Consumption & Consequences. Alcohol, Tobacco and Drugs in St. Joseph County rate per 100,000 population

St. Joseph County Treatment Rates by Primary Substance. 2002-2006 250.0 rate per 100,000 population 200.0 150.0 100.0 50.0 Alcohol Cocaine/Crack Marijuana 0.0 2002 2003 2004 2005 2006 Consumption & Consequences Alcohol, Tobacco and Drugs in St. Joseph County 2007

THE CONSUMPTION AND CONSEQUENCES OF ALCOHOL, TOBACCO AND DRUGS IN ST. JOSEPH COUNTY: AN EPIDEMIOLOGICAL PROFILE 2007 Developed by the St. Joseph County Epidemiology and Outcomes Workgroup Drug Free Community Council South Bend, Indiana

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St. Joseph County Local EPIDEMIOLOGY AND OUTCOMES WORKGROUP (LEOW) John Hagen, Ph.D. (Chair) President, Health Strategies, Inc. George Adler Community & Economic Development Specialist City of South Bend Capt. Robert Hammer Metro Special Operations Section South Bend Police Department Jeremy Linton, Ph.D. Professor of Counseling and Human Services Indiana University South Bend John Ritzler, Ph.D. Director of Research and Evaluation South Bend Community School Corporation Lory Timmer City of Mishawaka Redevelopment Department Lt. Tim Williams DUI Traffic Safety Task Force Mishawaka Police Department Chris Nowak Director, Alcohol & Drug Education University of Notre Dame Beth Baker (Staff) Director, Drug Free Community Council Healthy Communities Initiative Tanita Brown, Administrative Assistant Healthy Communities Initiative St. Joseph County Epidemiological & Outcomes Workgroup iii

TABLE OF CONTENTS Introduction...1 Methods...2 Summaries...4 1. Demographic Profile of St. Joseph County...12 2. Cocaine Use in St. Joseph County: Consumption Patterns and Consequences...34 Consumption (34) Consequences (44) 3. Alcohol Use in St. Joseph County: Consumption Patterns and Consequences...65 Consumption (65) Consequences (67) 4. Tobacco Use in St. Joseph County: Consumption Patterns and Consequences..85 Consumption (85) Consequences (86) 5. Marijuana Use in St. Joseph County: Consumption Patterns and Consequences.103 Consumption (103) Consequences (105) Appendix A: Major Data Sources...118 St. Joseph County Epidemiological & Outcomes Workgroup iv

INTRODUCTION In 2007, through a grant made available to Indiana from the U.S. Department of Health and Human Services Center for Substance Abuse Prevention (CSAP) as part of its Strategic Prevention Framework State Incentive Grant (SPF SIG) Program, St. Joseph County s Drug Free Community Council established a Local Epidemiology and Outcomes Workgroup (LEOW) to collate and analyze available epidemiological data and report findings to the State to facilitate databased decision-making regarding substance abuse prevention programming in St. Joseph County. St. Joseph County was one of 12 communities funded under the grant to initiate a Strategic Planning Framework process at the local level. This report represents the first official LEOW report completed under this initiative and summarizes both the methodology used and key findings. Since its first meeting in November 2007, the LEOW has met regularly to review data and examine critical substance use and abuse trends in the County. This first County epidemiological profile will be used by the Council s Strategic Planning Group to develop a strategic plan required under the SPF SIG program. The Plan will identify the significant challenges faced in St. Joseph County with regard to substance use and abuse and make recommendations to address those challenges. The State recommended that St. Joseph County focus on the use and abuse of cocaine as the priority drug of concern. This report includes attention to cocaine as well as the consequences and consumption patterns of alcohol, tobacco, and marijuana in St. Joseph County. The LEOW will continue to expand the scope of its analysis over the next few years and incorporate additional data sources in an effort to more fully understand the use and consequences of alcohol, tobacco, and illicit drugs in our community. Questions or comments about this report should be directed to: John R. Hagen, Ph.D. Chair, St. Joseph County Local Epidemiological Outcomes Workgroup (LEOW) C/o Beth Baker Director, Drug Free Community Council Healthy Communities Initiative 401 East Colfax Ave., Suite 310 South Bend, IN 46634 Phone: (574) 239-8585, x346 E-mail: bbaker@hcisjc.org St. Joseph County Epidemiological & Outcomes Workgroup 1

METHODS This report is an epidemiological examination of drug use and abuse in St. Joseph County, Indiana. As such, it is a description of drug consumption and drug consequence patterns for St. Joseph County residents associated with particular licit and illicit drugs and the risk and protective factors that influence the patterns observed. 1 For each drug at issue, the report essays the prevalence and incidence of use in general and for area youth (under age 18) and adults (over age 18) in particular. 2 Where possible, the County s overall, adult, and youth patterns were compared with the consumption and consequence patterns found in the North Central Region of the State, the State, and United States. For each drug, prevalence was specified by monthly use for the most part, and lifetime, annual, and daily use where available. Incidence was specified by age of first use. Risk and protective factors were expressed as attitudes about the risk of infrequent or regular use, and by the level of support or disapproval by peers and (for youth) by parents. In this regard, the report focuses attention on specific outcome measures chosen by the Nation and State. 3 In accordance with the directives of the State Advisory Council for the Strategic Prevention Framework State Incentive Grant (SPF SIG), this study reviewed consumption and consequences patterns for cocaine use and abuse in St. Joseph County, as well as the following drugs: alcohol, tobacco, and marijuana. Future refinements to this report will include attention to other drugs, such as heroin, methamphetamine, and prescription medications. For the most part, descriptive statistics are presented. Statistical analyses on publicly available local, regional, and national data sets were conducted wherever possible using statistical analysis software. For national and regional surveys that did not have publicly available data sets, analysis tables provided by the agencies that conducted the data collection were consulted. Descriptive comparisons were made across gender, racial, and age groups for both drugconsumption behaviors and drug use/abuse consequences. This report relied heavily on available data sets from national and State surveys that have been conducted on a regular basis. Accordingly, the report not only examines the experience of the County against external comparison groups (e.g., regions or the State), but also displays change internally by setting out multi-year comparisons. In some cases, in the absence of available data, the report relied upon special surveys of local providers. In such cases, no additional comparisons were performed. Slide presentations were given at each LEOW meeting. For the most part, these charts and graphs are not included in this report but will be made available as a separate file for public use. St. Joseph County Epidemiological & Outcomes Workgroup 2

The major data sets consulted in this report are listed in the Appendix. Additional sources are cited in the endnotes to each section. Focus Groups As part of the follow up to this epidemiological report, the LEOW of St. Joseph County will conduct a series of focus groups to gain clarification and enhanced understanding of the use and abuse of cocaine in the community. The information gathered will be used in subsequent epidemiological reports to supplement and focus the statistical data that has already been collected. The Workgroup proposed to conduct approximately five to seven focus groups over the course of next year. In addition to the usual groups represented - users, treatment providers, people who have never used, family members directly impacted by the cocaine abuse of a loved one, community leaders and law enforcement personnel - it has been suggested that an ideal group would be drug dealers. A protocol will be developed consisting of a set of common questions in order to gain comparable information from each focus group. The LEOW proposed to offer incentives for participation in the form, for example, of gift cards. End Notes 1 Epidemiology is broadly understood as the science concerned with health and illness in population groups and with the factors that affect them. 2 Prevalence measures the number of people in a population who have a particular disease or, in this case, use a particular drug. Expressed as a rate, it is the ratio (for a given time period) of the number of occurrences of a disease or event to the number of units at risk in the population. Incidence is a measure of the number of new cases in a population over a period of time (usually one year). For a more extended discussion, see: Wu, L.-T., Korper, S. P., Marsden, M. E., Lewis, C., & Bray, R. M. (2003). Use of Incidence and Prevalence in the Substance Use Literature: A Review. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Available at: http://oas.samhsa.gov/incidenceprevalence.pdf 3 See, e.g.: Substance Abuse and Mental Health Services Administration, National Outcomes Measures (NOMs). Accessed at: http://nationaloutcomemeasures.samhsa.gov/outcome/index_2007.asp St. Joseph County Epidemiological & Outcomes Workgroup 3

SUMMARIES Cocaine Use in St. Joseph County Consumption Prevalence Higher rates of past year use of cocaine were evident from the years 1999-2001 to the years 2002-2004 in the U.S., Indiana, and the North Central Indiana region. For all persons ages 12 and older, the North Central Indiana region s past year cocaine use rates were lower in both time periods compared to either Indiana or the U.S. (2.1% vs. 2.4% and 2.5% respectively). However, rates in North Central Indiana were higher for persons ages 18-25 in 1999-2001 compared to the State and higher for ages 12-17 in 2002-2004 than either the State or the U.S. At the national and State levels, past year use of cocaine showed a small decline between 2002-2004 and 2005-2006 among youths aged 12 to 17, persons aged 26 or older, and in the combined 12 or older population. In 2007, lifetime, annual, and monthly uses of cocaine and crack cocaine among 10 th grade students appeared higher in the North Central region and Indiana school compared to the U.S. levels. In St. Joseph County schools in 2007, students in the 9 th grade reported higher cocaine and crack lifetime, annual, and 30-day use rates than their peers in the State; students in the 10 th grade showed lower than expected annual cocaine and lifetime and annual crack use rates compared to North Central regional rates; and, annual use rates for 11 th graders were statistically significantly higher than 11 th graders in the State. Incidence In 2007, the mean age of first time use for St. Joseph County students was 14.2 and 12.7 years for cocaine and crack respectively. State mean ages of first use were 14.2 years for cocaine and 13.3 years for crack. Consequences Health System Between 2001 and 2005, over 39% of substance abuse clients were treated for cocaine use or abuse in St. Joseph County compared to State rate of 12%. While the overall substance abuse treatment rate in the County was 90% of the State rate, St. Joseph County s cocaine treatment rate per 100,000 population was 2.9 times higher than the State as a whole, Those between the ages of 35 and 44 represented the highest proportion of treatment episodes for cocaine in the County at 44.6 percent. Other groups with the highest percentage In St. Joseph County were Blacks (59.1%) and males (64.1%). The percent of general hospital inpatient discharges for cocaine use/abuse were higher in St. Joseph County than in the State over the years 2002-2006 The percent of cocaine discharges for abuse (compared to dependence) were higher in St. Joseph County than in the State. Of the total number of newborns screened for drugs in St. Joseph County over the years 2002-2006, 13.9 percent indicated the presence of cocaine/metabolite in their meconium. This compared unfavorably to the State rate of 6.5 percent. In the County, cocaine represented a larger proportion of all positive screens for drugs (37.7%) compared to the State (27.6%) about 36 percent higher. Visits to area hospital emergency departments for cocaine dependence or abuse averaged about 305 per year in 2006 and 2007. Cocaine dependence accounted for 17.4 percent of all drug dependence visits, while cocaine abuse comprised 3.1 percent of visits for non-dependent abuse of drugs. St. Joseph County Epidemiological & Outcomes Workgroup 4

Criminal Justice Arrest rates for drug abuse violations have increased in the State and in St. Joseph County. In St. Joseph County, arrest rates were lower for drug sales but higher for possession, and arrest rates for possession were notably higher in St. Joseph County than the State for 2003-05. Drug possession arrests for cocaine in St. Joseph County were 75% higher than the State for all ages and 27% higher than the State in 2003-05 for juveniles. Compared to other large counties in the State, overall drug abuse violation arrests in St. Joseph County in 2003-05 trailed those in Allen, Marion, and Vanderburgh Counties. However, arrest rates for opium/cocaine possession in St. Joseph County were second to Marion County. Trends in arrest rates show that rates were higher in St. Joseph County compared to the State as a whole for all ages and juveniles for total drug abuse violations, drug possession, and possession of opium/cocaine. For adults, trends were up and rates higher for total drug abuse violation and opium/cocaine possession. Over the years 2000 to 2005, the property crime index dropped 18.4 percent and property crime arrest rates declined 20.4 percent while the drug abuse violation arrest rates increased 21 percent and arrests for cocaine possession increased nearly 52 percent in St. Joseph County. Drug abuse arrests claimed an increasingly larger share of total arrests during the period with declining law enforcement officer resources. Little change in the enforcement of property crime suggests a reallocation of resources possibly from traffic control and DUI arrests to illicit drug arrests. Youth Risk and Protective Factors Among St. Joseph County students, 68.4 percent of 6 th graders believe their peers would disapprove of their using cocaine occasionally; that proportion climbs to 75 percent by grade 12. Surprisingly, higher proportions are not reported for peer disapproval for regular use of cocaine. Nearly eight in 10 6 th graders reported parental disapproval of their taking cocaine occasionally and nearly identical proportions believed their parents or guardians would disapprove of their using cocaine on a regular basis. The rates of parental disapproval rose gradually over the subsequent seven grades. About 71 percent of St. Joseph County students in the 6 th grade report moderate to great risk in occasional use of cocaine; by grade 12, that proportion rises to 82 percent. The risk perceptions of regular cocaine use are similar, increasing from 72 percent in grade 6 to 83 percent in grade 12. St. Joseph County Epidemiological & Outcomes Workgroup 5

Alcohol Use in St. Joseph County Consumption Prevalence Alcohol is the most frequently used drug in the North Central region of Indiana as well as in the State and the Nation. About 47 percent of persons ages 12 and older in the North Central region reported using alcohol in the past month, and 21.5 percent say they binge drank in the past month. When compared to Indiana and the Nation, adults (18 and older) in North Central Indiana were slightly less likely to have used alcohol in the past month. Average annual use based on 2002-2004 data indicate that 58.7 percent of adults ages 18-25 in North Central Indiana used alcohol in the month before the survey compared to 61.6 and 60.6 for Indiana and the U.S. respectively. Compared to an earlier period (1999-2001), the proportion of adults that drink has increased. In Indiana and the North Central region, past month use for those over 25 rose from 46.3 to 50 and from 42.6 to 49.4 percent respectively. Although the proportion of adults engaging in binge drinking has increased, the rates of binge drinking reported by adults over 25 and their perception of risk for heavy drinking were comparable for the region, the State and Nation. Youth (ages 12 to 17) in North Central Indiana were slightly more likely (but not significantly so) than their counterparts in the State or Nation to have used alcohol in the past month. Binge drinking among youth appears to be up in Indiana and the Region between two recent three-year time periods, rising 3.6 percentage points in the Region and 2.2 percentage points in the State. Survey estimates indicate that 28.5 percent of underage youth (12 to 20) used alcohol in the month prior to the survey, and that 19 percent had engaged in binge drinking at least once in the past 30 days. Students surveyed in 2007 from St. Joseph County Schools reported prevalence rates higher than the State rates for alcohol use: lifetime prevalence rates were higher than State rates for alcohol in the 6th, 7th, 8th, and 12th grades; annual prevalence rates were higher than State rates for alcohol in the 6th and 8th grades; monthly prevalence rates were higher than State rates for alcohol in the 6th, 8th, and 12th grades; and, daily prevalence rates were higher than State rates for binge drinking (6th, 8th, and 12th). The prevalence in the population of overall chronic addiction reported by the Indiana Division of Mental Health and Addiction varies by age group and income. In the North Central region, past year alcohol dependence or abuse at 7.8 percent was below the State level (8.0%) and nearly equal to the national figure of 7.7 percent over the years 2002-2004. Those 18- to 25-years of age are estimated to have the highest rate. Prevalence rates for persons that are poor (under 200% of federal poverty level) are estimated to be more than 1.5 times higher than the prevalence in the general population. In St. Joseph County in FY2006, it was estimated that there were about 20,140 individuals with a chronic drug or alcohol addiction, 8,728 or 43 percent of whom had incomes below 200 percent of FPL Incidence Nationally, the average age of first use among 12- to 17-year-olds who reported using alcohol was about 13 years old. The mean age of first use of alcohol in Indiana schools, grades 6 through 12 (roughly, ages 12-18), was 12.9 years in 2007. In St. Joseph County Schools in 2007, the average age of first use was 12.7 years. In grade 6, the average age of initiation was 9.9 years; for those in the 12th grade, the average age of first use was 14.9 years. Consequences Health System The majority of admissions to treatment programs in the County are for alcohol abuse or dependence. In 2003, 53.5 percent of clients were admitted for alcohol as the primary drug of abuse or dependence. While this was below the State average of 58.8 percent in 2001-2003, the percent of episodes treated for alcohol as the primary drug of abuse or dependence in the County rose from 43.7 percent to 53.5 percent, or about 11 percent. Those between the ages of 35 and 44 represented the highest proportion of treatment episodes for alcohol at 42 percent. The age-adjusted alcohol-related mortality rate for St. Joseph County covering the years 1994-2000 was 263 per 100,000 population. This compared unfavorably with the State rate of 259. From 2002 to 2006, 51.6 percent of all fatal traffic accidents in St. Joseph County were alcohol-related. St. Joseph County, with an alcohol-related fatality rate of 24.5 deaths per 100,000 population, ranked 6 th highest among counties in the State St. Joseph County Epidemiological & Outcomes Workgroup 6

St. Joseph County hospitals discharge about 275 persons each year for alcohol abuse, dependence, or psychoses. Alcohol dependence syndrome accounted for nearly two-thirds (63.4%) of County alcoholrelated discharges during 2002-2006. Patients with alcohol-related diagnoses treated in St. Joseph County hospitals accrued on average over $1.6 million annually for care in hospitals at an average charge per patient of $5,965. Over 2002-2006, patients in St. Joseph County stayed, on average, 10.2 days, although more typically the average length of stay was about 4.8 days. In 2006, the local community mental health center s psychiatric hospital discharged nearly two-thirds of all St. Joseph County hospitals patients with an alcohol-related diagnosis. Trends indicate a notable and consistent increase in the use of emergency department (ED) visits for alcohol-related diagnoses. Currently, about 12 percent of emergency department visits to the County s two area hospitals are for drug-related conditions. Of those visits, 17 percent were for alcohol-related diagnoses. The majority (67.8%) of those admitted to the ED for alcohol-related diagnoses are between the ages of 35 and 64. Non-dependent alcohol abuse is more likely to affect younger persons than either alcoholic psychosis or alcohol dependence. St. Joseph County students reported a number of ill-consequences from drinking. For those in grade 12, nearly four in 10 (39.2%) reported suffering a hangover while 35.7 percent suffered nausea or vomiting. About 35 percent said they had ridden in a car with a person that was drunk while 22 percent said they had driven while under the influence of alcohol. Criminal Justice St. Joseph County authorities have been arresting a considerably smaller proportion of the population for alcohol-related violations in comparison to the rest of Indiana. During the three-year period, 2003-2005, the rate for DUI in the County was 371.3 per 100,000 compared to the rest of the State at 606 or, about 60 percent of the rate of the State. Similarly, the liquor law violation rate was 67.3 compared to State at 277.4, while the arrest rate for public intoxication in St. Joseph County was only 20 percent of that of the rest of the State. For juveniles, the arrest rate for DUI was 13.8 per 100,000 population 0-17, about two-thirds of that of the rest of the State. For liquor law violations, St. Joseph County youth were arrested at a rate of about 85 percent of the rest of Indiana, and for public intoxication, the County rate was only about 9 percent of the State rate. Youth Risk and Protective Factors About four in 10 respondents to a national survey report that heavy drinking is a great risk. Among St. Joseph County students, about 60 percent at the 6 th grade level believe their peers would disapprove of their drinking one to two drinks occasionally, but that proportion drops considerably by grade 12 when only a quarter hold that belief. Higher proportions report peer disapproval for binge drinking, however; 68 percent of 6 th graders and 44 percent of 12 th grade students perceive peer disapproval. Rates of parental disapproval for occasional drinking decline over the grades, but disapproval rates for binge drinking in grade 12 are similar to those in grade 6. About one third of St. Joseph County students in the 6 th grade report moderate to great risk in the occasional drinking of alcohol; by grade 12, that proportion drops to one quarter. The risk perception of binge drinking is twice as high however, and remains fairly flat over the next six grade levels. St. Joseph County Epidemiological & Outcomes Workgroup 7

Tobacco Use in St. Joseph County Consumption Prevalence About a third of Indiana residents use tobacco products, and those ages 18 to 25 show the highest rate of use. Most tobacco product users smoke cigarettes and Indiana ranks third highest in the Nation for adults that smoke. Teenage smoking rates look more promising, however, with declines that by 2005 were lower than those in the U.S. Higher rates in Indiana have been due in part to a larger proportion of Hoosiers that do not believe regular smoking is harmful, and in part to high and unchanging smoking rates in non-metropolitan areas of the State. The North Central region, that includes St. Joseph County, has registered higher tobacco product and cigarette smoking rates along with lower risk perception than either the State or the Nation across all age groups for the years 2002-2004. More promising are the results of school surveys of youth in the 8 th, 10 th, and 12 th grades that show notable declines in cigarette smoking nationally over the past 10 years. Rates in Indiana have remained relatively high, however. In the North Central region, there were significantly lower differences compared to the State in daily use among 8 th graders, daily and ½ pack per day use among 10 th graders, and annual, 30-day, daily, and ½ pack per day use among 12 th graders. In 2007, the prevalence of smoking among St. Joseph County students was highest in the early grades and notably lower in later ones. Lifetime, annual, monthly, and daily cigarette use and lifetime, annual and monthly cigar use rates were higher than State rates for students in the 6 th grade, as were lifetime cigarette and cigar use rates for 8 th graders. However, in both the 10 th and 12 th grades, all measures were significantly lower for both cigarette and cigar use. On nearly all measures and in all grades use rates for smokeless tobacco were significantly lower in St. Joseph County than State rates. Over the years 2002-2004, St. Joseph County was among Indiana counties with the lowest smoking rates for women that are pregnant. Overall, the prevalence of smoking during pregnancy has declined significantly regardless of race or Hispanic origin, and County rates are notably lower than those in the State. Incidence Nationally, 2006 data indicate that the average age of first use among 12- to 17-year-olds who reported using cigarettes was about 13 years of age. In Indiana, 2007 data indicate the average age was 12.6, and in St. Joseph County it was 12.1 years of age. Consequences Health System The preeminent effect of tobacco use is on rates of lung cancer. While Indiana s overall cancer death rate has been about 5 percent higher than the national rate, cancer mortality of the lung and bronchus has been about 16 percent higher. The incidence rates for all cancers was about one percent higher in Indiana than the U.S. over the years 2000-2004; however, the rate for lung and bronchus cancer was 33 percent higher, and higher for males but less so for females. Age-adjusted death rates in St. Joseph County from malignant neoplasm of the trachea, bronchus, and lung have declined more rapidly than rates for the State. Over the six years 2000 to 2005 the death rate in the County fell 18.1 percent compared to the decline in the State of 4.1 percent. By 2005, the rate in St. Joseph County was 84 percent of the rate for the State. Incidence and mortality rates by gender show little difference between County and State rates. Roughly the same proportion of new cases of lung and bronchus malignancies was present for both the County and the State for both sexes. Criminal Justice Non-compliance rates under the Tobacco Retailer Inspection Program (TRIP) have declined considerably over the 2002-2007 period in the State from 19 percent to 13 percent non-compliance. St. St. Joseph County Epidemiological & Outcomes Workgroup 8

Joseph County s rate has varied from a high of 22.2 percent to a low of 8.1 percent. In 2007, 19 percent of the 210 businesses inspected, failed the TRIP inspections - matching highs in 2004 and 2005. The tobacco outlet density (outlets per 100,000 population) in St. Joseph County was about 87 percent of the rate for the State in 2004 and appears to have remained notably below that rate through 2007. While 57.5 percent of total failed inspections in the County from in South Bend businesses, 59 percent of businesses inspected were located in South Bend. Youth Risk and Protective Factors Nearly two-thirds (64%) of St. Joseph County 6 th grade students believe their peers would disapprove of their smoking a pack of cigarettes per day. That proportion remains fairly constant through grade 12. Students in the 6 th grade in St. Joseph County schools report that 77 percent of their parents or guardians would disapprove or strongly disapprove of their smoking a pack a day, and that figure rises over the next six grades to about 79 percent. Five of every eight (62.5%) St. Joseph County students in the 6th grade report moderate to great risk in smoking a pack of cigarettes daily; by grade 12, that proportion increases to nearly eight out of 10 students - a 17 percentage point increase. St. Joseph County Epidemiological & Outcomes Workgroup 9

Marijuana Use in St. Joseph County Consumption Prevalence Nearly 11 percent of persons ages 12 and older used marijuana in the past year whether in North Central Indiana, Indiana as a whole, or the Nation. Past month use was higher in the North Central region of the State compared to the State or Nation, and the trend was toward higher prevalence rates in the Region as well. Higher past year use rates for marijuana were reported by those ages 12 to 25 in the Region compared to the State or Nation, and similar patterns emerged for past month use as well. Higher prevalence rates in the North Central region of Indiana were driven by higher incidence of first use rates in the face of and despite no lower levels of risk perception than either State or national populations. In contrast, school surveys of U.S. 8 th, 10 th and 12 th grade students over the past 10 years indicate declining rates of regular use of marijuana. In recent years, while Indiana rates for 8 th grade students were slightly higher than national rates, in the North Central Region, rates for 10 th grade daily users were notably lower, and lower (but non-significant) differences were evident among all three grades. School surveys in St. Joseph County conducted in 2007 show reported prevalence rates for marijuana use higher than the State rates. Lifetime prevalence rates were higher in grades 6,8,10, and 12; annual prevalence rates were higher in grades 8, 10, and 12; and, monthly use rates were higher in grades 6, 8, and 12. Incidence The incidence rate of marijuana use (rate of new users) was higher in the North Central Region than in either the State or the Nation, and would appear to indicate higher prevalence rates in the near future. Most current data indicate about two new users for every 100 persons ages 12 and older in the Region. Nationally, the average age of first use among 12- to 17-year-olds who reported using marijuana was 14 years of age in 2006. In 2007 school surveys in Indiana grades 6 through 12 indicate an average age of first use of 13.7 years, while in St. Joseph County the average ages was 13.4 Consequences Health System Nearly 13 percent of substance abuse clients in St. Joseph County were treated for marijuana use/abuse over the years 2001-2006 compared to the overall State rate of nearly 27 percent. While all drug admission rates to facilities in St. Joseph County have been about 87 percent of total State rates, treatment rates for marijuana/ hashish in St. Joseph County were, on average over the six year period 2001-2006, only 42 percent of State rates. About 77 percent of all persons admitted in St. Joseph County and 85 percent admitted in the State overall for treatment of this drug were under 35 years of age. Other groups with high proportions relative to their representation in the general population in St. Joseph County were Blacks (43.4%) and males (78.1%). While the admission rate to treatment facilities for marijuana use/abuse for 2001-2006 in Indiana was 2.4 times higher than the rate in St. Joseph County, the admission rate in Indiana has increased over 37.5 percent between 2001 and 2006 and the rate in St. Joseph County has risen over 50 percent). Marijuana use is more likely to be reported by younger individuals as the primary drug of use/abuse at admission to treatment facilities. Still, in St. Joseph County, less than four percent of admissions are under 18 years of age compared to the State 3-year average of 17 percent. Criminal Justice Arrests for drug abuse violations for both the sale and possession of marijuana constituted 57.1 percent of all drug violations in St. Joseph County. In Indiana and the Nation it was it was 55.3 and 41.9 percent respectively. About six of ten arrests for drug possession in the County were for possession of marijuana about the same as the proportion for the State but considerably higher than the Nation. The St. Joseph County arrest rate for sales/manufacture of marijuana was about 60 percent of the State rate and 75 percent of the National rate. For possession, the rate in the County was comparable to the State rate (244 vs. 245 per 100,000), but 16 percent higher than the National rate. Marijuana sales arrest rates in the County increased at a faster clip than the State against a decline at the national level. Over the years 2000 to 2005, the County s marijuana possession rates increased 14.4 St. Joseph County Epidemiological & Outcomes Workgroup 10

percent while the State s rates were nearly flat at a 2.8 percent increase and the national rate declined 2.2 percent. While the arrest rate for marijuana possession violations among juveniles was exactly half the rate of adults in St. Joseph County in 2005, County possession arrest rates for juveniles rose dramatically between the years 2000 and 2005 from 113 per 100,000 under 18 years of age in 2000-2002 to 161.2 in 2003-2005. This was in stark contrast to juvenile arrest rates in the State and Nation that declined 5.1 and 8.3 percent respectively. Youth Risk and Protective Factors There has been a notable drop in the perception that smoking marijuana monthly presents a great risk. In 1999-2001, nearly 47 percent living in North Central Indiana held this belief; by 2002-2004, only 41 percent reported it. Perception of disapproval by peers and parents can lower drug use among youth. About two-thirds of St. Joseph County students at the 6th grade level believe their peers would disapprove of their using marijuana occasionally. That proportion drops considerably by grade 12 when only 45 percent hold that belief. Generally higher proportions report peer disapproval for smoking marijuana on a regular basis. Among St. Joseph County students in the 6 th grade, in 2007 surveys 78 percent reported parental disapproval of their using marijuana occasionally or regularly. There appeared to be no difference in perception of parental disapproval between occasional and regular use of this drug. Perceived risk of harm in using drugs has been found to be inversely related to prevalence of use. St. Joseph County students do not perceive the same level of risk for occasional use as they do for regular use. Two-thirds of those in the 6 th grade reported belief that occasional marijuana smoking presented moderate to great risk; by grade 12, that proportion dropped to 46 percent. While the risk perception of regular marijuana use is slightly higher, it remained fairly flat over the next six grade levels. St. Joseph County Epidemiological & Outcomes Workgroup 11

1. Demographic Profile of St. Joseph County 4 St. Joseph County is located in mid-northern Indiana. The County is bordered on the south by Marshall County, is adjacent to Elkhart County on the east, the State of Michigan to the north, and LaPorte County to the west. St. Joseph County is one of about 3,141 counties and County equivalents in the United States. Formed in 1830, it was named for the St. Joseph River which flows through it toward Lake Michigan. It is the fourth largest County in the State of Indiana. The County seat is South Bend. (See Map, Figure 1-A) It has 457.3 sq. miles in land area and a population density of 581.9 per square mile. In the last three decades of the 1900s, its population grew by 8.5%. On the 2000 census form, 98.0% of the population reported only one race, with 11.5% of these reporting African-American. The population of this County is 4.7% Hispanic (of any race). The average household size is 2.50 persons compared to an average family size of 3.07 persons. In 2006 manufacturing was the largest of 20 major sectors. It had an average wage per job of $48,458. Per capita income grew by 17.8% between 1995 and 2005 (adjusted for inflation). St. Joseph County is the regional center for higher education. The County is home to more than eight colleges and universities including but not limited to Notre Dame University, Indiana University South Bend, Purdue Extension, Bethel University and St. Mary s College. Households and Families In 2006 there were 100,000 households in St. Joseph County. The average household size was 2.5 people. Families made up 66 percent of the households in St. Joseph County. This figure includes both married-couple families (51 percent) and other families (15 percent). Nonfamily households made up 34 percent of all households in St. Joseph County. Most of the nonfamily households were people living alone, but some were composed of people living in households in which no one was related to the householder (Figure 1-B). A slightly larger proportion of households (68%) were comprised of families in the State as a whole, but a smaller proportion of nonfamily households (32%). The average household size in the State was 2.5. (Table 1.1) Nativity and Language Six percent of the people living in St. Joseph County in 2006 were foreign born compared to four percent in the State. Ninety-four percent were native, including 64 percent who were born in Indiana compared with 96 percent in the State that were native, including 69 percent who were born in Indiana. Among people at least five years old living in St. Joseph County in 2006, 10 percent spoke a language other than English at home. Of those speaking a language other than English at home, 60 percent spoke Spanish and 40 percent spoke some other language; 38 percent reported that they did not speak English "very well." Among people those living in Indiana in 2006, 8 percent spoke a language other than English at home. Of those speaking a language other than English at home, 57 percent spoke Spanish and 43 percent spoke some other language; 41 percent reported that they did not speak English "very well." (Table 1.2) Geographic Mobility In 2006, 84 percent of the people at least one year old living in St. Joseph County were living in the same residence one year earlier; 10 percent had moved during the past year from another residence in the same County, 2 percent from another County in the same State, 4 percent from another State, and less than 0.5 percent from abroad (Figure 1-C). In Indiana as a whole, 83 percent of the people at least one year old living in Indiana were living in the same residence one year earlier; 11 percent had moved during the past year from another residence in the same County, 4 percent from another County in the same State, 3 percent from another State, and less than 0.5 percent from abroad. (Table 1.2) St. Joseph County Epidemiological & Outcomes Workgroup 12

Figure 1-A. Map of St. Joseph County Indiana St. Joseph County Epidemiological & Outcomes Workgroup 13

Figure 1-B Figure 1-C Education In 2006, 85 percent of people 25 years and over had at least graduated from high school and 26 percent had a bachelor's degree or higher. Fifteen percent were dropouts; they were not enrolled in school and had not graduated from high school. (Figure 1-D) Compared to the State, St. Joseph County had a larger proportion of persons with bachelor s degrees or higher (25.7% vs. 21.7%). The total school enrollment in St. Joseph County was 80,000 in 2006. Nursery school and kindergarten enrollment was 8,600 and elementary or high school enrollment was 46,000 children. College or graduate school enrollment was 25,000. The County had a higher proportion of its population ages 3 and older that were enrolled in college or graduate school compared to the State, but a smaller proportion in kindergarten and elementary school. (Table 1.3) St. Joseph County Epidemiological & Outcomes Workgroup 14

Figure 1-D Disability In St. Joseph County, among people at least five years old in 2006, 15 percent reported a disability. The likelihood of having a disability varied by age - from 8 percent of people 5 to 15 years old, to 12 percent of people 16 to 64 years old, and to 41 percent of those 65 and older. Compared to the State, St. Joseph County showed a higher proportion of persons ages 5-15 years with a disability. (Table 1.4) Industries In 2006, for the employed population 16 years and older, the leading industries in St. Joseph County were Educational services, and health care, and social assistance, 26 percent, and Manufacturing, 18 percent. (Figure 1-E) The top two employment sectors in Indiana were: Educational services, and health care and social assistance (20.8%), and manufacturing (20.7%). (Table 1.5) Occupations and Type of Employer Among the most common occupations were: Management, professional, and related occupations, 32 percent; Sales and office occupations, 26 percent; Service occupations, 17 percent; Production, transportation, and material moving occupations, 16 percent; and Construction, extraction, maintenance and repair occupations, 9 percent. Eighty-five percent of the people employed were Private wage and salary workers; 10 percent was federal, State, or local government workers; and 4 percent was self-employed in own not incorporated business workers. The County had a higher percentage of workers in management and professional, service, and sales and office occupations compared to the percent in the State (75% vs. 70%) and a smaller proportion in construction and maintenance, and production and transportation (25% vs. 30%) (Table 1.5) Travel to Work Eighty-two percent of St. Joseph County workers drove to work alone in 2006, 9 percent carpooled, 1 percent took public transportation, and 5 percent used other means. The remaining 3 percent worked at home. Among those who commuted to work, it took them on average 20 minutes to get to work. A higher percent in Indiana carpooled, and a fewer proportion walked to work. (Table 1.6) St. Joseph County Epidemiological & Outcomes Workgroup 15

Figure 1-E Income The median income of households in St. Joseph County was $43,691 compared to the State figure of $45,394. Eighty percent of the households received earnings and 16 percent received retirement income other than Social Security. In Indiana in 2006 inflation-adjusted dollars, 18 percent received retirement income at a level that was nearly 20 percent higher than the County s mean retirement income. Twenty-seven percent of the households in St. Joseph County received Social Security at an average income of $14,204. 5 (Table 1.7a) St. Joseph County Epidemiological & Outcomes Workgroup 16

Median and mean family income in the County were 4.5 and 8.8 percent higher than in the State in 2006 inflation-adjusted dollars. Per capita income of $23,014 was slightly above the State average of $22,781. Non-family incomes, however, were only about 92 percent of State averages. Median earnings for full-time, year-around male workers in St. Joseph County were 40 percent higher than median earnings for full-time, year-around female workers. (Table 1.7b) Poverty and Participation in Government Programs In 2006, 12 percent of St. Joseph County residents were living in poverty. Sixteen percent of related children under 18 were below the poverty level, compared with 9 percent of people 65 years old and over. Eight percent of all families and 26 percent of families with a female householder and no husband present had incomes below the poverty level. (Table 1.8) Figure 1-F Population In 2006, St. Joseph County had a total population of 267,000-137,000 (52 percent) females and 129,000 (48 percent) males. The median age was 35.5 years. Twenty-five percent of the population was under 18 years and 13 percent was 65 years and older. St. Joseph County has a larger percentage of its population ages 15 to 24 (16.3%) compared to the State (14.3%), and a smaller proportion of persons ages 25 to 54 (39%) compared to the State (42%). The median age of State residents was 36.3 years. (Table 1.9) For people reporting one race alone in St. Joseph County, 82 percent were White; 12 percent were Black or African American; less than 0.5 percent were American Indian and Alaska Native; 2 percent were Asian; less than 0.5 percent were Native Hawaiian and Other Pacific Islander, and 4 percent were some other race. Two percent reported two or more races. Six percent of the people in St. Joseph County were Hispanic. Seventy-eight percent of the people in St. Joseph County were White non-hispanic. (People of Hispanic origin may be of any race.). A larger proportion of persons in Indiana reported being White (86%) and fewer said they were Black or African-American (8.7%). About 4.7 percent of all Hoosiers were Hispanic, and 84 percent said they were White non-hispanic. (Table 1.10) St. Joseph County Epidemiological & Outcomes Workgroup 17

Figure 1-G Housing Characteristics In 2006, St. Joseph County had a total of 113,000 housing units, 12 percent of which were vacant. Of the total housing units, 79 percent were in single-unit structures, 19 percent were in multi-unit structures, and 2 percent were mobile homes. Eighteen percent of the housing units were built since 1990. (Figure 1-H) Compared to the State average, St. Joseph County was slightly higher in both homeowner and rental vacancy rates. A higher proportion of housing units in the County were single-unit structures (79% vs. 74%), while a smaller proportion were mobile homes (1.8% vs. 5.8%). (Table 1.11) Fully one-quarter (24.9%) of housing units throughout the State were built since 1990 compared to 18 percent in St. Joseph County. Occupied Housing Unit Characteristics In 2006, St. Joseph County had 100,000 occupied housing units - 72,000 (72 percent) owner occupied and 27,000 (28 percent) renter occupied. Six percent of the households did not have telephone service and 7 percent of the households did not have access to a car, truck, or van for private use. Multi-vehicle households were not rare. Forty percent had two vehicles and another 18 percent had three or more. Housing tenure was similar statewide to the County. More recent movers were evident in the State as a whole where 51.5 percent had moved into current (2006) housing from 2000 onward. About 6 percent of Hoosiers lack vehicles. A significantly smaller proportion of those in occupied housing rely on natural gas for heating fuel compared to St. Joseph County (63.5% vs. 87.4%), while 24 percent of all Hoosiers used electricity for heating, only 9.7 percent of St. Joseph County occupants did. (Table 1.12) Housing Costs The median monthly housing costs for mortgaged owners was $1,020, non-mortgaged owners $348, and renters $671. Twenty-five percent of owners with mortgages, 16 percent of owners without mortgages, and 42 percent of renters in St. Joseph County spent 30 percent or more of household income on housing. (Figure 1-I) Median monthly mortgage costs were 6.8 percent higher statewide, while those without a mortgage spend the same as in the County and renters spent about 95 percent of what those in St. Joseph County spent. State averages for those that spent 30 percent of household income or more for housing were: 27 percent with a mortgage; 13 percent without a mortgage; and, 45 percent for renters. (Table 1.13) St. Joseph County Epidemiological & Outcomes Workgroup 18

Figure 1-H Figure 1-I St. Joseph County Epidemiological & Outcomes Workgroup 19

Table 1.1. Households by Type. St. Joseph County and Indiana (estimates), 2006 Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana HOUSEHOLDS BY TYPE Total households 99,727 2,435,274 100.0 100.0 Family households (families) 65,337 1,645,031 65.5 67.6 With own children under 18 years 29,471 763,834 29.6 31.4 Married-couple families 50,541 1,248,625 50.7 51.3 With own children under 18 years 20,763 518,041 20.8 21.3 Male householder, no wife present 3,018 112,552 3.0 4.6 With own children under 18 years 1,495 64,363 1.5 2.6 Female householder, no husband present 11,778 283,854 11.8 11.7 With own children under 18 years 7,213 181,430 7.2 7.5 Nonfamily households 34,390 790,243 34.5 32.4 Householder living alone 29,982 661,365 30.1 27.2 65 years and over 10,827 226,021 10.9 9.3 Households with one or more people under 18 years 32,433 839,268 32.5 34.5 Households with one or more people 65 years and over 23,220 539,677 23.3 22.2 Average household size 2.54 2.52 Average family size 3.18 3.06 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 20

Table 1.2. Nativity, Language, and Geographic Mobility. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana Total population 266,678 6,313,520 100.0 100.0 Native 251,394 6,049,913 94.3 95.8 Born in United States 250,522 6,015,579 93.9 95.3 State of residence 171,331 4,329,973 64.2 68.6 Different State 79,191 1,685,606 29.7 26.7 Born in Puerto Rico, U.S. Island areas, or born abroad to American parent(s) 872 34,334 0.3 0.5 Foreign born 15,284 263,607 5.7 4.2 LANGUAGE SPOKEN AT HOME Population 5 years and over 248,036 5,879,940 100.0 100.0 English only 223,815 5,434,897 90.2 92.4 Language other than English 24,221 445,043 9.8 7.6 Speak English less than "very well" 9,294 180,997 3.7 3.1 Spanish 14,437 254,219 5.8 4.3 Speak English less than "very well" 6,171 121,024 2.5 2.1 Other Indo-European languages 3,256 119,653 1.3 2.0 Speak English less than "very well" 496 30,773 0.2 0.5 Asian and Pacific Islander languages 3,601 53,830 1.5 0.9 Speak English less than "very well" 1,712 22,178 0.7 0.4 Other languages 2,927 17,341 1.2 0.3 Speak English less than "very well" 915 7,022 0.4 0.1 RESIDENCE 1 YEAR AGO Population 1 year and over 262,333 6,229,342 100.0 100.0 Same house 221,050 5,158,825 84.3 82.8 Different house in the U.S. 40,416 1,045,462 15.4 16.8 Same County 26,246 655,179 10.0 10.5 Different County 14,170 390,283 5.4 6.3 Same State 4,741 229,273 1.8 3.7 Different State 9,429 161,010 3.6 2.6 Abroad 867 25,055 0.3 0.4 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 21

Table 1.3. Educational Attainment and School Enrollment. St. Joseph County and Indiana, 2006 Estimates Percent Distribution EDUCATIONAL ATTAINMENT St. Joseph Indiana St. Joseph Indiana Population 25 years and over 167,281 4,110,754 100.0 100.0 Less than 9th grade 6,370 189,325 3.8 4.6 9th to 12th grade, no diploma 19,114 419,169 11.4 10.2 High school graduate (includes equivalency) 57,047 1,521,427 34.1 37.0 Some college, no degree 31,774 793,292 19.0 19.3 Associate's degree 10,063 296,052 6.0 7.2 Bachelor's degree 26,959 561,008 16.1 13.6 Graduate or professional degree 15,954 330,481 9.5 8.0 Percent high school graduate or higher 84.80% 85.20% Percent bachelor's degree or higher 25.70% 21.70% SCHOOL ENROLLMENT Population 3 years and over enrolled in school 79,782 1,655,250 100.0 100.0 Nursery school, preschool 5,504 101,694 6.9 6.1 Kindergarten 3,048 87,553 3.8 5.3 Elementary school (grades 1-8) 30,064 695,452 37.7 42.0 High school (grades 9-12) 16,283 356,346 20.4 21.5 College or graduate school 24,883 414,205 31.2 25.0 Source: American Community Survey, 2006 Table 1.4. Age-Specific Disability Rates. St. Joseph County and Indiana, 2006 Estimates Percent Distribution DISABILITY STATUS St. Joseph Indiana St. Joseph Indiana Population 5 years and over 244,309 5,782,926 100.0 100.0 With a disability 37,084 896,090 15.2 15.5 Population 5 to 15 years 40,794 959,942 100.0 100.0 With a disability 3,410 70,708 8.4 7.4 Population 16 to 64 years 171,999 4,087,653 100.0 100.0 With a disability 20,846 517,983 12.1 12.7 Population 65 years and over 31,516 735,331 100.0 100.0 With a disability 12,828 307,399 40.7 41.8 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 22

Table 1.5. Number and percent distribution of civilian employed population 16 and older by occupation and industry. St. Joseph County and Indiana, 2006. Percent Estimates Distribution St. Joseph Indiana St. Joseph Indiana Civilian employed population 16 years and over 125,868 3,030,454 100.0 100.0 OCCUPATION Management, professional, and related occupations 39,989 905,494 31.8 29.9 Service occupations 20,916 464,574 16.6 15.3 Sales and office occupations 33,175 741,281 26.4 24.5 Farming, fishing, and forestry occupations 98 12,860 0.1 0.4 Construction, extraction, maintenance and repair occupations 11,013 305,984 8.7 10.1 Production, transportation, and material moving occupations 20,677 600,261 16.4 19.8 INDUSTRY Agriculture, forestry, fishing and hunting, and mining 475 41,866 0.4 1.4 Construction 7,789 214,092 6.2 7.1 Manufacturing 23,124 628,384 18.4 20.7 Wholesale trade 4,808 97,589 3.8 3.2 Retail trade 14,114 341,792 11.2 11.3 Transportation and warehousing, and utilities 6,118 160,365 4.9 5.3 Information 2,468 54,557 2.0 1.8 Finance and insurance, and real estate and rental and leasing 7,164 167,220 5.7 5.5 Professional, scientific, and management, and administrative and waste management services 7,830 213,432 6.2 7.0 Educational services, and health care, and social assistance 32,099 630,452 25.5 20.8 Arts, entertainment, and recreation, and accommodation, and food services 9,700 240,405 7.7 7.9 Other services, except public administration 6,471 141,754 5.1 4.7 Public administration 3,708 98,546 2.9 3.3 CLASS OF WORKER Private wage and salary workers 107,419 2,522,109 85.3 83.2 Government workers 12,863 337,832 10.2 11.1 Self-employed workers in own not incorporated business 5,146 163,208 4.1 5.4 Unpaid family workers 440 7,305 0.3 0.2 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 23

Table 1.6. Commuting to Work for workers 16 years of age and older. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana Workers 16 years and over 122,116 2,951,039 100.0 100.0 Car, truck, or van -- drove alone 99,719 2,431,018 81.7 82.4 Car, truck, or van -- carpooled 10,988 291,072 9.0 9.9 Public transportation (excluding taxicab) 1,514 30,578 1.2 1.0 Walked 4,197 65,675 3.4 2.2 Other means 1,771 38,438 1.5 1.3 Worked at home 3,927 94,258 3.2 3.2 Source: American Community Survey, 2006 Table 1.7a. Household Income and benefits (in 2006 inflation-adjusted dollars). St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana Total households 99,727 2,435,274 100.0 100.0 Less than $10,000 8,418 192,319 8.4 7.9 $10,000 to $14,999 5,928 142,295 5.9 5.8 $15,000 to $24,999 12,996 301,314 13.0 12.4 $25,000 to $34,999 11,896 298,933 11.9 12.3 $35,000 to $49,999 15,572 391,308 15.6 16.1 $50,000 to $74,999 21,220 506,596 21.3 20.8 $75,000 to $99,999 11,214 291,886 11.2 12.0 $100,000 to $149,999 7,539 212,112 7.6 8.7 $150,000 to $199,999 2,536 55,073 2.5 2.3 $200,000 or more 2,408 43,438 2.4 1.8 Median household income (dollars) 43,691 45,394 Mean household income (dollars) 59,589 57,601 With earnings 79,334 1,962,904 79.6 80.6 Mean earnings (dollars) 62,705 58,533 With Social Security 26,744 657,022 26.8 27.0 Mean Social Security income (dollars) 14,204 14,523 With retirement income 16,067 439,206 16.1 18.0 Mean retirement income (dollars) 12,962 15,438 With Supplemental Security Income 2,046 78,621 2.1 3.2 Mean Supplemental Security Income ($) 9,112 7,603 With cash public assistance income 2,559 62,098 2.6 2.5 Mean cash public assistance income ($) 1,920 2,223 With Food Stamp benefits in the past 12 months 7,931 204,924 8.0 8.4 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 24

Table 1.7b. Family and Non-family Household Income (in 2006 inflation-adjusted dollars). St. Joseph County and Indiana, 2006. Percent Estimates Distribution St. Joseph Indiana St. Joseph Indiana Families 65,337 1,645,031 100.0 100.0 Less than $10,000 3,103 79,630 4.7 4.8 $10,000 to $14,999 1,361 52,035 2.1 3.2 $15,000 to $24,999 6,035 145,086 9.2 8.8 $25,000 to $34,999 6,486 182,024 9.9 11.1 $35,000 to $49,999 10,073 265,583 15.4 16.1 $50,000 to $74,999 17,007 393,770 26.0 23.9 $75,000 to $99,999 9,508 249,231 14.6 15.2 $100,000 to $149,999 7,202 188,863 11.0 11.5 $150,000 to $199,999 2,344 50,402 3.6 3.1 $200,000 or more 2,218 38,407 3.4 2.3 Median family income (dollars) 58,308 55,781 Mean family income (dollars) 73,631 67,650 Per capita income (dollars) 23,014 22,781 Nonfamily households 34,390 790,243 Median nonfamily income (dollars) 24,319 25,988 Mean nonfamily income (dollars) 31,366 34,290 Median earnings for workers (dollars) 24,827 26,383 Median earnings for male full-time, year-round workers (dollars) 42,234 41,991 Median earnings for female full-time, year-round workers (dollars) 30,226 30,537 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 25

Table 1.8. Percentage of families and people whose income in the past 12 months was below the poverty level. St. Joseph County and Indiana, 2006. Estimates St. Joseph Indiana All families 8.1 9.0 With related children under 18 years 12.7 14.7 With related children under 5 years only 15.9 18.3 Married couple families 3.6 3.7 With related children under 18 years 4.8 5.5 With related children under 5 years only 8.9 6.4 Families with female householder, no husband present 25.9 30.4 With related children under 18 years 30.5 38.2 With related children under 5 years only 37.1 48.6 All people 12.3 12.7 Under 18 years 16.2 17.9 Related children under 18 years 16.2 17.4 Related children under 5 years 20.8 21.6 Related children 5 to 17 years 14.4 15.8 18 years and over 11.0 10.9 18 to 64 years 11.3 11.5 65 years and over 9.4 7.8 People in families 9.6 10.1 Unrelated individuals 15 years and over 24.9 24.9 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 26

Table 1.9. Population by sex and age. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana Total population 266,678 6,313,520 100.0 100.0 SEX AND AGE Male 129,272 3,104,461 48.5 49.2 Female 137,406 3,209,059 51.5 50.8 Under 5 years 18,642 433,580 7.0 6.9 5 to 9 years 16,969 428,767 6.4 6.8 10 to 14 years 20,508 440,378 7.7 7.0 15 to 19 years 21,469 460,297 8.1 7.3 20 to 24 years 21,809 439,744 8.2 7.0 25 to 34 years 31,427 835,547 11.8 13.2 35 to 44 years 35,430 896,489 13.3 14.2 45 to 54 years 38,490 926,792 14.4 14.7 55 to 59 years 17,368 386,236 6.5 6.1 60 to 64 years 10,973 284,698 4.1 4.5 65 to 74 years 14,891 397,244 5.6 6.3 75 to 84 years 13,660 275,549 5.1 4.4 85 years and over 5,042 108,199 1.9 1.7 Median age (years) 35.5 36.3 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 27

Table 1.10. Population by Race and Latino Ethnicity. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana RACE One race 260,886 6,224,284 97.8 98.6 Two or more races 5,792 89,236 2.2 1.4 Total population 266,678 6,313,520 100.0 100.0 One race 260,886 6,224,284 97.8 98.6 White 215,100 5,427,561 80.7 86.0 Black or African American 31,388 551,864 11.8 8.7 American Indian and Alaska Native 624 10,964 0.2 0.2 Asian 4,476 81,054 1.7 1.3 Native Hawaiian and Other Pacific Islander 0 1,278 0.0 0.0 Some other race 9,298 151,563 3.5 2.4 Two or more races 5,792 89,236 2.2 1.4 White and Black or African American 2,958 32,277 1.1 0.5 White and American Indian and Alaska Native 1,191 25,413 0.4 0.4 White and Asian 507 10,499 0.2 0.2 Black or African American and American Indian and Alaska Native 354 1,915 0.1 0.0 Race alone or in combination with one or more other races Total population 266,678 6,313,520 100.0 100.0 White 220,246 5,510,059 82.6 87.3 Black or African American 34,880 593,293 13.1 9.4 American Indian and Alaska Native 2,169 42,899 0.8 0.7 Asian 5,215 93,568 2.0 1.5 Native Hawaiian and Other Pacific Islander 0 2,910 0.0 Some other race 9,947 164,947 3.7 2.6 HISPANIC OR LATINO AND RACE Total population 266,678 6,313,520 100.0 100.0 Hispanic or Latino (of any race) 15,723 299,398 5.9 4.7 Not Hispanic or Latino 250,955 6,014,122 94.1 95.3 White alone 208,963 5,291,080 78.4 83.8 Black or African American alone 31,030 549,805 11.6 8.7 American Indian and Alaska Native alone 377 9,315 0.1 0.1 Asian alone 4,476 79,842 1.7 1.3 Native Hawaiian and Other Pacific Islander alone 0 880 0.0 0.0 Some other race alone 809 8,748 0.3 0.1 Two or more races 5,300 74,452 2.0 1.2 Two races including Some other race 188 2,406 0.1 0.0 Two races excluding Some other race, and Three or more races 5,112 72,046 1.9 1.1 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 28

Table 1.11. Housing Characteristics. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana HOUSING OCCUPANCY Total housing units 113,044 2,756,583 100.0 100.0 Occupied housing units 99,727 2,435,274 88.2 88.3 Vacant housing units 13,317 321,309 11.8 11.7 Homeowner vacancy rate 3.8 3.3 Rental vacancy rate 12.1 11.2 UNITS IN STRUCTURE 1-unit, detached 85,735 1,979,098 75.8 71.8 1-unit, attached 3,476 98,324 3.1 3.6 2 units 3,101 81,398 2.7 3.0 3 or 4 units 3,764 100,474 3.3 3.6 5 to 9 units 6,437 135,579 5.7 4.9 10 to 19 units 4,316 98,225 3.8 3.6 20 or more units 4,179 102,064 3.7 3.7 Mobile home 2,036 160,812 1.8 5.8 Boat, RV, van, etc. 0 609 0.0 0.0 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 29

Table 1.12. Housing Characteristics of Occupied Housing Units. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana Occupied housing units 99,727 2,435,274 100.0 100.0 HOUSING TENURE Owner-occupied 72,238 1,756,328 72.4 72.1 Renter-occupied 27,489 678,946 27.6 27.9 Average household size of owner-occupied unit 2.61 2.62 Average household size of renter-occupied unit 2.34 2.25 YEAR HOUSEHOLDER MOVED INTO UNIT Moved in 2005 or later 17,311 514,851 17.4 21.1 Moved in 2000 to 2004 28,155 741,039 28.2 30.4 Moved in 1990 to 1999 25,754 582,280 25.8 23.9 Moved in 1980 to 1989 10,796 242,992 10.8 10.0 Moved in 1970 to 1979 8,478 183,201 8.5 7.5 Moved in 1969 or earlier 9,233 170,911 9.3 7.0 VEHICLES AVAILABLE No vehicles available 7,165 150,047 7.2 6.2 1 vehicle available 34,675 781,528 34.8 32.1 2 vehicles available 39,479 964,699 39.6 39.6 3 or more vehicles available 18,408 539,000 18.5 22.1 HOUSE HEATING FUEL Utility gas 87,156 1,546,225 87.4 63.5 Bottled, tank, or LP gas 1,686 211,840 1.7 8.7 Other fuel or no fuel used 9,710 574,389 10.9 27.8 SELECTED CHARACTERISTICS Lacking complete plumbing facilities 69 8,264 0.1 0.3 Lacking complete kitchen facilities 218 12,092 0.2 0.5 No telephone service available 6,226 160,102 6.2 6.6 OCCUPANTS PER ROOM 1.00 or less 98,523 2,399,951 98.8 98.5 1.01 to 1.50 1,151 30,477 1.2 1.3 1.51 or more 53 4,846 0.1 0.2 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 30

Table 1.13. Housing Cost Burdens. St. Joseph County and Indiana, 2006. Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS Housing units with a mortgage 51,492 1,237,171 100.0 100.0 Less than $300 229 5,494 0.4 0.4 $300 to $499 1,932 44,541 3.8 3.6 $500 to $699 6,379 135,506 12.4 11.0 $700 to $999 16,371 340,467 31.8 27.5 $1,000 to $1,499 17,612 439,715 34.2 35.5 $1,500 to $1,999 6,098 166,328 11.8 13.4 $2,000 or more 2,871 105,120 5.6 8.5 Median (dollars) 1,020 1,089 Housing units without a mortgage 20,746 519,157 100.0 100.0 Less than $100 195 4,147 0.9 0.8 $100 to $199 1,791 52,743 8.6 10.2 $200 to $299 5,750 133,091 27.7 25.6 $300 to $399 5,204 133,411 25.1 25.7 $400 or more 7,806 195,765 37.6 37.7 Median (dollars) 348 349 SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF HOUSEHOLD INCOME Housing unit with a mortgage 51,492 1,237,171 100.0 100.0 Less than 20.0 percent 23,535 529,928 45.7 42.8 20.0 to 24.9 percent 9,388 225,050 18.2 18.2 25.0 to 29.9 percent 5,335 147,754 10.4 11.9 30.0 to 34.9 percent 3,503 95,049 6.8 7.7 35.0 percent or more 9,571 235,135 18.6 19.0 Not computed 160 4,255 0.3 0.3 Housing unit without a mortgage 20,746 519,157 100.0 100.0 Less than 10.0 percent 7,768 210,119 37.4 40.5 10.0 to 14.9 percent 3,349 105,420 16.1 20.3 15.0 to 19.9 percent 2,996 64,964 14.4 12.5 20.0 to 24.9 percent 1,745 40,268 8.4 7.8 25.0 to 29.9 percent 1,421 25,577 6.8 4.9 30.0 to 34.9 percent 809 15,877 3.9 3.1 35.0 percent or more 2,589 52,618 12.5 10.1 Not computed 69 4,314 0.3 0.8 Renter-occupied units 27,489 678,946 100.0 100.0 GROSS RENT Less than $200 1,072 23,349 3.9 3.4 $200 to $299 835 20,808 3.0 3.1 $300 to $499 4,847 121,601 17.6 17.9 $500 to $749 10,414 272,964 37.9 40.2 $750 to $999 6,196 135,508 22.5 20.0 $1,000 to $1,499 1,954 52,349 7.1 7.7 $1,500 or more 1,031 10,552 3.8 1.6 No cash rent 1,140 41,815 4.1 6.2 Median (dollars) 671 638 St. Joseph County Epidemiological & Outcomes Workgroup 31

Table 1.13 (continued) Estimates Percent Distribution St. Joseph Indiana St. Joseph Indiana GROSS RENT AS A PERCENTAGE OF HOUSEHOLD INCOME Less than 15.0 percent 2,738 87,004 10.0 12.8 15.0 to 19.9 percent 4,566 86,068 16.6 12.7 20.0 to 24.9 percent 3,731 81,976 13.6 12.1 25.0 to 29.9 percent 3,381 70,260 12.3 10.3 30.0 to 34.9 percent 1,961 53,830 7.1 7.9 35.0 percent or more 9,510 248,229 34.6 36.6 Not computed 1,602 51,579 5.8 7.6 Source: American Community Survey, 2006 St. Joseph County Epidemiological & Outcomes Workgroup 32

End Notes 4 Source: U.S. Census Bureau, 2006 American Community Survey. NOTE. Although the American Community Survey (ACS) produces population, demographic and housing unit estimates, it is the Census Bureau's Population Estimates Program that produces and disseminates the official estimates of the population for the Nation, states, counties, cities and towns and estimates of housing units for states and counties. For more information on confidentiality protection, sampling error, non-sampling error, and definitions, see Survey Methodology. 5 These income sources are not mutually exclusive; that is, some households received income from more than one source. St. Joseph County Epidemiological & Outcomes Workgroup 33

2. Cocaine Use in St. Joseph County: CONSUMPTION PATTERNS AND CONSEQUENCES Cocaine is a powerfully addictive stimulant drug. The powdered, hydrochloride salt form of cocaine can be snorted or dissolved in water and injected. Crack is cocaine that has not been neutralized by an acid to make the hydrochloride salt. This form of cocaine comes in a rock crystal that can be heated and its vapors smoked. The term "crack" refers to the crackling sound heard when it is heated.* Regardless of how cocaine is used or how frequently, a user can experience acute cardiovascular or cerebrovascular emergencies, such as a heart attack or stroke, which could result in sudden death. Cocaine-related deaths are often a result of cardiac arrest or seizure followed by respiratory arrest cocaine and alcohol manufactures a third substance, cocaethylene, that intensifies cocaine's euphoric effects, while potentially increasing the risk of sudden death. - National Institute on Drug Abuse 6 Indiana is an active drug transportation and distribution area. The northern part of Indiana lies on Lake Michigan, which is a major waterway within the St. Lawrence Seaway system providing international shipping for all sections of the Midwest. Seven interstate highway systems and 20 U.S. highways provide interstate and intrastate links for drug trafficking, especially with the southwest border and California. Highway (automobile and trucking) and airline trafficking are the primary means of drug importation, with busing systems as a secondary means. Mexican criminal groups are the primary wholesale distributors of marijuana, powdered cocaine, and methamphetamine within Indiana. Powdered cocaine is readily available throughout the State, and crack cocaine is primarily available within the urban areas. Most of the heavily populated areas continue to experience shootings and other acts of violence over drug debts. Mexican trafficking organizations distribute cocaine to Caucasian, African American, and other Hispanic groups. - DEA, Briefs and Background: Indiana 7 The distribution and abuse of cocaine (particularly crack) and, to a lesser extent, heroin pose the greatest threats to most urban areas within the [Great Lakes] region, while the abuse of methamphetamine and marijuana are typically the greatest drug threats in rural areas and smaller cities. Crack cocaine, heroin, and methamphetamine pose greater threats to public safety because these drugs are more addictive and are often associated with violent and property crime. Crack cocaine typically is reported as the greatest drug threat in metropolitan areas because of its widespread abuse and the violence attendant to its distribution. - National Drug Intelligence Center, National Drug Threat Assessment, 2008 8 Consumption Prevalence: General Consumption Patterns The National Survey on Drug Use and Health (NSDUH) data for the U.S. for 2006 show that over 6.0 million individuals aged 12 and older used cocaine within the past year, up about 7 percent from 2004 (5.6 million) and 2005 (5.5 million users) and at a rate higher than for all other illegal drugs except marijuana. (Table 2.1) In 2006, there were 977,000 persons aged 12 or older who had used cocaine for the first time within the past 12 months; this averages to approximately 2,700 initiates per day. This estimate was not significantly different from the number in 2004 or 2005. Two out of every three of the 1 million recent cocaine initiates were 18 or older when they first used. The average age of first use among recent initiates aged 12 to 49 was 20.3 years - slightly higher than the average age in 2005. St. Joseph County Epidemiological & Outcomes Workgroup 34

Age, Race, and Gender. The percentage of youth ages 12 to 17 reporting lifetime use of cocaine was 2.4 percent in 2004. Among young adults aged 18 to 25, the rate was 15.2 percent, showing no significant difference from the previous year. Past month crack use was down for 16- or 17-year-olds but up for 21- to 25-yearolds; 21-year-olds also showed increases in past year use of both crack and cocaine. Past month use of cocaine was down among females aged 12 17 and Asians 12 or older, but up among Blacks aged 18 to 25. There was a decrease in past year cocaine use measured among Asians aged 18 to 25. Indiana. In comparison to U.S. figures and over the years 2002-2005, Indiana shows similar and declining prevalence rates overall, but higher and increasing proportions for those ages 18-25. (Table 2.2). Past year cocaine use was slightly lower in Indiana and the North Central Region than the Nation in the years 2002-2004. (Table 2.3) 9 Past year use of cocaine was lower during the 1999-2001 years compared to the years 2002-2004. The percent of past cocaine users in the North Central Indiana Region was lower than either the State or Nation for the 12-17 age group as well as those 26 and older. The proportion in the years 18-25 were higher in the North Central Region of the State compared to Indiana as a whole but not higher than the U.S. (Table 2.4) All three areas showed an increase in the percentage of past year cocaine users for the years 2002-2004. This time, in a reversal of prior status, the North Central age group 12-17 showed the highest proportion of users while the other two were lower than the State or Nation. (Table 2.4) St. Joseph County Epidemiological & Outcomes Workgroup 35

Figure 2-A: Indiana Substate Regions St. Joseph County Epidemiological & Outcomes Workgroup 36