Geroscience: Aging and Oral Health Research.

Research in aging has significantly advanced; scientists are now able to identify interventions that slow the biologic aging processes (i.e., the "hallmarks of aging"), thus delaying the onset and progression of multiple diseases, including oral conditions. Presentations given during the 3-part session "Geroscience: Aging and Oral Health Research," held during the 2023 American Association for Dental, Oral, and Craniofacial Research meeting, are summarized in this publication. Speakers' topics spanned the translational research spectrum. Session 1 provided an overview of the geroscience and health span (disease-free and functional health throughout life) concepts. The common molecular mechanisms between oral cancer and aging were discussed, and research was presented that showed periodontal microflora as a potential factor in Alzheimer's disease progression. Session 2 focused on behavioral and social science aspects of aging and their oral health significance. The keynote provided evidence that loneliness and isolation can have major health effects. These social conditions, along with poor oral health, tooth loss, and cognitive decline, could potentially affect healthy eating ability and systemic health in older adults. Research could help elucidate the directions and pathways connecting these seemingly disparate conditions. Session 3 focused on the delivery of oral care in different settings and the many barriers to access care faced by older adults. Research is needed to identify and implement effective technology and strategies to improve access to dental care, including new delivery and financing mechanisms, workforce models, interprofessional provider education and practice, and use of big data from medical-dental integration of electronic health records. Research to improve the "oral health span," reduce oral health disparities, and increase health equity must be tackled at all levels from biologic pathways to social determinants of health and health policies.

Edentulism Predicts Cognitive Decline in the US Health and Retirement Cohort Study.

This longitudinal cohort study examines if 1) cognitive decline varies by birth cohort, adjusting for covariates, and 2) edentulism and nonuse of dental care predict 10-y cognitive decline (2008-2018). The Health and Retirement Study (HRS) features a representative sample of US adults over age 50. Eligibility criteria included having cognitive interview data available and responding to the question, "Have you lost all of your upper and lower natural permanent teeth?" at 2+ time points between 2006 and 2018. Use of dental care in the past 2 y was assessed. Linear mixed models for repeated measures estimated the trajectories of mean cognition over time for the birth cohorts, adjusted for baseline cognition, dentition status, dental care use, and covariates (demographic characteristics, health behaviors, and medical conditions). Cohort-by-time interaction terms were included to assess if cognitive decline varied by birth cohort. Ten-year change in cognition status (measured by HRS Cogtot27)-categorized as dementia (<7); cognitive impairment, not demented (7-11) 7≤Cogtot27<12; and normal (≥12)-was also investigated according to birth cohort, dentition status, and dental care use. Mean (SD) baseline age was 63.4 (10.1) y (n = 22,728). Older birth cohorts had greater cognitive decline than younger cohorts. Linear mixed-model estimates and 95% confidence intervals for protective factors for cognitive decline included higher baseline cognition (HRS Cogtot27) (0.49; 0.48-0.50), use of dental care in the past 2 y (0.17; 0.10-0.23), and covariates such as greater household wealth and being married. Risk increased with being edentulous (-0.42; -0.56 to -0.28), history of stroke or diabetes, less education, Medicaid recipient, current smoker, loneliness, and poor/fair self-rated health. Edentulism and irregular dental care are among important predictors of cognitive decline. Tooth retention and regular dental care throughout life appear to be important for maintaining oral and cognitive health.

Prediction Model Development and Validation of 12-Year Incident Edentulism of Older Adults in the United States.

INTRODUCTION: Edentulism affects health and quality of life. OBJECTIVES: Identify factors that predict older adults becoming edentulous over 12 y in the US Health and Retirement Study (HRS) by developing and validating a prediction model. METHODS: The HRS includes data on a representative sample of US adults aged >50 y. Selection criteria included participants in 2006 and 2018 who answered, "Have you lost all of your upper and lower natural permanent teeth?" Persons who answered "no" in 2006 and "yes" in 2018 experienced incident edentulism. Excluding 2006 edentulous, the data set (n = 4,288) was split into selection (70%, n = 3,002) and test data (30%, n = 1,286), and Monte Carlo cross-validation was applied to 500 random partitions of the selection data into training (n = 1,716) and validation (n = 1,286) data sets. Fitted logistic models from the training data sets were applied to the validation data sets to obtain area under the curve (AUC) for 32 candidate models. Six variables were included in all models (age, race/ethnicity, gender, education, smoking, last dental visit) while all combinations of 5 variables (income, alcohol use, self-rated health, loneliness, cognitive status) were considered for inclusion. The best parsimonious model based on highest mean AUC was fitted to the selection data set to obtain a final prediction equation. It was applied to the test data to estimate AUC and 95% confidence interval using 1,000 bootstrap samples. RESULTS: From 2006 to 2018, 9.7% of older adults became edentulous. The 2006 mean (SD) age was 66.7 (8.7) for newly edentulous and 66.3 (8.4) for dentate (P = 0.31). The baseline 6-variable model mean AUC was 0.740. The 7-variable model with cognition had AUC = 0.749 and test data AUC = 0.748 (95% confidence interval, 0.715-0.781), modestly improving prediction. Negligible improvement was gained from adding more variables. CONCLUSION: Cognition information improved the 12-y prediction of becoming edentulous beyond the modifiable risk factors of smoking and dental care use, as well as nonmodifiable demographic factors. KNOWLEDGE TRANSFER STATEMENT: This prediction modeling and validation study identifies cognition as well as modifiable (dental care use, smoking) and nonmodifiable factors (race, ethnicity, gender, age, education) associated with incident complete tooth loss in the United States. This information is useful for the public, dental care providers, and health policy makers in improving approaches to preventive care, oral and general health, and quality of life for older adults.

Oral Diseases Associated with Nonalcoholic Fatty Liver Disease in the United States.

The US prevalence of nonalcoholic fatty liver disease (NAFLD) is 30.6% and increasing. NAFLD shares some risk factors with periodontitis and dental caries. We explored the association between NAFLD and several oral conditions among US adults, using data from the cross-sectional, nationally representative National Health and Nutrition Examination Survey (NHANES), 1988 to 1994. NAFLD was assessed with ultrasonography (USON), the screening gold standard not available in the more recent NHANES, and the noninvasive Fibrosis Score (FS), Fatty Liver Index (FLI), and US Fatty Liver Index (US-FLI) as other screening alternatives. There were 5,421 eligible dentate adults aged 21 to 74 y with complete relevant data, with transferrin levels ≤50%, without hepatitis B or C, who were not heavy drinkers. Multivariable models were developed to examine the independent effects of moderate-severe periodontitis, untreated dental caries, caries experience, and tooth loss (<20 teeth) on NAFLD while controlling for clinical, biological, and sociodemographic factors. Weighted estimates for odds ratios (ORs) and 95% CIs were calculated with logistic regression. Between 17% and 24% of adults had NAFLD depending on the classification criteria. In adjusted models, as compared with those with better oral health, adults with <20 teeth were more likely to have NAFLD depending on the measure (USON: OR = 1.50, 95% CI = 1.11 to 2.02; FS: OR = 4.36, 95% CI = 3.47 to 5.49; FLI: OR = 1.99, 95% CI = 1.52 to 2.59; US-FLI: OR = 2.32, 95% CI = 1.79 to 3.01). People with moderate-severe periodontitis were more likely to have NAFLD (USON: OR = 1.54, 95% CI = 1.06 to 2.24; FS: OR = 3.10, 95% CI = 2.31 to 4.17; FLI: OR = 1.61, 95% CI = 1.13 to 2.28; US-FLI: OR = 2.21, 95% CI = 1.64 to 2.98). People with any untreated caries were more likely to have NAFLD (USON: OR = 1.51, 95% CI = 1.20 to 1.90; FLI: OR = 1.80, 95% CI = 1.33 to 2.44). NAFLD was associated with tooth loss, periodontitis, and, for some NAFLD measures, untreated dental caries but not overall caries experience after controlling for several key sociodemographic and behavioral factors. Results suggest that further evaluation is needed to better understand this health-oral health interrelationship and potential opportunities for medical-dental integration.

Geography matters: state-level variation in children's oral health care access and oral health status.

OBJECTIVES: To ascertain differences across states in children's oral health care access and oral health status and the factors that contribute to those differences. STUDY DESIGN: Observational study using cross-sectional surveys. METHODS: Using the 2007 National Survey of Children's Health, we examined state variation in parents' report of children's oral health care access (absence of a preventive dental visit) and oral health status. We assessed the unadjusted prevalences of these outcomes, then adjusted with child-, family-, and neighbourhood-level variables using logistic regression; these results are presented directly and graphically. Using multilevel analysis, we then calculated the degree to which child-, family-, and community-level variables explained state variation. Finally, we quantified the influence of state-level variables on state variation. RESULTS: Unadjusted rates of no preventive dental care ranged 9.0-26.8% (mean 17.5%), with little impact of adjusting (10.3-26.7%). Almost 9% of the population had fair/poor oral health; unadjusted range 4.1-14.5%. Adjusting analyses affected fair/poor oral health more than access (5.7-10.7%). Child, family and community factors explained ∼» of the state variation in no preventive visit and ∼½ of fair/poor oral health. State-level factors further contributed to explaining up to a third of residual state variation. CONCLUSION: Geography matters: where a child lives has a large impact on his or her access to oral health care and oral health status, even after adjusting for child, family, community, and state variables. As state-level variation persists, other factors and richer data are needed to clarify the variation and drive changes for more egalitarian and overall improved oral health.

Renal Transplant Arterial Stenosis Treated With Bare-Metal Versus Drug-Eluting Stents: Comparison of Treatment Outcomes.

INTRODUCTION: This study aims to evaluate outcomes of bare-metal stents (BMS) versus drug-eluting stents (DES) in patients who undergo stenting for transplant renal arterial stenosis. MATERIALS AND METHODS: We retrospectively reviewed records of renal transplantation patients who underwent transplant renal arterial stenting from September 2009 to September 2013. All stents greater than 5 mm were excluded to allow for equivalent comparison between the DES and BMS groups. Statistical comparisons were performed using a two-tailed Fischer exact test, and analysis of continuous variables was analyzed using a one-way analysis of variance. RESULTS: The final study population included a total of 18 patients who received either BMS or DES (11 and 7 patients, respectively) for transplant renal arterial stenosis. The most common indications for stenting were increasing creatinine level and abnormal Doppler velocities. There were more re-interventions with BMS (n = 4/11) than DES (n = 0/7), but the trend was not statistically significant (P = .12). Three patients who received BMS had a clinically significant decrease in blood pressure versus 4 in the DES group (P = .33). Six patients who received BMS had a clinically significant decrease in creatinine level versus 3 in the DES group (P = 1.0). CONCLUSION: There is an absolute but not statistically significant difference in the incidence of restenosis requiring repeat intervention between the BMS and DES groups. No difference was detected in clinical success as measured by decreases in blood pressure or creatinine. Future larger studies are needed to corroborate these findings.

Maternal oral bacterial levels predict early childhood caries development.

OBJECTIVE: To calculate the association of maternal salivary bacterial challenge (mutans streptococci [MS] and lactobacilli [LB]) from pregnancy through 24 months' postpartum with child caries incidence (≥1 cavitated or restored teeth) at 36 months. MATERIALS & METHODS: Dental, salivary bacterial, sociodemographic, and behavioral measures were collected at three- to six-month intervals from a birth cohort of low-income Hispanic mother-child dyads (N = 243). We calculated the relative child caries incidence, adjusted for confounding, following higher maternal challenge of MS (>4500 colony-forming units per milliliter of saliva [CFU/mL]) and LB (>50 CFU/mL) based on multivariable models. RESULTS: Salivary MS and LB levels were greater among mothers of caries-affected children versus caries-free children. Mothers with higher salivary MS challenge were more likely to have MS-positive children (>0 CFU/mL), but maternal LB challenge was not a statistically significant predictor of child LB-positive status. Adjusting for sociodemographics, feeding and care practices, and maternal dental status, higher maternal salivary challenge of both MS and LB over the study period predicted nearly double the child caries incidence versus lower MS and LB (cumulative incidence ratio: 1.9; 95% confidence interval: 1.1, 3.8). CONCLUSION: Maternal salivary bacterial challenge not only is associated with oral infection among children but also predicts increased early childhood caries occurrence.

A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment).

This randomized parallel group clinical trial assessed whether combined antibacterial and fluoride therapy benefits the balance between caries pathological and protective factors. Eligible, enrolled adults (n = 231), with 1-7 baseline cavitated teeth, attending a dental school clinic were randomly assigned to a control or intervention group. Salivary mutans streptococci (MS), lactobacilli (LB), fluoride (F) level, and resulting caries risk status (low or high) assays were determined at baseline and every 6 months. After baseline, all cavitated teeth were restored. An examiner masked to group conducted caries exams at baseline and 2 years after completing restorations. The intervention group used fluoride dentifrice (1,100 ppm F as NaF), 0.12% chlorhexidine gluconate rinse based upon bacterial challenge (MS and LB), and 0.05% NaF rinse based upon salivary F. For the primary outcome, mean caries increment, no statistically significant difference was observed (24% difference between control and intervention groups, p = 0.101). However, the supplemental adjusted zero-inflated Poisson caries increment (change in DMFS) model showed the intervention group had a statistically significantly 24% lower mean than the control group (p = 0.020). Overall, caries risk reduced significantly in intervention versus control over 2 years (baseline adjusted generalized linear mixed models odds ratio, aOR = 3.45; 95% CI: 1.67, 7.13). Change in MS bacterial challenge differed significantly between groups (aOR = 6.70; 95% CI: 2.96, 15.13) but not for LB or F. Targeted antibacterial and fluoride therapy based on salivary microbial and fluoride levels favorably altered the balance between pathological and protective caries risk factors.

Value of drug-eluting stents after failed percutaneous transluminal angioplasty in the infrapopliteal vessels for the treatment of critical limb ischemia: favorable mid-term patency and limb salvage results.

AIM: The endovascular treatment of infrapopliteal arterial disease in the setting of critical limb ischemia (CLI) is increasing in use. In patients in whom percutaneous transluminal angioplasty (PTA) resulted in suboptimal angiographic results, flow limiting dissection or re-coil is thought to limit clinical success. This single-center experience examines the angiographic and clinical results when Drug-Eluting Stents (DES) were placed in a large cohort of patients with CLI after immediate infrapopliteal PTA failure. METHODS: A retrospective review of a prospectively collected single-center endovascular database was performed. Sixty-seven Rutherford grade 4, 5, and 6 patients were treated between October 2005 and February 2010 with PTA because lack of an acceptable autologous vein for bypass-grafting or severe medical comorbidities precluded them from surgical bypass. The study cohort had suboptimal angiographic results immediately after PTA that was subsequently treated with DES. Patients were then placed on clopidogrel and aspirin indefinitely. Angiographic, clinical, and the results of noninvasive vascular examinations were collected. RESULTS: In total, 123 stents (94 sirolimus, 27 everolimus, 2 paclitaxel) were placed in 67 patients to treat a total of 84 angiographic lesions. Simultaneous femoral-popliteal intervention was performed in 66% of the patients while 45% of the treated lesions were total occlusions. Lesion length ranged from 17 mm-142 mm (mean 50 mm). Initial technical success was 100%, with all 84 lesions being treated successfully with less than 10% stenosis after stent implantation. Mean follow-up was 20 months (1-42 months) with 6, 12, and 24-month primary patency rates of 90%, 86%, and 72% respectively. Freedom from major amputation was 91.1% (61/67) with all six amputations occurring in the Rutherford grade 6 group (6/11). Overall mortality rate was 19% (13/67) with one death occurring within 30 days. CONCLUSION: The use of drug-eluting stents following suboptimal PTA for the treatment of infrapopliteal arterial disease in this cohort of patients with CLI produced high primary patency and limb salvage rates supporting the efficacy of this treatment strategy.

Mothers' caries increases odds of children's caries.

There are many determinants of children's dental caries. We hypothesized that a mother's untreated caries was associated with increased likelihood of her children's untreated caries, after controlling for other factors. This population-based study was conducted in a rural, primarily Hispanic, California community. Interview and dental examination data for mother-child (children < 18 yrs old) dyads were analyzed. In a Generalized Estimation Equation (GEE) logit model for mothers (n = 179) and children (n = 387), maternal untreated caries was a statistically significant correlate of child's untreated caries, odds ratio (OR) = 1.76 (95%CI: 1.10, 2.70), adjusted for demographic factors. This relationship did not change when behavioral and dental utilization factors were added to the model, OR = 1.85 (95% CI: 1.12, 3.07). Maternal untreated caries almost doubled the odds of children's untreated caries and significantly increased child's caries severity by about 3 surfaces. Caries prevention and dental utilization programs for mothers and their children should be increased.

Multi-jurisdictional investigation of interactive fountain-associated cryptosporidiosis and salmonellosis outbreaks.

Interactive water fountains are established sources of gastrointestinal infections yet most health codes fail to regulate their design and operation. This report describes multi-agency, concurrent interactive fountain-associated cryptosporidiosis and salmonellosis outbreak investigations and highlights the need for the adoption of appropriate regulations for interactive fountains.

The effectiveness of sealants in managing caries lesions.

A barrier to providing sealants is concern about inadvertently sealing over caries. This meta-analysis examined the effectiveness of sealants in preventing caries progression. We searched electronic databases for comparative studies examining caries progression in sealed permanent teeth. We used a random-effects model to estimate percentage reduction in the probability of caries progression in sealed vs. unsealed carious teeth. Six studies, including 4 randomized-controlled trials (RCT) judged to be of fair quality, were included in the analysis (384 persons, 840 teeth, and 1090 surfaces). The median annual percentage of non-cavitated lesions progressing was 2.6% for sealed and 12.6% for unsealed carious teeth. The summary prevented fraction for RCT was 71.3% (95%CI: 52.8%-82.5, no heterogeneity) up to 5 years after placement. Despite variation among studies in design and conduct, sensitivity analysis found the effect to be consistent in size and direction. Sealing non-cavitated caries in permanent teeth is effective in reducing caries progression.

A randomized, placebo-controlled, double-blind clinical trial of curcuminoids in oral lichen planus.

We studied the efficacy of curcuminoids in the treatment of oral lichen planus (OLP), a chronic, mucocutaneous, immunological disease. Curcuminoids are components of turmeric (Curcuma longa) that have anti-inflammatory activity. Turmeric has been used in Ayurveda (Indian traditional medicine) for centuries. A randomized, double-blind, placebo-controlled trial was conducted. In all, 100 consecutive, eligible patients with OLP presenting to the oral medicine clinic at the University of California, San Francisco, were to be selected. Two interim analyses were to be conducted during the trial. The trial was conducted between February 2003 and September 2004. The first interim analysis was conducted in October 2004 using data from the first 33 subjects. Study subjects were randomized to receive either placebo or curcuminoids at 2000 mg/day for 7 weeks. In addition, all subjects received prednisone at 60 mg/day for the first 1 week. The primary outcome was a change in symptoms from baseline. Secondary outcomes were changes in clinical signs and occurrence of side effects. The first interim analysis did not show a significant difference between the placebo and curcuminoids groups. Conditional power calculations suggested a less than 2% chance that the curcuminoids group would have a significantly better outcome as compared with the placebo group if the trial were continued to completion. Therefore, the study was ended early for futility. Reaching a conclusion regarding the efficacy of curcuminoids based on the results of this study is not possible as it was ended early for futility. Curcuminoids at this dose were well tolerated and the results suggest that for future studies a larger sample size, a higher dose and/or longer duration of curcuminoids administration should be considered; however, for the next step, an RCT of a shorter duration, using a higher dose of curcuminoids, and without an initial course of prednisone, should be considered.

Fluoride varnish efficacy in preventing early childhood caries.

To determine the efficacy of fluoride varnish (5% NaF, Duraphat, Colgate) added to caregiver counseling to prevent early childhood caries, we conducted a two-year randomized, dental-examiner-masked clinical trial. Initially, 376 caries-free children, from low-income Chinese or Hispanic San Francisco families, were enrolled (mean age +/- standard deviation, 1.8 +/- 0.6 yrs). All families received counseling, and children were randomized to the following groups: no fluoride varnish, fluoride varnish once/year, or fluoride varnish twice/year. An unexpected protocol deviation resulted in some children receiving less active fluoride varnish than assigned. Intent-to-treat analyses showed a fluoride varnish protective effect in caries incidence, p < 0.01. Analyzing the number of actual, active fluoride varnish applications received resulted in a dose-response effect, p < 0.01. Caries incidence was higher for 'counseling only' vs. 'counseling + fluoride varnish assigned once/year' (OR = 2.20, 95% CI 1.19-4.08) and 'twice/year' (OR = 3.77, 95% CI 1.88-7.58). No related adverse events were reported. Fluoride varnish added to caregiver counseling is efficacious in reducing early childhood caries incidence.

Welfare dental intervention improves employment and quality of life.

Chronic, untreated oral disease adversely affects one's systemic health, quality of life, and economic productivity. This study evaluated the effect of rehabilitative dental treatment on the oral-health-related quality of life and employment of welfare recipients. Three hundred and seventy-seven participants in a novel welfare dental program received oral examinations, questionnaires, and rehabilitative dental treatment. Seventy-nine percent of participants exhibited improvement in their oral-health-related quality-of-life scores following dental treatment. Improved OHIP-14 change scores were associated with being Caucasian or African-American, initial poor general health, severity of treatment urgency, worse baseline oral-health-related quality-of-life scores, subsequent patient satisfaction with the Dental Program, and resolution of their chief complaint (all p < 0.04). Those who completed their dental treatment were twice as likely to achieve a favorable/neutral employment outcome (OR = 2.01, 95%CI = 1.12, 3.62). Thus, oral health improved the quality of life and employment outcome for this welfare population.

Clinical trial of a plant-derived antibody on recolonization of mutans streptococci.

OBJECTIVE: This double-blinded, placebo-controlled clinical trial tested the safety and efficacy of a topical secretory IgA antibody manufactured in tobacco plants (plantibody) in preventing recolonization of mutans streptococci (MS) in human plaque as measured by whole stimulated saliva samples. METHODS: Following a 9-day antimicrobial treatment with chlorhexidine (CHX), 56 eligible adults (enrollment salivary MS > or = 10(4) CFU/ml; no current caries) were randomized equally to a group receiving 0, 2, 4, or 6 topical applications of plantibody followed by 6, 4, 2, or 0 applications of placebo, respectively, over a 3-week period. RESULTS: Among the 54 subjects who completed the trial, the CHX regimen eliminated salivary MS in 69%. After 6 months, there were no significant differences in MS levels by number of applications, relative to placebo (p > 0.43). No adverse effects were observed. CONCLUSION: Plantibody is safe but not effective at the frequency, concentration, and number of applications used in this study.

A prospective study of the relationship between body mass index and cataract extraction among US women and men.

BACKGROUND: Obesity may influence several physiologic processes involved in cataract formation such as oxidative stress, glycosylation and osmotic stress. OBJECTIVE: To examine the association between increased body mass index (BMI) and the incidence of cataract extraction. DESIGN AND SETTING: The Nurses' Health Study and the Health Professionals Follow-up Study, both prospective cohort studies of US women and men. SUBJECTS: A total of 87 682 women and 45 549 men aged 45 y and older who did not have diagnosed cataract or cancer at baseline (1980 for women, 1986 for men). MEASUREMENTS: Cataract extractions occurring between baseline and 1996, confirmed by medical records. RESULTS: During 16 y of follow-up in the women, and 10 y in the men, (1 097 997 person-y), 4430 incident cases were documented. Compared to participants with BMI less than 23 kg/m(2), those with BMI greater than or equal to 30 kg/m(2) had 36% higher risk of any type of cataract (pooled multivariate relative risk (RR), 1.36; 95% CI, 1.23-1.49) after adjusting for smoking, age and lutein/zeaxanthin intake. The association was strongest for posterior subcapsular (PSC) cataract (pooled multivariate RR, 1.99; 95% CI, 1.55-2.55). With adjustment for diabetes, the RR of obesity associated with posterior subcapsular cataract was 1.68 (95% CI, 1.30-2.17). Obesity was not significantly associated with nuclear cataract. CONCLUSION: Obesity increases the risk of developing cataract overall, and of PSC cataract in particular; the etiology of PSC cataract may be mediated at least in part by glucose intolerance and insulin resistance, even in the absence of clinical diabetes.

Trends in prevalence of current smoking, Massachusetts and states without tobacco control programmes, 1990 to 1999.

OBJECTIVE: To assess the effect of a comprehensive tobacco control programme initiated in Massachusetts in 1993, and to compare the 1990 to 1999 trend in smoking prevalence to that in 41 states without tobacco control programmes, controlling for demographic shifts over time. DESIGN: Data from the Behavioral Risk Factor Surveillance System for the years 1990 to 1999 were used to examine changes and trends in prevalence of smoking using multivariate logistic regression models. MAIN OUTCOME MEASURES: Trend in prevalence of current smoking for the years 1990 to 1999. RESULTS: In 1990, the prevalence of current smoking in Massachusetts was 23.5% (95% confidence interval (CI) 21.0% to 26.1%), and 24.2% in the rest of the USA (95% CI 23.7% to 24.7%). By 1999, the prevalence had declined in Massachusetts to 19.4%, and to 23.3% in 41 other US states. Controlling for sex, age, race, and education, there was a greater decline in current smoking between 1990 and 1999 among Massachusetts men than among Massachusetts women, and the decline was greater in Massachusetts than in the rest of the USA for men and for both sexes combined. CONCLUSIONS: These results suggest that the Massachusetts Tobacco Control Program is having a beneficial impact, but suggest a need for additional targeted efforts to achieve similar declines among Massachusetts women.