DrugEpi 1-5 NSDUH Module 1 Overview Context Content Area: Descriptive Epidemiology & Surveillance Essential Question (Generic): How are health-related states or events distributed? Essential Question (Drug Abuse Specific): How is drug abuse distributed? Enduring Epidemiological Understanding: The frequency and distribution of health- related states or events in a population can be determined by systematically collecting, analyzing, and interpreting data. Synopsis In Module 1, students explore how to describe the distribution of health-related states or events. Students begin to uncover and develop the following epidemiological concepts and skills: observing groups of people, counting, the value of a denominator, a case definition, a representative sample, and creating circumstances that encourage truthful responses and protect confidentiality. Lesson 1-1: Counting and Rates Lesson 1-2: Introduction to Surveillance Lesson 1-3: Counting/Describing HIV / AIDS Lesson 1-4: Counting High School Marijuana Use Lesson 1-5: National Survey on Drug Use and Health Lesson 1-6: Other Drug Abuse Surveillance Systems

DrugEpi 1-5 NSDUH Module 1 - Descriptive Epidemiology and Surveillance Lesson 1-5 National Survey on Drug Use & Health Content Historical background on starting surveillance of marijuana use Review of definitions of surveillance Introduction to the National Survey on Drug Use and Health (NSDUH) Example of how one surveillance system can address the five main questions to consider (as described in Lesson 1-4). Sample results from NSDUH Big Ideas By the early 1970’s, concern about drug use among American youth lead to government action to set up a drug use surveillance system The NSDUH example can be used to illustrate rigorous methods of drug use surveillance NSDUH data show that marijuana is by far the most common illicit drug used by American youth This project is supported by a Science Education Drug Abuse Partnership Award, Grant Number 1R24DA , from the National Institute on Drug Abuse, National Institutes of Health.

DrugEpi 1-5 NSDUH 1.How is this disease distributed? Health-related conditions and behaviors are not distributed uniformly in a population. They have unique distributions that can be described by how they are distributed in terms of person, place, and time. 2.What hypotheses might explain the distribution of disease? Clues for formulating hypotheses can be found by observing the way a health-related condition or behavior is distributed in a population. 3.Is there an association between the hypothesized cause and the disease? Causal hypotheses can be tested by observing exposures and diseases of people as they go about their daily lives. Information from these observational studies can be used to make and compare rates and identify associations. 4.Is the association causal? Causation is only one explanation for an association between an exposure and a disease. Because observational studies are complicated by factors not controlled by the observer, other explanations also must be considered. 5.What should be done when preventable causes of disease are found? Policy decisions are based on more than the scientific evidence. Because of competing values - social, economic, ethical, environmental, cultural, and political factors may also be considered. Essential QuestionsEnduring Understandings Where are we?

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. National Survey on Drug Use and Health (NSDUH)

DrugEpi 1-5 NSDUH Marijuana and Health Reporting Act

DrugEpi 1-5 NSDUH In large measure, the marijuana issue is a child of the sixties, the visual and somewhat pungent symbol of dramatic changes which have permanently affected our nation in the last decade. The Report of the National Commission on Marijuana and Drug Abuse Marijuana and Health Reporting Act

DrugEpi 1-5 NSDUH National Household Survey on Drug Abuse ( ) Realizing that marijuana had never before in the American experience been the subject of a concentrated, authoritative governmental study, we launched a comprehensive research and fact-finding effort. National Survey on Drug Use and Health (NSDUH) (2002-present) Soon after funds became available on March 22, 1971, we commissioned more than 50 projects …. We commissioned a nationwide survey of public beliefs, information and experience referred to in this Report as the National Survey ( ). Marijuana and Health Reporting Act

DrugEpi 1-5 NSDUH marihuana: a signal of misunderstanding First Report of the National Commission on Marihuana and Drug Abuse Marijuana and Health Reporting Act - Early Reports

DrugEpi 1-5 NSDUH Go to NIDA Website for Information about Marijuana

DrugEpi 1-5 NSDUH The ongoing systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementation, and evaluation of public health practice closely integrated with the timely dissemination of these data to those who need to know. Surveillance System

DrugEpi 1-5 NSDUH The ongoing systematic collection, analysis, and interpretation of outcome-specific data Surveillance System

DrugEpi 1-5 NSDUH for use in planning, implementation, and evaluation of public health practice The White House Office of National Drug Control Policy (ONDCP) uses NSDUH data to track progress toward goals in the National Drug Control Strategy. The Office on Smoking and Health, a part of the Centers for Disease Control and Prevention (CDC), uses NSDUH data to study trends and patterns in youth tobacco use and to develop strategies for reducing youth tobacco use. Based on the trends and patterns of substance abuse evident in the data, the National Institute on Drug Abuse (NIDA) develops research programs targeted toward populations and types of drug use problems where the need is greatest. The Substance Abuse and Mental Health Services Administration (SAMHSA) prepares statistical reports on substance use patterns and trends to identify populations and geographic areas with particular substance abuse problems so that federal resources can be used efficiently. Surveillance System

DrugEpi 1-5 NSDUH closely integrated with the timely dissemination of these data to those who need to know. Newspaper, television and radio reporters use NSDUH data in their documentaries on substance abuse. The U.S. Department of Agriculture has used NSDUH data in publications addressing rural substance abuse. The Partnership for a Drug-Free America uses NSDUH data to design media advertising campaigns for the prevention of substance abuse. Surveillance System

DrugEpi 1-5 NSDUH NSDUH - Recent Reports Sept 7, 2006 SAMHSA Youth Drug Use Continues Downward Slide - Older Adult Rates of Use Increase The Substance Abuse and Mental Health Services Administration today announced that current illicit drug use among youth ages continues to decline. The rate has been moving downward from 11.6 percent using drugs in the past month in 2002 to 11.2 percent in 2003, 10.6 percent in 2004 and 9.9 percent in This initial report from the 2005 National Survey on Drug Use and Health (NSDUH), released at the annual observance of National Alcohol and Drug Addiction Recovery Month Observance, focuses on significant trends in substance abuse and mental health problems since

DrugEpi 1-5 NSDUH Similarly, the rate of current marijuana use among youth ages 12 to 17 declined significantly from 8.2 percent in 2002 to 6.8 percent in 2005, and the average age of first use of marijuana increased from under age 17 in 2003 to 17.4 years in Furthermore, drinking among teens declined, with 16.5 percent of youth ages reporting current alcohol use and 9.9 percent reporting binge drinking. This compares with 17.6 percent of this age group reporting drinking in 2004 and 11.1 percent reporting binge drinking in the past month in These declines in alcohol use by youth, ages 12-17, follow years of relatively unchanged rates. NSDUH - Recent Reports

DrugEpi 1-5 NSDUH “The trends among young people are encouraging,” said Health and Human Services Secretary Mike Leavitt. “We know prevention activities must start with our children. There is more to be done and we must build on our work to ensure that children and their parents understand that they must live free of drugs and alcohol to be healthy.” NSDUH - Recent Reports

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count of the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. Previous Lesson

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. NSDUH 1

DrugEpi 1-5 NSDUH 1. What question would you ask? URL: This is the actual cover for the 2004 report. Currently, NSDUH issues an annual report

DrugEpi 1-5 NSDUH 1. What question would you ask? “Tonight, we’re going to let the data speak for themselves.” A Data Description Case Definition A set of standard criteria for deciding whether a person has a particular disease or other health- related condition. Will the question mean the same thing to everyone?

DrugEpi 1-5 NSDUH “The next questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked – either in cigarettes called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called hash. It is usually smoked in a pipe. Another form of hashish is hash oil. Have you ever, even once, used marijuana or hash?” Marijuana 1. What question would you ask?

DrugEpi 1-5 NSDUH Number of current marijuana users 1. What question would you ask? “Have you ever, even once, used marijuana or hashish?” 1Yes 2No

DrugEpi 1-5 NSDUH 1. What question would you ask? “The answers that people give us about their use of marijuana and hashish are important to this study’s success. We know that this information is personal, but remember your answers will be kept confidential. 1Yes 2No Please think again about answering the question: Have you ever, even once, used marijuana or hashish?” Number of current marijuana users

DrugEpi 1-5 NSDUH A question that must be answered before a respondent is asked another question about a topic. For example, a respondent must first answer whether or not she / he has ever had a drink of an alcoholic beverage in order to be asked when she / he last drank an alcoholic beverage. 1. What question would you ask? Number of current marijuana users

DrugEpi 1-5 NSDUH Past Month: Any reported use in the past 30 days. Lifetime Use: Any reported use in a respondent’s lifetime. Past Year Use: Any reported use in the 12 months. Current Use: Any reported use in the past 30 days. 1. What question would you ask? Number of current marijuana users

DrugEpi 1-5 NSDUH The NSDUH does ask slightly different questions to adolescents (12-17) than it does adults (18+). Adolescents are asked questions about school, instead of being asked about work. There is also a separate module to assess depression among the adolescents, which only a random portion of our interviewees receive. There is a similar module for adults, but the questions are asked differently. All of the drug, tobacco and alcohol questions are the same no matter what the age of the respondent. 1. What question would you ask?

DrugEpi 1-5 NSDUH Who writes the questions? What is the process they go through to make sure they have a good question? Our survey methodologists write the questions for NSDUH. The core questions, about the use / non use of substances haven’t changed that much, only the wording has been adjusted. However, the methodologists do add new questions / sections and / or delete questions / sections every year. For instance, last year, they added a module targeting mental health. When SAMHSA and the methodologists decide they want to incorporate some new questions, they brainstorm and the panel comes up with the questions and wording. After that, cognitive interviews are conducted to test out the questions and answer categories (the interviewees are asked the questions and then asked for input). The information gathered from the cognitive interviews are incorporated, tested by the methodologists again, and then added or ‘thrown out.’ 1. What question would you ask?

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. NSDUH 2

DrugEpi 1-5 NSDUH 2. Who would you include in your survey? The set of people from which the potential survey participants will be selected Sampling Frame

DrugEpi 1-5 NSDUH 2. Who would you include in the survey? Civilians living on military bases Residents of households (Living in houses / townhouses, apartments, and condominiums) Noninstitutional group quarters (Shelters, rooming / boarding houses, college dormitories, migratory workers' camps, and halfway houses)

DrugEpi 1-5 NSDUH 2. Who would you include in the survey? X Homeless people who do not use shelters Active military personnel Residents of institutional group quarters (Correctional facilities, nursing homes, mental institutions, and long-term hospitals)

DrugEpi 1-5 NSDUH 2. Who would you include in the survey? The set of people from which the potential survey participants will be selected Sampling Frame A subset of a population from which all individuals have a known chance of being selected Probability Sampling

DrugEpi 1-5 NSDUH 2. Who would you include in the survey? 50 States and DC sampled independently States stratified into 900 state sampling regions Second stage sampling units/segments selected 3,500+ sampled in “large sample states” (CA, FL, IL, MI, NY, OH, PA, TX) Smaller samples in other states ( range in 2005 survey) Contiguous geographic areas designed to yield the same number of interviews on average Census tracts selected with probability proportional to size, then further sampling down to segments within census tracts, then addresses within segments, and finally, random selection of people at the addresses

DrugEpi 1-5 NSDUH NSDUH Sampling Details (page 1 of 3) For the 50-State design, 8 States were designated as large sample States (CA, FL, IL, MI, NY, OH, PA, TX) with samples large enough to support direct State estimates. In 2005, sample sizes in these States ranged from 3,562 to 3,699. For the remaining 42 States and the District of Columbia, smaller, but adequate, samples were selected to support State estimates using small area estimation (SAE) Sample sizes in these States ranged from 840 to 978 in States were first stratified into a total of 900 State sampling (SS) regions (48 regions in each large sample State and 12 regions in each small sample State). These regions were contiguous geographic areas designed to yield the same number of interviews on average. The first-stage sampling units were census tracts (unlike previous years) in order to contain sample segments within a single census tract to the extent possible.

DrugEpi 1-5 NSDUH NSDUH Sampling Details (page 2 of 3) A total of 48 census tracts per SS region were selected with probability proportional to size. Within sampled census tracts, adjacent census blocks were combined to form the second-stage sampling units or area segments. One segment was selected within each sampled census tract with probability proportional to population size to support the 5-year sample and any supplemental studies that the Substance Abuse and Mental Health Services Administration (SAMHSA) may choose to field.6 Of these segments, 24 were designated for the coordinated 5-year sample and 24 were designated as "reserve" segments. Eight sample segments per SS region were fielded during the 2005 survey year. These sampled segments were allocated equally into four separate samples, one for each 3-month period (calendar quarter) during the year, so that the survey was essentially continuous in the field.

DrugEpi 1-5 NSDUH NSDUH Sampling Details (page 3 of 3) In each of these area segments, a listing of all addresses was made, from which a sample of 175,958 was selected. Of the selected addresses, 146,912 were determined to be eligible sample units. In these sample units (which can be either households or units within group quarters), sample persons were randomly selected using an automated screening procedure programmed in a handheld computer. The number of sample units completing the screening was 134,055. Youths aged 12 to 17 years and young adults aged 18 to 25 years were over sampled at this stage. ( Informed consent from a parent or guardian is required before approaching a person aged ) A total of 83,805 persons were selected nationwide. Consistent with previous surveys in this series, the final respondent sample of 68,308 persons was representative of the U.S. general population (since 1991, the civilian, noninstitutionalized population) aged 12 or older. In addition, State samples were representative of their respective State populations.

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. NSDUH 3

DrugEpi 1-5 NSDUH 3. How will you conduct the survey? Utilizes in-person interviews at place of residence Since 1999, NSDUH uses the CAI - Computer -Assisted Interview (was paper and pencil before 1999) CAI combines two computerized methods:  Computer–assisted personal–interviewing (CAPI) conducted by the interviewer for some basic demographic information and audio computer  Assisted self–interviewing (ACASI) for most of the questions. ACASI provides a highly private and confidential means of responding to questions to increase the level of honest reporting of illicit drug use and other sensitive behavior.  Respondent listens to questions with headphones and keys responses directly into a laptop computer

DrugEpi 1-5 NSDUH “Thus, the interview begins in CAPI mode with the field interviewer (FI) reading the questions from the computer screen and entering the respondent's replies into the computer. The interview then transitions to the ACASI mode for the sensitive questions. In this mode, the respondent can read the questions silently on the computer screen and/or listen to the questions read through headphones and enter his or her responses directly into the computer. At the conclusion of the ACASI section, the interview returns to the CAPI mode with the interviewer completing the questionnaire. Each respondent who completes a full interview is given a $30.00 cash payment as a token of appreciation for his or her time.” 2005 National Survey on Drug Use & Health: National Results. Appendix A: Description of the Survey 3. How will you conduct the survey?

DrugEpi 1-5 NSDUH

DrugEpi 1-5 NSDUH 3. How would you conduct the survey? Show RTI “video” The section from minutes 6:56 to 14:04 presents a good example of the interview scenario Explain purpose of video, RTI, “lister,” sample dwelling unit (SDU), and field interviewer (FI).

DrugEpi 1-5 NSDUH Overview of the RTI International Screening Process

DrugEpi 1-5 NSDUH Overview of the RTI International Screening Process

DrugEpi 1-5 NSDUH 3. How would you conduct the survey?

DrugEpi 1-5 NSDUH 3. How would you conduct the survey?

DrugEpi 1-5 NSDUH 3. How would you conduct the survey?

DrugEpi 1-5 NSDUH 3. How would you conduct the survey? Trade-Offs

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. NSDUH 4

DrugEpi 1-5 NSDUH Will people be willing to answer the question, given the circumstances under which the data will be collected? 4. How would you assure accuracy? Any risk of disclosure? Being non- judgmental Assure anonymity Importance of subject matter Assure confidentiality Willing to answer

DrugEpi 1-5 NSDUH Have you ever, even once, used Percocet, Percodan, or Tylox that was not prescribed for you or that you took only for the experience or feeling it caused? Pain Relievers 1Yes 2No 4. How would you assure accuracy?

DrugEpi 1-5 NSDUH 4. How would you assure accuracy?

DrugEpi 1-5 NSDUH 4. How would you assure accuracy?

DrugEpi 1-5 NSDUH 4. How would you assure accuracy?

DrugEpi 1-5 NSDUH High School Marijuana Survey Create a plan for a survey that would result in an accurate count the number of current marijuana users in the public high schools in your state Answer the following questions about their plan. 1. What question(s) would you ask in order to count the number of current marijuana users? 2. Who would be in your sampling frame? Who would you sample from the sampling frame? 3. What mode of data collection will you use (telephone, mail, personal interview, on-line.)? 4. How would you increase the likelihood that your question(s) will be answered accurately? 5. What are the limitations of your plan? Prepare a 2 minute summary of your plan. Prepare to discuss in class your answers to the above questions. NSDUH 5

DrugEpi 1-5 NSDUH 5. What are the limitations of your plan? Sampling Adequacy of questions Biased answers Telling the truth

DrugEpi 1-5 NSDUH 5. What are the limitations of your plan? Sampling Adequacy of questions Biased answers Telling the truth Self-reported information may be inaccurate or biased

DrugEpi 1-5 NSDUH Sampling Frame 5. What are the limitations of your plan?

DrugEpi 1-5 NSDUH 91.3 % household response rate Response rate was highest among: Age: 12 to 17 year olds (87.1 %) Gender: Females (77.8 %) Race: Blacks (81.2%) Region: non-metropolitan (79.2%) and residents in South (77.2%) 2005 NSDUH 76.2 % interview response rate 5. What are the limitations of your plan?

DrugEpi 1-5 NSDUH National Household Survey on Drug Abuse National Survey on Drug Use and Health Changes in 2002 Survey 5. What are the limitations of your plan?

DrugEpi 1-5 NSDUH 5. What are the limitations of your plan?

DrugEpi 1-5 NSDUH 5. Importance of Ethics - Informed Consent

DrugEpi 1-5 NSDUH 5. Importance of Ethics - Informed Consent Handout

DrugEpi 1-5 NSDUH 5. Importance of Ethics - Informed Consent

64 Results from the 2005 National Survey on Drug Use and Health (NSDUH) Substance Abuse and Mental Health Services Administration (SAMHSA)

DrugEpi 1-5 NSDUH NSDUH Design Representative nationally and in each State Civilian, noninstitutionalized population Aged 12 or older Face-to-face interview Computer-assisted, self-administered 68,308 respondents in data comparable with 2002, 2003, and 2004, but not with data prior to 2002 (due to new survey title and initiation of a $30 incentive)

DrugEpi 1-5 NSDUH Google on NSDUH/NHSDA, click on What’s New Survey (or latest) See the most data this way, a few samples to follow Polished presentation slides but less information

DrugEpi 1-5 NSDUH Past Month Tobacco Use among Youths Aged 12 to 17: Sample - NSDUH Difference between estimate and the 2005 estimate is statistically significant at the.05 level.

DrugEpi 1-5 NSDUH Current, Binge, and Heavy Alcohol Use among Persons Aged 12 or Older, by Race/Ethnicity: 2005 Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2005 Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Sample - NSDUH 2005 Types of Drugs Used by Past Month Illicit Drug Users Aged 12 or Older: 2005

DrugEpi 1-5 NSDUH Past Month Use of Selected Illicit Drugs among Youths Aged 12 to 17: Difference between estimate and the 2005 estimate is statistically significant at the.05 level. Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Past Month Marijuana Use among Youths Aged 12 to 17, by Gender: Difference between estimate and the 2005 estimate is statistically significant at the.05 level. Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Past Month Marijuana Use among Youths Aged 12 to 17 by Geographic Region: Difference between estimate and the 2005 estimate is statistically significant at the.05 level. Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Past Month Binge Drinking and Marijuana Use among Youths Aged 12 to 17, by Perceptions of Risk: Difference between estimate and the 2005 estimate is statistically significant at the.05 level. Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Perceived Availability of Selected Illicit Drugs among Youths Aged 12 to 17: Difference between estimate and the 2005 estimate is statistically significant at the.05 level. Sample - NSDUH 2005

DrugEpi 1-5 NSDUH Big Ideas in this Lesson (1-5) By the early 1970’s, concern about drug use among American youth lead to government action to set up a drug use surveillance system The NSDUH example can be used to illustrate rigorous methods of drug use surveillance NSDUH data show that marijuana is by far the most common illicit drug used by American youth This project is supported by a Science Education Drug Abuse Partnership Award, Grant Number 1R24DA , from the National Institute on Drug Abuse, National Institutes of Health. Re-Cap

DrugEpi 1-5 NSDUH Next Lesson (1-6) Drug Abuse Warning Network Monitoring the Future Survey Youth Health Risk Behavior Survey College Health Risk Behavior Survey European School Survey Project on Alcohol and Other Drugs National Survey on Drug Use and Health