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. - 2 - 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. - 3 - 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 - 4-