US Cigarette Smoking Disparities by Race and Ethnicity - Keep Going and Going!

INTRODUCTION: Although current cigarette smoking among US adults decreased from 42.4% in 1965 to 12.5% in 2020, prevalence is higher among certain racial and ethnic groups, including non-Hispanic American Indian and Alaska Native (AIAN) adults. METHODS: We examined trends in current cigarette smoking prevalence, population estimates, and relative disparity among US adults (aged ≥18 y) between 2011 and 2020 by using data from the National Health Interview Survey. SAS-callable SUDAAN was used to obtain prevalence and population estimates, and relative disparity was calculated on the basis of findings in the literature. Trends were significant at P < .05. RESULTS: From 2011 to 2020, linear decreases in prevalence and population estimates were observed for non-Hispanic White (20.6% to 13.3%; 32.1 million to 20.7 million), non-Hispanic Black (19.4% to 14.4%; 5.1 million to 4.0 million), and Hispanic (12.9% to 8.0%; 4.2 million to 3.3 million) adults. For non-Hispanic AIAN adults, prevalence remained around 27%, and a linear increase in the population estimate was observed from 400,000 to 510,000. Relative disparity did not change across racial and ethnic categories. CONCLUSION: Linear decreases have occurred between 2011 and 2020 for non-Hispanic White, non-Hispanic Black, and Hispanic adults who smoke, but the number of non-Hispanic AIAN adults who currently smoke has increased by 110,000, and relative disparities persist. To reduce racial and ethnic disparities in smoking, understanding how factors at multiple socioecologic levels impact smoking and helping to inform paths to equitable reach and implementation of tobacco control interventions for all population groups are needed.

Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities.

OBJECTIVE: To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. STUDY DESIGN: Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012. RESULTS: Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively). CONCLUSIONS: Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

U.S. healthcare spending attributable to cigarette smoking in 2014.

INTRODUCTION: Cigarette smoking continues to be the leading cause of preventable disease and death in the U.S. Smoking also carries an economic burden, including smoking-attributable healthcare spending. This study assessed smoking-attributable fractions in healthcare spending between 2010 and 2014, overall and by insurance type (Medicaid, Medicare, private, out-of-pocket, other federal, other) and by medical service (inpatient, non-inpatient, prescriptions). METHODS: Data were obtained from the 2010-2014 Medical Expenditure Panel Survey linked to the 2008-2013 National Health Interview Survey. The final sample (n = 49,540) was restricted to non-pregnant adults aged 18 years or older. Estimates from two-part models (multivariable logistic regression and generalized linear models) and data from 2014 national health expenditures were combined to estimate the share of and total (in 2014 dollars) annual healthcare spending attributable to cigarette smoking among U.S. adults. All models controlled for socio-demographic characteristics, health-related behaviors, and attitudes. RESULTS: During 2010-2014, an estimated 11.7% (95% CI = 11.6%, 11.8%) of U.S. annual healthcare spending could be attributed to adult cigarette smoking, translating to annual healthcare spending of more than $225 billion dollars based on total personal healthcare expenditures reported in 2014. More than 50% of this smoking-attributable spending was funded by Medicare or Medicaid. For Medicaid, the estimated healthcare spending attributable fraction increased more than 30% between 2010 and 2014. CONCLUSIONS: Cigarette smoking exacts a substantial economic burden in the U.S. Continuing efforts to implement proven population-based interventions have been shown to reduce the health and economic burden of cigarette smoking nationally.

Receipt of Cessation Treatments Among Medicaid Enrollees Trying to Quit Smoking.

INTRODUCTION: Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. AIMS AND METHODS: Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. RESULTS: Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. CONCLUSIONS: The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. IMPLICATIONS: Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees' use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2008-2018.

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees† over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications§; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments.¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3-7).

Trends and Associations of Menthol Cigarette Smoking Among US Middle and High School Students-National Youth Tobacco Survey, 2011-2018.

INTRODUCTION: Youth cigarette smoking decreased significantly over the last two decades in the United States. This study provides estimates and trends from 2011 to 2018 and factors associated with youth menthol and non-menthol smoking from 2016 to 2018. METHODS: Using data from the 2011-2018 National Youth Tobacco Surveys, past 30-day (current) menthol and non-menthol cigarette smoking were estimated for all youth (prevalence) and youth smokers (proportions). Trends were examined using Joinpoint regression, calculating the annual percent change (APC). Multivariate logistic regression analyses identified factors associated with menthol smoking. RESULTS: From 2011 to 2018, menthol cigarette smoking among current youth cigarette smokers significantly decreased from 57.3% to 45.7% (APC: -3.0%), while non-menthol (38.2% to 47.3% [APC: 2.9%]) and unknown menthol status (not sure\missing) (4.5% to 7.0% [APC: 7.1%]) significantly increased. Menthol cigarette smoking among high school, male, female, and non-Hispanic white current cigarette smokers decreased, but remained unchanged among middle school, non-Hispanic black, and Hispanic smokers. Significantly higher proportions of menthol cigarette smokers smoked on ≥20 days, ≥2 cigarettes per day, and ≥100 cigarettes in their lifetime compared to non-menthol smokers. Among current cigarette smokers, non-Hispanic blacks, Hispanics, flavored non-cigarette tobacco users, frequent smokers (≥20 days), those smoking 2-5 cigarettes per day, and those living with someone who uses tobacco had higher odds of menthol cigarette smoking. CONCLUSIONS: In 2018, nearly half of current youth cigarette smokers smoked menthol cigarettes. While menthol cigarette smoking declined from 2011 to 2018 among all youth and among youth smokers, there was no change in menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school cigarette smokers. IMPLICATIONS: This study finds that overall cigarette and menthol cigarette smoking declined in youth from 2011 to 2018. However, menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school youth cigarette smokers did not change. Information from this study can help inform efforts to reduce menthol cigarette smoking among US youth, particularly racial/ethnic minority populations.

Budgetary impact from multiple perspectives of sustained antitobacco national media campaigns to reduce the harms of cigarette smoking.

BACKGROUND: High-intensity antitobacco media campaigns are a proven strategy to reduce the harms of cigarette smoking. While buy-in from multiple stakeholders is needed to launch meaningful health policy, the budgetary impact of sustained media campaigns from multiple payer perspectives is unknown. METHODS: We estimated the budgetary impact and time to breakeven from societal, all-payer, Medicare, Medicaid and private insurer perspectives of national antitobacco media campaigns in the USA. Campaigns of 1, 5 and 10 years of durations were assessed in a microsimulation model to estimate the 10 and 20-year health and budgetary impact. Simulation model inputs were obtained from literature and both pubic use and proprietary data sets. RESULTS: The microsimulation predicts that a 10-year national smoking cessation campaign would produce net savings of $10.4, $5.1, $1.4, $3.6 and $0.2 billion from the societal, all-payer, Medicare, Medicaid and private insurer perspectives, respectively. National antitobacco media campaigns of 1, 5 and 10-year durations could produce net savings for Medicaid and Medicare within 2 years, and for private insurers within 6-9 years. A 10-year campaign would reduce adult cigarette smoking prevalence by 1.2 percentage points, prevent 23 500 smoking-attributable deaths over the first 10 years. In sensitivity analysis, media campaign costs would be offset by reductions in medical care spending of smoking among all payers combined within 6 years in all tested scenarios. CONCLUSIONS: 1, 5 and 10-year antitobacco media campaigns all yield net savings within 10 years from all perspectives. Multiyear campaigns yield substantially higher savings than a 1-year campaign.

Tobacco Use and Tobacco-Related Behaviors - 11 Countries, 2008-2017.

Each year, tobacco use is responsible for approximately 8 million deaths worldwide, including 7 million deaths among persons who use tobacco and 1.2 million deaths among nonsmokers exposed to secondhand smoke (SHS) (1). Approximately 80% of the 1.1 billion persons who smoke tobacco worldwide reside in low- and middle-income countries (2,3). The World Health Organization's (WHO's) Framework Convention on Tobacco Control (FCTC) provides the foundation for countries to implement and manage tobacco control through the MPOWER policy package,* which includes monitoring tobacco use, protecting persons from SHS, warning them about the danger of tobacco, and enforcing bans on tobacco advertising, promotion, or sponsorship (tobacco advertising) (4). CDC analyzed data from 11 countries that completed two or more rounds of the Global Adult Tobacco Survey (GATS) during 2008-2017. Tobacco use and tobacco-related behaviors that were assessed included current tobacco use, SHS exposure, thinking about quitting because of warning labels, and exposure to tobacco advertising. Across the assessed countries, the estimated percentage change in tobacco use from the first round to the most recent round ranged from -21.5% in Russia to 1.1% in Turkey. Estimated percentage change in SHS exposure ranged from -71.5% in Turkey to 72.9% in Thailand. Estimated percentage change in thinking about quitting because of warning labels ranged from 77.4% in India to -33.0% in Turkey. Estimated percentage change in exposure to tobacco advertising ranged from -66.1% in Russia to 44.2% in Thailand. Continued implementation and enforcement of proven tobacco control interventions and strategies at the country level, as outlined in MPOWER, can help reduce tobacco-related morbidity and mortality worldwide (3,5,6).

Severe Pulmonary Disease Associated with Electronic-Cigarette-Product Use - Interim Guidance.

On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, "dabbing" involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

Prevalence and correlates of secondhand smoke exposure in the home and in a vehicle among youth in the United States.

Private settings are major sources of secondhand smoke (SHS) exposure among youth. We measured prevalence and correlates of youth exposures to home and vehicle SHS. The 2016 National Youth Tobacco Survey of U.S. 6th-12th graders was analyzed (n = 20,675). Past-7-day home or vehicle SHS exposures were self-reported. Descriptive and multivariable analyses were performed on weighted data. Among all students, past-7-day SHS exposures were: vehicle (21.4%, 5.56 million); home (21.7%, 5.64 million); home or vehicle (29.0%, 7.50 million); vehicle and home (14.0%, 3.63 million). By household tobacco-use status, home or vehicle SHS exposure was: tobacco-free households, 8.4%; households with combustible-only tobacco users, 59.8%; households with smokeless tobacco/e-cigarette-only users, 21.8%; and households with combined tobacco products usage, 73.9%. Where only the youth respondent but no other household member(s) used tobacco, the measure of association (vs. tobacco-free households) was ~two-fold higher for vehicle SHS exposures (Adjusted Odds Ratio [AOR] = 6.09; 95% Confidence Interval [CI] = 4.93-7.54 than for home SHS exposures (AOR = 3.16; 95%CI = 2.35-4.25). Conversely, where only household member(s) but not the youth respondent used tobacco, the measure of association was over two-fold higher for home SHS exposures (AOR = 22.15; 95%CI = 19.12-25.67) than for vehicle SHS exposure (AOR = 7.91; 95%CI = 6.96-8.98). In summary, nearly one-third of U.S. youth (7.50 million) were exposed to either home or vehicle SHS. Among non-tobacco-using youth with tobacco-using household member(s), the home was a dominant SHS exposure source; among tobacco-using youth with non-tobacco-using household member(s), a vehicle was a dominant exposure source, possibly peers'. Smoke-free environments, including homes and cars, can reduce youth SHS exposure.