The working-class context of pregnancy smoking

Health & Place 8 (2002) 167–175

The working-class context of pregnancy smoking Kate E Picketta,b,*, Lauren S. Wakschlagc, Paul J. Rathouza, Bennett L. Leventhalc, Barbara Abramsd a

Department of Health Studies, University of Chicago, Chicago, 5841 South Maryland Ave Chicago, IL 60637, USA b Department of Obstetrics and Gynecology, University of Chicago, Chicago, USA c Department of Psychiatry, University of Chicago, Chicago, USA d Division of Public Health Biology and Epidemiology, School of Public Health, University of California, Berkeley, USA

Abstract The risk of smoking during pregnancy in the US is strongly associated with women’s individual socioeconomic status (SES) but little is known about the influence of local area context. The aim of this study was to examine whether localarea characteristics increase the risk of smoking during pregnancy above and beyond individual SES. In a hospitalbased cohort of 878 pregnant women in California, who delivered between 1980 and 1990, we compared risk of smoking during pregnancy based on individual and local-area factors. Adjusting for individual SES, neighborhood social class was related to smoking in early pregnancy. Living in a predominantly working-class area significantly increased the risk of pregnancy smoking for both working-class and non-working-class women. However, local-area economic and demographic indicators were not related to smoking early in pregnancy. Individual and family characteristics alone may be insufficient to explain smoking during pregnancy; the social class context of the places in which pregnant women live may also influence this behavior. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Pregnancy; Smoking; Neighborhood; Socioeconomic status; Social class

Introduction The public health burden of maternal smoking is considerable and extends beyond effects on the smoker herself (Lightwood et al., 1999; Aligne and Stoddard, 1997). Smoking during pregnancy is associated with numerous adverse health effects for offspring, including short-term effects such as birth weight and perinatal mortality, and long-term outcomes, including medical and psychiatric morbidity (Walsh, 1994; Wakschlag et al., 2000). Despite overall reductions in smoking prevalence in the United States, the rate of smoking during pregnancy among women has not noticeably *Corresponding author. Department of Health Studies, University of Chicago, Chicago, 5841 South Maryland Ave, Chicago, IL 60637, USA. Tel.: +1-773-834-3926; fax: +1-773702-1979. E-mail address: [email protected] (K.E. Pickett).

declined; at least 50% of female smokers continue to smoke when pregnant (Ebrahim et al., 2000). Although individually oriented public health efforts to reduce smoking during pregnancy have met with modest success, as many as 75% of women who receive these interventions continue to smoke (Windsor et al., 1998; Orleans et al., 2000) and working-class women, in particular, respond less well to interventions (Wakefield et al., 1993). The socio-demographic profile of pregnant smokers has shifted over time as public awareness of the adverse consequences of smoking during pregnancy has increased (Ebrahim et al., 2000). This has led to significant variability in prevalence across US sub-populations. For example, while the US national prevalence of maternal smoking is 12.9%, among non-Hispanic whites 42% of women with less than a high school education smoke during pregnancy, compared to 22% of high school educated women and 2% of college educated women (Ventura et al., 2000). Currently in the US, women who

1353-8292/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 1 3 5 3 - 8 2 9 2 ( 0 1 ) 0 0 0 4 2 - 9

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report smoking during pregnancy are more likely to be white, unmarried, younger mothers with less than high school education (Mathews, 1998). Smoking does not occur in isolation but is embedded in a larger social context of family and community. The family context of maternal smoking has been studied extensively; women whose partners are smokers are significantly more likely to smoke during pregnancy (Curry et al., 1997). Being in the company of other smokers reportedly accounts for a substantial portion of variance in postpartum relapse rates (Shiffman, 1982) and having a smoking partner reduces the likelihood of cessation during pregnancy (Curry et al., 1997). Less is known, however, about the neighborhood context of pregnancy smoking. Neighborhoods may be characterized along a number of different dimensions (Pickett and Pearl, 2001). Economic indicators of neighborhood include proportion of families living below the poverty level, median income level, prevalence of male joblessness and receipt of public assistance. Demographic indicators include percent of female-headed families, ethnic diversity and urban/rural context. Social class indicators include proportions of residents in different social classes. For example, a neighborhood may be predominantly working class. Although local-area or neighborhood context has not been examined in relation to smoking during pregnancy, there is an emerging literature on local-area influences on smoking in non-pregnant adults (DiezRoux et al., 1997; Krieger, 1991; Kleinschmidt et al., 1995). Interestingly, published studies suggest that the nature of neighborhood influences on smoking in nonpregnant adults may be different for males and females. While economic indicators predict smoking in adult men, social class indicators predict smoking in adult females (Diez-Roux et al., 1997). The places where people live can affect their health and health-related behavior through several mechanisms (Catalano and Pickett, 1999; Macintyre et al., 1993; Yen and Syme, 1999). First, neighborhood variations in smoking during pregnancy may be associated with variations in hazards which increase the risk of smoking. For example, living in a high-stress environment may contribute to high smoking rates, particularly for women, who are more likely than men to smoke to relieve negative mood states (Pomerlau, 1999). In addition, some neighborhoods may make smoking more appealing (e.g., with high saturation of tobacco advertising) and more accessible (e.g., cigarettes may be available singly rather than by the pack). Second, social tolerance of pregnancy smoking may vary by neighborhood context. For example, living in a neighborhood where smoking is common, and smoking during pregnancy is acceptable, may increase the risk of a woman continuing to smoke while pregnant. In contrast, residence in a neighborhood where smoking is not

the norm, and in which smoking during pregnancy is viewed as irresponsible and harmful to the infant, may serve as a social deterrent. Working-class neighborhoods are likely to score high on both neighborhood hazards for, and tolerance of, smoking, making them a particularly fertile ground for maternal smoking. For example, a working-class environment is likely to be characterized by (a) high levels of work stress (e.g., low levels of job control and skill utilization combined with low job satisfaction) (Marmot et al., 1999; Theorell and Karasek, 1996; Krieger, 1992), (b) social attitudes that consider use of alcohol and cigarettes as normative (Curry et al., 1993) and (c) a low emphasis on preventive health behaviors (Jarvis and Wardle, 1999). The objective of this study was to examine the effect of local-area characteristics on smoking during pregnancy, independent of individual and family SES. We examined this question in a hospital-based cohort of white pregnant women in California. We restricted our sample to white women because rates of smoking in minority women in this sample were low, consistent with national prevalence patterns (Mathews, 1998).

Methods The University of California, San Francisco (UCSF) Perinatal Database contains information on all deliveries occurring at the UCSF Hospital between January 1, 1980 and December 31, 1990. As part of a larger study of preterm delivery, a random sub-sample was established of 1128 singleton term infants without congenital anomalies, delivered to white mothers who had not been transported to UCSF from other hospitals. Maternal smoking during pregnancy was measured via maternal report of the number of cigarettes smoked per day at the time of the first prenatal visit. A dichotomous maternal smoking variable (smoking vs. not smoking) was also constructed. Maternal age and marital status were also available in the computerized database. Information on maternal and family SES and maternal address at the time of delivery was abstracted from the medical chart. Medical charts were reviewed for 1109 (98% of) mothers. Usual maternal occupation and partner’s occupation were recorded at the time of delivery. We used occupation as an indicator of social class, although we conceptualized social class as implying more than working in particular jobs and also as more than membership in a group defined by its economic relationship to the means of production. Rather, we wished to create groups with shared attitudes (a culture) towards health, self-efficacy in regard to health, health behaviors, etc. Research suggests that persons can subjectively define their social class status and that this status is

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related to self-rated health (Ostrove et al., 2000). We felt that occupation, rather than education or income, best measures class as we conceptualized it. Many ‘‘working class’’ occupations pay the same actual wages as some ‘‘professional’’ occupations, yet the workers would not define themselves as having upper or middle class values. As women may stop working during pregnancy due to personal choice or medical complications, if no paid employment was indicated at delivery, we used occupation at first prenatal visit. As a measure of family social class, we formed three categories of occupational class, unemployed families, working-class families and nonworking-class families. Non-working-class families were those in which either mother or partner’s usual occupation was either a skilled or professional occupation. Maternal education was classified as less than high school education vs. completed high school. Health insurance status was available in the computerized database, categorized as MediCal, the California equivalent of Medicaid (public health insurance), or non-MediCal. In the US public health insurance acts as a specific, though not perfectly sensitive, proxy for income.

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Maternal address at the time of delivery was used to link each delivery record to the 1990 census tract in which the mother resided. Census tracts were used as local-area proxies for neighborhoods. The geo-coding process was carried out by Geographic Data Technology, Inc. of Lebanon, New Hampshire and was successful for 962 (90%) of the abstracted, eligible subjects. Ninety-five percent of the sample resided in San Francisco county (55%) and the four surrounding counties (Fig. 1). Women resided in 355 different census tracts and the maximum number residing within the same tract was 20. Census tracts are county subdivisions, typically containing around 4000 people, and boundaries are chosen to delineate homogeneous areas with regard to demographic and economic characteristics (Bureau of the Census, 1992). Neighborhood characteristics were drawn from the 1990 US Census. Neighborhood economic indicators used were: proportion of unemployed males in the workforce, median household income and proportion of people living below poverty. The proportion of adults with less than a high school education was used as an indicator of neighborhood demographics. A measure of neighborhood social class was derived from census data

Fig. 1. Map of counties in the San Francisco Bay Area, California, showing proportion of the study subjects residing in each county.

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on occupation. The US Census classifies occupations into 13 major categories that are types of work rather than categories of social class. Applying a scheme developed by Krieger (Krieger, 1991), neighborhood social class was defined with a continuous variable measuring the proportion of neighborhood residents with working-class occupations. In this scheme, administrative support, sales, service, operator and laborer occupations are classified as working class due to the relationship of these occupational groups to control and ownership of economic production, and executive, professional, technical, protective service, craftsman and farming occupations are classified as non-working class. Logistic regression models were used to examine the impact of the local-area characteristics on smoking during pregnancy, adjusting for individual and family socio-demographic risk factors. Generalized estimating equations (GEE) were used to fit the regression models to account for statistical dependence among observations on women living in the same neighborhoods, (Diggle et al., 1994) and to obtain robust estimates of the standard errors of model parameters.

Results Of the 962 eligible subjects, 84 women (8.7%) were missing information on study variables. As a group, women with missing data were not different from women with complete data with respect to smoking during pregnancy, maternal age, marital status or health insurance status, although they were more likely to have unemployed family occupation status (p-value = 0.04). The final analytic sample contained 878 women resident in 355 census tracts, the maximum number of women per tract was 20. Eighteen percent of the sample reported current smoking at the first prenatal visit. Among smokers, the median number of cigarettes smoked per day was 10 (1/2 pack). Descriptive statistics for the sample are presented in Table 1.

Economic and demographic neighborhood indicators (as defined in Methods above) were not associated with smoking during pregnancy. Neighborhood social class (measured as the proportion of working-class residents and ranging from 25% to 88%), however, was related to maternal smoking. The unadjusted odds ratio for smoking during pregnancy associated with living in a neighborhood with more than two-thirds working-class residents was 1.8 (95% CI: 1.2–2.6). We next examined potential maternal and family characteristics that might account for the relationship between neighborhood factors and smoking during pregnancy. Being in a working class or unemployed family, having less than a high school education or receiving MediCal significantly increased the odds of smoking during pregnancy. Being married significantly reduced the odds, whereas maternal age was not associated with smoking (Table 2). To estimate the independent contribution of workingclass neighborhoods to smoking during pregnancy across the entire range of variation in workingclass neighborhoods, we modeled the risk of smoking during pregnancy as a function of the proportion of working-class neighborhood residents (a continuous variable), adjusting for all maternal/family SES variables, in logistic regression models (Table 2). As the proportion of working-class residents in a neighborhood increases, the risk of smoking during pregnancy also increases. Fig. 2 shows the estimated odds ratios for smoking during pregnancy from the fully adjusted model. To further illustrate the independent contribution of neighborhood social class, we calculated the adjusted odds of smoking during pregnancy associated with living in a neighborhood with more than two-thirds working-class residents for working-class and nonworking-class women. Working-class women living in predominantly working-class neighborhoods had nearly four times the odds of smoking during pregnancy as the reference group comprised of women in middle–upper class families living in neighborhoods that were not

Table 1 Characteristics of 878 white women delivering infants at University of San Francisco’s Moffitt Hospital, 1980–1990 Maternal characteristic Frequency (%)

Pregnant smokers n ¼ 155 (18%)

Non-smokers and pregnancy quitters n ¼ 723 (82%)

Low maternal age (o21 yr) High maternal age (X35 yr) Married Maternal education ohigh school Working-class family status Unemployed family occupation status MediCal

8 21 83 16 55 15 50

21 129 584 24 150 18 92

(5%) (14%) (54%) (10%) (35%) (10%) (32%)

(3%) (18%) (81%) (3%) (21%) (2%) (13%)

K.E. Pickett et al. / Health & Place 8 (2002) 167–175

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Table 2 Association of individual/family factors and working-class neighborhood status with smoking during pregnancya Categorical variables

Unadjusted OR (95% CI)

Adjusted OR (95% CI)b

Age o21 yr vs. 21–34 yr Age X35 yr vs. 21–14 yr Married vs. not Unemployed familyc Working-class familyc Maternal education o high school vs. more than high school MediCal vs. not

1.82 0.71 0.27 5.49 2.39 3.38

0.55 1.06 0.38 2.43 1.88 1.57

3.26 (2.09, 5.09)

1.77 (1.04, 3.03)

Continuous variable Working-class residents in neighborhood (%)

Unadjusted b-coefficient (95% CI) 0.02 (0.01, 0.04)

Adjusted b-coefficient (95% CI)b 0.02 (0.01, 0.03)

(0.79, (0.43, (0.18, (2.30, (1.62, (1.58,

4.18) 1.19) 0.40) 13.08) 3.53) 7.21)

(0.18, (0.63, (0.25, (0.98, (1.25, (0.68,

1.63) 1.79) 0.56) 6.10) 2.82) 3.60)

a

From GEE logistic regression model. Adjusted model included all variables listed in table. c Reference group is non-working-class family. b

28 26 24

Odds Ratio

22

Lower 95% Confidence Interval

20

Upper 95% Confidence Interval

18 16 14 12 10 8 6 4 2 0 10

20

30

40

50

60

70

80

90

100

Percentage of neighborhood population with working class occupation

Fig. 2. Odds ratios* for smoking during pregnancy by neighborhood proportion of working-class residents (*adjusted for maternal age, marital status, low maternal education, working class and unemployed family status, MediCal).

predominantly working class (OR=3.80, 95% CI: 1.90, 7.59). Notably, women in middle–upper class families living in predominantly working-class neighborhoods also had more than twice the odds of smoking during pregnancy than the reference group (OR=2.04, 95% CI: 1.18, 3.50).

Neighborhood social class also predicted heaviness of maternal smoking. Among the 155 women who reported smoking, the proportion of working-class residents in the neighborhood was positively associated with the number of cigarettes smoked daily in a multivariable model (results not shown).

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Discussion Living in a predominantly working-class neighborhood doubles the odds that a woman will smoke during pregnancy, regardless of her own social class and other socioeconomic characteristics. In contrast, neighborhood economic and demographic contexts appear not to be associated with maternal smoking. These findings suggest that neighborhood social class may influence maternal behavior over and above the effects of neighborhood poverty and family socioeconomic risks (Klebanov et al., 1998). Understanding the nature of this association may shed light on factors within the broader social environment that influence women’s ability and motivation to quit or reduce smoking during pregnancy and, as such, provide important information for prevention efforts. To our knowledge, this is the first report of the influence of neighborhood characteristics on smoking prevalence in pregnant women. However, prior to interpreting these findings, several limitations of the present research must be noted. First, defining our outcome based on self-reported smoking at the first prenatal visit may have introduced bias or imprecision into our classification of maternal smoking. Pregnant women may underreport smoking to their physicians because of general social desirability bias, or direct pressure to quit (Windsor et al., 1998). Furthermore, there is substantial fluctuation in smoking patterns over the course of the pregnancy, including cycling between cessation and relapse (Pickett et al., 2001a). Constraints of the present dataset made it impossible for us to distinguish very early pregnancy quitters from never smokers in the non-smoking group, and later pregnancy quitters from continuing pregnancy smokers in the smoking group, which may have obscured important differences between these three groups of women. Second, neighborhood effects must always be interpreted with caution because of the possibility that they may serve as a proxy for unmeasured individual or family characteristics. Although our final models were adjusted for individual and family socio-demographic characteristics, factors that influence selection into a particular neighborhood rather than neighborhood characteristics themselves may confound this association. For example, the finding that middle–upper income women living in working-class neighborhoods are more likely to smoke during pregnancy may be due to the fact that such women are more likely to be married to working-class men, who, in turn, are more likely to be smokers. We could not control for partner smoking status. The use of census tracts as a neighborhood proxy also has limitations. Neighborhoods may be defined in other ways that might capture community effects more sensitively; census tracts do not capture smaller neighborhood units since the smallest census tract includes

approximately 4000 people (Klebanov et al., 1998; Pickett and Pearl, 2001). The fact that these findings are based on a sample from only one regional context, may also limit their generalizability. Our study sample is broadly comparable in socioeconomic and demographic status to the entire US population of white, pregnant women during the study decade. For example, 16% of our sample received MediCal, compared to 15% of the US population of white, pregnant women receiving Medicaid in 1990 (Thorpe, 1999, p. 726). As expected for the San Francisco Bay Area, our sample is older and better educated. For example, 17% of our subjects were aged 35 or older, compared to 14% of white women in California in 1997 and 9% of white US mothers delivering in 1990 (Ventura et al., 1999). As an additional caution, neighborhood effects may be very localized and not generalize to other contexts. As an example, a recent study of neighborhood impact on child development reported that neighborhood effects were weaker in western states than in other regions of the US (Chase-Lansdale and Gordon, 1996). Our study sample delivered infants between 1980 and 1990. Compared to the smoking prevalence of 18% in our sample, 21% of white women who delivered infants in the US in 1990 reported smoking during pregnancy (Mathews, 1998). Despite large declines in smoking among the general adult population since that time, smoking during pregnancy has been fairly stable. While prevalence gradually declined to 16% for white women in 1999, about a quarter of younger white women and women with less than a college education smoke during pregnancy, consistently from 1990–1999 (Mathews, 2001). Neighborhood characteristics may also have changed over the study decade, as may have the impact of neighborhood factors. Indeed, we have also found that change in neighborhood socioeconomic status is associated with increased risk of preterm delivery in this study population (Pickett et al., 2001b). We did examine the same neighborhood variables derived from the 1980 census as we report for the 1990 census, as well as the change in each neighborhood variable from 1980–1990. For the 1980 variables, as for the 1990 variables, only percentage of working-class residents was significantly associated with pregnancy smoking. For the 1980–1990 change variables only change in percentage of working-class residents was related to pregnancy smoking. However, in contrast to the working-class effect in 1990, which was robust to confounding by individual factors, the effect of workingclass neighborhoods in 1980 could be explained by a combination of individual-level factors, including maternal age, marital status, education, working-class status and Medicaid status. One interpretation is that the effect of working-class neighborhoods in 1990 is an

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artifact, however a plausible alternative explanation is that as societal norms began to discourage smoking in the San Francisco area, smoking during pregnancy became increasingly localized in working-class areas. This is compatible with known shifts in smoking prevalence from upper to lower class strata over time (Graham, 1996). These limitations notwithstanding, we believe the present findings provide thought-provoking preliminary data on the potential importance of local-area context as an influence on maternal smoking during pregnancy. These findings are consistent with previous research emphasizing the importance of social networks on maternal smoking (Graham, 1987; Wakefield et al., 1993). They are also consistent with previous research on non-pregnant smokers, which suggests that factors within the social context other than economic deprivation increase the risk of smoking (Diez-Roux et al., 1997; Krieger, 1992; Kleinschmidt et al., 1995; Reijneveld, 1998). One possible mechanism for explaining this association of neighborhood class and maternal smoking is via social attitudes towards smoking. Duncan et al. found that prevalence of smoking and actual cigarette consumption were correlated within neighborhoods, so that places where many people smoke also had a high proportion of heavy smokers (Duncan et al., 1996). Curry et al. report that community prevalence of both smoking and tolerant attitudes towards smoking were associated with individual attitudes towards smoking, even among non-smokers (Curry et al., 1993). In working-class neighborhoods, both the prevalence of other female smokers and the absence of strong messages of social disapproval about smoking while pregnant may reduce the likelihood that women will quit. Women’s heightened sensitivity to their broader social networks, as compared to men (Stansfeld, 1999) may increase their susceptibility to social messages of acceptability or disapproval by those around them, particularly when these messages are communicated in reference to ‘‘what a good mother does to protect her baby.’’ When such messages of disapproval are communicated (both directly and through modeling), they may amplify the impact of physician and public health communications about the detrimental effects of smoking on the fetus. Their relative absence in working-class neighborhoods may attenuate the behavioral effect of such communications from health providers, particularly if messages from health providers are viewed with skepticism within this context (Wakefield et al., 1998). The working-class context, with levels of strain, (both job-related and in general), and low resources and aspirations for the future, may also foster a presentoriented rather than future-oriented social context (Marmot et al., 1999; Klebanov et al., 1998; Jarvis and Wardle, 1999). Within such contexts, preventive health behaviors may receive a low priority in light of

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multiple, competing stressors (Drayton-Martin et al., 1999). Another explanation for the neighborhood effect may be that neighborhood class status is a proxy for other contexts that have an impact on smoking behavior, such as workplace environments (Wergeland et al., 1996). While workplace restrictions on smoking are currently widespread in California, during our study period work places may have regulated smoking in the workplace far less. We have recently reported data from a small study demonstrating that for many pregnant smokers, cigarette consumption varies from month to month, week to week and day to day (Pickett et al., 2001a). Women who are unable to smoke in the workplace but unable to quit often compensate by smoking more intensively when opportunity allows (Borland and Owen, 1995). It is likely that workplace contexts independently affect the pattern of women’s’ smoking rather than the absolute risk of smoking or not. Future research on local-area effects that ‘‘unpacks’’ the working-class construct will be useful in elucidating the nature of this association. First, more in-depth knowledge of neighborhood characteristics than can be derived from census tracts is needed (Chase-Lansdale and Gordon, 1996). This should include data on prevalence of smoking within neighborhoods as well as neighborhood resources, such as accessibility to health care. Second, data on the social and workplace context of maternal smoking in different neighborhoods (e.g., messages women receive from neighbors and co-workers about smoking while pregnant, number of women they know who smoked while pregnant, neighborhood attitudes about smoking, maternal smoking and preventive health behaviors, in general) will be useful. Third, identifying family factors that influence selection into working-class neighborhoods will be important. The present findings have potentially important public health implications. Public health smoking cessation interventions for pregnant smokers tend to be ‘‘one size fits all.’’ Treatments typically involve a brief didactic intervention at the first prenatal visit with little or no tailoring to maternal characteristics or social context (Windsor et al., 1998; Orleans et al., 2000). This type of intervention is not likely to be effective with hard-core smokers (Healton, 1999), a category in which will likely fall the majority of women who do not spontaneously quit upon learning of pregnancy. Pregnant women who are surrounded by other smokers (e.g., spouse, family, neighbors, friends and co-workers) may be less likely to benefit from such intervention, unless it is supplemented with information that is specifically designed to counteract messages of social acceptability. To be effective, such interventions must be informed by an awareness of attitudes and messages about smoking within a particular social context, since these may vary significantly from prevailing attitudes in society at large. For

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example, social contexts will vary in the extent to which scientific knowledge is viewed as an important reason to change smoking behavior (Graham, 1976; Wakefield et al., 1998). Similarly, maternal smokers living in high stress environments who utilize smoking to alleviate stress may require stress management interventions as an important complement to routine cessation interventions (Drayton-Martin et al., 1999). In addition, neighborhood-level and workplace interventions geared towards reducing social tolerance for smoking during pregnancy may be vitally important for enhancing the effectiveness of clinic-based interventions. In areas where general tolerance for smoking is high, one such strategy may be a media campaign that differentiates ‘‘smoking for two’’ (Drayton-Martin et al., 1999) from smoking in general in order to mobilize social pressure to reduce or quit in pregnancy. Despite substantial efforts, we are still far from achieving the national Healthy People goal of reducing the prevalence of smoking during pregnancy to 2% by 2010 (United States Department of Health and Human Services, 2000). Although smoking has dire health consequences for all individuals, these consequences are magnified substantially when possible long-term intergenerational consequences of smoking during pregnancy are taken into account (Wakschlag et al., 2000). As such, future research must focus on identifying multiple levels of influence on maternal smoking during pregnancy, in order to develop effective prevention strategies.

Acknowledgements This work was supported in part by a grant from the California Wellness Foundation to Dr Abrams. The writing of this paper was also supported by grants from the National Institute of Drug Abuse (K08 DA00330) to Dr. Wakschlag, and from the Walden and Jean Young Shaw Foundation and the Irving B. Harris Center for Developmental Studies to the Department of Psychiatry, University of Chicago. The address linkage to census data and study procedures were approved by the University of California, Berkeley Committee for Protection of Human Subjects and the University of California, San Francisco Committee on Human Research. The authors would like to thank Dr. Ted Karrison, Ph.D and Dezheng Huo, MS of the Department of Health Studies, University of Chicago for discussions related to the statistical analysis.

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