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Scotts Valley, CA, United States

Nearly all California casinos currently allow smoking, which leads to potentially high patron exposure to secondhand tobacco smoke pollutants. Some argue that smoking restrictions or bans would result in a business drop, assuming > 50% of patrons smoke. Evidence in Nevada and responses from the 2008 California tobacco survey refute this assertion. The present study investigates the proportion of active smokers in southern California tribal casinos, as well as occupancy and PM(2.5) levels in smoking and nonsmoking sections. We measured active-smoker and total-patron counts during Friday or Saturday night visits (two per casino) to smoking and nonsmoking gaming areas inside 11 southern California casinos. We counted slot machines and table games in each section, deriving theoretical maximum capacities and occupancy rates. We also measured PM(2.5) concentrations (or used published levels) in both nonsmoking and smoking areas. Excluding one casino visit with extremely high occupancy, we counted 24,970 patrons during 21 casino visits of whom 1,737 were actively smoking, for an overall active- smoker proportion of 7.0% and a small range of ~5% across casino visits (minimum of 5% and maximum of 10%). The differences in mean inter-casino active-smoker proportions were not statistically significant. Derived occupancy rates were 24% to 215% in the main (low-stakes) smoking-allowed slot or table areas. No relationship was found between observed active-smoker proportions and occupancy rate. The derived maximum capacities of nonsmoking areas were 1% to 29% of the overall casino capacity (most under 10%) and their observed occupancies were 0.1 to over 3 times that of the main smoking-allowed casino areas. Seven of twelve visits to nonsmoking areas with no separation had occupancy rates greater than main smoking areas. Unenclosed nonsmoking areas don't substantially protect occupants from PM2.5 exposure. Nonsmoking areas encapsulated inside smoking areas or in a separate, but unenclosed, area had PM(2.5) levels that were 10 to 60 μg/m(3) and 6 to 23 μg/m(3) higher than outdoor levels, respectively, indicating contamination from smoking. Although fewer than roughly 10% of casino patrons are actively smoking on average, these individuals substantially increase PM(2.5) exposure for all patrons in smoking and unenclosed nonsmoking areas. Nonsmoking areas may be too inconvenient, small, or undesirable to serve a substantial number of nonsmoking patrons. Imposing indoor smoking bans, or contained smoking areas with a maximum capacity of up to 10% of the total patronage, would offer protection from PM2.5 exposures for nonsmoking patrons and reduce employee exposures. Source

Wang S.-Y.,Yale University | Aldridge M.D.,Mount Sinai School of Medicine | Aldridge M.D.,James ters Va Medical Center | Gross C.P.,Yale University | And 4 more authors.
Medical Care | Year: 2016

Objectives: Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns. Methods: Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay. Results: End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days. Conclusions: At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use. © 2016 Wolters Kluwer Health, Inc. Source

Jiang R.-T.,Stanford University | Acevedo-Bolton V.,Stanford University | Cheng K.-C.,Stanford University | Klepeis N.E.,Stanford University | And 4 more authors.
Journal of Environmental Monitoring | Year: 2011

The amount of light scattered by airborne particles inside an aerosol photometer will vary not only with the mass concentration, but also with particle properties such as size, shape, and composition. This study conducted controlled experiments to compare the measurements of a real-time photometer, the SidePak™ AM510 monitor (SidePak), with gravimetric mass. PM sources tested were outdoor aerosols, and four indoor combustion sources: cigarettes, incense, wood chips, and toasting bread. The calibration factor for rescaling the SidePak measurements to agree with gravimetric mass was similar for the cigarette and incense sources, but different for burning wood chips and toasting bread. The calibration factors for ambient urban aerosols differed substantially from day to day, due to variations in the sources and composition of outdoor PM. A field evaluation inside a casino with active smokers yielded calibration factors consistent with those obtained in the controlled experiments with cigarette smoke. © The Royal Society of Chemistry. Source

Klepeis N.E.,San Diego State University | Klepeis N.E.,Stanford University | Klepeis N.E.,Training and Research Inc | Hughes S.C.,San Diego State University | And 8 more authors.
PLoS ONE | Year: 2013

Interventions are needed to protect the health of children who live with smokers. We pilot-tested a real-time intervention for promoting behavior change in homes that reduces second hand tobacco smoke (SHS) levels. The intervention uses a monitor and feedback system to provide immediate auditory and visual signals triggered at defined thresholds of fine particle concentration. Dynamic graphs of real-time particle levels are also shown on a computer screen. We experimentally evaluated the system, field-tested it in homes with smokers, and conducted focus groups to obtain general opinions. Laboratory tests of the monitor demonstrated SHS sensitivity, stability, precision equivalent to at least 1 μg/m3, and low noise. A linear relationship (R2 = 0.98) was observed between the monitor and average SHS mass concentrations up to 150 μg/m3. Focus groups and interviews with intervention participants showed in-home use to be acceptable and feasible. The intervention was evaluated in 3 homes with combined baseline and intervention periods lasting 9 to 15 full days. Two families modified their behavior by opening windows or doors, smoking outdoors, or smoking less. We observed evidence of lower SHS levels in these homes. The remaining household voiced reluctance to changing their smoking activity and did not exhibit lower SHS levels in main smoking areas or clear behavior change; however, family members expressed receptivity to smoking outdoors. This study established the feasibility of the real-time intervention, laying the groundwork for controlled trials with larger sample sizes. Visual and auditory cues may prompt family members to take immediate action to reduce SHS levels. Dynamic graphs of SHS levels may help families make decisions about specific mitigation approaches. © 2013 Klepeis et al. Source

Aldridge M.D.,Mount Sinai School of Medicine | Schlesinger M.,Yale University | Morrison R.S.,Mount Sinai School of Medicine | Morrison R.S.,Geriatric Research | And 3 more authors.
JAMA Internal Medicine | Year: 2014

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84%response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55%vs 82%; adjusted relative risk [ARR], 0.67 [95%CI, 0.59-0.76]), conducting research (18%vs 23%; ARR, 0.67 [95%CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95%CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22%vs 4%; ARR, 3.66 [95%CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P < .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61%vs 46%; ARR, 1.23 [95%CI, 1.05-1.44]) and minority communities (59%vs 48%; ARR, 1.18 [95%CI, 1.02-1.38]) and less likely to partner with oncology centers (25%vs 33%; ARR, 0.59 [95%CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase. Copyright © 2014 American Medical Association. All rights reserved. Source

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