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