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Addiction, Ask Stanford Med, Health Policy, Public Health, Stanford News

Is a proposed ban on smoking in public housing fair?

Is a proposed ban on smoking in public housing fair?

smoking ban sign - 560

Cigarette smoking kills nearly half a million Americans each year, making it the leading preventable cause of death in the United States.

So the Department of Housing and Urban Development thinks it’s time to ban cigarette smoking from some 1.2 million subsidized households across the nation.

HUD Secretary Julián Castro unveiled a proposal last week intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” Castro said, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, PhD, JD, who is a core faculty member with Stanford Health Policy, has researched and written about this issue extensively, including in a 2010 article in The New England Journal of Medicine.

In a piece published yesterday, I asked Mello about her views on the federal smoking ban proposal. A sampling of the Q&A:

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents’ efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous “third-hand smoke” exposure that especially affects babies and small children.

Beth Duff-Brown is communications manager for Stanford Health Policy.

Photo by Getty Images iStock

Clinical Trials, Ethics, Health Policy, Public Health, Stanford News

Using social media in clinical research: Case studies address ethical gray areas

Using social media in clinical research: Case studies address ethical gray areas


If a public-health researcher is reviewing Facebook profiles of 14-year-old males for firearm references and discovers photos or words referencing a potentially threatening situation, should the researcher intervene? What levels of privacy should these children expect in the online world?

These are the kinds of difficult questions that ethics consultants are faced with as they attempt to provide moral and legal guidance to researchers gathering health-related data from the Internet.

To help researchers with these nascent ethics issues, the Clinical Research Ethics Consultation Collaborative, a group of almost 50 bioethicists who provide free or low-cost ethics consultations across the United States, has begun publishing case studies on its most ethically challenging cases. Thus far they’ve posted 40 case studies in the categories of behavioral/social science research, clinical trials, genetics, pediatrics, research misconduct and surrogate decision making. The site also includes information on how to participate in educational webinars and collaborative case discussions.

This effort is being led by Benjamin Wilfond, MD, at Seattle Children’s Research Institute and University of Washington, and Mildred Cho, PhD, at the Stanford Center for Biomedical Ethics.

“Our bioethics consortium has learned a great deal from the complex ethics consultations that we’ve been providing since 2005,” said Cho. “Now we have a strategy for sharing these best practices with others, to provide moral and legal guidance to researchers across the country and to better inform policymakers on evolving ethical gray areas.”

More information on the collaborative or to request a consult can be found on this website.

Previously: The challenge – and opportunity – of regulating new ideas in science and technologySocial media brings up questions, ethical unknowns for doctorsBuild it (an easy way to join research studies) and the volunteers will come
Photo by NLshop/Shutterstock

Infectious Disease, Medicine and Society, Parenting, Public Health, Research, Stanford News

California’s vaccination exemptions cluster in white, affluent communities

California's vaccination exemptions cluster in white, affluent communities


California’s measles epidemic was no fluke; between 2007 and 2013 the percentage of kindergarteners using a “personal belief” exemption to enroll in school without vaccinations doubled.

In that year, 3 percent of kindergarteners entered school unvaccinated. In some schools, the percentage of vaccinated children was so low that it threatened herd immunity, or the ability for a population to keep a pathogen at bay, according to Stanford health-policy researcher Michelle Mello, PhD, JD.

To understand the rapid increase, Mello worked with a team led by Tony Yang, ScD, with George Mason University. Their research is published today in the American Journal of Public Health.

They found the highest resistance to vaccinations among white, affluent communities. In contrast to previous studies, however, they did not find a correlation between higher levels of education and vaccine exemptions.

“Beliefs about vaccination risk tend to be more entrenched among certain communities of mothers,” Mello said. The study didn’t investigate reasons for seeking exemption, but other studies suggest some mothers in affluent communities may believe they can adequately protect their children through “intensive parenting techniques” such as an organic diet and restricting contact with sick children, Mello said.

Although California eliminated the personal belief exemption this summer in a broad-reaching law that requires all medically eligible school students to be vaccinated, the study speaks to how other states might approach the problem of vaccine exemptions, Mello said.

Similar clusters of vaccine resistance exist elsewhere and the findings could help public health agencies refine outreach methods, she said. For example, by specifically targeting local groups and reaching out to community leaders, officials may have more success providing education about vaccine risks and benefits, Mello said.

The results are particularly striking given the history of vaccination efforts, she said. In the first half of the twentieth century, public health officials struggled to ensure vaccines reached disadvantaged communities. Now, as fear of the targeted diseases has paled, parents may be more fearful of vaccines, leaving the entire population vulnerable.

Previously: Infectious disease expert discusses concerns about undervaccination and California’s measles outbreak, Stanford researchers analyze California’s new vaccine law and The earlier the better: Study makes vaccination recommendations for next flu pandemic
Photo by woodleywonderworks

In the News, Medicine and Society, Mental Health, Public Health

Turning loss into hope for others: New website teaches about mental health

Turning loss into hope for others: New website teaches about mental health


Suicide slices close to the heart for me, and I remember well the story of Shelby Drazan, a Woodside, Calif. 17-year-old who died by suicide last year.

Now, the Drazan family is going public with their efforts to help others suffering from mental illness. A recent article in the Almanac explains their efforts:

The Drazans say they hope talking publicly about what happened to Shelby will ease some of the stigma attached to mental illness.

“A lot of people are struggling,” Stacy Drazan says, “a lot of people especially in this area. We’ve got to help get rid of the stigma so that people can seek help, and earlier.”

Her daughter Mackenzie has created an online trove of resources, Teaching Everyone About Mental Health or TEAM. “Hopefully we can lower the learning curve for everybody else,” Mackenzie said.

At the same time, Stacy Drazan is working to expand the number of adolescent beds for psychiatric patients in the San Francisco Bay area. Stanford’s Steven Adelsheim, MD, a child psychiatrist, is among those working with the family to expand local mental-health resources.

Previously: Advice and guidance on teen suicide, “Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention and Stanford’s Keith Humphreys on Golden Gate Bridge suicide prevention: Get the nets
Photo courtesy of TEAM

Events, Global Health, Health Policy, Public Health, Stanford News

Using innovation to improve health in the developing world

Using innovation to improve health in the developing world

Ramano RaoHow can Silicon Valley-style know-how help improve health and lift up the lives of the poor in the developing world? That question was the focus of a panel discussion among four distinguished speakers last week at a Stanford conference on global development and poverty.

Panelist Ramana Rao, MD, described one technologically-based solution he helped develop with colleagues in Hyderabad, India:  a 911-type emergency care system which now serves some 750 million people across the South Asian country.

Though the system, users can call a single number – 108 – to summon an ambulance and team of skilled providers who can provide treatment en route to the nearest hospital.  The system, a public-private partnership known as GVK EMRI (Emergency Management and Research Institute), uses advanced call center technology, in which trained operators typically respond to calls within the first ring and relay them immediately to paramedics and emergency medical technicians on ambulances in the field, Rao told an audience of more than 200 people at the Stanford Graduate School of Business.

The system uses Google maps to help quickly locate patients. And the designers have introduced a mobile device app, which can be easily downloaded to call the service and which can be used to track the location of a caller during the first hour, the critical “golden hour” for treating trauma patients, he said.

Panel moderator Paul Yock, MD, PhD, noted the system is far more effective than the fragmented, 911 emergency system in the United States. “It’s a marvelous example of technology leap-frogging what we do here in this country,” said Yock, founder and director of Stanford Biodesign.

The Indian system was made possible in part by the soaring popularity of cell phones in India, used by 950 million people, including the poor.

“The mobile phone has been the most transformational technological advance in the developing world in the last 15 years,” noted panelist Rajiv Shah, MD, administrator of the U.S. Agency for International Development.

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Addiction, Cancer, Events, Health Policy, Medicine and Society, Public Health

The devil you know: Experts discuss the public-health consequences of e-cigarettes

The devil you know: Experts discuss the public-health consequences of e-cigarettes

e-cigarettesHow do we reduce health risk in the face of harm that can’t be eradicated completely? That’s the question that the medical school’s dean, Lloyd Minor, MD, presented to the audience at Monday’s Health Policy Forum on e-cigarettes — a topic about which he said “intelligent and reasonable people can disagree.”

E-cigarettes are a heavily contested subject in the public-health community. Panelists at this event debated whether the recently developed devices hold promise to help long-time smokers move away from combustible cigarettes, or whether they carry the worrisome potential to re-normalize smoking.

All panelists agreed that those under 21 shouldn’t be using any nicotine delivery devices, and they shared a goal of minimizing general use of harmful health products. They disagreed, however, on what the advent of e-cigarettes means to the accomplishment of those goals.

David Abrams, PhD, a Johns Hopkins clinical psychologist specializing in health psychology, addictions, and tobacco-use behavior, described himself as a harm reductionist. He argued that as an alternative mode of nicotine delivery, e-cigarettes pave the way for saving lives by helping addicted smokers not use traditional cigarettes.

“I do think the evidence is very solid that they are dramatically less harmful than cigarettes…because they absolutely have very low, almost undetectable levels or trace amounts of the top eight carcinogens that are found in cigarettes and they have no carbon monoxide,” he explained.

But a lack of extensive research makes Stanford’s Robert Jackler, MD, and Bonnie Halpern-Felsher, PhD, question whether vaping is actually safe — and a prevalence of candy-flavored e-liquids leaves them concerned for the potential for harm to youth.

“Let me point out that you can smoke [combustible cigarettes] for many years before you get chronic destructive lung disease,” said Jackler, who leads a Stanford research team studying the impact of tobacco advertising, marketing, and promotion. “So while I agree… that they are safer, the presumption that they are safe for teenagers to adopt as opposed to combustible tobacco, we won’t know that for decades.”

In the meantime, he worries that “we’re experimenting with the lungs of teens.”

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Mental Health, Public Health, Public Safety, Sleep, Stanford News

From A to ZZZZs: The trouble with teen sleep

From A to ZZZZs: The trouble with teen sleep

go_to_bed_fullWhen I recently began working on a story on teen sleep for Stanford Medicine magazine, I was afraid I might not find teens who were troubled by sleep issues and willing to talk about them. I need not have worried: Virtually every teen I encountered had a story to tell about consistently having late nights stressing out over tests or papers or texting friends and cruising the web. It also wasn’t unusual for teens to say that they kept their cell phones on at night in case they got a message from a friend who needed to talk.

Some were tortured by the lack of sleep, often nodding off in class, but said they felt compelled to stay up in order to compete academically in these high-pressure local communities that worship at the altar of academic achievement.

“I’ve heard horror stories of being sleep-deprived,” one 17-year-old told me. “You’re not able to focus on homework, you feel moody and are not able to pay attention in class.”

Another teen reinforced what the National Sleep Foundation found in a recent poll – that 87 percent of American teens are chronically sleep-deprived. “You could probably talk to any teen when they reach their breaking point,” she told me. “You’ve pushed yourself so much and not slept enough and you just lose it.”

In my research, I learned that these students pay a heavy price, potentially compromising their physical and mental health. Study after study in the medical literature sounded the alarm over what can go wrong when teens suffer chronic sleep deprivation: drowsy driving incidents, poor academic performance, anxiety, depression, suicidal thoughts and even suicide attempts.

“I think high school is the real danger spot in terms of sleep deprivation,” Stanford’s William Dement, MD, PhD, the famed sleep researcher, told me. “It’s a huge problem.”

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Health Policy, Obesity, Public Health, Stanford News

“We should act now”: Stanford expert calls for more targeted anti-obesity policies

"We should act now": Stanford expert calls for more targeted anti-obesity policies

U. S. Department of Agriculture's Food Nutrition Service (FNS) helps educate shoppers about the value of food labeling in December 1975. Photo courtesy National Archives and Records Administration.

Reality TV shows like “The Biggest Loser” are popular in part because the audience can relate to the participants — more than two-thirds of adults and about one-third of children and adolescents are obese or overweight in the U.S. The Surgeon General and the Centers for Disease Control and Prevention have declared obesity to be a national epidemic and a major contributor to leading causes of death, including heart disease, stroke, diabetes and some types of cancer.

Although our country is committed to finding solutions to the increase in obesity, public policies have fallen short, according to Deborah Rhode, JD, a Stanford law professor and legal ethics scholar. In a recent journal article, she wrote:

Many policy responses have proven controversial, and those most often recommended have frequently faced an uphill battle at the federal, state, and local level. At the same time that obesity rates have been rising sharply, many jurisdictions have resisted, or rolled back, strategies such as soda taxes or regulation of advertising directed at children.

In the article, Rhode goes on to evaluate anti-obesity policies, including calorie disclosure requirements, taxes or bans on sugar-sweetened beverages, food stamp modifications, zoning regulations, children’s marketing restrictions, physical activities initiatives, food policies and education. She suggests that a more targeted approach is needed to combat obesity. For instance, Rhode recommends creative zoning regulations that restrict the location of fast-food restaurants near schools while encouraging healthy food retailers in underserved neighborhoods.

In a Stanford news release, Rhode noted that the first lady Michelle Obama’s “Let’s Move!” campaign against childhood obesity applies to politics as well as physical activity. Rhode summarized, “Although we need more evaluation of policy strategies, we know enough about what works to chart a course of reform. We should act now on what we know.”

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: Finding the sweet spot in public health law to regulate sugary drinksStudy shows banning soda purchase using food stamps would reduce obesity and type-2 diabetesCapturing the metabolic signature of obesity and How to combat childhood obesity? Try everything
Photo by U.S. Department of Agriculture

Global Health, Pediatrics, Public Health, Rural Health, Stanford News

Helping newborns through song

Helping newborns through song

Instead of drugs or fancy devices, a small village in India is using dhollak and dafali — drums traditional to the region — to spread awareness about post-natal care and to battle infant mortality. As Becky Bach explains in the latest issue of Stanford Medicine magazine, the effort started as part of a public-health research project led by researchers Gary Darmstadt, MD, and Vishwajeet Kumar, MBBS, who partnered with community leaders in an effort to communicate evidence-based health practices:

In a groundbreaking endeavor, [Darmstadt’s] team worked with communities to slash newborn mortality by 54 percent in less than two years in a large, impoverished area in northern India called Shivgarh.

Their strategy was simple, in principle: embrace the local culture, seek to understand its newborn-care practices, and partner with the community to translate evidence-based recommendations into meaningful communications — metaphors, songs — that could change behavior.

“Songs have traditionally played a key role in the community as a medium for transferring cultural knowledge inter-generationally and within groups,”  Vishwajeet Kumar, director of the Community Empowerment Lab in Shivgarh, told me. In the above video, a group of women, some holding infants, sing about the importance of skin-to-skin care:

Pregnant women and mothers-in-law, who play a critical role in perpetuating the community’s childbirth traditions, were shown how to provide skin-to-skin care, a simple practice that involves placing the bare-skinned baby on the caregiver’s skin, providing love, warmth and access to nourishment. The practice produces immediate, tangible benefits: It improves babies’ color and temperature, and reduces crying and startle responses. The villagers interpreted these signs as the absence of evil spirits, reinforcing their willingness to embrace the change.

A talented local songwriter named Santosh Kumar is responsible for many of these songs, which combine global knowledge with local wisdom, said Vishwajeet Kumar. He works in collaboration with the community to organize gatherings where important early care practices, from sanitation to breastfeeding, are conveyed through his songs.

The story of Shivgarh is a reminder that sometimes health is about more than doctors and big facilities. Sometimes the final puzzle piece can take the form of knowledge and a dedicated community.

Lindzi Wessel is a former neuroscience researcher and current student in the UC Santa Cruz Science Communication Program. She is an intern in the medical school’s Office of Communication and Public Affairs.

Previously: Stanford Medicine magazine tells why a healthy childhood matters and Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

Cancer, Imaging, Public Health, Research

Tattoo ink may mimic cancer on PET-CT images, researchers warn

tatoo lady

The hit new crime thriller “Blindspot is about a mysterious woman, Jane Doe, who is covered in extensive full-body tattoos. If Jane Doe were a real woman who ever needed medical imaging, she might need to be concerned.

In a case report published recently in the journal Obstetrics & Gynecology, researchers found that extensive tattoos can mimic metastases on positron emission tomography (PET) fused with computed tomography (CT). PET-CT imaging is commonly used to detect cancer, determine whether the cancer has spread and guide treatment decisions. A false-positive finding can result in unnecessary or incorrect treatment.

Ramez N. Eskander, MD, an assistant professor of obstetrics and gynecology at UC Irvine, and his colleagues describe the case study of a 32-year-old woman with cervical cancer and extensive tattoos. The pre-operative PET-CT scan using fluorine-18-deoxyglucose confirmed that there was a large cervical cancer mass, but the scan also identified two ileac lymph nodes as suspicious for metastatic disease. However, final pathology showed extensive deposition of tattoo ink and no malignant cells in those ileac lymph nodes.

It’s believed that carbon particles in the tattoo pigment can migrate to the nearby lymph nodes through macrophages, using mechanisms similar to those seen in malignant melanoma. The researchers explain in their case report:

Our literature search yielded case reports describing the migration of tattoo ink to regional lymph nodes in patients with breast cancer, melanoma, testicular seminoma, and vulvar squamous cell carcinoma, making it difficult to differentiate grossly between the pigment and the metastatic disease, resulting in unnecessary treatment.

The authors warn other physicians to be aware of the possible effects of tattoo ink on PET-CT findings when formulating treatment plans, particularly for patients with extensive tattoos.

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor. 

Previously: Stanford researcher discusses enhancing imaging methods with nanotechnology in NIH podcast and Stanford fellow addresses burden of cervical cancer in Mongolia
Photo by Paulo Guereta

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