Tobacco Surveillance in the United States Gary Giovino Roswell Park Cancer Institute National Conference on Tobacco OR Health San Francisco, California November 20, 2002
Outline of Presentation Public health surveillance Tobacco surveillance Conceptual models Historical, current, and emerging systems Data Key areas for surveillance
Public Health Surveillance Definition The ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and improve health. Data disseminated by a public health surveillance system can be used for immediate public health action, program and policy planning and evaluation, and formulating and testing research hypotheses. Adapted from: CDC. Updated Guidelines for Evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50(No. RR-13),page 2.
Evolution of Surveillance in the 20th Century 1900s Individual contacts of infected persons 1950s Communicable diseases 1970s Selected chronic diseases 1950s-present Behavioral, occupational, and environmental risk factors Source: Remington and Goodman, Chronic Disease Surveillance, in Brownson et al. (eds), Chronic Disease Epidemiology and Surveillance, 1998
Organizational Model for State-Based Chronic Disease Surveillance Programs Data Interpretation Program Evaluation Data Analysis Information Dissemination Program Implementation Data Collection Program Planning Source: Remington and Goodman; Chronic Disease Epidemiology and Surveillance, 1999
Purposes of a Tobacco-Related Surveillance System To provide timely information from populations on: prevalence of use of various products (tobacco and pharmaceutical) factors that influence their use incidence, prevalence, and mortality from tobacco-attributable diseases impact of tobacco control programs and policies on relevant outcomes
Uses of Tobacco Surveillance Data Learn about nature of the problem Justify policies, programs, and legislation Monitor and evaluate these Set realistic objectives Identify high risk groups Justify research initiatives Conduct research
Tobacco Control Model of Nicotine Addiction Environment Familial, Social, Cultural, Political, Economic, Historical, Media Vector Tobacco Product Manufacturers; Other Users Tobacco Products Agent Host Smoker/Chewer Incidental Host Involuntary Smoker Source: Orleans & Slade, 1993
Conceptual Model of Factors Influencing Trends in Adolescent Smoking United States, 1975-2001 PERCENT 45 40 35 30 25 20 15 10 5 0 1975 1977 1979 1981 198319851987198919911993 1995 1997 1999 2001 YEAR Data Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys
Major Sources of Data on Tobacco Use in the United States Consumption Data U.S. Department of Agriculture (USDA) Federal Trade Commission (FTC) State-specific data
Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 1900-2001 Number of Cigarettes 5000 4000 3000 2000 1000 1 st Surgeon General s Report End of WW II 1 st Smoking-Cancer Concern 1 st World Conference on Smoking and Health Broadcast Ad Ban Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins 1 st Great American Smoke-out Surgeon General s Report on ETS Federal Cigarette Tax Doubles OTC Nicotine Medications Master Settlement Agreement Great Depression 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 YEAR Source: United States Department of Agriculture
Trends in Per Capita Consumption of Various Tobacco Products United States, 1880-2001 16 14 Cigarettes Cigars Pipe/Roll your own Chewing Snuff 12 POUNDS 10 8 6 4 2 0 1880 1885 1890 1895 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 YEAR Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons >18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.
Domestic Market Share of Cigarettes by Tar Yield, Filter Status, Length, and Menthol Status: United States, 1963-2000 Percent 100 90 80 70 60 50 40 30 20 10 Filter 0 1945 1965 1985 Year <15 mg. tar yield Menthol > 94 mm. Source: United States Department of Agriculture, 1962; Federal Trade Commission, 2001
Major Sources of Data on Tobacco Use in the United States Surveys of Young People Teenage Tobacco Surveys Monitoring the Future Surveys (MTFS) National Household Survey on Drug Abuse (NHSDA) National Health and Nutrition Examination Survey (NHANES) Youth Risk Behavior Surveillance System (YRBSS) National Youth Tobacco Survey (NYTS) Youth Tobacco Survey (YTS) Global Youth Tobacco Survey (GYTS) Legacy Media Tacking Surveys
Current Use Among Middle and High School Students by Type of Tobacco Product National Youth Tobacco Survey, 2000 35 30 34.5 28.0 Middle School High School PERCENT 25 20 15 10 5 0 15.1 14.8 11.0 6.6 7.1 3.6 3.0 3.3 4.1 4.2 2.4 2.1 Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks Note: Used tobacco on ³ 1 of the 30 days preceding the survey Source: American Legacy Foundation, National Youth Tobacco Survey
Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School United States, 1975-2001 PERCENT 45 40 35 30 25 20 15 10 5 0 12 th Grade 10 th Grade 8 th Grade 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 YEAR 29.5% in 2001 21.3% in 2001 12.2% in 2001 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys
Major Sources of Data on Tobacco Use in the United States Surveys of Adults Current Population Surveys (CPS) Adult Use of Tobacco Surveys (AUTS); Adult Tobacco Surveys (ATS) National Health Interview Survey (NHIS) National Household Survey on Drug Abuse (NHSDA) National Health and Nutrition Examination Survey (NHANES) Behavioral Risk Factor Surveillance System (BRFSS) American Smoking and Health Survey (ASHES)
Trends in cigarette smoking* among adults aged >18 years, by sex - United States, 1955-2002 60 % CURRENT SMOKERS 50 40 30 20 10 Men Women 24.5% 18.8% 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 YEAR *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days. Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only
Current Use Among U.S. Adults of Various Tobacco Products, by Sex National Health Interview Survey, 2000 PERCENT 35 30 25 20 15 10 5 0 31.3 21.3 25.7 21.0 4.5 0.2 1.0 Any Use Cigarettes Cigars Pipes Snuff Chewing Tobacco 0.1 2.5 0.2 2.5 Males Females 0.1 0.1 0.1 Bidis Note: Current users report using either every day or on some days Source: National Center for Health Statistics
N H S D A ( 1 2-1 7 ) N H S D A ( 8, 1 0, 1 2 ) M T F ( 8, 1 0, 1 2 ) Y R B S ( 9-1 2 ) Cigarette Use Trends Among Youths: NHSDA, MTF, and YRBS 40 35 Percent Using in Past Month 1999 2001 34.8 30 25 20 15 14.9 13.0 21.1 17.5 25.9 21.0 28.5 10 5 0 NHSDA (Ages 12 to 17) -15% -17% -19% -18% NHSDA (Grades 8,10,12) MTF (Grades 8,10,12) YRBS (Grades 9 to 12)
Comparison of Current Cigarette Use Prevalences from NHSDA, MTF, and YRBS, by Grade: 1999 and 2001 Averages Percent Using in Past Month 45 40 35 30 25 20 15 10 5 0 30.6 32.1 39.0 19.2 23.5 30.8 8.2 14.9 NHSDA MTF YRBS NHSDA MTF 1 2 t h G r a d e NHSDA MTF 1 0 t h G r a d e YRBS 8 t h G r a d e 12 th Grade 10 th Grade 8 th Grade
Potential Reasons for Differences in Survey Estimates Setting Questionnaire content Sample design Perception that biochemical validation might occur Response rates Mode of Administration Definitions used Editing procedures Consent procedures
Major Sources of Legislative Data on Tobacco Issues in the United States Legislation Americans for Nonsmokers Rights (ANR) State Cancer Legislative Data Base (SCLD) State Legislated Actions on Tobacco Issues (SLATI) State Tobacco Activities Tracking and Evaluation System (STATE)
Restrictiveness Of State Laws Regulating Smoking In Public Places U.S., 1960-2001 NUMBER OF STATES 55 50 45 40 35 30 25 20 15 10 5 0 1960 1964 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 Extensive Moderate Basic Nominal YEAR Sources: 1989 Surgeon General s Report, ALA s SLATI, CDC s STATE system, Roswell Park Cancer Institute. Note: Includes the District of Columbia; Alabama = only state with no restrictions on public smoking.
Number of U.S. States including D.C.*, with Legislation Restricting the Purchase of Cigarettes to Persons aged >18 years, 1988-2001 50 # of States 40 30 20 10 10 14 14 18 21 24 26 27 29 32 33 36 36 37 0 1988 1989 *District of Columbia 1990 1991 1992 1993 1994 1995 Year Source: State Legislated Actions On Tobacco Issues, 1988-2001, CDC s STATE system, Roswell Park Cancer Institute. 1996 1997 1998 1999 2000 2001
Emerging Systems Bridging the Gap Assessing Youth Smoking Cessation Needs and Practices Survey Beliefs About Nicotine Dependence (BAND) survey International Tobacco Control (ITC) Policy Study
Emerging Issues CDC lab and NCI resources to better characterize the product. Massachusetts regulation. California and other systems to monitor vector. Often involves proprietary data. Environmental monitoring - legislation, media, price. Often involve proprietary data.
Key Areas for Surveillance Evaluating Tobacco Control Programs in a Multi-variate World Surveillance for Tobacco Harm Reduction Understanding Natural Histories Understanding Trends
Lessons Learned Why? is inevitable Timeliness matters Analyses and reporting takes time and resources Categorical surveys are needed Relationships count