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All activations are reported at peak level and are in standard MNI stereotactic space

Drug use data used for correlations with MRI data and PET data were acquired in MRI and PET scan days, respectively. In and , one subject was excluded due to lack of precise information about the number of days of abstinence prior to the MRI investigation day, but the person was eligible for other analysis due to a negative urine sample. Our a priori region of interest was the amygdala. At first, we therefore restricted the correction for multiple comparisons to the amygdala ROI, as defined by the SPM anatomy toolbox ; p-values are provided as p . We set the significance level for activated voxels at p<0.05 corrected for multiple comparisons using the family-wise error correction . The entry threshold was set to p<0.001 uncorrected with an extent threshold of five contiguous voxels. Second, a whole-brain analysis was performed. The significance level for activated voxels was set at p<0.05 corrected for multiple comparisons . The threshold was the same as in the ROI analysis.To test whether associations between ecstasy usage and BOLD response were mediated by SERT, a path analysis was used to decompose the total effect of MDMA usage into direct and indirect effects. The direct effect of ecstasy exposure on the mean BOLD response across the amygdala is the conditional effect adjusting for SERT binding. The indirect effect of MDMA on the mean BOLD response is the difference in the ecstasy effect between a model, where SERT BP is controlled for compared to when it is not. This difference in effect is equivalent to the product between the effect that ecstasy has on SERT and the effect that SERT has on BOLD response. Linearity assumptions were assessed graphically. Standard errors of the indirect effect were calculated by the delta method and were validated by comparison with 95% quantiles from a parametric bootstrap.

To our knowledge,how to dry cannabis this is the first study to examine the effects of long-term ecstasy use on the neural responses to emotional face expressions. Relative to neutral face stimuli, main effects of emotional processing were found bilaterally in the amygdala, showing increased neural activity, especially in response to fearful and angry faces. This concurs well with a number of studies showing that viewing emotional faces, fearful faces in particular, activates the amygdala . While there was no ecstasy effect on task performance, ecstasy users did, as hypothesized, show higher amygdala activity with increased lifetime ecstasy use during angry face processing; that is, the more ecstasy tablets the ecstasy users had taken during their lifetime, the more activation they displayed in amygdala when watching angry faces. In the ecstasy user group, SERT binding correlated negatively with amygdala activity in response to angry faces. Non-significant statistical trends for activity during processing of angry and sad face processing suggested that amygdala activity waned with increasing time since the last intake of ecstasy. Neither the analyses of emotional expressions other than anger nor the whole-brain analysis revealed any significant results. Thus, our results support the hypothesis that long-term ecstasy use alters the neural basis of emotional face processing. This effect is dose-dependently related to lifetime consumption of ecstasy and appears to be reduced with increased time since last use. Interestingly, the linear relationship was consistently expressed for angry faces but not for other aversive facial expressions. This observation is in line with the results of Bedi et al. who found that acute MDMA intake alters the amygdala response to angry, but not fearful, facial expressions. The limited sample size of this study does, however, not allow us to conclude that there is not an effect of lifetime ecstasy intake on processing of other aversive facial expressions. While acute MDMA intake has been shown to diminish amygdala activation , we found the opposite effect in long-term ecstasy users. This supports our hypothesis that long-term ecstasy users are in a chronic, albeit potentially reversible, serotonin-depleted state and therefore in accordance with studies showing that serotonin depletion, as induced by acute tryptophan depletion, leads to elevated amygdala activity when processing negative facial expressions .

When including the lifetime amphetamine use in the model, the effect of the lifetime intake of ecstasy tablets on amygdala activity was no longer significant. This may be due to high correlation between ecstasy and amphetamine use . Since the lifetime amphetamine use in itself did not have a significant effect on amygdala activity during angry face processing, our interpretation of the results is that the effect of ecstasy use on emotional processing would be present also in the absence of amphetamine use. The present study was carried out on a sub-sample of our previous study sample of chronic ecstasy users , and we confirmed a negative correlation between SERT binding and accumulated ecstasy use. Hence, it could be speculated that our present fMRI results, showing a positive correlation between lifetime use of ecstasy tablets and left amygdala activity, was mediated by SERT density; that is, a larger lifetime intake of ecstasy tablets was associated with lower SERT binding levels , possibly leading to a higher degree of amygdala activation during angry face processing. In the ecstasy user group, SERT binding was indeed negatively correlated with amygdala reactivity to angry faces, which is in line with Rhodes et al. , showing a negative correlation in the left amygdala between SERT density and activity during emotional face processing. Post hoc mediation analysis did, however, not support the mediation hypothesis, although these results need to be interpreted with caution given the small sample size and hence the low statistical power. In short, our study suggests that there are functional consequences of a chronically depleted serotonin system as indexed by lowered SERT. Of note, an augmented amygdala response to angry faces has also been observed in mood disorders and could within a population with reduced serotonergic tone represent a sub-clinical vulnerability marker for such conditions. In line with several other studies , we have recently reported that recovery of sub-cortical—but not cortical—SERT availability takes place after termination of ecstasy use. Importantly, here, we found trends showing that days of abstinence from ecstasy correlated negatively with left amygdala activity during angry face processing and with right amygdala activity during sad face processing.

Since lifetime use of ecstasy tablets correlated positively with amygdala activity during angry face processing, the trend toward a negative correlation between days of abstinence from ecstasy and amygdala activity during angry face processing might be a potential sign of functional reversibility.There are limitations to the current study. Because of the cross-sectional nature of our study, it cannot be ruled out that the exaggerated amygdala response to angry faces and/or the low cerebral SERT among heavy ecstasy users represents preexisting traits associated with an increased preference for the use of ecstasy. We consider this less likely because, as discussed already, interventional animal studies have shown that administration of MDMA lowers cerebral SERT levels, and data from our group and others support the presence of an ecstasy dose–response relationship and recovery of SERT binding with abstinence from ecstasy . As for all investigations of the long-term consequences of illicit drug use,best way to dry cannabis especially the use of ecstasy, there will be uncertainties about the precision of the users’ reporting of drug use and actual content of substance taken. As explained in more details elsewhere , hair analysis for MDMA, use of systematic semi-structured questionnaires, and access to systematically acquired data on the content of Danish ecstasy pills in the period of data collection was employed to minimize these factors. MDMA has several effects on the serotonergic system, such as inhibiting tryptophan hydroxylase, the rate-limiting enzyme for serotonin synthesis, and serotonin degradation by monoamine oxidase B . It is possible that it is not the specific effect of MDMA on SERT, but other effects of prolonged MDMA use on the serotonergic neurotransmitter system that mediate the effect of MDMA use on brain responses to emotional faces. MDMA also has noradrenergic and dopaminergic effects that could affect amygdala activation. An additional limitation of our study is that we did not record hormonal contraception or menstrual-cycle phase for the two females in each group. These factors have been shown to affect face processing . However, we do not have any reason to suspect differences in contraceptive use or cycle phase between groups, why the lack of this information is considered as added noise, potentially reducing the power of the study. In conclusion, these results emphasize the important role of serotonergic neurotransmission in the amygdala for processing angry face expressions. We show that long-term ecstasy use has a dose-dependent effect on the amygdala response to angry faces. Importantly, on the basis of earlier work on amygdala responses to emotional face stimuli after manipulation of serotonin levels, this finding is in support of the hypothesis that recreational use of ecstasy can cause serotonin depletion. The decreased SERT binding among ecstasy users in the current as well as in several previous samples further supports this notion.

The fact that changes observed in the current study showed signs, although at a trend level, of reversibility with sustained abstinence is also in agreement with previous PET/SPECT imaging studies. With the recent focus on MDMA as a potential therapeutic tool in psychiatry , it is important to emphasize that heavy use of the same substance in a recreational setting is associated with functional and molecular—possibly reversible—changes related to serotonergic neurotransmission.Use of non-cigarette tobacco is increasing among youth. Past 30-day use of electronic cigarettes among US high school students recently rose substantially, more than doubling in two years, from 11.7% in 2017 to 27.5% in 20191,2. Similarly, the use of conventional smokeless tobacco in 2018 nearly equaled the prevalence of cigarette smoking among male US high school students 1 . Use of e-cigarettes and smokeless tobacco exemplify a larger trend, in which a broadening range of non-cigarette and non-combustible tobacco products threatens to erode public health gains in reducing youth tobacco use1 . Tobacco product characteristics, such as flavors, nicotine strength, e-cigarette device type , or smokeless tobacco cut , can signal properties of tobacco products to potential consumers, including youth. Perceived properties might relate to the taste, potency, or relative safety of the product. To the extent that specific tobacco product characteristics lead to youth viewing certain tobacco products as more appealing or associated with fewer risks, those characteristics represent plausible targets of regulation or other restrictions intended to reduce youth use. A combination of branding, product design, and real or perceived properties likely operate individually and collectively to shape youth tobacco related attitudes and decision-making. Research that identifies and quantifies the contributions of specific tobacco product characteristics is potentially appealing to regulators seeking to reduce youth use without outright bans on entire classes of products. Discrete choice methods stem from economic theory that consumer preferences are based on the multiple intrinsic characteristics of goods or products, and have recently been applied to tobacco control and tobacco regulatory science. Discrete choice experiments are designed to identify the independent contributions of component parts of a good or service to potential consumers’ overall preferences and/or beliefs. In surveys, participants are often asked to choose between two different products or scenarios, each representing a composite set of relevant attributes at varying levels , allowing quantification of how these characteristics independently contribute to respondents’ choices. Recent work has examined adults’ preferences related to water pipe tobacco and e-cigarettes, as well as youth e-cigarette preferences. In the latter study, youth were more likely to prefer e-cigarettes with non-tobacco flavors and less likely to choose products with Food and Drug Administration warning labels or ‘cigalike’ devices. The present study expands on previous discrete choice studies by including a community-based sample of youth, assessing both e-cigarettes and smokeless tobacco, and considering multiple specific perceived properties, such as danger and ease of use. The study objective is to evaluate the extent to which specific characteristics of e-cigarette and moist snuff smokeless tobacco products convey product qualities to youth, especially those perceived qualities that may lead to greater youth appeal and product use. Such product characteristics are plausible targets of potential FDA regulation or local policy designed to reduce youth tobacco use.

Prompt linkage to HIV primary care services was provided for all clients

Consistent with most prior studies, the highest rates were observed for students of EA origin, the lowest among Asian students, with an intermediate rate for Hispanic individuals. This pattern of the number of ARBs persisted after controlling for maximum drinks and the prevention group in which a person participated in the larger study. While fluctuations in ARBs across the year were fairly similar for the three ethnic groups , rates of ARBs were different across ethnicities. As suggested by several recent papers and predicted in the first part of Hypothesis 2, women had higher ARB rates. However, contrary to the second half of that hypothesis, the relationship of ethnicities to ARBs over time was different in females and males. The expected pattern of highest ARBs in EA students and lowest in Asian individuals was most obvious for females and less prominent for males. The mixed-design ANOVA in Table 4 demonstrated significant sex main effects, as well as ethnicity by sex by time and sex by LR by time interactions. The key role of sex in the rates of ARBs over 55 weeks and the interactions of sex with ethnicity might reflect several mechanisms. First, women develop higher BACs per drink , which may translate into higher risks for ARBs. The differences across ethnicities may be especially strong in women vs. men as Asian and Hispanic women may also have stronger culture-based prohibitions against heavier drinking than seen in EA cultures . Also, while more research is needed, considering recent documentation of potentially genetically-related physiologic characteristics that may relate to the BAC required for ARBs ,slide grow tables higher rates of ARBs in EA women might reflect some sex-related biological mechanisms that contribute directly to the ARB risk. The first part of Hypothesis 3 was also supported in that a low LR was related to higher ARB rates in these subjects.

However, the data in Figure 3 indicate that the relationships of ethnicity to ARBs differ in high- and low-LR subjects. It is possible that greater differential in ethnicity-related ARB risks might be observed primarily in subjects with higher LRs where drinking quantities are not already elevated by a low sensitivity to alcohol. Finally regarding hypotheses, the prediction that the ethnic group status will interact with sex and LR to predict ARB propensity was partially supported. Table 4 demonstrates significant 3-way interactions for ethnicity by sex by time and sex by LR by time, but the overall 4-way interaction was not significant . Still, the findings underscore the contention that there is more to ARBs than just how much a person drinks, and support the prediction that ethnicity, sex and LR all relate to ARB patterns. The optimal understanding of how ARBs develop requires considering a range of characteristics, preferably in a prospective study . The complex relationships with which multiple factors relate to ARB risks may indicate opportunities for more focused and efficient prevention by identifying subgroups most likely to experience ARBs and who are most likely to gain from programs aimed at decreasing heavy drinking. The larger study from which these data were extracted and a smaller investigation at another university indicated that active education about alcohol-related risk factors are associated with less intense future drinking. In the current study, the significant active education group vs. control group main effect in Table 4 supports the conclusion that decreases in maximum drinks seen with participation in the educational videos were also associated with lower levels of ARBs over time . Thus, universities and other institutions interested in decreasing the risk for ARBs and associated problems might consider developing similar education programs and focusing their efforts on subgroups of subjects with the highest ARB risk. As is true for all research, it is important to recognize caveats regarding the current work. The data were extracted from a larger study evaluating different ways of decreasing heavy drinking among students, and consistent with a prior report focusing on heavy drinking , exposure to active intervention affected ARB rates, a factor that complicates interpretation of results.

However, as shown in Table 4, the current results remained robust when prevention group assignment was used as a covariate in the mixed design ANOVA. The relationships among ethnicity, LR and changes in drinking over time are the focus of several other papers and, due to space constraints, are not discussed in detail here . Also regarding the larger study, the subjects were from a single California university, and the generalizability of results to other settings needs to be established, including gathering data on additional ethnic minorities as our analyses were limited to EA, Hispanic and Asian individuals. Next, the data were gathered on-line rather than in person by research staff with whom students had no personal contact, a step that might have affected the veracity of the responses, but the level of impact or direction of effect cannot be determined. Also regarding the larger study from which these data were extracted, to maximize the number of students receiving educational videos only 13% of the subjects were controls, and differences in numbers of subjects across groups may have impacted on current results. While the time frame for the current study was 55 weeks and the proportion of subjects reporting ARBs during this interval approached 50% in females, ARBs occur over many years and longer term follow ups are needed. In addition, the short time frame of reporting for the prior month for each assessment resulted in relatively low numbers of ARBs per individual per evaluation. Additional caveats are worth noting. All information about ethnic identity and blackouts involved self-reports, which may underestimate ARBs because heavy drinking can interfere with accurate recognition of whether an ARB occurred. It is also important to recognize that while the SRE has proven to be a robust predictor of future heavy drinking and alcohol problems, the present analyses did not control for years of drinking, the type of beverage consumed or other covariates. However, prior studies demonstrated that the relationship of SRE scores to heavy drinking and related consequences remained robust even after controlling for sex, weight, marijuana use or smoking histories and operated similarly in 12- year-old subjects with recent drinking onsets and in young adults.

Finally, there are important subgroups among EA, Asian and Hispanic populations, which, reflecting our sample size, could not be evaluated, and additional risk factors associated with ARBs were not included in analyses. These caveats aside, the present findings indicate that the propensity toward ARBs goes beyond the amount of alcohol consumed and is related to interrelationships among ethnicities, sex, and the sensitivity to alcohol. There are important differences among subgroups of students regarding how characteristics contribute to the ARB risk. Understanding how these interrelationships operate can be important in identifying who carries the highest risk and in creating focused and efficient prevention programs. Universal HIV testing is a cornerstone in efforts to achieve epidemic control as HIV-infected and unaware people are associated with the majority of HIV transmission events. In particular, during acute and early HIV infection , people who are unaware of their HIV status represent a subgroup with a disproportionate risk of HIV transmission due to high HIV viral loads,sliding grow table ongoing sexual risk behaviors and greater per-contact infectivity.The CDC recommends provision of confidential partner services to provide HIV risk reduction education and HIV testing to the recent sex or needle-sharing partners of newly HIV diagnosed people. By linking recently exposed persons to testing and treatment, this public health intervention has been used to limit the spread of sexually transmitted infections , such as syphilis and gonorrhea, since the early 20th century. In the setting of HIV, however, partner services has had its limitations. In 2006, Katz et al. estimated that fewer than half of newly HIV-diagnosed persons received partner services at public health departments across the United States. Reasons include that partner services is not mandated by law for HIV infection and more importantly that HIV remains a highly stigmatizing condition with significant implications for direct or indirect disclosure. Not only is partner services underutilized, but it can be limited in finding HIV unawares in the setting of newly diagnosed chronic HIV infection in which persons are often required to recall partners from several years prior. In 2007, the Task Force on Community Preventive Services, in reviewing the efficacy of partner services, showed that 20% of all referred partners were newly diagnosed with HIV. Persons with AEH likely represent a group particularly appropriate for partner services, as recall of recent sexual or needle-sharing partners may be more likely to identify putative transmission partners . Studies of partner services in the setting of recent HIV infection are limited, but demonstrate a greater yield of new HIV diagnoses in the setting of newly diagnosed acute HIV infection as compared with partner services provided to chronically HIV-infected persons. We examined the yield of HIV partner services provided to persons newly diagnosed with AEH in San Diego for identification of HIV-unaware persons, individuals with AEH, genetically linked partners and HIV-uninfected individuals at high risk for acquiring HIV infection.

Adults and adolescents were offered confidential and free-of-charge screening for acute, early and established HIV infection at multiple community-based sites in San Diego as part of the San Diego Primary Infection Resource Consortium from 1996 to 2014. Before 2007, a quantitative HIV RNA was performed in HIVantibody–negative persons presenting with signs or symptoms of AEH and behavioral risks for HIV infection . Beginning in 2007, HIV nucleic acid testing was provided to all HIV antibody–negative persons regardless of symptoms and exposures. AHI was defined by a negative or indeterminate HIVantibody test in the presence of detectable HIV-1 RNA, corresponding to Fiebig stages I–II. Early HIV infection was characterized by using one of the available assays to estimate recency Less-Sensitive or Detuned Vitros anti-HIV 1þ2 assay and limiting antigen and defined as HIV antibodyþ/detuned HIV antibody consistent with infection less than 170 days. Consenting antiretroviral -naive individuals with AEH were offered enrollment and longitudinal follow-up in the observational SD PIRC study.Routine clinical laboratories and HIV drug resistance testing were performed at baseline; demographic and behavioral risk data were collected for all individuals. Longitudinal follow-up included visits at weeks 2, 4, 8, 12 and every 24 weeks thereafter. HIV partner services were offered to all AEH clients and included education and counseling to elicit information about recent sex or needle-sharing partners. Index cases were offered ‘self-disclosure’ , ‘dual-disclosure’ and ‘third-party notification’ for recruiting their recent sex or needle-sharing contacts. Study staff providing partner services received structured partner services training by the California Department of Public Health or Centers for Disease Control and Prevention. These structured trainings were repeated by our study staff every 5 years. The trainings included how to elicit partners from index cases, including prompts and reinterviews, and delivering exposure notifications to partners. Privacy concerns were taken very seriously, in particular when an index case chose third-party notification . Partners successfully contacted were offered free-of-charge HIV testing and counseling through SD PIRC or a testing facility of their choice and linkage to prevention and treatment services. Those with positive HIV test results who reported unknown or negative HIV serostatus before HIV testing were defined as newly HIV diagnosed, whereas those who reported positive serostatus or found to have been diagnosed previously were defined as previously diagnosed. All recruited partners who underwent HIV testing and counseling with the SD PIRC provided behavioral risk information, and recruited partners identified with AEHwere also offered enrollment into SD PIRC as index clients . Partnerships were characterized as genetically linked if the HIV population sequence from an index case and their recruited partner were less than or equal to 1.5% genetically different using the Tamura-Nei model. The study focused on sex or needle sharing partners recruited within 6 months of diagnosis of the index case. Statistical analysis was performed using SPSS version 22 and SAS 9.3 . The efficacy of partner services provided to AEH clients was assessed by the number of index cases needed to interview to identify recruited partners: for HIV/STI testing, newly diagnosed with HIV infection, AEH infection and genetically linked index and recruited partners.

Interventions to help MMT clients maintain abstinence from psychoactive substances are urgently needed

Findings should be interpreted within the context of the study limitations. First, this study used a cross-sectional design, so that we were unable to make causal inferences. Second, the psychoactive substance use was based on self-reports that might be under-reported due to social-desirability bias. Third, the study participants were recruited from only the MMT clinics with more than 80 current clients in five provinces of China, so the results might not be generalizable to clinics with fewer clients or clinics outside of the study areas. Despite the limitations, the study has implications for the MMT programs in China. The study findings highlight the importance for policy-makers and health administrators to recognize and respond to the issue of psychoactive substance use within MMT clinics.It is recommended that more attention should be paid to a subset of MMT clients who are young, those who concurrently use heroin, and those who demonstrate depressive symptoms. Overall rates of psychiatric diagnosis found in this juvenile population are fairly consistent with those reported in prior studies of mental health disorders in youths in the juvenile justice system.4,28 Rates are slightly higher than in some other general population detention samples, but the difference may be explained by the fact that juveniles in this study were specifically identified by the judge’s questions about psychiatric difficulties. Rates of detention increased over time and, consistent with our hypotheses,grow tables and trays receiving a dual diagnosis of substance use and other psychiatric disorders substantially heightened the risk of future juvenile detention for these young offenders.

This strong prospective association remained, even after we accounted for known demographic predictors, such as older age, male gender, repeat offender status, and primary externalizing diagnosis, all of which are commonly linked to reoffending and detention. Thus, severe substance use that co-occurs with an Axis I psychiatric disorder may be associated with an increased risk of committing another offense that results in detention. Those in juvenile justice settings should consider expanding their concern about status or criminal offending juveniles with co-occurring substance use and mental health problems, to reduce the risk of future detention. Within 48 hours of detention, many U.S. and international juvenile detention settings implement a brief mental health and substance use screening measure . This type of measure assists unit staff and correctional clinicians in identifying whether the juvenile requires substance use or psychiatric intervention or both. The MAYSI-2, for example, has been widely disseminated in detention and probation settings. To our knowledge, however, neither the MAYSI-2 nor any similar measure has been tested or implemented in court involved, non-incarcerated juveniles supervised in the community who may never be detained or on probation. Implementation and testing of a brief measure that screens for substance use and other psychiatric concerns could be useful in triaging juveniles to the appropriate treatment referral opportunities and thereby perhaps in reducing the risk of future detention. Our data suggest that repeat offenders referred for forensic evaluation have higher rates of psychiatric impairment and co-occurring substance use than those referred at the time of the first offense. Therefore, screening and possibly intervention at the time of the first offense could be critical in preventing entrenched behavioral problems, psychiatric difficulties, and repeat legal involvement. Paraprofessional court staff can be trained to conduct mental health and substance use diagnostic screenings on juveniles before the youths accumulate a history of status or criminal offenses.

Licensed court clinicians could then provide consultation on results and referrals, as needed. From a prevention standpoint, assisting these juveniles in receiving the appropriate treatment at the earliest point of court contact, particularly for substance use, could divert them from their course toward detention and result in positive outcomes for the juveniles and families as well as cost savings for mental health, legal, school, and health systems. From a legal and justice system standpoint, however, it should be considered that improved surveillance of dual-diagnosis offenders can actually lead to more detention than treatment. This possibility could be realized if our findings reflect the negative attitudes of the juvenile justice system toward substance-using young offenders versus the individual factors that we hypothesized are associated with detention. Likewise, judges may impose detention on these young substance abusers to mandate them to treatment within the detention setting, independent of the severity of the offense . The current chart review study was limited to the available clinical data, but future study designs may consider inclusion of data on the attitudes of the juvenile justice system toward substance-abusing young offenders, to understand more about these complex associations. It is also noteworthy that in a sample of juveniles with high rates of mental health disorders, most did not get detained. Thus, psychiatric disorders may not be indicative of the worst future legal outcomes for these youths. Specific psychiatric diagnoses, profiles, or comorbidities also may not be so useful in determining risk of detention among a group of adolescent offenders with severe mental health needs. Consistent with the small body of literature in this area, understanding more about specific mental health profiles or attempting to identify particular diagnoses with risk for detention may not be as helpful in understanding the prospective course of risk for these juveniles. Instead, identifying specific symptoms, symptom constellations, and differences in degree versus kind of symptomatology may be more relevant. Taking a more dimensional versus categorical approach to understanding psychiatric presentation and tailoring recommendations for screenings and interventions based on this dimensional approach may be more predictive of criterion outcomes , as has been demonstrated for the construct of juvenile psychopathy.

Finally, juvenile court clinics should perhaps consider ways to implement brief substance abuse treatment interventions to divert juveniles from future detention. Evidence-based, brief interventions for substance abuse, particularly those that involve motivational interviewing approaches, have achieved great success in reducing alcohol and drug use and associated negative consequences among those in the adolescent community and in clinical samples. However, such brief interventions have rarely been implemented and tested in juvenile detention or juvenile intake settings . To our knowledge, no such brief interventions have been developed or tested for juveniles referred to court clinics. However, our pattern of results suggests that enrolling juveniles and their families in a brief, evidence-based intervention at the point where the family is already referred for court clinic assessment services could be efficient, timely, and perhaps effective in reducing the likelihood of juvenile detention and other negative outcomes. Close to one billion people are affected by mental illness and substance misuse worldwide. In many developed countries, mental illness ranks top for burden of disease , is more common, impactful and costly than other health conditions, and is a core component of overall health. The total cost of mental illness in the USA is estimated to be $2.5 trillion ,marijuana grow tables the global antidepressant market is worth over $13.5billion and the wellness sector is estimated to be worth over $4.5 trillion . Despite record increases in psychiatric medication prescription rates, the prevalence of mental illness is not reducing and may well be increasing in certain populations, such as the young . There are indications that rates of mental illness have increased during the coronavirus disease 2019 pandemic . Evidence indicates that the efficacy of leading drug and psychological interventions is modest, and there is scope for improved tolerability and access . Most mental health interventions are reactive. Effective prophylactic intervention would be hugely valuable . Relatedly, early life trauma and mental illness are reliable predictors of future morbidity. There is a legacy of division between the biological and psychological arms of mental health care and research. A notable initiative towards innovation in biomedical psychiatry is the Research Domain Criteria . The main principle of RDoC is that, since diagnostic criteria are a product of clinical expediency, transdiagnostically relevant pathological mechanisms and treatment targets may have been overlooked. Relatedly, there is now good evidence for genetic overlap between psychiatric disorders . RDoC is primarily a biological initiative that aims to translate mental illness into ‘brain illness’, for the purpose of discovering candidate brain biomarkers and treatment targets .

Notable initiatives towards innovation in psychological health care include efforts to improve the cost-effectiveness of , access to and reach of psychotherapy – e.g. through utilising technological advances and social and familial networks . So-called ‘third wave’ psychotherapeutic approaches have gained traction, e.g. with a spike in the popularity of mindfulness and growing interest in – and evidence for – acceptance and commitment therapy . Bearing in mind relevance to RDoC, one important characteristic of these approaches is their alleged transdiagnostic relevance, i.e. that they seek to identify and target a common pathological mechanism, but more work is needed to link the relevant psychological constructs, such as ‘psychological flexibility’, with biological processes. There are promising signs of confluence between psychiatry’s biological and psychological divisions however, including a growing appreciation of the value of both psychological and neurobiological accounts of mental illness and its aetiology, as well as how environment, mind, brain and body interface and interact – consistent with the ‘biopsychosocial’ model . Specific examples of biopsychosocial research in psychiatry include studying: gene × environment and drug × environment interactions – of which drug assisted psychotherapy can be considered an example , neurophenomenology and the biological mechanisms of psychological interventions . Into this arena comes psychedelic therapy, a quintessentially biopsychosocial intervention. Evidence indicates that psychedelic therapy is a particularly promising and progressive mental health care solution . Classic serotonergic psychedelics can be most precisely defined by their pharmacology, i.e. agonist action at the serotonin 2A receptor, which, if blocked, effectively abolishes their signature psychological effects . Psychedelic therapy is defined here as psychologically supported classic psychedelic drug experiences – although we recognise that psychotherapy alongside experiences induced by certain other psychoactive substances, e.g. MDMA and ketamine, bears relation to classic psychedelic therapy. Psychedelic therapy has shown promise for a range of different mental health conditions, including: depression , end-of-life anxiety , addiction and obsessive compulsive disorder . Indirect evidence also supports its potential for treating eating disorders and chronic pain . See Andersen et al. for a review. The Food and Drug Administration has granted ‘breakthrough therapy’ status to two independent multi-site double-blind randomised controlled trials , aiming to bring psilocybin therapy to marketing authorisation for depression, while related work is currently underway across Europe. Population and controlled studies , as well as large retrospective and prospective surveys , are generating evidence for improved mental well-being across a large demographic, potentially opening psychedelic therapy up to a sizeable wellness market. The successful initiative to legalise psilocybin therapy in Oregon, USA, intentionally included access for healthy individuals. In addition to its putative transdiagnostic utility, other reasons to feel optimistic about psychedelic therapy include: its novel action , and rapid and enduring therapeutic impact . Unlike traditional psychiatric drugs, positive effects have been observed for several months after just one or two doses. In terms of safety, psychedelics such as psilocybin have a favourable toxicity profile and therapeutic index, and negligible addiction potential . Not wishing to neglect rare cases of putative iatrogenesis, including those of so-called ‘hallucinogen persisting perceptual disorder’ , the main hazards of psilocybin therapy relate to the intensity of the psychological state produced by higher doses, and associated need for a carefully engineered contextual container, e.g. with effective psychological preparation, supervision and aftercare. The utilisation of a drug-induced period of heightened cortical plasticity is likely to be a core component of psychedelic therapy’s mechanism of action and candidate functional and anatomical biomarkers of this are already being examined. In the context of a predictive processing framework, the ability of psychedelic therapy to relax and recalibrate cognitive and behavioural biases may be a central part of its action – as may an accelerated learning rate . How can we best advance the science of psychedelic medicine? Here we advocate pragmatic considerations , the utilisation of ‘basket’ protocols , as well as digitally aided data registries. Distinguishing pragmatic from confirmatory trials, the former refers to the actual, realistic conditions under which a therapeutic intervention will be received , whereas confirmatory trials typically engineer experimental conditions to support strong scientific inferences, but these often poorly reflect real-world conditions.

Mental health status was also found to be correlated with psychoactive substance use

Like their talks with the ARHA, coalition-building with organizations that had previously not allied with smoke free policy would later give Smoke-Free Arizona political credibility. ALBA had lobbied the ARHA to endorse Proposition 206.ARHA polled its members and found that they favored Proposition 201 over Proposition 206; in part, this was due to fear of some restaurant owners that Proposition 206 would drive restaurants’ smoking customers to bars. Restaurateurs believed the smoke free ordinance in Tempe had caused smokers to migrate to Phoenix and Scottsdale. According to a Scottsdale Tribune article, the ARHA “expressed concerns that Proposition 206 would favor restaurateurs who could afford to build expensive bar additions,” costing restaurants more to compete with other restaurants trying to skirt the no-smoking restaurants provision by offering sealed-off restaurant-bar smoking sections.The ARHA members, which only two years before had opposed a similar measure in the Legislature, when faced with the restaurants-only ban Proposition 206 proposed, supported Proposition 201 because it did not give a smoking “advantage” to bars. Campaign Chair Bill Pfeifer called the endorsement “significant”136 because ARHA’s support gave the Proposition 201 campaign the political proof they needed to refute Proposition 206’s campaign claim that Proposition 206 had a monopoly on political support from small businesses. Gov. Napolitano and the ARHA’s politically powerful endorsements gave the Smoke-Free Arizona campaign enough political traction to counter Proposition 206’s claim that Proposition 201 was anti-business.About the same time that the Committee to Oppose Smoke-Free Arizona was created,commercial indoor growing table a separate grassroots pro-tobacco group filed an initiative with the Secretary of State on December 20, 2005 and registered as a political committee.

Mostly orchestrated by cigar shops and tobacconists, this second opposition group called itself the “Keep Arizona Free Initiative.” Keep Arizona Free accrued $6,500 in contributions, which it had spent by June 5, 2006, on the Arizona Cigar Lobby, an organization run by Eric Ulis, cigar store owner and chair of the Keep Arizona Free Initiative.This committee’s proposed initiative did not oppose Smoke-Free Arizona, but instead posited its own weak smoking law – much weaker than RJ Reynolds’ eventual counter-initiative – that would have rolled back smoke free areas to only elevators, sections of health facilities, libraries, indoor theaters, halls, and buses.260 All other places would merely require signage indicating whether smoking was allowed or not, and would have required that all employers that allow smoking inform their employees “upon their application for employment, that smoking is permitted within the establishment.”The Keep Arizona Free Initiative never made it off the ground, and there is no evidence of coordination between Keep Arizona Free and ALBA’s Committee to Oppose Smoke-Free Arizona. ALBA President Bill Weigele later reported that, “in April 2006, ALBA [and its Committee to Oppose Smoke-Free Arizona] was asked by the RJ Reynolds Tobacco Company if we were interested in attempting to place a competing initiative on the ballot.”RJ Reynolds told ALBA that its polling showed that, unlike the past, when tobacco company involvement would have been detrimental to a campaign, voters had become so jaded that they expected corporations to be major political players, so that the involvement of a tobacco company did not have the same negative consequences it once did.Furthermore, as disclosed during a July RJ Reynolds Shareholders Teleconference, RJ Reynolds informed the Arizona pro-smoking groups that RJ Reynolds was prepared to spend around $8 million in Arizona to combat the Smoke-Free Arizona initiative.ALBA was set to just run an opposition campaign against Proposition 201 with its limited finances and without direct tobacco industry involvement.

Various members of ALBA, who had worked previously to shut down Tempe and Prescott’s smoke free initiatives on their own, had felt that the taint of tobacco money was not worth the trade-off of the moral high ground.Dr. Lee Fairbanks, who had wrestled with ALBA previously, had been told by ALBA representatives that they would never accept tobacco company contributions.Fairbanks received a call in May 2006 from Bill Weigele, president of ALBA, informing Fairbanks that ALBA board members had voted to work with RJ Reynolds – and their money – to launch the Non-Smokers’ Protection Act.194 In the Tempe and Prescott opposition campaigns, ALBA and associates purportedly did not take tobacco funds, and actually attempted to sue Tempe for Smoke-Free Workplaces for insinuating they had done so.The earlier pro-smoking campaigns against these local ordinances did, however, employ the tobacco industry’s lawyer for Proposition 206, Lisa Hauser,who had been Gov. Symington’s lawyer present at the September 9, 1996 meeting with the tobacco industry to win Symington’s opposition to the state’s lawsuit against the tobacco industry. The “Non-Smoker’s Protection Act,” was registered with the Arizona Secretary of State on May 24, 2006, nine months after Proposition 201 had filed, after ALBA agreed to abandon their campaign and join RJ Reynolds as a co-sponsor of what would become Proposition 206.ALBA’s Weigele later explained in the ALBA Reporter, the organization’s quarterly newsletter, that RJ Reynolds “would opt out bars and the bar area in restaurants from their smoking ban” if ALBA agreed to provide their organization’s name and spokespeople for the initiative.Rather than a committee opposing Proposition 201, ALBA now was part of an anti-smoking law prohibiting smoking in most workplaces and the non-bar sections of restaurants . Mark Anthony DeSimone, member of ALBA Board of Directors, Chaired the Proposition 206 campaign committee, with Fred Malliare as Treasurer. ALBA terminated its Committee to Oppose Smoke-Free Arizona on July 14, 2006.The tobacco industry had been exploring a statewide preemptive initiative in Arizona since at least 2000 to combat local smoke free ordinances where the tobacco industry had less success.However, internal Philip Morris emails regarding Arizona indicate that “the [tobacco] companies elected not to go forward with an initiative [at that time] based on a follow up poll that did not achieve the 60% baseline support said to be necessary for a statewide initiative.”

In response to the industry’s failure to stop the continuing passage of local ordinances,199 in 2001 the industry seriously considered a statewide preemptive smoking regulation initiative. They were prepared to make concessions to public health to gain votes, proposing similar specifications to what RJ Reynolds would include in 2006’s Proposition 206. Dillard wrote to Philip Morris Government Affairs managers Pam Inmann and Ted Lattanzio that as part of the initiative voters would “be asked to choose between the status quo and our [sic] wonderful proposal which would totally protect non-smokers from ETS [environmental tobacco smoke, what the tobacco industry calls secondhand smoke] but – at the same time – permit hospitality establishment owners to exercise their property rights by offering separately ventilated accommodations to smokers as well.”199 RJ Reynolds filed its petition signatures for the “Non-Smoker Protection Act” on July 6, 2006, 15 days after Smoke-Free Arizona filed its signatures for Proposition 201, with more than enough signatures to qualify for the ballot. The Yes on 206 Campaign gathered over 200,000 signatures in the shortest time of any initiative in Arizona’s history to put Proposition 206 on the ballot,paying signature gatherers sometimes $4-$8 per signature, unheard of amounts for Arizona.The Non-Smoker Protection Act included many provisions similar to the Smoke-Free Arizona Act , and portrayed itself as even more protective than Smoke-Free Arizona in preventing children’s exposure to smoke. Proposition 206 would have ended smoking in restaurants and workplaces, but not bars. Bar sections of larger establishments, such as restaurants, hotels, pool halls, and race tracks,commercial marijuana grow tables could allow smoking if completely sealed off and separately ventilated from the restaurant portion. Proposition 206 would also have prohibited children from entering bars and would prohibit children from entering veterans and fraternal clubs when smoking was present. RJ Reynolds’ answer to the universally accepted injunction against exposing children to tobacco smoke was not to outlaw the smoke, but outlaw the kids. Municipal and county ordinances restricting smoking in bars, the bar portions of restaurants, and tobacco shops would be preempted, and any local clean indoor air ordinance stricter in any aspect than Proposition 206 would be nullified. In short, the main effect of Proposition 206 would have been to protect smoking in bars, rolling back any preexisting ordinances prohibiting smoking in bars, and preventing any additional local smoking restrictions from occurring at the local level. Bars are one of the prime locations where the tobacco industry, especially RJ Reynolds, still markets its products under the MSA, and tobacco company-sponsored promotional events and advertising in bars is extremely important for the tobacco industry to sustain tobacco normalization.Furthermore, liquor associations and trade groups often represented tobacco industry interests in Arizona politics, and remaining tied with those industries shielded the tobacco industry. While RJ Reynolds spent almost $8.8 million to prohibit smoking in workplaces and restaurants, their long-term priority to entrench smoking in bars warranted the trade-off.

The criticism of Proposition 203 concentrated on the fact that it was a tax increase. Other claims included that cigarette taxes are regressive,no logical link exists between taxing smokers and paying for early childhood education , funding early childhood education with a tobacco tax is fiscally irresponsible, and the Legislature should be providing general funding sufficient for early childhood care and education.Finally, a criticism leveled at Proposition 203 stated that if tobacco consumption goes down, then funding for the First Things First program and other programs funded by preexisting tobacco excise taxes will also decrease, causing First Things First to ask the Legislature to appropriate more funds for the new program.The brother of the president of the Arizona Tax Research Association 28 wrote a letter to the editor stating that Proposition 203 was “just another ’feel good’ proposition that furtively increases taxes and further burdens the poorer sections of our society.” The pattern for the 2006 election cycle in Arizona, as in Nevada, Ohio, Missouri, and California, was that Phillip Morris focused primarily on fighting tobacco taxes and RJ Reynolds focused primarily on fighting clean indoor air acts. Phillip Morris registered a committee to oppose Proposition 203 on October 12, 2006 a little over three weeks before the election, but did not provide major funding.Unlike RJ Reynolds’ Proposition 206 campaign that had ALBA run the campaign and spent millions, Philip Morris’ No on 203 campaign had its Chair and Treasurer from out of state , and only spent a little over $66,000 on the campaign . This money never translated into any sort of campaign. Despite the fact that a cigarette text increase would reduce smoking, the tobacco companies did not mount a campaign against Proposition 203, instead concentrating on fighting the clean indoor air law, Proposition 201. There was no coordination or collaboration between Propositions 203 and 201, in part because they were different measures with different purposes, and in part because the Proposition 203 campaign was playing down the fact that it was a tobacco tax and did not want Proposition 203 to be associated with tobacco control in fear that this would alienate voters. While an association with Proposition 203’s powerful endorsers might have benefitted Proposition 201, it posed a risk to Proposition 203 because of the tremendous RJ Reynolds media opposition to Proposition 201. Especially given that RJ Reynolds in the last month of campaigning honed in on the 2 cent tax aspect of Proposition 201, First Things First did not want to get caught in the crossfire. Lee Fairbanks commented that “ordinarily [Proposition 203] would have been a target” on the tobacco industry’s radar, but because of Proposition 201, fighting the 80 cent excise tax increase was eclipsed by the industry’s need to fight Smoke-Free Arizona.In a way, Proposition 201 acted as a “shield” for Proposition 203, as $8.8 million was spent fighting Proposition 201, while only a pittance was spent against Proposition 203, and that only at the end of the election. One significant problem that Proposition 203 created for tobacco control in Arizona was that there was no revenue backfill for TEPP and other programs to compensate for the fact that the tax increase would reduce cigarette consumption. This omission meant that when tobacco consumption decreased as a result of the tax increase, funding for Arizona’s tobacco control program from existing tobacco taxes would decline. Long-time TEPP employee Jean-Robert Jeoffroy commented in a 2006 interview that the First Things First “initiative is also very troubling because, Heart, Cancer, and Lung went to them asking for backfill and they refused to put it in.”Sharlene Bozack of ACS explained, “We went to them and said that ‘if they were going to do the 80 cent tax that they needed to do backfill’ and we explained the whole thing and Mrs. Basha said ‘not interested,’ that was her message to us.”Bozack revealed in a 2007 interview that ACS, ALA, and AHA did not support Proposition 203 because it would hurt TEPP.

The voluntary health organizations supported this weak ordinance as their model

ACTA director Andrew Ortiz commented in a 2007 interview that, until 2004 when the statewide coalition developed for the Smoke-Free Arizona initiative, “we were working piecemeal, city-bycity, sometimes working with county governments, so it was much easier for the opponents to stay collectively arrayed against us.”Without a state-level approach to enacting clean indoor air in Arizona , ACTA’s expertise and resources could only reach those communities already primed to pass an ordinance . Nonetheless, ACTA’s role as a catalyst and technical support resource was crucial to the success of many of the local smoke free ordinances from 2001 through 2004. The small city of Surprise passed a smoke free ordinance through the City Council, 5-2 on January 10, 2002. It went into effect February 10 and prevented smoking “in any enclosed place where the public gathers,” including restaurants, businesses and government buildings. It excluded freestanding bars, smoke shops, 25 percent of all motel rooms, and outdoor areas as long as smoke does not enter buildings.First time violators were fined $100. Surprise became the first city in the West Valley of the metropolitan Phoenix area to end smoking in restaurants and workplaces, and helped spark Goodyear and other cities to act similarly. A grassroots group of Surprise citizens affiliated with ACAS first raised the issue when it filed a petition with signatures to put a smoke free city ordinance proposal on the March 2003 ballot, but the City Council, not wanting to wait a year for the election,plastic grow table decided to address the issue through the Council. A December 2000 poll by O’Neil Associates Inc. conducted for ACAS and ACTA had previously found 74% of Surprise voters favored smoke free enclosed public spaces.

The importance of Surprise’s ordinance lies in its timing because it happened just as the whole metropolitan Phoenix area attempted to negotiate a region wide smoke free law, including input from the Maricopa County Board of Health. Surprise’s City Council’s leadership inspired tobacco control advocates to take the lead and create smoke free ordinances throughout Maricopa County. In the East Valley , the town of Gilbert passed a clean indoor air ordinance on May 1, 2001 based on Mesa’s weakened 1996 ordinance that included workplaces, restaurants, bowling alleys and bingo halls, but excluded bars and restaurant bars and allowed for an exemption for restaurants “anticipating” a loss in revenues. Enforcement began November 12, 2001. Adopted unanimously by the Gilbert City Council, the ordinance was a product of Mayor Cynthia Dunham’s efforts in bringing the city, health groups, and local chambers of commerce to the table.Gilbert became the testing grounds for the “model ordinance” drafted by Jessica Pope, Government Relations Director of the Southwest Region of the American Heart Association and Eric Emmert of the East Valley Chamber of Commerce whom were working together to develop a region-wide smoke free law designed to be a model for all cities in the East Valley, including Chandler, Tempe, and Scottsdale. As a result of political compromises with Eric Emmert of the East Valley Chamber of Commerce, however, Gilbert’s “model ordinance” contained compromises particular to the politics of passing the ordinance in Gilbert that would have been passed down to other cities, including the “opt out” provision of anticipated hardship.Pope explained her reticence to include smoke free bars in Gilbert and the model ordinance for the East Valley on March 30, 2001, when she told the Southwest Valley Tribune, “We feel we should write an ordinance that reflects what the public wants. I understand where Dr. Fairbanks is coming from [in wanting to include bars as a health rather than a political issue] and I agree with him, but Arizona is not ready for smoke-free bars.

In time, I think Arizona will get there, but we’re not there yet.”While Pope and Emmert sought a region wide smoke free ordinance excluding bars, Fairbanks, who had disagreed with this exemption, actively resisted the AHA’s exemption-laden smoking ordinance proposal. Gilbert’s smoke free ordinance was not progressive for its time. The Gilbert ordinance allowed for hardship exemptions in restaurants showing 15% or greater loss in revenue compared to the previous year and allowed for separately sealed-off and ventilated smoking rooms for bar sections of restaurants. In addition to allowing hardship exemptions, the ordinance also allowed for anticipated hardship exemptions, that is, it permitted exemptions from the smoke free ordinance before evidence of economic harm occurred and prior to enforcement of the ordinance.At the time of the ordinance’s implementation in October 2001,seven restaurants were granted exemptions. Former Americans for Nonsmokers’ Rights staffer Tim Filler suggested in a 2007 interview that because the health voluntaries’ push for the clean indoor air ordinances was funded by a Robert Wood Johnson Foundation grant which they hoped to renew, there may have been pressure on the health voluntaries to go for quantity rather than quality in passing smoke free ordinances.204Several attempts at regional tobacco control existed prior to the 2006 statewide effort. Most notably, from September to December 2001 Phoenix area chambers of commerce and voluntary health associations entertained collaboration on a Greater Phoenix Area East Valley clean indoor air ordinance which would have provided uniform standards across the region. While the proposed clean air ordinance would have been a slight improvement on existing smoking policies – at the time most cities in the area only addressed municipal buildings and non-smoking sections in restaurant – the compromise ordinance was substantially weaker than Arizona’s benchmark ordinance at the time, the 1996 Mesa ordinance, which mandated smoke free restaurants and restaurant bars but exempted stand-alone bars with class-6 liquor licenses.

Instead of surpassing the weakened Mesa ordinance, the East Valley regional smoking ordinance would have ended smoking in restaurants in Gilbert, Scottsdale, Chandler, and Tempe, while not addressing bars or the bar portions of restaurants. During the stalled negotiations for the regional smoking ordinance, ACAS President Lee Fairbanks realized a region-wide smoke free ordinance including bars was not likely to materialize through the current chambers of commerce-health voluntary negotiations, so he started working on a petition for the Smoke-Free Tempe initiative, which would become the most comprehensive clean air ordinance in Arizona. Because the business-health coalition was attempting to hammer out a regional clean indoor air policy for the entire Phoenix Metropolitan region, both sides were willing to accept certain compromises. Restaurants would be smoke free, a stricter standard than the nonsmoking sections most of cities involved had on the books. But the catch to the region-wide agreement, however, was a caveat to only implement the law if Phoenix also passed the same ordinance. The main flaw of this policy was that the “model ordinance” the voluntaries and the East Valley Chamber of Commerce initially agreed upon included a hardship exemption for anticipated hardship, not proven hardship.The health voluntaries came to the table to negotiate with the business community from an already compromised position, leaving the East Valley ordinance a model only for protobacco interests. The major gap in Arizona’s local tobacco control has perpetually been Phoenix. In response to the discussion regarding a region-wide East Valley and Phoenix no-smoking ordinance proposed by Eric Emmert of the East Valley Chamber of Commerce together with the health voluntary organizations, Phoenix Mayor Skip Rimsza shrugged off the idea of Phoenix joining the plan, responding to reporters in a 2002 interview, “I know other cities are struggling with this [smoking ordinance] issue, but it has not hit our radar screen at all.”By 2004, however, the Phoenix Environmental Quality Commission, a standing Phoenix City Council-appointed board of 15 volunteers,rolling bench grow tables examined smoke free ordinance options for Phoenix, and asked the Phoenix City Council to support policy implementing a regional or statewide smoke free law covering at least workplaces and restaurants.The Commission’s recommendation, along with the East Valley chambers of commerce and the health voluntaries’ pressure to join in the region-wide smoking ordinance was not successful. Realizing that their capital city leaders did not have the political will to adopt a smoke free ordinance, and Arizona’s state Legislature would not pass a smoke free law, the statewide smoke free initiative campaign organizers viewed a statewide campaign as primarily benefitting Phoenix by providing it with smoke free coverage when government leadership was reticent to act. Despite the existence of organizations such as Smoke-free Phoenix and the AHA, ALA, ACS, and ACAS working between 2001 and 2005 to influence Phoenix city smoke free policy, Phoenix stood stubbornly with its 1988 policy that allowed smoking virtually in all public places including workplaces, as long as the establishment was accompanied by proper signage, the tobacco industry’s “accommodation” solution.

Phoenix’s refusal to address the smoking issue inhibited other cities in the greater Phoenix region from acting because of economic worries that smoke free ordinances would cause an exodus of smokers to cities without ordinances, which in the metropolitan area often meant merely crossing the street. While Guadalupe’s comprehensive smoke free ordinance passed without incident in its Town Council, out of all of the smoke free ordinances passed in Arizona, Tempe’s had both the most organized opposition and played the greatest role in setting into motion the statewide smoke free initiative that would come in 2006. Tempe’s success in passing Arizona’s first comprehensive smoke free city ordinance including bars by initiative on May 21, 2002 surprised the voluntary health organizations who believed Arizona was not “ready” for smoke free bars and convinced them Arizonans wanted 100% clean indoor air.Dr. Leland Fairbanks and Arizonans Concerned About Smoking created the momentum for Tempe’s groundbreaking smoke free ordinance initiative, Tempeans for Healthy Smoke-Free Workplaces, by investing the time and money necessary to run a viable local ballot initiative campaign. Tempe is home to Arizona State University and Mill Avenue, a central artery of bars, clubs and other venues which cater to the partying University population. A suburb of Phoenix, Tempe has a large student population, which led skeptics to think Tempe would be the last major city in Arizona to pass a comprehensive smoke free ordinance, not the first.As discussed earlier, in 2001 the heads of the greater Phoenix area city governments met with health groups and business leaders to hammer out a region-wide “East Valley Ordinance” that would be amenable to business groups.However, as political compromises and concessions began to unravel the East Valley regional ordinance, the voluntary health organizations’ acquiescence in exempting bars for the regional model ordinance led to Fairbanks and ACAS to strike out on their own in Tempe. In Summer 2001, the Tempe City Council refused to allow Fairbanks to discuss the possibility of a smoke free ordinance at their City Council meeting or put it on the agenda. The only Council member vocally sympathetic to the smoke free ordinance was Dennis Cahill, but he could not help Fairbanks with the Council . The next day Fairbanks collected the forms necessary to place an initiative on the May, 2002 ballot, filed with the City Clerk, and began gathering over 20,000 signatures for a law that would make all indoor spaces in Tempe smoke free, including bars. He submitted the required signatures in December, 2001 for the Tempe for Healthy Smoke-Free Workplaces initiative. ACAS spearheaded the effort, contributing almost the entire $100,000 the campaign raised. ACAS’s action threatened to disrupt the alliances the health groups had formed with business leaders and chambers of commerce to pass their weak regional smoking ordinance , so the health voluntaries attempted to dissuade the ACAS from pursuing their separate smoke free ordinance in Tempe.204 Because ACAS included bars, the one indoor area in which the voluntary health organizations were willing to allow smoking, ACAS did not enjoy the initial support of ACS, AHA, and ALA. These groups believed 1) Arizona was not ready to include bars, and 2) the ACAS did not have the support necessary in Tempe to include bars.ACAS soon proved the health voluntaries wrong. At the same time, the health voluntaries’ strategy of remaining in agreements with regional chambers of commerce was falling apart. Gilbert’s weak smoke free ordinance was to serve as the voluntaries’ model and Scottsdale Mayor Mary Manross had just announced that if Phoenix was not going to be part of the ordinance, then Scottsdale would not either, and Phoenix had made clear that they were not going to budge.

The Ash Kicker also served as a distribution center for anti-tobacco branded merchandise

Dillenberg initially argued that restricting the program’s scope occurred as a byproduct of the limited funds. However, Dillenberg may have been forced to limit the scope of the campaign by Governor Symington’s attempts to sabotage the program.In a 2006 interview, Matt Madonna, one of the key members of the 1994’s Arizona for a Healthy Future coalition that created TEPP, said, “there was a time when the [ADHS] chief was a puppet of the governor [Symington] and the governor was not in favor of doing anything that was going to block tobacco… We had to focus on pregnant women and children and that [decision] came right out of the governor’s office [emphasis added].”TEPP’s central administrative staff in Phoenix comprises its structural core, while TEPP services mainly operate through local projects at the county level and statewide contractors for media and evaluation . During its period of the high per capita funding from FY1998-2001, the US Centers for Disease Control and Prevention reported that Arizona smoking prevalence dropped rapidly , from 23.1% in 1996 to 18.3% in 1999.The CDC also noted that the decline in smoking occurred across low income and low education groups, decreasing health disparities. The Arizona Adult Tobacco Survey comparisons by the ADHS led the CDC in the 2001 Mortality and Morbidity Weekly Report to write: “On the basis of these findings, if all states implemented comprehensive programs similar to those in Arizona,garden grow table the national health objective for 2010 of reducing the adult smoking rate by half during this decade could be achieved.”One analysis estimated that roughly 61 percent of the reduction in smoking between 1993 and 2002 was due to price increases on tobacco products and 38 percent due to media campaigns.

Our previous report, Tobacco Control in Arizona concluded that despite securing stable funding for TEPP, “health advocates have generally failed to force the state to run an effective anti-tobacco program.”Initially, TEPP was prevented by the Symington administration from collecting baseline data on both youth and adult smoking prevalence before the media program started.Standardization of evaluation and surveillance did not become streamlined and consolidated into a single agency until after 2002 when Proposition 303’s language required TEPP to uniformize its procedures in this area by mandating biennial reports presented to the Arizona Legislature.TEPP since its inception in 1995 experienced a high rate of staff turnover, both among office employees and the Office Chief. Several factors contributed to Office Chief and staff turnover, including uncompetitive remuneration, hiring from within ADHS instead of seeking external applicants, and making the Office Chief position political by having it be an appointed position and at the will of the ADHS director instead of the position covered by the state merit employment procedures. The Office Chief position is subject to removal by executive branch superiors, which has contributed to more conservative and less effective programming, especially regarding media. Jesse Nodora, the second longest serving person in TEPP’s office from 1995-2005 observed in a 2006 interview, “the program went through four office chiefs in my tenure, from Martha Cliff to Rosalie Lopez to Kathy Bischoff to Patricia Tarango. And, you know, oddly enough, none of those people were ever recruited externally, under open searches, which is kind of the typical thing” for government recruitment at the manager-level and above.This lack of external job postings in the hiring process dragged into the equation political alliances and debts from hiring internally, and hindered the Office Chief from furthering TEPP’s aims to their fullest capability.

Especially during the years 2003-2006 when the program was in administrative and financial disarray and turnover was even more detrimental to the organization, the constantly vacant Office Chief position made it difficult for TEPP to sustain a consistent program. While TEPP’s local projects service providers kept TEPP from collapsing, the central administrative decision-making harmed the program and prevented it from being effective. The legislative budget cuts brought programmatic problems which were exacerbated by poor administrative handling of TEPP’s new financial situation, causing the dismantling of more programs than necessary. The Arizona Republic ran stories in 2001 describing how Governor Hull’s proposed TEPP defunding “guts” or “would end the nationally known… anti-smoking campaign.”Then-TEPP Office Chief Cathy Bischoff appears to have taken that prediction as a directive. Disproportionately decreasing the amount spent on media – TEPP’s most effective tool for tobacco prevention – while building up a reserve of unspent funds in TEPP’s Health Education Account weakened Arizona’s tobacco control program more than the actual budget diversions themselves required. As Office Chief of TEPP from 2000-2003 Bischoff played a decisive role in undoing Arizona’s successful tobacco control program. Nina Jones remarked that Bischoff “took a sinking ship [TEPP] and let it sink,”138 refusing to spend TEPP’s available funds on media efforts, and cutting key programs. Bischoff helped create the situation in TEPP as if Hull had gotten her originally requested $60 million from TEPP rather than the actual $32.8 which was transferred. Instead of aggressively sustaining existing programs which had proven successful, Bischoff instead wiped out the Arizona Cessation Training and Evaluation unit, the Arizona Tobacco Information Network, and other effective programs that TEPP developed. When many of these programs were cut, up to a year after the original budget cuts, TEPP had already been voter protected, its funds secured. Yet instead of spending the full revenue it received yearly, TEPP began building up a reserve of unspent funds it could have used instead to maintain and bolster its programs. From 2003 through 2006 TEPP endured large gaps of time without an Office Chief.

While Patricia Tarango filled the Office Chief role from mid-2004 through the first half of 2006, Tarango provided TEPP with only the minimal leadership and programming required to keep it afloat, and from June 2006 to March 2007 the Office Chief position was again vacant. In 2006 ADHS Director Sue Gerard invited TEPP’s oversight committee, the TRUST Commission, to assist in a nationwide search for a new TEPP Office Chief. Gerard also included a higher salary range, which gave tobacco control advocates and ADHS staff optimism they would be able to retain future officers.13 On January 29, 2007, ADHS announced Wayne Tormala as the new Office Chief of TEPP.142 The Bureau Chief Position paid $106,000, increased from previous TEPP Office Chief salaries from 2004 to 2006 of $69,000 and $80,000. While Tormala had no experience in tobacco control, he had worked as the City of Phoenix’s Community Initiatives Coordinator, and was viewed as a leader who could bring disparate members of Arizona’s tobacco control community together. Several TRUST Commission members noted as a positive sign Tormala’s willingness to attend a TEPP-TRUST Commission retreat to help foster relations between the program and the oversight committee. Previous TEPP directors had viewed the TRUST Commission less as an ally to reducing tobacco use and more as a committee they were forced to present reports to. In 2007, TEPP restructured,greenhouse grow tables completely replacing its central office staff, with no employees working in TEPP in 2005 remaining. TEPP also engaged in a lengthy strategic planning campaign, aiming to receive input from all those invested in Arizona tobacco control, such as county health departments, service providers, local project coordinators, and tobacco control advocates. TEPP also changed its name in December 2007 to BTEP – the Bureau of Tobacco Education and Prevention – in an effort to emphasize that TEPP was turning over a new leaf, breaking from the negative connotations some Arizonan leaders linked with TEPP’s history.Arizona’s anti-tobacco counter-advertising has never challenged the tobacco industry and seldom has squarely addressed the issue of addiction. While this policy originally resulted from ADHS Director Jack Dillenberg’s decision,no subsequent ADHS director decisively expanded TEPP’s media campaign to focus on secondhand smoke or tobacco industry manipulation. From 1996- 1998 TEPP focused roughly half of its resources on its media campaign while limiting its focus to pre-adolescent and pregnant women, opening it up to adult cessation in 1998 and nominally to secondhand smoke in 1999. From 1996 to mid-2001, TEPP contracted with Riester~Robb , a Phoenix-based advertising agency to handle its media campaign.

TEPP’s contract was the largest public media contract in the state at the time.Because ADHS Director Jack Dillenberg had limited TEPP’s media audience to only children and pregnant women and their spouses, Riester believed the target audience would best be reached by approaching tobacco as “gross” and disgusting, accentuating dramatizations of the short- and long-term effects of tobacco .Riester’s “teeth-staining, tumor-causing, smelly, puking habit” tagline was widely recognized, and TEPP went on to sell at-cost more than 2 million pieces of the “tumor-causing”- branded merchandise to local projects contractors from TEPP and schools and prevention agencies across Arizona, with substantial sales to other states’ tobacco control programs as well.The “tumor-causing” campaign was highly visible in Arizona from 1996 through 2001, depicting tobacco as a gross habit with severe adverse health consequences. A popular component of Riester’s initial 1996 “tumor-causing” campaign included a Hummer-towed 46-foot interactive traveling anti-tobacco exhibit that youth could walk through termed the “Ash Kicker.” TEPP Office Chief Rosalie Lopez at the time called the Ash Kicker “a pied piper that is leading [children] to a tobacco-free life.”By the end of 1997, 27% of Arizona teenagers had toured the Ash Kicker, and in 1998 Riester revamped the Ash Kicker as a “bio-hazard laboratory under siege from the effects of tobacco,” remodeling the previous version into a decaying human body, diseased by tobacco use.While there is no evidence that the Ash Kicker actually affected the smoking behavior of youth, it did provide media attention and served as a high-profile attraction that would bring youth to anti-tobacco events. Riester’s graphic television commercials contained shocking and humorous images geared toward adolescents. Numerous Riester~Robb commercials won awards and have been used by 38 states and Canada.One of them, “Theater Snacks,” shows a girl, thinking she’s sipping her soft-drink, inadvertently drinking out of her date’s spit tobacco cup at the movies, shrieking in horror as the character in the movie does. “P.P.” shows two boys smoking on a street corner. Their smoke hits the face of their Jack Russell Terrier, which in response urinates on the lit cigarette. “Maggots” depicts a girl who is smoking, who finds that her face soon falls apart and disintegrates with maggots crawling out of her mouth. This advertisement achieved high recall rate and impact on kids but offended a large number of adults. A TEPP employee at the time noted that “‘Maggots’ offended people inside the movement too.”While the target audience, kids, could handle it, the adults could not, and controversy created by the public backlash the advertising agency received reached the point where Riester included a warning announcement before the commercial notifying viewers of the graphic content of the commercial.Because graphic intensity and grossness were thought to be effective in reaching young viewers, Riester’s “Smoking Drill” later created in 2000 elevated these qualities to a new level.The graphically repulsive and gross Riester commercials were effective in getting the attention of viewers , according to evaluations by the University of Arizona for TEPP.The 1999 Arizona Adult Tobacco Survey Report released in May 2000, showed a 21 percent drop in Arizona adult tobacco use prevalence from 1996 to 1999. The ADHS acting director at the time credited Riester’s media campaign as the major contributing component.In September 1998, TEPP launched its first cessation media campaign, breaking the previous bar on tobacco-prevention counter-advertising to adults. Their “Chuck” and “Carlos” cessation campaigns were each comprised of a series of TV spots showing the protagonists’ progression toward quitting tobacco to encourage smokers to meet the challenges of quitting. Quitline calls increased dramatically during this period, as it was tied in with the commercials. While their “Chuck” campaign was a success, Riester-Robb and TEPP soon realized through the very low response rates from Spanish-speakers to the “Carlos” advertisements that language translations required accompanying cultural translation to succeed.TEPP used social marketing to disseminate their anti-tobacco message through print, TV, radio, movie on-screen billboards, websites, mall kiosks, and outdoor billboards. In an effort to mitigate Hollywood’s glamorization of tobacco in the movies, in FY1999 TEPP budgeted $156,000 for six different pre-movie on-screen billboard stills in 50 theaters across Arizona.

Is Vertical Farming Good For The Environment

Vertical farming has the potential to be beneficial for the environment in several ways, but its overall environmental impact depends on various factors, including the specific practices, technologies used, and the context in which it is implemented. Here are some potential environmental benefits of vertical farming:

Reduced Land Use: Vertical farming allows for the cultivation of crops in a smaller footprint compared to traditional agriculture. This can help protect natural ecosystems from conversion into farmland,greenhouse growing tables reducing deforestation and habitat loss.
Water Conservation: Vertical farming systems often use recirculating hydroponic or aeroponic systems that require significantly less water compared to conventional soil-based farming. Water is efficiently delivered to the plants, minimizing wastage and reducing the strain on local water resources.
Reduced Pesticide Use: Controlled indoor environments can reduce the need for pesticides and herbicides, which can have negative impacts on the environment and human health. Integrated pest management techniques can be employed to minimize the use of harmful chemicals.
Energy Efficiency: While vertical farms require energy for lighting, heating, and climate control, advancements in energy-efficient technologies like LED lighting and smart climate control systems can mitigate energy consumption. In some cases, vertical farms can use renewable energy sources, further reducing their carbon footprint.
Year-Round Production: Vertical farming allows for consistent crop production regardless of external weather conditions. This reduces the need for long-distance transportation of produce from regions with different growing seasons, lowering greenhouse gas emissions associated with transportation.
Local Food Production: Vertical farms can be established in urban areas, bringing food production closer to consumers and reducing the need for long transportation routes. This can cut down on the carbon emissions generated by food transportation.
Soil Health Preservation: Traditional agriculture can lead to soil degradation through erosion and nutrient depletion. Vertical farming doesn’t rely on soil, which can help protect valuable topsoil and preserve soil health.
Reduced Food Waste: Vertical farms can produce crops with predictable yields, minimizing the risk of crop failure due to weather events. This can contribute to reduced food waste, as less produce is lost to unpredictable weather conditions.

However, it’s important to note that vertical farming also comes with its own set of challenges and potential environmental concerns, such as:

Energy Consumption: The energy required for artificial lighting, climate control, and other operations in vertical farms can be significant, especially if the energy comes from non-renewable sources. Implementing energy-efficient technologies and utilizing renewable energy can help mitigate this concern.
Resource Intensiveness: The production of the infrastructure and equipment needed for vertical farming, such as LED lights and specialized growing systems,plant growing table can have environmental impacts due to resource extraction, manufacturing, and waste generation.
High Initial Costs: Setting up and maintaining a vertical farm can require a substantial financial investment, which might not be feasible for all farmers or regions.
E-Waste: The rapid pace of technological advancement could lead to the disposal of outdated equipment and components, contributing to electronic waste (e-waste) concerns.

In summary, vertical farming has the potential to be environmentally beneficial when practiced thoughtfully and with a focus on sustainable practices, efficient resource use, and renewable energy sources. Like any farming method, its impact on the environment will depend on the choices made by farmers and the technologies they employ.

Proposition 200 was sponsored by the AzHHA and their ally the Children’s Action Alliance

Working through local hospitality association affiliation is an important strategy for the tobacco industry, because it allows the tobacco industry involvement in politics and public health issues while keeping out of the public eye.In addition to assistance with lobbying and public relations, the restaurant and licensed beverage associations and several chambers of commerce aligned with the tobacco industry on tobacco public policy, first to oppose Proposition 200 in 1994, which increased the tobacco tax and created Arizona’s tobacco control program, which the tobacco industry labeled as bad for business. As elsewhere,the tobacco industry had convinced these Arizona industries their business would suffer if Arizona tobacco taxes were increased or workplaces were made smoke free. Independent research has consistently shown that smoke free laws have no effect or a positive effect on hospitality industry business.The Synar Amendment is federal legislation coupling mental health and drug abuse prevention block grant funding with meeting targets of reducing the sale of tobacco products to minors. The ADHS Division of Behavioral Health Services is responsible for conducting the inspections used to determine eligibility under the Synar Amendment to receive federal Substance Abuse and Mental Health Services Administration SAMHSA’s block grants to the state require tobacco youth access noncompliance rates of 20% or lower to receive full federal funding.Although Arizona could combine its Synar inspections with youth access law enforcement efforts in Arizona as some other states do, ADHS chooses not to.While at first glance Arizona’s history complying with the Synar Amendment appears positive and uneventful, with a low 7.6% violation rate in 2006 ,movable grow racks other government agencies’ differing reported youth access compliance rates raise questions about the situation.

ADHS’ Behavioral Health Division subcontracts with the Pima County Partnership and Community Bridges organizations to actually inspect tobacco retailers, which yielded the 7.6% noncompliance rate, which is well below the 20% threshold.This retailer noncompliance rate, however, is significantly lower than the noncompliance rates observed by Arizona Attorney General’s Office working with TEPP, which found 23% noncompliance. Law enforcement accompanies most AGO youth access compliance inspections,and, as a result, one would expect the AGO’s compliance checks to find higher – not lower – compliance.Potential reasons for the discrepancy given in Arizona’s application to receive SAMHSA funds include Behavioral Health and the AGO checking different retailers, drawn from different lists.For example, Behavioral Health does not check Native American Reservations, while the AGO checks do. Arizona’s AGO makes more than twice the amount of compliance checks that ADHS does, and also routinely brings law enforcement along to cite the offending retailers. The fact that the more vigorous AGO-TEPP youth access compliance checks are reporting retailer noncompliance rates three times that reported by the ADHS Division of Behavior of Health Services’ checks raises serious questions about the reliability of the data Arizona is submitting to the federal government to document its compliance with the Synar Amendment.The process that led to the Master Settlement Agreement began when the states of Mississippi and Minnesota sued the tobacco industry in 1994 to recover the costs of smoking-caused illness for state healthcare programs and to win restrictions on cigarette marketing, particularly those directed toward youth. Despite opposition from Governor Symington , in August, 1996 Arizona sued the tobaccoindustry. In 1998, Arizona was one of 46 states participating in the “Master Settlement Agreement” that resolved the state litigation in exchange for monetary payments to the states and the tobacco industry accepting some restrictions on its marketing activities.The MSA yielded $3.1 billion to Arizona over the first 25 years. In the end, all the MSA money went to the state Medicaid program , with no funds for tobacco control. The voluntary health agencies , which had led the 1994 initiative creating the state’s tobacco control program , made only minimal efforts to secure the MSA money as a source of funding for Arizona’s tobacco control program.

They did not pursue the MSA to fund tobacco control because in 1999-2000 when decisions on spending the MSA money were made, Arizona had one of the highest per capita expenditures for tobacco control in the U.S. and its funding seemed secure. Ironically, an unintended effect of Arizona’s MSA allocation actually would contribute to TEPP’s evisceration in FY2002.Proposition 200, “Healthy Children, Healthy Families,” would have provided prevention services for preschool-age children and families, health insurance coverage for eligible uninsured parents, schools to enroll uninsured children in KidsCare, hospice care for the terminally ill, and fund early detection and prevention for the most common causes of death in Arizona including cancer and stroke.Proposition 200 had the endorsement of the voluntary health organizations which had worked with the AzHHA to pass the 1994 tobacco tax because the 2000 Proposition 200 would have secured TEPP funding from the kind of legislative diversions that had occurred in the past.In addition to allocating MSA funds, Proposition 200 would “reenact” Proposition 200 of 1994 to “voter protect” the 1994 proposition. “Voter protection” in Arizona refers to a law created by a 1998 initiative stating that all ballot measures passed by the voters of Arizona are not subject to legislative change except under narrow circumstances. Because the voter protection amendment was not retroactive, it did not apply to the 1994 Proposition that created TEPP and its funding source, the 23% allocation from the 40 cent tobacco tax. By including the text of the 1994 Proposition along with the allocation of the MSA funds, the 2000 Proposition 200 would voter-protect 1994’s Proposition 200 and prevent the Legislature from raiding TEPP’s funding. Rival Proposition 204, the “Healthy Arizona Initiative,” was started by Mark Osterloh, a physician in Tucson, who wanted to expand the eligibility for AHCCCS to 100% of the federal poverty level . Proposition 204 required that AHCCCS serve everyone up to the federal poverty level and allocated all the MSA funds to help pay for doing so.

The state would be obligated to provide services to these people, even if the MSA funds were not adequate to cover the costs. Proposition 204 aimed to provide healthcare to “approximately 130,000 uninsured poor people through extension of the existing state health program, AHCCCS.”The initiative noted that at the time “only those with very low incomes–less than $5,500 a year for a family of four, or one-third the federal poverty level–[were] eligible for AHCCCS.”Proposition 204 not only increased the number of working poor eligible for medical care coverage, but also expand health education,plant growing racks nutrition and prevention programs, premium sharing,* and other health care programs. After a failed attempt to implement Healthy Arizona in 1996 when it passed on the ballot but the Legislature refused to fund it from the General Fund, Osterloh decided that the MSA funds were a perfect opportunity to expand Arizona’s Medicaid program. By April 1999 he had started to gather contributionsto finance his proposed initiative . He took out his first loan to fund his planned MSA initiative on September 29, 1999.AzHHA CEO John Rivers and his colleagues at the AzHHA saw the MSA money as an opportunity for funding hospital expenses for Medicaid. After Osterloh’s committee announced its initiative intentions for the MSA money, the gate was opened for Rivers’ initiative. To get the support of the health voluntaries and to appease tobacco control advocates – and because of Rivers’ long history of strong support for tobacco control, dating back to his leadership in passing Proposition 200 in 199411, 24 – the AzHHA included the text of the original 1994 Proposition 200 in their initiative to voter-protect the TEPP funds. Normally, if both initiatives passed, both would go into effect, with the provisions of the one receiving more votes taking priority in case of a conflict. The AzHHA, however, included additional “poison pill” language to ensure that the AzHHA allocation of funds would take priority if they won, creating a situation where only the initiative that received the most votes would go into effect if both passed. AzHHA included this language so that the Osterloh’s initiative would not go into effect should the AzHHA initiative get more votes, but it also prevented the AzHHA’s provisions should Osterloh’s campaign receive more votes. A legal challenge Proposition 204’s proponents filed against the State of Arizona demanding retraction of the sample ballot statement of the possible ramifications of the initiative may have contributed to their success at the ballot. The Arizona Legislative Council and the Joint Legislative Budget Committee includes analysis of each ballot measure in literature voters receive to assess each measure’s fiscal impact on the state.

Proposition 204 proponents challenged this statement in court and eventually won a decision by the Arizona Supreme Court, barring from inclusion in the Legislative Council analysis the concerning the future fiscal impact of expanding AHCCCS beyond the MSA’s revenues.The Healthy Arizona Initiative committee prevented the public from knowing the full ramifications of passing Proposition 204,84 even though the disputed analysis would in FY2002 become Arizona’s reality. In a 2006 interview, Rivers remarked that expanding AHCCCS eligibility “was a goal that we [Proposition 200] supported 100% but we knew there wasn’t enough tobacco settlement money to do that and that was where the divide occurred between our measures. We allocated the tobacco settlement money for early childhood development money and expanded access to our AHCCCS program, but only within the available resources of the MSA. [emphasis added]”To fully fund the AHCCCS up to the federal poverty level, much more money was required than the MSA would provide. By design, Proposition 204 was an underfunded program unalterable by the Legislature, which would suck resources from other program areas and the general fund. This situation would ultimately happen in FY2002, when $32.8 million was transferred from TEPP to AHCCCS. Both initiatives passed in the November 7, 2000 election, with Proposition 200 receiving 54% and Proposition 204 receiving 58% of the vote. The Proposition 200 “poison pill” language provided that in the case of both propositions passing, the one with the most votes would go into effect while preventing the less successful measure from having any effect. Had the poison pill provision not been included, Proposition 200would have voter protected the 1994 Proposition 200 even though 204 received more votes. Instead, the hospitals’ “poison pill” clause would have the unfortunate side effect of preventing the voter-protection provisions in Proposition 200 from going into effect, opening the door for a legislative raid on TEPP.The tobacco companies were closely watching the allocation of the MSA money in Arizona, as they were in all the states. The industry was prohibited from playing any direct role in the debate over allocation of MSA money because the MSA provides that no Participating Manufacturer “may support or cause to be supported the diversion of any proceeds of this settlement to any program or use that is neither tobacco-related nor health-related in connection with the approval of this Agreement or in any subsequent legislative appropriation of settlement proceeds.”Nonetheless, tobacco industry lawyers grew concerned over the reenactment of the 1994 tobacco tax increase that Proposition 200 contained; they mistakenly thought Proposition 200 intended to double the 1994 40 cent tobacco tax by reenacting it.Because of this false belief, the industry preferred Proposition 204 to Proposition 200.Despite the MSA’s restrictions on tobacco industry interference with decisions regarding spending the MSA funds, an email from Ginny Corwin to Ted Lattanzio and Pam Inmann among others, reported that, “we are looking at meeting in Phoenix on August 16 or 18 to determine interest by the industry in opposing [Proposition] 200.”Opposition to Proposition 200 did not appear to relate to voter-protection of the TEPP funds; the industry’s preoccupation revolved around Proposition 200’s actual language and its mistaken belief in an additional 40 cent tobacco tax.In a draft of a letter to Arizona Attorney General Janet Napolitano, Rip Wilson, lobbyist for Philip Morris, thanks Napolitano for meeting with him and Paul Eckstein “regarding ambiguities that we believe may be present in Proposition 200 regarding the repeal and implementation of the current $.40 per pack tax on cigarettes.”He goes on to provide four paragraphs arguing that Proposition 200 does not create an additional 40 cent tax, and asks Napolitano to communicate to him or his associate “should [she] be presented with an argument that indeed claims that the current tax on tobacco should be doubled under the provisions of Prop. 200.”

Diaries were used to detect effects of cooking and indoor combustion events

It is possible that associations between allergic respiratory illnesses and traffic density are due to NAAQS criteria air pollutants, particularly NO2, which is directly related to local traffic density . Krämer et al. assessed this possibility in a study of 306 children 9 years of age living at least 2 years in a home near major roads in Germany . Using passive samples with Palmes tubes, weekly average concentrations were measured for personal NO2 in March and September, and for outdoor home or near home NO2 at 158 locations in each of four seasons . Investigators showed that outdoor NO2 was a good predictor of home traffic density but a poor predictor for personal NO2 exposure reflecting the known importance of indoor NO2 sources. They followed the children with weekly parental questionnaires for atopic symptoms for 1 year. In suburban areas there was little variation in outdoor NO2, and inclusion of suburban subjects in regression models decreased parameter estimates and increased standard errors. For urban areas , they found that atopic sensitizations to pollen, to house dust mite or cat, and to milk or egg were each significantly associated with outdoor NO2 but not predicted personal NO2. They also found that outdoor NO2, but not predicted personal NO2, was significantly associated with reports of at least 1 week with symptoms of wheezing and of allergic rhinitis. Relationships for atopy and rhinitis symptoms by quartile of outdoor NO2 suggested a dose–response relationship . Although an ever diagnosis of hay fever was associated with outdoor NO2, diagnosed asthma was not . The maximum outdoor NO2 of the urban sites was 36 ppb ,grow shelf rack which is far less than the U.S. EPA NAAQS of 53 ppb annual mean . The overall results suggest that outdoor NO2 was serving as a marker for more causal airborne agents rather than a direct effect of NO2.

High personal exposures to PAHs near busy streets were possible in the study by Krämer et al. , as well as other studies in Table 2 for high traffic density. Dubowsky et al. measured total real-time, particle bound PAHs from three nonsmoking indoor sites with different traffic densities characteristic of urban, semiurban, and suburban residencies.A significant contribution of traffic related PAHs to indoor PAHs was detected. Indoor peaks occurred during morning rush hour on weekdays only . The geometric means of PAHs corrected for indoor sources were urban, 31 ng/m3; semiurban, 19 ng/m3; and suburban, 8 ng/m3. Despite the suggestion that NO2 may be acting as a surrogate pollutant, the respiratory effects of NO2 are still important. However, the magnitudes of effects of NO2 on asthma are not entirely clear, and there are considerable inconsistencies in the experimental literature. Some studies have shown alterations in lung function, airway responsiveness, or symptoms, whereas others have not, even at high concentrations [reviewed by Bascom et al. ]. Data that support the traffic density studies come from a clinical crossover study that used ambient exposures of 20 mild pollen-allergic adult asthmatic individuals . Subjects showed early- and late-phase bronchospastic reactions to pollen allergen challenge that were greater 4 hr after a 30-min exposure in a car parked in a road tunnel compared with a low control exposure in a suburban hotel . Specific airway resistance 15 min after allergen challenge increased 44% in 12 subjects exposed to road tunnel NO2 > 159 ppb compared with 24% for their control exposures . The higher NO2 tunnel exposures were associated with significantly more symptoms and beta-agonist inhaler use 18 hr after allergen challenge. In addition, FEV1 decreased significantly more than with control exposures 3–10 hr after allergen challenge . Effects were smaller using PM10 or PM2.5 as the exposure metric. The authors compared their results with those from earlier chamber studies using 265 ppb NO2 before allergen challenge. They concluded that although those results also showed an enhancement of early- and late-phase asthmatic reactions , effects were greater for lower NO2 exposures in the tunnel, suggesting other pollutants were important.

Other agents aside from either NAAQS criteria air pollutants or air toxics could explain some part of the association of asthma and allergy outcomes with traffic density. Latex allergen found on respirable rubber tire particles is likely common in urban air and could lead to sensitization and respiratory symptoms. In addition, the physical action of motor vehicles on road dust, which is known to contain pollen grains, could lead to the production and resuspension of smaller respirable pollen fragments . Other allergenic bio-aerosols such as fungal spores could be fragmented and resuspended as well. Interactions between pollutants and allergens could also influence effects. Allergenic molecules could be delivered to target sites in the airways on diesel carbon particles. as evidenced in vitro using the rye grass pollen allergen Lol p1 . Another study using immunogold labeling techniques found that indoor home soot particles, primarily in the sub-micrometer size range, had bound antigens of cat , dog , and birch pollen , and this adsorption was replicated in vitro with DEP particles . Other biologic interactions between pollutants and allergens on airways that favor inflammatory reactions have been hypothesized , including enhancement of allergen sensitization in asthmatic children with ETS exposure and pollutant-induced enhancements of the antigenicity of allergens .Experimental evidence supports the biologic plausibility of a role for PAHs from fossil fuel combustion products in the onset and exacerbation of asthma. However, the occupational data on DE and asthma onset are limited to one three-case series. In addition, despite high exposures, overall inconsistency is found in occupational studies of respiratory symptoms or lung function and diesel/gas exhaust exposures. Bias from the healthy worker effect is likely given the expectation of avoidance behavior among individuals with respiratory sensitivity to inhaled irritants, including asthmatics. This behavior has been hypothesized to result from a toxicant-induced loss of tolerance . The inconsistent and weak occupational evidence does not rule out different dose–response relationships for asthma in nonoccupational settings. Epidemiologic results showing associations between childhood asthma and ETS may be explained, in part, by PAHs.

Positive results in epidemiologic studies of asthma and traffic-related exposures also may be explained, in part, by PAHs. The question that remains is, what are the determinants of asthma associations with complex mixtures of ETS-related and traffic-related particle components and gases? The above review gives the overall impression that asthma, related respiratory symptoms, lung function deficits, and atopy are higher among people living near busy traffic. Some data coherent with this view are found in studies showing a higher prevalence of asthma and atopic conditions in more developed Westernized countries and in urban compared with rural areas [reviewed by Beasley et al. and Weinberg ]. For instance, studies in Africa have shown that pediatric asthma is rare in rural regions, whereas African children living in urban areas have experienced an increasing incidence of asthma . The urban-rural differences have tended to narrow as rural Africans became more Westernized . This suggests that the increase of asthma seen in developed countries may be attributable to some component of urbanization, including automobile and truck traffic. However, this urbanization gradient is not a consistent finding across the literature . For instance, in the traffic exposure–response study by Montnémery et al. , although there were significant associations of asthma symptoms and diagnosis to traffic density, there were no urban-rural differences. In addition, some recent studies that specifically examined farming environments, found a decreased risk of asthma and atopy among children living on farms ,indoor plant grow racks particularly where there is regular contact with farm animals. This prompted these investigators to hypothesize that a “protective farm factor” may reflect the influence of microbial agents on TH1 versus TH2 cell development or reflect the development of immuno tolerance . This possibility, in addition to potentially high levels of confounding by uncontrolled factors that vary by geography, makes it difficult to clearly interpret the cross-sectional studies on urban versus rural areas or ecologic studies of international differences.The following section will examine the epidemiologic literature on the relationship of asthma and atopy in children to formaldehyde. This serves to exemplify one of the few low molecular weight agents associated with asthma in both the occupational and nonoccupational literature, and to exemplify an air toxic that has effects from low to high exposure levels. However, there are little available nonoccupational data on the risk of asthma onset from formaldehyde. One study passively measured formaldehyde over 2 weeks in the homes of 298 children and 613 adults . In log-linear models controlling for SES variables and ethnicity, the study found a significantly higher prevalence of physician-diagnosed asthma and chronic bronchitis in children 6–15 years of age living in homes with higher formaldehyde concentrations over 41 ppb .

However, the room specific measurements revealed that the association was attributable to high formaldehyde concentrations in kitchens, particularly those homes with ETS exposures , suggesting possible confounding by other factors not measured. In random effects models controlling for SES and ETS, they found significant inverse associations between morning PEF rates and average formaldehyde from the bedroom, and between evening PEF and household average formaldehyde. There was no apparent threshold level. The PEF finding was independent of ETS, but the effects of age or of anthropomorphic factors were not mentioned. Symptoms of chronic cough and wheeze were higher, and PEF lower, in adults living in houses with higher formaldehyde levels. There was a significant interaction between formaldehyde and tobacco smoking in relation to cough in adults. Passive measurements of NO2 did not confound the associations in children or adults. Other nonoccupational data on formaldehyde relate indirectly to asthma. Wantke et al. evaluated levels of specific IgE to formaldehyde using RAST in 62 eight-year old children attending one school with particleboard paneling and urea foam window framing. The children were transferred to a brick building because of elevated formaldehyde levels in particleboard classrooms and complaints of headache, cough, rhinitis, and nosebleeds. Symptoms and specific IgE were examined before and 3 months after cessation of exposure. At baseline, three children had RAST classes ≥ 2 and 21 had classes ≥ 1.3 , whereas all 19 control children attending another school had classes < 1.3. After transfer, the RAST classes significantly decreased from 1.7 ± 0.5 to 1.2 ± 0.2 , and symptoms decreased. However, IgE levels did not correlate with symptoms. None of the children had asthma. Garrett et al. hypothesized that formaldehyde may adversely affect the lower respiratory tract by increasing the risk of allergic sensitization to common allergens. They studied 43 homes with at least one asthmatic child and 37 homes with only non asthmatic children . Atopy was evaluated in the children with SPTs for allergy to 12 common animal, fungal, and pollen allergens. Formaldehyde was measured passively throughout the homes over 4 days in four different times of 1 year. Atopic sensitization by SPT was associated with formaldehyde levels [OR for 20 µg/m3 increase, 1.42 ]. Across three formaldehyde exposure categories, there was also a significant increase in the number of positive SPTs and in the wheal ratio of allergen SPT over histamine SPT. Mean respiratory symptom scores were significantly and positively associated across the three categories. There was a significant positive association between parent-reported, physician-diagnosed asthma and formaldehyde, but this was confounded by history of parental asthma and parental allergy. It is unclear why these familial determinants were treated as confounders rather than effect modifiers, although knowledge of asthma by parents may lead to bias in the assessment of asthma in their children. Several other studies of non asthmatic subjects have examined health outcomes and biomarkers that are relevant to asthma. Franklin et al. studied 224 children 6–13 years of age with no history of upper or lower respiratory tract diseases, using expired nitric oxide as a marker for lower airway inflammation . Formaldehyde was passively monitored in the children’s homes for 3–4 days. Maximum end expiratory eNO was measured in each child with a fast response chemiluminescence analyzer. They found no effect of formaldehyde on lung function. However, controlling for age and atopy , eNO was significantly elevated to 15.5 ppb in homes with ≥ 50 ppb formaldehyde compared with 8.7 ppb eNO in homes with < 50 ppb formaldehyde.

The higher component scores indicate better adherence to a certain physical activity pattern

The standardized activity questionnaire consisted of 18 questions and physical activity was determined by asking subjects the average frequency and time spent on several occupational and leisure time activities during the last year. These activities were grouped into six categories according to their intensity or metabolic equivalents : lying quietly in bed: afternoon nap or rest and night sleep ; sitting ; light indoor activity such as standing at work or at home ; moderate outdoor activity such as gardening, light agriculture and construction, and walking on flat surfaces ; vigorous aerobic activity such as heavy agriculture and construction, walking uphill, climbing stairs, jogging and other sports ; strenuous anaerobic activity such as carrying, pushing and lifting heavy objects . Energy expenditure for each activity was calculated as the product of frequency, time, and intensity . Total activity-related energy expenditure per day was calculated by the sum of energy expenditure on each activity listed in our questionnaire and was measured by total METs of activity performed each day. This questionnaire was previously used in a study of 465 people conducted in Costa Rica. The data showed that the reported time spent on different types of daily activities using the questionnaire predicted higher fitness scores, lower LDL levels, and lower BMI. These results allow us to consider that the predictive validity of the questionnaire is reasonable.All analyses were carried out with SAS . The original sample size was composed of 2,273 cases and 2,274 controls. A total of 274 cases and 275 controls were excluded due to missing information on physical activity and the covariates in the data analysis ,commercial grow rack implausible total activity-related energy expenditure , and losing matched controls/cases after performing rematching based on the original matching criteria . The final study sample consisted of 1999 case-control pairs . We used PCA on the 18 questions of the standardized activity questionnaire to identify physical activity patterns.

The components were extracted using an orthogonal matrix to achieve a simple structure that facilitates interpretability and makes the derived patterns independent of each other. The following three criteria were used to determine the number of components to retain: the criterion of eigenvalues exceeding one, the scree plot, and the interpretability of each component. The component score of each pattern for each subject was calculated by summing the hours spent on physical activities weighted by their component loadings.As part of a sensitivity analysis, we performed PCA stratified by sex. We used paired t-tests and McNemar tests to compare means and proportions between cases and controls, given the matched design. We used parametric regression models and semi-parametric regression models to assess the association of AMI risk with extracted physical activities patterns and total activity-related energy expenditure. In the parametric regression models, component scores of each extracted pattern and total activity-related energy expenditure were divided into quintiles. Quintiles of those variables were entered in multivariate conditional logistic regression analysis to calculate odds ratios and 95% confidence intervals. Tests for trend were derived from conditional logistical regression with a single term representing the medians of quintiles 1-5. In semi-parametric regression models, natural cubic splines were fitted to conditional logistic regression models to examine the relationship between total activity-related energy expenditure and risk of AMI and the association between extracted physical activity patterns and risk of AMI. Natural cubic splines are smooth polynomial functions that can be used to fit data and accommodate potential changes in the direction of the association across the distribution of an exposure.

They are useful to examine non-parametrically the potential non-linear relation between the exposure and the outcome of interest. They are constructed of piece wise third-order polynomials which pass through a set of control points and it is linear in its tail beyond the boundary knots. Since they are numerically stable and allow computation of fit with great accuracy, natural cubic splines are widely used in semiparametric regression. A SAS macro named ‘lgtphcurv9’ was used which implements natural cubic spline methodology to fit potential non-linear dose-response curves in logistic regression models. Likelihood ratio tests were performed to test non-linear and linear relations. In semi-parametric regression models, the median value of the first quintile of exposure was used as reference.The baseline characteristics of the study population are shown in Table 1. Compared to controls, cases had lower annual income and higher total daily caloric intake. Cases were more likely to be current smokers, have hypertension, diabetes, hypercholesterolemia, and a sedentary lifestyle. The median total activity-related energy expenditure was 30.9 METs/day for cases and 32.4 METs/day for controls . Cases spent more time on lying and napping compared to controls. In contrast, controls spent more time on light indoor activities and light-moderate activities . The loadings for the first four components of our PCA are presented in Table 3. The first pattern had high positive loadings on sleep measures and high negative loadings on lying in bed during the day to watch TV, read books, or listen to music, and we labeled it as the rest/ sleep pattern. The second pattern had high positive loadings on items which are used to measure activities relevant to gardening and farming and high negative loadings on standing in very light activities at work or at home, and we labeled it as the agricultural job pattern. The third pattern had high positive loadings on items which are related to activities performed in the office or at home , and we labeled it as the light indoor activity pattern. The last pattern had high positive loadings on items which are used to assess activities related to construction and high negative loadings on napping, and we labeled it as the manual labor job pattern.

We performed PCA stratified by sex. There was no manual labor pattern in women, but the other three physical activity patterns were similar between women and men. Thus, we only report the results from the combined analysis to maximize power. Increased activity-related energy expenditure was associated with area of residence, less annual income, hypertension, higher saturated fat intake, and higher total calorie intake per day among controls . Table 5 summarizes conditional logistic regression models that were used to evaluate the associations between four extracted physical activity patterns, total activity-related energy expenditure, and risk of AMI. The first models were controlled by matching factors , and the fully adjusted models were controlled by matching factors plus adjustment for annual income, smoking status, and saturated fat intake per day. Among the four extracted physical activity patterns, only the light indoor activity pattern was significantly associated with AMI risk. As compared to subjects in the lowest level of component score, the OR for those in the highest level was 0.72 in the model adjusted for matching factors. This association remained statistically significant in the fully adjusted model . However, we observed a U-shaped relationship between the rest/sleep pattern and AMI risk. In the fully adjusted model, compared to subjects in the first quintile of component score,cultivation grow rack the ORs were 0.85 for subjects in the second quintile, 0.79 in the third quintile, 0.87 in the fourth quintile, and 0.85 in the highest quintile. No statistically significant associations were found between the remaining two physical activity patterns and risk of AMI. Total activity-related energy expenditure was negatively associated with risk of AMI. The OR for subjects in the highest vs. lowest category was 0.71 in the model adjusted for matching factors. This association did not change in the fully adjusted model. To further explore the association of AMI risk with the rest/sleep pattern, the light indoor activity pattern, and total activity-related energy expenditure, we fitted natural cubic splines. Models were controlled for the matching factors and potential confounders including annual income, smoking status, and daily saturated fat intake. As shown in Figure 1, there was a non linear relationship between the rest/sleep pattern and risk of AMI . Consistent with the parametric models, there was an inverse linear association between the light indoor activity pattern and risk of AMI . Figure 3 shows that the risk of AMI declined with the increase of total activity-related energy expenditure, but flattened out at high levels of physical activity .Four major physical activity patterns were identified from PCA in this Costa Rican population. The light indoor activity pattern was linearly and inversely associated with risk of AMI, whereas a U-shaped association was found for the rest/sleep pattern. No association was found between the agricultural job pattern and the manual labor job pattern and risk of AMI. In addition, we observed an inverse relationship between total activity related energy expenditure and AMI risk that reached a plateau at high levels.

In this study, we utilized two approaches for exposure response modeling: quintile presentation of the exposure and continuous presentation of the exposure fitting semiparametric models. Compared to the former approach, the latter one has several advantages: no need for the selection of cut-points to categorize exposure, which can influence the shape of a fitted dose-response curve; no power loss; and ease of comparisons across studies. The results from these two analytic approaches were consistent, indicating that semi-parametric models are valuable and powerful to explore the shape of an exposure-response relationship. Previous studies have observed an association between sleep duration and risk of CVD, finding an increased risk of CHD or stroke with habitual sleeping duration of less than 6 hours per night and long sleep duration. The potential mechanisms between decreased sleep duration and risk of CHD are not fully understood but likely include sympathetic over activity, increases in blood pressure, and decreased glucose tolerance. Consistent with these results, we observed a U-shaped association between the rest/sleep pattern and AMI risk. Although the component score of the rest/sleep pattern could not provide the exact range of sleep duration beyond which the risk of AMI would be increased, the majority of the rest sleep pattern is sleeping and our results suggest that either shortened or long sleep duration could increase the risk of CHD. It is possible that longer sleep duration is related to sleep apnea,however we cannot assess this association directly since we did not collected sleep apnea information. On the other hand sleep duration and BMI were not associated in this population Study results on the association between domestic physical activity and CVD risk vary from protective to null. Likewise, studies on the effects of occupational related physical activity on the risk of CVD also have shown inconsistent results ranging from protective effects and null effects, to harmful effects. These inconsistencies might be due to residual confounding effects, distinct definitions of domestic or occupational physical activity, measurement error, and different characteristics of the study population. In our study, the occupational physical activities in the light indoor activity pattern mainly correlated positively with standing and moving at work and inversely with sitting. These activities have been associated with a lower risk of CVD in previous studies. On the other hand, the light indoor activity pattern did not include some strenuous or very strenuous work , which have been found to increase the risk of AMI. We found no associations between the agricultural job pattern and the manual labor job pattern and risk of AMI. While walking and climbing steps could provide beneficial effects on CVD, some strenuous or very strenuous work such as lifting, carrying, and planting could increase the risk of AMI. Thus, it is possible that the protective effects of some activities in the agricultural job and manual labor job patterns, such as walking and climbing steps, are overshadowed by the potential detrimental effects of some very strenuous activities such as lifting and carrying. It is noteworthy that agricultural and manual labor jobs in Costa Rica still include very strenuous activities as opposed to other countries like the US. On the other hand, our null findings may also be the result of measurement error and residual confounding because of imperfect adjustment for socioeconomic status and other lifestyle factors such as diet and smoking. A dose-response relation between physical activity and risk of CVD has been well documented in several large scale prospective studies. However, the exact shape of the dose-response curve remains unclear. Consistent with previous studies, our study indicated that the association between total activity-related energy expenditure and AMI risk is protective. However, we observed that the decreasing risk flattened out at high levels.

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