An Ounce of Prevention...

A Publication of the
Program on Prevention
In Education & Practice

March 2001 - Volume 1, Number 8

Happy Spring! Happy Spring!

Special Edition Dedicated to the Issue of Smoking

The problem of smoking continues to plague the medical and public health communities. In this issue of "An Ounce of Prevention...", we highlight several recent journal articles covering a range of smoking-related issues, from worldwide trends in smoking rates to influences on smoking by adolescents in the US to the role of health care professionals.

Smoking Trends Around the World

A recent study in the American Journal of Public Health examined trends in cigarette smoking across the world. In the WHO MONICA study, 26 populations throughout the world were monitored from the early 1980's to the mid-1990's in order to describe changes in cigarette smoking trends. The study looked at whether changes were due to initiation or cessation, differences between men and women and different age groups, and overall smoking prevalence in the population.

Among men, smoking prevalence decreased by more than 5% in 16 of the study populations, increased in Beijing only and remained steady in the other 19 populations. Among women, smoking prevalence decreased by 5% in 9 study populations, increased in 6 populations and stayed the same in the other 21.

Rates of smoking decreased the most in both men and women in Australia, the United States, New Zealand and the United Kingdom. Perhaps this is a result of constant reminders of the health dangers of smoking through comprehensive anti-smoking campaigns and legal consequences for tobacco companies. The declines in daily smoking were generally due to increases in never smoking and, to a lesser extent, to increases in former smoking.

Overall the trends were in a positive direction. But increasing smoking rates among men in China and in some eastern and central European countries and among women in many populations is cause for concern. Vigorous steps need to be taken to counteract the forces that encourage tobacco use.
Molarius A et al. Trends in cigarette smoking in 36 populations from the early 1980's to the mid-1990's: Findings from the WHO MONICA project. Am J Public Health. 2001;91:206-212.

Media Influences on Youth Smoking

A study published in Tobacco Control looked at the association between adolescent smoking habits and susceptibility and the influence of their favorite movie stars. The study design is based on social learning theory which includes mass media along with parents and peers as socialization agents for young people. A 1999 study found that 57% of films released between 1990-1996 had major characters that used tobacco. UNC's own Adam Goldstein, MD reported in 1999 that even G rated films (including Disney and other animation) contain main characters who frequently use tobacco.

The newest study surveyed 10-19 year old students in rural New England schools to determine their tobacco use. Students were determined to be "never smokers," "experimental smokers," or "smokers." Students were also asked to name their favorite movie star. Film stars were ranked by how often they were seen using tobacco in films from the past three years. Most frequent tobacco users were Leonardo DiCaprio, Sharon Stone and John Travolta. Among the interesting findings, researchers found that movies portrayed tobacco use much more frequently than real life circumstances. And these actions most often have no negative consequences attached.

The results showed a clear association between adolescent tobacco use and the use of tobacco by their favorite movie stars (independent of other known predictors of teenage smoking). Kids were over three times more susceptible to smoke when they chose one of the three most frequent tobacco users (DiCaprio, Stone or Travolta) as their favorite. And susceptibility to smoke was even strong among "never smokers" who favored smoking stars, suggesting that media influence starts before kids even start to experiment with cigarettes.
Tickle J et al. Favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking. Tobacco Control. 2001;10:16-22.

Smoking Consequences

Past studies have shown a decrease in lung cancer risk by birth cohort (through 1950) which is consistent with declining smoking prevalence. A new study published in the Journal of the National Cancer Institute examined more recent trends and found that like previous studies, decreases in lung cancer since 1950 are consistent with periods of declining smoking prevalence. However, there is a significant and unexpected difference- the age at which lung cancer shows up. While the prevalence of lung cancer has steadily decreased, the age at which it is diagnosed has gotten younger and younger, reflecting an earlier age of smoking initiation. From 1965-1977, smoking initiation increased among 12-17 year olds. Effects such as lung cancer are rapidly appearing in people in their 20s and 30s indicating this earlier age of initiation.

The authors suggest ongoing national surveys on teenage smoking rates to monitor these trends. In addition, they suggest continued public education programs that discourage teenage smoking, providing evidence of major health effects earlier in life.
Jemal A; Chu K; and Tarone R. Recent trends in lung cancer mortality in the United States. JNCI. 2001;93:277-283.

Remedies to Smoking Trends and Consequences

Several studies have looked at ways to decrease tobacco initiation and consumption. One recent study in the American Journal of Public Health modeled the effect of an excise tax on cigarettes on population health in California. As expected, not only did an increase in tobacco tax provide additional government resources but it also improved quality adjusted life years (QALY- an index of morbidity and mortality) of the population by encouraging current smokers to cut back or stop and potential smokers to not start. Researchers looked at several scenarios of declines in tobacco demand (because of increased taxes), particularly among adolescents, and the effect on QALYs. With only an 8% decrease in demand, 2,714 years of potential life would be gained annually. Findings suggest that the health benefits will increase the longer the tax is in effect. Assuming that the tax increase works to deter youth from smoking, when projected forward 75 years, researchers found that 18,811 years of potential life would be gained each year with the 8% decrease in tobacco demand. Since fewer teenagers will initiate smoking because of increased prices, there will be fewer people in the pool to develop future tobacco-related illnesses.
Kaplan R et al. Simulated effect of tobacco tax variation on population health in California. Am J Public Health. 2001;91:239-244.

Another study in the same journal looked at a counteradvertising media campaign in Florida, one of seven states using this strategy to deter young people from starting to smoke. Twenty-seven more states plan to start campaigns by 2002 when tobacco settlement funds become available. This study tested whether a counteradvertising campaign lowered the probability of smoking initiation by empowering kids to take on the tobacco industry and be part of a tobacco-free generation. The campaign ran 12 "truth" advertisements statewide which portrayed the industry as predatory and manipulative targeting young people by lying to them. After 10 months, results from the Florida Youth Tobacco Survey showed an 11% decrease in smoking prevalence rates. Although these are short-term findings and may not be widely generalizable, the authors felt that the campaign was significant in preventing youth smoking initiation.
Sly D et al. Influence of a counteradvertising media campaign on initiation of smoking: The Florida "truth" Campaign. Am J Public Health. 2001;91:233-238.

New Institute of Medicine Report

Stuart Bondurant, MD, former Dean of the School of Medicine, recently chaired a committee of the Institute of Medicine that looked at the use of alternative tobacco forms as a means of reducing the harm done by smoking. The committee's report, "Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction," was released in February and outlines their recommendations. The committee was concerned that exposure to even low-nicotine or low-tar cigarettes is still harmful but that the public may get the message that these products are "softer." The report states that even with a reduced-harm product, the public health effect may be negative. http://www.nap.edu

The Healthcare Community's Response and Responsibility

Given the ongoing use of tobacco and the health burdens it causes two physicians from Harvard Medical School have made recommendations about the doctor's role in protecting patients and the community from the harmful effects of cigarette smoking. Their editorial was recently published in the Mayo Clinic Proceedings.

These physicians remind us that because of the lag time between initiation of tobacco use and the development of disease, even successful prevention programs won't show improvements in mortality for several decades. The only way to decrease the number of smoking-related deaths early in the 21st century is to reduce use in those individuals who have already started to smoke. Luckily we have good evidence that shows us what works and how we should approach patients about smoking cessation. A combination of counseling and pharmacotherapy has been found to be the best prescription. This is difficult due to the time required as well as the lack of reimbursement from insurance companies despite the fact that studies show that even short discussions with patients about smoking can increase cessation rates. Patients also appreciate the effort on their doctor's part to ask about smoking habits, even if they have no desire to quit. Still other research has also shown that because of the incredible burden of patients with tobacco-related disease, cessation treatment is highly cost-effective.

The role of the health care professional beyond the office walls, being an advocate for environmental changes, is another way to make a difference to your patients and the community. (Below we highlight one such doctor!) This can include lobbying for eliminating smoking in public places, reducing tobacco advertising or increasing tobacco taxes. The authors of this editorial make the case that physicians and other health care professionals are in a position to be strong advocates for spending much of the multistate tobacco settlement on tobacco treatment and prevention which some states, such as Massachusetts, have already done.
Rigotti N and Thorndike A. Editorial: Reducing the health burden of tobacco use: What's the doctor's role? Mayo Clinic Proceedings. 2001;76:121-123.

Special Recognition to Two VIPP's
(Very Important Prevention People)

Adam Goldstein, MD, MPH, Assistant Professor in the Department of Family Medicine, received a special award from Prevention Partners of North Carolina. Adam was the co-recipient of the first inaugural 2000 Physician Excellence Prevention Award for his research, education and advocacy efforts in the area of tobacco use and control in North Carolina and throughout the nation. Adam is a member of the Health Care and Prevention faculty committee and teaches a course in the School of Public Health on tobacco prevention and control.

Merry-K Moos, FNP, MPH, BSN, Research Associate Professor in the Department of OB/GYN, was recently recognized by the Eastern Carolina Chapter of the March of Dimes for her work to improve the health of mothers and babies in North Carolina. Merry-K serves on the March of Dimes Nursing Advisory Council nationally and is a key member of the state Folic Acid Council and a longtime chapter volunteer. She travels across the country with the March of Dimes teaching health care providers the importance of working with women to make sure they are healthy before getting pregnant. Merry-K is a member of the Program on Prevention's Executive Committee and longtime supporter of prevention education.

Around the World Wide Web...

A study done by Media Metrix, the source for web-based media research, revealed the top 10 health-related websites to be:
1. WebMD
2. Ediets.com
3. Drugstore.com
4. DrKoop.com
5. Mayohealth.com
6. Planetrx.com
7. Discoveryhealth.com
8. Healthscout.com
9. Thriveonline.com
10. Dietsmart.com
* Ranking was determined by the number of unique visitors who visited the site at least once in a given month.

People have more access to health care information than ever before. Not only do they hear about health news in the media but more and more individuals are looking to the WWW for information. Directing your patients to credible and reliable information is key. The Web can be a valuable resource for educational material for patients and providers alike if it is used wisely. Here are some great smoking websites.

This site offers a useful comprehensive evidence-based approach to smoking cessation. It offers help to the smoker in the form of peer-to-peer support, quitting tools including a quit date wizard, and expert resources to gather information.
http://www.quitnet.org

Iquitonline.com is an interactive site that offers patients, particularly adolescents and young adults, information specific to their age and sex on quitting.
http://www.iquitonline.com

Look for our next edition of "An Ounce of Prevention" in May, 2001.
If you have comments or questions about this newsletter or its contents, please e-mail alward@med.unc.edu.

Program Co-Directors: Russ Harris, MD, MPH and Linda Kinsinger, MD, MPH
Education Coordinator & Editor: Amy L. Ward

Go to the Program on Prevention Homepage