Building the evidence base for effective tobacco control policies: the International Tobacco Control Policy Evaluation Project (the ITC Project).

The Framework Convention on Tobacco Control (FCTC) is a seminal event in tobacco control and in global health. Scientific evidence guided the creation of the FCTC, and as the treaty moves into its implementation phase, scientific evidence can be used to guide the formulation of evidence-based tobacco control policies. The International Tobacco Control Policy Evaluation Project (ITC Project) is a transdisciplinary international collaboration of tobacco control researchers who have created research studies to evaluate and understand the psychosocial and behavioural impact of FCTC policies as they are implemented in participating ITC countries, which together are inhabited by over 45% of the world's smokers. This introduction to the ITC Project supplement of Tobacco Control presents a brief outline of the ITC Project, including a summary of key findings to date. The overall conceptual model and methodology of the ITC Project--involving representative national cohort surveys created from a common conceptual model, with common methods and measures across countries--may hold promise as a useful paradigm in efforts to evaluate and understand the impact of population-based interventions in other important domains of health, such as obesity.

State-specific trends in smoke-free workplace policy coverage: the current population survey tobacco use supplement, 1993 to 1999.

We examined trends in smoke-free workplace policies among all indoor workers in the United States using the National Cancer Institute's Tobacco Use Supplement to the Census Bureau's Current Population Survey (total n = 270,063). Smoke-free was defined as smoking not permitted in public or common areas or in work areas of a worksite. Nationally, we found that nearly 70% of the US workforce worked under a smoke-free policy in 1999. At the state level, a greater than 30-percentage-point differential existed in the proportion of workers with such policies. Although significant progress has been made to reduce worker exposure to environmental tobacco smoke on the job, we predict further progress may be difficult unless comprehensive regulations to protect all workers are implemented at the national, state, or local level.

Sex differences in workplace smoking policies: results from the current population survey.

OBJECTIVE: To determine the prevalence of smoking policies in indoor work environments in the United States, with a special focus on sex differences in the provision of these policies. METHOD: Information on the prevalence and restrictiveness of workplace smoking policies was obtained from 86,490 currently employed indoor workers (50,865 women and 35,625 men) 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey, a cross-sectional survey of households in all 50 states and the District of Columbia conducted between 1995 and 1996. RESULTS: Eighty-six percent of respondents reported that their workplaces had official smoking policies, and 63% reported that their workplaces were smoke free. Women reported significantly higher rates of both official smoking policies and smoke-free workplaces than men, regardless of racial/ethnic or age group. CONCLUSION: The overall rates of worksite smoking restrictions, including the establishment of smoke-free workplaces, were higher than those reported in earlier surveys. Disparities in coverage will need to be reduced if all workers, regardless of sex, race, age, or industry of employment, are to be protected from the demonstrated hazards of environmental tobacco smoke.

Health risks associated with cigar smoking.

This article summarizes principal findings from a conference convened by the American Cancer Society in June 1998 to examine the health risks of cigar smoking. State-of-the-science reports were presented and 120 attendees (representing government and private agencies, academia, health educators, and tobacco control experts) participated in panels and summary development discussions. The following conclusions were reached by consensus: (1) rates of cigar smoking are rising among both adults and adolescents; (2) smoking cigars instead of cigarettes does not reduce the risk of nicotine addiction; (3) as the number of cigars smoked and the amount of smoke inhaled increases, the risk of death related to cigar smoking approaches that of cigarette smoking; (4) cigar smoke contains higher concentrations of toxic and carcinogenic compounds than cigarettes and is a major source of fine-particle and carbon monoxide indoor air pollution; and (5) cigar smoking is known to cause cancers of the lung and upper aerodigestive tract. JAMA. 2000;284:735-740

Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking.

BACKGROUND: The American Cancer Society, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS), provide the second annual report to the nation on progress in cancer prevention and control, with a special section on lung cancer and tobacco smoking. METHODS: Age-adjusted rates (using the 1970 U.S. standard population) were based on cancer incidence data from NCI and underlying cause of death data compiled by NCHS. The prevalence of tobacco use was derived from CDC surveys. Reported P values are two-sided. RESULTS: From 1990 through 1996, cancer incidence (-0.9% per year; P = .16) and cancer death (-0.6% per year; P = .001) rates for all sites combined decreased. Among the 10 leading cancer incidence sites, statistically significant decreases in incidence rates were seen in males for leukemia and cancers of the lung, colon/rectum, urinary bladder, and oral cavity and pharynx. Except for lung cancer, incidence rates for these cancers also declined in females. Among the 10 leading cancer mortality sites, statistically significant decreases in cancer death rates were seen for cancers of the male lung, female breast, the prostate, male pancreas, and male brain and, for both sexes, cancers of the colon/rectum and stomach. Age-specific analyses of lung cancer revealed that rates in males first declined at younger ages and then for each older age group successively over time; rates in females appeared to be in the early stages of following the same pattern, with rates decreasing for women aged 40-59 years. CONCLUSIONS: The declines in cancer incidence and death rates, particularly for lung cancer, are encouraging. However, unless recent upward trends in smoking among adolescents can be reversed, the lung cancer rates that are currently declining in the United States may rise again.

Prevalence of cigar use in 22 North American communities: 1989 and 1993.

OBJECTIVES: This study examined the prevalence rate of and characteristics associated with cigar use. METHODS: Data were derived from population-based telephone surveys of adults conducted in 22 North American communities in 1989 and 1993 as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. RESULTS: Averaged across the 22 communities, the prevalence rate of regular cigar use increased 133% from 1989 to 1993. Regular cigar use increased in every gender, age, race, income, education, and smoking status category. CONCLUSION: These results confirm other data indicating that cigar use is increasing.

Workplace smoking policies in the United States: results from a national survey of more than 100,000 workers.

OBJECTIVE: To determine the prevalence of smoking policies in indoor work environments as reported by a nationally representative sample of workers in the United States. DESIGN: Cross-sectional survey of households within the United States. SETTING: All 50 state and the District of Columbia, 1992-93. PARTICIPANTS: Currently employed indoor workers 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey (n = 100,561). MAIN OUTCOME MEASURES: The prevalence and restrictiveness of workplace smoking policies as reported by workers currently employed in indoor workplaces in the United States. RESULTS: Most of the indoor workers surveyed (81.6%) reported that their place of work had an official policy that addressed smoking in the workplace; 46.0% reported that their workplace policy did not permit smoking in either the public/common areas--for example, restrooms and cafeterias--or the work areas of the workplace. The reporting of these "smoke-free" policies varied significantly by gender, age, race/ethnicity, smoking status, and occupation of the worker. CONCLUSIONS: Although nearly half of all indoor workers in this survey reported that they had a smoke-free policy in their workplace, significant numbers of workers, especially those in blue-collar and service occupations, reported smoke-free rates well below the national average. If implemented, the US Occupational Safety and Health Administration's proposed regulation to require worksites to be smoke-free has the potential to increase significantly the percentage of American workers covered by these policies and to eliminate most of the disparity currently found across occupational groups.

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti-tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.

Cigarette smoking among U.S. adults by state and region: estimates from the current population survey.

BACKGROUND: Cigarette smoking is responsible for at least one third of all cancer deaths annually in the United States. Few sources exist in the peer-reviewed literature documenting state and regional differences in smoking behavior, despite the fact that cancer prevention and control efforts are increasingly being implemented below the national level. PURPOSE: Our goals were to determine smoking prevalence rates among men and women, by region, and for each of the 50 states and the District of Columbia from census survey data collected in 1992 and 1993 and to compare these rates with rates determined in 1985. METHODS: Every month, the U.S. Bureau of the Census collects labor force statistics on more than 100000 individuals on its Current Population Survey (CPS). For the September 1992, January 1993, and May 1993 CPS, the National Cancer Institute sponsored a 40-item Tobacco Use Supplement. The definition of a current smoker changed slightly between 1985 and 1992-1993. For the 1985 CPS, individuals were considered current smokers if they had smoked 100 cigarettes in their lifetime and were smoking at the time of interview; for the 1992-1993 CPS, current smokers included anyone who had smoked 100 cigarettes and was currently smoking every day or just on some days. We calculated current smoking rates (every day and some days combined) based on more than a quarter million adults (n = 266988) interviewed in 1992-1993. RESULTS: Substantial geographic variation exists in rates of current cigarette use among adults within the United States. In general, adults in the southern United States have higher rates of smoking and adults in the western states have lower rates of smoking and adults in the rest of the country, although differences in smoking behavior between men and women and among various racial and ethnic populations strongly influence these patterns. Only two states, Kentucky and West Virginia, exhibited adult smoking rates (men and women combined) of 30% or higher in 1992-1993; in contrast, in 1985, such rates were reported from 20 states. The only states in which the prevalence was below 20% in 1992-1993 were Utah (17.1%) and California (19.5%). Rates approaching 20% were reported from New Jersey (20.7%), Massachusetts (21.5%), and Nebraska, New York, and Hawaii (22.0% each) in 1992-1993. Rhode Island experienced the greatest relative decline in smoking prevalence from 1985 to 1992-1993, with a calculated relative change of -30.7% (based on a change in rate from 33.5% to 23.2%), followed by Delaware (-25.9%) the District of Columbia and New Jersey (-23.9% each), Connecticut (-23.2%), California (-22.9%), Alaska (-22.8%), Georgia (-22.6%), Massachusetts (-22.1%), and New York (-22.0%). CONCLUSIONS: Smoking rates are not uniform in the United States but vary considerably from state to state, even within the same region of the country. The CPS is the only mechanism currently capable of simultaneously monitoring smoking trends nationally, regionally, and on a state-by-state basis.

Public health approaches to tobacco use prevention and cessation in the U.S.

Tobacco has a long history of use in the U.S., and its serious health effects have been well-documented during the past half century, U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 25 years, during which time there has been a 34 percent reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one-fourth of the population continuing to smoke. Many organizations are involved in tobacco use control activities, the most broadly focused of which is the National Cancer Institute (NCI). As an example of the type of program needed to address the problem of tobacco use on a national scale, the NCI's public health research plan and activities are described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco use control in the U.S. are suggested.

Tobacco use and its contribution to early cancer mortality with a special emphasis on cigarette smoking.

This paper provides an overview of the relationship between tobacco use and early cancer mortality. It presents a retrospective examination of trends in smoking behavior and how these trends affected the national lung cancer mortality pattern during this century. Information on smoking prevalence is presented for black and white men and women for each 5-year birth cohort between 1885 and 1969. The author argues that the lung cancer mortality pattern observed in the United States since 1950 is entirely compatible with changes in smoking behavior among the various birth cohorts examined. The paper also reviews our current scientific knowledge about the etiological relationship between cigarette smoking and site-specific cancer mortality, with particular emphasis on lung cancer. Data on other forms of tobacco use and cancer mortality risks are included as are data on environmental tobacco smoke exposures and nonsmokers' lung cancer risk. Data are presented to demonstrate that cigarette use alone will be responsible for nearly one-third of the U.S. cancer deaths expected in the United States in 1995, or 168,000 premature cancer deaths. Among males, 38% of all cancer deaths are cigarette related, while among women 23% of all cancer deaths are due to cigarettes. These totals, however, include neither the cancer deaths that could reasonably be attributed to pipe, cigar, and smokeless tobacco use among males nor the estimated 3000 to 6000 environmental tobacco smoke-related lung cancer deaths that occur annually in nonsmokers. It is concluded that tobacco use, particularly the practice of cigarette smoking, is the single greatest cause of excess cancer mortality in U.S. populations.

Smoking behavior, workplace policies, and public opinion regarding smoking restrictions in Maryland.

The Maryland Occupational Safety and Health (MOSH) advisory board recently proposed a smoking ban in most Maryland workplaces, including bars and restaurants, unless smoking is restricted to a separately ventilated area where nonsmoking workers cannot be required to enter. Results from the 1992-1993 Current Population Survey strongly suggest that there is broad support among Maryland residents for such restrictions and that the MOSH rules would merely extend an already widespread practice in the state. Efforts by the tobacco industry to gain an injunction against the proposed MOSH regulations would not appear to be supported by a clear majority of Maryland residents.

Trends in cigarette smoking among US adolescents, 1974 through 1991.

OBJECTIVES: The purpose of this study was to determine national trends in adolescent cigarette smoking prevalence. METHODS: We conducted trend analyses based on 1974 through 1991 current smoking prevalence data among persons aged 12 through 19 years from the National Household Surveys on Drug Abuse, High School Seniors Surveys, and National Health Interview Surveys. RESULTS: Overall smoking prevalence declined much more rapidly from 1974 through 1980 (1.9 percentage points annually among younger adolescents; the range among surveys of older adolescents was 0.2 to 2.0 percentage points annually) than from 1985 through 1991 (0 to 0.5 percentage points annually among all adolescents). Since 1980, smoking has generally declined at a slightly faster rate among older female adolescents than among male adolescents. Smoking among Black adolescents of all ages declined in nearly every survey population during each study period (range among surveys: 1974-1985 = 1.0 to 2.9 percentage points; 1985-1991 = 0.7 to 1.5 percentage points annually); for White adolescents, only minimal declines in smoking have occurred since 1985. CONCLUSIONS: Since 1974, major changes in adolescent smoking patterns have occurred, especially among Blacks. The overall slowing rate of decline in smoking prevalence since 1985 may indicate success of increased tobacco advertising and promotional activities targeted at adolescents or inadequate antitobacco education efforts.

The United States National Cancer Institute and the science of tobacco control research.

U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 3 decades, during which there has been a 34% reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one fourth of the population continuing to smoke. Many organizations are involved in tobacco-use control activities, the most broadly focused of which is that of the National Cancer Institute (NCI). The NCI's program is described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco-use control in the U.S. are suggested.