Tobacco Use Today

Earlier this year, the United States Surgeon General released a report that marked the 50th anniversary of the first Surgeon General Report that highlighted the consequences of smoking. The 2014 report, available here, acknowledged the successful decline of adult smoking rates. In 1965 nearly 43% of adults smoked compared to 18% of adults in 2014. However, there is still work to be done.  

The risks of tobacco are clear. Smoking increases the risk for coronary heart disease, stroke, many types of cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease, stroke, heart attacks, bronchitis, and low birth weight in newborns. Despite all we know, smoking is still the leading cause of preventable death in the United States and is responsible for one out of five deaths. New trends in types of tobacco products (for example e-cigarettes) and tobacco use along demographic indicators such as socioeconomic levels need to be addressed. A recent report from the Population Health Metrics found that while smoking rates are decreasing quickly in more affluent communities, the rates are staying the same among the poor.

Tobacco use in 1965

Tobacco is used differently now than it was in 1965 when the Surgeon General released the first report that warned American of the harmful effects of tobacco. In 1965, 43% of adults smoked. Smoking cigarettes was seen as something of status - rich people smoked cigarettes because they could afford to do so. Smoking was common in the workplace, in restaurants, and in schools. Kids didn’t learn about the harm of tobacco in health class. Advertisements like the ones below were everywhere. You can see many more advertisements like these here.everywhere.  

Tobacco use today

Tobacco use and smoking is no longer something for the wealthy. Instead smoking rates are higher in poor communities. Below is a map of federal smoking data by county. There is a correlation between smoking prevalence and county wealth. For example, Clay County in Eastern Kentucky is one of the country’s most impoverished counties and has the highest smoking rates. 

On an individual level, 29 percent of adults who are below the poverty level smoke, compared to 18% of adults who are at or above the poverty level.

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Now smoking is more common among adults who do not graduate high school - one-in-four adults without a high school level education smoke compared to one-in-ten adults with postgraduate degrees.

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Another change from 1960 is tobacco advertising. The Family Smoking Prevention and Tobacco Control Act was passed in 2009 that gave the FDA authority to regulate the manufacture, distribution, and marketing of tobacco products to protect public health. Jurisdictions have also banned smoking in public places such as restaurants. Cigarettes are now heavily taxed making them more expensive to purchase. Despite the federal, state, and local regulations smoking rates remain high, especially among low socioeconomic groups.

Why rates of tobacco use are higher in poor communities

There are several possible factors and reasons why poor communities have higher rates of tobacco use.

1. Stress. For many people tobacco use is a coping mechanism. For low socioeconomic people, stress is chronic and often caused by community violence and joblessness.
2. Targeted marketing. Researchers have found that there are fewer tobacco advertisements in the higher socioeconomic communities compared to the lower socioeconomic communities. Point of Sale tobacco marketing (including advertisements, price promotions, and product displays in stores) disproportionately affects youth, racial minorities and people of low income/education. For example, retailers located in minority and low-income neighborhoods are more likely to advertise tobacco products in store windows.
3. Less access to cessation programs. Compared to white collar workers, blue collar workers have less access to to cessation programs to help them quit. Blue collar workers are more likely to start smoking and less likely to quit.

Hope for the future

Anti-tobacco advocate groups as well as the federal government are working to raise awareness about the higher rates of tobacco use among poorer Americans. Awareness and data are a key part of solving a problem.

In addition to awareness, the Affordable Care Act changed Medicaid to support cessation. Medicaid enrollees smoke at a rate that is 50 percent higher than the general public so the cessation through Medicaid could help many Americans. In 2010, the ACA required all Medicaid programs to cover comprehensive tobacco cessation for pregnant woman. In 2014 the ACA required coverage of tobacco cessation medications in all states in 2014. Recently companies have been vocal about selling tobacco products. A few months ago, CVS, a major drug store, announced it would no longer sell tobacco products.

Great strides have been made in the fight against tobacco. However, an alarming number of families are impacted negatively by tobacco products so there is still work to do. As the fight against tobacco continues, it is important to not blame the individual who uses tobacco but instead to support those trying to quit.

The Prison Problem

Currently, there are more than 2.4 million people in prison in the United States - that means one out of every 100 people is imprisoned.  Although the US has 5% of the world population, we have 25% of the world’s prisoners.  It costs $21,000 a year to house one prisoner in a minimum security prison and $33,000 per year in a maximum security prison.  All in all, the US spends about $74 billion a year on prisons.  Whether you think that amount of money is appropriate to spend on imprisoning people or not, the reality is that what we spend on prisons, limits what we can spend on other things like job creation and education. With 68% of prisoners not finishing high school, we might connect lack of education with an increased likelihood to commit crime.  Below is a chart comparing how much it costs to educate a student or imprison someone in 40 states.  It is clear which one is more cost effective.

The cost of keeping someone in jail is not the only issue when it comes to how often the US imprisons people.  We have a serious issue with racial disparities in prison populations with African Americans being imprisoned 6 times as often as white Americans.  African Americans and Hispanics are 25% of the US population but 58% of the prison population.  Part of this disparity is due to the effect of race on sentencing.  Studies have shown that black and hispanic men tend to receive harsher penalties for the same crime than other populations, among other disparities (for more more info click here).

We also have high rates of recidivism (67.5% are rearrested within 3 years of release) in this country which is not surprising when a person’s ability to find a job, get housing or qualify for a loan are all negatively affected by having a criminal record.  It is no wonder that the highest recidivism rates are for those who committed property crimes like car theft, larceny, selling/possession of stolen property and burglary.

So to sum up, we are spending a great deal of money, to the detriment of other causes like education and job creation, to imprison people, but it isn’t stopping those people from committing future crimes and it disproportionately harms minorities.  Maybe it is time for us to re-think the way we address this issue.  New York, Washington and Texas have done just that by doing things like

• Ending mandatory minimum drug sentences;
• Diverting low-level drug offenders to treatment even before trial;
• Eliminating counter-productive “collateral sanctions” such as an automatic driver’s license suspension for drug offenses, and high fees for probation, parole, court costs, and telephone charges;
• Reforming the systems of parole and probation;
• Restoring educational programs including vocational education as well as college-level courses in prisons and jails;

My own home state of Massachusetts currently has a campaign called Jobs Not Jails to reform our own criminal justice system which is currently on par with French Guiana and Kazakhstan.

What Can You Do

If you live in Massachusetts, check out Jobs Not Jails.  If you live in another state, find out if there is an equivalent campaign or start your own!

Kidney Health

March is National Kidney Month.

Kidneys filter blood, remove waste to make urine, control blood pressure, and regulate hormones. Damaged kidneys limit the body’s ability to filter blood and causes waste to build up in the body. More than 26 million U.S. adults have been diagnosed with kidney disease. The risk factors for kidney disease are: diabetes, high blood pressure, cardiovascular disease, and a family history of kidney failure. If kidney disease is detected early, treatment might be available to delay or prevent kidney failure.

End stage renal disease (ESRD) is the last stage in the  progression of kidney disease and usually requires dialysis or a kidney transplant. Dialysis generally require three treatments a week, each lasting 3-4 hours. In the United States in 2010, 580,741 people were living with ESRD. Since Chronic Kidney Disease and ESRD generally impact Americans who are older and on Medicare, the economic cost for the public is high. Kidney disease costs Medicare about $41 billion a year in treatment.  

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Kidney Health Disparities

Chronic Kidney Disease and End Stage Renal Disease disproportionately affect minority communities. African Americans are 3.6 times more likely to have kidney failure compared to the general population. While African Americans are about 13 percent of the U.S. population, 32 percent of the people with kidney failure are African American. Hispanic Americans and Native Americans are also at increased risk compared to the general public. Since 2000, the number of Hispanics with kidney failure has increased by more than 70 percent.

Kidney disease is also linked to higher levels of poverty, especially in African Americans. Study results show that African Americans who had incomes less than $20,000 were three times more at risk for kidney disease that African Americans earning more than $75,000.  

Not only are racial minorities more likely to have kidney disease, they are more likely to die from it. Nearly 70,000 patients are on the waiting list for kidney transplants, with African Americans comprising 35% of these patients. In addition, minorities that do get kidney transplants are more likely to spend more time on the waiting list than whites.

Why the huge disparities?

Like many other diseases, the reason for the kidney health disparities is largely environmental. Diabetes is a leading cause of kidney disease, and minorities and those living in poverty are more likely to be diagnosed with diabetes than the general American population. In 2009, diabetes caused 38.4 percent of all kidney failure. The reason for the higher rates of diabetes among minorities may be attributed to lack of health services within minority communities, limited supply of nutritious foods, lack of safe places for exercise, and chronic sources of stress such as community violence and financial instability.

Another reason for the disparities in kidney disease is that historically, in the United States, there has been a racial disparity in who received organ transplants. Matches across race are more difficult and a higher proportion of organ donors are white while a higher proportion of those needing kidneys are black. Therefore more racial minorities die waiting for a kidney transplant.

Decreasing the burden of kidney disease

The Affordable Care Act will provide more Americans with access to preventative health services. For many people, diabetes, a leading cause of kidney disease, can be prevented through adequate diet and exercise. Access to insurance can also provide those with beginning stages of kidney disease treatments to delay the progression of the disease to kidney failure. Early diagnosis is the key and for a diagnoses, individuals must have a health care provider who is easily accessible and trusted. General awareness about kidney disease is also important, especially within minority communities. Many people who already have diabetes or high blood pressure are not aware of their increased risk of kidney disease. Even more alarming, a study in Mississippi found only one in six African-Americans found to have Chronic Kidney Disease was aware of having the condition. In honor of National Kidney Month, consider becoming an organ donor.

Should You Vaccinate Your Children? YES

In the last few years, there has been a surge in the number of people who believe that vaccinations cause autism.  Thanks to a few celebrities, this belief continues to spread.  The celebrity most associated with this belief is Jenny McCarthy, but the most recent to espouse it is Kristin Cavallari.  So, are they right?  No, let’s look at the arguments and address them one by one.

1.) Studies show that vaccines cause autism - FALSE

The article that started this myth, “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children” by Andrew Wakefield, was originally published in The Lancet in 1998.  Not only has no-one been able to reproduce the results of that study (which by the way only had 12 participants), but investigations into Wakefield found that “he had been paid by a law firm that intended to sue vaccine manufacturers” - a serious conflict of interest.  Over the years, not only has the Lancet retracted the article (which you can see by clicking the link), but Wakefield has been found guilty of unethical behavior by the General Medical Board in Great Britain and has since been barred from practicing medicine in the UK.

You can even check out a small list of some of the studies that have shown no relationship between vaccines and autism here or here.  Finally, there have been studies on the cause of autism that point toward environmental pollution, not vaccinations.  Multiple studies have shown a strong association between children exposed to high levels of air pollution in the wob and autism.  

2.) As the number of vaccines has increased, the incidence of autism has increased - TRUE-ISH

    Yes, the number of vaccinations that we give our children has increased over time, especially in the last 70 years.  It is also true that the number of children diagnosed with autism has increased over the years; however, the CDC has only tracked autism diagnoses since 2000 which leaves more than 50 years of increased vaccinations without data to connect to.

Moreover, “Mark Roithmayr, president of the advocacy group Autism Speaks, says more children are being diagnosed with autism because of better diagnosis, broader diagnosis, better awareness, and roughly 50% of 'We don't know’.”  Even experts understand that at least some of the increase in diagnosed cases is not from an increases in cases but in better recognition of cases.

    It is also important to note that just because there is a correlation between two events - increased number of vaccinations and increased incidence of autism - does not mean that there is a causal link between the two.  As cases of autism have increased, sales of organic foods have increased, but no one is arguing that organic food causes autism.

3.) But the Homefirst pediatric group and the Amish don’t vaccinate and have no cases of Autism. UNPROVEN and UNTRUE

    Kristin Cavallari mentioned the Homefirst pediatric group in Illinois who treat children whose parents refuse to vaccinate them (because many doctors refuse to for the safety of their other patients).  They claim to treat some 35,000 children and to have had no cases of autism in their unvaccinated patients; however, they have never published a study or proven that through data.  Moreover, Homefirst has a troubling history when it comes to financial conflicts of interest, medical malpractice and doctors lying/changing their story under oath.

    The idea that Amish children aren’t vaccinated and don’t have autism is patently untrue.  Amish parents do vaccinate their children, though potentially not on the recommended schedule.  You may be thinking “aha! that proves it!”, but no, it doesn’t.  The Amish live very different lives from the rest of us which means we can not ascribe causation to just one of the differences.  They are not exposed to the same chemicals, preservatives, and pollutants that we are and they are a fairly isolated genetic pool (not many people born outside of the Amish community decide to become Amish) which means that if a genetic abnormality causes autism, it may not be present in the Amish gene pool.

4.) The risk of the vaccine is worse than the disease - FALSE

    All medical interventions come with risks and that includes vaccinations.  The vaccine that most anti-vacciners target is the MMR, which can lead to mild forms of the diseases vaccinated against (symptoms include fever, rash, loss of appetite, swelling of glands, and painful joints); rare side effects can include bruise like spots, seizures, and allergic reactions.  

When thinking about if a medical intervention’s risks are worth it, you should look at the risks to contracting the disease.  Measles causes fever, a runny nose, a full body rash and a cough. “About one out of 10 children with measles also gets an ear infection, and up to one out of 20 gets pneumonia. About one out of 1,000 gets encephalitis, and one or two out of 1,000 die.”  Measles is highly contagious - 90% of people exposed who are not vaccinated will contract the disease.  The good news is that vaccines are generally 85-95% effective which means that if 100 people who were vaccinated were exposed to measles between 5 and 15 would become infected; whereas if 100 people who were not vaccinated were exposed about 90 would become infected.  

5.) “It’s our personal choice, you know, and if you’re really concerned about your kid, then get them vaccinated and it shouldn’t be a problem.” ~ Kristin Cavallari - FALSE

    Many parents who chose not to vaccinate their children say things just like this and it is completely untrue.  Diseases that had been completely or almost eliminated in the US have been making a comeback lately because of the increase in unvaccinated.  In 2010 there was an outbreak of whooping cough in California that was proven to be the spread by unvaccinated children.  9,120 people caught the disease and 10 died.  In Texas, 21 members of a church that advocated against vaccinations came down with Measles after a member brought the disease back from a mission trip.  New York City has had a recent out-break of measles as well - there have also been cases in California, Connecticut, Illinois, Massachusetts, Hawaii, Pennsylvania, Texas, Washington, Oregon, Florida, New Jersey, Virginia, Colorado, North Carolina, and Michigan since the beginning of 2013.

   

Keep in mind the vaccination schedule for children as well.  Children aren’t vaccinated against Measles (MMR) until they are a year old, which means if they are exposed to the disease before then, they could contract it when they are most vulnerable and when their parents could do nothing to protect them.  People with cancer who are currently receiving chemo, or those who are otherwise immunosuppressed are also at risk.  And, as I mentioned before, vaccinations are generally 85-95% effective, so some people who have been vaccinated can also contract the disease in an outbreak.  Of course, outbreaks are much more rare when everyone is vaccinated.

Conclusions

    Please do not take medical advice from celebrities or people who stand to make more money if you follow their advice.  It is fine to question the safety of medical interventions, and it is understandable that parents want to do anything they can to prevent their child from getting autism or any other disease/delay/health issue.  However, vaccines do not cause autism, have relatively few risks and protect not only your child but other people’s children from things far worse than those risks.

Community Health Workers

Who are Community Health Workers?

According to the U.S. Health Resources and Services Administration (HRSA), Community Health Workers (CHW) are “lay members of communities who work either for pay or as volunteers in association with the local health care system…and usually share ethnicity, language, socioeconomic status, and life experiences with the community they serve” (HRSA CHW tool kit).

While the concept of CHW is not new, the Affordable Care Act brought a new buzz to the topic. The Affordable Care Act (Section 5313) gives the Centers for Disease Control and Prevention (the CDC) the responsibility to award grants to public or nonprofit private entities to promote health behaviors in underserved communities through the use of CHWs.

CHWs go by several names including community health advisor, outreach worker, community health representative, promotora, promotores de salud, patient navigator, navigator promotores, peer counselor, and lay health worker. In 2012, there were 38,020 CHWs employed in the United States.

What do Community Health Workers do?

The Labor Bureau of Labor Statistics has an occupation code for CHWs that defines a CHW as someone who:

• Assists individuals and communities to adopt health behaviors through education
• Conducts outreach for medical personnel or health organizations to implement programs
• Links the community to available resources
• Provides social support, informal counseling and basic health screening
• Advocates on behalf of the community’s health needs

Benefits of Community Health Workers

There are several benefits to using CHWs, including:

1. Elimination of language barriers. One of the main criteria to be a CHW is that he/she must speak the same language as the community in which he/she serves. This is especially beneficial for newly immigrated populations.  An example is  increased screening rates for hepatitis B virus within the Hmong population.
2. Trust. There is a strong distrust of medical and government officials within some communities in the United States. For example, individuals that are undocumented immigrants or have undocumented immigrants in their family may be nervous to seek traditional medical care. CHWs usually have similar experiences and can relate to the people they serve. 
3. Cultural relevance. Many cultures have unique ways to improve health. For example, addressing obesity is highly cultural. It would not be helpful to completely ignore the cultural part of diet or the cultural barriers to exercise.
4. Traveling to the community. CHWs can go to the people, instead of relying on people to seek services. This is especially needed in isolated (either physically or culturally) communities. For example, Kentucky Homeplace employs community health workers to deliver services in rural counties and improve health outcomes in those communities.
5. Quick training. Unlike public health educators, an individual can be trained quickly. For non-profits with quick grant cycle turn around, this is helpful because a CHW can get out into the community delivery services with only a couple weeks of training.
6. Cost-effective. Much of CHW’s work is preventative - for example prevention of ER visits, prevention of low-birth weight, or prevention of obesity. The Christus Spohn Health System links CHW activities to reductions inappropriate emergency department usage translating into a substantial cost saving as well as better health for the patient. Prevention, in general, is hard to do cost-benefit analysis for because of the challenging calculation of the amount saved by preventing a disease. However, in the simplest of terms, we know that chronic conditions, like obesity, are expensive for families and society and with fewer obese people, dollars would be saved. Unfortunately, there is little published research on the effectiveness of outcomes of CHW interventions.

Challenges of Community Health Workers.

While there are many benefits and success stories, there are also many challenges:

1. Recruitment. Finding the right person in the community can be difficult. Ideally, the CHW should already have personal connections with neighbors and a history of casual relationships. For tight-knit communities with high distrust of others, it could be challenging to find a person for a CHW role. Not only is it challenging to find the right person to be a CHW, it is difficult to find the right person to supervise CHWs.
2. Training. There isn’t one definitive CHW training. Training, evaluation, and outcome deliverables vary widely, so it is hard to compare programs and develop best practices.
3. Low education levels. What is a benefit of CHW programs (no need for advanced degrees) is also a challenge. Unlike public health educators, CHWs do not have the educational background that might be necessary in all situations. It is a challenge to make sure CHWs know what they need to be effective with the community.
4. Accountability. Since there is a wide variation in CHW’s tasks, it is hard to track their impact. Traditional models of employee accountability (also used for grant reporting) focus on measures such as number of people talked to. This might not always be a good measure since this is an individual approach and sometimes some families need more than others. CHWs are also out in the field and working alone, which makes it difficult to audit the authenticity of service delivery.

The future for CHWs

CHWs can be effective to improve health within the community, especially within communities that face barriers to health. The opportunities to improve health using CHWs outweigh the challenges. Some people will scoff at promoting CHWs without extensive research on cost-effectiveness or randomized control trials. The research, in someway, does need to be done but in the meantime innovate programs have improved health and that alone is exciting.