U.S. adult smoking rate rises slightly

By MIKE STOBBE
AP Medical Writer
Thursday, November 19, 2009 10:05 AM CST
ATLANTA — Cigarette smoking rose slightly for the first time among Americans in almost 15 years, dashing health officials' hopes that the U.S. smoking rate had moved permanently below 20 percent.
A little under 21 percent of U.S. adults said they smoked, according to a 2008 national survey by the U.S. Centers for Disease Control and Prevention. That's up slightly from the year before, when just 19.8 percent said they were smokers. It also is the first increase in adult smoking since 1994, experts noted.

The increase was so small, it could be just a blip, so health officials and experts say smoking prevalence is flat, not rising. But they are unhappy.

"Clearly, we've hit a wall in reducing adult smoking," said Vince Willmore, spokesman for the Campaign for Tobacco-Free Kids, a Washington, D.C.- based research and advocacy organization.

There's a general perception that smoking is a fading public health danger. Feeding that perception are indoor smoking laws, cigarette taxes and Congress' recent decision to allow the government's Food and Drug Administration to regulate tobacco.

But health officials believe gains have been undermined by cuts in state tobacco control campaigns. Some advocates believe tobacco companies are overcoming increasing obstacles.

Cigarette marketing has persisted and is effectively reaching kids and minorities with messages about flavored or menthol products, said Dr. Clyde Yancy, president of the American Heart Association.

The tobacco industry also has been discounting cigarettes to offset tax increases, Willmore said.

Between 1997 and 2004, the average retail price of a pack of cigarettes — adjusted for inflation — jumped 63 percent, and adult smoking declined about 15 percent. Between 2004 and 2008, the price rose just 2 percent, while adult smoking declined by just about 1 percent, he said, citing industry sales data.

"There's a clear correlation," Willmore said.

Cigarette smoking is the leading preventable cause of death and illness in the United States, and is a cause of cancers, heart disease and other fatal conditions.

The adult smoking rate has been dropping, in starts and stops, since the mid-1960s when roughly 2 out of 5 U.S. adults smoked. Now it's 1 in 5. However, federal health goals for the year 2010 had hoped to bring the rate down to close to 1 in 10.

Adult smoking hovered at about 21 percent from 2004 to 2006, then dropped a full percentage point in 2007, said Dr. Matthew McKenna, director of the CDC's Office on Smoking and Health.

The 2007 drop gave CDC officials hope that U.S. smoking was plummeting again. "Now that appears to be a statistical aberration," McKenna said.

The new survey's results come from in-person interviews of nearly 22,000 U.S. adults.

The study was released Thursday, published in the CDC publication, Morbidity and Mortality Weekly Report.
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CDC-Commissioned Report Says More Evidence Is Needed to Decide Whether Smoking Bans Are Good

October 16, 2009
Jacob Sullum

Just kidding. The report, which an Institute of Medicine committee issued yesterday, concludes, per the press release, that "smoking bans reduce the risk of heart attacks associated with secondhand smoke." The committee's chairwoman, Lynn Goldman, a professor of environmental health sciences at Johns Hopkins, sums up the report's findings this way:

It's clear that smoking bans work. Bans reduce the risks of heart attack in nonsmokers as well as smokers. Further research could explain in greater detail how great the effect is for each of these groups and how secondhand smoke produces its toxic effects. However, there is no question that smoking bans have a positive health effect.

As with the 2006 surgeon general's report on secondhand smoke, the press release goes farther than the report itself, which in turn draws conclusions that are not justified by the evidence it presents. The judgment about the effectiveness of smoking bans is based on 11 studies that looked at heart attack rates in eight jurisdictions after smoking bans took effect. "None was designed to test the hypothesis that secondhand-smoke exposure causes cardiovascular disease or acute coronary events," the report concedes. Furthermore, "only two of the studies distinguished between reductions in heart attacks suffered by smokers versus nonsmokers." Even so, the report concludes that smoking bans reduce heart attacks, at least partly by reducing nonsmokers' exposure to secondhand smoke.

To accomplish that impressive feat, the report underplays two major problems with attempts to measure the impact of smoking bans through observational studies. First, in recent decades there has been a general decline in heart attack rates, driven mainly by improvements in preventive medication and treatment. A decrease in heart attacks seen after a smoking ban takes effect could be part of this pre-existing trend. One way to address that possibility is to use comparison jurisdictions that do not have smoking bans but are otherwise similar, a precaution most of these studies did not take. 

Second, random variation means that some jurisdictions with smoking bans are bound to see significant drops in heart attacks purely by chance, while others will see no real change or significant increases. The largest study of the issue, which used nationwide data instead of looking at cherry-picked communities, found that smoking bans "are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases." Furthermore, "An analysis simulating smaller studies using subsamples reveals that large short-term increases in myocardial infarction incidence following a workplace ban are as common as the large decreases reported in the published literature."

That study, published by the National Bureau of Economic Research in March, suggests that publication bias can explain what the IOM panel describes as the "consistent" results of the studies it considered (meaning that they all found drops in heart attacks, although the magnitude of these decreases varied widely, from 6 percent in Italy to an astonishing 47 percent in Pueblo, Colorado). If a researcher runs the numbers for a particular jurisdiction and finds no impact from a smoking ban, he is not likely to write up that result, especially if he supports smoking bans as part of the effort to reduce tobacco-related disease. Even if he does submit an article describing his findings, it is not likely to be published, not just because of an anti-smoking bias but because negative results are perceived as boring. 

The NBER paper was mysteriously excluded from the IOM report, even though the authors say they bent over backward to compensate for publication bias by looking for relevant data that did not appear in medical journals. They also ignored analyses that found no declines in heart attacks following smoking bans in California, Florida, New York, Oregon, England, Wales, and Scotland. The omission of the Scottish data is especially striking because they contradict one of the 11 studies included in the IOM report, showing that a decrease in heart attacks during the first year was exaggerated and in any case disappeared the following year.

The report is slippery in addressing the biological plausibility of attributing immediate, dramatic reductions in heart attacks to smoking bans.  For example, the study of Helena, Montana (the one that started it all) found a 40 percent drop in heart attacks within the first six months of the city's smoking ban. As I've said before, it is simply not possible that the smoking ban caused that big a drop so quickly, unless the CDC and the American Heart Association are wildly off in their estimates of the heart disease caused by smoking and secondhand smoke, respectively. If smoking and secondhand smoke together account for about 25 percent of all heart disease deaths, a smoking ban could not cause a 40 percent reduction in heart attacks even if everyone in the city immediately stopped smoking. 

For some reason (a convenient error, I assume), the IOM report describes the utterly implausible 40 percent reduction in Helena as a 16 percent reduction, as part of an attempt to show that bigger declines were found in the studies with longer follow-up periods. (Most of the studies had follow-up periods of a year or less.) What the comparison of studies actually shows is that the most dramatic results were found in the studies with the tiniest samples (e.g., Helena , Pueblo, and Monroe County, Indiana), where random variation would be expected to have the biggest impact.

Although the authors work hard to make patently ridiculous claims seem plausible, they never settle on an explanation of how, exactly, these reductions in heart attacks are accomplished. When people stop smoking, their heart attack risk declines gradually over several years, and it's hard to see why the heart attack risk in people exposed to secondhand smoke would fall any faster. Given a lack of information about individual exposure patterns in studies of secondhand smoke and heart attacks, the report says, "the committee could not determine whether acute exposures were triggering acute coronary events, chronic exposures were causing chronic damage that eventually resulted in acute coronary events, or a combination of chronic damage and an acute-exposure trigger led to the increased risk of acute coronary events." But if the impact of a smoking ban is seen within six months (or two, as in one of the Italian studies), the only possible explanation, since heart disease takes years to develop, is that the ban prevents heart attacks in people who would otherwise keel over from acute exposure.

Who are these people? The report acknowledges that people with severe heart disease are most vulnerable, but it also intimates that perfectly healthy people might drop dead from a heart attack after spending a half-hour in a smoky bar. "The risk of acute coronary events is likely to be increased if a person has preexisting heart disease," it says, implying that even people without pre-existing heart disease take their lives in their hands by grabbing a drink in a bar where smoking is allowed. At the same time, the report concedes "there is no direct evidence [as opposed to suggestive laboratory results] that a relatively brief exposure to secondhand smoke can precipitate an acute coronary event." No kidding. Not to put too fine a point on it, but where are the bodies? The sort of immediate effect they are talking about should be readily apparent. Yet the committee cites no reports of people, whether sick or healthy, having heart attacks after brief exposures to secondhand smoke.

Assuming that smoking bans do reduce heart attacks, that result could be due to declines in smoking, declines in secondhand smoke exposure, or some combination of the two. The report settles on that last explanation, even though only two of the 11 studies bothered to distinguish between smokers and nonsmokers. The authors do concede that, given the paucity of the data, "it is not possible to determine the magnitude of the effect that is attributable to changes in nonsmokers compared with smokers."

Likewise, because of the limitations of the studies and the wide variations between them, the report says, "the committee has little confidence in the magnitude of the effects and, therefore, thought it inappropriate to attempt to estimate an effect size." Michael Siegel, a Boston University public health professor who was one of the report's reviewers, notes that "if you can't even estimate the magnitude of an effect—if you have no confidence in even providing an estimate—you are hardly in a position to conclude that there is a significant effect of smoking bans on heart attacks, an effect which exceeds random variation combined with the known secular decline in heart attack rates." Siegel faults the authors for a "sensationalistic" approach, especially as reflected in their attempt to "scare people into thinking that they could drop dead from a heart attack from a brief tobacco smoke exposure."

The main goal of this project, which was commissioned by the CDC, seems  to have been producing a document that could be waved around at city council meetings and state legislative hearings. If so, the authors have succeeded. "The evidence is clear,'' says CDC Director Thomas Frieden. "Smoke-free laws...prevent heart attacks in nonsmokers." Although the IOM panel said it would be reckless to estimate the impact of smoking bans on heart attacks, Frieden (an avid smoking ban advocate when he was New York City's health commissioner) is willing to go there. "These findings suggest that tens of thousands of heart attacks could be prevented each year," he claims. "States and communities that do not have comprehensive smoke-free laws could have significant cardiovascular health benefits by doing so." Neal Benowitz, a member of the IOM panel, insists that "smoking bans need to be put in place as quickly as possible," because "the longer we wait, the more disease we are accepting."

My own view is that the scientific findings are not relevant to the policy question, which is a matter of property rights. Regardless of the hazards posed by secondhand smoke, business owners should be free to set the smoking rules on their own property, which no one is forced to enter. At the same time, I recognize that reports like this provide ammunition to advocates of smoking bans, so I am more inclined to be skeptical of claims about the impact of such laws than someone who has no problem with them would be. (I do agree that smoking bans, to the extent that they encourage smokers to quit, can be expected to gradually reduce heart disease over the long term, as opposed to dramatically reducing it immediately.) Yet the people conducting these reviews are not neutral observers either; as reflected by Benowitz's comments, they are committed partisans in the push to extend strict smoking bans across the country.
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Smoking bans cut down on heart attacks for everyone, study finds
October 16, 2009
By Thomas H. Maugh II
http://www.denverpost.com/ci_13572815


Analysis Reveals that Institute of Medicine Report Failed to Include Data that Found No Effect of Smoking Bans on Acute Coronary Events in 3 Countries
http://tobaccoanalysis.blogspot.com/2009/10/analysis-reveals-that-institute-of.html

Institute of Medicine Report's Conclusions on Smoking Ban Effects are Defied By Its Own Assertions; Study Conclusions, Press Release Severely Biased
http://tobaccoanalysis.blogspot.com/2009/10/institute-of-medicine-reports.html

Conclusion of IOM Report on Smoking Bans and Heart Attacks is Invalid on its Face: An Epidemiologic Analysis of the Report's Major Conclusion
http://tobaccoanalysis.blogspot.com/2009/10/conclusion-of-iom-report-on-smoking.html

Decades-Long U.S. Decrease in Smoking Rates Levels Off
November 9, 2007
By Marc Kaufman, Washington Post Staff Writer
The decades-long decline in smoking by Americans has stalled for three years, the first time smoking rates have leveled off for that long since the federal government began collecting statistics more than 40 years ago.
After more than a decade of steep decline, moreover, smoking rates for high school students also have hit a plateau in the past few years and even increased a bit. This comes amid controversy over the targeting of young women by the R.J. Reynolds Tobacco Co. with its Camel No. 9 cigarette -- which is packaged in "hot-pink fuchsia" and is advertised as "light and luscious."
Together, the data released by the Centers for Disease Control and Prevention yesterday present a worrisome picture of smoking patterns, experts said, especially because the trend had been downward for so long.
"Anytime we are not seeing a decline, it's a cause of real concern to us," said Corinne Husten, head of the epidemiology branch of the CDC's Office on Smoking and Health. "Smoking is the biggest cause of preventable disease we have, and we need to bring down the rates as quickly as we possibly can."
According to the CDC report, about 20.8 percent of American adults are smokers -- with 80 percent of them (36.3 million people) smoking every day and the rest smoking on some days. Adult smoking rates declined more than 15 percent from 1997 to 2004 but have been stubbornly unchanged since.
Husten pointed to several probable reasons for the unwelcome news. Cigarette companies have been spending billions of dollars to offset tax increases and to discount their products, and funding has been cut sharply for several very successful state anti-smoking campaigns, she said.
Some anti-tobacco advocates said the Bush administration has not made tobacco control a priority and has not highlighted or promoted the issue. In part, they said, the stalled smoking rates are a result.
William V. Corr, executive director of the Campaign for Tobacco-Free Kids, said the administration has been "AWOL regarding tobacco control -- doing little or nothing." He said it is "inexcusable that elected leaders have not done more, given the overwhelming scientific evidence of what works to reduce tobacco use among both children and adults."
The relatively unchanged price of cigarettes since 2002 is considered important, because more people stop smoking because of cost than for any other single reason. That is especially true of younger smokers. While some states have increased tobacco taxes, the federal government has not raised its rate for more than a decade, and President Bush has strongly opposed a congressional proposal to increase the tax to expand the State Children's Health Insurance Program.
The administration has also been skeptical of a bill that would give the Food and Drug Administration authority to regulate tobacco. FDA Commissioner Andrew von Eschenbach told Congress in October that the agency does not have the budget to take on the regulation of tobacco and has reservations about regulating a product known to be harmful.
Von Eschenbach said in a statement that "the bill could undermine the public health role of FDA." Two major reports this year, one by the Institute of Medicine of the National Academy of Sciences and another by the President's Cancer Panel, called for FDA regulation of tobacco.
The administration has also declined to send the World Health Organization's Framework Convention on Tobacco Control to the Senate for ratification. The treaty, signed by the United States in 2004, would require toughening of U.S. anti-smoking efforts. So far, more than 150 of the 168 nations that signed the treaty have ratified it, but the State Department has consistently said it is still studying the document.
The price of cigarettes increased after tobacco companies agreed in 1997 to pay billions to the states to settle a suit seeking compensation for Medicaid costs of smoking-related diseases. But statistics collected by the Federal Trade Commission show that tobacco companies then dramatically increased their advertising and marketing budgets, from $6.7 billion in 1998 to $15.1 billion in 2003 and $13 billion in 2005. From 2003 through 2005, price discounting accounted for more than 70 percent of the promotion expenditures.
David Sutton, a spokesman for Philip Morris USA, which supplies about half of the U.S. cigarette market, said the company agrees with the public health community that the "best way to reduce the health effects of cigarettes is to quit or not start in the first place." But he said that in the highly competitive domestic market for adult smokers, companies had to offer discounts to retailers to keep old customers and attract new ones.
Since 2000, there also has been a drop of 20 percent in state spending to keep children, in particular, from taking up smoking and to encourage and help smokers to stop, the CDC reported. That decline has been especially stark in several states that had had aggressive and effective programs, including Massachusetts, Florida and Minnesota.
Some of the spending decline has resulted from cuts in state appropriations, and some from a decrease in the amount of money available from the tobacco settlement. Under that landmark agreement, the amount paid by the tobacco companies declines if cigarette consumption falls off, or if more than 1 percent of the cigarette market is captured by small or foreign companies not covered by the settlement -- a threshold that was reached some time ago.
The rate of cigarette smoking began to fall steadily after the 1964 surgeon general's report on tobacco's health risks, although the decline leveled off for two years in the mid-1990s.
The new data, in the CDC's Morbidity and Mortality Weekly Report released yesterday, did not include specific information about youth smoking, but other reports have shown a similar leveling off among young people in the past several years.
The controversy over R.J. Reynolds's Camel No. 9 -- which came on the market in February -- has reached Congress, where Rep. Lois Capps (D-Calif.) has denounced the company's advertising for targeting women, especially young women. She and 40 other members of Congress twice wrote to 11 women's magazines asking them to stop running the ads, which generally feature slinky clothes in black and pink. One ad says the Camel No. 9s are now "available in stiletto" -- longer, thinner cigarettes. Capps has also accused the company of flavoring the cigarettes to taste like a chai latte.
The CDC report showed a small drop-off in adult smoking in the first three months of 2007, but Husten said that it is not considered significant and that rates often come in low at the beginning of a year.
Among the CDC findings was that in 2006, almost 37 percent of people with smoking-related chronic diseases were still smoking, a considerably higher percentage than the general population.
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Dear Editor,
 
Marc Kaufman's Nov. 9th article, "Decades-Long U.S. Decrease in Smoking Rates Levels Off" makes an interesting claim.
 
It claims that "The relatively unchanged price of cigarettes since 2002 is considered important" in this leveling.  The reason that claim is so interesting is that just the day before, Nov. 8th, William Corr, the executive director for the Campaign for Tobacco-Free Kids, said that “Since Jan. 1, 2002, 44 states, Puerto Rico and the District of Columbia have increased their cigarette-tax rates more than 75 times,”
 
We've known for a long time that cigarette smoke was magical, able to travel against strong winds from nonsmoking into smoking sections, able to defeat filtration and ventilation systems capable of handling 18 wheel trucks and bubonic plague units in hospitals, and showing deadliness at levels far below any picogram level instrumentation devised by 21st century human ingenuity.  But this is the first evidence we've seen that cigarette prices are also magical!  No matter how much they're raised, they somehow manage to stay the same!
 
If only we could transfer such magic to the rest of the economy!
 
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Reference: Corr quote from Winston-Salem Journal, Nov. 8th: Read   "Reynolds faces..." by Richard Craver
 
Michael J. McFadden
Author of "Dissecting Antismokers' Brains"
Mid-Atlantic Director, Citizens Freedom Alliance, Inc.
Director, Pennsylvania Smokers' Action Network (PASAN)
web page: http://pasan.thetruthisalie.com/
mailto: Cantiloper@aol.com