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High mortality in Central Southern states most likely due to smoking

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Laws and policies in the Central South do not strongly discourage smoking. A new study, "Geographic Divergence in Mortality in the United States," published online December 5, 2013 in the journal Population and Development Review, by Andrew Fenelon of Brown University suggests that smoking accounts for high mortality in the Central South of the United States.

US mortality data from vital statistics on cause of death for the period 1965-2004 show that by 2004, the gap in mortality attributable to smoking between the Central Southern states and other states was exceptionally large: Among men, smoking explained as much as 75 percent of the difference, says a December 26, 2013 news release, "New study: High mortality in Central Southern states most likely due to smoking."

The United States trails other developed countries in adult mortality, a process that has become more pronounced over the past several decades. However, comparisons are complicated by substantial geographic variations in mortality within the United States, says the study's abstract.

The second half of the twentieth century was characterized by a substantial divergence in adult mortality between the South and the rest of the United States

The article examines trends in US geographic variation in mortality between 1965 and 2004, in particular the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. Smoking is likely the reason for the higher mortality rates.

Relatively high smoking-attributable mortality in the South explains 50–100 percent of the divergence for men between 1965 and 1985 and up to 50 percent for women between 1985 and 2004, according to the study's abstract. There is also a geographic correspondence between the contribution of smoking and other factors, suggesting that smoking may be one piece of a more complex health-related puzzle.

The new study reveals that the high mortality in Central Southern states most likely due to smoking, since there's a geographic divergence in mortality in the United States

Between 1965 and 2004, the distribution of states with the highest mortality changed dramatically. In 1965, the states with the highest mortality (Rhode Island, Alaska, Delaware, Pennsylvania, and New Hampshire) were spread across geographic regions, reports the December 26, 2013 news release, "New study: High mortality in Central Southern states most likely due to smoking."

By 2004, however, the states with the highest mortality were geographically contiguous, and located in the south. The Central South (Alabama, Kentucky, Mississippi, and Tennessee) had the highest mortality rates in the United States. A new study by Andrew Fenelon of Brown University explores the possibility that smoking behaviors account for this situation.

Fenelon used US mortality data from vital statistics on cause of death for the period 1965-2004 and, for the purposes of this study, considered lung cancer deaths to be indicative of cigarette smoking. In the US, more than 90 percent of lung cancer deaths among men and more than 80 percent among women result from smoking. Although the prevalence of smoking declined in all states in that time period, southern states, particularly Kentucky, have maintained overall high levels of smoking.

Fenelon found that in the Central South, mortality attributable to smoking peaked later than in other regions and at a significantly higher death rate, indicating a greater and more persistent burden of smoking

By 2004, the gap in mortality attributable to smoking between the Central Southern states and states in other regions was exceptionally large: among men, smoking explained as much as 75 percent of the difference between the Central South and other US regions. Laws and policies in the Central South do not strongly discourage smoking.

There are currently 10 states with no statewide ban on smoking (for example, in workplaces or restaurants); nearly all of these states are in the South. State taxes on tobacco products also remain low in the Central Southern states compared to other states with lower mortality from smoking. Studies have shown that smoking bans and tobacco taxes reduce the prevalence of smoking.

The new study highlights geographic inequalities in health and mortality within the US and underscores the importance of narrowing these gaps as a public policy goal

The journal Population and Development Review (PDR) seeks to advance knowledge of the relationships between population and social, economic, and environmental change and provides a forum for discussion of related issues of public policy. PDR is published quarterly on behalf of the Population Council by Wiley-Blackwell.

The Population Council conducts biomedical, social science, and public health research. The Population Council delivers solutions that lead to more effective policies, programs, and technologies that improve lives around the world.

Smoking by young people sometimes is a cultural habit of older adults seen by the grandchildren

A new study published in the journal Respirology reveals that water pipe smoking, such as hookah or bong smoking, affects lung function and respiratory symptoms as much as cigarette smoking. Most users of water pipes and many physicians believe that smoking through a water pipe filters out the toxic components of tobacco and is considerably less harmful than smoking cigarettes.

Led by Mohammad Hossein Boskabady, MD, PhD, of Mashhad University of Medical Sciences, researchers set out to compare lung function and respiratory symptoms among water pipe smokers, deep or normal inhalation cigarette smokers, and non-smokers. Three groups of smokers, including 57 water pipe smokers, 30 deep inhalation cigarette smokers (S-DI), and 51 normal inhalation cigarette smokers (S-NI) were identified and studied. In addition, 44 non-smokers were studied as a control group.

Respiratory symptoms increase from smoking

A questionnaire was administered to assess the prevalence and severity of respiratory symptoms and lung function tests performed on smokers and control subjects using a spirometer. Results showed an increased prevalence and severity of respiratory symptoms among water pipe smokers and cigarette smokers. Similar effects of water pipe smoking and deep inhalation cigarette smoking on respiratory status were found.

Wheezing was present in 23% of water pipe smokers, 30% in S-DI, and 21.6% in S-NI. Chest tightness was present in 36.8% of water pipe smokers, 40% in S-DI, and 29.4% in S-NI. Cough was present in 21% of water pipe smokers, 36.7% of S-DI, and 19.6% of S-NI.

Wheezing and tobacco use coughs

Wheezing, chest tightness, and cough only occurred in non-smokers 9.1%, 13.3% and 6.8% respectively. "Our study is the first report regarding the importance of the method of cigarette smoke inhalation with respect to effects on the respiratory system," Boskabady concludes, in the news release, Water pipe smoking has the same respiratory effects as smoking cigarettes.

"Our findings reveal that there were profound effects of water pipe smoking on lung function values, which were similar to the effects observed in deep inhalation cigarette smokers." Water pipe smoking is similar to smoking cigarettes in the effects seen on the lungs.

The number of people smoking water pipes is rising dramatically throughout the world

A large proportion of new users are young, and many believe – contrary to facts – that water pipe smoking is less dangerous than cigarettes. Research into why people start smoking water pipes is under way at Uppsala University. Use of water pipes (also called "hookah" and "narghile") is on the rise, according to a number of studies conducted in Europe and North America. Anti-smoking campaigns typically focus on cigarettes and even, to some extent, snuff but rarely provide information about the negative effects associated with hookah use.

"Many adolescents and adults believe that hookah use is less dangerous than cigarette smoking," says Bengt Arnetz, Professor of Social Medicine at Uppsala University and Professor of Occupational and Environmental Medicine at the Wayne State University School of Medicine, according to the news release, More smoke water pipes -- family habits significant. "Some fail to understand that hookah use involves tobacco. In fact, smoking a hookah entails much greater exposure to carbon monoxide and other dangerous and carcinogenic substances in tobacco smoke than does smoking cigarettes."

Arnetz, in collaboration with various colleagues, has conducted a series of studies focusing on hookah smoking. One study, published in the journal Nicotine & Tobacco Research, involved investigating factors associated with increased likelihood of hookah use. Such studies have been conducted for many years in connection with cigarette smoking but are comparatively rare when it comes to hookah smoking.

Young people follow in their father's, mother's and sibling's smoking habit footsteps

One study conducted in Michigan determined that 26 per cent of the 800 participating subjects engaged in hookah use. Researchers found that the likelihood that a person engaged in hookah use was more than eight times higher if the father in the household smoked a hookah, seven times higher if the mother did so and 20 per cent higher if a sibling did so. More generally, men and young people constituted risk groups in connection with hookah use. The risk factors applied equally to people currently engaged in hookah use and those who had previously been so engaged but had stopped.

Arnetz and his colleagues are now planning comparative studies of hookah smoking in Sweden and the United States. They are also interested in investigating the spread of hookah use among adolescents and the effects of socio-economic and stress factors on smoking behavior. The knowledge in question is important from the standpoint of designing future preventative strategies.

The CDC reports a heavy increase in smoking among mental patients

Smoking is increasing among mental patients, persons with various addictions to drugs, alcohol, food, or strange objects eaten such as dirt or drywall chips, or anything not regular food, and people from countries where tobacco use is a popular past time for men and some women, for example, Middle Eastern and Southeast Asian immigrants and their American-born children.

The latest Centers for Disease Control and Prevention (CDC's) research published in the government's publication, "Vital Signs" shows cigarette smoking is a serious problem among adults with mental illness. More needs to be done to help adults with mental illness quit smoking and make mental health facilities tobacco-free, according to the CDC article, "Smoking Among Adults With Mental Illness."

The name used by the CDC in the article was 'Janice.' The character Janice is not drawn from any one person, but is a blend of the experiences of many smokers with mental illness. And Janice has suffered from mental illness for most of her life. She had depressive disorders starting in adolescence, and was admitted to a mental health facility for a time when her symptoms became severe.

While there, she began smoking because many other patients were doing it, and she wanted to fit in. She noticed that the staff didn’t seem to mind patients smoking, and sometimes even used cigarettes to reward good behavior. By taking medication for depression and carefully following her treatment plan, Janice has been able to live a more productive life. She graduated from college and now is able to maintain a job. But she hasn’t been able to give up smoking, despite repeated attempts.

More people with mental illness smoke than people without that disorder

Despite overall declines in cigarette smoking in the United States, more people with mental illness smoke than people without mental illness. And just like many others who smoke, many people with mental illness will get sick, become disabled, or die early from smoking-related diseases.

The latest Vital Signs from CDC notes that many adults with mental illness who smoke want to quit, can quit, and will benefit from proven stop-smoking treatments. It’s true that some people with mental illness face issues that can make it more challenging to quit, such as low income, stressful living conditions, and lack of access to health insurance and health care. All of these factors make it more challenging to quit. But that doesn’t mean that smokers with mental illness can’t benefit from the same proven treatments as anyone else. Read the full MMWR Vital Signs issue to find out more.

Smoking when mentally ill

Smoking prevalence is much higher among people with a mental illness, say researchers. Nationally, nearly 1 in 5 adults (or 45.7 million adults) have some form of mental illness, and 36% of these people smoke cigarettes. In comparison, 21% of adults without mental illness smoke cigarettes. (Mental illness is defined here as diagnosable mental, behavioral, or emotional conditions and does not include developmental and substance use disorders.)

You can read more about smoking prevalence among people with mental illness in the Vital Signs Report. There are other troubling statistics from the report:

  • 31% of all cigarettes are smoked by adults with mental illness.
  • 40% of men and 34% of women with mental illness smoke.
  • 48% of people with mental illness who live below the poverty level smoke, compared with 33% of those with mental illness who live above the poverty level.

What contributes to higher smoking prevalence in the study's population?

While many mental health providers and facilities have made progress in reducing smoking in their facilities and among their patients, others are just now beginning to address tobacco use. Because they are more focused on treating the mental illness of their patients, some providers and facilities may not consider smoking to be a problem, or ignore it. People who help those suffering from addictions may also see a large number of addicts smoking while trying to stop their addiction to particular substances, alcohol, foods, or unwanted compulsions and other behaviors.

Smoking can cause unique issues for people with mental illness. Nicotine has mood-altering effects that put people with mental illness at higher risk for cigarette use and nicotine addiction.
However, recent research has shown that adult smokers with mental illness—like other smokers—want to quit, can quit, and benefit from proven stop-smoking treatments. These treatments need to be made available to people with mental illness and tailored as needed to address the unique issues this population faces.

What can be done to reduce smoking among people with mental illness?

Mental Health Professionals:

  • Find out if patients smoke. Sometimes patients aren’t asked whether they smoke when beginning mental health treatment.
  • If they do smoke, offer to help patients quit by providing proven quitting treatments, including referring them to the government's Smoke Free website, or other resources. There's a toll-free phone number listed on the CDC Smoke Free website. It means you can become free of smoking, quit smoking, not that you can get free 'smokes.' The answer most people want to find out is how to quit smoking.
  • Make quitting tobacco part of an approach to mental health treatment and overall wellness. Mental health professionals should be especially aware of the behavior changes that may occur when withdrawing from nicotine, and should make sure that their patients are aware of them. Medicines used to treat mental illness may need to be monitored and adjusted for people with mental illness who are trying to quit tobacco use.

Mental health facilities:

  • Include tobacco cessation treatments as part of an overall mental health treatment strategy.
  • Make mental health facilities and campuses completely tobacco-free (no use of any tobacco product by anyone anywhere inside or outside at any time).
  • Call attention to and stop practices that encourage tobacco use (e.g., providing cigarettes to patients, allowing smoking as a reward, selling tobacco products on site, and allowing staff to smoke with patients).

Success stories: Rochester, New York, and Austin, Texas

Daryl Sharp, Associate Dean for Faculty Development and Diversity in the School of Nursing at the University of Rochester, developed a nurse-managed program in Rochester, New York, that provided intensive tobacco dependence interventions for clients through a university-based mental health outpatient facility. The program, which ran from 2006 to 2009, included a variety of interventions, and program nurses worked with the treatment staff to support the integration of tobacco dependence treatment into clients’ recovery plans.

The program doubled the proportion of people who were tobacco-free for at least 7 days, from 8.1% to 16.5% at 1 year, and reduced the average number of cigarettes smoked by participants from 21.6 to 13.5 per day. The program was even more successful among those who were moderately to highly nicotine dependent.

Clients, clinic staff, and administrators all reported very positive impressions of the program, including an increased likelihood that when there was an intensive intervention readily available on site, that treatment staff would talk with their clients about stopping smoking. The Smoking Cessation Leadership Center Web site—associated with the University of California, San Francisco—has additional information, including resources focusing on tobacco dependence treatment for people with mental illnesses and substance use disorders.

In another success story, officials with the Austin-Travis County (TX) Integral Care (ATCIC) program sought to change the culture by implementing a Tobacco Cessation Initiative (TCI), making all of the agency’s mental health facilities tobacco-free. They also treated patients and staff who were addicted to nicotine, and implemented nicotine prevention measures.

The Tobacco Free Workplace policy implemented in February 2011 prohibited consumption of all tobacco products on ATCIC property and resulted in a significant drop in smoking rates among staff and patients. According to Dale Mantey, Tobacco Cessation Coordinator for ATCIC, TCI's curriculum has been widely replicated statewide and has contributed significantly to Texas’s progress toward achieving its goal of making all state mental health facilities tobacco free.

Support to quit smoking

For free quit support, call the phone number listed on the CDC's Smoke Free line. Also check out the site, "How to Quit Resources." This number routes callers to their state quit lines, which provide free support and advice from experienced counselors, a personalized quit plan, self-help materials, the latest information about quitting medications, and more. Specific services vary from state to state. Also see the CDC's Smoking & Tobacco Use Web site.

Quitting services and resources are also available online in English and in Spanish. These Web sites provide free, evidence-based information and professional assistance to help support the immediate and long-term needs of people trying to quit tobacco use.

More information

For more information on the health consequences of tobacco use and exposure to secondhand smoke, as well as resources on how to quit, consult the following sites: CDC's Smoking & Tobacco Use Web site, Tips From Former Smokers campaign Web site, How Tobacco Smoke Causes Disease: What It Means to You, How to Quit Resources, Help for Smokers and Other Tobacco Users: Quit Smoking, Secondhand Smoke: What It Means to You, SAMHSA (Substance Abuse and Mental Health Services Administration).

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