Vital Signs: Smoking and striking health disparities

I was not surprised to learn at the Eighth Annual Texas Conference on Health Disparities that: • Forty-five million people in this country, more than 20 percent of the adult population, still smoke. • Smoking accounts for more than 400,000 premature deaths each year. • Fully one-half of smokers in the U.S. today – 20 million Americans – will be killed prematurely by a disease directly caused by their smoking, on average robbing them of more than 10 years of life.

But I was very surprised when Professor Ellen R. Gritz said the smoking rate among people already diagnosed with chronic diseases associated with smoking is much higher than the rate among the well population or even among the overall population. Gritz, chairman of the Department of Behavioral Science at the University of Texas MD Anderson Cancer Center in Houston, said the current smoking rate among people with chronic diseases – any smoking-related chronic disease – is 36.9 percent, compared with 19.3 percent among Americans with no chronic disease.

In addition, 30 percent of patients diagnosed with cardiovascular diseases, 49.1 percent of those with emphysema and 41.1 percent of those with chronic bronchitis continue to smoke despite those diagnoses. Lung and head and neck cancers are most often attributed to smoking but the high risk for esophageal, bladder and cervix cancer has also been firmly established. In fact, 18 types of cancer are now blamed, at least in part, on cigarette smoking, Gritz said. Still, the smoking rate among those being treated for cancers other than lung cancer is an astounding 38.8 percent. Even among lung cancer patients, the rate is 20.9 percent.

Granted, many more were smokers when their cancer was first diagnosed. Fear of death causes many to quit immediately, but smoking is a chronic, relapsing condition. The initial high quit rates after surgery decline over time. For example, some 36.9 percent are smoking again within one year after surgery for non-small-cell lung cancer, Gritz said. Patients with cancers less strongly associated with smoking have even lower long-time quit rates. Overall 30 to 50 percent of cancer patients who smoke at the time of their diagnosis do not quit or relapse after their first attempt to quit.

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Gritz was on a panel of distinguished physicians and researchers presenting data at the conference, which was presented by the Texas Center for Health Disparities at the University of North Texas Health Science Center in Fort Worth. Nearly 425 people attended, many of them medical students and public health officials. The Texas Center for Health Disparities was established in September 2005 as a center of excellence designated by the National Institutes of Health to prevent, reduce and eliminate health disparities between minority and majority populations in Texas for such diseases as diabetes, cardiovascular disease, cancer, stroke and HIV. Texas is disproportionately affected by such disparities because it is one of only four states in the U.S. where non-Hispanic whites are in the minority. The general minority population in Texas surpassed the non-Hispanic white population in 2004 and is projected to increase substantially in the coming years.

Hispanics have the highest rates of diabetes and African Americans have the highest rates of HIV in Texas. Previous health disparities conferences have taken aim at breast cancer, diabetes, vision problems and other issues that disproportionately affect the most vulnerable populations. The theme of this year’s conference was “Intersection of Smoking, HIV/AIDS and Cancer.” While they make up only 11.5 percent of the Texas population, black people represent 39 percent of people with HIV, according to the Texas Department of State Health Services. Tying this all together is the fact that smoking rates are highest – an estimated 47 to 70 percent – among people living with HIV infections and AIDS.

Much of the discussion at this year’s conference centered around behavioral and pharmacological treatments for smoking cessation in disadvantaged populations. Overall, some 70 percent of smokers say they want to quit, 44 percent try to quit each year and 81 percent try at least once, but most attempts to quit are unaided, and only 4 to 7 percent of those who try to quit without any special counseling, tobacco substitutes or medications succeed.

Surely this is a health care area well worth our financial support not only for humanitarian reasons but also for monetary ones. The return on the dollar for smoking cessation programs is bound to be great considering: • Health care spending attributable to smoking in this country is now estimated at $96 billion per year in direct medical expenses and $97 billion in lost productivity. • If all smokers covered by state Medicaid programs quit, the annual savings to Medicaid would be $9.7 billion after five years.