Building the evidence base for effective tobacco control policies: the International Tobacco Control Policy Evaluation Project (the ITC Project).

The Framework Convention on Tobacco Control (FCTC) is a seminal event in tobacco control and in global health. Scientific evidence guided the creation of the FCTC, and as the treaty moves into its implementation phase, scientific evidence can be used to guide the formulation of evidence-based tobacco control policies. The International Tobacco Control Policy Evaluation Project (ITC Project) is a transdisciplinary international collaboration of tobacco control researchers who have created research studies to evaluate and understand the psychosocial and behavioural impact of FCTC policies as they are implemented in participating ITC countries, which together are inhabited by over 45% of the world's smokers. This introduction to the ITC Project supplement of Tobacco Control presents a brief outline of the ITC Project, including a summary of key findings to date. The overall conceptual model and methodology of the ITC Project--involving representative national cohort surveys created from a common conceptual model, with common methods and measures across countries--may hold promise as a useful paradigm in efforts to evaluate and understand the impact of population-based interventions in other important domains of health, such as obesity.

Smoking-attributable cancer mortality in 1991: is lung cancer now the leading cause of death among smokers in the United States?

Findings from the new American Cancer Society prospective study of 1.2 million men and women indicate that mortality risks among smokers have increased substantially for most of the eight major cancer sites causally associated with cigarette smoking. Lung cancer risk for male smokers doubled, while the risk for females increased more than fourfold. On the basis of the new American Cancer Society relative risks, we project that cigarette smoking alone will contribute to slightly more than 157,000 of the 514,000 total cancer deaths expected to occur in the United States in 1991. Overall, smoking directly contributes to 21.5% of all cancer deaths in women but 45% of all cancer deaths in men. It would also appear that lung cancer has now displaced coronary heart disease as the single leading cause of excess mortality among smokers in the United States.

Prevalence of cigarette smoking in the United States: estimates from the 1985 current population survey.

In September 1985, the Census Bureau collected health information on 114,342 individuals as part of its Current Population Survey (CPS). A special supplement that included questions on smoking practices was sponsored by the Office on Smoking and Health. The CPS, with its large sample size, provides a unique opportunity to examine region, division, and state estimates of smoking prevalence. The overall prevalence rate for males in the 1985 CPS was estimated at 31.3%, compared with 25.0% for females. For males, smoking rates were highest in the South (34.5%) and lowest in the West (28.0%). For females, smoking rates were highest in the North Central region (26.3%) and lowest in the West (22.7%). Among males, blacks reported higher smoking rates (37.2%) than whites (30.7%) or Hispanics (30.9%). In contrast, white females (25.8%) and black females (26.0%) reported virtually identical smoking rates, while Hispanic females reported a considerably lower rate (16.5%). White-collar workers (both males and females) also reported substantially lower smoking rates than service or blue-collar workers. For both males and females, peak smoking prevalence occurred in the 40-49-year age group (males = 38.1%, females = 30.6%).

Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking.

BACKGROUND: The American Cancer Society, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS), provide the second annual report to the nation on progress in cancer prevention and control, with a special section on lung cancer and tobacco smoking. METHODS: Age-adjusted rates (using the 1970 U.S. standard population) were based on cancer incidence data from NCI and underlying cause of death data compiled by NCHS. The prevalence of tobacco use was derived from CDC surveys. Reported P values are two-sided. RESULTS: From 1990 through 1996, cancer incidence (-0.9% per year; P = .16) and cancer death (-0.6% per year; P = .001) rates for all sites combined decreased. Among the 10 leading cancer incidence sites, statistically significant decreases in incidence rates were seen in males for leukemia and cancers of the lung, colon/rectum, urinary bladder, and oral cavity and pharynx. Except for lung cancer, incidence rates for these cancers also declined in females. Among the 10 leading cancer mortality sites, statistically significant decreases in cancer death rates were seen for cancers of the male lung, female breast, the prostate, male pancreas, and male brain and, for both sexes, cancers of the colon/rectum and stomach. Age-specific analyses of lung cancer revealed that rates in males first declined at younger ages and then for each older age group successively over time; rates in females appeared to be in the early stages of following the same pattern, with rates decreasing for women aged 40-59 years. CONCLUSIONS: The declines in cancer incidence and death rates, particularly for lung cancer, are encouraging. However, unless recent upward trends in smoking among adolescents can be reversed, the lung cancer rates that are currently declining in the United States may rise again.

Cigarette smoking among U.S. adults by state and region: estimates from the current population survey.

BACKGROUND: Cigarette smoking is responsible for at least one third of all cancer deaths annually in the United States. Few sources exist in the peer-reviewed literature documenting state and regional differences in smoking behavior, despite the fact that cancer prevention and control efforts are increasingly being implemented below the national level. PURPOSE: Our goals were to determine smoking prevalence rates among men and women, by region, and for each of the 50 states and the District of Columbia from census survey data collected in 1992 and 1993 and to compare these rates with rates determined in 1985. METHODS: Every month, the U.S. Bureau of the Census collects labor force statistics on more than 100000 individuals on its Current Population Survey (CPS). For the September 1992, January 1993, and May 1993 CPS, the National Cancer Institute sponsored a 40-item Tobacco Use Supplement. The definition of a current smoker changed slightly between 1985 and 1992-1993. For the 1985 CPS, individuals were considered current smokers if they had smoked 100 cigarettes in their lifetime and were smoking at the time of interview; for the 1992-1993 CPS, current smokers included anyone who had smoked 100 cigarettes and was currently smoking every day or just on some days. We calculated current smoking rates (every day and some days combined) based on more than a quarter million adults (n = 266988) interviewed in 1992-1993. RESULTS: Substantial geographic variation exists in rates of current cigarette use among adults within the United States. In general, adults in the southern United States have higher rates of smoking and adults in the western states have lower rates of smoking and adults in the rest of the country, although differences in smoking behavior between men and women and among various racial and ethnic populations strongly influence these patterns. Only two states, Kentucky and West Virginia, exhibited adult smoking rates (men and women combined) of 30% or higher in 1992-1993; in contrast, in 1985, such rates were reported from 20 states. The only states in which the prevalence was below 20% in 1992-1993 were Utah (17.1%) and California (19.5%). Rates approaching 20% were reported from New Jersey (20.7%), Massachusetts (21.5%), and Nebraska, New York, and Hawaii (22.0% each) in 1992-1993. Rhode Island experienced the greatest relative decline in smoking prevalence from 1985 to 1992-1993, with a calculated relative change of -30.7% (based on a change in rate from 33.5% to 23.2%), followed by Delaware (-25.9%) the District of Columbia and New Jersey (-23.9% each), Connecticut (-23.2%), California (-22.9%), Alaska (-22.8%), Georgia (-22.6%), Massachusetts (-22.1%), and New York (-22.0%). CONCLUSIONS: Smoking rates are not uniform in the United States but vary considerably from state to state, even within the same region of the country. The CPS is the only mechanism currently capable of simultaneously monitoring smoking trends nationally, regionally, and on a state-by-state basis.

Tobacco use and its contribution to early cancer mortality with a special emphasis on cigarette smoking.

This paper provides an overview of the relationship between tobacco use and early cancer mortality. It presents a retrospective examination of trends in smoking behavior and how these trends affected the national lung cancer mortality pattern during this century. Information on smoking prevalence is presented for black and white men and women for each 5-year birth cohort between 1885 and 1969. The author argues that the lung cancer mortality pattern observed in the United States since 1950 is entirely compatible with changes in smoking behavior among the various birth cohorts examined. The paper also reviews our current scientific knowledge about the etiological relationship between cigarette smoking and site-specific cancer mortality, with particular emphasis on lung cancer. Data on other forms of tobacco use and cancer mortality risks are included as are data on environmental tobacco smoke exposures and nonsmokers' lung cancer risk. Data are presented to demonstrate that cigarette use alone will be responsible for nearly one-third of the U.S. cancer deaths expected in the United States in 1995, or 168,000 premature cancer deaths. Among males, 38% of all cancer deaths are cigarette related, while among women 23% of all cancer deaths are due to cigarettes. These totals, however, include neither the cancer deaths that could reasonably be attributed to pipe, cigar, and smokeless tobacco use among males nor the estimated 3000 to 6000 environmental tobacco smoke-related lung cancer deaths that occur annually in nonsmokers. It is concluded that tobacco use, particularly the practice of cigarette smoking, is the single greatest cause of excess cancer mortality in U.S. populations.

State-specific trends in smoke-free workplace policy coverage: the current population survey tobacco use supplement, 1993 to 1999.

We examined trends in smoke-free workplace policies among all indoor workers in the United States using the National Cancer Institute's Tobacco Use Supplement to the Census Bureau's Current Population Survey (total n = 270,063). Smoke-free was defined as smoking not permitted in public or common areas or in work areas of a worksite. Nationally, we found that nearly 70% of the US workforce worked under a smoke-free policy in 1999. At the state level, a greater than 30-percentage-point differential existed in the proportion of workers with such policies. Although significant progress has been made to reduce worker exposure to environmental tobacco smoke on the job, we predict further progress may be difficult unless comprehensive regulations to protect all workers are implemented at the national, state, or local level.

Toward the 1990 objectives for smoking: measuring the progress with 1985 NHIS data.

The Health Promotion and Disease Prevention component of the 1985 National Health Interview Survey allowed us to measure the progress made toward achieving the 1990 objectives for the nation concerning cigarette smoking. The first smoking-related objective, namely, to reduce to below 25 percent the proportion of the U.S. population who smoke, has not been achieved. Today 31 percent of the population smoke. More than 85 percent are aware of the special risk of developing and worsening chronic obstructive lung disease, chronic bronchitis, and emphysema among smokers. More than 90 percent are aware that smoking is a major cause of lung cancer; however, awareness of the risk of laryngeal, esophageal, bladder, and other kinds of cancer from smoking is not so great. More than 85 percent are aware that cigarette smoking is one of the major risk factors for heart disease. In general, then, the 1990 objectives concerning the population's knowledge of the health consequences of cigarette smoking have been met.

Geographic and gender variations in total tobacco use.

This study is the first to provide complete information on prevalence rates by gender and geographic variation for each type of tobacco product used in the United States. Results indicate that, in nearly half of all states, total tobacco use in men exceeded 40% and, in four states, exceeded 50%. In women, only Nevada, Kentucky, and Michigan reported prevalence exceeding 33%. Results also indicate, however, that concurrent use of multiple tobacco forms is relatively rare. Substantial regional variation in male total tobacco use was evident, with southern males exhibiting the highest prevalence rate (44.6%). As a result, this region represents a target group in special need of comprehensive and effective tobacco use interventions.

Smoking behavior, workplace policies, and public opinion regarding smoking restrictions in Maryland.

The Maryland Occupational Safety and Health (MOSH) advisory board recently proposed a smoking ban in most Maryland workplaces, including bars and restaurants, unless smoking is restricted to a separately ventilated area where nonsmoking workers cannot be required to enter. Results from the 1992-1993 Current Population Survey strongly suggest that there is broad support among Maryland residents for such restrictions and that the MOSH rules would merely extend an already widespread practice in the state. Efforts by the tobacco industry to gain an injunction against the proposed MOSH regulations would not appear to be supported by a clear majority of Maryland residents.

Prevalence of cigar use in 22 North American communities: 1989 and 1993.

OBJECTIVES: This study examined the prevalence rate of and characteristics associated with cigar use. METHODS: Data were derived from population-based telephone surveys of adults conducted in 22 North American communities in 1989 and 1993 as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. RESULTS: Averaged across the 22 communities, the prevalence rate of regular cigar use increased 133% from 1989 to 1993. Regular cigar use increased in every gender, age, race, income, education, and smoking status category. CONCLUSION: These results confirm other data indicating that cigar use is increasing.

Public health approaches to tobacco use prevention and cessation in the U.S.

Tobacco has a long history of use in the U.S., and its serious health effects have been well-documented during the past half century, U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 25 years, during which time there has been a 34 percent reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one-fourth of the population continuing to smoke. Many organizations are involved in tobacco use control activities, the most broadly focused of which is the National Cancer Institute (NCI). As an example of the type of program needed to address the problem of tobacco use on a national scale, the NCI's public health research plan and activities are described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco use control in the U.S. are suggested.

Tobacco use trends and control strategies in the United States.

The future of U.S. smoking control efforts and for all countries lies in strengthening existing cooperative relationships among smoking control advocates (Coalitions on Smoking or Health) and facilitating linkages among others who have not previously worked together. In this way with numerous Governmental and Non-Governmental organizations converging on the single issue of reducing prevalence, a multiplicative effect is possible. With it comes the realization of a smoke-free U.S. society by the year 2000.

Use of smokeless tobacco in the United States: recent estimates from the current population survey.

Chewing tobacco, snuff, and total smokeless tobacco use from the 1985 Current Population Survey (CPS) are reported. The CPS is the only survey capable of providing national, regional, and individual state tobacco use estimates for all 50 states and the District of Columbia. The prevalence of smokeless tobacco use varies considerably among and within regions of the country, by division and state. Smokeless tobacco use is highest in the South and lowest in the Northeast. Individual states with the highest smokeless tobacco use among males are West Virginia (23.1%), Mississippi (16.5%), Wyoming (15.8%), Arkansas (14.7%), and Kentucky (13.6%). In all regions of the country, use of smokeless tobacco among women is considerably less than men. Nationally, male use of such products was 5.5%; less than 1% of women use them. Snuff consumption is predominantly a behavior characteristic of white males; less than 1% of black or Hispanic males consume this product. Higher percentages of blue-collar and service workers use it compared with white-collar workers. Snuff and chewing tobacco use among teenage boys in the United States increased dramatically between 1970 and 1985, a time when their use of cigarettes was declining. The significance of individual state level estimates is discussed.

The United States National Cancer Institute and the science of tobacco control research.

U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 3 decades, during which there has been a 34% reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one fourth of the population continuing to smoke. Many organizations are involved in tobacco-use control activities, the most broadly focused of which is that of the National Cancer Institute (NCI). The NCI's program is described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco-use control in the U.S. are suggested.

Trends in cigarette smoking among US adolescents, 1974 through 1991.

OBJECTIVES: The purpose of this study was to determine national trends in adolescent cigarette smoking prevalence. METHODS: We conducted trend analyses based on 1974 through 1991 current smoking prevalence data among persons aged 12 through 19 years from the National Household Surveys on Drug Abuse, High School Seniors Surveys, and National Health Interview Surveys. RESULTS: Overall smoking prevalence declined much more rapidly from 1974 through 1980 (1.9 percentage points annually among younger adolescents; the range among surveys of older adolescents was 0.2 to 2.0 percentage points annually) than from 1985 through 1991 (0 to 0.5 percentage points annually among all adolescents). Since 1980, smoking has generally declined at a slightly faster rate among older female adolescents than among male adolescents. Smoking among Black adolescents of all ages declined in nearly every survey population during each study period (range among surveys: 1974-1985 = 1.0 to 2.9 percentage points; 1985-1991 = 0.7 to 1.5 percentage points annually); for White adolescents, only minimal declines in smoking have occurred since 1985. CONCLUSIONS: Since 1974, major changes in adolescent smoking patterns have occurred, especially among Blacks. The overall slowing rate of decline in smoking prevalence since 1985 may indicate success of increased tobacco advertising and promotional activities targeted at adolescents or inadequate antitobacco education efforts.