Hurricane Evacuation Laws in Eight Southern U.S. Coastal States - December 2018.

National Preparedness month is observed every September as a public service reminder of the importance of personal and community preparedness for all events; it coincides with the peak of the hurricane season in the United States. Severe storms and hurricanes can have long-lasting effects at all community levels. Persons who are prepared and well-informed are often better able to protect themselves and others (1). Major hurricanes can devastate low-lying coastal areas and cause injury and loss of life from storm surge, flooding, and high winds (2). State and local government entities play a significant role in preparing communities for hurricanes and by evacuating coastal communities before landfall to reduce loss of life from flooding, wind, and power outages (3). Laws can further improve planning and outreach for catastrophic events by ensuring explicit statutory authority over evacuations of communities at risk (4). State evacuation laws vary widely and might not adequately address information and communication flows to reach populations living in disaster-prone areas who are at risk. To understand the range of evacuation laws in coastal communities that historically have been affected by hurricanes, a systematic policy scan of the existing laws supporting hurricane evacuation in eight southern coastal states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas) was conducted. After conducting a thematic analysis, this report found that all eight states have laws to execute evacuation orders, traffic control (egress/ingress), and evacuation to shelters. However, only four of the states have laws related to community outreach, delivery of public education programs, and public notice requirements. The findings in this report suggest a need for authorities in hurricane-prone states to review how to execute evacuation policies, particularly with respect to community outreach and communication to populations at risk. Implementation of state evacuation laws and policies that support hurricane evacuation management can help affected persons avoid harm and enhance community resiliency (5). Newly emerging and re-emerging infectious diseases, such as SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), have and will continue to additionally challenge hurricane evacuations.

Attitudes, Motivators, and Barriers to Emergency Preparedness Using the 2016 Styles Survey.

This study assessed adults' perceptions toward preparedness to better inform emergency planning efforts for households and communities. The 2016 Styles, an Internet panel survey, was used to assess emergency preparedness competencies. Descriptive analyses were performed to describe the sociodemographic factors by preparedness status. Multivariable logistic regressions were used to examine the association between perceived preparedness and characteristics associated with preparedness attitudes, motivators, and barriers. Approximately 40% of adults surveyed reported that they were prepared for emergencies. The main motivator for those prepared was awareness of local disasters (38.9%), and a leading barrier was confusion about how to plan for the unknown (23.7%). Those prepared were more likely to have the right supplies (adjusted odds ratio [AOR] = 1.25, 95% confidence interval [CI] = [1.05, 1.50]), discuss emergency plans (AOR = 1.21, 95% CI = [1.02-1.42]), and act before an emergency occurred (AOR = 1.35, 95% CI = [1.15, 1.59]), compared with adults who did not report being prepared. Results from this research indicate that identifying motivation to prepare for emergencies can contribute to public health disaster planning. Preparation is a critical step that allows the community and its citizens to be more equipped to function during and after a disaster.

Cigarettes point of purchase patterns in 19 low-income and middle-income countries: Global Adult Tobacco Survey, 2008-2012.

BACKGROUND: There is little information on cigarette-purchasing behaviour among smokers globally. Understanding cigarette purchase and point-of-sale patterns can help guide the development and implementation of tobacco-control strategies in retail environments. OBJECTIVE: The purpose of this study was to identify where adults in 19 countries last purchased cigarettes. METHODS: Data were from 19 low-income and middle-income countries that conducted the Global Adult Tobacco Survey (GATS) during 2008-2012. GATS is a nationally representative household survey of adults aged 15 years or older using a standardised protocol to measure tobacco-related behaviours. Data were weighted to yield nationally representative estimates within each country and summarised by using descriptive statistics. RESULTS: Overall prevalence of current cigarette smoking ranged from 3.7% in Nigeria to 38.5% in the Russian Federation. Among current cigarette smokers, locations of last purchase were as follows: stores, from 14.6% in Argentina to 98.7% in Bangladesh (median=66.8%); street vendors, from 0% in Thailand to 35.7% in Vietnam (median=3.0%); kiosks, from 0.1% in Thailand to 77.3% in Argentina (median=16.1%); other locations, from 0.3% in China and Egypt to 57.5% in Brazil (median=2.6%). CONCLUSION: Cigarettes are purchased at various retail locations globally. However, stores and kiosks were the main cigarette purchase locations in 18 of the 19 countries assessed. Knowledge of where cigarette purchases occur could help guide interventions to reduce cigarette accessibility and use.

School District Crisis Preparedness, Response, and Recovery Plans - United States, 2006, 2012, and 2016.

Children spend the majority of their time at school and are particularly vulnerable to the negative emotional and behavioral impacts of disasters, including anxiety, depressive symptoms, impaired social relationships, and poor school performance (1). Because of concerns about inadequate school-based emergency planning to address the unique needs of children and the adults who support them, Healthy People 2020 includes objectives to improve school preparedness, response, and recovery plans (Preparedness [PREP]-5) (2). To examine improvements over time and gaps in school preparedness plans, data from the 2006, 2012, and 2016 School Health Policies and Practices Study (SHPPS) were analyzed to assess changes in the percentage of districts meeting PREP-5 objectives. Findings from these analyses indicate that districts met the PREP-5 objective for requiring schools to include post-disaster mental health services in their crisis preparedness plans for the first time in 2016. However, trend analyses did not reveal statistically significant increases from 2006 to 2016 in the percentage of districts meeting any of the PREP-5 objectives. Differences in preparedness were detected in analyses stratified by urbanicity and census region, highlighting strengths and challenges in emergency planning for schools. To promote the health and safety of faculty, staff members, children, and families, school districts are encouraged to adopt and implement policies to improve school crisis preparedness, response, and recovery plans.

Point-of-sale cigarette purchase patterns among U.S. adult smokers-National Adult Tobacco Survey, 2012-2014.

Tobacco products are ubiquitous in most U.S. retail environments. Given that data on preferred point-of-sale purchase locations among U.S. adult tobacco users are limited, an enhanced understanding of tobacco purchase locations can help inform tobacco control policy, planning, and practice. We investigated prevalence and sociodemographic characteristics associated with cigarette purchase location among U.S. adult smokers. Pooled data came from the 2012-2013 (N=60,192) and 2013-2014 (N=75,233) National Adult Tobacco Surveys. Current cigarette smokers (n=18,005) aged ≥18 were asked if they purchased cigarettes within the previous 30days (n=15,182) and, if so, where they last purchased cigarettes. In 2016, logistic regression adjusted for sex, age, race/ethnicity, education level and annual household income was used to assess characteristics associated with purchase location. Among current smokers, 90.2% reported purchasing cigarettes in the past 30days. The most common purchase locations were convenience stores/gas stations (69.1%), tobacco discount stores (9.9%), drug stores (5.0%), supermarkets (4.9%), and liquor stores (3.6%). The odds of purchasing cigarettes at convenience stores/gas stations were higher among men (adjusted odds ratio (AOR)=1.4; 95% confidence interval (CI)=1.2-1.5) than women; and among adults aged 18-24 (AOR=3.1; 95% CI=2.4-3.9), 25-44 (AOR=3.1; 95% CI=2.7-3.7), and 45-64years (AOR=1.8 95% CI=1.6-2.1) than adults aged ≥65years. Over two-thirds of U.S. smokers last purchased cigarettes from convenience stores/gas stations. Understanding the relationship between purchase location and smoker characteristics may inform tobacco control strategies in the retail environment.

School District Crisis Preparedness, Response, and Recovery Plans - United States, 2012.

The unique characteristics of children dictate the need for school-based all-hazards response plans during natural disasters, emerging infectious diseases, and terrorism (1-3). Schools are a critical community institution serving a vulnerable population that must be accounted for in public health preparedness plans; prepared schools are adopting policies and plans for crisis preparedness, response, and recovery (2-4). The importance of having such plans in place is underscored by the development of a new Healthy People 2020 objective (PREP-5) to "increase the percentage of school districts that require schools to include specific topics in their crisis preparedness, response, and recovery plans" (5). Because decisions about such plans are usually made at the school district level, it is important to examine district-level policies and practices. Although previous reports have provided national estimates of the percentage of districts with policies and practices in place (6), these estimates have not been analyzed by U.S. Census region* and urbanicity.(†) Using data from the 2012 School Health Policies and Practices Study (SHPPS), this report examines policies and practices related to school district preparedness, response, and recovery. In general, districts in the Midwest were less likely to require schools to include specific topics in their crisis preparedness plans than districts in the Northeast and South. Urban districts tended to be more likely than nonurban districts to require specific topics in school preparedness plans. Southern districts tended to be more likely than districts in other regions to engage with partners when developing plans. No differences in district collaboration (with the exception of local fire department engagement) were observed by level of urbanicity. School-based preparedness planning needs to be coordinated with interdisciplinary community partners to achieve Healthy People 2020 PREP-5 objectives for this vulnerable population.

Receipt of evidence-based brief cessation interventions by health professionals and use of cessation assisted treatments among current adult cigarette-only smokers: National Adult Tobacco Survey, 2009-2010.

BACKGROUND: Helping tobacco smokers to quit during a medical visit is a clinical and public health priority. Research suggests that most health professionals engage their patients in at least some of the '5 A's' of the brief cessation intervention recommended in the U.S. Public Health Service Clinical Practice Guideline, but information on the extent to which patients act on this intervention is uncertain. We assessed current cigarette-only smokers' self-reported receipt of the 5 A's to determine the odds of using optimal cessation assisted treatments (a combination of counseling and medication). METHODS: Data came from the 2009-2010 National Adult Tobacco Survey (NATS), a nationally representative landline and mobile phone survey of adults aged ≥18 years. Among current cigarette-only smokers who visited a health professional in the past 12 months, we assessed patients' self-reported receipt of the 5 A's, use of the combination of counseling and medication for smoking cessation, and use of other cessation treatments. We used logistic regression to examine whether receipt of the 5 A's during a recent clinic visit was associated with use of cessation treatments (counseling, medication, or a combination of counseling and medication) among current cigarette-only smokers. RESULTS: In this large sample (N = 10,801) of current cigarette-only smokers who visited a health professional in the past 12 months, 6.3 % reported use of both counseling and medication for smoking cessation within the past year. Other assisted cessation treatments used to quit were: medication (19.6 %); class or program (3.8 %); one-on-one counseling (3.7 %); and telephone quitline (2.6 %). Current cigarette-only smokers who reported receiving all 5 A's during a recent clinic visit were more likely to use counseling (odds ratio [OR]: 11.2, 95 % confidence interval [CI]: 7.1-17.5), medication (OR: 6.2, 95 % CI: 4.3-9.0), or a combination of counseling and medication (OR: 14.6, 95 % CI: 9.3-23.0), compared to smokers who received one or none of the 5 A's components. CONCLUSIONS: Receipt of the '5 A's' intervention was associated with a significant increase in patients' use of recommended counseling and medication for cessation. It is important for health professionals to deliver all 5 A's when conducting brief cessation interventions with patients who smoke.

Smoke-free home and vehicle rules by tobacco use status among US adults.

OBJECTIVE: To assess the prevalence and characteristics of smoke-free home and vehicle rules by tobacco use. METHODS: Data came from the 2012-2013 National Adult Tobacco Survey, a telephone survey of adults aged ≥18. Respondents who reported smoking is 'never allowed' inside their home or any family vehicle were considered to have smoke-free home and vehicle rules, respectively. Prevalence and characteristics of smoke-free rules were assessed overall and by current tobacco use (combustible only, noncombustible only, combustible and noncombustible, no current tobacco use). Assessed characteristics included: sex, age, race/ethnicity, education, marital status, income, region, and sexual orientation. RESULTS: Nationally, 83.7% of adults (n=48,871) had smoke-free home rules and 78.1% (n=46,183) had smoke-free vehicle rules. By tobacco use, prevalence was highest among nonusers of tobacco (homes: 90.8%; vehicles: 88.9%) and lowest among combustible-only users (homes: 53.7%; vehicles: 34.2%). Prevalence of smoke-free home and vehicle rules was higher among males, adults with a graduate degree, and adults living in the West. CONCLUSIONS: Most adults have smoke-free home and vehicle rules, but differences exist by tobacco use. Opportunities exist to educate adults about the dangers of secondhand smoke and the benefits of smoke-free environments, particularly among combustible tobacco users.

Secondhand smoke and smoking restrictions in casinos: a review of the evidence.

OBJECTIVE: There is no safe level of secondhand smoke (SHS) exposure. Most US casinos continue to allow smoking, thus exposing workers and patrons to the hazards of SHS. This paper reviews the scientific literature on air quality, SHS exposure, health effects and economic outcomes related to SHS and smoking restrictions in casinos, as well as on smoking prevalence among casino patrons and problem gamblers. DATA SOURCES: Peer reviewed studies published from January 1998 to March 2011. DATA SYNTHESIS: Evidence from air quality, biomarker and survey studies indicates that smoking in casinos is a significant public health problem. Workers and patrons in casinos that allow smoking are exposed to high levels of SHS, as documented by elevated levels of SHS constituents in the air of casinos and by elevated levels of tobacco-specific biomarkers in non-smokers' blood, urine and saliva. Partial smoking restrictions in casinos do not effectively protect non-smokers from SHS. Findings suggest that the smoking prevalence of casino patrons is comparable with that of the general public, although this prevalence may be higher among problem gamblers. Few studies have examined the economic impact of smoke-free policies in casinos, and the results of these studies are mixed. CONCLUSIONS: Employees and patrons are exposed to SHS in casinos, posing a significant, preventable risk to their health. Policies completely prohibiting smoking in casinos would be expected to greatly reduce or eliminate SHS exposure in casinos, thereby protecting the health of casino workers and patrons.

National and State Attitudes of US Adults Toward Tobacco-Free School Grounds, 2009-2010.

INTRODUCTION: Schools are an important environment for addressing tobacco use among youth. Tobacco-free school policies can help reduce the social acceptability of tobacco use and prevent tobacco initiation among youth. This study assessed attitudes toward tobacco-free school grounds among US adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of adults aged 18 or older in the 50 US states and District of Columbia. Respondents were considered to have a favorable attitude toward tobacco-free school grounds if they reported tobacco use should be completely banned on school grounds, including fields and parking lots, and at all school events. Data were assessed using descriptive statistics and multivariable logistic regression, overall and by tobacco use status. Correlates were sex, age, race/ethnicity, education, marital status, income, sexual orientation, US region, and whether respondent lived with any children aged 17 years or younger. RESULTS: Nationally, 86.1% of adults had a favorable attitude toward tobacco-free school grounds, with larger percentages among nontobacco users (91.9%) than current users (76.1%). State prevalence ranged from 80.0% (Kentucky) to 90.9% (Washington). Overall odds of favorable attitudes were higher among nontobacco users (referent, current users), women (referent, men), and adults aged 25 or older (referent, aged 18-24); odds were lower among residents of the South (referent, West) and lesbian, gay, bisexual, or transgender adults (referent, heterosexual or straight). CONCLUSION: Nearly 9 in 10 US adults have a favorable attitude toward tobacco-free school grounds, but attitudes vary across states and subpopulations. Opportunities exist to educate the public about the benefits of tobacco-free school grounds, which might help reduce tobacco use among youth.

Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians.

BACKGROUND: The US Public Health Service clinical practice guideline treating tobacco use and dependence: 2008 update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication. FINDINGS: To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended "any" (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange). CONCLUSIONS: This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

Cigarette price minimization strategies in the United States: price reductions and responsiveness to excise taxes.

INTRODUCTION: Because cigarette price minimization strategies can provide substantial price reductions for individuals continuing their usual smoking behaviors following federal and state cigarette excise tax increases, we examined independent price reductions compensating for overlapping strategies. The possible availability of larger independent price reduction opportunities in states with higher cigarette excise taxes is explored. METHODS: Regression analysis used the 2006-2007 Tobacco Use Supplement of the Current Population Survey (N = 26,826) to explore national and state-level independent price reductions that smokers obtained from purchasing cigarettes (a) by the carton, (b) in a state with a lower average after-tax cigarette price than in the state of residence, and (c) in "some other way," including online or in another country. Price reductions from these strategies are estimated jointly to compensate for known overlapping strategies. RESULTS: Each strategy reduced the price of cigarettes by 64-94 cents per pack. These price reductions are 9%-22% lower than conventionally estimated results not compensating for overlapping strategies. Price reductions vary substantially by state. Following cigarette excise tax increases, the price reduction available from purchasing cigarettes by cartons increased. Additionally, the price reduction from purchasing cigarettes in a state with a lower average after-tax cigarette price is positively associated with state cigarette excise tax rates and border state cigarette excise tax rate differentials. CONCLUSIONS: Findings from this large, nationally representative study of cigarette smokers suggest that price reductions are larger in states with higher cigarette excise taxes, and increase as cigarette excise taxes rise.

Cigarette price minimization strategies used by adults.

We used multivariate logistic regressions to analyze data from the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey, a nationally representative sample of adults. We explored use of cigarette price minimization strategies, such as purchasing cartons of cigarettes, purchasing in states with lower after-tax cigarette prices, and purchasing on the Internet. Racial/ethnic minorities and persons with low socioeconomic status used these strategies less frequently at last purchase than did White and high-socioeconomic-status respondents.

Health care providers' advice to quit smoking, National Health Interview Survey, 2000, 2005, and 2010.

Although the prevalence of cigarette smoking has declined in the United States, little documentation exists to ascertain which health care providers (HCPs) promote smoking cessation. We used data from the 2000, 2005, and 2010 Cancer Control Supplement of the National Health Interview Survey to examine changes in the number of adults who received smoking cessation advice from their HCP. The percentage of smokers who received cessation advice was 53.3% in 2000, 58.9% in 2005, and 50.7% in 2010. To affect noticeably declining rates, HCPs should increase their efforts to advise smokers to quit.

A Policy Analysis of Preparedness for Hurricane Evacuations in the United States, 1990 to 2019: Implementation in Coastal States.

Hurricane or typhoon evacuations in the United States are typically managed by state, territorial, or tribal emergency management officials with federal, state, and local agency operational support. The evacuation process may involve issuing mandatory or "voluntary" evacuation orders to alert the community and mitigate loss of life and injury. We conducted an analysis of state and local hurricane evacuation policies identified through a literature review (January 1990 to June 2019) and key informant interviews with state public health and emergency management officials in Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas in October and November 2019. Findings from the literature review show that most gaps in hurricane evacuation preparedness-based on 44 policy-related publications identified in the review-could be categorized into 4 themes: shelters, evacuation decisionmaking, at-risk populations, and transportation. Findings from key informant interviews for 7 states revealed that coastal states have been able to address most of these gaps since Hurricane Katrina in 2005. However, an important remaining gap in preparedness is providing timely warnings to at-risk populations during hurricane evacuations.

Prevalence of highly active adults--Behavioral Risk Factor Surveillance System, 2007.

BACKGROUND: The 2008 Physical Activity Guidelines for Americans (2008 Guidelines) included a novel aerobic physical activity standard, in excess of minimum standards, for more extensive health benefits (>300 minutes/week of moderate-intensity, 150 minutes/week of vigorous-intensity, or an equivalent combination). Prevalence estimates among US states have yet to be described for this new standard. METHODS: Respondents self-reported physical activity in the 2007 Behavioral Risk Factor Surveillance System was used (n=398,397). Total weekly aerobic activity was calculated for each respondent and 2008 Guidelines standards guided classification. RESULTS: In 2007, 43.5% (95% CI: 43.1%-43.8%) of adults met the new 2008 Guidelines standard and were classified as highly active (male, 48.3%; female, 38.9%). Linear patterns were noted by age and education, where younger age and higher levels of education had a higher proportion of highly active. Non-Hispanic whites (45.7%) had a significantly higher proportion of highly active compared with non-Hispanic blacks (37.5%) and Hispanics (37.6%). Variations in estimates were noted among those categorized as sufficiently active, insufficiently active, and inactive. CONCLUSION: More than half of 2007 Behavioral Risk Factor Surveillance System respondents did not meet the new 2008 Guidelines standard. Aerobic activity levels commensurate with more extensive health benefits should be encouraged among US adults.

Perceptions of menthol cigarette use among U.S. adults and adult smokers: findings from the 2009 HealthStyles survey.

INTRODUCTION: Perceptions of menthol cigarette use may have implications for smoking initiation and cessation. This study explores harm and health perceptions of menthol cigarette use among a national sample of U.S. adults and current smokers. METHODS: We examined data from the 2009 HealthStyles survey (n = 4,556), an annual mail survey of adults ≥18 years of age that collects information on attitudes and behaviors, including smoking. Frequencies and weighted percentages were calculated by sex, race/ethnicity, age, education level, household income, and smoking status. Unadjusted odds ratios (OR) were used to compare perceptions of menthol cigarette use between demographic groups. RESULTS: Close to half of adults (45.8%) believed that menthol cigarettes are just as harmful as nonmenthol cigarettes, and 40.9% of adults did not know whether menthol cigarettes are more or less harmful than nonmenthol cigarettes. Few adults (0.6%), including smokers, perceived menthol cigarettes to be less harmful than nonmenthol cigarettes. Blacks (OR = 3.22, 95% CI = 1.80-5.76) were more likely to believe that menthol cigarettes have health benefits when compared with Whites. Almost half of current smokers believed menthol cigarettes are equally addictive as nonmenthol cigarettes and 74.9% believed menthol and nonmenthol cigarettes are equally hard to quit. CONCLUSIONS: Findings suggest directions for targeted public health messages for menthol cigarette use. Future research is needed among a nationally representative sample to capture more subtle differences in perceptions among menthol and nonmenthol smokers.

Effects of the built environment on physical activity of adults living in rural settings.

OBJECTIVE: To conduct a systematic review of the literature to examine the influence of the built environment (BE) on the physical activity (PA) of adults in rural settings. DATA SOURCE: Key word searches of Academic Search Premier, PubMed, CINAHL, Web of Science, and Sport Discus were conducted. STUDY INCLUSION AND EXCLUSION CRITERIA: Studies published prior to June 2008 were included if they assessed one or more elements of the BE, examined relationships between the BE and PA, and focused on rural locales. Studies only reporting descriptive statistics or assessing the reliability of measures were excluded. DATA EXTRACTION: Objective(s), sample size, sampling technique, geographic location, and definition of rural were extracted from each study. Methods of assessment and outcomes were extracted from the quantitative literature, and overarching themes were identified from the qualitative literature. DATA SYNTHESIS: Key characteristics and findings from the data are summarized in Tables 1 through 3. RESULTS: Twenty studies met inclusion and exclusion criteria. Positive associations were found among pleasant aesthetics, trails, safety/crime, parks, and walkable destinations. CONCLUSIONS: Research in this area is limited. Associations among elements of the BE and PA among adults appear to differ between rural and urban areas. Considerations for future studies include identifying parameters used to define rural, longitudinal research, and more diverse geographic sampling. Development and refinement of BE assessment tools specific to rural locations are also warranted.