title: Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston.
abstract: OBJECTIVE
  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.
authors.affiliation: Travis P. Baggett and James J. O'Connell are with the Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, the Department of Medicine, Harvard Medical School, Boston, MA, and the Boston Health Care for the Homeless Program, Boston, MA. Bianca C. Porneala is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Yuchiao Chang, Daniel E. Singer, and Nancy A. Rigotti are with the Division of General Internal Medicine, Massachusetts General Hospital, Boston, and the Department of Medicine, Harvard Medical School, Boston. Jessie M. Gaeta is with the Boston Health Care for the Homeless Program and the Section of General Internal Medicine, Department of Medicine, Boston University, School of Medicine, Boston, MA.
authors.forename: Travis P
authors.initials: TP
authors.lastname: Baggett
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Singer
authors.forename: Bianca C
authors.initials: BC
authors.lastname: Porneala
authors.forename: Jessie M
authors.initials: JM
authors.lastname: Gaeta
authors.forename: James J
authors.initials: JJ
authors.lastname: O'Connell
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Rigotti
mesh_terms: D000328:Adult; D019973:Alcohol-Related Disorders / Q000401:mortality; D001900:Boston / Q000453:epidemiology; D002423:Cause of Death; D062787:Drug Overdose / Q000401:mortality; D005260:Female; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009010:Monte Carlo Method; D019966:Substance-Related Disorders / Q000401:mortality*; D014029:Tobacco Use Disorder / Q000401:mortality