Tobacco Surveillance in the United States

National Conference on Tobacco OR HealthSan Francisco, California

November 20, 2002

Gary Giovino

Roswell Park Cancer Institute

Outline of Presentation

• Public health surveillance• Tobacco surveillance• Conceptual models• Historical, current, and emerging systems• Data• Key areas for surveillance

Public Health Surveillance

DefinitionThe 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

Information Dissemination

Program Evaluation

Program Implementation

Program Planning

Data Interpretation

Data Collection

Data Analysis

Source: Remington and Goodman; Chronic Disease Epidemiology and Surveillance, 1999

Organizational Model for State-Based Chronic Disease Surveillance Programs

Purposes of a Tobacco-Related Surveillance System

• 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

To provide timely information from populations on:

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

Agent

Vector Host

Tobacco Products

Tobacco Product Manufacturers;

Other Users

Smoker/ChewerIncidental Host

EnvironmentFamilial, Social,

Cultural, Political, Economic, Historical,

Media

Involuntary Smoker

Source: Orleans & Slade, 1993

Conceptual Model of Factors Influencing Trends in Adolescent

Smoking – United States, 1975-2001

0

5

10

15

20

25

30

35

40

45

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001YEAR

PE

RC

EN

T

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

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000YEAR

Nu

mb

er o

f C

igar

ette

s

Source: United States Department of Agriculture

End of WW II

1st Smoking-Cancer Concern

Fairness Doctrine Messages on TV

and Radio

Non-Smokers Rights Movement

Begins

Federal Cigarette Tax Doubles

Surgeon General’s Report on ETS

1st Surgeon General’s

Report

1st World Conference on Smoking and Health

Broadcast Ad Ban

1st Great American Smoke-out

OTC Nicotine Medications

Master Settlement Agreement

Great Depression

Trends in Per Capita Consumption of Various Tobacco Products – United

States, 1880-2001

Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. CensusNote: Among persons >18 years old.

Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.

0

2

4

6

8

10

12

14

16

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

PO

UN

DS

Cigarettes Cigars Pipe/Roll your own Chewing Snuff

Domestic Market Share of Cigarettes by Tar Yield, Filter Status, Length, and Menthol Status: United

States, 1963 - 2000

0

10

20

30

40

50

60

70

80

90

100

1945 1965 1985

Year

Per

cen

t

Source: United States Department of Agriculture, 1962; Federal Trade Commission, 2001

Filter

<15 mg. tar yield

> 94 mm.

Menthol

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

0

5

10

15

20

25

30

35

Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks

PE

RC

EN

T

Middle SchoolHigh School

Note: Used tobacco on ³ 1 of the 30 days preceding the survey Source: American Legacy Foundation, National Youth Tobacco Survey

15.1

34.5

11.0

28.0

7.1

14.8

3.6

6.6

3.0 3.3

4.1

2.12.44.2

Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School

– United States, 1975-2001

0

5

10

15

20

25

30

35

40

45

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

12th Grade

8th Grade

10th Grade

29.5% in 2001

21.3% in 2001

12.2% in 2001

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)

Men

Women

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

YEAR

% C

UR

RE

NT

SM

OK

ER

STrends in cigarette smoking* among adults aged

>18 years, by sex - United States, 1955-2002

Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only

*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.

24.5%

18.8%

Current Use Among U.S. Adults of Various Tobacco Products, by Sex – National Health

Interview Survey, 2000

0

5

10

15

20

25

30

35

Any Use Cigarettes Cigars Pipes Snuff ChewingTobacco

Bidis

PE

RC

EN

T

Males

Females

Note: Current users report using either every day or on some days Source: National Center for Health Statistics

31.3

21.3

25.7

21.0

4.5

0.2 1.0 0.1

2.5 0.1 0.1

2.50.10.2

-15% -17% -19% -18%

14.9

21.1

25.9

34.8

13.0

17.5

21.0

28.5

0

5

10

15

20

25

30

35

40

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

Percent Using in Past Month

1999 2001

NHSDA(Ages 12 to 17)

YRBS(Grades 9 to 12)

MTF(Grades 8,10,12)

NHSDA(Grades 8,10,12)

Comparison of Current Cigarette Use Prevalences from NHSDA, MTF, and YRBS,

by Grade: 1999 and 2001 Averages

Percent Using in Past Month

NHSDA MTF YRBS NHSDA MTFNHSDA MTF YRBS

12th Grade 8th Grade10th Grade

Potential Reasons for Differences in Survey Estimates

• Setting Mode of Administration• Questionnaire Definitions used

content• Sample design Editing procedures• Perception that Consent procedures

biochemical validation might

occur• Response rates

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)

0

5

10

15

20

25

30

35

40

45

50

5519

60

1964

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

YEAR

NU

MB

ER

OF

ST

AT

ES

ExtensiveModerateBasicNominal

Restrictiveness Of State Laws Regulating Smoking

In Public Places – U.S., 1960-2001

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

1014 14

1821

24 26 27 2932 33

36 36 37

0

10

20

30

40

50

Year

# of

Sta

tes

*District of Columbia

Source: “State Legislated Actions On Tobacco Issues”, 1988-2001, CDC’s STATE system, Roswell Park Cancer Institute.

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