Implementation of Clean Indoor Air Laws: Complaints, Citations, and Fines or Sanctions Related to Possible Violations of the Kansas Clean Indoor Air Act.

OBJECTIVE: To determine how well the Kansas Clean Indoor Air Act was being observed and enforced. DESIGN: A survey inquired about complaints, citations, and fines or sanctions after the implementation of the Kansas Clean Indoor Air Act; inquiry was also made about the law's effectiveness. Descriptive statistics and Poisson tests of statistical significance were used. SETTING: Each of the 55 Kansas cities with more than 5000 in population. PARTICIPANTS: Law enforcement personnel. MAIN OUTCOME MEASURES: Monthly rates of complaints, citations, fines or sanctions, and reports of the law's effectiveness during the 30-month period after implementation of the act. RESULTS: Responses were received from 100% of the sampled cities. The number of citizen complaints and citations decreased over time from 4.33 to 2.42 per month and from 3.17 to 0.92 per month, respectively. The number of fines or sanctions decreased from 1.67 per month to 0.50 per month. In 51 of 55 cities (92.7%), respondents reported that the Kansas Clean Indoor Act appeared to be working effectively. There was a statistically significant difference between the first and second and first and third time periods for citations and fines or sanctions. However, there was only a statistically significant difference between the first and third time periods for citizen complaints. CONCLUSIONS: The law appears to be functioning effectively. This approach could be used to supplement measured or self-reported exposures to secondhand smoke in future studies in other jurisdictions, particularly in identifying areas with potential problems. Given the conservative nature of Kansas, adoption of such a law in the remaining states seems realistic.

Cigarette Consumption and Cigarette Smoking Prevalence Among Adults in Kansas.

INTRODUCTION: Recent tobacco prevention and cessation activities have focused on nonsmoking ordinances and behavioral changes, and in Kansas, the overall prevalence of cigarette smoking among adults has decreased. The objective of this study was to determine whether overall cigarette consumption (mean annual number of cigarettes smoked) in Kansas also decreased. METHODS: Data on cigarette smoking prevalence for 91,465 adult Kansans were obtained from the Behavioral Risk Factor Surveillance System survey for 1999 through 2010. Data on annual cigarette consumption were obtained from the 2002 and 2006 Kansas Adult Tobacco Survey and analyzed by totals, by sex, and by smoking some days or smoking every day. Linear regression was used to evaluate rate changes over time. RESULTS: Among men, but not women, cigarette smoking prevalence decreased significantly over time. The prevalence of smoking every day decreased significantly among both men and women, whereas the prevalence of smoking on some days increased significantly for women but not men. For current smokers, the mean annual number of cigarettes consumed remained the same. CONCLUSION: The decline in overall smoking prevalence coupled with the lack of change in mean annual cigarette consumption may have resulted in a more intense exposure to cigarettes for the smoking population. The significant increase in some day use among women indicates a need for additional prevention and education activities; the impact on future lung cancer incidence rates needs further investigation.

Continuing educational needs of APHA members within the professional public health workforce.

OBJECTIVE: To examine the continuing education needs of and method of course delivery for American Public Health Association (APHA) members. METHODS (DESIGN, SETTING, PARTICIPANTS): The APHA Education Board developed a list of 37 potential continuing education courses, 20 of which were linked to course competencies. An electronic survey of 22 104 APHA members was conducted to determine members' priorities. Survey data included age, gender, race/ethnicity, highest academic degree obtained, workplace setting, educational needs, and preferred method of course delivery. Data were primarily analyzed using descriptive statistics. MAIN OUTCOME MEASURES: Demographic data, educational needs, and preferred method of course delivery. RESULTS: Respondents numbered 5058, with 3836 (75.8%) interested in continuing education. For those indicating an interest, approximately 6 course areas per person were identified. A number of specific course areas were emphasized, including Leadership and Systems Thinking Skills and Policy Development and Program Planning. More than 50% of respondents favored obtaining courses using an online or computer-based format. Of the 24% uninterested in continuing education, 78% were in the age range of 25 to 65 years. CONCLUSIONS: Although this study identified continuing education needs of a wide cross section of APHA members, the response rate was low. Additional surveys should be conducted periodically to update course offerings and identify gaps in workforce training. Reasons for any disinterest in continuing education in public health should be explored.

Evaluation of a local health department's food handler training program.

The impact of a food handler training (FHT) program was measured by comparing rates of total and critical violations from routine inspections of food service establishments before (2001-2004) and after (2005-2007) the implementation of an FHT program. A quasiexperimental design compared rates of inspection violations related and unrelated to the responsibilities of food handlers. A subset analysis focused on establishments in business for the entire time period. Violation rates decreased for total and critical food handler-related violations and in practically all individual categories of food handler-related violations. The rate of control violations, however, decreased even more (e.g., critical violations decreased by 4.9% in the food handler group and 24.7% in the control group). Results were similar in the subset analyses. Compared to the control group, no measurable benefit was seen from the FHT program. Improved training through the use of multiple teaching methods and process and qualitative evaluations are recommended.

Indoor smoking ordinances in workplaces and public places in Kansas.

INTRODUCTION: The purpose of this study was to investigate the preferences of elected city officials regarding the need for a statewide clean indoor air law and to analyze the content of local smoking ordinances. METHODS: A survey of elected officials in 57 larger Kansas cities obtained information on the perceived need for statewide legislation, venues to be covered, and motivating factors. Clean indoor air ordinances from all Kansas cities were analyzed by venue. RESULTS: The survey response rate was 190 out of 377 (50.4%) for elected officials. Over 70% of the respondents favored or strongly favored greater restrictions on indoor smoking. Sixty percent favored statewide legislation. Among these, over 80% favored restrictions in health care facilities, theaters, indoor sports arenas (including bowling alleys), restaurants, shopping malls, lobbies, enclosed spaces in outdoor arenas, and hotel/motel rooms. Officials who had never smoked favored a more restrictive approach. Employee and public health concerns were cited as influential by 76%-79% of respondents. Thirty-eight ordinances, covering over half of the state's population, were examined. They varied considerably in their exemptions. DISCUSSION: Official's attitudes toward smoking regulations were associated with their smoking status. The examination of existing ordinances revealed a piecemeal approach to smoking regulations.

The prevalence of multiple sclerosis in 3 US communities.

INTRODUCTION: We estimated the prevalence of multiple sclerosis (MS) in 3 large geographic areas in the southern, middle, and northern United States. METHODS: The primary data source was medical records from office visits to private neurologists' practices or to neurology departments in tertiary care facilities during a 3-year period. Additional data sources included patient advocacy groups, nursing homes, and general practitioners. RESULTS: Three-year US age-adjusted prevalence estimates for the study areas varied substantially. The prevalence was lowest (47.2 per 100,000 population) in the Texas study area (33 degrees 30' north latitude), intermediate (86.3 per 100,000 population) in the Missouri study area (39 degrees 07' north latitude), and highest (109.5 per 100,000 population) in the Ohio study area (41 degrees 24' north latitude). The geographic differences remained strong after age-adjustment to the world standard population. The inverse association between UV light exposure and MS prevalence estimates was consistent with this observed latitude gradient. In all 3 areas, MS prevalence was highest among women, people aged 40 to 59 years, and non-Hispanics. CONCLUSION: These results provide necessary prevalence estimates for community cluster investigations and establish baseline estimates for future studies to evaluate temporal trends in disease prevalence.

Potential health impacts of heavy-metal exposure at the Tar Creek Superfund site, Ottawa County, Oklahoma.

The potential impact of exposure to heavy metals and health problems was evaluated at the Tar Creek Superfund site, Ottawa County, Oklahoma, USA. Observed versus expected mortality was calculated for selected conditions in the County and exposed cities. Excess mortality was found for stroke and heart disease when comparing the exposed County to the state but not when comparing the exposed cities to the nonexposed rest of the County. However, sample sizes in the exposed area were small, population emigration has been ongoing, and geographic coding of mortality data was incomplete. In an exposed community, 62.5% of children under the age of 6 years had blood lead levels exceeding 10 microg/dl. The relationships between heavy-metal exposure and children's health and chronic disease in adults are suggestive that a more thorough investigation might be warranted. A number of possible environmental and health studies are suggested, including those focusing on possible central nervous system impacts. Unfortunately, the exposed population is dispersing. One lesson learned at this site is that health studies need to be conducted as soon as possible after an environmental problem is identified to both study the impact of the most acute exposures and to maximize study sample size-including those exposed to higher doses-and minimize the loss of individuals to follow-up.

The effect of health communications on a statewide West Nile Virus public health education campaign.

OBJECTIVES: To determine knowledge, behavior, and attitude among Kansas residents exposed to a statewide West Nile Virus health education campaign. METHODS: Telephone survey employing random selection of urban and rural counties and telephone numbers. RESULTS: Knowledge was widespread, preventive behaviors less so. TV, newspapers, and word-of-mouth were most frequently cited sources of information. A small percentage of individuals received information from health professionals. CONCLUSIONS: Recommendations are made for designing and implementing future campaigns, including taking into account target population demographics, populations at highest risk, and channels of communication. Greater use of the Internet, word of mouth, and newspapers appear most promising.

Occupation and lung cancer in nonsmokers.

Lung cancer remains a significant burden on society, with approximately 157,200 deaths from this disease in 2003 occurring in the United States alone. Smoking causes the vast majority of cases (and deaths) from lung cancer, occupation may account for as many as 16,700 of such deaths. To examine the influence of occupation independent of smoking, we reviewed the literature on occupational lung cancer in nonsmokers. We found that most individual studies and summaries of occupational lung cancer are based on data having a heavy preponderance of male smokers. Relatively little data are available concerning females and nonsmokers. Specific dose-response information is often lacking. Although many studies have been adjusted for smoking, there remains a significant potential for residual confounding because of the overwhelming importance of smoking in the etiology of this disease. Our review has found some evidence that asbestos, environmental tobacco smoke, and radon decay products (progeny) are occupational carcinogens in nonsmokers. Increased risk for lung cancer might also occur in nonsmokers from occupational exposure to arsenic. Nevertheless, for many agents and occupations occupations or industries listed in the database of the International Agency for Research on Cancer (IARC), we could not locate any study that found them to be occupational risk factors for lung cancer in nonsmokers. Thus, considerable uncertainty exists about their ability to cause lung cancer in the nonsmoking working population. We discuss problems with the original occupational studies and the IARC list of carcinogens. Besides the absence of information on nonsmokers, these problems include lack of sufficient detail on exposure to the primary agent of concern and to other occupational lung carcinogens. Further research on occupational causes of lung cancer in nonsmokers should be given high priority.

Residential radon exposure and lung cancer: risk in nonsmokers.

Lung cancer is a disease that is almost entirely caused by smoking; hence, it is almost totally preventable. Yet there are a small percentage of cases, perhaps as many as 5 to 15%, where there are other causes. Risk factors identified for this other group include passive smoking, occupational exposure to certain chemicals and ionizing radiation, diet, and family history of cancer. In the United States cigarette smoking is on the decline among adults, occupational exposures are being reduced, and people are being made more aware of appropriate diets. These changes are gradually resulting in a reduced risk for this disease. Lung cancer in the U.S. may, therefore, eventually become largely a disease of the past. It remains important, however, to continue to study the cause(s) of lung cancer in non-smokers, particularly never smokers. Because of our interest in the effects of residential radon exposure on the development of lung cancer in non-smokers, we conducted a critical review of the scientific literature to evaluate this issue in detail. Strict criteria were utilized in selecting studies, which included being published in a peer reviewed journal, including non-smokers in the studied populations, having at least 100 cases, and being of case-control design. A total of 12 individual studies were found that met the criteria, with 10 providing some information on non-smokers. Most of these studies did not find any significant association between radon and lung cancer in non-smokers. Furthermore, data were not presented in sufficient detail for non-smokers in a number of studies. Based on the most recent findings, there is some evidence that radon may contribute to lung cancer risk in current smokers in high residential radon environments. The situation regarding the risk of lung cancer from radon in non-smokers (ex and never) is unclear, possibly because of both the relatively limited sample size of non-smokers and methodological limitations in most of the individual studies. A summary of these studies is provided concerning the state of knowledge of the lung cancer risk from radon, methodological problems with the residential studies, the need for the provision of additional data on non-smokers from researchers, and recommendations for future research in non-smokers.

Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis.

OBJECTIVES: A systematic review and a meta-analysis were performed to determine the association between public smoking bans and risk for hospital admission for acute myocardial infarction (AMI). BACKGROUND: Secondhand smoke (SHS) is associated with a 30% increase in risk of AMI, which might be reduced by prohibiting smoking in work and public places. METHODS: PubMed, EMBASE, and Google Scholar databases plus bibliographies of relevant studies and reviews were searched for peer-reviewed original articles published from January 1, 2004, through April 30, 2009, using the search terms "smoking ban" and "heart" or "myocardial infarct." Investigators supplied additional data. All published peer-reviewed original studies identified were included. Incidence rates of AMI per 100,000 person-years before and after implementation of the smoking bans and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. Random effects meta-analyses estimated the overall effect of the smoking bans. Funnel plot and meta-regression assessed heterogeneity among studies. RESULTS: Using 11 reports from 10 study locations, AMI risk decreased by 17% overall (IRR: 0.83, 95% CI: 0.75 to 0.92), with the greatest effect among younger individuals and nonsmokers. The IRR incrementally decreased 26% for each year of observation after ban implementation. CONCLUSIONS: Smoking bans in public places and workplaces are significantly associated with a reduction in AMI incidence, particularly if enforced over several years.

Risk factors for lung cancer in Iowa women: implications for prevention.

BACKGROUND: Multiple risk factors possibly associated with lung cancer were examined as part of a large-scale residential radon case-control study conducted in Iowa between 1994 and 1997. We were particularly interested in stratifying risk factors by smoking status. Relatively little risk factor information is available for Midwestern rural women. METHODS: Four hundred thirteen female lung cancer cases and 614 controls aged 40-84, who were residents of their current home for at least 20 years, were included. Risk factors examined included cigarette smoking, passive smoking, occupation, chemical exposure, previous lung disease, family history of cancer, and urban residence. Multiple logistic regression analysis was conducted after adjusting for age, education, and cumulative radon exposure. RESULTS: As expected, active cigarette smoking was the major risk factor for lung cancer. While cessation of smoking was significantly associated with a reduced risk for lung cancer, the risk remained significantly elevated for 25 years. Among all cases, asbestos exposure was a significant risk. Among ex-smokers, pack-year history predominated as the major risk. Among never smokers, a family history of kidney or bladder cancer were significant risk factors (OR=7.34, 95% CI=1.91-28.18; and OR=5.02, 95% CI=1.64-15.39, respectively), as was a history of previous lung disease (OR=2.28, 95% CI=1.24-4.18) and asbestos exposure. No statistically significant increase in lung cancer risk was found for occupation or urban residence. CONCLUSIONS: Smoking prevention activities are urgently needed in rural areas of the United States. Relatives of individuals with smoking-related cancers are potentially at increased risk. Genetic risk factors should be more fully investigated in never smokers.

Evaluation of West Nile virus education campaign.

We evaluated the 2003 Kansas West Nile virus public education campaign. Awareness was widespread but compliance was low. Spanish-speaking persons were poorly informed. Relevant factors included population segment variability, campaign content, media choice, and materials delivery methods.

Cancer cluster investigations: use of a hybrid approach in a rural county.

A rural community expressed concern about a perceived excess of kidney and pancreatic cancer coupled with contamination of drinking water with atrazine, benzene, ethylene dibromide, and nitrate. Incidence and mortality for these two cancers were compared to what might be expected. A literature review was conducted for risk factors for kidney and pancreatic cancer as well as for the effects of the above 4 chemicals on these 2 cancers. Interviews with cases or surrogates ascertained chemical and risk factor exposures for these 2 cancers. Chemical exposures found in the public drinking water supply were evaluated as to their carcinogenicity. Hospital cases were compared to cases in the cancer registry. No statistically significant increases in kidney and pancreatic cancer incidence or mortality were found. The major risk factor found in the literature for these 2 cancers was smoking. Most of the cases were smokers and the chemicals found in the drinking water were not found to pose a risk for these 2 cancers. This approach provided considerable information, suggested prevention options and additional research, and is recommended for responding to cancer cluster concerns originating in the community (reactive approach). A proactive approach to cancer cluster surveillance and research was also used and is recommended for state or large local health departments.

Brain cancer in a residential area bordering on an oil refinery.

Both in response to community concerns about brain cancer related to an oil refinery and in order to more fully understand the etiology of primary site brain cancer (glioma), a highly focused cancer cluster investigation was conducted. The components included: (1) a literature review of occupational exposures in the petroleum refining and petrochemical industries, (2) comparisons between observed and expected cases, (3) comparisons between mean age at diagnosis and median survival time and (4) interviews concerning exposures of cases. Evidence from the literature review revealed little, if any, effect of petroleum refinery or petrochemical exposure on the risk for brain cancer. There was no statistically significant increase in the number of brain cancer cases in the community (observed = 12, expected = 9.46, standardized mortality ratio = 1.27). There was no statistically significant decrease in mean age at diagnosis or median survival time among those most exposed. Reports of exposure from the case interviews were highest for eating processed meats (98.5%), dental X-rays (96.6%), dog ownership (91.2%) and swimming (80.3%). There were no major occupational exposures identified. It seems unlikely that petrochemicals are involved in any significant way in the etiology of most brain cancers (gliomas). A follow-up case-control study should focus primarily on those risk factors mentioned frequently by the cases.