Prevention and the Continuum of Disease Causation

UW Population Health Program Prevention and the Continuum of Disease Causation Patrick Remington, MD, MPH Overview • Thinking upstream in disease prevention • Disease prevention continuum and the role of epidemiology • Lung cancer example • Monitoring population health in tobacco control Causes of Death, 1900 Pneumonia Tuberculosis Gastritis Heart disease Stroke Kidney disease Injuries Cancer Diphtheria Other Causes of Death, 2000 Heart disease Cancer Stroke Lung Disease Injuries Pneumonia Diabetes HIV Suicide Other What is the leading cause of cancer death in the United States? a. Breast cancer b. Lung cancer c. Colon cancer d. Prostate cancer e. None of the above What is the leading cause of cancer death in the United States? e. None of the above Causes of Cancer Death, 1997 29% 46% 10% 7% 8% Lung Colon Breast Prostate All other Disease Continuum • Disease can be thought of as developing along a continuum, that ranges from health, to risk factors, to disease, and finally to death. Disease Continuum Health Risk Factors Disease Death Disease Continuum • Progression along continuum can be rapid – Drinking and driving • Progression can take lifetime – Poor diet and heart disease – Smoking and lung cancer Pathologic diagnosis: • Neck cancer • Lung cancer • Brain tumor Well-Differentiated Squamous Cell Carcinoma of the Lung Well-Differentiated Squamous Cell Carcinoma of the Lung Basic Science Approach • Learn the biomolecular mechanisms of lung cancer • Discover why cells become cancerous • Understand how cells communicate with one another Clinical approach • • • • • Surgery (thoracotomy) Radiation therapy Chemotherapy Pain relief Hospice and end-of-life care Epidemiology in Tobacco Control • Discover the “upstream” causes of lung cancer using epidemiology • Monitor population health to: – Define burden – Identify disparities – Evaluate impact • Support interventions Cancer Prevention Continuum Health Risk Factors Treatment Cancer Death Cancer Prevention Continuum Health Risk Factors Smoking? Cancer Death Definition of Epidemiology “The study of the distribution and determinants of health and diseases, morbidity, injuries, disability, and mortality in populations” Friis, 1996 Epidemiologic Studies • Compare the risk of disease in people who smoke to those who do not smoke • Control for differences in other factors • Calculate the “relative risk” – For example, “smokers are 10 times more likely to get lung cancer” Study Designs • Observational Studies – Descriptive – Case-control – Cohort • Interventional/Experimental – Clinical trials – Community trials Examples of Cohort Studies • Cancer Prevention Study I (Hammond) – 68,116 volunteers recruited over 1 million adults – completed form on health habits – followed every two years for 20 years – death certificates obtain for each death Age-Adjusted Death Rates from Lung Cancer by Smoking Level, CPS-I Rate/100,000 person-years 250 200 155 150 100 55 50 10 0 89 200 Nonsmoker 1-9 cig./day 10-19 cig/day 20-39 cig/day 40+ cig/day Source: Lilienfeld (p.207) Causes of Lung Cancer Risk Factors? Lung Cancer Causes of Lung Cancer Smoking Lung Cancer Causes of Lung Cancer Radon Lung Cancer Causes of Lung Cancer Passive smoke Lung Cancer Causes of Lung Cancer Genetics? Lung Cancer Causes of Lung Cancer 10% 2% Smoking Radon ETS 88% Can use epidemiology to learn the causes of: • • • • • Colon cancer Breast cancer Prostate cancer Other cancers Other diseases Causes of Colon Cancer 20% 20% High fat diet Low vegetable diet Physical inactivity Unknown 30% 30% Causes of Breast Cancer 12% 7% Obesity 5% 2% 74% Late birth No children Radiation Unknown Causes of Prostate Cancer 20% Diet? 5% Occupational exposures Unknown 75% Preventable Causes of Cancer Lung C a n ce r T o b a cco u se A lco h o l u se D ie t In a ctivity O b e sity M icro b e s/to xin s STDs TO TAL C o lo n C a n ce r B re a st C a n ce r P ro state C a n ce r O th er C a n ce r Preventable Causes of Cancer Lung C a n ce r T o b a cco u se A lco h o l u se D ie t In a ctivity O b e sity M icro b e s/to xin s STDs TO TAL X X X X X X X X X X X C o lo n C a n ce r B re a st C a n ce r P ro state C a n ce r O th er C a n ce r X X X X X X X Preventable Causes of Cancer Lung C a n ce r T o b a cco u se A lco h o l u se D ie t In a ctivity O b e sity M icro b e s/to xin s STDs TO TAL X X X X X X X X X X X C o lo n C a n ce r B re a st C a n ce r P ro state C a n ce r O th er C a n ce r X X X X X X X Preventable Causes of Cancer Lung C a n ce r T o b a cco u se A lco h o l u se D ie t In a ctivity O b e sity M icro b e s/to xin s STDs TO TAL X X X X X X X X X X X C o lo n C a n ce r B re a st C a n ce r P ro state C a n ce r O th er C a n ce r X X X X X X X “Preventable” Causes Cancer 9% 3% 7% 7% 10% Tobacco 29% Diet Microbes Toxins STDs Alcohol 35% Other Preventable Causes of Death C a n ce r H e a rt d ise a se C h ro n ic lu n g d ise a se T o b a cco u se A lco h o l u se H ig h ch o le ste ro l H yp e rte n sio n D ie t P h ysica l in a ctivity O b e sity TO TAL X X X X X X X X X X X X X X X X X TOTAL D ia b e te s C irrh o sis Preventable Causes of Death Tobacco Diet/activity Alcohol Microbes Toxins Sexual act. Firearms MVC Drugs McGinnis and Foege What is the leading cause of cancer death in the United States? e. None of the above (i.e., smoking) But what causes cigarette smoking? Cancer Prevention Continuum ? Health ? Smoking Cancer Death Epidemiology Studying why people move from one stage to another along the continuum Epidemiology of Smoking • Distribution – Who smokes? – What are the trends? • Determinants – What causes some children to start to smoke? – Why can some people quit and others not? Trends in Percent of Adults who Smoke, Wisconsin, 1985-2000 Percent smokers 30 25 20 15 10 5 0 1985 1987 1989 1991 1993 Year 2000 Goal 1995 1997 1999 BRFS Trends in Smoking by Education U.S., 1966-1995 Percent 50 40 30 20 10 0 1966 1974 1985 Year Health U.S., 1998 (1966 from SGR 1989) < HS High school Some college College degree 1995 Current Smoking by Education, Wisconsin Adults, 1996-2000 Percent Smokers 50 45 40 35 30 25 20 15 10 5 0 < High School High School Some College College Grad Current Smoking by Education, Wisconsin Adults, 1996-2000 Percent Smokers 50% 40% 30% 20% 10% 0% < High School High School Some College College Grad White Black Current Smoking by Income, Wisconsin Adults, 1996-2000 Percent Smokers 40% 35% 30% 25% 20% 15% 10% 5% 0% < $15,000 $15-$24,999 $25-$49,999 $50,000 + White Black Trends in Smoking During Pregnancy, Wisconsin, 1994-96 Percent Smokers 40 35 30 25 20 15 10 5 0 < High School High School Some College College Grad Trends in the Amount Smoked, Wisconsin Adults, 1985-1999 Percent of Smokers 70% 60% 50% 40% 30% 20% 10% 0% 1985 1987 1989 1991 Year 1993 1995 1997 1999 Trends in the Amount Smoked, Wisconsin Adults, 1985-1999 Percent of Smokers 70% 60% 50% 40% 30% 20% 10% 0% 1985 1987 1989 1991 Year 1993 1995 1997 1999 Current Smoking Prevalence among Adults in Wisconsin, by Age, 1984-1999 40 35 30 25-44 18-24 Percent 25 20 15 10 5 0 65+ 45-64 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 Source: Wisconsin Behavioral Risk Factor Survey, Bureau of Health Information, Department of Health and Family Services, 1984-1999. 00 (e st .) 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Current Smoking Prevalence among Adults in Wisconsin, by Age, 1984-1999 40 35 30 25-44 18-24 Percent 25 20 15 10 5 0 65+ 45-64 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 Source: Wisconsin Behavioral Risk Factor Survey, Bureau of Health Information, Department of Health and Family Services, 1984-1999. 00 (e st .) 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Summary of Trends in Tobacco Use • Cigarette smoking rates have declined only slightly since 1980 in Wisconsin and the US • Smoking rates are declining faster among those with more education • Smoking rates are increasing among young adults What are the Public Health Successes? • Examine trends in smoking over the past 50 years Trends in Per Capita Cigarette Sales, U.S., 1950-2000 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Trends in Per Capita Cigarette Sales, U.S., 1950-2000 Reader’s Digest 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Public Health Success Smoking may cause lung cancer Industry Response Filters make it safer Domestic Market Share of Filter vs. Non-Filter Cigarettes, 1952-1999 Filter 100% 90% 80% 70% Non-filter Percent 60% 50% 40% 30% 20% 10% 0% 1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 Trends in Per Capita Cigarette Sales, U.S., 1950-2000 Reader’s Digest 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Industry Response Trends in Per Capita Cigarette Sales, U.S., 1950-2000 1964 Surgeon General’s Report 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year First Report of the Surgeon General on Smoking and Health Public Health Success Smoking is harmful to health Industry Response Low tar and nicotine cigarettes are safer Domestic Market Share of Cigarettes by Tar Yield, 1967-1999 100 90 0-15 mg tar Percent of market (%) 80 70 60 50 40 30 20 10 0 0-6 mg tar 0-9 mg tar 0-12 mg tar 19 67 19 69 19 71 19 73 19 75 19 77 19 79 19 81 19 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 0-3 mg tar Trends in Per Capita Cigarette Sales, U.S., 1950-2000 1964 Surgeon General’s Report 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Industry Response Trends in Per Capita Cigarette Sales, U.S., 1950-2000 Non-smokers Rights 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Percent of Communities that have Banned Smoking in Gov‟t Buildings, 1997 Percent 100 90 80 70 60 50 40 30 20 10 0 1990 1995 Year Counties Cities/villages 1996 1997 Public Health Success Changing to a non-smoking social norm Industry Response Aggressive and targeted mass media campaign Cigarette Industry Advertising and Promotion Expenditures, 1963-1999 Millions of Dollars 8000 7000 6000 5000 4000 3000 2000 1000 0 Advertising Promotion 1976 1981 1986 1991 1996 Industry Statements on Advertising and Teenagers Philip Morris, Special Report: Young Smokers, Prevalence, Trends, Implications and Related Demographic Trends, March 31, 1981 “Today’s teenager is tomorrow’s potential regular customer, and the overwhelming majority of smokers first begin to smoke while still in their teens…The smoking patterns of teenagers are particularly important to Philip Morris.” Public Health Success Increasing price of cigarettes through excise taxes Tax on Cigarettes in Wisconsin, 1955-2000 Cents 70 60 50 40 30 20 10 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Tax in Cents Public Health Success Increasing price of cigarettes through excise taxes Industry Response Will not permit taxes to be indexed for inflation Tax on Cigarettes in Wisconsin, 1955-2000 Percent of Price/Cents 70 60 50 40 30 20 10 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Percent of Price Tax in Cents Trends in Per Capita Cigarette Sales, U.S., 1950-2000 Non-smokers Rights 140 130 120 110 100 90 80 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Industry Response Summary • For every success in tobacco control, the tobacco industry has a response • These responses present a new challenge to the tobacco control community What are Future Trends in Tobacco Use? • Disparities in tobacco use by socioeconomic status will continue to grow Trends in Smoking During Pregnancy, Wisconsin, 1994-96 Percent Smokers 40 35 30 25 20 15 10 5 0 < High School High School Some College College Grad What are the Recommended Public Health Strategies? What are the Recommended Public Health Strategies? What will be the Industry Response? • Lobby against increasing the excise tax • Continue to aggressively advertise and market cigarettes to youth and current smokers • Prevent communities from enacting smoke-free ordinances Smoking in the Movies Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Wisconsin Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Tobacco Industry Response? Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Tobacco Settlement? Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Trends in Per Capita Cigarette Sales, U.S., 1950-2010? Reader’s Digest 160 140 120 100 80 60 40 20 0 19 50 55 60 SGR Non-smokers Rights Public Health Success? Year 20 10 65 70 75 80 85 90 95 '0 0 '0 5 Recommendation #1 • Continue to monitor trends in tobacco use in the state and in communities – Local surveys – Data on smoking in pregnancy – The health and economic burden of smoking Recommendation #2 • Monitor the industry responses – International: Explosive growth in developing country markets – National level: New products such as Omni and advertising in movies – State level: Lobbying efforts in the capitol and contributions to legislators – Local level: Point of purchase advertising/ efforts to counter local clean air policies Summary • Diseases are caused by multiple factors • Epidemiology must focus „upstream‟ to look for the underlying causes of disease • Surveillance systems need to address the entire spectrum of tobacco control Pathologic diagnosis: • Metastatic adenocarcinoma of lung Epidemiologic diagnosis: • Cigarette smoking • Nicotine addition • Tobacco industry marketing Question • What are the best indicators to monitor for tobacco control?