Health Risk Factors and Disease Prevention

Tobacco Use

In recent years, progress in reducing tobacco use has slowed.

Cigarette smoking remains the Nation’s leading cause of premature, preventable death; during 2000–2004, approximately 443,000 premature deaths in the United States each year were attributed to cigarette smoking (1). Smoking causes deaths from heart disease, stroke, lung and other types of cancer, and chronic lung diseases. Smoking during pregnancy is an important preventable cause of poor pregnancy outcomes (2). Exposure to secondhand smoke causes premature death and disease in children and adults who do not smoke themselves (3). Decreasing cigarette smoking among adolescents and adults is a major public health objective for the United States. Preventing smoking among teenagers and young adults is essential because smoking usually begins in adolescence (4). Helping smokers quit smoking, as early in life as possible, is critical to avoid the negative health effects of long-term tobacco use. The Institute of Medicine has issued a blueprint for further reducing tobacco use, including several measures aimed at reducing use among youth (5).

Following the Surgeon General’s report on smoking in 1964, cigarette smoking declined sharply for men and at a slower pace for women, thus narrowing the gap between smoking rates for men and women (Figure 6). Declines in current cigarette smoking over the past two decades have slowed compared with earlier periods (data table for Figure 6). In 2007, 22% of men and 17% of women were current cigarette smokers (crude estimate, Table 60). Men 25–34 years of age were most likely to smoke cigarettes (29% in 2007), and this percentage decreased with increasing age. Among women 18–64 years of age, 19%–20% were current cigarette smokers, and the percentage of current cigarette smoking declined substantially among women 65 years of age and over (8%).

Figure 6. Cigarette smoking among men, women, and high school students: United States, 1965–2007.

Figure 6

Cigarette smoking among men, women, and high school students: United States, 1965–2007. Click here for spreadsheet version Click here for Powerpoint NOTES: Estimates for men and women are age-adjusted. Cigarette smoking is defined as (for men (more...)

Educational attainment is closely linked to cigarette use. In 2007, adults with less than a high school education were three times as likely to smoke as those with a bachelor’s degree or more education (Table 61). Cigarette smoking also varied by race and ethnicity and gender, with the highest prevalence found among non-Hispanic black men and American Indian and Alaska Native men (Table 62).

In 2007, 20% of high school students in grades 9–12 had smoked cigarettes in the past month. Male high school students were equally as likely to smoke as female high school students (6). Cigarette smoking rates among high school students peaked during 1995–1999 and then decreased (Figure 6). Since 2003, cigarette smoking rates among high school students have held steady at 20%–23%. Fourteen percent of high school students had smoked cigars, and 8% had used smokeless tobacco in the past month in 2007 (4). Also in 2007, about one-half of high school students who were current cigarette smokers reported they had tried to quit smoking cigarettes in the past year.

References

1.
CDC. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR . 2008. pp. 1226–8. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5745a3.htm. [PubMed: 19008791]
2.
CDC. The health consequences of smoking: A report of the Surgeon General. Washington, DC: U.S. Government Printing Office; 2004. Available from: http://www​.cdc.gov/tobacco​/data_statistics​/sgr/sgr_2004/index.htm.
3.
CDC. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Washington, DC: U.S. Government Printing Office; 2006. Available from: http://www​.cdc.gov/tobacco​/data_statistics/sgr/2006/index​.htm.
4.
CDC. Preventing tobacco use among young people: A report of the Surgeon General. Washington, DC: U.S. Government Printing Office; 1994. Available from: http://www​.cdc.gov/tobacco​/data_statistics/sgr/1994/index​.htm.
5.
Institute of Medicine. Ending the tobacco problem: A blueprint for the nation. Washington, DC: National Academies Press; 2007. Available from: http://www​.nap.edu/catalog/11795.html.
6.
Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth Risk Behavior Surveillance— United States, 2007. In: Surveillance Summaries, 6 Jun 2008. MMWR. 2008. pp. 1–131. Available from: www​.cdc.gov/HealthyYouth​/yrbs/pdf/yrbss07_mmwr.pdf. [PubMed: 18528314]

Overweight and Obesity

The percentage of American adults who are obese has doubled over the past three decades to about one-third of all adults.

Excess body weight is associated with excess morbidity and mortality (1). Obesity is correlated with excess mortality and is associated with increased risk of heart disease, stroke, diabetes, some cancers, hypertension, osteoarthritis, gallbladder disease, and disability (1–7). The health care costs associated with obesity and its associated conditions are thought to be substantial, and a recent study suggests that the health care costs associated with obesity are rising for both private and public payers (1,8). Among children and adolescents, overweight increases the risk of hypertension, high cholesterol, orthopedic disorders, sleep apnea, diabetes, low self-esteem, and becoming an overweight adult (9,10). Diet, physical inactivity, genetic factors, environment, and health conditions all contribute to overweight and obesity. The potential health benefits from reducing the prevalence of overweight—and obesity in particular—are of significant public health importance.

The prevalence of overweight (body mass index (BMI) greater than or equal to 25) and obesity (BMI greater than or equal to 30, a subset of overweight) changed little between the early 1960s and 1976–1980 (Figure 7). Findings from the National Health and Nutrition Examination Survey show substantial increases in overweight among adults starting with 1988–1994 data. The upward trend in overweight since 1976–1980 reflects an increase in the percentage of adults who are obese, although the adult population is heavier in general (11). The percentage of adults 20–74 years of age who are obese (BMI greater than or equal to 30) has more than doubled from 15% in 1976–1980 to 35% in 2005–2006 (age-adjusted) (Figure 7). The sharp increases in the percentage of adults who are obese seen from 1976–1980 to 1999–2000 have tapered off in more recent years (data table for Figure 7). There was no significant change in the prevalence of adult obesity between 2003–2004 and 2005–2006 (11). In contrast to increases in obesity over time, the percentage of adults who are overweight but not obese (BMI greater than or equal to 25 but less than 30) has held steady at about one-third since 1960–1962 (Figure 7 and Table 72), although the trends for some subgroups differ from the overall pattern.

Figure 7. Overweight and obesity, by age: United States, 1960–2006.

Figure 7

Overweight and obesity, by age: United States, 1960–2006. Click here for spreadsheet version Click here for Powerpoint NOTES: Estimates for adults are age-adjusted. For adults: overweight including obese is defined as a body mass index (BMI) greater (more...)

The increasing prevalence of obesity among adults has been accompanied by an increase of overweight among children (defined as a BMI at or above the sex- and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts). The percentage of children (6–11 years of age) and adolescents (12–17 years of age) who are overweight has risen since 1976–1980. In 2005–2006, 15%–18% of school-age children and adolescents were overweight (Figure 7). The percentage of preschool-age children (2–5 years of age) who are overweight doubled from 1976–1980 (5%) to 2005–2006 (11%) (12) (Figure 7; also see Table 73).

Overall, the prevalence of obesity among adults did not vary by sex. In 2003–2006, 33% of men and 35% of women 20–74 years of age were obese (Table 72, age-adjusted). The prevalence of obesity among women differed significantly by racial and ethnic group (among the groups presented). In 2003–2006, one-half of non-Hispanic black women and two-fifths of Mexican American women were obese compared with one-third of non-Hispanic white women. In contrast, the prevalence of obesity among men was similar by race and ethnicity.

References

1.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. NIH pub no 98-4083. Bethesda, MD: National Institutes of Health; 1998. Available from: http://www​.nhlbi.nih​.gov/guidelines/obesity/ob_gdlns.htm.
2.
National Task Force on the Prevention and Treatment of Obesity. Overweight, obesity, and health risk. Arch Intern Med. 2000;160(7):898–904. [PubMed: 10761953]
3.
U.S. Department of Health and Human Services (DHHS) The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: DHHS; 2001. Available from: http://www​.surgeongeneral​.gov/topics/obesity/
4.
Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology. 2007;132(6):2087–102. [PubMed: 17498505]
5.
Gregg EW, Guralnik JM. Is disability obesity’s price of longevity? JAMA. 2007;298(17):2066–7. [PubMed: 17986703]
6.
Alley DE, Chang VW. The changing relationship of obesity and disability, 1988–2004. JAMA. 2007;298(17):2020–7. [PubMed: 17986695]
7.
World Cancer Research Fund/American Institute for Cancer Research (AICR) Food, nutrition, physical activity, and the prevention of cancer: A global perspective. Washington, DC: AICR; 2007.
8.
Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Aff (Millwood) 2009;28(5):w822–w831. [PubMed: 19635784]
9.
Dietz WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics. 1998;101(3 Pt 2):518–25. [PubMed: 12224658]
10.
Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, Kelnar CJH. Health consequences of obesity. Arch Dis Child. 2003;88(9):748–52. [PMC free article: PMC1719633] [PubMed: 12937090]
11.
Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—No statistically significant change since 2003–2004. NCHS data brief; no 1. Hyattsville, MD: NCHS; 2007. Available from: http://www​.cdc.gov/nchs​/data/databriefs/db01.pdf.
12.
CDC/NCHS. Health E-stats. Hyattsville, MD: NCHS; 2006. Prevalence of overweight among children and adolescents: United States, 2003–2004.

Sleep

In 2005–2006, women were more likely than men to report having trouble sleeping or frequently using sleeping pills or other medications to help them sleep.

Americans are not getting enough sleep, and it is more than just a nighttime annoyance. Sleep deprivation affects decision making, memory, and mood, in addition to negatively impacting hormone release, glucose regulation, and cardiovascular function (1,2). Sleep deprivation may also be associated with the increased prevalence of obesity and Type 2 diabetes (3). Lack of sleep has direct costs, including the cost of physician visits for diagnosis and treatment of insomnia, tests for the evaluation of sleep, prescription and over-the-counter medications to aid sleep, and other types of treatment for insomnia (4). Indirect societal costs include increased absenteeism, decreased worker productivity, and higher injury rates, including motor vehicle crash rates (4,5).

Primary insomnia is difficulty getting to sleep or staying asleep, or having nonrefreshing sleep for at least 1 month without any known physical or mental condition (6). Common causes of primary insomnia include alcohol, caffeine, stress, and anxiety. Secondary insomnia is insomnia caused by a medical condition, often depression. Symptoms of insomnia include difficulty falling asleep, waking up several times during the night, and feeling tired. The new generation of prescription medications may help sleep without the addictive component of older medications, but as with all medications, they are not without side effects or concerns (7,8).

In 2005–2006, 30% of American adults reported they often or almost always (5–30 times in the past month) had trouble sleeping, which included trouble falling asleep, staying asleep, or waking up too early in the morning and not being able to get back to sleep (data table for Figure 8). Women 18–64 years of age were more likely than men of the same age group to report often or almost always having difficulty sleeping in the past month (Figure 8). Among older adults, women and men were equally as likely to report they often or almost always had trouble sleeping.

Figure 8. Trouble sleeping or sleeping pill use in the past month among adults 18 years of age and over, by sex and age: United States, 2005–2006.

Figure 8

Trouble sleeping or sleeping pill use in the past month among adults 18 years of age and over, by sex and age: United States, 2005–2006. Click here for spreadsheet version Click here for Powerpoint NOTES: Often or almost always is defined as 5–30 (more...)

In 2005–2006, 9% of American adults reported they often or almost always (5–30 times in the past month) took sleeping pills or other medications to help them sleep (data table for Figure 8). Women 18–64 years of age were more likely than men to have used sleeping pills or other medications in the past month to help them sleep. Women 18–44 years of age were nearly three times as likely, and women 45–64 were nearly two and a half times as likely, as men of the same age group to often or almost always use sleeping pills or medications to help them sleep (Figure 8).

References

1.
Harrison Y, Horne JA. The impact of sleep deprivation on decision making: A review. J Exp Psychol Appl. 2000;6(3):236–49. [PubMed: 11014055]
2.
Knutson KL, Spiegel K, Penev P, Van Cauter E. The metabolic consequences of sleep deprivation. Sleep Med Rev. 2007;11:163–78. [PMC free article: PMC1991337] [PubMed: 17442599]
3.
Van Cauter E, Spiegel K, Tasali E, Leproult R. Metabolic consequences of sleep and sleep loss. Sleep Med. 2008;9(Suppl 1):S23–28. [PubMed: 18929315]
4.
Kryger MH. The burden of chronic insomnia on society. Manag Care. 2006;15:1–5. 17. [PubMed: 17175621]
5.
Stutts JC. Sleep deprivation countermeasures for motorist safety National Cooperative Highway Research Program Synthesis 287. Washington, DC: Transportation Research Board, National Research Council; 2000. Available from: http://onlinepubs​.trb​.org/onlinepubs/nchrp/nchrp_syn_287.pdf.
6.
National Institutes of Heath, National Library of Medicine. Primary insomnia [online] Medline Plus Encyclopedia. Available from: http://www​.nlm.nih.gov​/medlineplus/ency/article/000805​.htm#Definition.
7.
News & Events. U.S. Food and Drug Administration; 14 Mar, 2007. FDA requests label change for all sleep disorder drug products [press release] Available from: http://www​.fda.gov/NewsEvents​/Newsroom/PressAnnouncements​/2007/ucm108868.htm.
8.
Pagel JF. Medications and their effects on sleep. Prim Care. 2005;32(2):491–509. [PubMed: 15935197]

Influenza and Pneumococcal Vaccination Among Middle-age and Older Adults

Between 1989 and 2007, influenza and pneumococcal vaccination levels increased substantially, but differences by age remain.

Vaccination of persons at risk for complications from influenza is a key public health strategy for preventing morbidity and mortality in the United States. In the United States, annual epidemics of influenza occur typically during the winter season (1). It was estimated that during 1990–1999, approximately 36,000 of the respiratory and circulatory deaths that occurred each year were associated with influenza (1). During 1979–2001, an estimated 226,000 of the primary respiratory and circulatory hospitalizations that occurred each year, on average, were associated with influenza (2).

In April 2000, the Advisory Committee on Immunization Practices (ACIP) recommended that all adults 50 years of age and over receive an annual influenza vaccination (3). In response to the unexpected shortfall in the 2000–2001 and 2004–2005 influenza vaccine supply, the ACIP and CDC modified the universal recommendation for influenza vaccination among adults 50 years of age and over and established vaccine priority groups. These groups included persons 65 years of age and over and children and adults with chronic underlying health conditions (4,5).

Between 1989 and 1997, influenza vaccine coverage among persons living in the community tripled for adults 50–64 years of age and approximately doubled for all age groups of adults 65 years and over (Figure 9). Between 1997 and 2004, influenza vaccine coverage remained essentially stable. As a result of the 2004–2005 influenza vaccine shortage, 2005 estimates of vaccine coverage decreased among adults 50–64 years, 65–74 years, and 75–84 years of age and were unchanged among adults 85 years of age and over. In 2006 and 2007, influenza vaccine coverage generally returned to the 2004 level. Influenza vaccine coverage increases with older age; persons 85 years of age and over were twice as likely as those 50–64 years of age to have had a vaccination in the past 12 months in 2007.

Figure 9. Influenza and pneumococcal vaccination among middle-age and older adults, by age: United States, 1989–2007.

Figure 9

Influenza and pneumococcal vaccination among middle-age and older adults, by age: United States, 1989–2007. Click here for spreadsheet version Click here for Powerpoint NOTES: In 1997, the Advisory Committee on Immunization Practices recommended (more...)

Pneumococcal infection is a serious disease that kills more people in the United States each year than any other vaccine-preventable bacterial disease (6). Each year in the United States, pneumococcal infection causes an estimated 40,000 deaths, with the highest death rates among older persons and those with underlying medical conditions. A one-time pneumococcal polysaccharide vaccine has been recommended by the ACIP since 1997 for all adults 65 years of age and over.

Between 1989 and 2007, the percentage of noninstitutionalized adults 65 years of age and over who reported ever having received a pneumococcal vaccination increased from 14% to 58% (Figure 9). Pneumococcal vaccination coverage has remained consistently below that of influenza vaccination coverage. Pneumococcal vaccination rates were lower among adults 65–74 years of age than among adults 75–84 years of age and 85 years of age and over.

References

1.
Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, Fukuda K. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003;289(2):179–86. [PubMed: 12517228]
2.
Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox NJ, Fukuda K. Influenza-associated hospitalizations in the United States. JAMA. 2004;292(11):1333–40. [PubMed: 15367555]
3.
CDC. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR. 2007. pp. 1–60. Available from: http://www​.cdc.gov/mmwr/PDF/rr/rr5606​.pdf. [PubMed: 17625497]
4.
CDC. Notice to readers: Updated recommendations from the Advisory Committee on Immunization Practices in response to delays in supply of influenza vaccine for the 2000–01 season. MMWR. 2000. pp. 619–22. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm4927a4.htm. [PubMed: 10914929]
5.
CDC. Interim influenza vaccination recommendations 2004–05 influenza season. MMWR. 2004. pp. 923–4. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5339a6.htm. [PubMed: 15614237]
6.
CDC. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR. 1997. pp. 1–24. Available from: http://www​.cdc.gov/mmwr/PDF/rr/rr4608​.pdf. [PubMed: 9132580]