Promotion of smoking cessation in developing countries: a framework for urgent public health interventions.

The rapid rise in smoking in many developing countries will have devastating consequences; by 2030 the developing world is expected to have 7 million deaths annually from tobacco use. Many smokers express a desire to quit, but they often fail because they are addicted to tobacco. Although a number of cessation aids are now available in the developed world, their applicability and affordability in developing countries is less clear. Successful interventions will require many stakeholder groups to take action at the local, national, and international levels. We discuss smoking cessation as a means of reducing disease burden, examine factors that may limit the promotion of smoking cessation in developing countries, and propose a framework for public health action. This framework should comprise intervention with healthcare professionals, strengthening national commitment, development of a model for developing countries, changing the social acceptability of smoking, strengthening community participation, integration of smoking cessation with other healthcare services, specifying the role of healthcare professionals, development of guidelines, mobilisation of the business community, provision of financial incentives, establishing population specific smoking cessation services, increased collaboration between countries, and development of international initiatives.

Cigarette acquisition and proof of age among US high school students who smoke.

OBJECTIVE: To determine how US high school students who are under 18 years of age and who smoke obtain their cigarettes and whether they are asked for proof of age. DESIGN AND SETTING: Data from the Centers for Disease Control and Prevention's 1995, 1997, and 1999 national Youth Risk Behavior Surveys which employed national probability samples of students in grades 9-12 (ages 14-18 years). MAIN OUTCOME MEASURES: Associations of usual source of cigarettes and request for proof of age with variables such as sex, race/ethnicity, grade, and frequency of smoking. RESULTS: In 1999, among current smokers under age 18 years, 23.5% (95% confidence interval (CI), -4.5% to +4.5%) usually purchased their cigarettes in a store; among these students, 69.6% (95% CI -5.7% to +5.7%) were not asked to show proof of age. As days of past month smoking increased, reliance on buying cigarettes in a store (p < 0.001) and giving someone else money to buy cigarettes (p < 0.001) increased, and usually borrowing cigarettes decreased (p < 0.001). From 1995 to 1999, relying on store purchases significantly decreased (from 38.7% (95% CI -4.6% to + 4.6%) to 23.5% (95% CI -4.5% to +4.5%)); usually giving someone else money to buy cigarettes significantly increased (from 15.8% (95% CI -3.6% to +3.6%) to 29.9% (95% CI -4.5% to + 4.5%)). CONCLUSIONS: Stricter enforcement of tobacco access laws is needed to support other community and school efforts to reduce tobacco use among youth. Furthermore, effective interventions to reduce non-commercial sources of tobacco, including social, need to be developed and implemented.

Smoking cessation counseling by primary care women physicians: Women Physicians' Health Study.

OBJECTIVES: The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians. The objectives of this study were to: describe the prevalence of self-reported smoking cessation counseling among primary care women physicians and determine the association between physician demographic, professional, and personal characteristics and smoking cessation counseling. METHODS: Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians and included 4,501 respondents representing all major specialties. Primary care physicians included 5 specialty areas and were grouped into 3 categories: (1) general primary care; (2) obstetrics/gynecology (ob/gyn); and (3) pediatrics. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year. RESULTS: Women physicians in general primary care (84%) and ob/gyn (83%) were more likely to frequently counsel their patients about cessation than were pediatricians (41%). Perceived relevance of counseling to a physician's practice was significantly associated with frequent counseling. Personal characteristics (current smoking status, personal or family history of a smoking-related disease, or living with a smoker as an adult or child) were not significantly correlated with counseling. CONCLUSION: The majority (71%) of physicians reported frequently counseling their patients. However, there was significant variation by physician specialty. In addition, perceived relevance of counseling was strongly associated with counseling behavior. Physician counseling on cessation can reduce tobacco-related morbidity and mortality. Increasing perceived relevance, implementing system changes, and creating accountability can facilitate cessation counseling by physicians.

Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke.

This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.

Non-primary care physicians and smoking cessation counseling: Women Physicians' Health Study.

OBJECTIVES: The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians in various specialties. In this study we describe the prevalence of self-reported counseling on smoking cessation among non-primary care women physicians and examine the association between their demographic, professional, and personal characteristics and such counseling on smoking cessation. METHODS: Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians with 4,501 respondents representing all major specialties. Physicians in 9 specialty areas were grouped in 6 categories: (1) anesthesiology; (2) general surgery and surgical subspecialties; (3) emergency medicine; (4) medical subspecialties; (5) psychiatry; and (6) other. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year. RESULTS: Overall, 45% of the physicians frequently counseled smokers to quit. Medical subspecialists (80%) were most likely and psychiatrists (29%) least likely to counsel frequently. Specialty, perceived relevance of counseling to the physician's practice, and self-confidence in counseling about smoking cessation were associated with frequent counseling. CONCLUSION: Cessation counseling by non-primary care physicians can reduce tobacco-related morbidity and mortality. Increasing perceived relevance and self-confidence among this group of physicians, combined with implementation of system changes and the creation of physician accountability can facilitate the provision of such counseling.

Relationship between cigarette, smokeless tobacco, and cigar use, and other health risk behaviors among U.S. high school students.

This study examined relationships between tobacco use and use of other substances, intentional injury risk behaviors, and sexual risk behaviors among US high school students. Data about tobacco use and other health risk behaviors were analyzed from the 1997 national Youth Risk Behavior Survey implemented by the Centers for Disease Control and Prevention. One-fourth of students (24%) reported current use of a single tobacco product (i.e., cigarettes, smokeless tobacco, or cigars during the 30 days preceding the survey), and 19.5% reported currently using more than one tobacco product. Generally, students who reported current tobacco use also reported engaging in other substance use, intentional injury risk behaviors, and sexual risk behaviors. For many risk behaviors, these results were especially pronounced among students who reported using two or all three tobacco products. Programs designed to prevent tobacco use should consider that such use often occurs concomitantly with other health risk behaviors.

Effect of the tobacco price support program on cigarette consumption in the United States: an updated model.

OBJECTIVES: This study evaluated the direct effect of the tobacco price support program on domestic cigarette consumption. METHODS: We developed an economic model of demand and supply of US tobacco to estimate how much the price support program increases the price of tobacco. We calculated the resultant increase in cigarette prices from the change in the tobacco price and the quantity of domestic tobacco contained in US cigarettes. We then assessed the reduction in cigarette consumption attributable to the price support program by applying the estimated increase in the cigarette price to assumed price elasticities of demand for cigarettes. RESULTS: We estimated that the tobacco price support program increased the price of tobacco leaf by $0.36 per pound. This higher tobacco price translates to a $0.01 increase in the price of a pack of cigarettes and an estimated 0.21% reduction in cigarette consumption. CONCLUSION: Because the tobacco price support program increases the price of cigarettes minimally, its potential health benefit is likely to be small. The adverse political effect of the tobacco program might substantially outweigh the potential direct benefit of the program on cigarette consumption.

Women and smoking: patterns, health effects, and treatments.

Tobacco use remains the number one cause of preventable death among women in the United States. Of particular concern to obstetricians and gynecologists is the morbidity caused by tobacco use and by exposure to secondhand smoke among women of childbearing age, pregnant women, and their newborns. Women who smoke have lower fertility rates and are more likely to experience negative side effects from oral contraceptives. Pregnant women who smoke are more likely to suffer miscarriages and to have low birth weight and preterm babies, and infants with sudden infant death syndrome. Over one of every four women aged 18 to 44 smoke in the U.S. Unfortunately, at least 14% of women smoke during pregnancy. The good news is that research shows that tobacco treatment interventions by health care providers can increase the number of patients who successfully quit. The Agency for Health Care Policy and Research developed recommendations and guidelines to assist health care providers to integrate a tobacco treatment intervention into an office setting. It is recommended that every physician 1) ask patients about their tobacco use; 2) advise them to stop using tobacco; 3) assist patients interested in cessation efforts; and 4) arrange appropriate follow-up.

Sociocultural influences on smoking and drinking.

Numerous research studies have shown that sociocultural factors influence the initiation and continued use of alcohol and tobacco among adolescents and adults. Few studies have examined the effects of sociocultural factors on the tendency of smokers to drink and drinkers to smoke. However, the limited evidence available suggests that such factors exist and that the strength of the association between alcohol and tobacco use behaviors varies with the levels of alcohol use. Public health interventions focused on concurrent tobacco and alcohol use could yield further reductions in the morbidity and mortality associated with these substances.

Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students.

BACKGROUND: Most adult smokers report trying their first cigarette before age 18 years. Understanding the impact of smoking initiation at young ages may help public health policy makers and practitioners improve strategies to prevent or delay adolescent cigarette smoking. METHODS: This paper examined age of initiation of cigarette smoking and subsequent patterns of smoking among U.S. high school students 16 years of age and older (N = 13,858). We used data from the 1991-1997 national Youth Risk Behavior Surveys, conducted by the Centers for Disease Control and Prevention. RESULTS: The majority of students 16 years of age and older (60.4%) reported ever having smoked a whole cigarette, and 11.1% initiated smoking at age 10 years or younger. Age of smoking initiation was significantly related to current frequent smoking, daily smoking, and whether students had ever smoked daily. A younger age of smoking initiation was associated with smoking more cigarettes per day than was initiating at an older age. CONCLUSIONS: Delaying the onset of smoking may affect the likelihood of becoming addicted to nicotine and smoking heavily. For students who are already addicted to nicotine, smoking cessation programs are needed.

Smoking initiation and smoking patterns among US college students.

The ages at which 18- to 24-year-old college students started smoking and its relationship to subsequent smoking were explored, using data from the 1995 National College Health Risk Behavior Survey. Most students (70%) had tried smoking; among those who had tried, 42% were current smokers, 19% were current frequent smokers, and 13% were current daily smokers. The majority (81%) who had ever smoked daily began doing so at age 18 years or younger, and 19% began smoking daily at age 19 years or older. Women were as likely as men to report ever having smoked a whole cigarette or ever having smoked daily. Most students (82%) who had ever smoked daily had tried to quit, but 3 in 4 were still smokers. Policies and programs designed to prevent the initiation of smoking and to help smokers quit are needed at both the high school and the college levels to reduce the proportion of young adults who smoke cigarettes.

State laws on tobacco control--United States, 1998.

PROBLEM/CONDITION: State laws addressing tobacco use, the leading preventable cause of death in the United States, are summarized. Laws address smoke-free indoor air, minors' access to tobacco products, advertising of tobacco products, and excise taxes on tobacco products. REPORTING PERIOD COVERED: Legislation effective through December 31, 1998. DESCRIPTION OF SYSTEM: CDC identified laws addressing tobacco control by using an on-line legal research database. CDC's findings were verified with the National Cancer Institute's State Cancer Legislative Database. RESULTS: Since a previous surveillance summary on state tobacco-control laws published in November 1995 (covering legislation effective through June 30, 1995), several states have enacted new restrictions or strengthened existing legislation that addresses smoke-free indoor air, minors' access to tobacco, tobacco advertising, and tobacco taxes. Five states strengthened their smoke-free indoor air legislation. All states and Washington, D.C., continued to prohibit the sale and distribution of tobacco products to minors; however, 21 states expanded minors' access laws by designating enforcement authorities, adding license suspension or revocation for sale to minors, or requiring signage. Since the 1995 report, eight additional states (a total of 19 states and Washington, D.C.) now ban vending machines from areas accessible to minors. Thirteen states restrict advertising of tobacco products, an increase of four states since the 1995 report. Although the number of states that tax cigarettes and smokeless tobacco did not change, 13 states increased excise taxes on cigarettes, and five states increased excise taxes on smokeless tobacco products. The average state excise tax on cigarettes is 38.9 cents per pack, an increase of 7.4 cents compared with the average tax in the 1995 report. INTERPRETATION: State laws addressing tobacco control vary in relation to restrictiveness, enforcement and penalties, preemptions, and exceptions. ACTIONS TAKEN: The data summarizing state tobacco-control laws are available through CDC's State Tobacco Activities Tracking and Evaluation (STATE) System; the laws are collected and updated every quarter. The STATE System also contains state-specific data on the prevalence of tobacco use, tobacco-related deaths, and the costs of tobacco use. Information from the STATE System is available for use by policy makers at the state and local levels to plan and implement initiatives to prevent and reduce tobacco use. In addition, CDC is using this information to assess the ongoing impact of tobacco-control programs and policies on tobacco use.

Surveillance for five health risks among older adults--United States, 1993-1997.

PROBLEM/CONDITION: Overweight, drinking and driving, inadequate fruit and vegetable consumption, physical inactivity, and smoking are associated with the leading causes of morbidity and mortality among older adults (i.e., persons aged > or =65 years) in the United States. REPORTING PERIOD: This report presents data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1994-1997 and from the National Health Interview Survey (NHIS) for 1993-1995. DESCRIPTION OF SYSTEMS: BRFSS and NHIS are maintained by CDC and have been used for surveillance purposes. Each survey is administered annually and includes questions about health risks and health behaviors from a representative sample of the U.S. civilian, noninstitutionalized population. The NHIS is designed to provide national estimates and the BRFSS, state estimates. RESULTS: Prevalences of overweight, drinking and driving, inadequate fruit and vegetable consumption, and smoking decreased with increasing age among older adults in the United States; physical inactivity was the only health risk that increased with increasing age. Sex and race were differentially associated with all five health risks. INTERPRETATION: Specific subgroups of older adults are at risk for being overweight, drinking and driving, inadequate fruit and vegetable consumption, physical inactivity, and smoking. These health risks varied by age, race, residential state, and socioeconomic status and highlight the heterogeneous nature of older adults. PUBLIC HEALTH ACTION: Surveillance for health risks among older adults provides information to help identify effective interventions for the growing population of older adults in the United States.

Impact of the Tobacco Price Support Program on tobacco control in the United States.

OBJECTIVES: To evaluate the impact of the United States Tobacco Price Support Program (TPSP) on domestic cigarette consumption and the potential political impact of the TPSP on efforts to reduce smoking. DATA SOURCES: Published studies known to the authors and a search of AGRICOLA from 1980 to 1996. STUDY SELECTION: Studies published in a refereed journal or research reports published by an accredited university or institution. DATA SYNTHESIS: The TPSP decreases cigarette use by increasing the price of cigarettes. The price increase resulting from the TPSP, however, is small--about one cent per pack. The resulting decrease in cigarette consumption is also very modest--an estimated 0.23%. However, the TPSP creates tobacco quota owners, who have a strong financial interest in opposing measures to reduce smoking. The TPSP also changes the political influence of tobacco farmers by keeping a large number of small farmers in tobacco production. CONCLUSIONS: The negative impact of the TPSP (opposition to tobacco control measures) is probably greater than the positive impact of the programme (reducing smoking). Therefore, the net impact of the TPSP on tobacco control efforts is likely to be negative.

Trends in tobacco use among high school students in the United States, 1991-1995.

This study examined demographic characteristics of tobacco-using high school students in the United States from 1991 through 1995. Data about cigarette smoking and smokeless tobacco use among adolescent were collected in 1991, 1993, and 1995 using the Youth Risk Behavior Survey, part of the Youth Risk Behavior Surveillance System implemented by the Centers for Disease Control and Prevention. Data indicated current smoking increased 26.5% from 1991 to 1995 with one-third [31.2% (+/- 1.7)] of ninth grade students and 38.2% (+/- 3.5) of 12th grade students reporting current smoking in 1995. Smokeless tobacco use remained stable with 11.4% (+/- 1.7) of all students and one-fourth [25.1% (+/- 3.0)] of White male students reporting smokeless tobacco use in 1995. Many students already have begun using tobacco before reaching high school. Thus, interventions should begin well before high school to prevent adolescents from using and becoming addicted to tobacco.

Intermittent smokers: a descriptive analysis of persons who have never smoked daily.

OBJECTIVES: This study assessed the prevalence of and demographic variables associated with lifetime never-daily smoking in the United States. METHODS: Descriptive demographic data and logistic regression analyses were used to examine associations with never-daily smoking. RESULTS: Lifetime never-daily smokers constituted a significant minority of non-White smokers. There was a strong association between never-daily smoking and college education among young adults, particularly men. Although never-daily smoking was associated with initiation behavior among young smokers, it also represented a persistent pattern for some smokers, particularly non-Whites and Hispanics. CONCLUSIONS: The demographic distribution of never-daily smoking may have implications for developing culturally appropriate smoking prevention and cessation strategies.