Tobacco Surveillance in the UnitedStates

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 ahealth-related event for use in public health action toreduce morbidity and mortality and improve health.

Data disseminated by a public health surveillancesystem can be used for immediate public health action,program and policy planning and evaluation, andformulating and testing research hypotheses.

Adapted from: CDC. Updated Guidelines for Evaluating public health surveillance systems: recommendations fromthe guidelines working group. MMWR 2001;50(No. RR-13),page 2.

Evolution of Surveillance inthe 20th Century

1900s – Individual contacts of infected persons

1950s – Communicable diseases

1970s – Selected chronic diseases

1950s-present – Behavioral, occupational, andenvironmental risk factors

Source: Remington and Goodman, “Chronic Disease Surveillance,” in Brownson et al. (eds), Chronic DiseaseEpidemiology and Surveillance, 1998

InformationDissemination

ProgramEvaluation

ProgramImplementation

ProgramPlanning

DataInterpretation

DataCollection

DataAnalysis

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

Organizational Model for State-BasedChronic Disease Surveillance Programs

Purposes of a Tobacco-RelatedSurveillance 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 frompopulations 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 ControlModel of Nicotine Addiction

Agent

Vector Host

Tobacco Products

Tobacco ProductManufacturers;

Other Users

Smoker/ChewerIncidental Host

EnvironmentFamilial, Social,

Cultural, Political,Economic, Historical,

Media

Involuntary Smoker

Source: Orleans & Slade, 1993

Conceptual Model of FactorsInfluencing Trends in Adolescent

Smoking – United States, 1975-2001

0

5

10

15

20

25

30

35

40

45

1975 1977 1979 1981 198319851987198919911993 1995 1997 1999 2001YEAR

PER

CE

NT

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

Major Sources of Data on TobaccoUse 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 MajorSmoking and Health Events – United States, 1900-2001

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-CancerConcern

Fairness DoctrineMessages on TV

and Radio

Non-SmokersRights Movement

Begins

Federal CigaretteTax Doubles

SurgeonGeneral’sReport on ETS

1st SurgeonGeneral’s Report

1st World Conferenceon Smoking and Health

BroadcastAd Ban

1st Great AmericanSmoke-out

OTC NicotineMedications

MasterSettlementAgreement

Great Depression

Trends in Per Capita Consumption ofVarious 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

Perc

ent

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

Filter<15 mg. tar yield

> 94 mm.

Menthol

Major Sources of Data on TobaccoUse 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 SchoolStudents 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

PER

CE

NT

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 Anytimein 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 2001YEAR

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 TobaccoUse in the United States

Surveys of Adults

• Current Population Surveys (CPS)

• Adult Use of Tobacco Surveys (AUTS); Adult TobaccoSurveys (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 whocurrently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100cigarettes 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 VariousTobacco Products, by Sex – National Health

Interview Survey, 2000

0

5

10

15

20

25

30

35

Any Use Cigarettes Cigars Pipes Snuff ChewingTobacco

Bidis

PER

CE

NT

MalesFemales

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

31.3

21.3

25.7

21.0

4.5

0.2 1.0 0.1

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 PastMonth

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 UsePrevalences 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 Differencesin 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 onTobacco 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 andEvaluation 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 RegulatingSmoking

In Public Places – U.S., 1960-2001

Sources: 1989 Surgeon General’s Report, ALA’s SLATI, CDC’s STATE system, Roswell ParkCancer Institute. Note: Includes the District of Columbia; Alabama = only state with norestrictions on public smoking.

Number of U.S. States including D.C.*, withLegislation 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

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

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 CessationNeeds and Practices Survey

• Beliefs About Nicotine Dependence(BAND) survey

• International Tobacco Control (ITC)Policy Study

Emerging Issues

• CDC lab and NCI resources to bettercharacterize the product. Massachusettsregulation.

• California and other systems to monitorvector. Often involves proprietary data.

• Environmental monitoring - legislation,media, price. Often involve proprietarydata.

Key Areas for Surveillance

• Evaluating Tobacco Control Programs ina Multi-variate World

• Surveillance for Tobacco HarmReduction

• Understanding Natural Histories

• Understanding Trends

Lessons Learned

• “Why?” is inevitable• Timeliness matters• Analyses and reporting takestime and resources

• Categorical surveys are needed• Relationships count