Georgia tobacco surveillance report

2004 Georgia Tobacco
Surveillance Report

Acknowledgements
Georgia Department of Human Resources B.J. Walker, Commissioner
Division of Public Health Kathleen E. Toomey, M.D., M.P.H., Director
Chronic Disease Prevention and Health Promotion Branch Carol Steiner, R.N., M.N., Acting Director
Tobacco Use Prevention Section Carol Steiner, R.N., M.N., Acting Director Epidemiology Branch Paul A. Blake, M.D., M.P.H., Director Chronic Disease, Injury, and Environmental Epidemiology Section Kenneth E. Powell, M.D., M.P.H., Chief Division of Mental Health, Developmental Disabilities and Addictive Diseases Gregory C. Hoyt, Acting Director Addictive Diseases Section Bruce Hoopes, MSW, CAC II, Chief Georgia Cancer Coalition William J. Todd, President Nancy M. Paris, Vice-President Georgia Department of Revenue Bart L. Graham, Commissioner Alcohol and Tobacco Division Ronald D. Johnson, Director
Data for this report were provided by: Manxia Wu, M.D., M.P.H., Surveillance and Special Studies; Linda Martin, M.S., BRFSS Coordinator; Emily Kahn, Ph.D., Chief, Maternal and Child Health; and Travis Fretwell, MAC, NCAC II, CCS, State Synar Coordinator/Addictive Diseases Specialist. This report was produced with funding and support from the Georgia Cancer Coalition. Suggested Citation: Figueroa A, Kanny D, Chowdhury PP, Powell KE. 2004 Georgia Tobacco Surveillance Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, September 2004. Publication Number: DPH04/232HW Further information on this report may be obtained by contacting: Argelia Figueroa, M.Sc., Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section. 2 Peachtree St., 14.494, Atlanta, GA 30303-3142 404-463-4629 afigueroa@dhr.state.ga.us For more information about the Tobacco Use Prevention Program contact Delmonte Jefferson, Georgia Department of Human Resources, Division of Public Health, Chronic Disease Prevention and Health Promotion Branch. 2 Peachtree St., 16th Floor, Atlanta, GA 30303-3142 404-657-6611 dpjefferson@dhr.state.ga.us
i 2004 Georgia Tobacco Surveillance Report

Table of Contents

Executive Summary .......................................................................................................................................1 Introduction ...................................................................................................................................................2 Burden of Tobacco in Georgia.......................................................................................................................3
Mortality ..........................................................................................................................................................3 Years of Potential Life Lost..............................................................................................................................4 Economic Costs ..............................................................................................................................................4 Tobacco Use in Georgia.................................................................................................................................5 Cigarette use among adults.............................................................................................................................5 Cigarette use among pregnant women...........................................................................................................7 Tobacco use among youth...............................................................................................................................8 Reducing Tobacco Use in Georgia...............................................................................................................11 Former smokers............................................................................................................................................11 Smoking cessation .........................................................................................................................................12 Georgia Tobacco Quit Line Survey ...............................................................................................................13 Policy and Environment Surveillance..........................................................................................................14 School Health Education Profile....................................................................................................................14 Georgia Worksite Health Promotion Policies and Practices Survey .............................................................15 Restaurant Survey..........................................................................................................................................16 Local Tobacco Ordinance Tracking Survey....................................................................................................16 Enforcement..................................................................................................................................................17 Taxation .........................................................................................................................................................17 Summary and Conclusions ..........................................................................................................................19 Methodology and Limitations......................................................................................................................20 Glossary ........................................................................................................................................................26 References....................................................................................................................................................28
Tables

Table 1. Table 2.
Table 3. Table 4. Table 5.
Table 6.
Table 7. Table 8.

Causes of death for which tobacco is a contributing cause .....................................................................2
Years of potential life lost (YPLL), number of deaths, and average YPLL attributed to smoking by disease category and sex, Georgia, 2001 ...............................................4
Annual smoking-attributable economic costs, Georgia, 2001 .................................................................4
Cessation strategies used after calling the Georgia Quit Line, 2002......................................................13
Schools with policies prohibiting the use of tobacco products by type of product, Georgia, 2002 ..............................................................................................................14
Schools with policies prohibiting the use of tobacco products by school environment, Georgia, 2002 .........................................................................................................................................14
Jurisdictions with tobacco-related ordinances by jurisdiction type, Georgia, 2001 ...............................16
Excise taxes on cigarettes, cigars, and smokeless tobacco, United States and Georgia, 2002-2003 ..................................................................................................18

ii 2004 Georgia Tobacco Surveillance Report

Table of Contents
Figures
1. Deaths among adult Georgians ages 35 years and older, 2001 .............................................................................3 2. Deaths among infants one year and younger, Georgia, 2001................................................................................3 3. Current smoking among Georgia adults 18+ years, 1984-2001 ..........................................................................5 4. Smoking status among Georgia adults 18+ years, 2001 .......................................................................................5 5. Smoking prevalence by sex and race/ethnicity, Georgia adults 18+ years, 2001 .................................................6 6. Smoking prevalence by sex and age, Georgia adults 18+ years, 2001 .................................................................6 7. Smoking prevalence by education and sex, Georgia adults 18+ years, 2001.......................................................7 8. Smoking during pregnancy by race, Georgia, 2001 ...............................................................................................7 9. Tobacco use by school type and tobacco product, Georgia, 2001 .......................................................................8 10. Smoking prevalence by school type and sex, Georgia, 2001.................................................................................8 11. Smoking prevalence by school type and race/ethnicity, Georgia, 2001.................................................................9 12. Place of purchase of cigarettes by school type and place, Georgia, 2001 .............................................................9 13. Percentage of students living with smoker by school type and smoking status, Georgia, 2001..........................10 14. Percentage of former smokers among ever smokers by age, Georgia adults 18+years, 2001 ..........................11 15. Percentage of former smokers among ever smokers by education, Georgia
adults 18+years, 2001.........................................................................................................................................11 16. Percentage of current smokers who quit for 1 day in past year by race/ethnicity,
Georgia adults 18+ years, 2001 ..........................................................................................................................12 17. Percentage of current smokers who quit for 1 day in past year by age,
Georgia adults 18+ years, 2001 ..........................................................................................................................12 18. Percentage of callers to quit line who had not used tobacco by number
of quit days, Georgia, 2002..................................................................................................................................13 19. Percentage of schools that teach tobacco use prevention courses by grade, Georgia, 2002 .............................15 20. Percentage of worksites with formal tobacco policy by number of employees, Georgia, 2002.........................15 21. Smoking provisions in food service establishments, Southeast Health District, Georgia, 2001 ..........................16 22. Percentage of retailers that sell tobacco to persons younger than 18 years, Georgia, 2001 ..............................17
Appendix Tables
Table A. Annual deaths, smoking-attributable mortality (SAM) and years of potential life lost (YPLL) by cause of death and sex, Georgia adults 35 and older and infants one year and younger, 2001.................................................................................31
Table B. Annual deaths and smoking-attributable mortality (SAM) in 19 Georgia public health districts by cause of death, Georgia adults 35 and older, 2001.........................................33
Table C. Smoking prevalence among adults 18 and older by public health district, Georgia, 2001 .....................36
Table D. Smoking prevalence among middle and high school students by participating public health district, Georgia, 2001 ..................................................................................37
Table E. Healthy People 2010 objectives and current status of objectives in Georgia related to tobacco use ..............................................................................................................38
iii 2004 Georgia Tobacco Surveillance Report

Executive Summary
Tobacco use, particularly cigarette smoking, is a leading preventable cause of death in Georgia and the United States.
Mortality Over 11,000 adult Georgians die every year from tobacco-related illnesses.
o About 4,200 die from cancer o About 4,200 die from cardiovascular diseases o About 2,600 die from respiratory diseases About 26 infants die every year because their mothers smoked during pregnancy.
Economic Costs $1.8 billion in healthcare costs in Georgia for adults 18 years and older are attributed to smoking annually. $2.9 billion in lost productivity costs in Georgia for adults 18 years and older are attributed to smoking annually. $9 million in infant healthcare costs in Georgia are attributed to smoking annually.
Tobacco Use in Georgia 24 percent of adult Georgians smoke cigarettes The prevalence of current smoking among adults is significantly higher among younger age groups and those
with fewer years of education. 8 percent of pregnant women in Georgia smoke during pregnancy 9 percent of middle school and 24 percent of high school students in Georgia smoke cigarettes Gas stations and convenience stores are the most common places where Georgia youth purchase
their cigarettes.
Reducing Tobacco Use in Georgia 59 percent of adult Georgian smokers stopped smoking cigarettes for one day or longer during the previous
year because they wanted to quit 76 percent of callers to the Georgia Tobacco Quit Line made at least one attempt to quit smoking and 21 per-
cent had not used tobacco for 30 days or more
Policy and Environment Surveillance 98 percent of public middle and high schools in Georgia had policies prohibiting tobacco use, but only about half
of middle (56 percent) and high (55 percent) schools had a designated employee responsible for enforcement of the policies 90 percent of Georgia worksites had a formal policy prohibiting smoking on the job 38 percent of county governments and 14 percent of city governments in Georgia have ordinances related to tobacco use About 16 percent of retailers sell tobacco to persons younger than 18 years of age
1 2004 Georgia Tobacco Surveillance Report

Introduction

The effect of tobacco use on health has been a topic of research since the beginning of the 20th century (1). Many epidemiological and clinical studies provide evidence of a causal relationship between tobacco use and disease, disability, and death. Tobacco use is related to many health conditions (Table 1) and is recognized as one of the most common preventable causes of death in the United States (2). Cigarettes, the most commonly used tobacco product in the nation, are not only harmful to smokers but also to non-smokers who are exposed to secondhand smoke (3). Over the past 35 years, the nationwide percentage of smokers has declined, falling from 40 percent in 1965 to 23 percent in 2000 (4, 5, 6); still many people continue to smoke. Tobacco is responsible for more than 11,000 deaths, more than 190,000 years of potential life lost, and approximately $1.8 billion in direct adult medical costs in Georgia every year. In the United States, it is responsible for more than 440,000 deaths, more than 5 million years of potential life lost, and $75 billion in direct adult medical costs (2, 7).

Table 1. Causes of death for which tobacco is contributing cause Causes of death

Cancer Lip, oral cavity, pharynx Esophagus Pancreas Larynx Trachea, lung, bronchus Cervix Bladder Kidney and renal pelvis

Cardiovascular diseases Hypertension Ischemic heart disease Other heart disease Stroke Atherosclerosis Aortic aneurysm Other diseases of
circulatory system

Respiratory diseases Pneumonia, influenza Bronchitis, emphysema Chronic airway
obstruction

Perinatal conditions Short gestation /
Low birth weight Respiratory distress
syndrome Respiratory conditions
newborn Sudden infant death
syndrome

2 2004 Georgia Tobacco Surveillance Report

This report describes the array of surveillance activities pertaining to tobacco use in Georgia. It provides information about a) the toll of tobacco on Georgians in terms of smoking-related diseases and their associated costs, b) the prevalence of smoking among Georgia adults and youth, and c) efforts to reduce the burden of smoking through quit line services and policy and environmental measures. It describes new surveillance activities related to schools, worksites and restaurants, city and county ordinances, and enforcement activities that restrict youth from accessing tobacco products. It also indicates the status of the tobacco use goals in Georgia as they relate to those stated in the Healthy People 2010 Objectives (Table F).
The Georgia Department of Human Resources and the Georgia Cancer Coalition are committed to making this surveillance data available to facilitate program evaluation, evidence-based decision-making and outcomes measurement.
Data from this report will be used by the Georgia Department of Human Resources, the Georgia Cancer Coalition and partner organizations to redesign and enhance strategies implemented for tobacco use prevention in Georgia.

Burden of Tobacco in Georgia

Mortality
Cigarette smoking is a leading cause of preventable illness and death in Georgia. An estimated 11,065 (18 percent) of the 60,002 deaths in 2001 among Georgians 35 years and older were attributed to cigarette smoking; of these estimated deaths, 4,235 (38 percent) were due to cancer, 4,226 (38 percent) were due to cardiovascular disease, and 2,604 (24 percent) were due to respiratory diseases (Figure 1). In 2001, the most common causes of death due to tobacco use in Georgia were lung cancer (3,434 deaths), ischemic heart disease (1,904 deaths), chronic airway obstruction (1,874 deaths), and stroke (564 deaths).
Smoking caused an estimated 6,946 adult male deaths and 4,119 adult female deaths in Georgia in 2001 (Table A).1
An estimated 26 (2 percent) of the 1,141 infant deaths in 2001 were attributed to smoking (Figure 2). Of all smoking-related infant deaths in Georgia, 54 percent were from short gestation/low birth weight, 38 percent were from sudden infant death syndrome and eight percent were from respiratory conditions of the newborn (Table A).
1 The smoking-attributable mortality estimates for each of the public health districts in Georgia are found in Table B of the Appendix.
3 2004 Georgia Tobacco Surveillance Report

Figure 1. Deaths among adult Georgians ages 35 years and older, 2001

Cardiovascular diseases 38%

Attributed to Smoking 18%

Respiratory diseases 24%

Cancer 38%

Total adult deaths n=60,002

Adult deaths attributed to smoking n=11,065

Sources: Georgia Vital Statistics, 2001; CDC SAMMEC

Figure 2. Deaths among infants one year and younger, Georgia, 2001

Attributed to Smoking
2%

Sudden infant death syndrome
38%
Respiratory conditions -
newborn 8%

Short gestation/Low birth weight
54%

Total infant deaths n=1,141

Infant deaths attributed to smoking n=26

Sources: Georgia Vital Statistics, 2001; CDC SAMMEC

Burden of Tobacco in Georgia

Table 2. Years of Potential Life Lost (YPLL), number of deaths, and

average YPLL attributed to smoking by disease category and sex,

Georgia, 2001

YPLL attributed to smoking

Deaths attributed to smoking

Average YPLL per death from smoking

Disease Category

Neoplasms Male Female Total Neoplasms
Cardiovascular Diseases Male Female Total Cardiovascular Diseases
Respiratory Diseases Male Female Total Respiratory Diseases
Total Adult (35+ years)
Perinatal Conditions Male Female Total Perinatal Conditions
Overall Total

48,573 25,425 73,998
46,578 26,178 72,756
16,973 17,439 34,412 181,166
1,110 874
1,984 183,150

2,893 1,342 4,235
2,682 1,544 4,226
1,371 1,233 2,604 11,065
15 11 26 11,091

16.8 18.9 17.5
17.4 17.0 17.2
12.4 14.1 13.2 16.4*
74.0 79.4 76.3 16.5

* Indicates the average years of potential life lost attributed to smoking per adult smoker Indicates the average years of potential life loss attributed to smoking per child born of a woman who smoked during pregnancy

Table 3. Annual smoking-attributable economic costs, Georgia, 2001

Cost component

Total

Annual smoking-attributable productivity losses, 2001 Men Women
Total

$1,918,000,000 $935,000,000
$2,853,000,000

Smoking-attributable adult healthcare costs, 1998* Ambulatory care Hospital care Prescription drugs Nursing home Other care

$742,000,000 $421,000,000 $149,000,000 $311,000,000 $135,000,000

Total Total adult (35+ years) costs

$1,758,000,000 $4,611,000,000

Infant costs Smoking-attributable neonatal healthcare costs
Total costs

$9,000,000 $4,620,000,000

* Expenditure smoking-attributable fractions obtained from Miller, et.al and 1998 personal healthcare expenditure data obtained from Centers for Medicare and Medicaid Services. Neonatal expenditures are based on the reimbursement levels used by a sample of private insurers in 1996. Smoking-attributable neonatal expenditures are based on data from 1999 Georgia Birth Certificate and Natality Reports.

4 2004 Georgia Tobacco Surveillance Report

Years of Potential Life Lost
Years of potential life lost (YPLL), a calculation used to measure premature mortality, is the sum of the years of life lost annually by all persons who died before their expected age of death. Over 183,000 years of life were lost in Georgia in 2001 due to smoking. Adult male and female smokers lost an average of 16.1 and 16.8 years, respectively, because they smoked. Smokers who died from smoking-attributed cancer lost an average of 17.5 years of potential life; those who died from smokingattributed cardiovascular disease lost an average of 17.2 years; and those who died from smokingattributed respiratory disease lost an average of 13.2 years (Table 2).
Economic Costs
Smoking-related productivity losses in Georgia for 2001 totaled $2.9 billion and smoking-related healthcare costs reached $1.8 billion for adults 18 years and older. In addition, $9 million of infant healthcare costs in Georgia were attributed to smoking annually (Table 3).

Tobacco Use in Georgia

Cigarette use among adults
Cigarette use among adult Georgians has been stable for the past decade. From 1985 through 1993 the prevalence of adult smokers declined by an average of 2.6 percent per year. From 1994 through 2001, however, the prevalence did not change significantly, rising by an average of 0.6 percent per year (Figure 3).

Percent

Figure 3. Current smoking among Georgia adults 18+ years, 1984-2001

40

30

20

Smoking Rate Decreased

Smoking Rate Increased

by 2.6% per year

by 0.6% per year

10

0
1984 1985 198619871988 1989 1990 199119921993 1994 199519961997 1998 1999 2000 2001
Year Source: BRFSS

In 2001, 24 percent of adult Georgians 18 years and older were current smokers, 21 percent were former smokers, and 55 percent were never smokers (Figure 4).2

Figure 4. Smoking status among Georgia adults 18+ years, 2001

24%

Current smokers

Never smokers

55%

21%

Former smokers

2 The adult smoking prevalence rates for each of the public health districts in Georgia are found in Table C of the Appendix.
5 2004 Georgia Tobacco Surveillance Report

Source: BRFSS 2001

Tobacco Use in Georgia

Figure 5. Smoking prevalence by sex and race/ethnicity, Georgia adults 18+ years, 2001

Percent

50

40

32

30

26 25

23

20

24

22

18

18

10

0 Male

Female

White Black Hispanic Other

Source: BRFSS 2001

There were no significant differences in the prevalence of cigarette smoking between males (26 percent) and females (22 percent) or among racial or ethnic groups (non-Hispanic whites, 25 percent; non-Hispanic blacks, 21 percent; Hispanics, 26 percent; and other race/ethnicity, 21 percent). Non-Hispanic white females (24 percent) were significantly more likely than non-Hispanic black females (18 percent) to smoke cigarettes; however, no significant differences were found among males by race (Figure 5).

Figure 6. Smoking prevalence by sex and age, Georgia adults 18+ years, 2001

Percent

50

40 36
30

29 31

21 20
10

20 15

29

24

25

21

19

10

0 Male

Female

18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65+

Source: BRFSS 2001

6 2004 Georgia Tobacco Surveillance Report

For both males and females, the prevalence of current smoking in 2001 was significantly higher among the younger age groups than the older age groups (Figure 6).

Tobacco Use in Georgia

Adults with less than a high school education were significantly more likely than those with a high school education or above to smoke cigarettes (Figure 7). A sex-specific trend analysis indicates that the smoking rates among college graduates have decreased since 1984, whereas the smoking rates among groups with fewer years of education have not changed significantly.
Cigarette use among pregnant women
Smoking during pregnancy is associated with an increased risk for premature rupture of membranes, spontaneous abortion or miscarriage, hemorrhaging during delivery, and preterm delivery. The longer the mother smokes throughout pregnancy, the lower the birth weight of the newborn and the greater the risk of being premature, developing sudden infant death syndrome, and having respiratory illnesses (8).
In 2001, eight percent of pregnant women in Georgia smoked throughout their pregnancy. The prevalence of smoking during pregnancy was higher for nonHispanic whites (10 percent) than for non-Hispanic blacks (four percent) (Figure 8). On average, the number of cigarettes smoked per day was 10 for non-Hispanic white pregnant women who smoked and six for non-Hispanic black pregnant women who smoked.

Figure 7. Smoking prevalence by education and sex, Georgia adults 18+ years, 2001

Percent

50 40
40 33
30
20
10
0 <HS

33 24

25 24

14 13

HS/GED Male

Some/Tech College
Female

Source: BRFSS 2001

College Graduate

Figure 8. Smoking during pregnancy by race, Georgia, 2001

Percent

50

40

30

20 10
10
0 White

4 Black

3 Other

Source: Georgia Vital Statistics, 2001

7 2004 Georgia Tobacco Surveillance Report

Tobacco Use in Georgia

Figure 9. Tobacco use by school type and tobacco product, Georgia, 2001

Percent

50

40

30

20 15

10

9

5

0 Middle School

32 24 10
High School

Any Tobacco Product* Cigarettes Smokeless Tobacco
*Because this variable includes use of cigarettes, cigars, smokeless tobacco, pipe, or
bidis, the rate represented is not the result of adding the rates of cigarette and smokeless tobacco use.
Source: GYTS 2001

Figure 10. Smoking prevalence by school type and sex, Georgia, 2001

Percent

50

40

30
20 11
10 7
0 Middle School

27 20
High School

Male

Female

Source: GYTS 2001

8 2004 Georgia Tobacco Surveillance Report

Tobacco use among youth In Georgia, 15 percent of middle school students and 32 percent of high school students used some form of tobacco in 2001; nine percent of middle school students and 24 percent of high school students smoked cigarettes, while five percent of middle school students and 10 percent of high school students used smokeless tobacco (Figure 9).3
Middle school male and female students smoked at comparable rates. However, high school males had a significantly higher prevalence of smoking than high school females (Figure 10).
3 The youth smoking prevalence for participating public health districts in Georgia are found in Table D of the Appendix.

Tobacco Use in Georgia

Non-Hispanic black students in middle and high school were less likely than non-Hispanic white and Hispanic students to smoke cigarettes (Figure 11). Among students who ever smoked, nearly one in four (27 percent) middle school and one in seven (15 percent) high school students smoked a whole cigarette before age 11.

Figure 11. Smoking prevalence by school type and race/ethnicity, Georgia, 2001

Percent

50

40

30

20

15

10

10

10

6

31
21 19
10

0 Middle School

High School

White Black Hispanic Other

Source: GYTS 2001

Gas stations and convenience stores were the places where about one third of middle school and two thirds of high school students made their most recent cigarette purchase (Figure 12). Choice of place for purchasing cigarettes did not differ by sex or by race/ethnicity.

Figure 12. Place of purchase of cigarettes by school type and place, Georgia, 2001

Percent

50

47

40

30

20

18

13

10

6

0 Middle School

19
2 High School

Gas station

Convenience store Vending machine Source: GYTS 2001

9 2004 Georgia Tobacco Surveillance Report

Tobacco Use in Georgia

Figure 13. Percentage of students living with smoker by school type and smoking status, Georgia, 2001

Percent

100

80 70
60

40

34

20

57 31

0 Middle School

High School

Current Smokers Non-Smokers

Source: GYTS 2001

Nearly three-fourths of middle school smokers (70 percent) and over half of high school smokers (57 percent) lived with a smoker. About one-third of middle school non-smokers (34 percent) and high school non-smokers (31 percent) lived with a smoker (Figure 13).

10 2004 Georgia Tobacco Surveillance Report

Reducing Tobacco Use in Georgia

Former smokers
The quit ratio, defined as the proportion of former smokers in a given population divided by the proportion of ever smokers in that same population, is used as an indicator of quitting behavior among people who have ever smoked. In Georgia, the percentage of ever smokers who have quit has been increasing, rising from 38 percent in 1985 to 47 percent in 2001. Adults 45 years and older and adults with more than high school education had a higher quit ratio than younger adults and those with fewer years of education, respectively (Figures 14 and 15).

Figure 14. Percentage of former smokers among ever smokers by age, Georgia adults 18+ years, 2001

Percent

100

80

76

60

55

40 36

20

16

0

18-24 years

25-44 years

45-64 years

65+ years

Source: BRFSS 2001

Figure 15. Percentage of former smokers among ever smokers by education, Georgia adults 18+ years, 2001

Percent

100

80

64

60

46

42

40

35

20

0

Less than High

Some/ College

high school school/GED Tech. Coll. graduate

Source: BRFSS 2001

11 2004 Georgia Tobacco Surveillance Report

Reducing Tobacco Use in Georgia

Figure 16. Percentage of current smokers who quit* for 1 day in past year by race/ethnicity, Georgia adults 18+ years, 2001

Percent

100

80

73

74

60

54

54

40

20

0

White

Black Hispanic Other

*BRFSS Question: During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

Source: BRFSS 2001

Figure 17. Percentage of current smokers who quit* for 1 day in past year by age, Georgia adults 18+ years, 2001

100

Percent

80

72

68

60

55

57

52

44

40

20

0

18-24 years

25-34 years

35-44 years

45-54 years

55-64 years

65+ years

* BRFSS Question: During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

Source: BRFSS 2001

12 2004 Georgia Tobacco Surveillance Report

Smoking cessation
More than half of adult Georgian smokers (59 percent) reported having stopped smoking for one day or longer during the past 12 months because they were trying to quit smoking. There were no statistically significant differences in the prevalence of male and female smokers who had quit for one day or longer (60 percent vs. 59 percent, respectively). NonHispanic black smokers had a significantly higher prevalence of quitting for one day or longer (73 percent) than non-Hispanic white smokers (54 percent) (Figure 16).
Current smokers between the ages of 18 and 24 stopped smoking for one day or longer at a significantly higher rate (72 percent) than those between 35 and 44 years of age (55 percent) and those between 55 and 64 years of age (44 percent) (Figure 17).

Reducing Tobacco Use in Georgia

Georgia Tobacco Quit Line Survey
The Georgia Tobacco Quit Line (GAQL) is a statewide, toll-free, telephone-based resource that provides stage-appropriate screening, written materials, tobacco cessation counseling, and referrals for follow-up assistance, based on an individual's readiness to quit. The GAQL began providing services in November 2001 and received more than 16,000 calls for assistance during its first year.
A Quit Status Survey was conducted in 2002 among a sample of 508 GAQL callers to assess the number of quit attempts they had made since their last cessation counseling session and to determine their abstinence rates. Results indicate that at the time of the survey, 76 percent had made at least one attempt to quit smoking (Figure 18). Twenty-one percent had not used tobacco for 30 days or more.
Among the respondents who made at least one quit attempt, 84 percent reported using more than one quit method. Many used some form of pharmacotherapy; one in four (26 percent) used nicotine patches, one in six (15 percent) used nicotine gum, and one in eight (12 percent) used Zyban. Many made changes to their consumption patterns, such as reducing their tobacco use (82 percent) or switching to a brand with lower nicotine content (33 percent). More than half (62 percent) had tried to quit "cold turkey." Few (eight percent) joined a cessation program (Table 4).
13 2004 Georgia Tobacco Surveillance Report

Figure 18. Percentage of callers to quit line who had not used tobacco by number of quit days, Georgia, 2002
100

80

Percent

60

53

30
24 21
20

2

0

None

1 - 6

7 - 29

30+

Number of quit days

Source: Group Health Cooperative, 2002

Table 4. Cessation strategies used after calling the Georgia Quit Line, 2002

Used pharmacotherapy Nicotine patch Yes No Refused patches/ had medical contraindications Nicotine gum Yes No Refused gum use/ had medical contraindications Zyban Yes No Refused Zyban / had medical contraindications

N

(386)

%

102

26.4

274

71.0

10

2.6

56

14.5

323

83.7

7

1.8

48

12.4

325

84.2

13

3.4

Used behavior modification Fading (Switching brands) Yes No Don't know Tapering (Cutting down on tobacco use) Yes No

128

33.2

256

66.3

2

0.5

316

81.9

70

18.1

Tried to quit without assistance ("cold turkey") Yes No

241

62.4

144

37.3

Joined a program to help with the quit process Yes No
Among the 386 respondents who made serious quit attempts, 84.1% reported more than one quit method. Source: Group Health Cooperative Center for Health Promotion.

32 354

8.3 91.7

Policy and Environment Surveillance

Table 5. Schools with policies prohibiting the use of tobacco products by type of product, Georgia, 2002

Middle School

Cigarettes %

Students

98.8

School staff

92.1

Visitors

88.6

High School

Students School staff Visitors
Source: School Health Education Profile, 2002.

99.2 93.9 88.0

Banned Products

Smokeless Tobacco %

Cigars %

98.8

98.8

92.1

92.8

85.1

88.6

98.4

98.4

93.8

93.0

88.0

87.2

Pipes %
98.8 92.8 88.6
99.2 93.0 87.2

Policies or environments that restrict or prohibit smoking prevent some people from starting to smoke, help current smokers quit, and reduce exposure to environmental tobacco smoke. Surveillance activities focusing on policy and environment, such as the School Health Education Profile, the Georgia Worksite Health Promotion Policies and Practices Survey, the Restaurant Survey, and the Local Tobacco Ordinance Tracking Survey, have taken place in Georgia since 2001 to assess the presence of policies and environments that prevent or reduce tobacco use among Georgians.

Table 6. Schools with policies prohibiting the use of tobacco products by school environment, Georgia, 2002

Middle School

School buildings
%

Students

99.4

School staff

98.8

Visitors

94.3

High School

Students School staff Visitors

100.0 98.0 95.5

Source: School Health Education Profile, 2002.

School grounds
%

Restricted Areas

School events
%

School hours
%

Non-school hours %

99.4

99.4

99.3

86.4

93.0

96.0

93.8

76.5

84.4

65.9

91.2

74.6

100.0

97.6

100.0

84.1

91.5

84.8

93.0

70.4

79.6

52.6

86.4

57.2

14 2004 Georgia Tobacco Surveillance Report

School Health Education Profile
The School Health Education Profile (SHEP) was conducted in the spring of 2002 to assess existing school health policies and programs in public middle and high schools in Georgia.
Findings from SHEP indicate that a vast majority of public schools in Georgia (98 percent) have adopted policies prohibiting tobacco use (i.e., cigarettes, smokeless tobacco, cigars, and pipes) (Table 5). These policies are valid in school buildings, grounds, and at school events and apply to students, school staff, and visitors during both school and after-school hours (Table 6).

Policy and Environment Surveillance

Although almost all schools have policies, only about half of middle (56 percent) and high (55 percent) schools had a designated school employee responsible for enforcing existing tobacco use prevention policies.
Tobacco use prevention courses were more common in grades 6 through 9 (84 percent to 95 percent) than in grades 10 through 12 (51 percent to 58 percent) (Figure 19).

Figure 19. Percentage of schools that teach tobacco use prevention courses by grade, Georgia, 2002

Percent

100 84
80
60
40
20
0 6

95

88

88

58

7

8

9

10

Grade

51

51

11

12

Georgia Worksite Health Promotion Policies and Practices Survey
The Georgia Worksite Health Promotion Policies and Practices Survey was designed to assess existing worksite policies and environments affecting the health of Georgia workers. In 2002, 90 percent of Georgia worksites had a formal policy prohibiting smoking on the job. Worksites with 250 or more employees were significantly more likely than those with 15 to 99 employees to have formal policies (97 percent vs. 89 percent, respectively) (Figure 20). Only eight percent of Georgia worksites offered smoking cessation programs and two percent had cigarette vending machines on site.
15 2004 Georgia Tobacco Surveillance Report

Source: School Health Education Profile, Georgia 2002

Figure 20. Percentage of worksites with formal tobacco policy by number of employees, Georgia, 2002

Percent

100 90
80 60 40 20
0 Overall

94

97

89

15 - 99

100 - 249

250+

Number of employees at worksite

Source: Georgia Worksite Health Promotion Policies and Practices Survey, 2002

Policy and Environment Surveillance

Figure 21. Smoking provisions in food service establishments, Southeast Health District, Georgia, 2001

Percent

100
80 69
60
40 22
20
0 100% non-smoking Separate smoking and non-smoking sections

8
No separate sections

Source: MMWR 2003

Table 7. Jurisdictions with tobacco-related ordinances by jurisdiction type, Georgia, 2001

Jurisdiction Type

Total Jurisdictions in Georgia

Jurisdictions participating in survey

N

%

Jurisdictions with 1 tobacco ordinance

N

%

County

159

159

100

61

38

Incorporated city 532

466

88

67

14

Total

691

625

90

128

20

Source: Georgia Local Tobacco Ordinance Tracking Survey, 2001

Restaurant Survey
In March 2001, the Southeast Health District (Waycross) conducted a survey to assess smoking provisions, such as designated smoking areas and ventilation systems, in food service establishments (9). Of 928 food service establishments in the district, 729 (79 percent) were surveyed; of these, 69 percent were completely smoke-free, 22 percent had separate smoking and non-smoking areas, and less than ten percent did not have separate smoking and non-smoking areas (Figure 21).
Local Tobacco Ordinance Tracking Survey
The Local Tobacco Ordinance Tracking Survey was conducted in 2002-2003. It was designed to determine the existence of ordinances pertaining to the use of tobacco products in counties and cities throughout the state.
In 2001, 38 percent of county governments and 14 percent of city governments in Georgia have tobacco-related ordinances (Table 7). An ordinance may cover one or more topics, such as government property, indoor recreation areas, and licensure. The ordinances vary widely in scope, ranging from simple proscriptions against smoking in city hall with no specific penalties attached to comprehensive ordinances covering a range of public and private locations.

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Policy and Environment Surveillance

Enforcement
It is against Georgia law to sell tobacco to individuals younger than 18 years of age (Georgia Law 16-12-171). Establishments violating the law are subject to a citation with a standard $500.00 fine for the first violation. The licensees are put on notice that any additional violations will result in additional citations, suspension and revocation of their tobacco license.
Surveys conducted by the Division of Mental Health, Developmental Disabilities, and Addictive Diseases of the Georgia Department of Human Resources and by the Alcohol and Tobacco Division of the Georgia Department of Revenue estimated non-compliance with the law at 13 percent and 19 percent, respectively (Figure 22).
Taxation
Research has shown that higher cigarette prices are associated with lower overall cigarette consumption among both adults and youth (10, 11, 12). Most studies indicate that a 10 percent increase in price reduces overall cigarette consumption by three percent to five percent. Youth, minorities, and lower income smokers are two to three times more likely to quit or to smoke less than other smokers due to an increase in the price of cigarettes. The Surgeon General's report on tobacco use reduction concluded that raising tobacco taxes is one of the most effective strategies for tobacco prevention and control (13).

Figure 22. Percentage of retailers that sell tobacco to persons younger than 18 years, Georgia, 2001

Percent Non-Compliant

50

40

30

20

19

13

10

0 DHR Survey

DOR Survey

Sources: Georgia Dept. of Human Resources, Division of Mental Health, Developmental Disabilities, and Addictive Diseases; Georgia Dept. of Revenue, Alcohol and Tobacco Division

17 2004 Georgia Tobacco Surveillance Report

Policy and Environment Surveillance

Table 8. Excise taxes on cigarettes, cigars, and smokeless tobacco, United States and Georgia, 2002-2003

Product

US, 12/31/02

GA, 12/31/02

GA, 7/1/03

Per pack of cigarettes

All states have a tax Range: $0.025 - $1.51 Average: $0.60

$0.12

$0.37

Cigars

16 states with tax Range: $0.015/10 cigars - 129.42% wholesale price Average: N/A

13% of wholesale price

23% of wholesale price

Smokeless tobacco 45 states with tax

No

Range: $0.008/ounce

- 129.42% whole-

sale price

Average: N/A

10% of wholesale price

Sixteen states have dedicated a percent of tobacco taxes to cancer or tobacco control. Georgia has not adopted this law. Source: National Cancer Institute, State Cancer Legislative Database Program, April 2003

All 50 states and the District of Columbia impose excise taxes on cigarettes, which, as of December 31, 2002, ranged from 2.5 cents to $1.51 per pack and averaged at 60 cents per pack nationally (14). A portion of the cigarette excise tax revenue is dedicated to cancer or tobacco control programs by law in 16 states. In addition, 45 states impose excise taxes on chewing tobacco and snuff (smokeless tobacco) (Table 8).
Prior to July 1, 2003, the excise tax on cigarette sales in Georgia was 12 cents per pack and the excise tax on cigars was 13 percent of a wholesaler's cost. There was no excise tax on smokeless tobacco or snuff and no portion of excise taxes on tobacco products was specifically dedicated to tobacco use prevention or control activities (14). Georgia's net revenue collections from tobacco taxes in 2002 totaled $86 million, compared to $87 million and $88 million in 2001 and 2000, respectively (15).
As of July 1, 2003, the excise tax on cigarette sales in Georgia increased to 37 cents per pack, the excise tax on cigars increased to 23 percent of a wholesaler's cost, and for the first time there is an excise tax on smokeless tobacco and snuff at 10 percent of a wholesaler's cost (Table 8).

18 2004 Georgia Tobacco Surveillance Report

Summary and Conclusions

Data from the surveillance systems described in this report provide information about the burden and prevention of tobacco-related illness in Georgia. The major findings include:
Over 11,000 adult Georgians die every year from tobacco-related illnesses, about one death out of every six. Of these deaths, 38 percent are due to cancer, 38 percent to heart disease, and 24 percent to respiratory illness.
Implications for prevention:
o The burden of tobacco-related illness in Georgia is high. More widespread application of complementary proven prevention programs could reduce the burden.
About 26 infants die every year in Georgia because their mothers smoked during pregnancy.
Implications for prevention:
o Smoking cessation programs for pregnant women have shown to be cost effective and to double the rates for quitting, thus reducing the prevalence of smoking during pregnancy (8).
o Although many women voluntarily quit smoking during pregnancy, about two-thirds of them are smoking again a year after delivery. Smoking cessation and prevention efforts tailored to these women should resume post partum (16, 17).
The costs of tobacco-related adult deaths and illnesses are $1.8 billion in health care costs and $2.9 billion in lost productivity annually in Georgia.
Implications for prevention:
o Reducing tobacco use in Georgia would save money for individuals, businesses, and government.
One out of four (24 percent) adult Georgians smokes cigarettes. This percent has not changed since 1993. People in younger age groups and people with fewer years of education are more likely to smoke than older persons or persons with more years of education.
Implications for prevention:
o Although smoking is prevalent among all segments of society, some groups are more likely to smoke than others. Smoking cessation and prevention activities should include efforts targeting groups in which smoking is most prevalent, namely, younger people and people with fewer years of education.
o Youth and lower income smokers are more likely to quit or smoke less than other smokers because of an increase in the cost of cigarettes. A 10 percent

increase in the cost of cigarettes reduces consumption of cigarettes by 3 5 percent (13).
9 percent of middle school and 24 percent of high school students in Georgia smoke cigarettes. Although they obtain their cigarettes in a variety of ways, the most common places of purchase are gas stations and convenience stores.
Implications for prevention:
o School-based smoking prevention policies and education have helped reduce the prevalence of smoking among middle and high school students by half within a decade (18).
o Strict enforcement of laws and regulations that prohibit the sale of tobacco products to individuals younger than 18 years of age has been shown to hinder youth purchases of tobacco, which may reduce the youth smoking prevalence (19).
More than half (59 percent) of current adult smokers tried to quit in the past year, with younger smokers more likely than older smokers to stop for one day or longer.
Implications for prevention:
o Raising the cost of tobacco products is helpful to many smokers who are trying to stop smoking (13). Low-income smokers may be more likely than high-income smokers to benefit from a higher cost of tobacco.
o Promoting use of the quit line, combined with health education interventions or clinical assistance, helps smokers quit (20). One out of every five smokers who used the Georgia Quit Line and were contacted about their current smoking had not smoked for at least 30 days.
Most public schools (98 percent) and worksites (90 percent) in Georgia have policies limiting or prohibiting tobacco use on the premises; 38 percent of counties and 14 percent of city governments have ordinances related to tobacco use.
Implications for prevention:
o County and city governments should be encouraged to establish smoking regulations within their borders. Smoking restrictions in public places (e.g., restaurants) help smokers stop or reduce smoking (13). Establishments in cities where smoking restrictions in restaurants and bars have been enacted have not been financially hurt (21).

19 2004 Georgia Tobacco Surveillance Report

Methodology and Limitations
This report compiles tobacco-related information from different available data sources in Georgia.
Mortality Data
Mortality data in Georgia were provided by the Office of Health Information and Policy, Georgia Division of Public Health. Deaths for 22 conditions that are related to smoking were counted and categorized using the ICD-10 codes listed in Appendix tables A and B.
Smoking-Attributable Mortality Estimates
The Smoking Attributable Morbidity, Mortality, and Economic Costs (SAMMEC) application developed by the Centers for Disease Control and Prevention (CDC) derives smoking-attributable mortality (SAM) using an attributable-fraction formula (24). The smoking-attributable fractions (SAF) of adult deaths for 18 smoking-related diseases are calculated using sex-specific smoking prevalence and relative risk (RR) of death for adult current and former smokers aged 35. Infant mortality SAFs are calculated using maternal smoking prevalence and RR of death for four infant conditions caused by smoking. SAFs for each disease and sex are derived using the following formula:
SAF = [(p0 + p1(RR1) + p2(RR2)) - 1] / [p0 + p1(RR1) + p2(RR2)] For adults:
p0 = Percentage of adult never smokers in study group p1 = Percentage of adult current smokers in study group p2 = Percentage of adult former smokers in study group RR1 = Relative risk of death for adult current smokers relative to adult never smokers RR2 = Relative risk of death for adult former smokers relative to adult never smokers For infants: p0 = Percentage of maternal non-smokers in study group p1 = Percentage of maternal smokers in study group p2 = Not applicable RR1 = Relative risk of death for infants of maternal smokers relative to infants of maternal nonsmokers RR2 = Not applicable Data for former smokers are not included in the SAF for infants because it calculates the impact of maternal smoking during pregnancy.
Prevalence Data SAMMEC uses separate prevalence data for adult smokers aged 35-64 and 65 years. The adult smoking prevalence estimates for 2001 were obtained from the Georgia Behavioral Risk Factor Surveillance System (BRFSS). The maternal smoking prevalence for 2000 was obtained from Georgia Vital Statistics as noted on birth certificates.
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Methodology and Limitations
Relative Risk Data SAMMEC uses age-adjusted RR estimates for adults aged 35 years from the second wave of the American Cancer Society's Cancer Prevention Study (CPS-II) six year follow-up. Separate RR data are used for smokers aged 35-64 and 65 years for ischemic (or coronary) heart disease and cerebrovascular disease (stroke). The RR of death from smoking drops dramatically after age 65 for these two conditions. SAMMEC also uses infant RR estimates for short gestation/low birth weight, Sudden Infant Death Syndrome (SIDS), Respiratory Distress Syndrome (RDS), and other infant conditions of the newborn from a meta analysis of epidemiological literature conducted by Gavin et al. (2001).
Estimation of Smoking-Attributable Mortality SAMMEC applies the age- and sex-specific adult SAFs to adult mortality data for each smoking-related disease in the population under study. Mortality data by cause of death in Georgia for 2001 were obtained from Georgia Vital Statistics. The number of deaths is multiplied by the relevant SAF for each smoking-related cause of death. SAMMEC applies the infant SAF to infant mortality data derived from Georgia Vital Statistics' infant birth and death records. The following formula is used to calculate the SAM:
SAM =Number of deaths x SAF Summing across age categories provides the sex-specific estimate of SAM for each cause of death. Total SAM is the sum of smoking-attributable deaths across age groups, and across causes of death for both sexes combined.
Estimation of Years of Potential Life Lost SAMMEC estimates the total impact of premature deaths on the life expectancy of adult smokers and infants of maternal smokers. Smoking-attributable years of potential life lost (YPLL) are the sum of years of life lost from premature deaths caused by smoking. SAMMEC multiplies the number of smoking-attributable adult deaths by the midpoint estimate of remaining life expectancy (RLE) for each smoking-related cause of death, sex, and 5-year age group, while for infants it uses the RLE at birth for both sexes to calculate adult and infant YPLL through the following formula:
Smoking-attributable YPLL = SAM x RLE Age- and sex-specific remaining life expectancy data for the nation for 2000 were obtained from National Center for Health Statistics (25). Total YPLL estimates are generated for each disease, major disease category, and all diseases combined, by sex and both sexes combined.
Estimation of Average Years of Potential Life Lost The average smoking-attributable YPLL per smoker was calculated using the following formula: Average smoking-attributable YPLL per smoker = smoking-attributable YPLL due to a cause of death
SAM due to a cause of death
21 2004 Georgia Tobacco Surveillance Report

Methodology and Limitations
Medical Expenditures The SAMMEC application can be used to estimate the medical costs of smoking based on econometric methods. Smoking-attributable medical expenditures (SAE) are the excess personal health care costs of smokers and former smokers compared to never smokers. SAMMEC includes pre-calculated national and state-level expenditure data for adults aged 18 years and over. The precalculated estimates include:
1998 total personal health care expenditures smoking-attributable fraction (SAF) of expenditures 1998 smoking-attributable medical expenditures (SAE) Total personal health care expenditures were obtained from the state health care expenditure files provided by the Centers for Medicare and Medicaid Services (CMS). SAMMEC provides estimates for each of five adult expenditure categories: ambulatory care, hospital care, prescription drugs, nursing home care, and other care (including home health, nonprescription drugs and nondurable medical products). Mental health care, dental care, and vision care products are not included. The smoking-attributable fraction (SAF) of expenditures reflects the proportion of annual personal health care expenditures that could be avoided if smoking were eliminated from the population. SAMMEC uses expenditure SAFs from Miller et al. (1999) for each of the five expenditure categories. Miller et al. calculated expenditure SAFs for ambulatory care, hospital care, prescription drug, and other care (including home health care, vision care, and durable and nondurable medical equipment), by estimating models that alternatively included and excluded the influence of smoking history on expenditures. Expenditures were estimated using a two-step econometric model, used to account for the large proportion of individuals who have no medical expenditures in any given year. To calculate SAF, two sets of estimates were calculated for each expenditure category. The first set of estimates included all individuals, including smokers. The second set of estimates was calculated after setting the smoking history variables to zero and holding all other factors constant. This generated expenditure estimates as if smoking were eliminated from the study population. SAFs were derived by dividing the difference in the expenditure estimates by the expenditures that included smoking history.
Mortality-Related Productivity Costs Mortality-related productivity costs are the estimated costs of lost future earnings from paid market and unpaid household labor resulting from premature death due to smoking-related disease. Estimates of the present value of lifetime future earnings (PVFE) are based on the human capital methodology, which assumes average earnings reflect the contribution workers make to the value of goods and services. As the economic analog of the YPLL measure, the mortalityrelated productivity costs estimates incorporate both the number of deaths and number of premature deaths due to smoking-related causes. Rather than assessing this loss of life in terms of person-years, SAM data are translated into future earnings losses (including the value of unpaid household work). For each smoking-attributable death, by sex and 5-year age group, the number of deaths is multiplied by the corresponding PVFE value:
Smoking-attributable productivity costs = SAM x PVFE Summing across age categories provides the sex-specific estimate of smoking-attributable lifetime earnings losses (productivity costs) for each cause of death. Total smoking-attributable productivity costs are generated for each disease, disease category, and all diseases, for each sex and both sexes combined.
22 2004 Georgia Tobacco Surveillance Report

Methodology and Limitations

Smoking-attributable Death Estimates at the Health District Level

Proportions were used to calculate estimates of smoking-attributable deaths for each health district. Presuming that each district's risk of dying from tobacco use was similar to the state's risk, the smoking-attributable deaths for each disease category were divided by the total number of deaths for each disease category and this resulting rate was in turn multiplied times the district's total number of deaths for each disease category:

District SAM = State SAM for each disease category X State deaths for each disease category

District deaths for each disease category

Calculation of the Quit Ratio The quit ratio was calculated to obtain the percent of former adult smokers using the following formula:
Quit ratio = Former smoker x 100 Ever smokers

Behavioral Risk Factor Surveillance System The Georgia Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to obtain the smoking prevalence and quit ratios among adult Georgians. The BRFSS is a survey conducted annually by the Division of Public Health of the Georgia Department of Human Resources. The survey is administered by telephone to the non-institutionalized, civilian population aged 18 years and older in Georgia using standardized methods and questionnaires. The BRFSS covers a wide range of modifiable health behaviors related primarily to chronic diseases, including high blood pressure, obesity, binge drinking, and cigarette smoking. Data have been collected in Georgia annually since 1984. In 2001, a total of 4,532 adult Georgians were included in the survey. All estimates presented in this report are based on the 2001 survey except for the analysis of time trends, which uses data from 1984 through 2001.
Youth Tobacco Survey Data on tobacco use among youth were obtained from the 2001 Georgia Youth Tobacco Survey, a school-based survey administered to a representative sample of middle and high school students in the state (22). The survey provides comprehensive data on tobacco use, exposure to environmental tobacco smoke, smoking cessation, minors' ability to purchase or obtain tobacco products, knowledge and attitudes about tobacco, and familiarity with media messages.
Georgia Tobacco Quit Line Data on the cessation status among users of the Georgia tobacco quit line were obtained from a cessation status survey conducted by Group Health Cooperative on behalf of Georgia's tobacco use prevention program (23). Findings indicate the effectiveness of the services provided by the quit line in its first year of implementation.
School Health Education Profile The School Health Education Profile (SHEP) was administered to principals and lead health education teachers of a representative sample of 374 randomly selected public middle and high schools in Georgia (26). Survey topics included health education requirements, health education coordination, physical education and physical activity programs, tobacco prevention policies, nutrition-related policies and practices, violence prevention, asthma management, and HIV
23 2004 Georgia Tobacco Surveillance Report

Methodology and Limitations
prevention programs and policies. The response rates were 71% for principals (n=266) and 70% for lead health education teachers (n=260). The questionnaires answered by principals assessed school policies prohibiting tobacco use, advertising, sponsorship of school events, actions taken when students are caught smoking, and school referrals to cessation programs for students, faculty, and staff. The teacher questionnaire indicated which topics are covered in the school's health education curriculum and the grades at which those topics are taught.
The Georgia Worksite Health Promotion Policies and Practices Survey The Georgia Worksite Health Promotion Policies and Practices Survey, a computer-assisted telephone interview modeled after the 1999 National Worksite Health Promotion Survey, was administered to a stratified random sample of worksites in Georgia (27). A total of 1,085 interviews were completed. The data were weighted so that each stratum represented its true proportion in the worksite population.
Restaurant Survey The survey conducted in the Southeast Health District of Georgia was developed to determine the status of smoking allowed on restaurant premises and the existence of provisions that minimize exposure to secondhand smoke. Provisions included signage designating smoking and non-smoking sections, non-adjacent smoking and non-smoking sections, physical barriers between sections, separate ventilation systems for each section, and the exclusion of common-use areas from the smoking sections (9). A total of 729 restaurants met study criteria of having indoor seating for patrons. District sanitarians completed the survey by observing a restaurant's existing physical provisions to minimize secondhand smoke and conducted their routine food safety inspections simultaneously.
Local Tobacco Ordinance Tracking Survey Georgia law (O.C.G.A. 36-80-19; passed in 2000 and amended in 2001) requires that counties and municipalities make their codes available to the public. Not all governments had listed their codes in the State of Georgia Law Library, the county law library, or on city and county websites. The majority of local governments had to be contacted directly by mail in July of 2002 with a letter requesting a copy of their entire code of ordinances, from which all tobacco-related ordinances would be identified after being received. A follow-up postcard was mailed two weeks later. Governments that had not replied were contacted by telephone the following month and until March of 2003 to obtain tobacco-related ordinances. Georgia is home to 159 counties and 532 incorporated cities. All county governments, 366 municipal governments with populations over 500 residents, and an additional 100 cities with populations under 500 people were accounted for, thus representing over 95 percent of the population of the state. For purposes of this survey, the unit of analysis is the jurisdiction, not the ordinance. A jurisdiction may have one or multiple ordinances relating to tobacco.
Enforcement Findings of the inspections conducted by the Addictive Diseases Section, as required by the Synar Amendment, were provided by the Division of Mental Health, Developmental Disabilities and Addictive Diseases of the Georgia Department of Human Resources. A stratified proportional two-stage random sampling design was used to select the sample for the 2001 Georgia Annual Synar Report. The geographical unit for the first-stage sampling frame was the county and outlets within a county made up the second stage. Outlet density was used as a stratification variable. All businesses that sell either consumer products
24 2004 Georgia Tobacco Surveillance Report

Methodology and Limitations
or services, including tobacco products were included in the sampling frame. These were categorized by business type and divided into those that sell tobacco as over-the-counter vendors and those that sell tobacco in vending machines. Outlets that require identification or membership were not considered in the sampling frame because they were not accessible to youth. The sampling frame for over-the-counter vendors totaled 12,770 and 1,862 for vending machines. The random selection of outlets yielded a sample size of 800 over-the-counter outlets and 150 vending machine vendors. Findings of the inspections conducted by the Department of Revenue were provided by the Division of Alcohol and Tobacco.
Limitations The methodology used to calculate the smoking-attributable deaths is subject to several limitations. 1) The smoking-attributable mortality figures in this report were estimated by using smoking prevalence and mortality data for 2001, whereas actual smoking-attributable deaths are the result of cumulative exposure to tobacco at higher rates from previous decades. 2) Relative risks were adjusted for the effects of age but not for other potential confounders, although studies have shown that these confounders have little impact on the relative risk of death from smoking. 3) Mortality estimates do not include deaths from smoking cigars or pipes, from using smokeless tobacco, or from environmental tobacco (second-hand) smoke. 4) Smoking-attributable expenditures were derived by applying 1993 smoking-attributable fractions of expenditures to 1998 personal health care expenditure data. Changes in the health care system, economic and demographic characteristics, and risk behaviors between 1993 and 1998 may have influenced the smoking-attributable fractions. 5) Productivity loss estimates do not include the value of lost work time from smoking-related illness, absenteeism, excess work breaks, and secondhand smoke-related disease morbidity and mortality. 6) The medical costs of maternal smoking may be underestimated because the future medical costs of children born to women who smoked during pregnancy and the costs of treating conditions related to secondhand smoke are not taken into account. 7) SAMMEC does not yet calculate smoking-attributed morbidity estimates.
25 2004 Georgia Tobacco Surveillance Report

Glossary
Aortic aneurysm: a bulge in the wall of the aorta (a large blood vessel that carries blood from the heart to the rest of the body) that has become stretched out and thin, and in which blood clots may form. Asthma: a chronic inflammatory disorder of the airways characterized by periodic attacks of wheezing, shortness of breath, chest tightness, and coughing. Atherosclerosis: thickening and hardening of artery walls. Bronchitis: a form of chronic obstructive pulmonary disease characterized by persistent cough that brings up mucus from the lungs. Cancer: a group of diseases characterized by uncontrolled growth and spread of abnormal cells that can result in death. Cardiovascular disease: includes a wide variety of diseases of the heart and blood vessels, such as ischemic heart disease, stroke, congestive heart failure, hypertensive disease, and atherosclerosis. Current adult smokers: adults who have smoked at least 100 cigarettes in their lifetime and now smoke every day or some days. Current youth smokers: middle and high school students who have smoked cigarettes on one or more days in the 30 days preceding the survey. Emphysema: a form of chronic obstructive pulmonary disease characterized by irreversible damage to the air sacs in the lungs. The air sacs are unable to completely deflate and are therefore unable to fill with fresh air to ensure adequate oxygen supply to the body. Environmental tobacco smoke (ETS): tobacco smoke that is generated from the burning end of a cigarette, pipe or cigar and the smoke that is exhaled by smokers of these tobacco products. ETS is also known as second-hand smoke. Ever smokers, adults: adults who have smoked 100 cigarettes in their lifetime. Ever smokers, youth: middle and high school students who have ever smoked at least one cigarette every day for 30 days. Former adult smokers: adults who have smoked 100 or more cigarettes in their lifetime but who do not currently smoke. Hypertension: also known as high blood pressure, occurs when the systolic pressure is consistently over 140 mmHg, or the diastolic blood pressure is consistently over 90 mmHg. Influenza: a viral illness that comes on suddenly, causing fever, shaking chills, body aches, headache, and fatigue, which usually last for 3 to 4 days, followed by a dry cough, runny nose, and sore or scratchy throat for another week or so. International Classification of Diseases, 10th Revision (ICD-10): an alphanumeric coding scheme developed by the World Health Organization, used for mortality data since 1999, that arranges diseases and injuries into groups according to established criteria. It is used to improve comparability of cause of death statistics reported by different governmental entities.
26 2004 Georgia Tobacco Surveillance Report

Glossary

Ischemic heart disease: also known as coronary heart disease, is the term given to heart problems caused by a narrowing of the coronary arteries. It includes heart attacks and related problems, such as chest pain or discomfort.
Low birth weight: a live birth with a weight of less than 2500 grams (5lbs. 8oz.).
Non-smokers, adults: persons who have not smoked 100 cigarettes in their lifetime.
Non-smokers, youth: middle and high school students who have not smoked cigarettes on one or more days in the 30 days preceding the survey.
Prevalence: an estimate of how many people in a defined population have a specific disease at a given point in time.
Pneumonia: a bacterial or viral infection of the lungs that may cause fevers, coughing, chills, shallow breathing, chest pains, rapid heartbeat, and weakness or fatigue.
Quit ratio: the percentage of ever smokers who have quit.
Respiratory distress syndrome: respiratory difficulty in newborn infants common in babies born prematurely.
Short gestation: a fetus born before 37 weeks after conception.
Stroke: occurs when a blood vessel (artery) that supplies blood to the brain bursts or becomes blocked by a blood clot resulting in damage and death of nerve cells in the affected area of the brain.
Sudden infant death syndrome: the sudden and unexpected death of a baby with no known illnesses, typically affecting sleeping infants between the ages of two weeks to six months.
Years of potential life lost: a measure of the impact of premature mortality on a population, calculated as the sum of the differences between some predetermined minimum or desired life span and the age of death for individuals who died earlier than that predetermined age.

27 2004 Georgia Tobacco Surveillance Report

References
1. US Public Health Service. Smoking and Health Report of the Advisory Committee to the Surgeon General of the Public Health Service. US Department of Health, Education, and Welfare, Public Health Service, Centers for Disease Control. PHS Publication No. 1103, 1964.
2. Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). http://www.cdc.gov/tobacco/issue.htm
3. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph no. 10. Bethesda, MD. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Pub. No. 99-4645, 1999.
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10. Liang L, Chaloupka FJ. Differential Effects of Cigarette Price on Youth Smoking Intensity. ImpacTeen Research Paper Series No. 6, February 2001.
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References
14. National Cancer Institute: State Cancer Legislative Database Program, Bethesda, MD, 2003. http://www.scld-nci.net.
15. Georgia Department of Revenue, 2002 Statistical Report. Accessed at: http://www2.state.ga.us/departments/dor/oic/2002stats/2002statisticalreport.pdf
16. Wall MA, Severson HH, Andrews JA, Lichtenstein E, Zoref L. Pediatric Office-based Smoking Intervention: Impact on Maternal Smoking and Relapse. Pediatrics 1995; 96(4): 622-628.
17. Mullen PD, DiClemente CC, Bartholomew LK. Theory and Context and Project PANDA: a Program to Help Postpartum Women Stay Off Cigarettes. In Bartholomew LK, Parcel GS, Kok G, Gottlieb H. Designing Theory- and Evidence-based Health Promotion Programs. Mountain View, California: Mayfield Publishers, 2000; 453-477.
18. Centers for Disease Control and Prevention. Trends in Cigarette Smoking among High School Students United States 1991-1999. MMWR 2000; 49: 755-758.
19. National Cancer Institute. State and Local Legislative Action to Reduce Tobacco Use. Smoking and Tobacco Control Monograph No. 11. Bethesda, MD. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Pub. No. 00-4804, 2000.
20. Centers for Disease Control and Prevention. Strategies for Reducing Exposure to Environmental Tobacco Smoke, Increasing Tobacco-Use Cessation, and Reducing Initiation in Communities and Health-Care Systems. MMWR 2000;49:RR-12.
21. Bartosch WJ, Pope GC. The Economic Effect of Smoke-free Restaurant Policies on Restaurant Businesses in Massachusetts. Journal of the Public Health Management Practice. 1999; 5(1): 53-62.
22. Kanny D, Powell KE, Copes K. Georgia Youth Tobacco Survey, 2001. Georgia Department of Human Resources, Division of Public Health, Tobacco Use Prevention Section, June, 2002. Publication number: DPH02.72HW.
23. Zbikowski SM, Bush T, Yepassi-Zembrou P, McAffee T, O'Hara A, Hantz K. Georgia Tobacco Quit Line: Quit Status Report, Year 1. Group Health Cooperative Center for Health Promotion. Tukwila, WA, 2002.
24. Centers for Disease Control and Prevention. Smoking-attributable mortality, morbidity, and economic costs (SAMMEC): adult SAMMEC and maternal and child health (MCH) SAMMEC application, 2002. http://www.cdc.gov/tobacco/sammec
25. National Center for Health Statistics. Deaths: Final data for 2000. National Vital Statistics reports; vol. 50 no. 15. Hyattsville, MD, 2002.
26. Kanny D, Choi, HS, Hammond, DA. School Health Education in Georgia: Results from the 2002 School Health Education Profile (SHEP) Survey. Georgia Department of Human Resources, Division of Public Health, February 2004. Publication Number DPH04.181HW.
27. Choi HS, Bricker SK, Troy K, Kanny D, Powell KE. Worksite Health promotion Policies and Practices in Georgia: 2002 Georgia Worksite Survey. Georgia Department of Human Resources, Division of Public Health, January 2004. Publication Number DPH03/156HW.
28. Mellinger-Birdsong A, Blackwell A, Wu M, Mertz KJ, Powell KE. Childhood Asthma in Georgia: Prevalence and Management Practices. Georgia Epidemiology Report. 2003; 19:1-3.
29 2004 Georgia Tobacco Surveillance Report

Appendix Tables

Table A. Annual deaths, smoking-attributable mortality (SAM) and years of potential life lost (YPLL) by cause of death and sex, Georgia adults 35 and older and infants one year and younger, 2001

Disease Category
Neoplasms Lip, Oral cavity, Pharynx Esophagus Pancreas Larynx Trachea, Lung, Bronchus Cervix Bladder Kidney and Renal Pelvis
Total Neoplasms
Cardiovascular Diseases: Hypertension Ischemic Heart Disease
Aged 35-64 years Aged 65+ years Other Heart Disease Cerebrovascular Disease Aged 35-64 years Aged 65+ years Atherosclerosis Aortic Aneurysm Other diseases of circulatory system
Total Cardiovascular Diseases
Respiratory Diseases: Pneumonia, Influenza Bronchitis, Emphysema Chronic Airway Obstruction
Total Respiratory Diseases
Total Adult
Perinatal Conditions: Short Gestation / Low Birth Weight Respiratory Distress Syndrome Respiratory Conditions - Newborn Sudden Infant Death Syndrome
Total Perinatal Conditions

ICD-10*
C00-C14 C15 C25 C32
C33-C34 C53 C67
C64-C65
I10-I13 I20-I25 I00-I09, I26-I51 I60-I69
I70 I71 I72-I78
J10-J18 J40-J43
J44
P07 P22 P23-P28 R95

Deaths 127 251 349 101
2,598 0
165 144
3,735
587
1,675 3,507 2,812
411 1,233
153 199
99
10,676
621 272 1,186
2,079
16,490
125 16 37 68
246

Overall Total
* International Classification of Diseases, Tenth Revision used since 1999 for specifying cause of death. Mortality data were taken from the Georgia Vital Statistics Report.

16,736

Male
SAM 96
183 85 85
2,306 0
80 58
2,893
121
682 569 840
160 128
45 47 90
2,682
148 248 975
1,371
6,946
8 0 1 6
15
6,961

YPLL 1,841 3,390 1,493 1,481
38,124 0
1,127 1,117
48,573
2,222
17,811 5,802
12,806
4,236 1,210
553 714 1,224
46,578
1,815 3,134 12,024
16,973
112,124
577 19 43
471
1,110
113,234

31 2004 Georgia Tobacco Surveillance Report

Deaths 79 63
342 19
1,584 106 106 97
2,396

Female
SAM 37 37 79 14
1,128 13 29 5
1,342

YPLL 670 792
1,358 298
21,407 380 418 102
25,425

Deaths 206 314 691 120
4,182 106 271 241
6,131

872
649 4,059 3,678
339 2,252
280 139 175
12,443

95
242 411 338
153 123
23 19 140
1,544

1,576
7,163 4,043 5,190
4,707 1,172
237 276 1,814
26,178

1,459
2,324 7,566 6,490
750 3,485
433 338 274
23,119

854 271 1,211
2,336
17,175

117 217 899
1,233
4,119

1,466 3,235 12,738
17,439
69,042

1,475 543
2,397
4,415
33,665

96

6

475

221

19

0

24

35

38

1

48

75

44

4

327

112

197

11

874

443

17,372

4,130

69,916

34,108

Total
SAM 133 220 164 99
3,434 13
109 63
4,235

YPLL 2,511 4,182 2,851 1,779
59,531 380
1,545 1,219
73,998

216
924 980 1,178
313 251
68 66 230
4,226

3,798
24,974 9,845
17,996
8,943 2,382
790 990 3,038
72,756

265 465 1,874
2,604
11,065

3,281 6,369 24,762
34,412
181,166

14

1,052

0

43

2

91

10

798

26

1,984

11,091

183,150

32 2004 Georgia Tobacco Surveillance Report

Table B. Annual deaths and smoking-attributable mortality (SAM) in 19 Georgia public health districts, by cause of death, Georgia adults 35 and older, 2001

Cause of Death (ICD-10 Descriptions)

Georgia

Clayton

Coastal Cobb/Douglas DeKalb

ICD-10* Deaths SAM Total SAM Total SAM Total SAM Total SAM

Malignant Neoplasms: Lip, Oral cavity, Pharynx Esophagus Pancreas Larynx Trachea, Lung, Bronchus Cervix Bladder Kidney and Renal Pelvis

C00-C14 206 133 <5

C15 314 220

5

C25 691 164 13

C32 120 99

6

C33-C34 4,182 3,434 84

C53 106 13 <5

C67 271 109

7

C64-C65 241 63

6



7

4 11

3 16

5

0

69 101

<5

3 10

2

7

5

9

6 11

7

8 20 14 13

9

4 46 11 39

9

0 <5

10

8

83 266 218 204 168



6

1

5

1

4 15

6 18

7

2 16

4 11

3

Total Neoplasms

6,131 4,235 121 86 152 106 378 260 311 212

Cardiovascular Diseases:

Hypertension

I10-I13 1,459 216 40

Ischemic Heart Disease

I20-I25 9,890 1,904 233

Other Heart Disease

I00-I09, I26-I51 6,490 1,178 121

Cerebrovascular Disease

I60-I69 4,235 564 55

Atherosclerosis

I70 433 68

8

Aortic Aneurysm

I71 338 66

6

Other diseases of circulatory system

I72-I78 274 230 <5

6 27

45 186

22 149

7 103

1

8

1

7



7

4 81 12 121 18

36 549 106 521 100

27 490 89 319 58

14 225 30 273 36

1 31

5 13

2

1 24

5 19

4

6 15 13 18 15

Total Cardiovascular Diseases

23,119 4,226 463 82 487 89 1,415 260 1,284 233

Respiratory Diseases: Pneumonia, Influenza Bronchitis, Emphysema Chronic Airway Obstruction

J10-J18 1,475 265 30

5 33

6 72 13 99 18

J40-J43 543 465 11

9 35 30 41 35 27 23

J44 2,397 1,874 63 49 56 44 163 127 102 80

Total Respiratory Diseases

4,415 2,604 104 63 124 80 276 175 228 121

Total Adult

33,665 11,065 688 231 763 275 2,069 695 1,823 566

* International Classification of Diseases, Tenth Revision, used since 1999 for specifying cause of death. This symbol is shown instead of the estimate when the number of deaths in the health district is less than five.

33 2004 Georgia Tobacco Surveillance Report

East

East Central East Metro

Fulton

LaGrange

North

North Central North Georgia

Total SAM Total SAM Total SAM Total SAM Total SAM Total SAM Total SAM Total SAM

10

6

11

7

10

6

16

10

12

8 12

8

21

14

12

8

14

10

19

13

29

20

30

21 25

18

25

18

28

7

42

10

38

9

67

16

61

14 41

10

51

12

5

4

9

7

7

6

10

8

11

9 <5



11

9

149 122 264 217 271 223 310 255 342 281 250 205 309 254

<5

<5



9

1

7

1

12

1 <5



6

1

11

4

19

8

18

7

20

8

30

12 18

7

20

8

8

2

18

5

17

4

21

5

24

6 11

3

15

4

223 153 377 264 389 269 480 323 522 352 357 251 458 320

7

5

6

4

25

6

<5



189 155

<5



9

4

10

3

246 177

27

4

81

12

71

11 247

37 111

16 53

8

128 19

445

86 633 122 503

97 833 160 782 151 640 123 746 144

349

63 364

66 339

62 507

92 564 102 419 76 431 78

143

19 301

40 220

29 358

48 401

53 238 32 303 40

6

1

17

3

10

2

31

5

52

8 18

3

64

10

14

3

22

4

34

7

27

5

22

4 15

3

30

6

7

6

18

15

12

10

33

28

21

18 14

12

14

12

991 182 1,436 262 1,189 218 2,036 375 1,953 352 1,397 257 1,716 299

36

5

344

66

302

55

150

20

36

6

14

3

11

9

893 164

67

12

97

17

81

15 148

27 131

24 96

17 106 19

16

14

14

12

55

47

45

39

40

34 42

36

29

25

85

66 148 116 119

93 148 116 226 177 157 123 169 132

168 92 259 145 255 155 341 182 397 235 295 176 304 176

72

13

22

19

103

81

197 113

1,382 427 2,072 671 1,833 642 2,857 880 2,872 939 2,049 684 2,478 795 1,336 454

34 2004 Georgia Tobacco Surveillance Report

Table B. Annual deaths and smoking-attributable mortality (SAM) in 19 Georgia public health districts, by cause of death, Georgia adults 35 and older, 2001 cont'd. . .

Northeast Northwest

South South Central South East Southwest West Central

Total SAM Total SAM Total SAM Total SAM Total SAM Total SAM Total SAM

6

4 12

8 10

6

9

26 18 18 13 12

8 <5

29

7 47 11 23

5 20

<5

12 10

7

6 <5

172 141 383 314 161 132 84

7

1

6

1 <5



7

17

7 19

8 <5

<5

13

3 15

4 12

3 <5

270 181 512 369 225 160 120

6 13

8

16

10

13

8

11

8

18

13

20

14

5 29

7

44

10

35

8

<5



6

5

9

7

69 208 171 239 196 200 164

1 10

1 14

2

8

1



9

4 14

6

11

4



6

2 16

4

12

3

81 286 201 367 246 308 209

74 11 70 10 47

525 101 869 167 295

257 47 435 79 230

219 29 269 36 136

13

2 38

6 18

18

4 21

4

9

8

7 30 25 14

7 19

57 229

42 206

18 107

3

9

2

5

12

6

3 63 44 462 37 424 14 259
1 20 1 21 5 16

9

82

12

96

14

89 546 105 594 114

77 405

74 349

63

34 272

36 253

34

3 13

2

28

4

4 17

3

20

4

13

20

17

12

10

1,114 201 1,732 327 749 141 581 105 1,265 229 1,355 249 1,352 243

42

8 93 17 72 13 30

23 20 40 34 16 14

5

112 88 197 154 103 81 71

177 116 330 205 191 108 106

5 79 14 73 4 26 22 36 56 137 107 109

13

83

15

31

21

18

85 133 104

65 242 143 218 129 237 137

1,561 498 2,574 901 1,165 409 807 251 1,793 573 1,940 624 1,897 589

35 2004 Georgia Tobacco Surveillance Report

Table C. Smoking prevalence among adults 18 and older by public health district, Georgia, 2001

District

Current Smoker

%

95% CI

1-1: Northwest (Rome) 1-2: North Georgia (Dalton) 2: North (Gainesville) 3-1: Cobb/Douglas (Marietta) 3-2: Fulton (Atlanta) 3-3: Clayton (Morrow) 3-4: East Metro (Lawrenceville) 3-5: DeKalb (Decatur) 4: LaGrange (LaGrange) 5-1: South Central (Dublin) 5-2: North Central (Macon) 6: East Central (Augusta) 7: West Central (Columbus) 8-1: South (Valdosta) 8-2: Southwest (Albany) 9-1: East (Savannah) 9-2: Southeast (Waycross) 9-3: Coastal (Brunswick) 10: Northeast (Athens)
Source: BRFSS 2001

31.4

( 6.7)

28.1

( 6.8)

23.5

( 6.2)

16.6

( 5.5)

22.1

( 6.6)

25.1

( 6.4)

29.2

( 6.9)

18.5

( 6.1)

22.7

( 5.8)

24.1

( 7.0)

28.0

( 7.1)

26.0

( 6.4)

18.8

( 6.8)

24.0

( 6.7)

19.1

( 5.6)

26.3

( 6.4)

32.2

( 6.8)

28.1

( 6.3)

24.6

( 7.1)

Former Smoker

%

95% CI

22.1

( 5.9)

21.0

( 5.8)

32.0

( 6.8)

21.6

( 6.5)

18.4

( 6.3)

13.7

( 4.8)

21.6

( 5.5)

15.4

( 5.6)

24.0

( 5.9)

22.6

( 6.2)

22.5

( 5.9)

19.1

( 5.3)

21.9

( 5.9)

19.8

( 5.9)

23.8

( 6.1)

22.8

( 6.1)

18.4

( 5.7)

19.0

( 5.3)

18.6

( 5.5)

Never Smoker

%

95% CI

46.4

( 6.9)

50.9

( 7.6)

44.5

( 7.4)

61.8

( 7.6)

59.6

( 7.9)

61.2

( 7.0)

49.2

( 7.5)

66.1

( 7.7)

53.3

( 6.9)

53.3

( 8.0)

49.5

( 7.2)

54.8

( 7.2)

59.3

( 8.0)

56.1

( 7.8)

57.1

( 7.1)

50.9

( 7.4)

49.4

( 7.2)

52.9

( 7.1)

56.8

( 8.0)

36 2004 Georgia Tobacco Surveillance Report

Table D. Smoking prevalence among middle and high school students by participating public health district, Georgia, 2001

Health District
1-2: North Georgia (Dalton) 3-2: Fulton (Atlanta) 4: LaGrange (LaGrange) 5-1: South Central (Dublin) 6: East Central (Augusta) 7: West Central (Columbus) 8-2: Southwest (Albany) 9-2: Southeast (Waycross) 9-3: Coastal (Brunswick)
- Data not available for high schools in these districts.

Middle School

%

95% CI

12.7

(5.4)

4.3

(2.5)

12.8

(4.3)

11.9

(2.1)

10.1

(6.0)

7.6

(2.3)

10.2

(2.0)

11.8

(2.3)

8.8

(1.4)

High School

%

95% CI

-

-

-

-

-

-

25.7

(5.9)

21.4

(6.9)

23.7

(4.9)

28.2

(4.4)

25.5

(4.5)

23.2

(3.3)

37 2004 Georgia Tobacco Surveillance Report

Table E. Healthy People 2010 Objectives and Current Status of Objectives in Georgia Related to Tobacco Use

Healthy People 2010 Objective

Status in Georgia

Objective 27-1a: Reduce the proportion of adults who currently smoke cigarettes.
Target: 12%
Objective 27-2a: Reduce the proportion of students in grades 9 through 12 who are current users of any tobacco products.
Target: 21%
Objective 27-2b: Reduce the proportion of students in grades 9 through 12 who are current cigarette smokers.
Target: 16%
Objective 27-2c: Reduce the proportion of students in grades 9 through 12 who are current smokeless tobacco users.
Target: 1%
Objective 27-2d: Reduce the proportion of students in grades 9 through 12 who are current cigar smokers.
Target: 8%
Objective 27-3: Reduce the proportion of children and adolescents who begin using tobacco products (in Development)
Target: in development

24% of Georgia adults are current cigarette smokers.
32% of Georgia high school students currently use any tobacco product.
24% of Georgia high school students are current cigarette smokers.
10% of Georgia high school students are current smokeless tobacco users.
15% of Georgia high school students are current cigar smokers.
Objective in development, has not yet been established nationally.

38 2004 Georgia Tobacco Surveillance Report

Table E. Healthy People 2010 Objectives and Current Status of Objectives in Georgia Related to Tobacco Use

Healthy People 2010 Objective

Status in Georgia

Objective 27-4a: Increase the average age of first use of tobacco products by adolescents aged 12 to 17 years.
Target: 14
Objective 27-4b: Increase the average age of first use of tobacco products by young adults aged 18 to 25 years.
Target: 17
Objective 27-5: Increase the proportion of adult smokers who have attempted to quit smoking.
Target: 75%
Objective 27-6: Increase the proportion of pregnant women who quit smoking during the first trimester of their pregnancy.
Target: 30%
Objective 27-7: Increase the proportion of smokers in grades 9 through 12 who have attempted to quit smoking.
Target: 84%
Objective 27-8: Increase in insurance coverage of evidence-based treatment for nicotine dependency.
Target: 100%
Objective 27-9: Reduce the proportion of children 6 years and under who are regularly exposed to tobacco smoke at home.
Target: 10%

The most prevalent age of initiation for high school students who smoke is in the age group 13-14.
Data have not been collected in Georgia.
59% of adult smokers in Georgia have attempted to quit smoking.
Data for planning purposes only.
53% of high school smokers in Georgia have attempted to quit smoking in the past 12 months.
Data collection in planning (Health Plan Policy Survey).
33% of children 5 years and under lived in a household where at least one adult smoked inside or away from the house (28).

39 Tobacco Surveillance in Georgia 2004 Report

Table E. Healthy People 2010 Objectives and Current Status of Objectives in Georgia Related to Tobacco Use

Healthy People 2010 Objective

Status in Georgia

Objective 27-10: Reduce the proportion of non-smokers aged 4 years and older who are exposed to environmental tobacco smoke.
Target: 45% (Through measurements of serum cotinine levels in the blood.)
Objective 27-11: Increase the proportion of schools that are smoke-free and tobacco-free, to include all school facilities, property, vehicles, and school events.
Target: 100%
Objective 27-12: Increase the proportion of worksites with formal policies prohibiting or limiting smoking to separately ventilated areas.
Target: 100%
Objective 27-13: Increase or establish laws on smoke-free indoor air that prohibit or limit smoking to separately ventilated areas in public places and worksites.
Target: 51%
Objective 27-14: Increase the number of States and Territories that reduce the proportion of illegal sales of tobacco products to minors through the enforcement of laws prohibiting the sale of tobacco products to minors.
Target: all 50 States, the District of Columbia, and all US territories.

Laboratory test-confirmed data are not available.
99% of middle schools and high schools in Georgia have policies that specifically prohibit tobacco use in school buildings, in school vehicles, and at off-campus events.
90% of Georgia worksites have formal policies that specifically prohibit smoking on the job.
20% of Georgia jurisdictions have laws on smoke-free indoor air that prohibit or restrict smoking.
Synar Amendment and Georgia Synar Report, conducted by the Division of Mental Health, Developmental Disabilities, and Addictive Diseases of the Georgia Department of Human Resources.

40 Tobacco Surveillance in Georgia 2004 Report

Table E. Healthy People 2010 Objectives and Current Status of Objectives in Georgia Related to Tobacco Use

Healthy People 2010 Objective

Status in Georgia

Objective 27-15: Increase the number of States and the District of Columbia that suspend or revoke State retail licenses for violations of laws prohibiting the sale of tobacco products to minors.
Target: all 50 States and the District of Columbia
Objective 27-16: Eliminate tobacco advertising and promotions that influence adolescents and young adults (in development).
Objective 27-17: Increase the proportion of students in 8th, 10th and 12th grades who disapprove smoking.
Target: 95%
Objective 27-18: Increase the number of Tribes, Territories and States and the District of Columbia with comprehensive, evidence-based tobacco control programs (in development).
Objective 27-19: Eliminate the number of States with laws that preempt stronger tobacco control laws.
Target: Zero States
Objective 27-20: Reduce the toxicity of tobacco products by establishing a regulatory structure to monitor toxicity (in development).

The Alcohol and Tobacco Division of the Georgia Department of Revenue is in charge of enforcement.
Objective in development, has not yet been established nationally.
Data not collected in Georgia.
The Tobacco Use Prevention Section, Division of Public Health, Georgia Department of Human Resources was established in October 2001 and is a comprehensive, evidence-based tobacco control program. There are no preemptive laws in Georgia.
Objective in development, has not yet been established nationally.

41 Tobacco Surveillance in Georgia 2004 Report