WHO is Smoking and Using Tobacco in Muskegon and Michigan ?

Farid Shamo: State Tobacco Control Program shamof@Michigan.gov

Who is Smoking/Using Tobacco in Michigan and Muskegon?

Smoking Behavior Among ADULTS.

Prenatal Smoking in Michigan and Muskegon.

Smoking/Tobacco Use Among High School Students.

Tobacco Use in Michigan 20.4% of Michigan adults currently smoke cigarettes

(BRFSS-2016)

21.5% of Muskegon adults currently smoke cigarettes BRFS 2014-2016)

10% of Michigan high school students currently smoke cigarettes (YRBS-2015)

7.5% of Muskegon high school students currently smoke cigarettes (YRBS-2015)

23% of Michigan high school students currently use E-Cigarette (YRBS-2015)

17.5% of Muskegon high school students currently use E-Cigarette (YRBS-2015)

23.3%

21.4% 20.7% 20.4%

21.2%

19.2%

17.5% 17%

26%

23.8%

22% 21.5%

0%

5%

10%

15%

20%

25%

30%

2011 2013 2015 2016

Adult smoking prevalence in Muskegon compared to Michigan and USA (BRFSS 2011-2016)

Michigan

USA

Muskegon

2

8

17

17

16

18

34 246

0 50 100 150 200 250 300

AIDS

Homicide

Alcohol

Auto…

Suicide

Drug…

Secondhan…

Cigarettes

Deaths/ Year

* Source: CDC-SAMMEC- 2009 and MDHHS Vital Statistic 2015

Causes of Preventable DeathMuskegon County-Michigan

Tobacco kills more people in Michigan *

than AIDS, alcohol, auto accidents, cocaine, heroin, murders and suicides -

combined.

43.2

46.3

39.3

42.9

40.3 39.7 [VALUE]%

27.4 26.4 25.5

26.7 25.8 25.8 [VALUE]%

8.8 8.8 8.1 7.2 7.3 7.5 [VALUE]%

0

5

10

15

20

25

30

35

40

45

50

2011 2012 2013 2014 2015 2016 2016

Adult Smoking Rates by Educational Levels over the period from 2011-2016 in Michigan (MiBRFSS) and Muskegon

< HS

HS

College

35.3

39.9

37.5 36.4

35.5 35.7 [VALUE]%

21.5 20.6

21.6 21.3 21.8 21

22%

13.2 12.2

10.9 10.8 10.9 11 [VALUE]%

0

5

10

15

20

25

30

35

40

45

2011 2012 2013 2014 2015 2016 2016

Adult Smoking Rate by Household Income Level Over the Period From 2011-2016 (MiBRFSS) in Michigan and Muskegon

<$20K

<$35-49K

>$75K

[VALUE]%

19.7% 18.7

23.6%

0

5

10

15

20

25

Michigan Muskegon

Adult Smoking Rates By Gender in Michigan and Muskegon – 2016 BRFSS

Male

Female

24.9%

28%

25.6%

32.3%

41.4%

39.8%

40.3%

46.2%

41%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

African American

With disability

Arab American **

Uninsured

LGBT

With poor MentalHealth

Native American

Low SES

HIV-positive person*

Adult Current Smoking Rates by Populations Disproportionately Impacted by Tobacco Use in Michigan, 2016 Behavioral Risk Factor Survey.

* HIV Client Survey 2017

** Arab & Chaldean American Survey 2017

State Average = 20.4%

15.6%

25.3 26.9%

24.9

21.8%

[VALUE]%

[VALUE]%

[VALUE]%

[VALUE]% [VALUE]%

[VALUE]%

[VALUE]%

11.4

6

0

5

10

15

20

25

30

35

18-24 years 25-34 35-44 45-54 55-64 65-74 75+

Adult Current Smoking Rate by Age Groups in Muskegon (Red columns) Compared to Michigan - BRFSS 2016

Muskegon average =21.5%

58.2%

41.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current and former smokers Never smoked

Smoking Status Among Adults Ever Told They Have Cancer (other than skin cancer)* MiBRFSS 2016

* There is a statistically significant difference between the 2 groups of Cancers .

62.7%

37.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current and former smokers Never smoked

Smoking Status Among Adults Ever Told They Have Stroke* MiBRFSS 2016

* There is a statistically significant difference between the 2 groups

68%

32.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current and former smokers Never smoked

Smoking Status Among Adults Ever Told They have Heart Attack* MiBRFSS 2016

* There is a statistically significant difference between the 2 groups

55%

45%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current and former smokers Never smoked

Smoking Status Among Adults Ever Told They Have Diabetes MiBRFSS 2016

42.9% 40.6% 39.2%

38.2% 38.0% 39.8%

23.3% 23.3% 21.4% 21.2% 20.7% 20.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2011 2012 2013 2014 2015 2016

Current Smoking Rate Among Adults Reporting Poor Mental Health* Compared to the State Average, Michigan BRFSS 2011-2016

Adults With Poor Mental Health

State Average

* With Poor Mental Health 14 or More Days of the Past 30 Days.

36.9% 41.2% 42.2% 39.3% 39.0%

35.3%

23.3% 23.3% 21.4% 21.2% 20.7% 20.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2011 2012 2013 2014 2015 2016

Current Smoking Rate Among Adults Who are Heavy Alcohol Drinkers* Compared with the State Average, MiBRFSS 2011-2016

Adults Who are Heavy Alcohol Drinker

State Average

* Heavy Alcohol Drinker = consuming an average of > 2 alcoholic drinks per day for men and > 1 per day for women

[Y VALUE]%

26.5

[Y VALUE]%

[Y VALUE]%

[Y VALUE]%

[Y VALUE]% 29

[Y VALUE]%

[Y VALUE]%

24.5%

[Y VALUE]%

[Y VALUE]% [Y VALUE]%

17.7

19.3 19.8 [Y VALUE]%

[Y VALUE]% [Y VALUE]%

16%

12

17

22

27

32

2006 2008 2010 2012 2014 2016 2018

%

Rate of Live Births to Mothers Who Smoked During Pregnancy in Muskegon Compared to Michigan for the years 2007-2016

(MDHHS-Vital Statistics)

Muskegon Michigan

[VALUE]% [VALUE]% [VALUE]%

[VALUE]%

[VALUE]%

[VALUE]%

121314151617181920212223242526272829303132333435

2011 2012 2013 2014 2015 2016

Prevalence of Current Smoking During Pregnancy Among Pregnant Women in Muskegon, Vital Statistics 2011-2016

[VALUE]%

24.9

15.3

11.1

0

5

10

15

20

25

30

All ages 18-24 Yr 25-34 Yr 35-45Yr

Smoking Rates of the Pregnant Women by Age Groups in Michigan. Vital Statistics 2015

17.3

32.4

26.8

17.3

2.7

0

5

10

15

20

25

30

35

All Levels Less than High School High School Some College College

Smoking Rates of the Pregnant Women by Educational Levels in Michigan. Vital Statistics 2015

17.3 18.6

16.6

42.3

11.5

1.9 2.6

[VALUE]%

0

5

10

15

20

25

30

35

40

45

All Races White Black NativeAmerican

Hispanic Asian Arab Other

Smoking Rates of the Pregnant Women

By Their Race in Michigan. Vital Statistics 2015

27.9 28.4 28.8

23.6

8.9

18.3

7.3 6.1

0

5

10

15

20

25

30

35

All ages 18-24 Yr 25-34 Yr 35-45Yr

Smoking Rates of the Pregnant Women by their Type of Health Insurance Plans in Michigan. Vital Statistics 2015

Medicaid

Private insurance

8.7 8.5

9.1 8.7 9.5

10.4

6 5.8

6.1 6.4

5.9 6.1

0

2

4

6

8

10

12

2010 2011 2012 2013 2014 2015

%

Infant Mortality Rate in Michigan by Smoking Status of the Mother for the Period from 2010-2015 (per 1000 live births-Vital Statistics)

Smoking Mom

Non-smoker

Quitlines are effective and recommended in Pregnancy :

Because Pregnant Women does not need to leave her home.

Because of social stigma attached to “Smoking during Pregnancy” the Quitline may be the most attractive method.

May work very well when there are transportation barriers or mobility issues for some pregnant women.

……………………………. BUT

354

194 168 148

1114

1287

1602

2350

0

500

1000

1500

2000

2500

2013 2014 2015 2016

Number of Successful Intake Calls for Fax Referred Smokers Compared to Unreachable Phones- “Quitline database 2013-2016”

Intake calls Unreachable Phones

What can we do to increase reachability and enrollment

Educate and train providers:

To convince the pregnant to quit, and this will cover the 3 As (Advise, Assess and Assist)

To fill out patient’s information completely in the FAX referral form specifically her preferred time to be reached by quitline..

To be sure that patient/client likes and understands the fax referral to quitline. Tell patient/client to expect a call from “1800-784-8669” the quitline number next

day or so. Ask patient/client to save the quitline number 1(800)-784-8669 in her cell phone as

the “Quitline” (When applicable) Follow up calls to ask about patient/client’s quitting status.

There are specially trained counselors who have been dedicated to working with prenatal callers

Prenatal enrollees will receive 9 counseling calls:

-5 calls prior to delivery and

-4 calls post-partum

Prenatal enrollees receive incentives for participation

Quitline Prenatal Protocol

Quitline Prenatal Incentives

Studies have shown that incentives are effective in the prenatal population.

Prenatal Calls – For each counseling call an enrollee completes with her coach, she will receive a $5 Visa gift card. (5 in total=$25)

Postpartum Calls – For each counseling call completed after delivery, the enrollee will receive a $10 gift Visa gift card. (4 in total=$40)

Total incentives = $65 (when complete all 9 calls)

4%

2.1%

7% 6.8%

13%

8.4%

0%

2%

4%

6%

8%

10%

12%

14%

2014 2016

Percentage of Current Cigarette Smoker Among School Students by grade and year of the survey in Muskegon Co. MiPHY 2014 and 2016

7th Grader

9th Grader

11th Grader

[VALUE]

6.8%

8.4%

5.6%

15.5%

20%

0%

5%

10%

15%

20%

25%

7th grader 9th grader 11th grader

Percentage of Current Cigarette Smokers compared to E-cigarette Users By grade of the students in Muskegon, MiPHY 2016

Current cigarette smokers

E-cigarette user

23%

[VALUE]*

23.5%

10%

[VALUE]*

10.8%

0%

5%

10%

15%

20%

25%

Michigan Muskegon USA

Current Cigarette Smoker and Current E-cigarette User Rates Among High School Students in Muskegon Compared to Michigan and USA- Average. YRBS 2015

* Michigan Profile for Healthy Youth 2015-2016-Muskegon

E-cigarette Users (Current)

Cigarette Smoker(Current)

Five Myths about E-Cigs we need to know:

Myth 1: There is no gateway effect. A recent meta-analysis shows 100% consistent evidence that never cigarette smoking youth who begin nicotine use with e-cigarettes are significantly more likely to progress to cigarette smoking than youth who do not use e-cigarettes

Myth 2: E-cigarettes increase smoking cessation.

A meta-analysis showed that e-cigarettes are associated with depressed cessation.

Myth 3: E-cigarettes are 95% safer than conventional cigarettes. There has been a substantial literature published indicating important cardiovascular and pulmonary risks associated with e-cigarette use.

Five Myths about E-Cigs we need to know:

Myth 4: Even if smokers don’t quit when they use e-cigarettes they

smoke fewer cigarettes and the health risks go down Even low levels of smoking convey substantial risks, especially for cardiovascular disease, where smoking even a few cigarettes is as dangerous as smoking 20 cigarettes a day.

Myth 5: Nicotine is addictive, but it doesn’t pose any other substantial risks.

While not a carcinogen, nicotine plays an important role in promoting tumor progression by promoting cell proliferation and inhibiting normal cell death. Nicotine also promotes the angiogenesis needed to supply blood to growing tumors

Surgeon General Report-2016

U.S. Surgeon General Dr. Vivek H.

Murthy SAID, in releasing the

report : “All Americans

need to know that e-

cigarettes are

dangerous to youth

and young adults,”.

* * *

1. Adults–Both Genders -Low Education-Low Income.

2. Native Americans and black Americans – LGBT- Poor Mental Health – Uninsured - with chronic diseases (Cancer, Stroke, Heart Attack, Diabetes)

3. Women of 18-44 years, Pregnant women (18-24 yrs. - Low Education - Have Medicaid )

4. High School Students, Tobacco use in general and

E-cigarette specifically.

1. Low SES visit FQHCs/Community Dental Clinics/Health Department clinics/ WIC …etc.

2. Train and Educate Providers in 5As and how correctly do the FAX referral.

3. Reach out to African Americans, Native Am. and LGBT community.

4. Work with Muskegon Community Mental Health to offer training, educations and materials for TF campuses and 5As adoption.

5. Work with Women of 18-44 yrs. & pregnant women:

(a) OB/GYN clinics (b) WIC clinics (c) Family planning clinics (d) Native Am., White & African Am. (e) Work w/local DHHS for Medicaid beneficiaries

6. Normalize Tobacco Free Environment and Culture:

TF parks - Comprehensive TF schools and colleges – Tobacco 21- …etc

7. Media campaign to educate the public on the harms of E-cigarette

8. You can submit a complaint anonymously to the FDA about a violation like selling e-cigarettes /hookah to minors here; it is very easy BUT important:

HTTPS://WWW.ACCESSDATA.FDA.GOV/SCRIPTS/PTVR/INDEX.CFM

94%

93%

54%

49%

48%

46%

45%

44%

42%

39%

39%

37%

36%

35% 33%

28% 25%

24%

23%

22%

21% 19%

17% 14%

12%

11%

11%

10%

10% 10%

10%

9%

9%

8% 6%

5%

5% 3%

3% 3%

2%

2%

2% 2% 1% 1%

1% 1%

0%

20%

40%

60%

80%

100%

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Percentages of CDC Recommended Current Spending for the Tobacco Program by the States for 2018*

Michigan is among the

lowest States in spending

on tobacco prevention

in the Nation!

$1.267 B

$ 954.5M

$256 M

$57 M $1.6M

$295.3M

Total TobaccoRevenue

Tobacco ExciseTax

TobaccoSettlement

(MSA)

Tobacco SalesTax

TobaccoPrevention

AnnualTobacco

CompanyMarketing in

MI

Michigan Tobacco Revenues By (Millions) compared to the Funding for the Tobacco Prevention -2015

0.5

1.0

1.5

2.0

1 25 49 73 97 121

Figure 1 The rate of asthma hospitalizations from 2002-2012

Hospitalizations Model Model No Ban

2008 2002 2006 2010 2012 2004

Smoke Free Law

RACIAL DISPARITIES IN MICHIGAN ASTHMA HOSPITALIZATIONS FOLLOWING THE SMOKE FREE AIR LAW: A LONGITUDINAL COHORT STUDY

RACIAL DISPARITIES IN MICHIGAN ASTHMA HOSPITALIZATIONS

FOLLOWING THE SMOKE FREE AIR LAW: A LONGITUDINAL COHORT STUDY

After adjusting for age, sex, race, insurance type and month of year, there was an 8% reduction in the population-wide rate of asthma hospitalizations in the 12 months after the implementation of the SFA law.

The study published in peer reviewed journal “Preventing Chronic Disease Journal” This is the link:

http://dx.doi.org/10.5888/pcd12.150144.

RACIAL DISPARITIES IN MICHIGAN ASTHMA HOSPITALIZATIONS FOLLOWING THE SMOKE FREE AIR LAW: A LONGITUDINAL COHORT

STUDY

We found the average charge for hospitalizations in Michigan citing asthma as the primary diagnosis to be $15,047 per one hospital stay only, in 2011 dollars.

In the 32 months following implementation of the SFA law, our model shows a reduction of 3,230 adult asthma hospitalizations, saving approximately $48.6 million (=3,230 X $15,047) in health care costs.