Final Project Milestone One: Problem Identification and Statement : (Tobacco use and dependence in New Hampshire)

NH DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES JUNE 2014

TOBACCO PREVENTION AND CONTROL PROGRAM 1 TOBACCO DATA BRIEF

Tobacco Use in New Hampshire New Hampshire Behavioral Risk Factor Surveillance Survey (NH BRFSS) 2011 and 2012 Combined

A Note about the Data This report combines 2011 and 2012 NH BRFSS data

which represents the first two years of data collected

and analyzed using new methodology. Non-

overlapping 95% confidence intervals were used to

determine the statistical significance. All graphs

depicted show statistically significant data.

Background Deaths from tobacco use total more than the combined

deaths from car crashes, illegal drugs, suicides

murders, alcohol, and AIDS. Secondhand and

thirdhand smoke exposures are linked to thousands of

additional deaths. Finally, fires caused by unattended

cigarettes cause over 1,000 deaths per year, nationally.

Cigarette smoking costs the nation $96 billion in direct

medical costs and $97 billion in lost productivity

annually. According to the latest research published in

Tobacco Control Journal, annual estimates per

smoker: excess absenteeism costs an average of $517

per year; “presenteeism” (reduced productivity) related

to the effects of nicotine addiction, $462; smoke

breaks, $3,077; and extra health care costs (for self-

insured employers), $2,056. 1

BRFSS Data on Adult (18+) Smoking and

Other Tobacco Product (OTP) Use in New

Hampshire The BRFSS is the largest telephone survey in the

world that assesses the health status of non-

institutionalized adults in each of the 50 states, the

District of Columbia, American Samoa, Palau, Puerto

Rico, the U.S. Virgin Islands, and Guam. This data

brief compares the demographics, health behaviors,

and health status of New Hampshire tobacco users and

non-users. Combined data for 2011 and 2012 showed

that 19.7% of New Hampshire adults reported using a

tobacco product (cigarettes or other tobacco products

[OTP]).

Other tobacco products are defined as tobacco

products that deliver nicotine to the brain, but are not

combusted (burned). These include: chewing tobacco,

moist snuff and snus (rhymes with moose), which are

packaged in tins and deliver nicotine through the

mucosal (mouth) tissue when placed between the

cheek and gum.

New Hampshire Tobacco Users Demographics

Among New Hampshire adults responding to the NH

BRFSS in 2011 and 2012, the mean age of those using

cigarettes or OTPs was 41 and the mean age of the

respondents not using cigarettes or OTPs was 46. This

graph depicts the percent of respondents using and not

using tobacco products that are under age 65 and the

proportion of respondents using and not using tobacco

products that are male. Data differences represented

here are statistically significant. Not all demographics

are discussed here (income, etc.).

Figure 1. Tobacco use (combined) by age and gender,

NH BRFSS, 2011 & 2012.

Health Risk Behaviors

Good health outcomes can often be managed through

healthy behaviors. In this section, data are presented

on additional health risk behaviors that have been

cross-referenced with tobacco use. Smoking decreases

the body’s capacity to fight infection. The Centers for

Disease Control and Prevention (CDC) recommends

that all adults who smoke cigarettes receive the

influenza and pneumococcal vaccines. 2 Periodontal

(gum) disease is the results of infection and

inflammation of the gums and bone that surround and

support the teeth. Adults who smoke and/or use OTPs

are more likely to have periodontal disease than

nonsmokers/non-OTP users 3 but less likely to have

seen a dentist within the last year.

NH DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES JUNE 2014

TOBACCO PREVENTION AND CONTROL PROGRAM 2 TOBACCO DATA BRIEF

Figure 2. Tobacco use (combined) by education,

income, type of employment and insurance, NH

BRFSS, 2011 & 2012.

Figure 3. Tobacco use (combined) by health risk

behaviors, NH BRFSS, 2011 & 2012.

Figure 4. Tobacco use (combined) by health risk

behaviors, NH BRFSS, 2011 & 2012.

The CDC recommends a healthy lifestyle to prevent

obesity, which includes getting regular physical

activity and developing healthy eating habits. New

Hampshire adults who use tobacco products exercise

statistically significantly less often than adults who do

not use tobacco products. As smokers report exercise

less often, one might expect the obesity to be higher

among smokers; the difference, however is not

statistically significant.

Smoking plays a major role in the development of

HIV-associated lung cancer, and the cancer risk is 2–4

times greater in HIV-infected persons than in the

general population. 4 Another health risk behavior

tracked through the NH BRFSS is seatbelt usage. New

Hampshire has increased seatbelt usage from 62.5% in

2006 to 68.9% in 2009 with over half of non-seatbelt

wearers also reporting tobacco use. 5 There is no

statistically significant difference for drinking while

driving between those who smoke and/or using OTPs

than those who do not smoke/use OTPs.

Figure 5. Tobacco use (combined) by health risk

behaviors, NH BRFSS, 2011 & 2012.

Health Conditions

Health conditions are assessed in the NH BRFSS with

a series of questions about dental health, respiratory

health, mental health, and cancer. General health is

closely related to oral health. Based on the NH

BRFSS, there is a statistically significant difference in

tooth loss between those who use tobacco and those

who do not. Further, the proportion of non-tobacco

users having a dentist visit in the past year is

statistically significantly greater than those who do use

tobacco products.

NH DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES JUNE 2014

TOBACCO PREVENTION AND CONTROL PROGRAM 3 TOBACCO DATA BRIEF

Figure 6. Tobacco use (combined) by health risk

behaviors, NH BRFSS, 2011 & 2012.

Additional health conditions tracked through the

BRFSS are asthma, chronic obstructive pulmonary

disease, and cancer. Asthma is a chronic inflammatory

disease that causes airways to spasm and swell,

narrowing airway passages in the lungs. 6 Chronic

Obstructive Pulmonary Disease (COPD) is a group of

lung diseases that obstruct airflow–this condition

cannot be reversed. No statistically significant

difference was noted in the proportions of those

reporting having asthma or a history of cancer between

those who do and do not use tobacco products.

Smoking is a major cause of COPD. 7

Figure 7. Tobacco use (combined) by health condition,

NH BRFSS, 2011 & 2012.

Anxiety /Depression and Tobacco Use Mental illness and smoking related disease/death is

disproportionately higher than in other populations.

Approximately 44.3% of adults with a mental illness

use tobacco. 8

The 2011 NH BRFSS asks current smokers questions

pertaining to mental health status. Among current

smokers, 28.1% reported having one or more days of

poor mental health a month, and 22.9% indicated

frequent mental distress (defined as 14 or more days a

month feeling in bad mental health).

Figure 8. Tobacco use (combined) by anxiety and

depression, NH BRFSS, 2011 & 2012.

Chronic Disease A chronic disease is one lasting three months or more,

by the definition of the U.S. National Center for

Health Statistics. Extensive research has been

completed since 1964 when the first Surgeon

General’s Report on active smoking was published.

The 50 years of research has confirmed that smoking is

a major risk factor for developing chronic disease and

premature death. Chemicals in the smoke result in

plaque (waxy substance) build up on the inside of

arteries. Coronary heart disease (CHD) occurs when

plaque builds up is in coronary arteries. CHD can lead

to chest pain, heart attack, heart failure, arrhythmias,

and death. There are statistically significant

differences between those who use tobacco products

and those who do not when looking at arterial diseases.

Figure 9. Tobacco use (combined) by chronic disease,

NH BRFSS, 2011 & 2012.

NH DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES JUNE 2014

TOBACCO PREVENTION AND CONTROL PROGRAM 4 TOBACCO DATA BRIEF

Those who use tobacco products are statistically

significantly more likely to have a history of stroke,

CHD, and heart attack. Those who do not use tobacco

products are statistically significantly more likely to

have health insurance allowing for healthcare to

address high blood pressure or cholesterol with

medication. Tobacco users are statistically

significantly more likely to have been told at some

point in their health history that they have high

cholesterol but do not follow up over time to be placed

on medication.

Figure 10. Tobacco use (combined) by chronic

disease, NH BRFSS, 2011 & 2012.

We now know that smoking causes type 2 diabetes. In

fact, smokers are 30–40% more likely to develop type

2 diabetes than nonsmokers. People with diabetes who

smoke are more likely than nonsmokers to have

trouble with insulin dosing and with controlling their

disease. 9

According to the NH BRFSS, the proportion

of those with diabetes and using tobacco is 7.3% and

was not significantly different than 7.2% of those with

diabetes and not using tobacco.

Summary and Looking Ahead Since 1964 an overwhelming body of evidence has

been developed around the health consequences of

using tobacco products. The medical and economic

wellness of New Hampshire residents is compromised

by the nicotine addiction epidemic. Sound public

health policies will assist in the prevention of initiation

of tobacco use as well as the treatment of those using

tobacco who want to quit. Sound surveillance systems,

such as the BRFSS, are critical to monitor trends in

health behaviors.

The spread of the Electronic Nicotine Delivery

Systems (ENDS) market has opened up complex

discussions around clean indoor air standards, dual

use, product manufacturing standards, and causation of

relapse. The BRFSS will begin to look at behaviors

around ENDS in the coming years, and the results will

be analyzed and shared in a future data brief.

References 1 Berman, Micah, Rob Crane, Eric Seiber, and Mehmet

Munur. “Estimating the Cost of a Smoking Employee,”

Tobacco Control, June 2013, accessed 2014 Mar 18.

doi:10.1136/tobaccocontrol-2012-050888 2 “Seasonal Influenza (Flu), Centers for Disease Control and

Prevention, accessed 2014 Mar 18.

http://www.cdc.gov/flu/protect/smoking.htm 3 “Gum Disease Risk Factors,” American Academy of

Periodontology, accessed 2014 Mar 18.

http://www.perio.org/consumer/risk-factors 4 Mani, Deepthi, Missak Haigentz Jr, and David M.

Aboulafia, “Lung Cancer in HIV Infection,” Clinical Lung

Cancer. Jan 2012; 13(1): 6–13, accessed 2014 Mar 18. doi:

10.1016/j.cllc.2011.05.005 5 Smith, Andrew E., Ph.D., “2009 NH Seat Belt Observation

Study for NH Highway Safety Agency,” University of New

Hampshire Survey Center August, 2009, accessed 2014 Mar

18. http://www.nh.gov/hsafety/data/documents/seat-

belt2009.pdf 6 “Asthma,” The Free Medical Dictionary, accessed 2014

Mar 18. http://medical-

dictionary.thefreedictionary.com/asthma 7 “Diseases and Conditions: COPD,” Mayo Clinic, accessed

2014 Mar 18. http://www.mayoclinic.org/diseases-

conditions/copd/basics/definition/CON-20032017 8 Lasser, Karen, J. Wesley Boyd, Steffie Woolhandler,

David U. Himmelstein, Danny McCormick, and David H.

Bor, “Smoking and Mental Illness. A Population-Based

Prevalence Study,” The Journal of the American Medical

Association, 284: 20 (November 22/29, 2000), accessed

2014 Mar 18. doi:10.1001/jama.284.20.2606. 9 U.S. Department of Health and Human Services. “The

Health Consequences of Smoking—50 Years of Progress: A

Report of the Surgeon General,” Atlanta: U.S. Department of

Health and Human Services, Centers for Disease Control and

Prevention, National Center for Chronic Disease Prevention

and Health Promotion, Office on Smoking and Health, 2014.

NH Department of Health and Human Services

Division of Public Health Services

Tobacco Prevention and Control Program

29 Hazen Drive

Concord, NH 03301

http://www.dhhs.nh.gov 1-800-852-3345 ext. 6891