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. 2015 Jun;105(6):1189-97.
doi: 10.2105/AJPH.2014.302248. Epub 2014 Dec 18.

Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston

Travis P Baggett  1 , Yuchiao Chang, Daniel E Singer, Bianca C Porneala, Jessie M Gaeta, James J O'Connell, Nancy A Rigotti
Affiliations

Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston

Travis P Baggett et al. Am J Public Health. 2015 Jun.

Abstract

Objectives: We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults.

Methods: We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences.

Results: Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults.

Conclusions: In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

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Figures

FIGURE 1—
FIGURE 1—
Proportion of deaths attributable to tobacco, alcohol, and drug use among decedents (a) of all ages (N = 1302), (b) younger than 50 years (n = 587), and (c) 50 years and older (n = 715): Boston Health Care for the Homeless Program, MA, 2003–2008.
FIGURE 2—
FIGURE 2—
Age- and gender-stratified tobacco-, alcohol-, and drug-attributable mortality rates for (a) men aged 20–34 years, (b) women aged 20–34 years, (c) men aged 35–49 years, (d) women aged 35–49 years, (e) men aged 50 –64 years, and (f) women aged 50–64 years: Boston Health Care for the Homeless Program, MA, and the Massachusetts adult population, 2003–2008. Note. RtD = rate difference; RtR = rate ratio. The lower 95% confidence bounds are greater than 1 for all rate ratios and greater than zero for all rate differences.
FIGURE 3—
FIGURE 3—
Substance- and non–substance-attributable mortality rates, stratified by age and gender, for adults aged 20–64 years among BHCHP participants and Massachusetts (MA) adults: 2003–2008. Note. BHCHP = Boston Health Care for the Homeless Program; DF = disparity fraction; RtD = rate difference; RtR = rate ratio. Mortality rate is expressed as deaths per 100 000 person-years for BHCHP adults and as annual deaths per 100 000 persons for MA adults. The mortality rate for all MA adults aged 20–64 years is standardized to the age and gender distribution of the BHCHP cohort. The lower 95% confidence bounds are greater than 1 for all rate ratios and greater than zero for all rate differences. The DF is the substance-attributable rate difference divided by the all-cause mortality rate difference.
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References

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