Structural Variables Leading to Childhood Lead Poisoning, Teen Pregnancy, and Tobacco Use Robert H. Keefe, PhD, ACSW Sandra D. Lane, PhD, MPH Robert A. Rubinstein, PhD, MSPH Noah J. Webster, MA Brooke A. Levandowski, MPH

Purpose of the Study To investigate the persistent relationships between childhood lead exposure and: Repeat teen pregnancy Tobacco use

Hypotheses Among females, childhood lead poisoning is associated with repeat teen pregnancy. Among females, childhood lead poisoning is associated with cigarette smoking.

Suffer from additional health problems Have repeat pregnancies In our prior research we found that teens who give birth are likely to: Suffer from additional health problems Have repeat pregnancies Live in impoverished neighborhoods Live in poorly maintained housing, increasing the risk of lead exposure Have limited access to health care Lane et al, 2004. Lane et al, in press Journal of Urban Health. Lane et al, in press, Health and Place.

Lead Poisoning in Syracuse 2nd highest prevalence of elevated blood level (EBL) in NY in 2001-2002. 5 zip codes in Syracuse had 76% of the total number of lead poisoning cases 7.7% of the entire incidence of EBL in NY. NYSDOH, 2003.

Highest Risk Exposures Old lead-based paint in dilapidated buildings Around windowsills In the soil around buildings In lead-tainted water Around windowsills Powdery dust emitted from opening and closing the windows In the soil Where paint chips accumulate In lead-tainted water From corroded lead solder in old copper pipes. NYSDOH, 2004. Schilling & Bain, 1988.

Effects of Lead Exposure Decreased intelligence levels Increased neurological impairments premature sexual maturation impulsive or aggressive behavior delinquency Canfield et al, 2003a, 2003b. Espy, 2004. Needleman et al, 2002. Bellinger, 2001, 2003, 2004.

Neurotoxicity from lead poisoning affects the ability to: Plan Learn from prior experience Control impulsive behavior Use executive functioning skills Canfield et al, 2003a, 2003b. Espy, 2004. Needleman et al, 2002. Bellinger, 2001, 2003, 2004

Lead Levels and Birth rates by Race/Ethnicity in Syracuse 15-19 year olds (per mcb/dl) Birth rates (per 100,000) White 7.38 32.9 African American 11.35 91.7 Hispanic 9.83 N/A

Syracuse Healthy Start Database 15 - 19 year olds 1998 - 2002 > 75% of all mothers < 20 years old Routine screening included: Childhood lead levels Tobacco use EBL reported to woman’s obstetrician Note: The teens were born after the phase out of leaded gasoline and the ban on lead-based residential paint. 1998 to first quarter of 2002

Dichotomous measures Maternal race: White, African American Childhood BLL: <20, >20mcg/dl Tobacco use: none, any Previous pregnancy: first, repeat pregnancy Maternal age: 15-17, 18-19 years The pregnant teens were born between 1981 – 1989.

Data Analysis Univariate and bivariate associations Multivariate logistic regression Controlling for maternal race and Medicaid use Descriptive statistics were run on teens in the SHS data based regarding Childhood lead level Maternal age Medicaid insurance Number of pregnancies Tobacco use Separate bivariate associations were assessed between all these same variables where “childhood lead level was the exposure variable. Multivariate logistic regression was conducted using Childhood lead level as the exposure Repeat teen pregnancy or tobacco use as the outcomes Maternal race and Medicaid use as confounders

Sample: 536 pregnant teens 64.6% were African American 47.0 were between 18-19 years old 76.1% were on Medicaid 39.6% second or higher order pregnancy 37.5% were smokers 71.6% had childhood BLL less than 20mcg/dl 28.4% had childhood BLL greater than 20mcg/dl 13.8% had BLL between 20mcg/dl and 29/mcg/dl 9.0% had BLL between 30-39mcg/dl 5.6% had BLL between 4099mcg/dl 64.6% were African American 47.0 were between 18-19 years old 76.1% were on Medicaid, 39.6% were experiencing their second or higher order pregnancy 37.5% were smokers.

Sample: 536 pregnant teens 71.6% had childhood BLL less than 20mcg/dl 28.4% had childhood BLL greater than 20mcg/dl 13.8% had BLL between 20mcg/dl and 29/mcg/dl 9.0% had BLL between 30-39mcg/dl 5.6% had BLL between 4099mcg/dl 64.6% were African American 47.0 were between 18-19 years old 76.1% were on Medicaid, 39.6% were experiencing their second or higher order pregnancy 37.5% were smokers.

Sample: 536 pregnant teens 71.6% had childhood BLL less than 20mcg/dl 28.4% had childhood BLL greater than 20mcg/dl 13.8% had BLL between 20mcg/dl and 29/mcg/dl 9.0% had BLL between 30-39mcg/dl 5.6% had BLL between 4099mcg/dl 64.6% were African American 47.0 were between 18-19 years old 76.1% were on Medicaid, 39.6% were experiencing their second or higher order pregnancy 37.5% were smokers. The CDC considers 10 mcg/dl dangerous!

Baseline characteristics of pregnant teens by childhood BLL % of the pregnant teens by number of pregnancies, smoking, maternal age, Medicaid vs. private insurance, and maternal race when dichotomized by BLL. Repeat pregnancy was associated with elevated childhood lead and mother’s age (older teens were more likely to have a repeat birth) (p < .05). Tobacco use was also significantly associated with maternal race (white teens smoked more than African American teens) (p < .05).

Baseline characteristics of pregnant teens by childhood BLL Those with BLLs < 20 mcg/dl were pretty comparable in race, age, pregnancy, smoking and insurace

Baseline characteristics of pregnant teens by childhood BLL So where the women with BLLs >=20 mcg/dl, so these two groups are comparable within the categories of BLL

Baseline characteristics of pregnant teens by childhood BLL Repeat pregnancy was associated with elevated childhood lead and mother’s age (p < .05) Tobacco use was significantly associated with maternal race (p < .05) Repeat pregnancy was associated with elevated childhood lead and mother’s age (older teens were more likely to have a repeat birth) (p < .05). Tobacco use was also significantly associated with maternal race (white teens smoked more than African American teens) (p < .05).

Logistic regression results One exposure: childhood BLL Two outcomes: repeat teen pregnancy Controlled for race, age and insurance type Tobacco use Stratified by insurance type Controlled for race & age

Outcome: repeat pregnancy Predictor variables Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl,) 1.59 (95% CI 1.04, 2.43) Mother’s Race (African American vs. white) 1.46 (95% CI 1.25, 1.71) Mother’s Age (18-19 vs. 15-17 years) 1.45 (95% CI 0.95, 2.21) Medicaid (Medicaid vs. Private insurance) 1.70 (95%CI 1.06, 2.73) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Outcome: repeat pregnancy Predictor variables Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl,) 1.59 (95% CI 1.04, 2.43) Mother’s Race (African American vs. white) 1.46 (95% CI 1.25, 1.71) Mother’s Age (18-19 vs. 15-17 years) 1.45 (95% CI 0.95, 2.21) Medicaid (Medicaid vs. Private insurance) 1.70 (95%CI 1.06, 2.73) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Outcome: tobacco use Predictor variables Medicaid non-users Medicaid users Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl) 4.25 (95% CI 1.89, 9.57) 1.25 (95% CI 0.78,2.00) Mother’s Race (African American vs. white) 0.32 (95% CI 0.15, 0.72) 0.29 (95% CI 0.19, 0.45) Mother’s Age (18-19 vs. 15-17 years) 0.93 (95% CI 0.42, 2.05) 1.35 (95% CI 0.88, 2.05) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Outcome: tobacco use Predictor variables Medicaid non-users Medicaid users Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl) 4.25 (95% CI 1.89, 9.57) 1.25 (95% CI 0.78,2.00) Mother’s Race (African American vs. white) 0.32 (95% CI 0.15, 0.72) 0.29 (95% CI 0.19, 0.45) Mother’s Age (18-19 vs. 15-17 years) 0.93 (95% CI 0.42, 2.05) 1.35 (95% CI 0.88, 2.05) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Outcome: tobacco use Predictor variables Medicaid non-users Medicaid users Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl) 4.25 (95% CI 1.89, 9.57) 1.25 (95% CI 0.78,2.00) Mother’s Race (African American vs. white) 0.32 (95% CI 0.15, 0.72) 0.29 (95% CI 0.19, 0.45) Mother’s Age (18-19 vs. 15-17 years) 0.93 (95% CI 0.42, 2.05) 1.35 (95% CI 0.88, 2.05) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Outcome: tobacco use Predictor variables Medicaid non-users Medicaid users Childhood lead level (20+ mcg/dl vs. 0-19mcg/dl) 4.25 (95% CI 1.89, 9.57) 1.25 (95% CI 0.78,2.00) Mother’s Race (African American vs. white) 0.32 (95% CI 0.15, 0.72) 0.29 (95% CI 0.19, 0.45) Mother’s Age (18-19 vs. 15-17 years) 0.93 (95% CI 0.42, 2.05) 1.35 (95% CI 0.88, 2.05) We performed two separate logistic regression analyses with childhood lead level as the exposure, or risk factor, as presented in Table 2. In the first analysis repeat birth was the outcome variable (Model 1) and in the second tobacco use was the outcome variable (Model 2). In each logistic regression, we controlled for confounders of maternal race and mother’s age. Receipt of Medicaid was a confounder of Model 1 and an effect modifier of Model 2, resulting in stratified effect estimates. The analyses found childhood lead poisoning to be a risk factor for subsequent repeat birth among teens and for tobacco use. Among those not covered by Medicaid, the odds of having an elevated childhood lead level among smokers was 4.25 (95%CI 1.89, 9.57) times the odds of having an elevated childhood blood lead among non-smokers, controlling for maternal race and age. Among those receiving Medicaid, the odds of elevated childhood lead level among smokers was 1.26 (95%CI 0.79, 2.03) times the odds of elevated childhood blood lead among non-smokers, controlling for maternal race and age. Controlling for maternal age, maternal race, and Medicaid use, the odds of elevated childhood lead level among those women having their second pregnancy was 1.59 (95%CI 1.04, 2.43) times the odds of elevated childhood blood lead among those having their first child.

Discussion: Repeat Pregnancy Community factors Family factors Individual factors Developmental delays All may lead to residence in older housing with peeling paint Community factors: high unemployment, community stress. Family factors: single parents Individual factors: race, ethnicity, school dropout, greater number of sexual partners. Developmental delays in cognitive ability and executive functioning. All may lead to residence in older housing with peeling paint.

Discussion: Addiction Smoking and race are determinants of EBL among women of reproductive age Early lead exposure associated with decreased ability to delay gratification and alterations in dopamine system and other neurochemicals Early lead exposure has been associated with decreased ability to delay gratification and alterations in dopamine system and other neurochemicals that suggest that early lead exposure could increase sensitivity to tobacco addition.

Limitations Small sample size Other community factors as potential confounders Poverty Community stress Residence location Family level factors Small sample size could mask an even larger effect estimate. Other community factors could confound the relationship between childhood lead exposure and health outcomes: Poverty Community stress Residence location Family level factors such as single-parent families These factors are unmeasured. How would/should we attempt to measure them accurately?

Further research Inclusion of community-level factors Individual vs. community level responsibility