Tobacco Surveillance in the United States
National Conference on Tobacco OR HealthBoston, Massachusetts
December 10, 2003
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
Epidemiologic Model of Tobacco Addiction and Control
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
1975197719791981 198319851987 1989 1991 1993 1995199719992001YEAR
PER
CE
NT
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, 1900-2002
0
1000
2000
3000
4000
5000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000YEAR
Num
ber
of 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
cent
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• 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 surveySource: 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 4.12.12.4
4.2
Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School
– United States, 1975-2002
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
Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys
12th Grade
8th Grade
10th Grade
26.7% in 2002
17.7% in 2002
10.7% in 2002
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
*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.
25.2%
20.0%
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
MalesFemales
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 1.00.1
2.50.1 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 AveragesPercent Using in Past Month
30.6
19.2
8.2
32.1
23.5
14.9
39.0
30.8
05
1015202530354045
1 2 t h G r a d e 1 0 t h G r a d e 8 t h G r a d e
NHSDA MTF YRBS NHSDA MTFNHSDA MTF YRBS
12th Grade 8th Grade10th Grade
Potential Reasons for Differences in Survey Estimates
• Setting• Mode of Administration• Questionnaire content• Definitions used • Sample design• Editing procedures• Perception about biochemical validation• Consent procedures• 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)
• ImpacTeen/Roswell Park Cancer Institute
0
5
10
15
20
25
30
35
40
45
5019
60
1964
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
YEAR
NU
MB
ER
OF
ST
AT
ES
ExtensiveModerateBasicNominal
Restrictiveness Of State Laws Regulating Smoking In Public Places – U.S., 1960-2003*
Sources: 1989 Surgeon General’s Report, ALA’s SLATI, CDC’s STATE system, MayaTech Corporation, Roswell Park Cancer Institute. Note: Includes the District of Columbia;
* 2003 data are represented for the first three quarters of the year.
Smoke-Free Air Legislation in the 50 States and the District of Columbia -- United States, 1991-2003
Sources: ALA’s SLATI, CDC’s STATE system, the MayaTech Corp., and the Roswell Park Cancer Institute.
0
5
10
15
20
25
30
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003YEAR
NU
MB
ER
OF
ST
AT
ES
Priv WS, restaurants, & bars S-FRestaurants & bars S-FPrivate WS & restaurants S-FPrivate worksites smoke freeRestaurants smoke free2+ sites smoke free1 site smoke free
1415 15
18 19 19 2021
2425 26
2729
0
0.5
1
1.5
2
2.5
3
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Pos
sess
ion,
Use
, and
Pur
chas
e In
dex
(Mea
n)
Mean Number of Possession, Use, and Purchase Laws per State* -- United States, 1988-2003**
Mean Number of Possession, Use, and Purchase Laws per State* -- United States, 1988-2003**
*Includes the District of Columbia; Theoretical Range = 0-3; Includes 1st quarter of 2003 only.
**Sources: ALA’s SLATI, CDC’s STATE system, the MayaTech Corporation, and the Roswell Park Cancer Institute.
Emerging Systems
• Bridging the Gap
• National Youth Smoking Cessation Survey
• Beliefs About Nicotine Dependence (BAND) survey
• International Tobacco Control (ITC) Policy Evaluation Survey
Emerging Issues
• CDC lab and NCI resources to better characterize the product.
• 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 take time and resources
• Categorical surveys are needed • Relationships count
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