Recent Publications

Feeling heard and not judged: Perspectives on substance use services among youth formerly in foster care.
   Child Maltreatment (2018)
    Braciszewski, J. M. ; Tran, T. B.; Moore, R. S. ; Bock, B. C.; Tzilos, G. K.; Chamberlain, P.; Stout, R. L. ; Vose-O’Neal, A.
Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.

Impacts of alcohol availability on Tribal lands where alcohol is prohibited: A community-partnered qualitative investigation (In Press)
   International Journal of Drug Policy (2018)
    Lee JP ; Pagano A ; Moore RS ; Tilsen N; Henderson JA; Iron Shell A; Davids S; LeBeaux L; Gruenewald P

Spatial epidemiology of alcohol and drug-related health problems among Northern Plains American Indians: Nebraska and South Dakota, 2007-2012 (In Press)
   Alcoholism: Clinical and Experimental Research (2018)
    Ponicki WR ; Henderson JA; Gaidus A; Gruenewald PJ ; Lee JP ; Moore RS ; Davids S; Tilsen N

Does a Little Drinking Make Your Heart Grow Stronger?
   Journal of Studies on Alcohol & Drugs (2017)
    Caetano, Raul

Using panel vendors for recruitment into a web-based family prevention program: Methodological considerations
   Evaluation & the Health Professions (2017)
    Wang-Schweig, Meme ; Miller, Brenda ; Byrnes, Hilary ; Bourdeau, Beth ; Buller, David; Rogers, Veronica
Use of online panel vendors in research has grown over the past decade. Panel vendors are organizations that recruit participants into a panel to take part in web-based surveys and match panelists to a target audience for data collection. We used two panel vendors to recruit families (N = 411) with a 16- to 17-year-old teen to participate in a randomized control trial (RCT) of an online family-based program to prevent underage drinking and risky sexual behaviors. Our article addresses the following research questions: (1) How well do panel vendors provide a sample of families who meet our inclusion criteria to participate in a RCT? (2) How well do panel vendors provide a sample of families who reflect the characteristics of the general population? and (3) Does the choice of vendor influence the characteristics of families that we engage in research? Despite the screening techniques used by the panel vendors to identify families who met our inclusion criteria, 23.8% were found ineligible when research staff verified their eligibility by direct telephone contact. Compared to the general U.S. population, our sample had more Whites and more families with higher education levels. Finally, across the two panel vendors, there were no significant differences in the characteristics of families, except for mean age. The online environment provides opportunities for new methods to recruit participants in research studies. However, innovative recruitment methods need careful study to ensure the quality of their samples.

Personality and life events in a personality disorder sample
   Personality Disorders: Theory, Research, and Treatment (2017)
   Timoney, L. R.; Walsh, Z.; Shea, M. T.; Yen, S.; Ansell, E. B.; Grilo, C. M.; McGlashan, T. H.; Stout, R. L. ; Bender, D. S.; Skodol, A. E.; Sanislow, C. A.; Morey, L. C.; Gunderson, J. G.
Individuals with a personality disorder (PD) tend to experience more negative life events (NLEs) than positive life events (PLEs). In community samples, the Five Factor Model of personality (FFM) predicts both positive and negative life events. The present research examined whether FFM normal personality traits were associated with positive and negative life events among individuals with 1 of 4 PDs: avoidant, borderline, schizotypal, and obsessive-compulsive, and tested whether associations between the FFM of personality and PLEs and NLEs were similar across the 4 PD groups and a control group. Among aggregated PDs, neuroticism was positively associated with NLEs, whereas extraversion, openness to experience, and conscientiousness were positively associated with PLEs. Comparisons of each PD group to a control group of individuals with a major depressive disorder indicated that the FFM traits operated similarly across clinical samples with and without PD. Our findings indicate that normal personality traits can be used to help understand the lives of individuals with PD.

70 lives saved by laws and regulations that resulted from the Bloomberg Road Safety Program
   Injury Prevention (2017)
    Swedler, David ; Miller, Ted ; Levy, David
The Bloomberg Road Safety Program (BRSP) supports the development of traffic safety laws, regulations, and activities. Six low- and middle-income countries (LMICs) enacted over a dozen such regulations between 2007 and 2013. Purpose: This evaluation estimates the lives saved by these laws in 2007–2013 then projects future reductions in motor vehicle crash (MVC) mortality through 2023. Methods: Local BRSP staff identified traffic laws in Brazil, China, Kenya, Mexico, Turkey, and Vietnam that we categorised as driving while intoxicated, seat belt use, motorcycle-related, and other. To calculate reductions in deaths, we used domestic and international systematic reviews to identify effectiveness of such laws. Discounts in reductions were made for those laws that had poor enforcement, as determined by BRSP staff. Historic MVC deaths saved were estimated using data from the Global Burden of Disease (GBD). Historic growth rates from the GBD were then used to project mortality reductions through 2023. Results: BRSP helped pass laws and regulations that saved an estimated 19?000 lives from 2007–2013. Those laws and regulations will save another 90?000 lives in 2014–2023. Of the 1?09?000 estimated lives likely to be saved, over half will be in China and one-third will be in Vietnam. Limitations for our estimates include use of historic fatality rates; paucity of country-specific intervention publicity, enforcement and effectiveness data; and inherent weaknesses of GBD data. Conclusion: In LMICs, traffic safety interventions associated with the BRSP have the potential to save over 1?00?000 lives from 2007–2023. Significance: Economic analyses can estimate lives saved due to traffic safety regulations in LMICs. Better estimates of local implementation, enforcement, and effectiveness could improve such estimates in the future.

Long-term recall of social relationships related to addiction and HIV risk behaviors
   Drug and Alcohol Dependence (2017)
    Stout, R. L. ; Janssen, T.; Braciszewski, J. M. ; Vose-O'Neal, A.
Social relationships have been demonstrated as a key predictor of relapse among addicted persons and are likely to be important determinants of HIV risk behaviors also. However, the degree to which this population can reliably and consistently identify important people (IPs) in retrospect has been understudied. Using the modified Important People and Activities questionnaire, we investigated to what degree IPs were dropped, added, or retained, and whether data about individual IPs were reported accurately on 6- and 12-month follow up periods using a sample of 50 drug or alcohol abusing participants. We found that IPs were largely retained, and that those retained versus dropped/added differed by their reaction to participant alcohol/drug use, as well as frequency of contact. We further found that there were differences in reliability of data describing specific IPs. While both 6- and 12-month follow up periods led to reliabilities ranging from excellent to fair, we found poorer reliability on responses to recall of "frequency of contact" and "reactions to drinking", as well as "reactions to drug use". Future investigations of reliability of social relationships recalled retrospectively should attempt to examine possible systematic biases in addition to the reliability of specific IP data. More sophisticated studies are needed on factors associated with systematic variation in reporting of aspects of social relationships that are associated with addictions or HIV risk outcomes.

Determinants of driving under the influence of alcohol or drugs among Latino immigrants in Miami-Dade County, Florida
   Journal of Ethnicity in Substance Abuse (2017)
    Romano, E. ; Sanchez, M.; De La Rosa, M.; Ertman, B
Little is known about the pre- and postimmigration drinking and drunk- and drugged-driving behavior of Latino immigrants. Despite showing risky drinking behaviors, many recent immigrants of low socioeconomic status (SES) do not drive while impaired by alcohol (DWI) due largely to limited access to a vehicle. This effort examines the DWI and driving while impaired by drugs (DWID) behaviors of Latino immigrants who have access to a vehicle. Data came from an ongoing longitudinal sample of Latino immigrants to Miami-Dade County, Florida. Bivariate analyses and logistic regression were applied. Preimmigration DWI and DWID was the best predictor of postimmigration DWI and DWID. Future interventions should make efforts to (a) identify immigrants who had DWI and DWID in their country of origin and (b) design and deliver specific and culturally relevant messages to persuade them not to engage in DWI and DWID after immigration.

Receipt of warnings regarding potentially impairing prescription medications and associated risk perceptions in a national sample of U.S. drivers
   Journal of Studies on Alcohol and Drugs (2017)
    Pollini, Robin A ; Waehrer, Geetha ; Kelley-Baker, Tara
Objective: Reducing drug-involved driving is a national policy priority, but little is known about the extent to which drivers receive warnings about the impairment potential of their prescribed medications. We used data from the 2013–2014 National Roadside Survey (NRS) to quantify the proportion of drivers who received warnings regarding potentially impairing medications and the association with driving-related risk perceptions. Method: Drivers randomly selected at 60 sites completed the self-administered survey, which contained questions on their use of prescription medications. Results: Overall, 7,405 drivers completed the prescription drug portion of the NRS. Of these, 19.7% reported recent use (within the past 2 days) of a potentially impairing prescription drug, and 78.2% said the drug had been prescribed for their use. Users of prescribed sedatives (85.8%) and narcotics (85.1%) were most likely to report receiving information about potential impairment, compared with only 57.7% and 62.6% of users of prescribed stimulant and antidepressant medications, respectively. Receipt of warnings varied by sex, race/ethnicity, income, geographic region, and time of day. For a majority of drug categories, drivers who reported receiving warnings had significantly higher odds of perceived risk of impaired driving/crash and criminal justice involvement. Conclusions: Most users of prescription medications reported that the drug was prescribed for their use, but not all reported receiving warnings about driving impairment. Our study provides evidence of missed opportunities for information provision on impaired driving, identifies subgroups that may warrant enhanced interventions, and provides preliminary evidence that receipt of impairment warnings is associated with increased perceptions of driving-related risk.

Ethnographic research in immigrant-specific drug abuse recovery houses
   Journal of Ethnicity in Substance Abuse (2017)
    Pagano, Anna ; Lee, Juliet P. ; Garcia, V.; Recarte, C.
Access to study populations is a major concern for drug use and treatment researchers. Spaces related to drug use and treatment have varying levels of researcher accessibility based on several issues, including legality, public versus private settings, and insider/outsider status. Ethnographic research methods are indispensable for gaining and maintaining access to hidden or "hard-to-reach" populations. Here, we discuss our long-term ethnographic research on drug abuse recovery houses created by and for Latino migrants and immigrants in Northern California. We take our field work experiences as a case study to examine the problem of researcher access and how ethnographic strategies can be successfully applied to address it, focusing especially on issues of entrée, building rapport, and navigating field-specific challenges related to legality, public/private settings, and insider/outsider status. We conclude that continued funding support for ethnography is essential for promoting health disparities research focused on diverse populations in recovery from substance use disorders.

Cigarette smoking and quit attempts among Latinos in substance use disorder treatment
   The American Journal of Drug and Alcohol Abuse (2017)
    Pagano, Anna ; Gubner, Noah; Le, Thao; Guydish, Joseph
Background: Differences in tobacco use behaviors have been identified between Latinos and non-Latino whites in the general US population. Little is known about cigarette smoking and quitting behaviors of Latinos in treatment for substance use disorders (SUDs), who represent two major tobacco-vulnerable groups. Objectives: To compare, in a national sample of persons enrolled in SUD treatment, demographic, drug use, and smoking and quitting prevalence and behaviors between Latinos and non-Latino whites. Methods: We surveyed 777 SUD treatment clients, sampled from 24 clinics selected at random from the National Institute on Drug Abuse Clinical Trials Network (Latino client n = 141; 40% female). We then conducted univariate and multivariate analyses to identify correlates of smoking behaviors by Latino/non-Latino white ethnicity. Results: Latinos’ smoking prevalence resembled that of non-Latino whites (78.7% vs. 77.4%). In regression analyses, Latino smokers (n = 111) tended to smoke fewer cigarettes per day (CPD) than non-Latino white smokers (n = 492); were more often nondaily smokers and menthol smokers; more often reported a smoking quit attempt in the last year; and tended to report higher numbers of past-year quit attempts. Among Latino smokers, those with less education and those reporting opioids as their primary drug of use reported higher CPD. Conclusions: Latinos in SUD treatment are at equally high risk of being current heavy smokers as compared to non-Latino whites in SUD treatment. At the same time, Latinos in SUD treatment exhibit ethnic-specific smoking and quitting behaviors that should be considered when designing smoking interventions for this group.

Lifetime cost of abusive head trauma at ages 0–4, USA
   Prevention Science (2017)
    Miller, Ted ; Steinbeigle, Ryan; Lawrence, Bruce ; Peterson, Cora; Florence, Curtis; Barr, Marilyn; Barr, Ronald
This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids’ Inpatient Database, and previous studies. Unit costs were derived from published sources. From society’s perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2–9.2 million) for a death. It averages $2.6 million (95% CI $1.0–2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5–16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

A Comparison of Long- vs. Short-Term Recall of Substance Use and HIV Risk Behaviors
   J Stud Alcohol Drugs (2017)
   Janssen, T.; Braciszewski, J. M. ; Vose-O'Neal, A. ; Stout, R. L.
The Timeline Follow-back (TLFB) questionnaire has become a pre-eminent tool in substance use and human immunodeficiency virus (HIV) risk research, allowing researchers to assess fine-grained changes in risk behavior over long periods. However, data on accuracy of recall over long (12-month) periods are sparse, especially combined data on HIV risk and substance use from post-treatment samples. Studies on the development of substance use and HIV risk stand to benefit from data on the accurate recall of such behavior over longer retroactive spans of time. The present study offers data on the test-retest reliability of current TLFB assessment versus 6- and 12-month delayed TLFB assessment, using a post-treatment sample (n = 50). Long-term reliability of TLFB data on HIV risk was predominantly good to excellent, with 13 of 20 assessed variables in that range. TLFB data on substance use was similar, with 22 of 26 variables resulting in good/excellent reliability. Our findings support the notion that, notable exceptions aside, the TLFB may be effectively used to assess retroactive HIV risk and substance use in periods of 12 months.

Global, regional, and national burden of neurological disorders during 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015
   The Lancet Neurology (2017)
   GBD Neurological Disorders Collaborator Group; Miller, Ted
Background: Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level. Methods: We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development. Findings: Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4 [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tension-type headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication overuse headache (58·5 [50·8 to 67·4 million]), and Alzheimer's disease and other dementias (46·0 [40·2 to 52·7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by 36·7%, and the number of DALYs by 7·4%. These increases occurred despite decreases in age-standardised rates of death and DALYs of 26·1% and 29·7%, respectively; stroke and communicable neurological disorders were responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the changes in DALY rates of neurological disorders with development were driven by changes in YLLs. Interpretation: Neurological disorders are an important cause of disability and death worldwide. Globally, the burden of neurological disorders has increased substantially over the past 25 years because of expanding population numbers and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders. The number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate services.

Estimation of the potential effectiveness of lowering the blood alcohol concentration (BAC) limit from .08 to .05 grams per deciliter in the United States
   Alcoholism: Clinical and Experimental Research (2017)
    Fell, J. C. ; Scherer, M.
Background: In 2013, the National Transportation Safety Board (NTSB) issued a report recommending that states lower the illegal blood alcohol concentration (BAC) limit for driving from 0.08 to 0.05 g/dl. The NTSB concluded that there is a strong evidence-based foundation for a BAC limit of 0.05 or lower. Most industrialized nations have already enacted a 0.05 illegal BAC limit. This study was undertaken to contribute to the scientific evidence as to whether lowering the BAC limit to 0.05 will be an effective alcohol policy in the United States. Methods: We accomplished our objective by: (i) conducting a meta-analysis of qualifying international studies to estimate the range and distribution of the most likely effect size from a reduction to 0.05 BAC or lower; (ii) translating this synthesis toward estimating the effects of reducing the current 0.08 BAC limit to 0.05 in the United States; and (iii) estimating the life-saving benefits of the proposed 0.03 reduction in the driving limit from 0.08 to 0.05 BAC. Results: In our meta-analysis of studies on lowering the BAC limit in general, we found a 5.0% decline in nonfatal alcohol-related crashes, a 9.2% decline in fatal alcohol-related crashes from lowering the BAC to 0.08, and an 11.1% decline in fatal alcohol-related crashes from lowering the BAC to 0.05 or lower. We estimate that 1,790 lives would be saved each year if all states adopted a 0.05 BAC limit. Conclusions: This study provides strong evidence of the relationship between lowering the BAC limit for driving and the general deterrent effect on alcohol-related crashes.

Empirical validation of the New Zealand serious non-fatal injury outcome indicator for ‘all injury’
   Injury Prevention (2017)
   Cryer, Colin; Davie, Gabrielle S; Gulliver, Pauline J; Petridou, Eleni Th; Dessypris, Nick; Lauritsen, Jens; Macpherson, Alison K; Miller, Ted R ; de Graaf, Brandon
Our purpose was to empirically validate the official New Zealand (NZ) serious non-fatal ’all injury' indicator. To that end, we aimed to investigate the assumption that cases selected by the indicator have a high probability of admission. Using NZ hospital in-patient records, we identified serious injury diagnoses, captured by the indicator, if their diagnosis-specific survival probability was =0.941 based on at least 100 admissions. Corresponding diagnosis-specific admission probabilities from regions in Canada, Denmark and Greece were estimated. Aggregate admission probabilities across those injury diagnoses were calculated and inference made to New Zealand. The admission probabilities were 0.82, 0.89 and 0.90 for the regions of Canada, Denmark and Greece, respectively. This work provides evidence that the threshold set for the official New Zealand serious non-fatal injury indicator for ’all injury' captures injuries with high aggregate admission probability. If so, it is valid for monitoring the incidence of serious injuries.

Alcohol use severity among adult Hispanic immigrants: Examining the roles of family cohesion, social support, and gender
   Substance Use & Misuse (2017)
   Cano, Miguel Ángel; Sánchez, Mariana; Rojas, Patria; Ramírez-Ortiz, Daisy; Polo, Katherine L.; Romano, Eduardo ; De La Rosa, Mario
Background: This study examined (a) the direct association of family cohesion on alcohol use severity among adult Hispanic immigrants; (b) the indirect association of family cohesion on alcohol use severity via social support; and (c) if gender moderates the direct and indirect associations between family cohesion and alcohol use severity. Method: Mediation and moderation analyses were conducted on a cross-sectional sample of 411 (men = 222, women = 189) participants from Miami-Dade, Florida. Results: Findings indicate that higher family cohesion was directly associated with higher social support and lower alcohol use severity. Higher social support was also directly associated with lower alcohol use severity. Additionally, family cohesion had an indirect association with alcohol use severity via social support. Moderation analyses indicated that gender moderated the direct association between family cohesion and alcohol use severity, but did not moderate the indirect association. Conclusions: Some potential clinical implications may be that strengthening family cohesion may enhance levels of social support, and in turn, lower alcohol use severity among adult Hispanic immigrants. Furthermore, strengthening family cohesion may be especially beneficial to men in efforts to lower levels of alcohol use severity.

Social drinking groups and risk experience in nightclubs: Latent class analysis
   Health, Risk & Society (2017)
    Bourdeau, Beth ; Miller, Brenda A. ; Voas, Robert B. ; Johnson, Mark B. ; Byrnes, Hilary F.
Nightclubs are a setting in which young adults purposefully seek out experiences, such as drug use and alcohol intoxication that can expose them to physical harm. While physical harm occurs fairly frequently within clubs, many patrons have safe clubbing experiences. Further, not all patrons experience potential harms the same way, as there are differences in aggression and intoxication. In this article, we draw on data from a research study in which we sought to better understand the role of social drinking groups in experiences of risk within nightclubs, as the majority of patrons attend with others. We collected data from 1642 patrons comprising 615 social drinking groups as they entered and exited nightclubs in a major US city. We focused on six experiences that might cause physical harm: alcohol impairment, alcohol intoxication, drug use, physical aggression, sexual aggression, and impaired driving. We aggregated patron responses across social groups and used latent class statistical analysis to determine if and how experiences tended to co-occur within groups. This analysis indicated that there were five distinct classes which we named limited vulnerability, aggression vulnerability, substance users, impaired drivers, and multi-issue. We assessed the groups within each class for distinctions on characteristics and group context. We found differences in the groups in each class, such as groups containing romantic dyads experienced less risk, while those groups with greater familiarity, greater concern for safety, and higher expectations for consumption experienced more risk. Group composition has an impact on the experiences within a club on a given night, in particular when it comes to risk and safety assessment.

School-based health centers and adolescent substance use: Moderating effects of race/ethnicity and socioeconomic status
   Journal of School Health (2017)
    Bersamin, M. ; Paschall, M. J. ; Fisher, D. A.
BACKGROUND: School-based health centers (SBHCs) have been associated with many positive health and academic outcomes. The current study extends previous research and examines possible differences in the association between SBHC exposure and adolescent alcohol, tobacco, and other drug use by race/ethnicity, sex, and socioeconomic status (SES). METHODS: California Healthy Kids Survey data from 504 traditional high schools in California were linked with publicly available data on SBHCs and school demographics. Multilevel logistic regression analyses were conducted controlling for school and individual characteristics. RESULTS: Significant interactions suggest that SBHC exposure was inversely associated with past 30-day alcohol use, binge drinking, and cigarette and e-cigarette use among African American youth and negatively associated with cigarette and marijuana use among Asian youth, relative to whites. There was also a significant interaction between SBHC exposure and parent education for past 30-day alcohol use and binge drinking. No significant sex interactions were observed. CONCLUSIONS: SBHC exposure appears to be inversely related to substance use among youth in some ethnic minority groups and youth of lower SES. This may have implications regarding SBHC placement and investment. Additional research is necessary to understand the mechanisms through which SBHCs may influence adolescent substance use and other health behaviors.