Effects of smoking reduction during pregnancy on the birth weight of term infants.

This study was undertaken to determine 1) whether reducing tobacco exposure during pregnancy increases the birth weight of term infants and 2) the relative effects of early- and late-pregnancy exposure to tobacco on infant birth weight. Data were obtained from the Smoking Cessation in Pregnancy project, conducted in public clinics in three states (Colorado, Maryland, and Missouri) between 1987 and 1991. Self-reported cigarette use and urine cotinine concentration were collected from 1,583 pregnant smokers at study enrollment and in the third trimester. General linear models were used to generate mean adjusted birth weights for women who reduced their tobacco exposure by 50 percent or more and for those who did not change their exposure. Regression smoothing techniques were used to characterize the relation between birth weight and early exposure and birth weight and third-trimester exposure. Reducing cigarette use was associated with an increase in mean adjusted birth weight of only 32 g, which was not significant (p = 0.33). As third-trimester cigarette use increased, birth weight declined sharply but leveled off at more than eight cigarettes per day. Findings were similar when urine cotinine concentration was used. Women who smoke during pregnancy may need to reduce to low levels of exposure (less than eight cigarettes per day) to improve infant birth weight.

Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994.

OBJECTIVES: This study compared trends in adult cigarette smoking prevalence in California and the remainder of the United States between 1978 and 1994. METHODS: We used data from National Health Interview Surveys and Behavioral Risk Factor Surveillance System surveys to compare trends in smoking prevalence among persons 18 years and older. RESULTS: In both California and the remainder of the United States, the estimated annual rate of decline in adult smoking prevalence accelerated significantly from 1985 to 1990: to -1.22 percentage points per year (95% confidence interval [CI] = -1.51, -0.93) in California and to -0.93 percentage points per year (95% CI = -1.13, -0.73) in the remainder of the nation. The rate of decline slowed significantly from 1990 to 1994: to -0.39 percentage points per year (95% CI = -0.76, -0.03) in California and to -0.05 percentage points per year (95% CI = -0.34, 0.24) in the remainder of the United States. CONCLUSIONS: The presence of an aggressive tobacco control intervention has supported a significant decline in adult smoking prevalence in California from 1985 to 1990 and a slower but still significant decline from 1990 to 1994, a period in which there was no significant decline in the remainder of the nation. To restore nationwide progress in reducing smoking prevalence, other states should consider similar interventions.

Trends in pregnancy-related smoking rates in the United States, 1987-1996.

CONTEXT: Rates of smoking are increasing among adolescents and young adults, but trends in smoking among pregnant women have not been studied. OBJECTIVE: To assess pregnancy-related variations in smoking behaviors and their determinants among women of childbearing age in the United States. DESIGN: Analysis of data collected between 1987-1996 from the Behavioral Risk Factor Surveillance System survey. SETTING AND SUBJECTS: A total of 187302 (178499 nonpregnant and 8803 pregnant) noninstitutionalized women aged 18 to 44 years from 33 states. MAIN OUTCOME MEASURES: Prevalence rates of smoking initiation and current smoking, median number of cigarettes smoked, and adjusted odds ratios for smoking stratified by pregnancy status; prevalence rate ratio for current smoking comparing pregnant with nonpregnant women. RESULTS: The overall percentage of women who had ever initiated smoking decreased significantly from 44.1% in 1987 to 38.2% in 1996. During that 10-year period, the prevalence of current smoking also decreased significantly among both pregnant women (16.3% to 11.8%) and nonpregnant women (26.7% to 23.6%). Overall, pregnant women were about half (54%) as likely as nonpregnant women to be current smokers during 1987-1996. Over time, the median number of cigarettes smoked per day by pregnant smokers remained at 10, whereas among nonpregnant smokers it decreased from 19 to 15 (P<.05 for trend). In the same period, among young women (aged 18-20 years), prevalence rates of smoking initiation and current smoking increased slightly. Sociodemographic subgroups of women at increased risk for current smoking were the same for pregnant and nonpregnant women (ie, those with a completed high school education or less, whites, and those who were unmarried). CONCLUSIONS: In this analysis, the decline in smoking over time among pregnant women was primarily due to the overall decline in smoking initiation rates among women of childbearing age, not to an increased rate of smoking cessation related to pregnancy. To foster effective perinatal tobacco control, efforts are needed to further reduce the number of young women who begin smoking. Clinicians should query all pregnant women and women of childbearing age about smoking and provide cessation and relapse interventions to each smoker.

Race and cigarette smoking among United States adolescents: the role of lifestyle behaviors and demographic factors.

OBJECTIVE: Cigarette smoking is on the rise among adolescents in the United States. Although both African-American and white adolescents have experienced increases in cigarette smoking over time, the prevalence of smoking has remained consistently lower among African-American adolescents than their white counterparts. The purpose of this study was to determine whether the race differential in the prevalence of cigarette smoking is attributed to differences in selected lifestyle behaviors and demographic factors. DESIGN: A cross-sectional study was conducted among African-American and white adolescents (aged 12 to 17 years) who participated in the Youth Risk Behavior Survey supplement to the 1992 National Health Interview Survey. Analyses were restricted to those who had complete data on all study variables (n = 5569). Logistic regression analysis was used to estimate the prevalence odds ratios (POR) of current smoking for white adolescents (versus African-American adolescents) before and after adjustment for confounding factors. RESULTS: The crude POR of current smoking for white adolescents compared with African-American adolescents was 2.8 (95% confidence interval = 2.1 to 3.9). Simultaneous adjustment for confounding factors resulted in a POR of 2.6 (95% confidence interval = 1.8 to 3.7). CONCLUSIONS: Selected lifestyle behaviors and demographic factors do not account for the race differential in the prevalence of adolescent cigarette smoking. This study underscores the need for more research on contributors to the race gap. Such research could advance theoretical understanding of the etiology of cigarette smoking among adolescents and lead to more effective smoking prevention programs for all youths.

State smoking prevalence estimates: a comparison of the Behavioral Risk Factor Surveillance System and current population surveys.

OBJECTIVES: This study examined whether there are systematic differences between the Behavioral Risk Factor Surveillance System (BRFSS) and the Current Population Survey (CPS) for state cigarette smoking prevalence estimates. METHODS: BRFSS telephone survey estimates were compared with estimates from the US Census CPS tobacco-use supplements (the CPS sample frame includes persons in households without telephones). Weighted overall and sex- and race-specific BRFSS and CPS state estimates of adults smoking were analyzed for 1985, 1989, and 1992/1993. RESULTS: Overall estimates of smoking prevalence from the BRFSS were slightly lower than estimates from CPS (median difference: -2.0 percentage points in 1985, -0.7 in 1989, and -1.9 in 1992/1993; P < .05 for all comparisons), but there was variation among states. Differences between BRFSS and CPS estimates were larger among men than among women and larger among Blacks than among Hispanics or Whites; for most states, these differences were not significant. CONCLUSIONS: The BRFSS generally provides state estimates of smoking prevalence similar to those obtained from CPS, and these are appropriate for ongoing state surveillance of smoking prevalence.

Prevalence of tobacco use among Alaska Natives: a review.

BACKGROUND: Previous reports documented high rates of tobacco use among Alaska Natives (Eskimos, Indians, and Aleuts). In this population, tobacco use is the leading preventable cause of death. Lung cancer is the leading cause of cancer death among Alaska Natives and tobacco is responsible for over one-third of all cancer deaths in this population. Until recently there has been no systematic surveillance of the prevalence of tobacco use in this high-risk population. Data that did exist were not readily available to those primarily responsible for the health care of this population. This is the first time since 1990 that data on Alaska Natives have been collected in one analysis; this permits a more representative evaluation of tobacco use. METHODS: Data on tobacco use were obtained and analyzed from national and state surveys and selected research projects from 1988 to 1993. RESULTS: Alaska Natives have high prevalence of tobacco use, including both cigarettes and smokeless tobacco. Tobacco use prevalence among Alaska Natives exceeds that of Alaska non-Natives, U.S. whites, and American Indians/Alaska Natives in the United States outside of Alaska. Smoking prevalence among Alaska Native women is twice that of non-Native women in Alaska and nearly twice as high among pregnant Alaska Natives than pregnant non-Natives. Overall, prevalence of smokeless tobacco use was four times higher among Alaska Natives than comparative state and national populations. CONCLUSION: Because this population has such high rates of tobacco use, it is important to public health that monitoring and educational programs be in place and that data specific to Alaska Natives be made available.

Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.

Smoking onset has 4 levels, with a "susceptibility" level preceding early experimentation. This study assessed the predictive validity of smoking susceptibility in a longitudinal study of a nationally representative sample of 4,500 adolescents who at baseline reported never having puffed on a cigarette. At follow-up 4 years later, 40% of the sample had experimented with smoking, and 8% had established a smoking habit. Baseline susceptibility to smoking, defined as the absence of a firm decision not to smoke, was a stronger independent predictor of experimentation than the presence of smokers among either family or the best friend network. However, susceptibility to smoking was not as important as exposure to smokers in distinguishing adolescents who progressed to established smoking from those who remained experimenters at follow-up.

Women and smoking: an update for the 1990s.

Cigarette smoking is associated with many health hazards, ranging from lung cancer to low infant birth weight. In the United States in 1994, 23.1% of all women and 14.6% of pregnant women smoked. Few physicians ask their patients about smoking, although minimal effort by physicians could help many smokers to quit. This article summarizes the current data on smoking prevalence, reviews quitting techniques, covers topics of particular interest to physicians caring for women, and suggests ways in which physicians may become more active in preventing smoking among teens.

The extent of cigarette brand and company switching: results from the Adult Use-of-Tobacco Survey.

To evaluate the effects of cigarette advertising on brand switching, an accurate estimate of the extent of cigarette brand and company switching among current smokers is needed. Data from the 1986 Adult Use-of-Tobacco Survey were analyzed to estimate the percentage of adult smokers who switched cigarette brands and companies in the previous year. Approximately 9.2% of adult smokers (4.2 million) switched cigarette brands in 1986, and 6.7% (3.1 million) switched cigarette companies. The aggregate profitability of brand switching in 1986 was approximately $362 million. Based on this analysis, brand switching alone justifies only a small percentage of a cigarette company's advertising and promotion expenditures, suggesting that future research should address other potential effects of advertising, including maintenance of brand loyalty and expanding the cigarette market. Medical Subject Headings (MeSH): addictive behavior, advertising, smoking, tobacco.

Physical activity trends among 26 states, 1986-1990.

Data to monitor physical activity from large, representative samples are rare. Therefore, we conducted standardized telephone surveys for 26 states participating in the Behavioral Risk Factor Surveillance System from 1986 through 1990. More than 34,800 adults aged 18 and older responded annually. We scored leisure time physical activity data into four patterns: 1) physically inactive, 2) irregularly active, 3) regularly active, not intensive, and 4) regularly active, intensive. Over time, roughly 6 in 10 persons were physically inactive or irregularly active. While almost 4 in 10 persons were regularly active, less than 1 in 10 were regularly active, intensive. There were statistically significant decreases (-2.3%) in physically inactive persons and significant increases (+2.1%) in persons classified as regularly active, intensive. The irregularly active pattern did not change, while only men of all ages and men less than age 30 increased the regularly active, not intensive pattern (+1.7% and +3.8, respectively). Improvements across the activity patterns varied by demographic group: women and older adults made the most beneficial changes, while races other than white and the least educated groups had unfavorable changes. Despite many improvements, most persons still did little or no physical activity, signaling the need for enhanced intervention efforts.

Trends in cigarette smoking and physicians' advice to quit smoking among people with diabetes in the U.S.

OBJECTIVE: This study describes changes in the distribution of cigarette smoking and in physicians' advice to quit smoking among the U.S. population with and without diabetes from the mid-1970s to 1990. RESEARCH DESIGN AND METHODS: Data on self-reported smoking status, physicians' advice to quit smoking, history of diabetes, and demographic characteristics were obtained from the 1974, 1985, and 1990 National Health Interview Surveys. We examined the age-adjusted prevalence of smoking and physicians' advice to quit smoking by race, sex, and educational level among individuals with diabetes and those without diabetes. RESULTS: The prevalence of smoking decreased 9.8 percentage points from 1974 to 1990 among individuals with diabetes (from 35.6 to 25.8%, P < 0.01) and 11.7 percentage points among those without diabetes (from 37.3 to 25.6%, P < 0.01). For all years, younger individuals, men, and people with less than a high school education were more likely to smoke, regardless of diabetes status. Among individuals who had ever smoked, those with diabetes were more likely to have received advice to quit than those without diabetes; from 1974 to 1990, the percentage advised to quit smoking by a physician increased from 35.1 to 58.4% for smokers with diabetes and from 26.8 to 46.0% for smokers without diabetes. CONCLUSIONS: Despite decreases in smoking prevalence over time, people with diabetes are still as likely to smoke as those without diabetes. More than 40% of smokers with diabetes currently report never having received advice from a physician to quit smoking. Health care providers should increase their efforts to reduce smoking among people with diabetes.

Surveillance for selected tobacco-use behaviors--United States, 1900-1994.

PROBLEM/CONDITION: Surveillance of tobacco use is an essential component of any tobacco-control program. The information gathered can be used to guide research initiatives, intervention programs, and policy decisions. REPORTING PERIODS: This report covers the period 1900-1994 for per capita cigarette consumption; 1965-1991 for trends in cigarette smoking prevalence and cessation; 1974-1991 for trends in the number of cigarettes smoked daily by current smokers; 1987-1991 for recent patterns of tobacco use; 1970, 1987, and 1991 for trends in cigar/pipe smoking and snuff/chewing tobacco use; 1984-1992 for trends in state-specific prevalences of regular cigarette smoking; 1987-1992 for state-specific estimates of smokeless-tobacco use; and 1976-1993 for trends in cigarette smoking among U.S. high school seniors. DESCRIPTION OF SYSTEMS: Estimates of cigarette consumption are reported by the U.S. Department of Agriculture, which uses data from the U.S. Department of the Treasury, the U.S. Department of Commerce, the Tobacco Institute, and other sources. The National Health Interview Survey uses household interviews to provide nationally representative estimates (for the civilian, noninstitutionalized population) of cigarette smoking and other behaviors related to tobacco use. The Behavioral Risk Factor surveillance System uses telephone surveys of civilian, noninstitutionalized adults (> or = 18 years of age) to provide state-specific estimates of current cigarette smoking and use of smokeless tobacco. The University of Michigan's Institute for Social Research uses school-based, self-administered questionnaires to gather data on cigarette smoking from a representative sample of U.S. high school seniors. RESULTS: During the period 1900-1963, per capita cigarette consumption increased; after 1964, consumption declined. During the years 1965-1991, current cigarette smoking prevalence among persons ages > or = 18 years declined overall and in every sociodemographic category examined. Decrease in current smoking prevalence was slow in some groups (e.g., among persons with fewer years of formal education). Both the prevalence of never smoking and the prevalence of cessation increased from 1965 through 1991. The prevalence of current cigarette smoking, any tobacco smoking, and any tobacco use was highest among American Indians/Alaska Natives and non-Hispanic blacks and lowest among Asians/Pacific Islanders. The prevalence of cigar smoking and pipe smoking has declined substantially since 1970. The prevalence of smokeless-tobacco use among white males ages 18-34 years was higher in 1987 and 1991 than in 1970; among persons > or = 45 years of age, the use of smokeless tobacco was more common among blacks than whites in 1970 and 1987. Cigarette smoking prevalence has decreased in most states. The prevalence of smokeless tobacco use was especially high among men in West Virginia, Montana, and several southern states. From 1984-1993, prevalence of cigarette smoking remained constant among U.S. high school seniors. However, prevalence increased slightly for male seniors and white seniors, decreased slightly for female high school seniors, and decreased sharply for black high school seniors. INTERPRETATION: With the exceptions of increases in cigarette smoking among white and male high school seniors and in the use of smokeless tobacco among white males ages 18-34 years, reductions in tobacco use occurred in every subgroup examined. This decrease must continue if the national health objectives for the year 2000 are to be reached. ACTIONS TAKEN: Surveillance of tobacco use is ongoing. Effective interventions that discourage initiation and encourage cessation are being disseminated throughout the United States.

Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990.

PROBLEM/CONDITION: Mortality and years of potential life lost attributable to cigarette smoking. REPORTING PERIOD COVERED: 1990. DESCRIPTION OF SYSTEM: Mortality and years of potential life lost were estimated for each state by using the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software. These estimates were based on attributable risk formulas for smoking-related causes of death. Estimates of smoking prevalence were obtained from the Behavioral Risk Factor Surveillance System and the U.S. Bureau of the Census, and mortality data were obtained from CDC. RESULTS: The median estimate for the number of smoking-attributable deaths among states was 5,619 (range: 402 [Alaska] to 42,574 [California]). Within each state, the number of smoking-attributable deaths among males was approximately twice as high as among females. Utah had the lowest mortality rate (218.0 per 100,000 population) and the lowest percentage of all deaths attributable to cigarette smoking (13.4%). Nevada had the highest mortality rate (478.1 per 100,000 population) and the highest percentage of deaths from smoking (24.0%). The number of years of potential life lost ranged from 6,720 (Alaska) to 498,297 (California). INTERPRETATION: The number of deaths attributable to cigarette smoking in 1990 remained high. Efforts are needed to control tobacco use in all states. ACTIONS TAKEN: SAMMEC data are used in many states to assist policymakers in strengthening tobacco control efforts.

Trends in nonfatal coronary heart disease in the United States, 1980 through 1989.

BACKGROUND: Although coronary heart disease mortality has been decreasing, little is known about trends in morbidity from coronary heart disease. We evaluated trends in nonfatal coronary heart disease in the United States during 1980 through 1989. METHODS: We analyzed data from the National Health Interview Survey, an ongoing survey of representative samples of the civilian, noninstitutionalized population of the United States. Survey respondents were determined to have coronary heart disease if they reported ever having a myocardial infarction or heart attack, angina pectoris, or coronary heart disease. Incidence was defined as initial onset of a coronary heart disease condition during the year preceding the interview date. RESULTS: About 6 million people were estimated to be living with coronary heart disease. The age-standardized prevalence was relatively constant at about 25 per 1000. Among white men, however, prevalence increased significantly over the 10-year period. Among 75- to 84-year-old men, prevalence increased from 100 per 1000 in 1980 to 179 per 1000 in 1989. Among men and women 45 to 54 years old, prevalence decreased. Overall, the incidence rate of nonfatal coronary heart disease was relatively flat (at about 3 per 1000 per year after 1983). Among white women, the incidence rate increased from 1.4 to 2.8 per 1000, and by the end of the decade it nearly equaled the incidence rate among white men. CONCLUSIONS: Overall, the burden of nonfatal coronary heart disease remained fairly constant during the 1980s. The trends, however, were not uniform in all population groups. The apparent increasing incidence among women deserves continued monitoring. An encouraging trend is the decreasing prevalence in the younger age groups.

Recent trends in the identification and treatment of high blood cholesterol by physicians. Progress and missed opportunities.

OBJECTIVE: To investigate recent trends in the percentage and characteristics of patients being treated by a physician for high blood cholesterol (HBC) and to assess missed clinical opportunities to screen for HBC. DESIGN, SETTING, PARTICIPANTS: Telephone interviews of 154,735 adults in 37 states that participated in the Behavioral Risk Factor Surveillance System during 1988-1990 to assess trends in the percentage of patients treated for HBC by a physician. An opportunity was considered missed if a person did not report being screened for HBC despite seeing a physician for preventive care in the last 2 years. RESULTS: Between the first quarter of 1988 and the last quarter of 1990, the percentage of persons treated by a physician for HBC increased from 7.6% to 11.7% (P < .001). However, since an estimated 36% of US adults need treatment for HBC, fewer than one third of persons who need treatment are receiving it. Persons with two or more cardiac risk factors were more likely to be treated, while men, blacks, persons in lower socioeconomic groups, and persons between 20 and 34 years of age were less likely to be treated. Among the 126,571 persons who had seen a physician for preventive care within the last 2 years, missed opportunities to screen for HBC were most common among persons aged 20 through 34 years (59%) and among women who had seen obstetricians/gynecologists for preventive care (43%). CONCLUSIONS: Fewer than one third of persons who need treatment for HBC as estimated by data from the second National Health and Nutrition and Nutrition Examination Survey are receiving treatment. Better use of clinical opportunities to screen for HBC could substantially accelerate the progress in identifying persons, young adults in particular, who are likely to benefit from cholesterol reduction.

Physical activity behaviors in lower and higher socioeconomic status populations.

Few data on physical activity habits among populations of low socioeconomic status have been published. The authors studied physical activity habits--leisure-time physical activity, job-related physical activity, household physical activity, and walking--among 172 lower socioeconomic status women and 84 lower socioeconomic status men and compared their habits with those of 208 higher socioeconomic status women and 95 higher socioeconomic status men. All subjects resided in the greater Pittsburgh, Pennsylvania, area. Data collection occurred throughout 1986. Lower socioeconomic status women, the least active group, averaged 1,536 +/- 1,701 minutes/week (+/- standard deviation) of total physical activity, whereas higher socioeconomic status women, the most active group, averaged 2,079 +/- 1,807 minutes/week (p less than 0.0001). Higher socioeconomic status men averaged 1,952 +/- 1,799 minutes/week, and lower socioeconomic status men averaged 1,948 +/- 1,916 minutes/week. Higher socioeconomic status women spent significantly more time each week in leisure-time physical activity, job-related physical activity, and household physical activity than did lower socioeconomic status women. Lower socioeconomic status men spent significantly more time each week walking and doing household chores, whereas higher socioeconomic status men tended to be more active in leisure-time physical activity. These data suggest important quantitative and qualitative differences in physical activity among population subgroups. In view of the important role of physical activity in promoting physical and mental health, reasons for the differences among groups of varying socioeconomic status must be examined and elucidated.