The Epidemiology of Tobacco Use among Populations with Low Socioeconomic Status

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1 The Epidemiology of Tobacco Use among Populations with Low Socioeconomic Status Shanta R. Dube, PhD, MPH Lead Health Scientist Team Lead, Surveillance Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

2 Outline of Presentation Epidemiological data on tobacco use in low SES populations Epidemiology of tobacco use among youth Implications for surveillance and evaluation at the state and local levels

3 About 443,000 U.S. Deaths per Year Attributable to Cigarette Smoking Other diagnoses 44,000 Stroke 15,900 Other cancers 35,500 Chronic Obstructive Pulmonary Disease 92,900 Lung cancer 128,900 Ischemic Heart Disease 126,000 Average annual number of deaths, Source: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses United States, MMWR 2008;57(45):

4 OSH PRIORITY AREAS ENHANCED SURVEILLANCE PRODUCT PRICING SMOKE-FREE POLICIES TOBACCO PRODUCTS AND FDA SUPPORT COUNTERMARKETING OFFICE ON SMOKING AND HEALTH

5 Epidemiological Evidence of the Protective Effects of Education Across the Lifespan Compared to persons with < high school diploma, those with > high school: Lower mortality rates (Health, United States, 2006, NCHS) Lower prevalence of poor self-rated health (MMWR Surveillance Summaries, Oct. 28, 2005) Lower rates of cardiovascular disease (CVD) (Prevalence of Heart Disease, United States Feb t 16, 2007 MMWR)

6 Trends in Current Cigarette Smoking Among Adults, National Health Interview Survey Adults Percent Year Adults: Total population adults who were current cigarette smokers. Source: National Health Interview Surveys,

7 Epidemiology of Adult Smoking in the U.S. Current smoking among all adults in million adults = 19.3% of population (21.5% of men and 17.3% of women) By Race/Ethnicity: Highest among American Indians/Alaska Natives (31.4%); non-hispanic whites (21.0%); non-hispanic blacks (20.6%). By Age: Adults years (22.0%) and years (21.1%) had the highest prevalence amongst all age groups. By SES: Smoking prevalence decreased with increasing education and was higher among adults living below the poverty level (28.9%) compared to those living at or above poverty level (18.3%). ) Source: CDC. MMWR: Vital Signs: Current Cigarette Smoking Among Adults Aged 18 Years --- United States, , September 6, 2011, 59 (Early Release) OFFICE ON SMOKING AND HEALTH Photo Courtesy of trinketsandtrash.org

8 Percentage of adults 25 years who were current smokers* by education, National Health Interview Survey, United States < High School Graduate High School Graduate Some College College Grad *For NHIS survey years , current smokers included adults who reported smoking >100 cigarettes in their lifetime and current smoking. For , current smokers included adults who reported smoking 100 cigarettes in their lifetime and specified they currently smoked "every day" or "some days." Data on education are presented for persons 25 years of age. Persons <25 years of age might not have completed college or graduate school.

9 Prevalence of Current Cigarette Use Among Adults 18 Years by Educational Status, National Health Interview Survey, United States * * 5.0 < High School GED High School Grad > High School Highest prevalence seen for persons with < HS and GED across time and has not change significantly among persons with < HS and GED Current cigarette use defined as smoking at least 100 cigarettes and now smokes every day or some days.

10 Prevalence of Any Tobacco Use Among Adults 18 Years by Educational Status, National Health Interview Survey, United States < High school GED 50.0 High School Graduate > High Sh School Percent (%) Year Overall 23% of U.S. population used any tobacco in 2010 Highest for persons with GED and < HS; No change over time for these groups Lowest for persons with > HS * Any tobacco use defined as current use of cigarettes, cigars or smokeless tobacco

11 Prevalence of Current Cigar Use and Current Smokeless Use Among Adults 18 Years by Educational Status-- National Interview Health Survey, United States, Highest prevalence of current cigar use and Smokeless us among persons with < HS Percent (%) 2.0 < High School GED 1.5 High School Graduate > High School Cigar Use 2010 Smokeless Use Current cigar use defined as persons who smoked 50 cigars in their lifetime and currently smoke cigars Current smokeless tobacco users reported using chewing tobacco or snuff >20 times in their lifetime and currently used chewing tobacco or snuff.

12 Percentage of adults 18 years who were current smokers* by poverty status, National Health Interview Survey, United States Below Poverty At/Above Poverty *For NHIS survey years , current smokers included adults who reported smoking >100 cigarettes in their lifetime and current smoking. For , current smokers included adults who reported smoking 100 cigarettes in their lifetime and specified they currently smoked "every day" or "some days." Based on self reported family income and poverty thresholds published by the US Census Bureau, (

13 Prevalence of Current Cigar Use by Poverty Status Among Adults 18 Years-- National Interview Health Survey, United States In 2000 and 2005 prevalence was very similar. Percent (%) At or above poverty However, in 2010, an increase was observed in persons below poverty 0.5 Below poverty Year

14 Prevalence of Current Smokeless Use by Poverty Status Among Adults 18 Years-- National Interview Health Survey, United States, Declines observed in both groups (%) Percent Above poverty level However, from 2005 to 2010, prevalence remained unchanged for persons at or below poverty At or below poverty level Year

15 Percentage of the nonsmoking population aged 3 years with serum cotinine levels ng/ml, by selected characteristics - -- National Health and Nutrition Examination Survey, United States, Reductions in secondhand BelowPoverty level 80 smoke exposure 71.6 At or above poverty level by poverty level observed over time. nt (%) Perce However, a higher proportions of nonsmokers living at or below poverty are exposed to secondhand smoke NHANES Year CDC. Vital Signs: Nonsmokers' Exposure to Secondhand Smoke --- United States, MMWR, September 10, 2010 / 59(35);

16 Current cigarette smoking prevalence among currently working adults aged 18 years, by selected characteristics --- National Health Interview Survey, Characteristic Currently working adults Current smoking prevalence Education Number in millions % 95% CI Less than high school diploma ( ) High school/ged ( ) Some college ( ) Bachelor, masters, or higher h degree ( ) Unknown ( ) Poverty status Poor ( ) Near poor ( ) Not poor ( ) Unknown ( ) Health insurance status Uninsured ( ) Insured ( ) Unknown ( ) CDC. Current Cigarette Smoking Prevalence Among Working Adults --- United States, September 30, 2011 / 60(38);

17 Current cigarette smoking prevalence among currently working adults aged 18 years, by Industry group --- National Health Interview Survey, Current cigarette smoking prevalence % (95% CI) Industry group g 3 ( ) By industry, age-adjusted cigarette smoking prevalence among working adults ranged from 9.7% in education services to 30.0% in mining. Mining 30.0 ( ) services to 30.0% in mining. Accommodation and food services 30.0 ( ) Construction 29.7 ( ) Administrative and support and waste 24.5 ( ) management and remediation services Transportation and warehousing 24.3 ( ) Real estate and rental and leasing 23.4 ( ) **For healthcare industry prevalence was 15.9% By occupation group, prevalence ranged from 8.7% in education, training, and library to 31.4% in construction and extraction. Manufacturing 23.2 ( ) CDC. Current Cigarette Smoking Prevalence Among Working Adults --- United States, 2004 Retail trade 23.1 ( ) September 30, 2011 / 60(38); Wholesale trade 22.0 ( )

18 PREVENTING INITIAION: Youth Smoking Adolescence is a period of human development marked by experimentation In the United States, approximately 3,900 young people between the ages of 12 and 17 years initiate cigarette smoking every day 4 An estimated 1,000 young people become daily cigarette smokers 4 Most (80%) of established smokers initiated during youth Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings, Office of Applied Studies, 2008 National Survey on Drug Use and Health.

19 Youth Smoking In 2009 among U.S. high school students: 46.3% of students reported ever smoking* cigarettes; highest among Hispanics (51.0%); Blacks (43.5%) and Whites (46.1%) % of students were current cigarette smokers**; approximately 19.0% of females and 20.0% of males % of white, 18.0% of Hispanic, and 9.5% of African American students were current cigarette smokers. 1 The rate of decline in youth smoking has slowed in recent years. 1 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2009 Surveillance Summaries, [June 4, 2010]. MMWR 2010;59(No. SS-5). * Ever smoking defined as ever tried smoking even one or two puffs **Curent cigarette smoking defined as having smoked during the past 30 days.

20 CIGARETTE SMOKING IN U.S. HIGH SCHOOLS YRBS initiated in 1991 NYTS initiated in 2000 In 1998, Master Settlement Agreement (MSA); reduced marketing and advertisement toward youth In 1995, OSH initiated media campaigns which led to formal and more effective youth tobacco prevention & cessation programs nationwide Source: Youth Risk Behavior Surveys (YRBS) and National Youth Tobacco Surveys (NYTS) OFFICE ON SMOKING AND HEALTH

21 Factors Associated with Youth Smoking Include: Low socioeconomic status Low levels of academic achievement Use and approval of tobacco use by peers or siblings Smoking by parents or guardians, Accessibility, availability and price of tobacco products Perception that tobacco use is normative Lack of skills to resist influences to tobacco use Low self-image or self-esteem OFFICE ON SMOKING AND HEALTH

22 Weighted Prevalence (95% CI) of Ever Smoking among Youth by Number of School Days Skipped, National a Survey on Drug Use and Health, cigarettes % Youth who ever smoked days 1 day 2 days Ever having smoked part or all of a cigarette was highest among students who had skipped school two to thirty days within the past month as compared to those who skipped only one day and those who did not skip at all. * Chi squares significant at p <.01

23 Adjusted odds ratios of Smoking Outcomes as a Function of Truancy, Monitoring the Future Truancy No truancy 1.0 referent 1.0 referent Current Smoking Overall 8 th 10 th 12th 1.0 referent 1.0 referent Low truancy 2.1*** 2.9*** 2.1*** 1.6*** Medium truancy 3.0*** 4.8*** 3.2*** 2.2*** High truancy 4.2*** 5.6*** 4.6*** 3.4*** Truancy Heavy Smoking Overall 8 th 10 th 12th No truancy 1.0 referent referent 1.0 referent referent Low truancy 1.7*** 2.7*** 1.8*** 1.3*** Medium truancy 2.6*** 4.5*** 3.0*** 1.9*** High truancy 5.0*** 9.7*** 5.8*** 3.5*** Compared to students who did not skip: Positive relationship between level of truancy and current smoking. Similar relationship for Heavy smoking Magnitude somewhat decreases across grades, but still strong and significant relationship for all grades. Models include: race, sex, grade,, family/social characteristics, school measures, geographic controls, and time.

24 School SES and Youth Smoking School characteristic and youth smoking Using Monitoring the Future data: High SES schools had lower rates of smoking among 8 th and 10 th graders compared to lower SES schools (O Malley et al., 2006). Among 8 th grade female students, t a statistically ti ti significant ifi association was found between low SES schools and female 30 day cigarette use (Wallace et al., 2009) Ui Using Nti National Longitudinal Study of Adolescent Health: Researchers identified private schools as statistically significant in protecting against the onset of youth smoking (Wen et al. 2009). O Malley P., Johnston L., Bachman J., Schulenberg J., Kumar R. (2006). How Substance Use Differs Among American Secondary Schools. Preventive Science, v. 7, pg Wallace J., Vaughn M., Bachman J., O Malley P., Johnston L., and Schulenberg J. (2009). Race/Ethnicity, Socioeconomic Factors, and Smoking Among Early Adolescent Girls in the United States. Drug and Alcohol Dependence, v. 104S, S42-S49. Wen M., Van Duker H., Olson L. (2009). Social Contexts of Regular Smoking in Adolescence: Towards a Multidimensional Ecological Model. Journal of Adolescence, v. 32, pg

25 Secondhand Smoke (SHS) Exposure and School Absenteeism Evidence that secondhand smoke exposure in the home is associated with excessive school absenteeism Children s Health Study: Youth 8-12 year olds with asthma who were exposed to SHS had higher odds of school absences than those not exposed to SHS. (RR = 2.35, CI 1.49, 3.71). 1 Dose response relationship between absences and the number of household smokers: as the number of household smokers increased, so did the number of school absences. 1 Among Hispanic youth there was a statistically significant association between being absent from school and exposure to SHS (OR = 2.29, CI = , 298) 2.98). 2 Recent study found that 24%-34% of school absences among 6-11 year olds could be prevented if there was no smoking in the household Gilliland F., Berhane K., Islam T., Wenten M., Rappaport E., Avol E., Gauderman J., McConnell R., and Peters J. (2003). Environmental Tobacco Smoke and Absenteeism Related to Respiratory Illness in Schoolchildren. American Journal of Epidemiology, v. 157, pg Freeman N., Schneider D., McGarvey P. (2003). Household Exposure Factors, Asthma, and School Absenteeism in a Predominantly Hispanic Community. Journal of Exposure Analysis and Environmental Epidemiology, v. 13, pg Levy DE, Winickoff J, Rigotti N. (2011). School absenteeism among children who live with smokers. Pediatrics, 128,

26 Conclusions Tobacco use, particularly smoking is high in adults with low levels of education and persons below poverty level Need to take an upstream approach adults don t drop out, youth do Assess disparities in tobacco use among youth Sub-state level data critical to understand pro-tobacco influences among gyouth Continued surveillance and evaluation of key tobacco indicators needed especially to monitor populations with high prevalence of smoking

27 Implications for Surveillance and Evaluation

28 Best Practices 2007: Surveillance and Evaluation Ten percent of overall budget (and maybe more) toward surveillance and evaluation Focus on maintaining core surveillance systems Documenting the lack of change can inform interventions and policies Importance of establishing sound baselines on key indicators

29 Surveillance and Evaluation National perspective can inform assessments at the state and local levels low SES, other populations States may have unique situations with respect to addressing tobacco related disparities one size cannot fit all May begin by making an assessment of key tobacco indicators at the state level Population based surveys are a good place to start May take other types of assessments, especially to examine tobacco industry tactics May first ask: are there particular populations where we see lack of change over time

30 Where We Are with OSH Surveillance Continue to track Healthy People Objectives for Tobacco HHS Initiative in Tobacco Control Surveillance, Evaluation, and Research Continue to monitor Performance Measures Continue to use Key Outcomes Indicator as a guidance for surveillance and evaluation in Tobacco Control (logic models, measures) Enhancing surveillance also critical component when monitoring key indicators in tobacco

31 Enhancing Surveillance to: Support existing tobacco surveillance systems Develop protocols on emerging areas in tobacco surveillance (pricing, i rapid response) Conducting pilot studies to establish feasibility of novel methods for data collection (smart phones) Investigating and improving survey methodology Creating key tobacco surveillance reports

32 Other Surveys with Tobacco and SES Indicators National Health Interview Survey (NHIS) National Health and Nutrition Examination Survey (NHANES) National Survey on Drug Use and Health (NSDUH) Medical Expenditure Panel Survey (MEPS) Behavioral Risk Factor Surveillance (BRFSS) Health Information National Trends Survey (HINTS) National Adult Tobacco Survey (NATS) State Adult Tobacco Survey (ATS) Current Population Survey Tobacco Use Supplement (CPS-TUS) (Telephone

33 Surveillance Systems Used to Monitor Tobacco and SES Indicators Youth Survey (YRBS, NYTS &YTS) All surveys evaluated cover year olds and most are school based Youth and Adult Surveillance Systems Youth MTF and NSDUH cover the most educational indicators NHANES and PRAMS (household/telephone based surveys) don t ask any questions besides educational attainment and/or enrollment TUS-CPS asks about enrollment, attainment, school type and drop out but doesn t include academic success and behavioral issues Health care delivery rarely asks about educational status Adult Survey Many adult surveys do not differentiate between GED and high school diploma

34 Questions? Contact: Shanta R. Dube, PhD, MPH Lead Health Scientist Surveillance Team Lead, Epidemiology Branch Centers for Disease Control and Prevention Office on Smoking and Health (OSH)

35 A Model of Human Well-being Health and population people enjoy long lives in good health; not just the absence of disease Household and national wealth Individuals, households, and communities have the material goods and income to secure basic goods and income to secure basic needs and decent livelihoods and community resources to support enterprise Knowledge people have knowledge to innovate and cope with change, live well, maintain sustainability, and fulfill their potential Culture avenues for spiritual growth, creativity, and self-expression Eco-systems- support towards environment and environmental consciousness; synergy between communities and environment to promote health and prevent disease Adapted from The Wellbeing of Nations by Prestcott-Allen, Robert