Georgia epidemiology report, Vol. 14, no. 4 (Apr. 1998)

Georgia Epidemiology Report
The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources

April 1998

Volume 14 Number 4

http://www.ph.dhr.state.ga.us
Division Of Public Health
Kathleen E.Toomey, MD, MPH- Director
Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, MD, MPH- Acting Director
Epidemiology Section Paul A Blake, MD, MPH- Chief
Notifiable Diseases
Jeffrey D. Berschling, MPH; Cherie L. Drenzek, DVM, MS; Katherine Gibbs McCombs, MPH; Jane E. Koehler, DVM, MPH; Preeti Pathela, MPH, Laura Gilbert, MPH
Chronic Disease
Ken Powell, MD,MPH- Program Manager , Nancy E. Stroup, PhD, Patricia M. Fox, MPH; A. Rana Bayakly, MPH; Mary P. Mathis, PhD, MPH
Tuberculosis
Rose Marie Sales, MD, MPH- Program Manager Naomi Bock, MD, MS; Beverly DeVoe, MPH
HIV/AIDS/Sexually Transmitted Diseases
John F Beltrami, MD, MPH- Program Manager Andrew Margolis, MPH, Lyle McCornick, MPH, Ann Buckely, MPH, Amy Hephner, MPH Laura Axelson, MPH
Perinatal Epidemiology
James W. Buehler, MD- Program Manager Leslie E. Lipscomb, MPH, Cheryl Silberman,PHD,MPH
Preventive Medicine Residents
Scott E. Kellerman, MD,MPH; Alexander K. Rowe, MD,MPH
EIS Officer
Michael S. Friedman, MD
Georgia Epidemiology Report
Editorial Board
Editorial Executive Committee Cherie Drenzek, DVM, MS - Editor Jeffrey D. Berschling, MPH Paul A. Blake, MD, MPH Kathleen E. Toomey, MD, MPH
Mailing List Marsha Wilson
Graphics Jimmy Clanton & Christopher DeVoe

Smoking in Georgia: Prevalence and
Mortality for 1996
Background
Cigarette smoking is the most important avoidable cause of death in the United States (1). Smoking has been associated with heart disease and stroke, chronic obstructive pulmonary disease, low birth weight, sudden infant death syndrome, fire-related deaths, and cancers of the lung, head and neck, pancreas, cervix, urinary bladder, and kidney (2). The burden and costs associated with death and disease due to smoking are staggering. Nationally, tobacco use causes over 400,000 deaths per year, about 19% of all reported deaths. Tobacco use costs an estimated $50 billion in direct health care costs and $45 billion in indirect costs (1,3).
Until recently, the prevalence of smoking among adult Georgians was declining. From 1984 to 1992, the prevalence decreased by one-third, from 31% to 19%. However, from 1992 to 1993, the prevalence increased to 24% (4). Youth smoking rates are lower than those of adults, but are not negligible: in 1995, an estimated 10% of Georgia high school students reported frequent cigarette use1 (5).
The purpose of this analysis is to describe the prevalence of smoking among Georgia adults and estimate the mortality attributable to smoking in Georgia for 1996.
Methods
Mortality attributable to smoking was estimated using the Centers for Disease Control and Prevention's (CDC) SAMMEC 3.0 software package (2). In the SAMMEC model, cause-, sex-, and agespecific smoking attributable risks for three exposure categories (current smokers, former smokers, and women who smoked during pregnancy) were estimated from several large prospective studies (2). Smoking attributable deaths are estimated by using smoking attributable risks and smoking prevalence to estimate smoking attributable fractions (in other words, a population attributable risk percent) and then applying the smoking attributable fractions to the cause-, sex- and age-specific numbers of deaths in the population under study. The SAMMEC model does not include deaths from passive exposure to environmental cigarette smoke.
The mortality estimates from SAMMEC for Georgia are based upon Georgia deaths, smoking prevalences, and population estimates for 1996. Mortality data were compiled by the Georgia Department of Human Resources' Health Assessment Services Section. The number of smoking-related burn deaths for 1996 was estimated by multiplying the total number of 1996 Georgia burn deaths (from all causes) by the estimated proportion of burn deaths caused by fires started by "careless smoking." (6,7)
In the SAMMEC analysis of years of potential life lost, the difference between the actual age at death and the United States 1991 years of life remaining to life expectancy was used to estimate the prematurity of smoking attributable deaths (2).
Smoking prevalence was estimated by the 1996 Georgia Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of a representative sample of Georgia adults 18 years of age and older (8). A current smoker was defined as any respondent who reported smoking at least 100 cigarettes during his or her lifetime and who reported smoking either "every day" or "some days." For pregnant women, the prevalence of smoking was estimated by the 1996 Georgia Pregnancy Risk Assessment Monitoring System (PRAMS), a representative sample of post-partum women in Georgia (9,10). Georgia smoking prevalences for 1984 to 1995 were estimated by the BRFSS in those years. Questions on smoking were modified slightly in 1994 and 1996. Population estimates were supplied by the U.S. Bureau of the Census (11).
Since the BRFSS is a cluster survey in which responses within clusters may be correlated, estimates of standard errors and hypothesis testing were performed using SUDAAN 7.50, a statistical software package that accounts for correlation in the data (12). Weighted point prevalences were estimated using SAS 6.11 (SAS Institute Inc., Cary, NC).

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

Results

In 1996, 20.3% of Georgia adults 18 years and older reported being a current smoker, and 14.2% reported being a former smoker. In other words, there were about 1.1 million current smokers and 750,000 former smokers among adult Georgians in 1996. Among current smokers, most (85.2%) reported smoking every day while the remainder reported smoking some days. The smoking prevalence among women who gave birth in 1996 was 12.5%.
The prevalence of smoking among Georgians has increased in recent years. From 1984 to 1992, the smoking prevalence decreased by an average of 5.7% per year. In contrast, from 1992 to 1996, the prevalence increased by an average of 1.9% per year (Figure 1).
In 1996, the smoking prevalence among men (24.7%) was 50% greater than among women (16.3%) (Table 1). This difference was found in most subgroups of age, income, marital status, employment status, and education level (data not shown). By age group, Georgians 45-54 years of age had the highest prevalence (28.4%) while those 65 years and older had the lowest prevalence (12.9%). The prevalence was about twice as high among Georgians who reported being divorced or separated (38.1%) compared to those who reported being married (17.6%), widowed (18.0%), or never married (20.0%). Smoking was also more commonly reported among Georgians who said they were unemployed or unable to work (34.8%) compared to those who said they were employed (21.4%), retired (16.0%), a homemaker (13.8%) or a student (11.0%). Smoking was less common among Georgians with higher incomes and education levels. Smoking prevalences were similar among Blacks, Whites, and Hispanics.
Smoking attributable deaths accounted for 10,057 (17.1%) of the 58,767 deaths occurring among Georgians in 1996, or one out of every six deaths (Table 2). The smoking-related diseases that most commonly caused these deaths were cardiovascular diseases (4090 deaths, or 40.7%), lung cancer (2947 deaths, or 29.3%) and chronic obstructive lung disease (1776 deaths, or 17.7%). Over one-third of these deaths occurred among Georgians younger than 65 years of age.
Of the 10,057 smoking attributable deaths, 9998 occurred among smokers and former smokers; the remaining 59 deaths occurred in either infants of smokers or people who died in fires started by a cigarette. Among the 9998 smokers and formers smokers who died because of their smoking habit, 145,831 years of potential life were lost. In other words, smoking shortened the lives of these Georgians by an average of 14.6 years.

Discussion
There are four key findings of this study: 1) one of every six deaths in Georgia was caused by smoking; 2) smokers who died from a smoking-related disease died an average of 15 years prematurely; 3) one of every five Georgia adults reported being a current smoker; and 4) the decline in the Georgia smoking prevalence has stopped.

Table 1. The Prevalence of smoking among Georgia adults 18 years and older, 1996

Attribute

[%]

Total

20.3

Sex

Female

16.3

Male

24.7

Race

White, non-Hispanic

21.0

Black, non-Hispanic

18.0

Hispanic

19.9

Age group

18-24 years

18.7

25-44 years

20.6

45-54 years

28.4

55-64 years

18.0

65+ years

12.9

Education level

Did not graduate high school 26.2

High school graduate

27.6

Some college

18.2

College graduate

11.3

Income

Less than $15,000

23.6

$15-34,999

27.6

$35-74,999

18.1

$75,000 or more

10.6

95%CI (18.4 - 22.2)
(14.1 - 18.4) (21.5 - 27.8)
(18.9 - 23.3) (14.2 - 21.8) (8.3 - 31.4)
(11.9 -25.4) (18.0 - 25.3) (23.2 - 33.5) (12.4 - 23.6) (9.6 - 16.3)
(20.4 - 31.9) (23.5 - 31.7) (15.2 - 21.2) (8.3 - 14.3)
(17.4 - 29.9) (23.5 - 31.7) (15.3 - 20.9) (6.5 - 14.8)

Difference1 p-value2

reference 8.4
reference -3.1 -1.2
reference 2.0 9.7 -0.7 -5.7
reference 1.4 -8.0
-14.9
reference 3.9 -5.5
-13.0

<0.01
0.16 0.83
0.60 0.03 0.88 0.13
0.69 0.02 0.01
0.30 0.12 <0.01

Attribute

[%]

Marital status

Married

17.6

Divorced or separated

38.1

Widowed

18.0

Never married

20.0

Employment status

Employed or self-employed 21.4

Unemployed or unable to work 34.8

Homemaker

13.8

Student

11.0

Retired

16.1

95%CI
(15.3-19.8) (31.8-44.3) (11.9-24.1) (14.9-25.0)
(19.1-23.7) (24.9-44.6) (8.1-19.6) (3.1-18.9) (11.5-20.7)

Difference1
reference 20.5 0.4 2.4
reference 13.3 -7.6 -10.4 -5.3

p-value2
<0.01 0.90 0.40
0.01 0.02 0.01 0.04

Source is the 1996 Georgia Behavioral Risk Factor Suveillance System. CI denotes confidence interval. 1. Absolute difference relative to the reference group. 2.Testing whether the difference from the reference group
(column 4) is equal to zero.
Among adults in Georgia, high-risk groups for smoking include men, people who are middle-aged, divorced or separated, unemployed, have not attended college; and have low incomes. These findings agree with other studies of smoking in Georgia (3,4). In addition to activities aimed at preventing smoking (especially among children and adolescents), clinicians and tobacco screening programs may want to focus their smoking cessation efforts on these groups in which smoking is most common.
The low prevalence among older Georgians may reflect a high mortality rate experienced by smokers as they age. Because smokers are less likely to survive to their 65th birthday, the remaining pool of Georgians 65 years of age and older contains relatively fewer smokers. The low prevalence among older Georgians is probably not caused by higher quitting rates because the proportion of former smokers (ie, those who have quit) is similar among Georgians 65 years of age and older and Georgians 55-64 years of age (data not shown).
The SAMMEC model is likely to underestimate the mortality in 1996 due to cigarette smoking. First, smoking attributable mortality was based upon smoking prevalence estimates for 1996. Since most smoking-related diseases develop slowly, using the higher smoking prevalence estimates from the decades preceding 1996 may give a more accurate estimate of the number of deaths. Second, the SAMMEC model does not account for deaths from passive exposure to environmental cigarette smoke. Nationally, an estimated 37,000-40,000 cardiovascular deaths and 3,000 lung cancer deaths are attributed to passive smoke exposure each year (2,13).
In spite of the news of lawsuits against tobacco companies, smoking continues to exact a heavy toll. However, smoking can be prevented and controlled, and efforts to do so will need to be continued regardless of the outcomes of the lawsuits. CDC's tobacco control program emphasizes six strategies (14): 1) prevention; 2) treatment and cessation; 3) reduction of exposure to environmental tobacco smoke;4) counter-advertising and promotion; 5) economic incentives; and, 6) product regulation.
For clinicians encouraging their patients to quit smoking, the Agency for Health Care Policy and Research (AHCPR) published a clinical practice guideline on smoking cessation2 (15). This guideline describes successful smoking cessation interventions and presents supporting research. A recent article found the guideline to be "extremely cost-effective" (16).
In conclusion, smoking continues to be a major cause of preventable death in Georgia, causing approximately one out of every six deaths. Tobacco control requires a multifaceted strategy implemented by legislators, employers, communities, health care providers, and individuals3 .

1 Frequent cigarette use was defined as smoking on at least 20 of the 30 days preceding the survey.
2 For more information, call 1-800-358-9295, or visit the website of the AHCPR (http://www.ahcpr.gov/).
3 For more information, contact Pam Eidson, Georgia Department of Human Resources, Tobacco Prevention Education Program. Phone: 404-657-2570 Fax: 404-657-6631 Internet address: ple0600@dhr.state.ga.us/

Contributors This report was contributed by AK Rowe MD, MPH, KE Powell, MD, MPH and NE Stroup, Ph D, Chronic Disease and Injury Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources.

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Table 2. Smoking related1 and total mortality among Georgians in 1996, by cause and sex.

Cause of death
Neoplasms Lung, bronchus, trachea Other neoplasms2
Cardiovascular diseases Hypertension Ischemic heart disease Cerebrovascular disease Other cardiovascular diseases3
Respiratory diseases Pneumonia, influenza Bronchitis, emphysema, chronic airway obstruction Other respiratory diseases4
Perinatal conditions5
Burn deaths
Conditions not associated with smoking

No. of deaths attributed to smoking

Male

Female Total

2114

833 2947

509

214

723

102

63

165

1216

556 1772

453

243

696

970

487 1457

257

174

431

1065

711 1776

17

14

31

21

15

36

15

8

23

0

0

0

All deaths
3691 1759
1150 9504 4253 8459
2102 2381
154 441 174 24,699

Percent of all deaths attributed
to smoking
79.8 41.1
14.3 18.6 16.4 17.2
20.5
74.6 20.1
8.2
13.2
0

Total

6739

3318 10,057

58,767

17.1

Footnotes: 1. Using the Smoking Attributable Morbidity Mortality and Economic Cost software package, version 3.0. 2. Other neoplasms includes lip, oral cavity, pharynx, larynx, esophagus, pancreas, cervix uteri, urinary bladder and kidney. 3. Other cardiovascular diseases includes rheumatic heart disease, pulmonary embolism, pulmonary hypertension, cardiomyopathies, arrhythmias, congestive heart failure, atherosclerosis, aortic
aneurysms and peripheral vascular disease. 4. Other respiratory diseases include pulmonary tuberculosis and asthma.
5. Perinatal conditions include short gestation, low birth weight, respiratory distress syndrome and sudden infant death syndrome

References

Figure 1. Prevalence of smoking among Georgia adults, 1984-1996.

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-2212.
2. U.S. Department of Health and Human Services. Smoking-

Percent 35

Attributable Mortality, Morbidity, and Economic Costs

(SAMMEC) 3.0: Computer Software and Documentation.

30

Rockville, MD: Public Health Service, Centers for Disease Control

and Prevention, National Center for Chronic Disease Prevention

25

and Health Promotion, Office on Smoking and Health, August

1996.

3. Centers for Disease Control and Prevention. State Tobacco

20

Control Highlights--1996. Atlanta: Centers for Disease Control

and Prevention, National Center for Chronic Disease Prevention

15

and Health Promotion, Office on Smoking and Health, 1996.

4. Chronic Disease, Epidemiology and Prevention Branch. Health
risk behaviors among Georgia adults, 1992-1993. Atlanta: Georgia 10
Division of Public Health, 1996.

Prevalence decreased by 5.7% per year

Prevalence increased by 1.9% per year

5. Centers for Disease Control and Prevention. Youth Risk Factor

5

Behavior Surveillance--United States, 1995. MMWR 1996;45

SS-4. 6. Office of Safety Fire Commissioner. Fax-Wire May/June 1997. 7. Patetta, MJ, Cole TB. A population-based descriptive study of

0 84 85 86 87 88 89 90 91 92 93 94 95 96

housefire deaths in North Carolina. Am J Public Health 1990;80:1116-7.

Year

8. Health Risks in America. Gaining insight from the Behavioral Risk

Source: The Georgia Behavioral Risk Factor Surveillance System.

Factor Surveillance System. Atlanta, GA: Nation Center for

Note: Refusals and unknown responses were excluded.

Chronic Disease Prevention and Health Promotion.

9. Adams MM, Shulman HB, Bruce C, Hogue C, Brogan D, the PRAMS Working Group. The Pregnancy Risk Assessment Monitoring System: design,questionnaire, data collection and

response rates. Paediatric and Perinatal Epidemiology 1991;5:333-346

10. Rohweder C. The Pregnancy Risk Assessment Monitoring System (PRAMS): defining behaviors and experiences of mothers in Georgia. Georgia Epidemiology Report July 1995;

Volume 11, Number 7, pages 1-3.

11. Population Estimates Program, Population Division, United States Bureau of the Census, Washington, DC. Release date April 21, 1997. Accessed via Internet address

http://www.census.gov/population/www/estimates county pop.html

12 Shah BV, Barnwell BG, Bieler GS (1996). SUDAAN User's Manual, Release 7.0. Research Triangle Part, NC: Research Triangle Institute.

13. The 1997 Heart and Stroke Statistical Update. American Heart Association, National Center, Dallas, TX, 1996.

14. CDC's Tobacco Use Prevention Program: Working Toward a Healthier Future. At-A-Glance, 1996. Atlanta, GA: Office on Smoking and Health, Nation Center

for Chronic Disease Prevention and Health Promotion.

15. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No 18. Rockville, MD: US Department of Health and Human Resources, Public Health Service,

Agency for Health Care Policy and Research. AHCPR Publication number. 96-0692. April 1996.

16. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the Clinical Practice Recommendations in the AHCPR Guideline for Smoking

Cessation. JAMA. 1997;278:1759-1766.

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The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

April 1998

Volume 14 Number 4

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for January 1998

Selected Notifiable Diseases

Total Reported for Jan. 1998 1998

Previous 3 Months Total

Ending in Jan.

1996

1997

1998

Previous 12 Months Total

Ending in Jan.

1996

1997

1998

Campylobacteriosis

50

178

131

198

1026

776

686

Chlamydia genital infection

1368

2523

2263

4687

11635

13531

16714

Cryptosporidiosis

5

17

13

17

114

91

77

E. coli O157:H7

2

4

13

5

29

48

37

Giardiasis

63

119

212

251

596

847

907

Gonorrhea

1455

5785

3893

4917

21358

19470

18587

Haemophilis influenzae (invasive)

10

12

16

18

40

51

48

Hepatitis A (acute)

51

15

97

176

88

429

783

Hepatitis B (acute)

27

7

17

66

91

68

241

Lead Poisoning (capillary BLL >= 10 ug/dL)

n/a

616

531

61

2998

2997

1651

Lead Poisoning (venous BLL >= 10 ug/dL)

n/a

120

161

44

618

661

705

Legionellosis

0

1

0

3

14

3

6

Lyme Disease

1

0

1

2

14

2

9

Meningococcal Disease (invasive)

20

43

28

34

109

140

115

Mumps

0

4

3

1

12

10

9

Pertussis

0

6

8

2

30

36

15

Rubella

0

0

0

0

0

0

0

Salmonellosis

90

365

353

302

1687

1444

1356

Shigellosis

79

139

399

406

1260

1155

1132

Syphilis - Primary

9

61

43

27

284

191

147

Syphilis - Secondary

12

138

98

48

640

478

331

Syphilis - Early Latent

64

346

301

184

1639

1322

992

Syphilis - Other

55

245

326

165

1142

1086

1108

Syphilis - Congenital

1

18

4

1

64

28

23

Tuberculosis

26

200

197

132

768

775

657

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period

Total Cases Reported *

Percent Female

Risk Group Distribution (%)

Race Distribution (%)

MSM IDU MSM&IDU HS Blood Unknown White Black Other

Latest 12 Months: 04/97 to 03/98 Five Years Ago: 04/92 to 03/93 Cumulative: 7/81 to 03/98

1521

20.1

38.2

19.2

3.4

16.9 1.5

20.8

23.9

1898

14.5

49.4

22.2

6.4

11.7 2.2

8.1

35.9

19017

15.0

51.2

19.2

5.8

11.9 2.0

9.9

39.1

MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

73.4 2.8 62.5 1.6 58.9 2.0

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