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Secondhand smoke (SHS) causes immediate and long-term adverse health effects in nonsmoking adults and children, including heart disease and lung cancer, and SHS exposure occurs primarily in homes and workplaces (1). Smoke-free policies, including not allowing smoking anywhere inside the home (i.e., having a smoke-free home rule), are the best way to provide protection from exposure to SHS. To assess SHS exposure in homes and indoor workplaces and the prevalence of smoke-free home rules, CDC analyzed 2008 Behavioral Risk Factor Surveillance System (BRFSS) data from 11 states and the U.S. Virgin Islands (USVI). This report summarizes the results, which showed wide variation among states in exposure to SHS in homes (from 3.2% [Arizona] to 10.6% [West Virginia]) and indoor workplaces (from 6.0% [Tennessee] to 17.3% [USVI]). The majority of persons surveyed in the 11 states and USVI reported having smoke-free home rules (from 68.8% [West Virginia] to 85.7% [USVI]). This report also provides the 2008 results for CDC's annual BRFSS-based state-specific estimates of current smoking in 50 states, the District of Columbia (DC), and three territories (Guam, Puerto Rico, and USVI). As in previous years, the results showed substantial variation in self-reported cigarette smoking prevalence (range: 6.5%--27.4%; median for 50 states and DC = 18.4%). Additional legislation is needed to increase the number of smoke-free workplaces and other public places. Health-care providers should continue to encourage persons to make their homes completely smoke-free.
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Chronic obstructive pulmonary disease (COPD) is becoming a global public health problem and an economic burden. The World Health Organization estimates that, by 2030, COPD will be the third leading cause of death worldwide (1). The Global Initiative for Chronic Obstructive Lung Disease, in collaboration with health-care professionals and COPD patient groups throughout the world, is sponsoring World COPD Day on November 18, 2009. The aim of World COPD Day is to raise awareness about COPD and improve COPD care throughout the world.
Tobacco smoking is the most important risk factor for the development and progression of COPD.
Cigarette smoking rose slightly for the first time in almost 15 years, dashing health officials' hopes that the U.S. smoking rate had moved permanently below 20 percent.
A little under 21 percent of U.S. adults said they smoked, according to a 2008 national survey by the U.S. Centers for Disease Control and Prevention. That's up slightly from the year before, when just 19.8 percent said they were smokers. It also is the first increase in adult smoking since 1994, experts noted.
The increase was so small, it could be just a blip, so health officials and experts say smoking prevalence is flat, not rising. But they are unhappy.
"Clearly, we've hit a wall in reducing adult smoking," said Vince Willmore, spokesman for the Campaign for Tobacco-Free Kids, a Washington, D.C.- based research and advocacy organization.
There's a general perception that smoking is a fading public health danger. Feeding that perception are indoor smoking laws, cigarette taxes and Congress' recent decision to allow the Food and Drug Administration to regulate tobacco.
But health officials believe gains have been undermined by cuts in state tobacco control campaigns. Some advocates believe tobacco companies are overcoming increasing obstacles. . . .
Many of the states that have the lowest smoking rates are those that have been the most aggressive about indoor smoking laws and about state taxes that drive up the cost of cigarettes, said Dr. Thomas Frieden, the CDC's director.
While the CDC said this increase was not statistically significant, it is the first increase in the adult smoking rate since 1994.
There is no question that we know how to significantly reduce tobacco use, as demonstrated by sharp reductions in adult smoking over the past several decades and a remarkable 45 percent reduction in high school smoking since 1997 (from a peak of 36.4 percent to 20 percent in 2007). But it is also clear from the recent stall in progress that elected officials at all levels must redouble efforts to implement scientifically proven strategies that prevent kids from smoking, help smokers quit and protect everyone from secondhand smoke. The challenge today is to resist complacency and finally fight tobacco use with the political will and the resources that match the scope of the problem.
Congress and President Obama have taken major strides this year by approving a 62-cent increase in the federal cigarette tax and enacting the new law granting the U.S. Food and Drug Administration (FDA) authority to regulate tobacco products and marketing. The 2008 data released today does not reflect the impact of the federal cigarette tax increase, which took effect on April 1 of this year. There is evidence that the cigarette tax increase has already had a significant impact. Cigarette manufacturers reported a 10 percent decline in cigarette sales in the third quarter of this year, and calls by smokers to smoking cessation quitlines increased dramatically following the tax increase.
However, there is much more that must be done at all levels of government
Cigarette smoking continues to be the leading cause of preventable morbidity and mortality in the United States (1). Full implementation of population-based strategies (2) and clinical interventions can educate adult smokers about the dangers of tobacco use and assist them in quitting (3,4). To assess progress toward the Healthy People 2010 objective of reducing the prevalence of cigarette smoking among adults to <12% (objective 27-1a) (5), CDC analyzed data from the 2008 National Health Interview Survey (NHIS). This report summarizes the results of that analysis, which indicated that during 1998--2008, the proportion of U.S. adults who were current cigarette smokers declined 3.5% (from 24.1% to 20.6%). However, the proportion did not change significantly from 2007 (19.8%) to 2008 (20.6%). In 2008, adults aged ≥25 years with low educational attainment had the highest prevalence of smoking (41.3% among persons with a General Educational Development certificate [GED] and 27.5% among persons with less than a high school diploma, compared with 5.7% among those with a graduate degree). Adults with education levels at or below the equivalent of a high school diploma, who comprise approximately half of current smokers, had the lowest quit ratios (2008 range: 39.9% to 48.8%). Evidence-based programs known to be effective at reducing smoking should be intensified among groups with lower education, and health-care providers should take education level into account when communicating about smoking hazards and cessation to these patients. . . .
Although comprehensive tobacco control programs have been effective in decreasing tobacco use in the United States, they remain underfunded. . . .
Effective population-based strategies for preventing tobacco use and encouraging tobacco use cessation (including enforcing bans on advertisement) are outlined in the World Health Organization's MPOWER package.� Despite partial bans on some forms of advertisement, the tobacco industry continues to conduct targeted marketing toward socially disadvantaged subgroups and vulnerable populations, such as persons with low socioeconomic status and youths (10).
Offering and providing effective cessation counseling and treatments are integral to reducing the smoking epidemic, especially in subpopulations with high rates of smoking. Because persons with lower educational attainment generally have higher rates of smoking, are less likely to quit, and have less knowledge about the health effects of smoking but are interested in quitting, health-care providers should take education level into account when communicating with such patients (3,4).
Today Thailand became the first of fourteen countries to release final results from the Global Adult Tobacco Survey (GATS). Many countries conduct surveys to monitor adult tobacco use, but until recently, no one standard global survey for adults has consistently tracked tobacco use, exposure to second-hand tobacco smoke, and tobacco control measures. . . .
Thirteen countries besides Thailand participated in the first round of GATS: Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Turkey, Ukraine, Uruguay and Vietnam. Results from the Global Adult Tobacco Survey will help Thailand, and the other participating countries that will soon be releasing results, translate its data into action through improved policies and programs.
More people die from lung cancer than any other type of cancer. In 2004,* lung cancer accounted for more deaths than breast, prostate, and colon cancer combined. The most important thing you can do to prevent lung cancer is to not start smoking or to quit if you currently smoke.
In 2004,*
* 108,355 men and 87,897 women were diagnosed with lung cancer.†
* 89,575 men and 68,431 women died from lung cancer.†
Smoking and Secondhand Smoke
The prevalence of tobacco use among adults in the United States has been reduced by half since the 1960s (1,2). Despite this progress, low-income populations, such as Medicaid enrollees, continue to smoke at substantially higher rates than the general population (33% versus 20%) (1). The Public Health Service's Clinical Practice Guideline (2) and the Partnership for Prevention's Call for ACTTION (3) recommend comprehensive insurance coverage of tobacco-dependence treatments without barriers such as copayments, limitations in duration of treatment, prior authorization, and stepped-care therapy. Healthy People 2010 aims to expand coverage of evidence-based treatments for nicotine dependency to all 51 Medicaid programs (objective 27-8b) (4). To monitor progress toward that objective, in 2007, the Center for Health and Public Policy Studies at the University of California, Berkeley, surveyed all 51 Medicaid programs. This report summarizes the results of that survey, which found that 43 (84%) programs offered coverage for some form of tobacco-dependence treatment to Medicaid enrollees in traditional fee-for-service (FFS) Medicaid, with four Medicaid programs adding coverage since 2006 and 20 programs adding coverage in the past decade. Only two states (New Mexico and New Jersey) reported access to tobacco-dependence treatments without any limitations or restrictions. Of the 25 states covering pharmacotherapy for Medicaid enrollees in both FFS and managed-care organizations (MCOs), only 13 covered the same tobacco-dependence treatments for enrollees in both populations. Research demonstrates that providing access to comprehensive tobacco-dependence treatments increases quit rates. Providing Medicaid coverage for these treatments would ensure that all enrollees can access and benefit from these treatments.
Acute Myocardial Infarction Hospitalization Statistics: Apparent Decline Accompanying an Increase in Smoke-free Areas. Villalbi, J.R.; Castillo, A.; Cleries, M.; Salto, E.; Sanchez, E.; Martinez, R.; Tresserras, R.; Vela, E. Revista Espanola de Cardiologia. July 2009, 62(7): 812-815. Abstract Abstract at the National Library of Medicine Are Nicotine Replacement Therapy, Varenicline or Bupropion Options for Pregnant Mothers to Quit Smoking? Effects on the Respiratory System of the Offspring.
A Before-After Implementation Trial of Smoking Cessation Guidelines in Hospitalized Veterans.
Katz, D.A.; Vander Weg, M.; Fu, S.; Prochazka, A.; Grant, K.M.; Buchanan, L.; Tinkelman, D.; Reisinger, H.S.; Brooks, J.; Hillis, S.L.; Joseph, A.M.; Titler, M.
Implementation Science. September 10, 2009, 4(58): [Epub ahead of print].
Abstract Abstract at the National Library of Medicine
Complete Article: http://www.implementationscience.com/content/pdf/1748-5908-4-58.pdf
A Cross Sectional Study on Levels of Secondhand Smoke in Restaurants and Bars in Five Cities in China.
Alcohol-induced Increases in Smoking Behavior for Nicotinized and Denicotinized Cigarettes in Men and Women.
King, A.; McNamara, P.; Conrad, M.; Cao, D.
Psychopharmacology. September 16, 2009, [Epub ahead of print].
Anti-PGP or Anti-elastin Autoantibodies Are Not Evident in Chronic Inflammatory Lung Disease.
Greene, C.M.; Low, T.B.; O'Neill, S.J.; McElvaney, N.G.
American Journal of Respiratory and Critical Care Medicine. September 17, 2009, [Epub ahead of print].
Are Obstetricians Following Best-practice Guidelines for Addressing Pregnancy Smoking? Results From Northeast Tennessee.
Results: Around 50.3% of the increase from the un-lagged SAM estimate of 3859 deaths to the final SAM estimate of 8664 deaths in 2003 is attributable to the introduction of lag times. More robust estimates of risk accounted for a further 29.6% of the increase. While 21.2% is attributable to the inclusion of additional disease categories, only 1.5% was attributable to the widening of existing diseases categories.
Conclusion: This difference in estimates is attributable to expansion of the list of diseases included, updating the estimates of RR for smoking-attributable death, and the use of smoking prevalence from previous years to more accurately reflect the effect of tobacco use on disease occurrence. There is a need to establish an 'authority' to implement a multi-faceted intervention strategy to decrease the considerable burden from smoking in Israel.
When I directed the CDC's Office on Smoking and Health, we wanted to learn how to use marketing techniques to keep kids from starting to smoke and convened an expert panel of teen marketing experts from the private sector.
Experts from companies like Adidas, Levi-Straus, and Proctor and Gamble -- companies that sell products to teens -- advised us that if we wanted to be successful in competing with the tobacco industry's multibillion-dollar effort to get people to smoke, we needed to do more than educate teens on the harm of smoking, and rather create a "brand" . . .
This "brand" became known as the "Truth Campaign" . . .
The tobacco industry hates the truth and hates counter-marketing campaigns that tell the truth. Why? Because it works. Given the tobacco industry has recently been found guilty in a federal district court of racketeering and perpetuating a fraud on the American people, upheld in a May federal appeals court decision, it seems to be that there is a need for more "truth" and not less.
Statistical analysis that I've conducted shows that there is a very tenuous link between cigarette sales and state anti-tobacco spending. At best, spending large amounts of money on anti-tobacco programs seems to produce a trivial drop in cigarette sales -- less than a pack a year per capita. States would be better advised to put these resources toward other public health policies that produce larger results. . . .
The CDC is now arguing that state anti-tobacco programs are underfunded. Tobacco-control advocates -- many of whom receive money through these programs -- repeat the CDC under-funding claims when pleading their cases for spending increases. It will be truly unfortunate if states simply accept these claims and increase funding without investigating the programs' effectiveness. However difficult it is to look beyond noble intentions, appraisal of a program's effectiveness is vital -- particularly in these tight fiscal times -- if we truly want to improve public health effectively.
CONCLUSIONS
Empirical evidence does not generally support the cdc claim that states that spend more on tobacco control deter more tobacco use than states that spend less. Contemporaneous spending on tobacco control is never found to exert an inverse effect on sales, and at times is found to exert a significant and positive effect on sales, contrary to the claims of the cdc. The true effect, however, appears to be zero based on current and past spending discounted at various rates. There is limited support for cdc claims regarding its recommendations on funding adequacy when this spending measure is discounted at rates of 5 and 10 percent, but not at rates of 15 and 20 percent. When significant, however, these effects arise at fairly low levels of confidence and with trivial effects on cigarette sales, and therefore suggest very cautious support for the cdc recommendations concerning adequacy. These conclusions are based on a battery of tests that consider various measures of contemporaneous and past spending and adequacy and are conducted over an eight-year period in which over $5 billion (in 2005 dollars), or roughly $18 per capita, was spent on tobacco control.
This study raises questions about the process by which the cdc determines its spending recommendations and whether the process is designed to reach a particular conclusion about tobacco control policy rather than to uncover policies that may best allocate resources toward controlling tobacco use. There may be a similarity to what I noted in a 2008 Econ Journal Watch paper on why the cdc and various researchers conclude that indoor smoking bans exert either positive or no adverse economic effects on restaurants and bars when, in fact, published studies demonstrate that numbers of businesses harmed are not zero. Factors include biases by governments and researchers that favor government solutions to perceived smoking problems, ample funding for researchers that conclude that bans exert no economic harm, simply ignoring industry funded research that indicates some degree of harm, and tacit agreement between many researchers to not openly scrutinize the quality of colleagues’ published research on this topic. It would be interesting to explore whether any of those factors might be influencing the policy process whereby the cdc makes spending recommendations regarding tobacco control. Those factors might also explain why the cdc is not compelled to demonstrate the effectiveness of its recommendations.