Health Effects and Epidemiology of Tobacco Use Gary A. Giovino, PhD, MS Professor and Chair Department of Health Behavior School of Public Health and Health Professions University at Buffalo, SUNY 5/7/2009

Overview of Today’s Talk  Conceptual Models  Consequences of tobacco use and exposure to tobacco smoke pollution  Patterns of use ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Conceptual Models ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Epidemiologic Model of Tobacco Control and Nicotine Addiction Tobacco Products Agent Environment Familial, Social, Cultural, Political, Economic, Historical, Media Host Vector Smoker/Chewer Tobacco Product Manufacturers; Other Users Incidental Host Involuntary Smoker Source: Orleans & Slade, 1993; Giovino 2002 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Source: Tax Burden on Tobacco, 2006, and author’s calculations ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Paradigm for Tobacco Control Price/economic Smoke-free air Anti-Tobacco Mass Media Cessation activities Prevention activities Product Regulation Liability Access Industry Marketing Individual ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Consequences of Use ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Global Burden of Tobacco Tobacco killed 100 million people worldwide in the 20th Century Leading preventable cause of death - kills up to half of people who use it Unless urgent action is taken By 2030 tobacco will kill >8 million people each year - 80% in developing countries Tobacco could kill 1 billion people during the 21st Century - unless we act now ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS 8

Slides Prepared by Gary A Giovino, PhD, MS ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Chronic Disease and Related Factors Leading Causes of Death, United States, 2000* Actual Causes of Death, United States, 2000* Source: Mokdad et al. JAMA 2004; 291:1238-1245 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Establishing Causal Inference Noncausal Association (or repeat study in a larger sample) No Statistical association established Yes No Bias excluded Noncausal Association Yes No Noncausal Association Confounding excluded or neutralized and association persists Yes Confirmatory criteria of causality (e.g., temporality, strength, consistency, dose-response relationship, biological plausibility, coherence) satisfied Noncausal Association No Yes CAUSAL INFERENCE

Slides Prepared by Gary A Giovino, PhD, MS 132,332 (30%) 147,009 (33%) Source: CDC. MMWR; November 14, 2008 Slides Prepared by Gary A Giovino, PhD, MS

Diseases Caused by Cigarette Smoking  Coronary heart disease, cerebrovascular disease, atherosclerosis, and abdominal aortic aneurysm  Cancers of the lung, larynx, mouth, esophagus, bladder, pancreas, kidney, cervix, stomach, and acute myeloid leukemia  Chronic obstructive pulmonary disease, pneumonia, premature onset of and an accelerated age-related decline in lung function, all major respiratory symptoms (e.g., coughing, phlegm, wheezing, dyspnea), poor asthma control Source: US DHHS 2004. The Health Consequences of Smoking. A Report of the Surgeon General. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Diseases Caused by Cigarette Smoking  Impaired lung growth, respiratory symptoms, and asthma-related symptoms (e.g., wheezing) in childhood and adolescence; early onset of lung function decline during late adolescence and early adulthood  Sudden infant death syndrome, reduced fertility in women, fetal growth restriction, low birth weight, premature rupture of the membranes, placenta previa, placental abruption, preterm delivery and shortened gestation Source: US DHHS 2004. The Health Consequences of Smoking. A Report of the Surgeon General. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Diseases Caused by Cigarette Smoking  Cataracts, hip fractures, low bone density  Peptic ulcer disease in persons who are Helicobacter pylori positive  Diminished health status (i.e., increased absenteeism from work, increased use of medical care services); adverse surgical outcomes related to wound healing and respiratory complications Source: US DHHS 2004. The Health Consequences of Smoking. A Report of the Surgeon General. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Disease Caused by Tobacco Use Tobacco smoke pollution (secondhand smoke, environmental tobacco smoke) is a cause of:  Lung cancer and coronary heart disease in nonsmokers - 49,400 annual deaths (11% of SAM)  Respiratory infections and symptoms in the children of parents who smoke Smokeless tobacco causes:  Oral cancer  Oral leukoplakia  Dental caries (possibly) Cigars cause:  Cancers of the mouth, larynx, and lung  Coronary heart disease  COPD ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS The Health Consequences of Involuntary Exposure to Tobacco Smoke Major Conclusions: Secondhand smoke causes premature death and disease in children and in adults who do not smoke. Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Source: USDHHS; A Report of the Surgeon General (2006) ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS The Health Consequences of Involuntary Exposure to Tobacco Smoke 3) Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke. Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control. Source: USDHHS; A Report of the Surgeon General (2006) ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS The Health Consequences of Involuntary Exposure to Tobacco Smoke 6) Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke. Source: USDHHS; A Report of the Surgeon General (2006) ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Disease Caused by Tobacco Use Tobacco smoke pollution (secondhand smoke, environmental tobacco smoke) is a cause of:  Lung cancer and coronary heart disease in nonsmokers - 49,400 annual deaths (11% of SAM)  Respiratory infections and symptoms in the children of parents who smoke Smokeless tobacco causes:  Oral cancer  Oral leukoplakia  Dental caries (possibly) Cigars cause:  Cancers of the mouth, larynx, and lung  Coronary heart disease  COPD ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

$193 Billion Economic Burden in the United States  $97 billion average annual smoking-attributable productivity losses  $96 billion average annual smoking-attributable healthcare expenditures  5.1 million years of potential life lost Source: CDC, MMWR, November 14, 2008 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Carcinogens in Tobacco Smoke Chemical Class # cmpds. Representative carcinogens PAH 14 BaP, dibenz[a,h]anthracene Nitrosamines 8 NNK, NNN Aromatic amines 12 4-aminobiphenyl 2-naphylamine Aldehydes 2 formaldehyde, acetaldehyde Phenols 2 catechol Volatile hydrocarbons 3 benzene, 1,3-butadiene Nitrohydrocarbons 3 nitromethane Other organics 8 ethylene oxide, acrylonitrile Inorganic compounds 9 cadmium, nickel, polonium-210 TOTAL 61 Source: SS Hecht, Nature Reviews Cancer 2003;3:733-744; Hoffman et al. Chemical Research in Toxicology 2001;14:767-790. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Carcinogens in Unburned Tobacco Chemical class___No. of compounds Representative carcinogens__ PAH 1 BaP Nitrosamines 6 NNK NNN Aldehydes 2 formaldehyde acetaldehyde Inorganic compounds 7 cadmium________________ TOTAL 16 Source: SS Hecht, Nature Reviews Cancer 2003;3:733-744 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Scheme Linking Nicotine Addiction and Lung Cancer via Tobacco Smoke Carcinogens Mutations and Other Changes: RAS, MYC, p53, p15, RB, FHIT and Other Critical Genes DNA Adducts Cigarette Smoking Metabolic Activation Persistence Miscoding Nicotine Carcinogens Lung Cancer Metabolic Detoxification Repair Excretion Normal DNA Apoptosis Source: SS Hecht, Journal National Cancer Institute, 91:1194-1210 (1999) ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Smoking Damages the Heart Carbon monoxide and other oxidative gases contribute to: endothelial injury & dysfunction atherosclerosis platelet aggregation thrombosis low-grade inflammation increased levels of carboxyhemoglobin Nicotine makes the heart work harder, requiring more oxygen Lack of oxygen = Ischemia ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS State-Specific Estimates of Current Smoking Prevalence (1) and Ischemic Heart Disease Mortality (2) among Persons 35 to 64 Years in the United States, 1998-2000 MS r2 =0.548 ß =3.929 P <0.001 N = 51 OK KY AR CA UT 1. Source: NCI-sponsored Tobacco Use Supplement to the Current Population Survey, 1998-99; 2. Source: NCHS mortality data from CDC Wonder System, 1999-2000. Note: Mortality data were age-adjusted to the 2000 U.S. population. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Prevalence of Current and Former Smoking Quit Less than 15 Years (1) and Lung Cancer Mortality (2) among Persons 35 Years or Older in the United States, 1998-2000 r2 =0.520 ß =4.161 P <0.001 N = 51 KY WV ME CA HI UT 1. Source: NCI-sponsored Tobacco Use Supplement to the Current Population Survey, 1998-99; 2. Source: NCHS mortality data from CDC Wonder System, 1999-2000. Note: Mortality data were age-adjusted to the 2000 U.S. population. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS State-Specific Estimates of Cigarette Smoking Prevalence (1) and Smoking-Attributable Mortality Rate(2) among U.S. Adults r2 = 0.49 ß = 10.36 P < 0.001 N = 51 KY NV WV CA MN HI UT 1. Among persons age 30 years and older; Source: NCI Tobacco Use Supplement to the Current Population Survey, 2003 estimates 2. Source: MMWR 2005;54:625-628. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Age-adjusted Lung Cancer Mortality Rates among Men > 35 years old: 1979-2002 KENTUCKY ARKANSAS UNITED STATES CALIFORNIA UTAH Age-adjusted to the 2000 US population ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Age-adjusted Lung Cancer Mortality Rates among Women > 35 years old: 1979-2002 KENTUCKY ARKANSAS CALIFORNIA UNITED STATES UTAH Age-adjusted to the 2000 US population ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS The Health Consequences of Smoking: Nicotine Addiction Major Conclusions: Cigarettes and other forms of tobacco are addictive. Nicotine is the drug in tobacco that causes addiction. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Source: USDHHS; A Report of the Surgeon General (1988) ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Patterns of Use ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Trends in Per Capita Consumption of Various Tobacco Products – United States, 1880-2004 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Estimates for 2002 and 2003 are preliminary.

Per Capita Consumption (in pounds) of Tobacco Products Other than Cigarettes -- United States, 1992-2005 Source: US Department of Agriculture; Cristine Delnevo, UMDNJ 34

Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – United States, 1900-2005 Broadcast Ad Ban 1st Surgeon General’s Report 1st Great American Smoke-out End of WW II OTC Nicotine Medications Master Settlement Agreement Fairness Doctrine Messages on TV and Radio 1st Smoking-Cancer Concern Non-Smokers Rights Movement Begins Surgeon General’s Report on ETS Federal Cigarette Tax Doubles Great Depression Source: United States Department of Agriculture; Centers for Disease Control and Prevention ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Brown & Williamson on Nicotine…. “Moreover, nicotine is addictive… We are, then, in the business of selling nicotine, an addictive drug….” Addison Yeaman; General Counsel to the Brown & Williamson Tobacco Company; July 17, 1963. Source: U.S. Food and Drug Administration, 1996. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Philip Morris on Nicotine…. “Think of the cigarette pack as a storage container for a day’s supply of nicotine…. Think of the cigarette as a dispenser for a unit dose of nicotine… Think of a puff of smoke as a vehicle of nicotine… Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.” Dr. William Dunn; Philip Morris Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS R. J. Reynolds chimes in…. “In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized, and stylized segment of the pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a potent drug with a variety of physiological effects.” Claude Teague, R.J. Reynolds Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

US Consumption of Cigars 1950 - 2002 SGR Ban advertising of little cigars Cigar Aficionado Begin advertising little cigars Source: USDA Tobacco Yearbook 2002; Tobacco Outlook 2003 TBS-254 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Current Use Among U.S. Adults of Various Tobacco Products, by Sex – National Health Interview Survey, 2000 31.3 25.7 21.3 21.0 4.5 2.5 2.5 0.1 1.0 0.2 0.1 0.2 0.1 0.1 Note: Current users report using either every day or on some days Source: National Center for Health Statistics ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in cigarette smoking* among adults aged >18 years, by sex - United States, 1955-2007 Men Women 22.3% 17.4% *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. Source: 1955 Current Population Survey; 1965-2007 National Health Interview Surveys (NCHS, CDC). ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Trends in cigarette smoking* by age - United States, 1965-2007 *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. Source: 1955 Current Population Survey; 1965-2007 National Health Interview Surveys (NCHS, CDC). ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in cigarette smoking* among adults aged >25 years, by education- United States, 1970-2006 *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. Source: 1955 Current Population Survey; 1965-2007 National Health Interview Surveys (NCHS, CDC). ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Cigarette Smoking Trends among Adults, by Race/Ethnicity, 1978-2004 Hispanic African American White Asian American Indian Between 1978 and 2000, the prevalence of current smoking fell in all racial and ethnic groups except for American Indians and Alaska Natives. Looking at these trends by race and ethnicity, this slide shows that smoking prevalence have been higher for American Indians and Alaska Natives, followed by African Americans, non-Hispanic whites, Latinos and lower among Asian Americans and Pacific Islanders. 1983- 1985 1987- 1988 1990- 1991 1992- 1993 1994- 1995 1997- 1998 1999- 2000 Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - United States, 2007 Source: National Center for Health Statistics, 2007 National Health Interview Survey ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in cigarette smoking* among adults, by poverty status - United States, 1983-2007 28.8% 20.3% *Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. Source: 1955 Current Population Survey; 1965-2007 National Health Interview Surveys (NCHS, CDC). ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS 46

Slides Prepared by Gary A Giovino, PhD, MS Percentage of Ever Smokers* Who Are Former Smokers , by Age – United States, 1965 -2006 Source: various National Health Interview Surveys, 1966 - 2006 *Ever-smoked 100 + Cigarettes Also known as the “quit ratio”, estimates since 1992 incorporates same-day smoking ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Percentage of Ever Smokers* Who Are Former Smokers, by Education, Adults Aged > 25 Years – United States, 1970 -2006 Source: various National Health Interview Surveys, 1966 - 2006 *Ever-smoked 100 + Cigarettes Also known as the “quit ratio”, estimates since 1992 incorporates same-day smoking ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Only one-third of smokers correctly report that patches are less likely to cause a heart attack than cigarettes... Cummings KM, Hyland A, Giovino GA, Hastrup J, Bauer JE, Bansal MA. Are Smokers Adequately Informed About the Health Risks of Smoking and Medicinal Nicotine? Nicotine & Tobacco Research 2004;6(Supplement 3):S333-S340. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Youth Tobacco Use Approximately 90% of adult smokers in the US smoked their first cigarette before age 18 years. Each day in the United States approximately 4,000 12-17 year old youths try their first cigarette and another 1,140 become daily cigarette smokers ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Current Use Among Middle and High School Students by Type of Tobacco Product – National Youth Tobacco Survey, 2004 28.0 22.3 12.8 11.7 8.1 6.0 5.2 2.9 2.6 3.1 2.3 2.6 2.3 1.5 Note: Used tobacco on > 1 of the 30 days preceding the survey Source: American Legacy Foundation, National Youth Tobacco Survey ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Cigarette Smoking Anytime in the Past 30 days by Grade in School – United States, 1975-2008 12th Grade 10th Grade 20.4% in 2008 8th Grade 12.3% in 2008 6.8% in 2008 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in cigarette smoking among adults and high school seniors -- United States, 1974-2007 *Adult data are from the National Health Interview Surveys., ages > 18 year olds. Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. High School Senior data are on daily smoking. Source: University of Michigan, Institute for Social Research, Monitoring the Future ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Gender – United States, 1975-2008 Female Male Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Race – United States, 1977-2008 White Hispanic Black Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups, data for the current year and the previous year are combined ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Smokeless Tobacco Use Anytime in the Past 30 days by Grade in School – United States, 1991-2008 10th Grade 12th Grade 6.5% in 2008 5.0% in 2008 8th Grade 3.5% in 2008 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Smokeless Tobacco Use Anytime in the Past 30 Days Among High School Seniors by Sex – United States, 1992-2008 Males 11.8% in 2008 Females 1.0% in 2008 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Trends in Smokeless Tobacco Use Anytime in the Past 30 Days Among High School Seniors by Population Density – United States, 1992-2008 Non-MSA 11.8% in 2008 Other MSA 6.2% in 2008 Large MSA 2.6% in 2008 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Percentage of High School Students Who Currently Used Smokeless Tobacco,* by Sex** and Race/Ethnicity,*** 2007 Nationwide in 2007, 7.9% of high school students had used smokeless tobacco (e.g., chewing tobacco, snuff, or dip) on at least 1 day during the 30 days before the survey. (i.e., current smokeless tobacco use). Overall, the prevalence of current smokeless tobacco use was higher among male than female students, higher among white than black and Hispanic students, and higher among Hispanic than black students. * Used chewing tobacco, snuff, or dip on at least 1 day during the 30 days before the survey. ** M > F *** W > H > B National Youth Risk Behavior Survey, 2007 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Slides Prepared by Gary A Giovino, PhD, MS Percentage of High School Students Who Currently Smoked Cigars,* by Sex** and Race/Ethnicity,*** 2007 Nationwide in 2007, 13.6% of high school students had smoked cigars, cigarillos, or little cigars on at least 1 day during the 30 days before the survey. (i.e., current cigar use). Overall, the prevalence of current cigar use was higher among male than female students, higher among white than black and Hispanic students, and higher among Hispanic than Black students. * Used chewing tobacco, snuff, or dip on at least 1 day during the 30 days before the survey. ** M > F *** W > H > B National Youth Risk Behavior Survey, 2007 ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS

Past Month Cigarette Use among Persons Aged 12 or Older, by Age: 2006 Percent Using in Past Month Age in Years Source: National Survey on Drug Use and Health, SAMHSA ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS