Influenza Vaccination in Health Centers During the Coronavirus Disease 2019 Pandemic-United States, 7-27 November 2020.

BACKGROUND: Influenza vaccination is the most effective way to prevent influenza and influenza-associated complications including those leading to hospitalization. Resources otherwise used for influenza could support caring for patients with coronavirus disease 2019 (COVID-19). The Health Resources and Services Administration (HRSA) Health Center Program serves 30 million people annually by providing comprehensive primary healthcare, including influenza vaccination, to demographically diverse and historically underserved communities. Because racial and ethnic minority groups have been disproportionately affected by COVID-19, the objective of this analysis was to assess disparities in influenza vaccination at HRSA-funded health centers during the COVID-19 pandemic. METHODS: The Centers for Disease Control and Prevention and HRSA analyzed cross-sectional data on influenza vaccinations from a weekly, voluntary health center COVID-19 survey after addition of an influenza-related question covering 7-11 November 2020. RESULTS: During the 3-week period, 1126 of 1385 health centers (81%) responded to the survey. Most of the 811 738 influenza vaccinations took place in urban areas and in the Western US region. There were disproportionately more health center influenza vaccinations among racial and ethnic minorities in comparison with county demographics, except among non-Hispanic blacks and American Indian/Alaska Natives. CONCLUSIONS: HRSA-funded health centers were able to quickly vaccinate large numbers of mostly racial or ethnic minority populations, disproportionately more than county demographics. However, additional efforts might be needed to reach specific racial populations and persons in rural areas. Success in influenza vaccination efforts can support success in severe acute respiratory syndrome coronavirus 2 vaccination efforts.

Physical Activity Before and During Pregnancy, Colorado Pregnancy Risk Assessment Monitoring System, 2012-2015.

We used 2012-2015 data from the Colorado Pregnancy Risk Assessment Monitoring System to describe changes in self-reported physical activity (PA) before and during pregnancy and used logistic regression to examine factors associated with regular PA. The prevalence of regular PA (ie, 30 or more minutes per day on 5 or more days per week) was 19.1% before pregnancy and decreased to 10.2% during pregnancy. At both times, adjusted odds of regular PA were lower among women who were overweight or had obesity before pregnancy than among those with normal weight. Findings suggest that most women with a recent live birth in Colorado, particularly those who are overweight or have obesity, are not obtaining many health benefits of PA either before or during pregnancy.

Quality of Maternal Height and Weight Data from the Revised Birth Certificate and Pregnancy Risk Assessment Monitoring System.

BACKGROUND: The 2003 revision of the US Standard Certificate of Live Birth (birth certificate) and Pregnancy Risk Assessment Monitoring System (PRAMS) are important for maternal weight research and surveillance. We examined quality of prepregnancy body mass index (BMI), gestational weight gain, and component variables from these sources. METHODS: Data are from a PRAMS data quality improvement study among a subset of New York City and Vermont respondents in 2009. We calculated mean differences comparing prepregnancy BMI data from the birth certificate and PRAMS (n = 734), and gestational weight gain data from the birth certificate (n = 678) to the medical record, considered the gold standard. We compared BMI categories (underweight, normal weight, overweight, obese) and gestational weight gain categories (below, within, above recommendations), classified by different sources, using percent agreement and the simple κ statistic. RESULTS: For most maternal weight variables, mean differences between the birth certificate and PRAMS compared with the medical record were less than 1 kg. Compared with the medical record, the birth certificate classified similar proportions into prepregnancy BMI categories (agreement = 89%, κ = 0.83); PRAMS slightly underestimated overweight and obesity (agreement = 84%, κ = 0.73). Compared with the medical record, the birth certificate overestimated gestational weight gain below recommendations and underestimated weight gain within recommendations (agreement = 81%, κ = 0.69). Agreement varied by maternal and pregnancy-related characteristics. CONCLUSIONS: Classification of prepregnancy BMI and gestational weight gain from the birth certificate or PRAMS was mostly similar to the medical record but varied by maternal and pregnancy-related characteristics. Efforts to understand how misclassification influences epidemiologic associations are needed.

Vital Signs: Trends and Disparities in Infant Safe Sleep Practices - United States, 2009-2015.

INTRODUCTION: There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

Reliability of Reported Maternal Smoking: Comparing the Birth Certificate to Maternal Worksheets and Prenatal and Hospital Medical Records, New York City and Vermont, 2009.

Maternal smoking is captured on the 2003 US Standard Birth Certificate based on self-reported tobacco use before and during pregnancy collected on post-delivery maternal worksheets. Study objectives were to compare smoking reported on the birth certificate to maternal worksheets and prenatal and hospital medical records. The authors analyzed a sample of New York City (NYC) and Vermont women (n = 1,037) with a live birth from January to August 2009 whose responses to the Pregnancy Risk Assessment Monitoring System survey were linked with birth certificates and abstracted medical records and maternal worksheets. We calculated smoking prevalence and agreement (kappa) between sources overall and by maternal and hospital characteristics. Smoking before and during pregnancy was 13.7 and 10.4% using birth certificates, 15.2 and 10.7% using maternal worksheets, 18.1 and 14.1% using medical records, and 20.5 and 15.0% using either maternal worksheets or medical records. Birth certificates had "almost perfect" agreement with maternal worksheets for smoking before and during pregnancy (κ = 0.92 and 0.89) and "substantial" agreement with medical records (κ = 0.70 and 0.74), with variation by education, insurance, and parity. Smoking information on NYC and Vermont birth certificates closely agreed with maternal worksheets but was underestimated compared with medical records, with variation by select maternal characteristics. Opportunities exist to improve birth certificate smoking data, such as reducing the stigma of smoking, and improving the collection, transcription, and source of information.

Validation of obstetric estimate of gestational age on US birth certificates.

OBJECTIVE: The birth certificate variable obstetric estimate of gestational age (GA) has not been previously validated against GA based on estimated date of delivery from medical records. STUDY DESIGN: We estimated sensitivity, specificity, positive predictive value, negative predictive value and the corresponding 95% confidence intervals (CIs) for preterm delivery (<37 weeks' gestation) based on obstetric estimate using estimated date of delivery-based GA as the gold standard. Trained abstractors obtained the estimated date of delivery from the prenatal record (64.8% in New York City, and 94.6% in Vermont), or, when not available, from the hospital delivery record for 2 population-based samples: 586 live births delivered in New York City and 649 live births delivered in Vermont during 2009. Weights were applied to account for nonresponse and sampling design. RESULTS: In New York City, the preterm delivery rate based on estimated date of delivery was 9.7% (95% CI, 7.6-12.4) and 8.2% (95% CI, 6.3-10.6) based on obstetric estimate; in Vermont, it was 6.8% (95% CI, 5.4-8.4) based on estimated date of delivery and 6.3% (95% CI, 5.1-7.8) based on obstetric estimate. In New York City, sensitivity of obstetric estimate-based preterm delivery was 82.5% (95% CI, 69.4-90.8), specificity 98.1% (95% CI, 96.4-99.1), positive predictive value 98.0% (95% CI, 95.2-99.2), and negative predictive value 98.8% (95% CI, 99.6-99.9). In Vermont, sensitivity of obstetric estimate-based preterm delivery was 93.8% (95% CI, 81.8-98.1), specificity 99.6% (95% CI, 98.5-99.9), positive predictive value 100%, and negative predictive value 100%. CONCLUSION: Obstetric estimate-based preterm delivery had excellent specificity, positive predictive value and negative predictive value. Sensitivity was moderate in New York City and excellent in Vermont. These results suggest obstetric estimate-based preterm delivery from the birth certificate is useful for the surveillance of preterm delivery.

Telephone smoking cessation quitline use among pregnant and non-pregnant women.

To describe characteristics, referrals, service utilization, and self-reported quit rates among pregnant and non-pregnant women enrolled in a smoking cessation quitline. This information can be used to improve strategies to increase pregnant and non-pregnant smokers' use of quitlines. We examined tobacco use characteristics, referral sources, and use of services among 1,718 pregnant and 24,321 non-pregnant women aged 18-44 years enrolled in quitline services in 10 states during 2006-2008. We examined self-reported 30-day quit rates 7 months after enrollment among 246 pregnant and 4,123 non-pregnant women and, within groups, used Chi-square tests to compare quit rates by type of service received. The majority of pregnant and non-pregnant callers, respectively, smoked ≥10 cigarettes per day (62 %; 83 %), had recently attempted to quit (55 %; 58 %), smoked 5 or minutes after waking (59 %; 55 %), and lived with a smoker (63 %; 48 %). Of callers, 24.3 % of pregnant and 36.4 % of non-pregnant women were uninsured. Pregnant callers heard about the quitline most often from a health care provider (50 %) and non-pregnant callers most often through mass media (59 %). Over half of pregnant (52 %) and non-pregnant (57 %) women received self-help materials only, the remainder received counseling. Self-reported quit rates at 7 months after enrollment in the subsample were 26.4 % for pregnant women and 22.6 % for non-pregnant women. Quitlines provide needed services for pregnant and non-pregnant smokers, many of whom are uninsured. Smokers should be encouraged to access counseling services.

Risk Factors for Suffocation and Unexplained Causes of Infant Deaths.

BACKGROUND: Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome). METHODS: We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios. RESULTS: We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants. COCLUSIONS: We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

Chronic diseases and related risk factors among low-income mothers.

The aim is to describe the burden of chronic disease and related risk factors among low-income women of reproductive age. We analyzed population-based data from the 2005-2006 Pregnancy Risk Assessment Monitoring System (PRAMS) for 14,990 women with a live birth in 7 states. We examined the prevalence of selected chronic diseases and related risk factors (preexisting diabetes, gestational diabetes, chronic hypertension, pregnancy-induced hypertension, obesity, smoking or binge drinking prior to pregnancy, smoking or excessive weight gain during pregnancy, and postpartum depressive symptoms) by Federal Poverty Level (FPL) (≤100% FPL; 101-250% FPL; >250% FPL). Approximately one-third of women were low-income (≤100% FPL), one-third were near-low-income (101-250% FPL), and one-third were higher-income (>250% FPL). Compared to higher-income women, low-income women were significantly more likely to smoke before or during pregnancy (34.2% vs. 14.4%, and 24.8% vs. 5.4%, respectively), be obese (22.2% vs. 16.0%), experience postpartum depressive symptoms (23.3% vs. 7.9%), have 3 or more chronic diseases and/or related risk factors (28.1% vs. 14.4%) and be uninsured before pregnancy (48.9% vs. 4.8%). Low-income women of reproductive age experienced a higher prevalence of selected chronic diseases and related risk factors. Enhancing services for these women in publicly-funded family planning clinics may help reduce disparities in pregnancy and long-term health outcomes in the poor.

Prevalence of Experiencing Physical, Emotional, and Sexual Violence by a Current Intimate Partner during Pregnancy: Population-based Estimates from the Pregnancy Risk Assessment Monitoring System.

Intimate partner violence (IPV) during pregnancy presents a risk for maternal mental health problems, preterm birth, and having a low birthweight infant. We assessed the prevalence of self-reported physical, emotional, and sexual violence during pregnancy by a current partner among women with a recent live birth. We analyzed data from the 2016-2018 Pregnancy Risk Assessment Monitoring System in six states to calculate weighted prevalence estimates and 95% confidence intervals for experiences of violence by demographic characteristics, health care utilization, and selected risk factors. Overall, 5.7% of women reported any type of violence during pregnancy. Emotional violence was most prevalent (5.4%), followed by physical violence (1.5%), and sexual violence (0.9%). Among women who reported any violence, 67.6% reported one type of violence, 26.5% reported two types, and 6.0% reported three types. Reporting any violence was highest among women using marijuana or illicit substances, experiencing pre-pregnancy physical violence, reporting depression, reporting an unwanted pregnancy, and experiencing relationship problems such as getting divorced, separated, or arguing frequently with their partner. There was no difference in report of discussions with prenatal care providers by experience of violence. The majority of women did not report experiencing violence, however among those who did emotional violence was most frequently reported. Assessment for IPV is important, and health care providers can play an important role in screening. Coordinated prevention efforts to reduce the occurrence of IPV and community-wide resources are needed to ensure that pregnant women receive needed services and protection.

Emergency Department and Intensive Care Unit Overcrowding and Ventilator Shortages in US Hospitals During the COVID-19 Pandemic, 2020-2021.

OBJECTIVE: In 2020, the COVID-19 pandemic overburdened the US health care system because of extended and unprecedented patient surges and supply shortages in hospitals. We investigated the extent to which several US hospitals experienced emergency department (ED) and intensive care unit (ICU) overcrowding and ventilator shortages during the COVID-19 pandemic. METHODS: We analyzed Health Pulse data to assess the extent to which US hospitals reported alerts when experiencing ED overcrowding, ICU overcrowding, and ventilator shortages from March 7, 2020, through April 30, 2021. RESULTS: Of 625 participating hospitals in 29 states, 393 (63%) reported at least 1 hospital alert during the study period: 246 (63%) reported ED overcrowding, 239 (61%) reported ICU overcrowding, and 48 (12%) reported ventilator shortages. The number of alerts for overcrowding in EDs and ICUs increased as the number of COVID-19 cases surged. CONCLUSIONS: Timely assessment and communication about critical factors such as ED and ICU overcrowding and ventilator shortages during public health emergencies can guide public health response efforts in supporting federal, state, and local public health agencies.

Trends in selected chronic conditions and behavioral risk factors among women of reproductive age, behavioral risk factor surveillance system, 2001-2009.

INTRODUCTION: Some potentially modifiable risk factors and chronic conditions cause significant disease and death during pregnancy and promote the development of chronic disease. This study describes recent trends of modifiable risk factors and controllable chronic conditions among reproductive-aged women. METHODS: Data from the 2001 to 2009 Behavioral Risk Factor Surveillance System, a representative state-based telephone survey of health behavior in US adults, was analyzed for 327,917 women of reproductive age, 18 to 44 years. We calculated prevalence ratios over time to assess trends for 4 selected risk factors and 4 chronic conditions, accounting for age, race/ethnicity, education, health care coverage, and individual states. RESULTS: From 2001 to 2009, estimates of 2 risk factors improved: smoking declined from 25.9% to 18.8%, and physical inactivity declined from 25.0% to 23.0%. One risk factor, heavy drinking, did not change. From 2003 to 2009, the estimates for 1 risk factor and 4 chronic conditions worsened: obesity increased from 18.3% to 24.7%, diabetes increased from 2.1% to 2.9%, high cholesterol increased from 10.3% to 13.6%, asthma increased from 13.5% to 16.2%, and high blood pressure increased from 9.0% to 10.1%. All trends were significant after adjustment, except that for heavy drinking. CONCLUSION: Among women of reproductive age, prevalence of smoking and physical inactivity improved, but prevalence of obesity and all 4 chronic conditions worsened. Understanding reasons for the improvements in smoking and physical activity may support the development of targeted interventions to reverse the trends and help prevent chronic disease and adverse reproductive outcomes among women in this age group.

Age and racial/ethnic disparities in prepregnancy smoking among women who delivered live births.

INTRODUCTION: Prenatal smoking prevalence remains high in the United States. To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessation interventions to women who are most likely to smoke before pregnancy. Our objective was to identify groups with the highest prepregnancy smoking prevalence by age within 6 racial/ethnic groups. METHODS: We analyzed data from 186,064 women with a recent live birth from 32 states and New York City from the 2004-2008 Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women. We calculated self-reported smoking prevalence during the 3 months before pregnancy for 6 maternal racial/ethnic groups by maternal age (18-24 y or ≥25 y). For each racial/ethnic group, we modeled the probability of smoking by age, adjusting for education, Medicaid enrollment, parity, pregnancy intention, state of residence, and year of birth. RESULTS: Younger women had higher prepregnancy smoking prevalence (33.2%) than older women (17.6%), overall and in all racial/ethnic groups. Smoking prevalences were higher among younger non-Hispanic whites (46.4%), younger Alaska Natives (55.6%), and younger American Indians (46.9%). After adjusting for confounders, younger non-Hispanic whites, Hispanics, Alaska Natives, and Asian/Pacific Islanders were 1.12 to 1.50 times as likely to smoke as their older counterparts. CONCLUSION: Age-appropriate and culturally specific tobacco control interventions should be integrated into reproductive health settings to reach younger non-Hispanic white, Alaska Native, and American Indian women before they become pregnant.

Adverse Birth Outcomes Associated With Prepregnancy and Prenatal Electronic Cigarette Use.

OBJECTIVE: To evaluate the risk of adverse birth outcomes among adults who use electronic cigarettes (e-cigarettes) before and during pregnancy. METHODS: Data from the 2016-2018 PRAMS (Pregnancy Risk Assessment Monitoring System) were used to assess the association between e-cigarette use during the 3 months before and last 3 months of pregnancy among 79,176 individuals with a recent live birth and the following birth outcomes: preterm birth, small for gestational age, and low birth weight (LBW). Adjusted prevalence ratios were generated using average marginal predictions from multivariable logistic regression models. Models were stratified by prenatal combustible cigarette smoking and frequency of e-cigarette use (daily or less than daily use). RESULTS: In the 3 months before pregnancy, 2.7% (95% CI 2.6-2.9%) of respondents used e-cigarettes; 1.1% (95% CI 1.0-1.2%) used e-cigarettes during the last 3 months of pregnancy. Electronic cigarette use before pregnancy was not associated with adverse birth outcomes. Electronic cigarette use during pregnancy was associated with increased prevalence of LBW compared with nonuse (8.1% vs 6.1%; adjusted prevalence ratio 1.33; 95% CI 1.06-1.66). Among respondents who did not also smoke combustible cigarettes during pregnancy (n=72,256), e-cigarette use was associated with higher prevalence of LBW (10.6%; adjusted prevalence ratio 1.88; 95% CI 1.38-2.57) and preterm birth (12.4%; adjusted prevalence ratio 1.69; 95% CI 1.20-2.39). When further stratified by frequency of e-cigarette use, associations were seen only for daily users. CONCLUSION: E-cigarette use during pregnancy, particularly when used daily by individuals who do not also smoke combustible cigarettes, is associated with adverse birth outcomes.

Building capacity of community health centers to overcome data challenges with the development of an agile COVID-19 public health registry: a multistate quality improvement effort.

OBJECTIVE: During the coronavirus disease 2019 (COVID-19) pandemic, federally qualified health centers rapidly mobilized to provide SARS-CoV-2 testing, COVID-19 care, and vaccination to populations at increased risk for COVID-19 morbidity and mortality. We describe the development of a reusable public health data analytics system for reuse of clinical data to evaluate the health burden, disparities, and impact of COVID-19 on populations served by health centers. MATERIALS AND METHODS: The Multistate Data Strategy engaged project partners to assess public health readiness and COVID-19 data challenges. An infrastructure for data capture and sharing procedures between health centers and public health agencies was developed to support existing capabilities and data capacities to respond to the pandemic. RESULTS: Between August 2020 and March 2021, project partners evaluated their data capture and sharing capabilities and reported challenges and preliminary data. Major interoperability challenges included poorly aligned federal, state, and local reporting requirements, lack of unique patient identifiers, lack of access to pharmacy, claims and laboratory data, missing data, and proprietary data standards and extraction methods. DISCUSSION: Efforts to access and align project partners' existing health systems data infrastructure in the context of the pandemic highlighted complex interoperability challenges. These challenges remain significant barriers to real-time data analytics and efforts to improve health outcomes and mitigate inequities through data-driven responses. CONCLUSION: The reusable public health data analytics system created in the Multistate Data Strategy can be adapted and scaled for other health center networks to facilitate data aggregation and dashboards for public health, organizational planning, and quality improvement and can inform local, state, and national COVID-19 response efforts.

Frequency of cannabis use during pregnancy and adverse infant outcomes, by cigarette smoking status - 8 PRAMS states, 2017.

BACKGROUND: Research on prenatal cannabis use and adverse infant outcomes is inconsistent, and findings vary by frequency of use or cigarette use. We assess (1) the prevalence of high frequency (≥once/week), low frequency (

Infant Safe Sleep Practices in the United States.

Risk of sleep-related infant deaths can be reduced by improving safe sleep practices.

Marijuana use during and after pregnancy and association of prenatal use on birth outcomes: A population-based study.

BACKGROUND: We sought to describe the correlates of marijuana use during and after pregnancy, and to examine the independent relationship between prenatal marijuana use and infant outcomes. STUDY DESIGN: We used state-specific data from the Pregnancy Risk Assessment Monitoring System (N = 9013) to describe correlates of self-reported prenatal and postpartum marijuana use. We estimated differences in mean infant birth weight and gestational age among prenatal marijuana users and nonusers, controlling for relevant covariates (i.e., cigarette smoking). RESULTS: Respectively, 4.2% (95% CI: 3.8-4.7) and 6.8% (95% CI: 6.0-7.7) of women reported using marijuana during and after pregnancy. Compared to nonusers, prenatal marijuana users were more likely to be ≤24 years; non-Hispanic white, not married, have <12 years of education, have Medicaid/IHS/Other insurance, be on WIC during pregnancy, have annual household income <$20,000, cigarette smokers, and alcohol drinkers during pregnancy (p-values < 0.05). After adjustment, no differences in gestational age or birthweight were observed. Postpartum users were more likely to smoke cigarettes (48.7% vs. 20.3%), experience postpartum depressive symptoms (14.0% vs. 9.0%), and breastfeed for <8 weeks (34.9% vs. 18.1%). CONCLUSION: Co-use of substances was common among prenatal and postpartum marijuana users. Prenatal marijuana use was not independently associated with lower average birthweight or gestational age. Postpartum marijuana use was associated with depressive symptoms and shorter breastfeeding duration. Surveillance of marijuana use among pregnant and postpartum women is critical to better understanding the relationship of marijuana use with birth outcomes, and postpartum experiences such as depression and breastfeeding.

Community guide recommendations and state level tobacco control programmes: 1999-2004.

OBJECTIVE: To identify the level of effort state tobacco control programmes and partners have expended on interventions recommended by the community guide and how those efforts have changed over time between 1999 and 2004. DESIGN: Longitudinal study. SETTING: United States. PARTICIPANTS: State tobacco control partners, including the state health department, voluntary agencies and tobacco control coalitions. MAIN OUTCOME MEASURE: We used the Strength of Tobacco Control survey responses in 1999, 2002 and 2004 to calculate the mean proportion of state tobacco control partners working on recommended interventions and subsequently analysed changes in effort over time. RESULTS: The proportion of state tobacco control partners working to promote clean indoor air legislation remained at more than 70% in all three years. The proportion working to increase taxes on tobacco rose significantly between 1999 and 2002 (from 54% to 70%), and those working to reduce patient costs for tobacco cessation treatments never exceeded 31% in any year. Use of mass media targeting youths decreased significantly in all years (from 40% to 32% to 26%), and the proportion of state tobacco control partners participating in a quitline has increased steadily and significantly in all years (from 24% to 36% to 41%). The level of effort in each area varied widely between states and over time. CONCLUSIONS: State tobacco control partners are implementing evidence based interventions, but more focus is needed on the tobacco cessation and mass media campaign components of comprehensive tobacco control programmes.

Are smokers only using cigarettes? Exploring current polytobacco use among an adult population.

BACKGROUND: The primary focus of tobacco prevention and cessation interventions has been on cigarette smoking. Polytobacco use (the concurrent use of cigarettes and one or more other tobacco product[s]), may present additional health risks and make cessation more difficult. METHODS: We determined population estimates of tobacco product use and of polytobacco use for more than 50000 adults from 10 states. Logistic regression analyses were used to determine factors independently associated with polytobacco use among men only (due to low use among women). RESULTS: The overall adult prevalence was 22.4% for cigarettes and 3.4% for polytobacco use. Polytobacco use was more common among men who smoked cigarettes, with 26.0% using at least one other product, compared to 4.4% of women cigarette smokers. Polytobacco use among men was significantly associated with younger age, all races/ethnicities except Hispanic, less educational attainment, less income, and more-than-moderate alcohol use. CONCLUSIONS: Prevention and cessation efforts need to target use of other forms of tobacco besides cigarettes, especially among younger men and men who are more-than-moderate drinkers of alcohol.