 2008-2017, by selected decedent characteristics. The national age-adjusted rate of fall-related TBI deaths increased by 17% from 2008 to 2017. Rate trends at the national level increased significantly for nearly all decedent characteristics, with the most notable increases observed among persons living in noncore (i.e., most rural), nonmetropolitan counties and those aged >/=75 years. Analysis of state-specific rate trends determined that rates of fall-related TBI deaths increased significantly in 29 states over the 10-year study period. A fall can happen to anyone of any age, but falls are preventable. Health care providers and the public need to be aware of evidence-based strategies to prevent falls, given that rates of fall-related TBI deaths are increasing. Health care providers can educate patients on fall and TBI prevention, assess their risk for falls, and when needed, encourage participation in appropriate evidence-based fall prevention programs.(dagger).

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

INTRODUCTION: Each year from 1999 through 2015, residential fires caused between 2,000 and 3,000 deaths in the U.S., totaling approximately 45,000 deaths during this period. A disproportionate number of such deaths are attributable to smoking in the home. This study examines national trends in residential fire death rates, overall and smoking-related, and their relationship to adult cigarette smoking prevalence, over this same period. METHODS: Summary data characterizing annual U.S. residential fire deaths and annual prevalence of adult cigarette smoking for the years 1999-2015, drawn from the National Vital Statistics System, the National Fire Protection Association, and the National Health Interview Survey were used to relate trends in overall and smoking-related rates of residential fire death to changes in adult cigarette smoking prevalence. RESULTS: Statistically significant downward trends were identified for both the rate of residential fire death (an average annual decrease of 2.2% - 2.6%) and the rate of residential fire death attributed to smoking (an average annual decrease of 3.5%). The decreasing rate of residential fire death was strongly correlated with a gradually declining year-to-year prevalence of adult cigarette smoking (r=0.83), as was the decreasing rate of residential fire death attributed to smoking (r=0.80). CONCLUSIONS AND PRACTICAL APPLICATIONS: Decreasing U.S. residential fire death rates, both overall and smoking-related, coincided with a declining prevalence of adult cigarette smoking during 1999-2015. These findings further support tobacco control efforts and fire prevention strategies that include promotion of smoke-free homes. While the general health benefits of refraining from smoking are widely accepted, injury prevention represents a potential benefit that is less recognized.

Firearm homicides and suicides represent a continuing public health concern in the United States. During 2015-2016, a total of 27,394 firearm homicides (including 3,224 [12%] among persons aged 10-19 years) and 44,955 firearm suicides (including 2,118 [5%] among persons aged 10-19 years) occurred among U.S. residents (1). This report updates an earlier report (2) that provided statistics on firearm homicides and suicides in major metropolitan areas during 2006-2007 and 2009-2010, and places continued emphasis on youths, in recognition of the importance of early prevention efforts. Firearm homicide and suicide rates were determined for the 50 most populous U.S. metropolitan statistical areas (MSAs)* during 2012-2013 and 2015-2016 using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. In contrast to the earlier report, which indicated that firearm homicide rates among persons of all ages had been declining both nationally and in large MSAs overall, current findings show that rates have returned to levels comparable to those observed during 2006-2007. Consistent with the earlier report, these findings show that firearm suicide rates among persons aged >/=10 years have continued to increase, both nationally and in large MSAs overall. Although firearm suicide rates among youths remain notably lower than those among persons of all ages, youth rates have also increased both nationally and in large MSAs collectively. These findings can inform ongoing development and monitoring of strategies directed at reducing firearm-related violence.

INTRODUCTION: Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS: Trends in age-adjusted suicide rates among persons aged >/=10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS: During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS: Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

OBJECTIVE: To investigate the potential dietary impact of the opening of new retailers of healthy foods. DESIGN: Systematic review of the peer-reviewed research literature. SETTING: References published before November 2015 were retrieved from MEDLINE, EMBASE and Web of Science databases using keyword searches. SUBJECTS: The outcome of the review was change in fruit and vegetable consumption among adults. RESULTS: Of 3514 references retrieved, ninety-two articles were reviewed in full text, and twenty-three articles representing fifteen studies were included. Studies used post-test only (n 4), repeated cross-sectional (n 4) and repeated measures designs (n 7) to evaluate the dietary impact of supermarket (n 7), farmers' market (n 4), produce stand (n 2) or mobile market (n 2) openings. Evidence of increased fruit and vegetable consumption was most consistent among adults who began shopping at the new retailer. Three of four repeated measures studies found modest, albeit not always statistically significant, increases in fruit and vegetable consumption (range 0.23-0.54 servings/d) at 6-12 months after baseline. Dietary change among residents of the broader community where the new retailer opened was less consistent. CONCLUSIONS: The methodological quality of studies, including research designs, sampling methods, follow-up intervals and outcome measures, ranged widely. Future research should align methodologically with previous work to facilitate meta-analytic synthesis of results. Opening a new retailer may result in modest short-term increases in fruit and vegetable consumption among adults who choose to shop there, but the potential longer-term dietary impact on customers and its impact on the broader community remain unclear.

BACKGROUND: During the previous century the average lifespan in the United States (US) increased by over 30 years, with much of this increase attributed to public health initiatives. This report examines further gains that might be achieved through reduced occurrence of injury-related death. METHODS: US life tables and injury death rate data were used to estimate potential increases in life expectancy assuming various reductions in the rate of fatal injuries. Corresponding numbers of deaths potentially averted annually were also estimated; unit (per death) medical and lifetime work loss costs were employed to estimate total costs potentially averted annually. RESULTS: Through elimination of injury as a cause of death, average US life expectancy at birth could be increased by approximately 1.5 years, with notable variations by sex, ethnicity, and race. More conservatively, average life expectancy at birth could be increased by 0.41 years assuming that the national injury death rate could be brought into line with the lowest state-specific rate. Under this more conservative but plausible assumption, an estimated 48,400 injury deaths and $61 billion in medical and work loss costs would be averted annually. CONCLUSIONS: Increases in life expectancy of the magnitude considered in this report are arguably attainable based on long-term historical reductions in the US injury death rate, as well as significant continuing reductions seen in other developed countries. Contemporary evidence-based interventions can play an important role in reducing injury-related deaths, such as those due to drug overdoses and older adult falls, as well as suicides.

Suicide is a major and continuing public health concern in the United States. During 1999-2015, approximately 600,000 U.S. residents died by suicide, with the highest annual rate occurring in 2015 (1). Annual county-level mortality data from the National Vital Statistics System (NVSS) and annual county-level population data from the U.S. Census Bureau were used to analyze suicide rate trends during 1999-2015, with special emphasis on comparing more urban and less urban areas. U.S. counties were grouped by level of urbanization using a six-level classification scheme. To evaluate rate trends, joinpoint regression methodology was applied to the time-series data for each level of urbanization. Suicide rates significantly increased over the study period for all county groupings and accelerated significantly in 2007-2008 for the medium metro, small metro, and non-metro groupings. Understanding suicide trends by urbanization level can help identify geographic areas of highest risk and focus prevention efforts. Communities can benefit from implementing policies, programs, and practices based on the best available evidence regarding suicide prevention and key risk factors. Many approaches are applicable regardless of urbanization level, whereas certain strategies might be particularly relevant in less urban areas affected by difficult economic conditions, limited access to helping services, and social isolation.

A statistical framework for evaluating definitions of extreme weather phenomena can help weather agencies and health departments identify the definition(s) most applicable for alerts and other preparedness operations related to extreme weather episodes.

In the United States (U.S.), secondhand smoke (SHS) exposure causes more than 41,000 deaths among nonsmoking adults annually. Adoption of smoke-free laws in public areas has increased, but private settings such as vehicles remain a source of SHS exposure. This study assessed change in voluntary smoke-free vehicle rules and SHS exposure in personal vehicles among U.S. adults between two periods, 2009-2010 and 2013-2014, using data from the National Adult Tobacco Survey (NATS). NATS is a national landline and cellular telephone survey of non-institutionalized adults aged ≥18 years in the 50 U.S. states and the District of Columbia. We assessed percentage change in the prevalence of smoke-free vehicle rules among all adults and SHS exposure in vehicles among nonsmoking adults, overall, by sociodemographic factors (sex, age, race/ethnicity, education, marital status, annual household income, U.S. region), and by cigarette smoking status. During 2009-2010 to 2013-2014, the percentage of adults with a 100% smoke-free vehicle rule increased from 73.6% to 79.5% (% change = +8.0%; p < 0.05). Among nonsmokers, SHS exposure in vehicles in the previous 7 days decreased from 9.2% to 8.2% (% change = -10.9%; p < 0.05). Smoke-free rules in private settings such as vehicles, in coordination with comprehensive smoke-free policies in indoor public settings, can help reduce SHS exposure and promote smoke-free norms.

Outdoor places, such as parks, remain a source of secondhand smoke (SHS) exposure. We assessed attitudes toward smoke-free parks among U.S. adults. Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of noninstitutionalized adults aged ≥18 in the 50 U.S. states and D.C. Descriptive statistics and logistic regression were used to assess the prevalence and sociodemographic correlates of attitudes toward smoke-free parks, overall and by current tobacco use. Overall, 38.5% of adults reported favorable attitudes toward complete smoke-free parks; prevalence ranged from 29.2% in Kentucky to 48.2% in Maine. Prevalence of favorable attitudes toward smoke-free parks was higher among nonusers of tobacco (44.6%) and noncombustible-only users (30.0%) than any combustible users (21.3%). The adjusted odds of having a favorable attitude were higher among: women; Hispanics and Black non-Hispanics, American Indian and Alaska Native non-Hispanics, and other non-Hispanics; those with an unspecified sexual orientation; and those with children aged ≤17 in the household, relative to each characteristics respective referent group. Odds were lower among: any combustible tobacco and noncombustible-only tobacco users; adults aged 45-64; and those with some college or an undergraduate degree. Opportunities exist to educate the public about the benefits of smoke-free outdoor environments.

OBJECTIVE: To leverage a state health department's operational data to allocate in-kind resources (children's car seats) to counties, with the proposition that need-based allocation could ultimately improve public health outcomes. METHODS: Retrospective analysis of administrative data on car seats distributed to counties statewide by the Georgia Department of Public Health and development of a need-based allocation tool (presented as interactive supplemental digital content, adaptable to other types of in-kind public health resources) that relies on current county-level injury and sociodemographic data. RESULTS: Car seat allocation using public health data and a need-based formula resulted in substantially different recommended allocations to individual counties compared with historic distribution. CONCLUSIONS: Results indicate that making an in-kind public health resource like car seats universally available results in a less equitable distribution of that resource compared to deliberate allocation according to public health need. Public health agencies can use local data to allocate in-kind resources consistent with health objectives; that is, in a manner offering the greatest potential health impact. Future analysis can determine whether the change to a more equitable allocation of resources is also more efficient, resulting in measurably improved public health outcomes.

BACKGROUND: Exposure to secondhand smoke (SHS) causes significant disease and death. We assessed the prevalence and correlates of perceptions about the health harm of SHS among U.S. adults at the national and state level. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a national landline and cellular telephone survey. Perceptions about the health harms of SHS were assessed as follows: 'not at all harmful', 'somewhat harmful', and 'very harmful'. Descriptive statistics were used to assess the prevalence of SHS harm perceptions by tobacco use and sociodemographic factors, including sex, age, race/ethnicity, education, marital status, annual household income, region, sexual orientation, children in the household, and smoke-free law coverage. Logistic regression was used to assess odds of perceiving SHS to be "very harmful" (vs. "not at all harmful" or "somewhat harmful"), adjusting for the aforementioned factors. RESULTS: Nationally, 64.5 % of adults perceived SHS as 'very harmful' (state range: 73.5 % [Utah] to 53.7 % [Kentucky]). By tobacco use, the perception that SHS is 'very harmful' was: 76.5 % among nonusers of tobacco; 62.1 % among noncombustible only users; 47.9 % among combustible only users; and 40.8 % among dual combustible and noncombustible users. Following adjustment, the perception that SHS was 'very harmful' was higher among females, non-Hispanic minorities and Hispanics, respondents living with children, and states with 100 % smoke-free law coverage. Among current tobacco users the odds of perceiving SHS to be 'very harmful' was lower in the Midwest than the West. CONCLUSIONS: Almost two-thirds of American adults perceive SHS as 'very harmful'; however, currently only half of all Americans are protected by comprehensive state or local smoke-free laws. These findings underscore the importance of public education campaigns to increase awareness of SHS exposure harm and the benefits of smoke-free environments. Expanding comprehensive smoke-free laws could protect all Americans from SHS.

INTRODUCTION: Schools are an important environment for addressing tobacco use among youth. Tobacco-free school policies can help reduce the social acceptability of tobacco use and prevent tobacco initiation among youth. This study assessed attitudes toward tobacco-free school grounds among US adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of adults aged 18 or older in the 50 US states and District of Columbia. Respondents were considered to have a favorable attitude toward tobacco-free school grounds if they reported tobacco use should be completely banned on school grounds, including fields and parking lots, and at all school events. Data were assessed using descriptive statistics and multivariable logistic regression, overall and by tobacco use status. Correlates were sex, age, race/ethnicity, education, marital status, income, sexual orientation, US region, and whether respondent lived with any children aged 17 years or younger. RESULTS: Nationally, 86.1% of adults had a favorable attitude toward tobacco-free school grounds, with larger percentages among nontobacco users (91.9%) than current users (76.1%). State prevalence ranged from 80.0% (Kentucky) to 90.9% (Washington). Overall odds of favorable attitudes were higher among nontobacco users (referent, current users), women (referent, men), and adults aged 25 or older (referent, aged 18-24); odds were lower among residents of the South (referent, West) and lesbian, gay, bisexual, or transgender adults (referent, heterosexual or straight). CONCLUSION: Nearly 9 in 10 US adults have a favorable attitude toward tobacco-free school grounds, but attitudes vary across states and subpopulations. Opportunities exist to educate the public about the benefits of tobacco-free school grounds, which might help reduce tobacco use among youth.

Recent changes in policy and social norms related to marijuana use have increased its use and concern about how/where marijuana should be used. We aimed to characterize rules regarding marijuana and its use in homes. We recruited 1,567 US adults aged 18-34 years through Facebook advertisements to complete an online survey assessing marijuana use, social factors, perceptions of marijuana, and rules regarding marijuana and its use in the home, targeting tobacco and marijuana users to ensure the relevance of this topic. Overall, 648 (41.6%) were current marijuana users; 46.0% of participants reported that "marijuana of any type is not allowed in their home or on their property." Of those allowing marijuana on their property, 6.4% prohibited use of marijuana in their home. Of the remainder, 29.2% prohibited smoking marijuana, and 11.0% prohibited vaping, eating, or drinking marijuana. Correlates of more restrictive rules included younger age, being female, having <Bachelor's degree, not having parents or people living with them who use marijuana, perceiving use to be less socially acceptable and more harmful, and being a nonuser (p's <.05). Attitudes and subjective norms regarding marijuana are correlates of allowing marijuana in residential settings. Future work should examine areas of risk regarding household marijuana rules.

BACKGROUND: The definition of injury that underpins the contemporary approach to injury prevention is an etiological definition relating to bodily damage arising from transfer of energy to tissues of the body beyond the limits compatible with physiological function. Causal factors proximal to the energy transfer are nested within a more complex set of contextual determinants. For effective injury control, understanding of these determinants is critical. OBJECTIVES: The primary aims of this study were to describe the area-level determinants that have been included in multilevel analyses of childhood injury and to quantify the relationships between these area-level exposures and injury outcomes. SEARCH METHODS: We conducted a systematic review of peer-reviewed, English-language literature published in scientific journals between January 1997 and July 2014, reporting studies that employed multilevel analyses to quantify the eco-epidemiological causation of physical unintentional injuries to children aged 16 years and younger. We conducted and reported the review in accordance with the PRISMA guidelines. SELECTION CRITERIA: We included etiological studies of causal risk factors for unintentional traumatic injuries to children aged 0 to 16 years. Methodological inclusion criteria were as follows: * Epidemiological studies quantifying the relationship between risk factors (at various levels) and injury occurrence in the individual; *Studies that recognized individual exposure and at least 1 higher level of exposure with units at lower levels or microunits (e.g., individuals) nested within units at higher levels or macrounits (e.g., areas or neighborhoods); *Injury outcomes (dependent variable) examined at the individual level; and * Central analytic techniques belonging to the following categories: multilevel models, hierarchical models, random effects models, random coefficient models, covariance components models, variance components models, and mixed models. We combined criteria from the checklist described by the Cochrane Effective Practice and Organization of Care Review Group with factors in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, and we used several quality assessment items from other injury-related systematic reviews to create a quality assessment checklist for this review. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and selected analysis features for the included studies by using preformatted tables. They extracted information as reported in the articles. We determined statistical significance of estimates and effects by using the conventional threshold, P < .05. Any differences in the information extracted were resolved by discussion between authors and by specifically rereading and rechecking the facts as reported in the relevant articles. We tabulated results from the final multilevel model(s) in each of the included articles with key aspects summarized in text. Interpretations of the results and identification of key issues raised by the collated material are reported in the Discussion section of this article. MAIN RESULTS: We identified 11 967 articles from the electronic search with only 14 being included in the review after a detailed screening and selection process. Nine of the 14 studies identified significant fixed effects at both the area and individual levels. The area-level variables most consistently associated with child injury rates related to poverty, education, employment, and access to services. There was some evidence that injury rates were lower in areas scoring well on area-level summary measures of neighborhood safety. There was marked variation in the methods used and in the mapping of measured variables onto the conceptual model of ecological causation. Author conclusions. These results help establish the scope for the public policy approach to injury prevention. More consistent reporting of multilevel study results would aid future interpretation and translation of such findings. (Am J Public Health. Published online ahead of print October 15, 2015: e1-e7. doi:10.2105/AJPH.2015.302883).

BACKGROUND: Lung cancer screening recommendations are based on results from the National Lung Screening Trial (NLST). The authors determined how the screening-eligible US population differs from NLST participants in terms of characteristics that affect their ability to benefit from screening. METHODS: The authors identified respondents to the 2012 Health and Retirement Study (HRS), a national survey of individuals aged ≥50 years who are eligible for screening based on US Preventive Services Task Force and Centers for Medicare and Medicaid Services criteria. Comorbidities, life expectancy, smoking history, and other characteristics were compared between the screening-eligible population and NLST participants. RESULTS: The authors estimated that in 2013, 8.4 million individuals (95% confidence interval, 7.9-8.9 million individuals) would have met the eligibility criteria for lung cancer screening established by the US Preventive Services Task Force. Compared with NLST participants, HRS screening-eligible respondents were older, more likely to be current smokers, and more likely to have been diagnosed with comorbidities. The 5-year survival rate was 87% in the HRS screening-eligible individuals versus 93% in the NLST participants (P<.001, based on a 2-sided test). Life expectancy was 18.7 years in the HRS screening-eligible individuals versus 21.2 years in the NLST participants. CONCLUSIONS: The US population eligible for lung cancer screening is probably less likely to benefit from early detection than NLST participants because they face a high risk of death from competing causes. The results of the current study highlight the need for smoking cessation interventions targeting those patients eligible for screening and tools to help clinicians determine the potential benefits of screening in individual patients.

Special events such as health fairs, cultural festivals and charity runs are commonly employed in the community to increase cancer screening; however, little is known about their effectiveness. The purpose of this study is to assess the activities, screening outcomes, barriers and recommendations of special events to increase breast, cervical and colorectal cancer screening. In-depth interviews were conducted nationally with 51 coordinators of events in June to September 2012. Health fairs and screening days were the most common events conducted, primarily for breast cancer education. Goals were to increase awareness of cancer screening and reach special populations. Evidence-based Community Guide strategies to increase cancer screening employed were: small media, reducing structural barriers, one-on-one education or group education. For each event that provided screening on-site or through referral, a mean of 35 breast, 28 cervical and 19 colorectal cancer screenings were reported. Coordinators made recommendations for further evaluation of special events, and most plan to conduct another special event. These data are novel and provide baseline documentation of activities and recommendations for a commonly used community-based cancer screening intervention that lacks evidence of effectiveness. Additional research to better understand the use of special events for increasing cancer screening is warranted.

BACKGROUND: Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening. METHODS: Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers. RESULTS: Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50-1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening. CONCLUSIONS: Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening.

IMPORTANCE: Detailed, nationally representative data describing high-risk populations and circumstances involved in insulin-related hypoglycemia and errors (IHEs) can inform approaches to individualizing glycemic targets. OBJECTIVE: To describe the US burden, rates, and characteristics of emergency department (ED) visits and emergency hospitalizations for IHEs. DESIGN, SETTING, AND PARTICIPANTS: Nationally representative public health surveillance of adverse drug events among insulin-treated patients seeking ED care (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project) and a national household survey of insulin use (the National Health Interview Survey) were used to obtain data from January 1, 2007, through December 31, 2011. MAIN OUTCOMES AND MEASURES: Estimated annual numbers and estimated annual rates of ED visits and hospitalizations for IHEs among insulin-treated patients with diabetes mellitus. RESULTS: Based on 8100 National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance cases, an estimated 97 648 (95% CI, 64 410-130 887) ED visits for IHEs occurred annually; almost one-third (29.3%; 95% CI, 21.8%-36.8%) resulted in hospitalization. Severe neurologic sequelae were documented in an estimated 60.6% (95% CI, 51.3%-69.9%) of ED visits for IHEs, and blood glucose levels of 50 mg/dL (to convert to millimoles per liter, multiply by 0.0555) or less were recorded in more than half of cases (53.4%). Insulin-treated patients 80 years or older were more than twice as likely to visit the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and nearly 5 times as likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for IHEs than those 45 to 64 years. The most commonly identified IHE precipitants were reduced food intake and administration of the wrong insulin product. CONCLUSIONS AND RELEVANCE: Rates of ED visits and subsequent hospitalizations for IHEs were highest in patients 80 years or older; the risks of hypoglycemic sequelae in this age group should be considered in decisions to prescribe and intensify insulin. Meal-planning misadventures and insulin product mix-ups are important targets for hypoglycemia prevention efforts.

BACKGROUND: Recent data on digoxin prescribing and adverse events are lacking but could help inform the management of digoxin in contemporary heart failure treatment. METHODS AND RESULTS: We determined nationally-representative numbers and rates of emergency department (ED) visits for digoxin toxicity in the United States using 2005-2010 reports from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and the National Ambulatory (and Hospital Ambulatory) Medical Care Surveys. Based on 441 cases, an estimated 5,156 (95% confidence interval [CI], 2,663-7,648) ED visits for digoxin toxicity occurred annually in the United States; over three-fourths (78.8% [95% CI, 73.5%-84.1%]) resulted in hospitalization. Serum digoxin level was ≥2.0 ng/mL for 95.8% (95% CI, 93.2%-98.4%) of estimated ED visits with levels reported (n=251 cases). The rate of ED visits per 10,000 outpatient prescription visits among patients ≥85 years was twice that of patients 40-84 years (rate ratio, 2.4 [95% CI, 1.2-5.0]); among females, the rate was twice that of males (rate ratio, 2.3 [95% CI, 1.1-4.7]). Digoxin toxicity accounted for an estimated 1.0% (95% CI, 0.6%-1.4%) of ED visits for all adverse drug events (ADEs) among patients ≥40 years, but an estimated 3.3% (95% CI, 2.3%-4.4%) of ED visits and 5.9% (95% CI, 4.0%-7.9%) of hospitalizations for all ADEs among patients ≥85 years. Estimated annual ED visits and hospitalizations remained relatively constant from 2005-2010. CONCLUSIONS: Digoxin toxicity is not declining; more careful prescribing to high-risk groups and improved monitoring of serum levels might be needed to reduce morbidity from outpatient digoxin use.