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AJPH First Look, published online ahead of print Mar 29, 2006
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May 2006, Vol 96, No. 5 | American Journal of Public Health 804-807
© 2006 American Public Health Association
DOI: 10.2105/AJPH.2004.058925

RESEARCH AND PRACTICE

Exposure to the World Trade Center Attack and the Use of Cigarettes and Alcohol Among New York City Public High-School Students

Ping Wu, PhD, Cristiane S. Duarte, PhD, Donald J. Mandell, PhD, MPH, Bin Fan, MD, Xinhua Liu, PhD, Cordelia J. Fuller, MA, George Musa, MS, Michael Cohen, PhD, Patricia Cohen, PhD and Christina W. Hoven, DrPH

Ping Wu, Cristiane S. Duarte, Patricia Cohen, and Christina W. Hoven are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York; and New York State Psychiatric Institute, New York. Donald J. Mandell, Bin Fan, and George Musa are with New York State Psychiatric Institute, New York. Xinhua Liu is with the Department of Biostatistics, Mailman School of Public Health, Columbia University, New York. Cordelia J. Fuller is with the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York. Michael Cohen is with The Michael Cohen Group, LLC, New York.

Correspondence: Requests for reprints should be sent to Ping Wu, PhD, Department of Psychiatry, Columbia University-NYSPI, 1051 Riverside Dr, Unit 43, New York, NY 10032 (e-mail: pw11{at}columbia.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

We examined exposure to the World Trade Center attack and changes in cigarette smoking and drinking among 2731 New York City public high-school students evaluated 6 months after the attack. Increased drinking was associated with direct exposure to the World Trade Center attack (P < .05). Increased smoking was not directly associated with exposure to the World Trade Center attack but was marginally significantly associated with posttraumatic stress disorder (P= .06). Our findings suggest that targeted substance-use interventions for youths may be warranted after large-scale disasters.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Millions of Americans, especially those living in New York City, were affected, many of them traumatically, by the World Trade Center (WTC) attack on September 11, 2001. Studies of adults have documented elevated rates of posttraumatic stress disorder (PTSD),1 psychological stress,2,3 and substance use immediately after the attack.4–6 The immediate effect on children and adolescents of the WTC attack was not assessed as intensively as it was on adults.7–9 Studies have shown increases in substance use in relation to exposure to trauma and PTSD, suggesting that substance use may develop as one attempts to relieve traumatic memories, sleep disturbances, and other PTSD symptoms.10–13 To our knowledge, no studies have been published assessing exposure to the WTC attack and changes in cigarette smoking and alcohol use among adolescents. We sought to understand (1) how different types of exposure to the WTC attack contributed to an increase in smoking and/or drinking among New York City adolescents, and (2) whether PTSD related to the WTC attack can explain increases in use of cigarettes and alcohol among New York City adolescents.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Our analyses were based on self-reported14 data from 2731 high-school students who participated in a New York City Board of Education–sponsored post–September 11 needs assessment and were asked about smoking and drinking after September 11, 2001 (response rate = 79%). Details of the study’s methodology and a description of the total sample (N = 8236) of students in grades 4 to 12 are given elsewhere.9,15,16 Participation was anonymous with parental notification. The study was carried out in full compliance with institutional review board requirements.

The survey was conducted 6 months after the WTC attack. Adolescents were asked questions about changes in smoking and drinking after September 11. Adolescents who reported that they "started to smoke cigarettes" or "smoked more cigarettes" after September 2001 were considered to have increased smoking. Adolescents who reported that they "drank more alcohol" after September 2001 were considered to have increased alcohol consumption.

We collected information on different types of exposure to the WTC attack: (1) direct exposure, (2) family exposure, (3) media exposure, and (4) attendance at a school in the Ground Zero area. We also obtained information about previous exposure to traumatic situations, such as having had a severe injury in violent circumstances or having lived through war or another pre–September 11, 2001, disaster. Detailed definitions of these exposure categories can be found elsewhere.9

We assessed PTSD related to the WTC attack using the Diagnostic Interview Schedule for Children Predictive Scales.17,18 We considered a student to have probable PTSD if he or she had positive screening results for 5 of 8 PTSD symptoms and reported significant impairment. Sociodemographic information also was obtained.

Initially, we examined bivariate associations between 2 dichotomous outcome variables (increased smoking and increased drinking) and independent variables of interest. We used logistic regression analysis to assess the association between an outcome variable and each independent variable, after we adjusted for other risk factors. We used SUDAAN software (Research Triangle Institute, Research Triangle Park, NC) to account for the complex sampling design and to obtain correct variance estimates.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Table 1Go shows that 5.4% of the students reported increased cigarette use or having started smoking after the WTC attack, and 10.9% reported increased drinking. Among all types of exposure, only direct exposure was significantly associated with increased drinking (odds ratio [OR] = 1.8; P < .05). Increased smoking was significantly associated with prior trauma (OR = 2.0; P < .05) and PTSD (OR = 3.1; P < .05). Older age was associated with increased drinking (OR = 1.5; P < .05) but not smoking. Non-White students, especially Black and Hispanic students, were less likely to report increased smoking or drinking than were non-Hispanic White students.


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  		TABLE 1— Bivariate Associations of Sociodemographic Factors, Exposures to the World Trade Center Attack, and Probable Posttraumatic Stress Disorder (PTSD) With Increased Cigarette Smoking and Alcohol Consumption Among 2731 New York City Public High-School Students
 
Table 2Go shows the results from the logistic regression analyses when all factors were considered simultaneously. Most associations that were significant in bivariate analyses remained significant in the multiple logistic regression analyses. However, the adjusted odds ratio for the association between increased smoking and PTSD decreased to 2.5 (P = .06).


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  		TABLE 2— Increased Smoking and Drinking Among 2731 New York City Public High-School Students, by Demographics, Exposure to the World Trade Center Attack, and Probable Posttraumatic Stress Disorder (PTSD): Results of Multiple Logistic Regression Analyses
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
As in studies of adults,4,5 our study identified an association between exposure to the events of September 11, 2001, and alcohol use in adolescents. Different factors were associated with increases in cigarette smoking and alcohol consumption after September 11, 2001, suggesting distinct underlying mechanisms. We found a significant association between direct exposure to the WTC attack and increased alcohol consumption, which suggests that alcohol was used as a way of coping with the immediate effect of the attack. We found a marginally significant association between PTSD and cigarette smoking and no direct association between any form of exposure to the WTC attack and smoking, which may indicate that youths used nicotine as a self-medication strategy to obtain relief from their PTSD symptoms related to the WTC attack. We found that prior trauma increased youth vulnerability to an adverse behavior change (increased smoking), after exposure to the WTC attacks, which parallels findings reported elsewhere of increased vulnerability to psychiatric symptoms.9

Our study was limited by its cross-sectional design, retrospective survey method, and lack of detailed information on changes in smoking and drinking behaviors, which may have affected the interpretation of the findings. However, these findings have important clinical and policy relevance, especially in preparation for other possible large-scale traumatic events. Appropriate and targeted prevention and intervention programs are needed to help youths better respond to such crises.


   Acknowledgments
 
Work on this brief was supported by a grant to the first author from the National Institute on Drug Abuse (R01 DA016894). The US Department of Education School Emergency Response to Violence (SERV) Project funded the data collection with a subcontract.

Without the leadership of Francine Goldstein from the New York City Department of Education and participation of Vincent Giordano, Linda Wernikoff, superintendents, principals, teachers, and, most of all, students, this study could not have succeeded. Special thanks also go to: Pamela Cantor (Children’s Mental Health alliance); J. Larry Aber, Christopher P. Lucas, Ezra Susser, Judith Wicks, Renee Goodwin, Andrea Versenyi, Barbara P. Aaron, Henian Chen, Mark Davies, Steven Greenwald, and Patricia Zybert (Mailman School of Public Health, Columbia University–New York State Psychiatric Institute); Nellie Gregorian, Chris Bumcrot, Craig Rosen, and Victoria Francis (The Michael Cohen Group, LLC); Bradley Woodruff, Victor Balaban (Centers for Disease Control and Prevention); Steven Marans (National Center for Children Exposed to Violence, Yale University); New York University (Elissa Brown); Claude Chemtob (Department of Veterans Affairs, Honolulu, Hawaii); Betty Pfefferbaum (University of Oklahoma); and Robert Pynoos, Alan Steinberg, and William Saltzman (National Center for Child Traumatic Stress, University of California–Los Angeles).

Human Participant Protection
The study was approved by the institutional review board of the New York State Psychiatric Institute.


   Footnotes
 
Peer Reviewed

Contributors
P. Wu conceptualized and designed this study of a sub-sample of the data from the New York City Post-9/11 School Survey, performed data analyses, and wrote the brief. C. S. Duarte contributed to the study design, questionnaire preparation, data imputation, and interpretation of the results. D. J. Mandell contributed to the study design, questionnaire preparation, and interpretation of the results. B. Fan was he data manager and was involved in data imputation. X. Liu provided statistical advice and was involved in data analyses. C. J. Fuller was involved in writing the literature review. G. Musa was involved in designing the study and preparing the questionnaires. M. Cohen managed the data collection process. P. Cohen was involved in designing the study and provided advice on data imputation and analysis. C. W. Hoven was the principal investigator of the World Trade Center–Board of Education Study of the Psychological Effects on New York Public School Students and was involved in all aspects of the study.

Accepted for publication May 13, 2005.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Galea S, Resnick H, Ahern J, et al. Posttraumatic stress disorder in Manhattan, New York City, after the September 11th terrorist attacks. J Urban Health. 2002; 79:340–353.[ISI][Medline]

2. Galea S, Ahern J, Resnick H, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med. 2002;346:982–987.[Abstract/Free Full Text]

3. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med. 2001;345: 1507–1512.[Abstract/Free Full Text]

4. Vlahov D, Galea S, Ahern J, et al. Consumption of cigarettes, alcohol, and marijuana among New York City residents six months after the September 11 terrorist attacks. Am J Drug Alcohol Abuse. 2004;30: 385–407.[CrossRef][Medline]

5. Vlahov D, Galea S, Resnick H, et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. Am J Epidemiol. 2002;155:988–996.[Abstract/Free Full Text]

6. Costello EJ, Erkanli A, Keeler G, Angold A. Distant trauma: a prospective study of the effects of September 11th on young adults in North Carolina. Appl Dev Sci. 2004;8:211–220.[CrossRef]

7. Hoven C, Duarte C, Lucas CP, et al. Effects of the World Trade Center Attack on NYC Public School Students—Initial Report to the New York City Board of Education. New York, NY: Columbia University Mailman School of Public Health–New York State Psychiatric Institute and Applied Research and Consulting, LLC; 2002.

8. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA. 2002;288:581–588.[Abstract/Free Full Text]

9. Hoven CW, Duarte CS, Lucas CP, et al. Psychopathology among New York City public school children 6 months after September 11. Arch Gen Psychiatry. 2005;62:545–552.[Abstract/Free Full Text]

10. Brown PJ, Wolfe J. Substance abuse and post-traumatic stress disorder comorbidity. Drug Alcohol Depend. 1994;35:51–59.[CrossRef][ISI][Medline]

11. Keane TM, Wolfe J. Comorbidity in post-traumatic stress disorder: an analysis of community and clinical studies. J Appl Soc Psychol. 1990;20(21, Pt 1): 1776–1788.[CrossRef]

12. Saladin ME, Brady KT, Dansky BS, Kilpatrick DG. Understanding comorbidity between PTSD and substance use disorder: two preliminary investigations. Addict Behav. 1995;20:643–655.[CrossRef][ISI][Medline]

13. Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addict Behav. 1998;23:827–840.[CrossRef][ISI][Medline]

14. Hoven CW, Duarte CS, Mandell DJ, et al. WTCNYC Child and Adolescent Questionnaire. New York, NY: Columbia University–NYSPI; 2002.

15. Hoven CW, Duarte CS, Mandell DJ. Children’s mental health after disasters: the impact of the World Trade Center attack. Curr Psychiatry Rep. 2003;5: 101–107.[Medline]

16. Hoven CW, Mandell DJ, Duarte CS. Mental health of New York City public school children after 9/11: an epidemiologic investigation. In: Rosenthal JL, Schechter D, Coates SW, eds. September 11: Trauma and Human Bonds Relational Perspectives Book Series. Hillsdale, NJ: Analytic Press Inc; 2003: 51–74.

17. Lucas CP, Zhang H, Fisher PW, et al. The DISC Predictive Scales (DPS): efficiently screening for diagnoses. J Am Acad Child Adolesc Psychiatry. 2001;40: 443–449.[CrossRef][ISI][Medline]

18. Shaffer D, Fisher P, Dulcan MK, Davies M. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA study. J Am Acad Child Adolesc Psychiatry. 1996;35: 865–877.[CrossRef][ISI][Medline]




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This Article
Right arrow Abstract Freely available
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AJPH.2004.058925v1
96/5/804    most recent
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Right arrow Articles by Wu, P.
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Related Collections
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