Georgia Tobacco Use Surveillance Report
2009
Acknowledgements
Georgia Department of Human Resources B.J. Walker, Commissioner
Division of Public Health S. Elizabeth Ford, MD, MBA, Acting Director
Health Information, Policy, Strategy, and Accountability Martha N. Okafor, Ph.D., Deputy Director
Office of Epidemiology, Evaluation and Health Information Dafna Kanny, Ph.D., Senior Director
Epidemiology Section
John Horan, MD, MPH, Director
Office of Healthy Behavior
Kimberly Redding, MD, MPH, Senior Director
Health Promotion Section Shonta Chambers, MPH, Director
Tobacco Use Prevention Program Kenneth Ray, MPH, Program Manager
Graphic Design: Jimmy Clanton, Jr.
Suggested citation: Figueroa A. 2009 Georgia Tobacco Surveillance Report. Georgia Department of Human Resources, Division of Public Health, Office of Epidemiology, Evaluation and Health Information, March 2009. Publication Number: DPH 09.345 HW.
This publication was supported by Cooperative Agreement Number UC58/CCU422885-03022 from the Centers for Disease Control and Prevention (CDC), State Tobacco Prevention and Control Program. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
2
2009 Georgia Tobacco Use Surveillance Report
Table of Contents
Executive Summary............................................................................................................................. 4
Introduction.......................................................................................................................................... 6
Burden of Tobacco Use in Georgia...................................................................................................... 7 Mortality..................................................................................................................................... 7 Years of potential life lost.......................................................................................................... 8 Economic costs......................................................................................................................... 8
Tobacco Use in Georgia....................................................................................................................... 9 Tobacco use among youth........................................................................................................ 9 Tobacco use among adults....................................................................................................... 11 Tobacco use among pregnant women..................................................................................... 13
Secondhand Smoke and Asthma........................................................................................................ 14
Reducing Tobacco Use in Georgia...................................................................................................... 15 Former smokers....................................................................................................................... 15 Smoking cessation................................................................................................................... 16
Policy................................................................................................................................................... 17 Home and worksite policies...................................................................................................... 17 School policies......................................................................................................................... 18 Support of smoke-free laws and taxation................................................................................. 19
Summary and Implications for Prevention.......................................................................................... 20
Methodology and Limitations.............................................................................................................. 22
Glossary.............................................................................................................................................. 27
References.......................................................................................................................................... 29
Appendices......................................................................................................................................... 31
2009 Georgia Tobacco Use Surveillance Report
3
Executive Summary
Cigarette smoking remains a leading preventable cause of illness and death in Georgia. Mortality
Over 10,000 adult Georgians die from smoking-related illnesses annually. About 4,400 die from cancer About 3,300 die from cardiovascular diseases About 2,700 die from respiratory diseases
About 35 infants die every year because their mothers smoked during pregnancy. Economic Costs
$3.4 billion in lost productivity costs in Georgia for adults are attributed to smoking annually. $1.8 billion in healthcare costs in Georgia for adults are attributed to smoking annually. Tobacco Use in Georgia Approximately 23,000 (6%) middle school students and 81,000 (19%) high school students in
Georgia smoke cigarettes. Approximately 1,400 (6%) middle school smokers and 24,000 (30%) high school smokers buy their
cigarettes at gas stations or convenience stores. Approximately 1.3 million (19%) 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. 10% of pregnant women in Georgia smoked during the last three months of their pregnancy. Secondhand Smoke and Asthma Approximately 41,000 (11%) middle school students, 44,000 (10%) high school students, and
524,000 (8%) adults in Georgia have asthma. Among persons with asthma, approximately 3,000 (8%) middle school students, 8,000 (19%) high
school students, and 126,000 (24%) adults smoke cigarettes.
4
2009 Georgia Tobacco Use Surveillance Report
Executive Summary (continued)
Reducing Tobacco Use in Georgia
Approximately 1.5 million (54%) adult Georgians who had ever smoked report having quit smoking.
Approximately 760,000 (57%) adult smokers in Georgia have ever stopped smoking cigarettes for one day or longer in an attempt to quit.
Approximately 151,000 (25%) adult smokers who made a quit attempt used medication such as nicotine patch or gum on their last quit attempt.
Approximately 673,000 (59%) adult smokers are seriously considering stopping smoking.
Approximately 485,000 (67%) adult smokers who visited their health care provider in the past year indicated their health care provider advised them not to smoke.
Of all current adult smokers who were advised not to smoke when they visited their health care provider in the past year, approximately 144,000 (30%) of them were given a prescription for medication to help them quit and approximately 80,000 (17%) of them were advised to participate in a smoking cessation class or program.
Policy
A majority (81%) of adults in Georgia do not allow smoking anywhere inside their homes.
A majority (85%) of employed adults in Georgia indicate their worksite has a policy that prohibits smoking at work.
Almost all public middle (99%) and high schools (99%) have a policy prohibiting tobacco use.
Most middle schools and high schools have procedures to inform students (99% MS, 100% HS), and faculty and staff (88% MS, 93% HS) of the actions taken when someone is non-compliant with the school policy; however, the procedures were applicable to visitors in only 69% of middle schools and 65% of high schools.
Half of adult smokers and a majority (82%) of adult non-smokers support laws making restaurants smoke-free.
Nearly half (46%) of adult smokers and three-fourths (75%) of adult non-smokers would support an additional tax on cigarettes.
2009 Georgia Tobacco Use Surveillance Report
5
Introduction
The effect of tobacco use on health has been a topic of research since the beginning of the 20th century (1). There is ample scientific literature providing 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). Smoking is not only harmful to smokers but also to children and non-smokers who are exposed to secondhand smoke. Exposure to secondhand smoke is associated with decreased lung function and development, bronchitis, respiratory infections, asthma severity, lung cancer, and heart disease (3).
Table 1. Causes of death for which tobacco use is a contributing cause
Causes of death
Cancer
Cardiovascular diseases
Respiratory diseases
Lip, oral cavity, pharynx Esophagus Stomach Pancreas Larynx Trachea, lung, bronchus Cervix Kidney and renal pelvis Bladder Acute myeloid leukemia
Ischemic heart disease Other heart disease Stroke Atherosclerosis Aortic aneurysm Other diseases of the circulatory system
Pneumonia Influenza Bronchitis Emphysema Chronic airway obstruction
Perinatal conditions
Short gestation Low birth weight Respiratory distress syndrome Respiratory conditions of newborrns Sudden infant death syndrome (SIDS)
Over the past 40 years, the nationwide percentage of smokers has declined, falling from 40% in 1965 to 20% in 2007 (4, 5, 6); still many people continue to smoke. Cigarette smoking is responsible for over 10,000 deaths, more than 170,000 years of potential life lost, and approximately $3.4 billion in productivity losses in Georgia every year.
The 2009 Georgia Tobacco Use Surveillance Report presents data on smoking-related deaths and costs, tobacco use prevalence, and policies affecting tobacco use. It also indicates the status of the tobacco use goals for Georgia as they relate to the Healthy People 2010 Objectives (Appendix Table I). This is the second comprehensive surveillance report describing the burden of tobacco use in Georgia. Data from this report will be used by the Georgia Department of Human Resources and partner organizations to evaluate, redesign, and enhance program activities and strategies focusing on tobacco use prevention in Georgia.
6
2009 Georgia Tobacco Use Surveillance Report
Burden of Tobacco Use in Georgia
Mortality Cigarette smoking is a leading cause of preventable illness and death in Georgia. From 2002 to 2006, an estimated annual average of 10,359 deaths -or 17% of the annual average of 61,762 deaths due to all causes- among Georgians ages 35 years and older were attributed to cigarette smoking. Of these estimated deaths, 4,360 (42%) were due to cancer, 3,289 (32%) were due to cardiovascular diseases, and 2,710 (26%) were due to respiratory diseases (Figure 1). The most common causes of death attributed to smoking in Georgia were lung cancer (3,464 deaths), chronic obstructive pulmonary disease (COPD) (2,253 deaths), ischemic heart disease (1,686 deaths), and stroke (496 deaths).
Figure 1. Average annual smoking-attributable deaths among adults ages 35 and older, Georgia, 2002-2006
Attributed to smoking 17%
Average annual adult deaths, all causes = 61,762
Sources: Georgia Vital Statistics; CDC SAMMEC
32%
Cardiovascular
diseases
26%
Respiratory
42%
diseases
Cancer
Average annual adult deaths attributed to smoking = 10,359
From 2002 to 2006, cigarette smoking caused an estimated annual average of 6,463 deaths among adult males and 3,896 deaths among adult females in Georgia (Appendix Table A).
From 2002 to 2006, cigarette smoking during pregnancy resulted in an estimated annual average of 17 infant deaths due to short gestation or low birth weight and 15 infant deaths due to sudden infant death syndrome (SIDS) (Appendix Table A).
From 2002 to 2006, the average annual estimates of adult deaths attributed to smoking for each of the 18 public health districts ranged from 202 to 887 deaths (Appendix Table B).
2009 Georgia Tobacco Use Surveillance Report
7
Burden of Tobacco Use in Georgia
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 die before their expected age of death. From 2002 to 2006, an estimated 173,302 years of life were lost on average annually in Georgia from smoking. Adult male and female smokers lost an average of 16.5 years of potential life because they smoked. Adults who died from cancer, particularly lung cancer attributed to smoking, lost an average of 17.7 years of potential life. Adults who died from cardiovascular diseases and respiratory diseases attributed to smoking lost an average of 17.6 years and 13.1 years,
respectively (Table 2).
Table 2. Average annual years of potential life lost (YPLL), number of deaths, and average YPLL attributed to smoking by disease category and sex, Georgia, 2002-2006
Cancer Male Female Total Cancer
YPLL attributed to Deaths attributed
smoking
to smoking
50,325 26,731 77,056
2,945 1,415 4,360
Average YPLL per death from smoking
17.1 18.9 17.7
Cardiovascular Diseases
Male
38,088
2,091
18.2
Female
19,827
1,198
16.6
Total Cardiovascular Diseases
57,915
3,289
17.6
Respiratory Diseases
Male
17,954
1,427
12.6
Female
17,661
1,283
13.8
Total Respiratory Diseases
35,615
2,710
13.1
Total Adult (35+ years)
170,586
10,359
16.5*
Perinatal Conditions
Male
1,477
20
Female
1,239
15
Total Perinatal Conditions
2,716
35
73.9 82.6 77.6
Overall Total
173,302
10,394
16.7
* Indicates the average years of potential life lost attributed to smoking per adult smoker Indicates the average years of potential life lost attributed to smoking per child born of a woman who smoked during pregnancy Source: Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) application
Table 3. Average annual smoking-attributable economic costs, Georgia, 2002-2006
Economic Costs
Cost component
The average annual smokingrelated productivity losses in Georgia during 2002-2006 were estimated at almost $2.3 billion for men and $1.2 billion for women. In 1998, the smoking-related adult healthcare costs were estimated at almost $1.8 billion. These healthcare costs plus the average annual productivity losses exceeded $5.2 billion per year (Table 3).
Smoking-attributable productivity losses Men Women Total
Smoking-attributable adult healthcare costs, 1998* Ambulatory care Hospital care Prescription drugs Nursing home Other care Total
Total adult (35+ years) costs
Total
$2,278,000,000 $1,169,000,000 $3,447,000,000
$742,000,000 $421,000,000 $149,000,000 $311,000,000 $135,000,000 $1,758,000,000
$5,205,000,000
Infant costs
Smoking-attributable neonatal healthcare costs
$9,000,000
Total costs
$5,214,000,000
* 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.
8
2009 Georgia Tobacco Use Surveillance Report
Tobacco Use in Georgia
Figure 2. Percentage of youth tobacco users, by school type and tobacco product, Georgia, 2007
Percent
50
40
30
20
10
10
6
4
0 Middle School
26 19 8
High School
Any Tobacco Product* Cigarettes Smokeless Tobacco
* Combined variable that includes use of cigarettes, cigars, smokeless tobacco, pipe, or bidis.
Source: Georgia Student Health Survey (YRBS)
Tobacco Use among Youth
In 2007, approximately 36,000 (10%) middle school students and 113,000 (26%) high school students in Georgia used some form of tobacco; 23,000 (6%) middle school students and 81,000 (19%) high school students smoked cigarettes, while 15,000 (4%) middle school students and 39,000 (8%) high school students used smokeless tobacco (Figure 2).
Figure 3. Percentage of youth smokers, by school type and sex, Georgia, 2007
Male and female students smoked cigarettes at comparable rates (Figure 3).
Percent
50
40
30
20
10
8
5
0 Middle School
Male
Source: Georgia Student Health Survey (YRBS)
21 17
High School Female
Figure 4. Percentage of youth smokers, by school grade, Georgia, 2007
50
40
30
24
20
15
17
19
10
4
6
9
0
6th
7th
8th
9th 10th 11th 12th
Percent
Among middle school students, 8th graders (9%) were significantly more likely than 6th graders (4%) to smoke cigarettes. Among high school students, 12th graders (24%) were significantly more likely than 9th graders (15%) to smoke cigarettes (Figure 4).
Source: Georgia Student Health Survey (YRBS)
2009 Georgia Tobacco Use Surveillance Report
9
Tobacco Use in Georgia
In both middle and high school, the smoking prevalence was significantly higher among non-Hispanic whites than among nonHispanic blacks (Figure 5).
In 2007, approximately 22,000 (6.1%) middle school students smoked a whole cigarette before age 11 and approximately 68,000 (14.5%) high school students smoked a whole cigarette before age 13 (Appendix Table C).
Figure 5. Percentage of youth smokers, by school type and race/ethnicity, Georgia, 2007
50
40
Percent
30
20
10
9
4
6
0 Middle School
White
Black
* Data not presented, n<100 respondents
Source: Georgia Student Health Survey (YRBS)
25 20
10
High School Hispanic
In 2007, approximately 1,400 (6%) middle school smokers and 24,000 (30%) high school smokers bought cigarettes at gas stations or convenience stores. Male and female middle school smokers were similarly likely to purchase cigarettes at gas stations or convenience stores; however, in high school, cigarettes purchases at gas stations or convenience stores were more common among male smokers than among female smokers (Figure 6).
Figure 6. Percentage of youth who purchased cigarettes at gas stations or convenience stores,
by school type and sex, Georgia, 2007
Percent
50
40
30
20
10
8
5
0 Middle School
Male
Source: Georgia Student Health Survey (YRBS)
34 24
High School Female
10
2009 Georgia Tobacco Use Surveillance Report
Tobacco Use in Georgia
Tobacco Use among Adults
Cigarette use among adult Georgians has remained stable during the past decade. From 1985 through 1995 the prevalence of adult smokers declined by an average of 3% per year. From 1996 through 2007, however, the prevalence did not change significantly, declining by an average of 0.2% per year (Figure 7).
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Figure 8. Percentage of adult smokers, Georgia, 2007
50
40
Percent
30
20
19
10
21 18
19 20 15
0 Total
MF Sex
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
WB H Race/Ethnicity
In 2007, approximately 1.3 million (19%) adult Georgians were current smokers, 23% were former smokers, and 58% were never smokers. More males (21%) than females (18%) smoked cigarettes. Non-Hispanic black adults (20%) were equally likely as nonHispanic white adults (19%) to smoke (Figure 8).
Figure 9. Percentage of adult smokers, by age,
Georgia, 2007
50
40
30
23
22
23
20
19
18
10
8
0
18-24
25-34
35-44
45-54
55-64
65+
The overall adult smoking prevalence was significantly higher among adults ages 18-64 than among adults ages 65 and older (Figure 9).
Percent
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
2009 Georgia Tobacco Use Surveillance Report
11
Tobacco Use in Georgia
The smoking prevalence among adults in Georgia decreased with increasing education level. Adults who did not finish high school have the highest smoking prevalence (35%) among all educational attainment groups (Figure 10).
The annual average adult smoking prevalence varied by public health district (Map 1). Table D in the Appendix lists the smoking prevalence for each of the public health districts.
Figure 10. Percentage of adult smokers, by educational attainment, Georgia, 2007
50
40
35
30
25
23
20
10
0 < High school High school Some College
8
College Graduate
Percent
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Map 1. Percent of Adults Who Smoke Cigarettes by Health District, Georgia
2000 - 2003
2004 - 2007
Significantly above the state prevalence Same as the state prevalence Significantly below the state prevalence
12
2009 Georgia Tobacco Use Surveillance Report
Tobacco Use in Georgia
Figure 11. Percentage of women who smoked during the last 3 months of their pregnancy, by educational attainment, Georgia, 2006
50
40
Percent
30 23
20
11
10
7
0 <High School High School Some College
2
College Graduate
Source: Georgia Pregnancy Risk Assessment and Monitoring System (PRAMS)
Tobacco Use among Pregnant Women
In 2006, 9.5% of women who delivered babies in Georgia smoked cigarettes during the last three months of pregnancy. Women with less than a high school education (23%) were significantly more likely than women with at least some college education to have smoked cigarettes in the last three months of pregnancy (Figure 11). Women with annual household incomes of less than $15,000 (15%) and women with annual household incomes between $15,000 and $24,999 (12%) were significantly more likely than women with annual household incomes of $50,000 or more (3.5%) to have smoked cigarettes in the last three months of pregnancy (Appendix Table E).
2009 Georgia Tobacco Use Surveillance Report
13
Secondhand Smoke and Asthma
Figure 12. Percentage of youth and adults with asthma who smoke, Georgia, 2007
Percent
100 80 60
40 20
8 0
Middle School
19 High School
24 Adults
SSoouurrcceess:: GGeeoorrggiaiaSYtuoduethntTHoebaalcthcoSuSruvrevye(yY; RGBeSo)r;gGiaeBoreghiaavBioerhaalvRioisrakl FRaiscktoFraSctuorrvSeiullravnecilelanScyestSeymst(eBmR(FBSRSF)SS)
Figure 13. Percentage of youth and adults who live with a smoker, by smoking status, Georgia, 2004 and 2005
100
80
70
60
56
59
Percent
40
29
31
20
16
0 Middle School
High School
Adults
Smokers
Non-smokers
Sources: 2004 Georgia Adult Tobacco Survey and 2005 Georgia Youth Tobacco Survey
Figure 14. Percentage of youth exposed to SHS* at home, room, or car,
by school type and asthma status, Georgia, 2005
Percent
100
80
66
59
60
40
20
0 Middle School
73
69
High School
* Secondhand smoke (SHS)
Asthma
Source: Georgia Youth Tobacco Survey
No Asthma
Secondhand smoke is a known environmental trigger for asthma. Persons with asthma may experience severe asthma episodes or attacks as a result of being exposed to secondhand smoke. Despite this fact, many people with asthma choose to smoke.
Approximately 41,000 (11%) middle school students, 44,000 (10%) high school students, and 524,000 (8%) adults in Georgia have asthma. Among these, approximately 3,000 (8%) middle school students, 8,000 (19%) high school students, and 126,000 (24%) adults smoke (Figure 12).
The 2006 Surgeon General's report (3) concluded that exposure to secondhand smoke poses a health risk in children and non-smoking adults. Much progress has been achieved in the adoption of smokefree policies in public places during the past decade. Despite these efforts, many persons are exposed to secondhand smoke at home. Nearly three-fourths of middle school smokers (70%) and over half of high school smokers (56%) live with a smoker. Nearly one-third of middle school non-smokers (29%) and high school non-smokers (31%) live with a smoker. Nearly three in five (59%) adult smokers and one in six (16%) adult non-smokers in Georgia live with a smoker (Figure 13).
Among youth with asthma, approximately twothirds (66%) of middle school students and three-fourths (73%) of high school students are exposed to secondhand smoke at home or from being in the same room or car with a smoker (Figure 14).
14
2009 Georgia Tobacco Use Surveillance Report
Reducing Tobacco Use in Georgia
Former Smokers
The quit ratio, defined as the number of former smokers in a given population divided by the number of ever smokers in that same population, is used as an indicator of quitting behavior among people who have ever smoked. In 2007, approximately 1.5 million (54%) adults in Georgia who had ever smoked reported that they were not currently smoking (Figure 15).
Percent
Figure 15. Proportion of former smokers among ever smokers, Georgia, 1996-2007
60 50 40 30 20 10
0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year
The quit ratio was significantly higher among adults ages 55 and older than among adults ages 18-54 (Figure 16).
The quit ratio was significantly higher among adults with a college education (73%) than among adults with fewer years of education (Figure 17).
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Figure 16. Percentage of adult former smokers among adult ever smokers,
by age, Georgia, 2007
100
81 80
66
60
49
51
40 40
20
15
0
18-24
25-34
35-44
45-54
55-64
65+
Percent
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Figure 17. Percentage of adult former smokers among adult ever smokers, by educational attainment, Georgia, 2007
100
80
73
Percent
60 43
45
50
40
20
0 <High School High School Some College
College Graduate
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
2009 Georgia Tobacco Use Surveillance Report
15
Reducing Tobacco Use in Georgia
* Adults who stopped smoking for one day or longer during the past 12 months because they were trying to quit smoking. Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Smoking Cessation
Approximately 760,000 (57%) adult smokers in Georgia stopped smoking for one day or longer during the past 12 months because they were trying to quit. More females than males made an attempt to quit smoking. NonHispanic black smokers were more likely than non-Hispanic white smokers to have stopped smoking for one day or longer in an attempt to quit. More smokers ages 18-24 made a quit attempt in 2007 than their older counterparts (Figure 18).
Figure 2109. Percentage of adult smokers whose health care providers advised to quit,
by type of assistance given, Georgia, 2004
100
80
Percent
60
40
30
23
20
17
0
Prescribed medication
Suggested setting a Suggested taking a
specific date for cessation class or
quitting
program
Source: Georgia Adult Tobacco Survey
Approximately 151,000 (25%) adult smokers who made a quit attempt used medication such as nicotine patch or gum on their last quit attempt. Approximately 673,000 (59%) adult smokers are seriously considering stopping smoking.
Approximately 485,000 (67%) adult smokers who visited their health care provider in the past year indicated their health care provider advised them not to smoke. Among them, approximately 144,000 (30%) were given a prescription for medication to help them quit and approximately 80,000 (17%) were advised to participate in a smoking cessation class or program (Figure 19).
16
2009 Georgia Tobacco Use Surveillance Report
Policy
Policies that restrict or prohibit smoking prevent some people from starting to smoke, help current smokers quit, and reduce exposure to secondhand smoke.
Home and Worksite Policies
Over half (53%) of adult smokers and a majority (88%) of adult non-smokers do not allow smoking anywhere inside their home (Figure 20).
Figure 201. Percentage of adults who live in smoke-free* homes,
by smoking status and sex, Georgia, 2006
100
80
60
55
50
88
88
Percent
40
20
0 Smokers
Non-smokers
Male
*Smoking is not allowed anywhere inside the home.
Female
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Three-fourths (78%) of adult smokers and a majority (87%) of adult non-smokers indicated that their worksite does not allow smoking anywhere in the workplace. Females were more likely than males to indicate their worksite does not allow smoking (Figure 21).
FFigure 221. Percentage of adults who work in smoke-free* workplaces,
by smoking status and sex, Georgia, 2006
100
80
76
80
85
90
Percent
60
40
20
0 Smokers
Non-smokers
Male
*Worksite's official policy prohibits smoking in all work areas.
Female
Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)
2009 Georgia Tobacco Use Surveillance Report
17
Policy
School Policies The School Health Profiles (Profiles) was conducted in the spring of 2006 to assess existing health-related school policies and to monitor characteristics of health education programs in public middle and high schools in Georgia.
FFiigguurree2223aa.. Percentage of middle schools that have a policy prohibiting tobacco use,
by group and time, Georgia, 2006
Percent
99
100
86
80
60
40
20
0 Students
98 81
Faculty/staff
96 76
Visitors
During school hours During non-school hours
Source: Georgia School Health Profiles Survey
Findings from Profiles indicate that almost all public schools in Georgia (99%) had a policy prohibiting tobacco use (i.e., cigarettes, smokeless tobacco, cigars, and pipes) (Figures 22a, 22b, Appendix Table F). Most schools (95%) had a policy prohibiting tobacco use by students, faculty, and staff during school hours and in school buildings, grounds and property (Appendix Table G).
Figure 232b. Percentage of high schools that
have a policy prohibiting tobacco use,
by group and time,
Georgia, 2006
99
100
88
80
96 80
94 71
Percent
60
40
20
0 Students
Faculty/staff
Visitors
During school hours During non-school hours
Source: Georgia School Health Profiles Survey
Most middle schools and high schools had procedures to inform students (99% MS, 100% HS) and school faculty and staff (88% MS, 93% HS) about compliance with the school's policy on tobacco use; however, only about two-thirds of middle schools and high schools had procedures to inform visitors about compliance (Appendix Table H).
18
2009 Georgia Tobacco Use Surveillance Report
Policy
Support of Smoke-free Laws and Taxation The Adult Tobacco Survey (ATS) was conducted in 2004 to obtain information about knowledge, attitudes, and beliefs on tobacco use and to assess the level of support of tobacco-related policies among the adult population in Georgia. The survey was conducted prior to the enactment of the Georgia Smokefree Air Act of 2005. It included a question on the level of support of laws making restaurants smoke-free.
Survey findings indicate that 50% of smokers and 82% of non-smokers supported laws making restaurants smoke-free. Black smokers (70%) were more likely than white smokers (41%) to support smoke-free laws (Figure 23).
Figure 243. Percentage of adults who support laws making restaurants smoke-free*, by smoking status and race, Georgia, 2004
100
80
70
60
50
41
40
82 82 84
Percent
20
0 Smokers
Non-smokers
Total
White
Black
* Responses were obtained prior to the enactment of the Georgia Smokefree Air Act of 2005
Source: Georgia Adult Tobacco Survey
The ATS also included a question on the level of support of an additional tax on cigarettes if the money raised was used to support tobacco use prevention programs. Survey findings indicate that 46% of smokers and 75% of non-smokers were willing to support an additional tax on cigarettes. The proportion of non-smoking adults who support a cigarette tax increased with increasing educational attainment (Figure 24).
FFiigguurree 2245.. Percentage of adults who support an additional tax on cigarettes,
by smoking status and educational attainment, Georgia, 2004
100
80
60
51 43 48 44
40
70 77 81 58
Percent
20
0 Smokers
Non-smokers
<High School High School
Source: Georgia Adult Tobacco Survey
Some College
College Graduate
2009 Georgia Tobacco Use Surveillance Report
19
Summary and Implications for Prevention
Data described in this report provide information about the burden and prevention of tobacco-related illness in Georgia.
Over 10,000 adult Georgians die from smoking-related illnesses annually, about one death out of every 6. Implications for prevention: o The burden of smoking-related illness in Georgia is high. Health promotion messages educating the public about the dangers of tobacco use should continue to be provided at all levels of patient care. o Stopping smoking is beneficial to all smokers, regardless how long they have smoked (8). Tobacco users should be encouraged to kick the habit and referred to cessation professionals for assistance in quitting. o Maintaining and supporting statewide comprehensive tobacco use prevention programs is necessary to reduce the burden.
About 35 infants die every year in Georgia because their mothers smoked during pregnancy. Implications for prevention:
o Smoking cessation programs for pregnant women have been shown to be cost effective and to double the rates for quitting, thus reducing the prevalence of smoking during pregnancy (9).
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 (10, 11).
Tobacco use costs over $3 billion in productivity losses alone annually in Georgia. Implications for prevention:
o Reducing tobacco use in Georgia saves money for individuals, businesses, and government.
Approximately one out of five (19%) adult Georgians smoke cigarettes. This percentage has remained stable in recent years. More males than females smoke cigarettes. Younger adults and adults with fewer years of education are more likely to smoke than older adults or adults 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, males, 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% (12).
20
2009 Georgia Tobacco Use Surveillance Report
Summary and Implications for Prevention
6% of middle school students and 19% of high school students in Georgia smoke cigarettes. Youth usually purchase their cigarettes at gas stations or convenience stores. Implications for prevention: o Establishing comprehensive school policies restricting tobacco use may help reduce the prevalence of smoking among students (13). o Strict enforcement of laws and regulations that prohibit the sale of tobacco products to individuals younger than 18 years of age have been shown to hinder youth purchases of tobacco, which may reduce the youth smoking prevalence (14).
One in three non-smokers in both middle and high schools live with a smoker. Implications for prevention:
o Establishing voluntary home rules that prohibit smoking anywhere inside the home protects non-smokers from secondhand smoke exposure while at home.
o Reducing and eliminating secondhand smoke at home helps minimize complications from asthma and other respiratory conditions in children and adults.
The prevalence of cigarette smoking among persons with asthma in Georgia is as high as among the general population. Many youth living with asthma are exposed to secondhand smoke. o Stopping smoking and avoiding exposure to secondhand smoke help persons with asthma manage their condition by reducing the frequency and severity of asthma attacks. o Eliminating indoor smoking in public places helps reduce potential environmental triggers for asthma (3).
More than half (57%) of current adult smokers tried to quit smoking during the past year. Implications for prevention:
o Raising the cost of tobacco products is helpful to many smokers who are trying to stop smoking (12). Low-income smokers may be more likely to benefit than high-income smokers from a higher cost of tobacco.
o Comprehensive health education interventions or clinical counseling helps smokers quit (15).
Most public schools (99%) in Georgia have policies limiting or prohibiting tobacco use on the premises. Many employed adults (85%) indicate their worksite has a policy that does not allow smoking at work. Implications for prevention: o Compliance with and enforcement of the state law restricting smoking in public places promote clean livable environments and make public smoking less acceptable. o County and local governments should be encouraged to establish strong smoking regulations within their borders. Smoking restrictions in public places (e.g., restaurants) help smokers stop or reduce smoking (12). In areas where smoking restrictions in restaurants and bars have been enacted, the establishments are not financially hurt (16).
2009 Georgia Tobacco Use Surveillance Report
21
Methodology and Limitations
Methodology
This report compiles tobacco-related information from a variety of available data sources in Georgia. Mortality data Mortality data in Georgia were obtained from Georgia Vital Statistics. Deaths for 23 conditions for which smoking is a contributing cause were counted and categorized using the ICD-10 codes listed in appendix table A. 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 (17). The smoking-attributable fractions (SAF) of adult deaths for 19 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 2000-2006 were obtained from the Georgia Behavioral Risk Factor Surveillance System (BRFSS). Maternal smoking prevalence estimates for 2000-2006 were obtained from Georgia Vital Statistics as noted on birth certificates.
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.
22
2009 Georgia Tobacco Use Surveillance Report
Methodology and Limitations
For infants, SAMMEC uses RR estimates for short gestation/low birth weight, Sudden Infant Death Syndrome (SIDS), Respiratory Distress Syndrome (RDS), and other respiratory infant conditions of the newborn from a meta analysis of epidemiological literature conducted by Gavin et al. (2001).
Estimation of the Average Annual 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 2002-2006 were obtained from Georgia Vital Statistics. The average annual 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. The average annual SAM is the sum of smoking-attributable deaths across age groups, and across causes of death for both sexes combined.
Estimation of Average Annual Years of Potential Life Lost
SAMMEC estimates the annual average 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 2002-2006 were obtained from National Center for Health Statistics (18). Average annual YPLL estimates are generated for each disease, major disease category, and all diseases combined, by sex and both sexes combined.
Estimation of Years of Potential Life Lost per Smoker
The average annual smoking-attributable YPLL per smoker was calculated using the following formula:
Average annual smoking -attributable YPLL per smoker
=
Average annual smoking-attributable YPLL due to a cause of death
SAM due to a cause of death
2009 Georgia Tobacco Use Surveillance Report
23
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 the risk of dying from tobacco use in each district was similar to the risk in the state, the smoking-attributable deaths for each disease category were divided by the total number of deaths for each disease category during 2002-2006, and this resulting rate was in turn multiplied times the district's average annual number of deaths for each disease category:
District SAM =
State SAM for each disease category State deaths for each disease category
X
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 smokers X 100 Ever smokers
Behavioral Risk Factor Surveillance System
Georgia Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to obtain the adult smoking prevalence and quit ratios. The BRFSS is a survey conducted annually by the Division of Public Health, Georgia Department of Human Resources. The survey is administered by telephone to the noninstitutionalized, civilian population ages 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.
All estimates presented in this report are based on 2007 survey findings.
Youth Surveys
Data on tobacco use among youth and purchasing ability were obtained from the 2007 Georgia Student Health Survey (Georgia's Youth Risk Behavior Survey). Data on exposure to secondhand smoke were obtained from the 2005 Georgia Youth Tobacco Survey. Both are school-based surveys administered to a representative sample of middle and high school students in the state (19, 20).
24
2009 Georgia Tobacco Use Surveillance Report
Methodology and Limitations
Adult Surveys Data on support of tobacco-related laws and taxation were obtained from the 2004 Georgia Adult Tobacco Survey. The survey provided data on knowledge, attitudes and beliefs related to tobacco use among the adult Georgian population (21).
School Health Profiles The School Health Profiles (Profiles) was administered to principals and lead health education teachers of a representative sample of randomly selected public middle and high schools in Georgia. 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 prevention programs and policies (22). 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 assessed topics covered in the school's health education curriculum and the grades at which those topics were taught.
Limitations
Smoking-Attributable Morbidity, Mortality, and Economic Costs (SAMMEC)
The methodology used to calculate the smoking-attributable deaths is subject to several limitations. The smoking-attributable mortality figures in this report were estimated by using smoking prevalence and mortality data for 2002-2006, whereas actual smoking-attributable deaths are the result of cumulative exposure to tobacco at higher rates from previous decades. 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. Mortality estimates do not include deaths from smoking cigars or pipes, from using smokeless tobacco, or from secondhand smoke. 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. 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. 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. SAMMEC does not provide smoking-attributed morbidity estimates.
Youth Risk Behavior Survey (YRBS) and Youth Tobacco Survey (YTS)
Youth prevalence data apply only to middle school and high school students enrolled in Georgia's public education system, and, therefore, are not representative of all persons in this age group. All data are selfreported and, for certain behaviors, the reported estimates may be subject to recall bias.
2009 Georgia Tobacco Use Surveillance Report
25
Methodology and Limitations
PRAMS
PRAMS data are representative only of pregnant women who delivered live-born infants. Smoking estimates during pregnancy are based on self-reported data and may be subject to recall bias. Because PRAMS does not collect data on alcohol or tobacco use during the first or second trimesters of pregnancy, the prevalence of use of these substances in early pregnancy could be underestimated. PRAMS may not accurately obtain the prevalence of folic acid intake in the form of multivitamin use. The prevalence of unintended pregnancies is probably underestimated because PRAMS reports only unintended pregnancies resulting in a live birth.
Behavioral Risk Factor Surveillance System (BRFSS) and Adult Tobacco Survey (ATS)
Both BRFSS and ATS are telephone-based surveys. The survey sample includes only persons residing in households with telephone land lines. It excludes persons living in institutions such as assisted living facilities and the military. Prevalence data may not be representative of all adults in Georgia. All data are self-reported and, for certain behaviors, the reported estimates may be subject to recall bias.
Profiles
Policy data from the School Health Profiles are self-reported by school principals and lead health education teachers and may be subject to bias. Private and alternative schools are not included in the survey sample.
26
2009 Georgia Tobacco Use Surveillance Report
Glossary
Acute myeloid leukemia: a cancer of the blood and bone marrow that affects the normal development of white blood cells necessary for fighting off infections and that can spread to other parts of the body.
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, chronic: 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.
Cerebrovascular disease: also known as 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.
Chronic Obstructive Pulmonary Disease (COPD): a group of chronic lung conditions characterized by obstruction of the airways in the lungs, which traps air in the lungs, making it difficult for an individual to breathe in and out normally.
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.
Ever adult smokers: adults who have smoked 100 cigarettes in their lifetime.
Ever youth smokers: middle and high school students who have ever tried cigarette smoking, even one or two puffs.
Former adult smokers: adults who have smoked 100 or more cigarettes in their lifetime but who do not currently smoke.
2009 Georgia Tobacco Use Surveillance Report
27
Glossary
Former youth smokers: middle and high school students who have smoked 100 or more cigarettes in their lifetime but who have not smoked in the last 30 days.
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.
Ischemic heart disease: also known as coronary heart disease, is the term given to heart problems caused by a narrowing of the coronary arteries and includes heart attacks.
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 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.
Secondhand smoke: 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. It is also known as environmental tobacco smoke (ETS).
Short gestation: a fetus born before 37 weeks after conception.
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.
28
2009 Georgia Tobacco Use Surveillance Report
References
1. U.S. 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. Smoking and Tobacco Use. http://www.cdc.gov/tobacco/ basic_information/index.htm
3. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.
4. U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411, Prepublication version, January 11, 1989.
5. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS), Nationwide Prevalence Data, 2007. http://www.apps.nccd.cdc.gov/brfss/index.asp
6. Centers for Disease Control and Prevention. Tobacco Use Among Adults United States, 2005. MMWR 2006; 55(42);1145-1148.
7. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses United States, 1997-2001. MMWR 2005; 54(25);625-628.
8. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416. 1990.
9. U.S. Department of Health and Human Services. Women and Smoking. A Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.
10. 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.
11. Mullen PD, DiClemente CC, Bartholomew LK. Theory and Context and Project PANDA: a Program to Help Post-partum 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.
12. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000.
2009 Georgia Tobacco Use Surveillance Report
29
References
13. Moore L, Roberts C, Tudor-Smith C. School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tobacco Control 2001;10:117-123 (Summer).
14. 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.
15. 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.
16. 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.
17. 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://apps.nccd.cdc.gov/sammec/
18. National Center for Health Statistics. United States Life Tables, 2003. National Vital Statistics reports; vol. 54 no. 14. Hyattsville, MD, Revised March 28, 2007.
19. Kanny D, Horan J, Figueroa A. 2007 Georgia Student Health Survey Report. Georgia Department of Human Resources, Division of Public Health, July 2008. Publication Number: DPH08/190HW. http://health.state.ga.us/pdfs/epi/cdiee/2003-2005-2007_GaStudentHealthSurveyReport.pdf.
20. Kanny D and Figueroa A. 2005 Georgia Youth Tobacco Survey Report. Georgia Department of Human Resources, Division of Public Health, September 2006. Publication Number: DPH06/143HW. http://health.state.ga.us/pdfs/epi/cdiee/2005%20Georgia%20Youth%20Tobacco%20Survey%20Report.pdf.
21. Figueroa A and Kanny D. 2004 Georgia Adult Tobacco Survey Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, October 2006. Publication Number: DPH07/005HW. http://health.state.ga.us/pdfs/epi/cdiee/Adult%20Tobacco%20Survey%20Report,%20Georgia,%202004.pdf.
22. Falb M, Figueroa A, Kanny D. 2006 Georgia School Health Profiles Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, March 2007. Publication Number: DPH07/027HW. http://health.state.ga.us/pdfs/epi/cdiee/2006GASchoolHealthProfiles.pdf.
30
2009 Georgia Tobacco Use Surveillance Report
Table A. Average annual smoking-attributable mortality (SAM) and years of potential life lost (YPLL) by cause of death and sex, adults 35 and older and TablienfAa.nStsmoonkeinyge-aatrtraibnudtayboluenmgoerrt,aGliteyo(rSgAiaM, )2a0n0d2 y- e2a0r0s6of potential life lost (YPLL) by cause of death and sex, adults 35 and older and infants one year and younger, Georgia, 2002-2006
Appendices | Table A
2009 Georgia Tobacco Use Surveillance Report
Disease Category Neoplasms Lip, Oral cavity, Pharynx Esophagus Stomach Pancreas Larynx Trachea, Lung, Bronchus Cervix Kidney and Renal Pelvis Bladder Acute myeloid leukemia
ICD-10*
C00-C14 C15 C16 C25 C32
C33-C34 C53
C64-C65 C67
C92.0
Deaths 144 248 161 377 83
2,610 0
185 177
87
Male SAM
106 178
44 83 69 2,292
0 71 83 20
YPLL 2,112 3,386 778 1,523 1,267
38,556 0
1,279 1,091
333
Deaths 69 79
119 387
22 1,672
114 118
89 75
Female SAM 32 45 13 87 16 1,172 13 6 24 7
YPLL 614 881 241
1,518 334
22,190 373 140 299 140
Both sexes
Deaths SAM
213
138
327
223
280
57
764
170
105
84
4,282
3,464
114
13
303
77
266
107
162
27
YPLL 2,726 4,267 1,019 3,040 1,601
60,746 373
1,419 1,391
473
Total Neoplasms
4,072
2,945 50,325
2,744
1,415 26,731
6,816
4,360 77,055
Cardiovascular Diseases: 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
I20-I25
I00-I09, I26I51
I60-I69
I70 I71 I72-I78
1,661 3,219
2,905
412 1,169
108 199 109
648 17,308
483
4,767
536
8,315
152
4,096
98
910
29
373
128
2,078
15
240
626 3,495
3,634
341 2,081
174 126 147
206
6,094
2,287
350
3,175
6,714
303
4,078
6,539
137
4,278
753
108
953
3,250
14
140
282
61
868
325
20
242
256
854 23,401
833
7,942
840 12,393
290
8,374
206
1,863
43
513
190
2,946
35
482
Total Cardiovascular Diseases
9,782
2,091 38,088 10,624
1,198 19,827 20,406
3,289 57,915
Respiratory Diseases: Pneumonia, Influenza Bronchitis, Emphysema Chronic Airway Obstruction
J10-J18 J40-J43
J44
677 238 1,304
152 216 1,059
1,780 2,913 13,261
897 215 1,346
116
1,337
172
2,622
994 13,702
1,574 453
2,650
269 388 2,053
3,116 5,535 26,963
Total Respiratory Diseases
2,219
1,427 17,954
2,458
1,283 17,661
4,677
2,710 35,615
Total Adult
16,073
6,463 106,366 15,826
3,896 64,219 31,899 10,359 170,585
Perinatal Conditions: Short Gestation / Low Birth Weight Respiratory Distress Syndrome Respiratory Conditions - Newborn Sudden Infant Death Syndrome
P07 P22 P23-P28 R95
125
10
713
101
26
1
56
23
30
1
88
16
73
8
621
57
8
616
226
1
53
49
1
50
46
6
519
130
17
1,329
1
110
2
138
15
1,139
Total Perinatal Conditions
254
20
1,477
197
15
1,239
451
35
2,716
Overall Total
16,327
6,483 107,844
* International Classification of Diseases, Tenth Revision used since 1999 for specifying cause of death. * InternationaTloCtalalsmsifaicyatnioont oafdDdisuepaseexsa, cTtelyntbheRceavuissioenouf sroedunsdinicneg1t9o9n9efoarrespset cinifyteinggecr.ause of death. Mortality daMtaosrotaulrictye:dGaetaorgsioauVrcitael:SGtaetiosrtigcisa. Vital Statistics.
16,023
3,912 65,458 32,350 10,394 173,301
31
Appendices | Table B & C
Table B. AveTraabglee Ba.nAnvuearlasgme oankninuga-lastmtriobkuintagb-alettrmibourttaablilteym(SoArtaMli)t,y b(SyAcMa)u,sbeyocfaduesaethofadnedatphuabnldicphuebalilcthhdeaisltthricdti,stardicut,lts ages 35 andadouldltesraGgesor3g5iaa,n2d0o0l2d-e2r0G06eorgia, 2002-2006
Cancer
Cardiovascular Disease
Respiratory Disease
Total smokingrelated diseases
Deaths SAM Deaths SAM Deaths SAM Deaths SAM
Georgia
6,186 4,360 20,406 3,289 4,677 2,710 31,899 10,359
Northwest Health District (Rome)
570
365 1,644
265
403
234 2,617
864
North Georgia Health District (Dalton)
311
199
836
135
228
132 1,375
466
North Health District (Gainesville)
452
289 1,312
211
349
202 2,113
702
Cobb/Douglas Health District
397
254 1,236
199
277
161 1,910
614
Fulton Health District
528
338 1,505
243
315
183 2,348
764
Clayton County Health District (Morrow)
145
93
374
60
84
49
603
202
East Metro Health District (Lawrenceville)
423
271 1,058
171
259
150 1,740
592
DeKalb Health District
386
247 1,028
166
205
119 1,619
532
LaGrange Health District
561
359 1,793
289
412
239 2,766
887
South Central Health District (Dublin)
141
90
574
93
110
64
825
247
North Central Health District (Macon)
462
296 1,391
224
316
183 2,169
703
East Central Health District (Augusta)
423
271 1,240
200
292
169 1,955
640
West Central Health District (Columbus)
343
219 1,169
188
246
143 1,758
550
South Health District (Valdosta)
216
138
688
111
178
103 1,082
352
Southwest Health District (Albany)
377
241 1,139
184
232
134 1,748
559
Southeast Health District (Waycross)
440
281 1,311
211
290
168 2,041
660
Coastal Health District (Savannah)
327
209 1,066
172
261
151 1,654
532
Northeast Health District (Athens)
314
201 1,040
168
216
125 1,570
494
SAM is an average annual total that does not include burn or secondhand smoke deaths.
TaanbdleseCx.,PGeerocTbreaegnbfitoaleo,re2fC0ma.0gPi7deesdrlc1ee1snactanhgdoeo1lo3af*-nmbdyidhgdirglaehdsseccahhnoodoollsasentxud-Gdheeingothrsgsiwach-h2oo0o0sl7msotukdedenatsciwgharoesttme obkeefodrea acgigeasre1t1teand 13*, by grade
Grade Smoked before age 11
6th 7th 8th
Males
%
95% CI
7.07.0 (5.3-9.1)
8.4 (5.5-12.7)
4.0 (2.2-7.3)
8.4 (5.8-11.9)
Females
%
95% CI
5.25.2 (3.6-7.4)
3.1 (1.7-5.4)
6.2 (3.5-10.9)
6.2 (3.5-10.8)
Total
%
95% CI
6.16.1 (4.9-7.6)
5.8 (3.8-8.8)
5.1 (3.3-7.7)
7.3 (5.3-10.0)
Smoked before age 13 181.82.2 (15.7-21.0) 101.07.7 (8.8-13.0) 141.45.5
9th
22.1 (18.1-26.7)
9.9 (7.2-13.4)
16.4
10th
20.7 (14.0-29.6)
10.3 (7.0-14.8)
15.7
11th
13.1 (9.9-17.2)
14.3 (9.9-20.2)
13.7
12th
12.3 (7.9-18.6)
8.1 (5.0-12.8)
10.1
*Ages of initiation are defined as 11 years for middle school students and 13 years for high school students.
(12.6-16.7) (13.5-19.7) (12.5-19.6) (11.0-17.0) (6.8-14.7)
*Ages of initiation are defined as 11 years for middle school students and 13 years for high school students.
32
2009 Georgia Tobacco Use Surveillance Report
Appendices | Table D
Table D. Percent of adult smokers by public health district, Georgia, 2000-2007
District
2000-2003 % 95% CI
2004-2007 % 95% CI
Northwest Health District (Rome) North Georgia Health District (Dalton) North Health District (Gainesville) Cobb/Douglas Health District Fulton Health District Clayton County Health District (Morrow) East Metro Health District (Lawrenceville) DeKalb Health District LaGrange Health District South Central Health District (Dublin) North Central Health District (Macon) East Central Health District (Augusta) West Central Health District (Columbus) South Health District (Valdosta) Southwest Health District (Albany) Coastal Health District (Savannah) Southeast Health District (Waycross) Northeast Health District (Athens)
31.7 (28.3-35.3) 29.9 (26.4-33.7) 24.0 (20.9-27.3) 19.5 (16.5-22.8) 18.6 (15.7-21.8) 26.8 (23.0-30.9) 24.5 (21.3-27.9) 18.9 (15.7-22.5) 23.7 (20.7-27.0) 22.1 (19.3-25.3) 27.8 (24.5-31.5) 25.2 (22.4-28.3) 22.7 (19.6-26.1) 25.6 (22.1-29.5) 24.3 (21.3-27.5) 26.6 (24.3-29.1) 27.8 (24.7-31.1) 24.5 (21.4-27.8)
27.2 (24.0-30.6) 24.4 (20.9-28.2) 21.6 (19.1-24.3) 14.9 (12.6-17.7) 15.3 (12.6-18.5) 23.4 (18.5-29.1) 16.5 (13.8-19.6) 13.7 (11.1-16.9) 20.2 (17.3-23.5) 21.9 (19.3-24.9) 24.9 (21.7-28.5) 22.9 (20.3-25.7) 22.8 (19.7-26.2) 25.4 (22.2-29.0) 21.7 (19.1-24.7) 24.8 (22.2-27.6) 25.8 (23.1-28.7) 20.2 (17.4-23.4)
2009 Georgia Tobacco Use Surveillance Report
33
Appendices | Table E & F
Table E. Percentage of women who smoked during the last three months of pregnancy by race, age, and educational attainment, Georgia, 2006
% Smokers 95% CI
Total
9.5 (8.2-10.8)
Race
White
13.9 (11.7-16.2)
Black
5.7 (4.3-7.1)
Age
0-17
9.1 (3.4-14.8)
18-24
12.0 (9.6-14.4)
25-34
7.9 (6.2-9.6)
35-44
8.9 (5.5-12.4)
45+
0.0
Education
<High school
23.4 (17.9-28.8)
High school/GED
10.6 (8.2-12.9)
Some college
6.7 (4.4-8.9)
College graduate
1.8 (0.6-3.0)
Household income
<$15,000
14.8 (12.1-17.6)
$15,000 - $24,999
12.0 (7.9-16.1)
$25,000-$49,999
7.1 (4.3-10.0)
Table F. Percentage of schools that had a p$o5li0c,y00p0r+ohibiting tobacc3o.5us(e1.b8y- 5to.2b)acco product,
Table gF.roPueprc, eanntdagsechoofoslcthyopoel,sGtehoartghiaa,d2a00p6olicy prohibiting tobacco use by tobacco product, group, and school type,
Georgia, 2006
Middle School
High School
%
95% CI
%
95% CI
Had a policy prohibiting cigarettes Students Faculty/staff Visitors
98.2 (96.2-100) 98.2 (96.1-100) 93.9 (90.4-97.3)
97.7 (95.1-100) 94.8 (90.9-98.7) 90.1 (85.2-95.1)
Had a policy prohibiting smokeless Students Faculty/staff Visitors
97.6 (95.2-99.9) 96.3 (93.4-99.2) 88.9 (84.4-93.3)
96.9 (93.8-100) 94.8 (90.8-98.7) 87.0 (81.1-92.8)
Had a policy prohibiting cigars Students Faculty/staff Visitors
98.2 (96.2-100) 98.2 (96.1-100) 94.5 (91.2-97.7)
97.7 (95.1-100) 95.6 (92.1-99.2) 90.1 (85.2-95.1)
Had a policy prohibiting pipes Students Faculty/staff Visitors
98.2 (96.2-100) 98.2 (96.1-100) 94.5 (91.2-97.7)
97.7 (95.1-100) 95.6 (92.1-99.2) 89.4 (84.2-94.5)
34
2009 Georgia Tobacco Use Surveillance Report
Appendices | Table G & H
Table G. Georgia,
P2e0r0c6entageTanoabdf lsesccGhho.ooPolelsrtctyhepanett,ahGgaeedooargfpisaoc,lhi2co0yo0pl6srothhaibtihtiandg
atopboalciccyopursoehibbyitcinogvetorabgaec,cgoruosuep,bayncdosvcehraogoel ,tygproe,up,
Middle School
%
95% CI
High School
%
95% CI
Policy prohibits tobacco use during school hours
Students Faculty/staff Visitors
99.4 (98.2-100) 98.0 (95.8-100) 96.2 (94.3-98.0)
98.5 (96.4-100) 95.6 (92.0-99.1) 93.9 (90.4-97.5)
Policy prohibits tobacco use during nonschool hours
Students Faculty/staff Visitors
86.1 (80.5-91.6) 81.0 (74.9-87.1) 76.2 (69.5-82.9)
88.4 (82.3-94.5) 79.9 (72.4-87.5) 71.3 (62.3-80.2)
Policy prohibits tobacco use in school buildings
Students Faculty/staff Visitors
98.8 (97.2-100) 98.8 (97.2-100) 96.3 (93.4-99.3)
98.3 (96.0-100) 97.6 (94.9-100) 96.0 (92.5-99.5)
Policy prohibits tobacco use outside onf school grounds*
Students
Faculty/staff
Visitors
98.8 (97.2-100) 95.6 (92.3-98.9) 86.3 (80.8-91.8)
98.3 (96.0-100) 93.9 (89.7-98.2) 87.7 (82.0-99.3)
Policy prohibits tobacco use on school buses
Students Faculty/staff Visitors
98.8 (97.2-100) 98.8 (97.2-100) 95.0 (91.5-98.5)
98.3 (96.0-100) 97.6 (94.9-100) 94.6 (90.5-98.6)
* School grounds include school parking lots and playing fields.
Table H. Percentage of schools that had procedures to inform specific groups about compliance with their tobacco use policy by group TanabdlescHh.oPoelrtcyepnet,aGgeeoorfgsiac,h2o0o0l6s that had procedures to inform specific groups about compliance
with their tobacco use policy by group and school type, Georgia, 2006
Middle School
%
95% CI
High School
%
95% CI
Had procedures to inform students
98.7 (96.8-100)
100
Had procedures to inform faculty/staff
87.9 (83.3-92.5)
93.2 (88.7-97.7)
Had procedures to inform visitors
69.3 (62.4-76.2)
64.9 (56.6-73.2)
2009 Georgia Tobacco Use Surveillance Report
35
Appendices | Table 1
Table I. Tobacco-related Healthy People 2010 objectives and current status in Georgia Table I. Tobacco-related Healthy People 2010 objectives and current status in Georgia
Obj. # Objective
HP 2010 Target
Status in Georgia
27-1a Reduce the proportion of adults who currently smoke cigarettes.
12%
19%
27-2a Reduce the proportion of students in grades 9 through 12 who are current users of any tobacco products.
21%
26%
27-2b Reduce the proportion of students in grades 9 through 12 who are current cigarette smokers.
16%
19%
27-2c Reduce the proportion of students in grades 9 through 12 who are
current smokeless tobacco users.
1%
8%
27-2d Reduce the proportion of students in grades 9 through 12 who are
current cigar smokers.
8%
16%
27-3 Reduce the proportion of children and adolescents who begin using tobacco products.(in development)
In deNv/eAlopment
N/A
27-4a Increase the average age of first use of tobacco products by adolescents angdedyo1u2ntgo a1d7uyltesars.
1144%years
Ag1e3-g1r4oup y1e3a-r1s4
27-4b Increase the average age of first use of tobacco products by young adults aged 18 to 25 years.
17%
Data not collected
27-5 Increase the proportion of adult smokers who have attempted to quit smoking.
75%
56%
27-6 Increase the proportion of pregnant women who quit smoking during the first trimester of their pregnancy.
30%
Data not colNle/cAted
27-7 Increase the proportion of smokers in grades 9 through 12 who have attempted to quit smoking.
84%
58%
27-8 Increase in insurance coverage of evidence-based treatment for nicotine dependency.
100%
Data not colNle/cAted
27-9 Reduce the proportion of children 6 years and under who are regularly exposed to tobacco smoke at home.
10%
Data not colNle/cAted
27-10 Reduce the proportion of non-smokers aged 4 years and older who are exposed to environmental tobacco smoke.
Increase the proportion of schools that are smoke-free and tobacco27-11 free, to include all school facilities, property, vehicles, and school
events.
45% 100%
Data not colNle/cAted
N2/0A%
36
2009 Georgia Tobacco Use Surveillance Report
27-12 27-13 27-14 27-15
Increase the proportion of worksites with formal policies prohibiting or limiting smoking to separately ventilated areas.
100%
Increase or establish laws on smoke-free indoor air that prohibit or limit smoking to separately ventilated areas in public places and worksites.
51%
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.
50 States, DC, and all US territories
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.
50 States and DC
27-16 Eliminate tobacco advertising and promotions that influence adolescents and young adults
In development
27-17 27-18
Increase the proportion of students in 8th, 10th and 12th grades who disapprove smoking. Increase the number of Tribes, Territories and States and the District of Columbia with comprehensive, evidence-based tobacco control programs.
95%
In development
27-19 Eliminate the number of States with laws that preempt stronger tobacco control laws.
No States
27-20 Reduce the toxicity of tobacco products by establishing a regulatory
In
structure to monitor toxicity.
development
Data not collNe/cAted Data not collNec/Ated
Met
Met
N/A Data not collected
Met
Met
N/A
27-21a Increase the average Federal and State tax on cigarettes.
$2
$0.37- GSetaotregia