US Surgeon Research Articles

Use of Electronic Nicotine Delivery Systems (ENDS) by pregnant women I: Risk of small-for-gestational-age birth.

INTRODUCTIONThe 2016 US Surgeon General’s Report suggests that the use of electronic nicotine delivery systems (ENDS) is a fetal risk factor. However, no previous study has estimated their effect on adverse pregnancy outcomes. We assessed the prevalence of current ENDS use in pregnant women and explored the effect on birth weight and smallness-for-gestational-age (SGA), correcting for misclassification from nondisclosure of smoking status.METHODSWe conducted a cohort study with 248 pregnant women using questionnaire data and biomarkers (salivary cotinine, exhaled carbon monoxide, and hair nicotine). We evaluated the association between birth weight and the risk of SGA by applying multivariate linear and log-binomial regression to reproductive outcome data for 232 participants. Participants who did not disclose their smoking status were excluded from the referent group. Sensitivity analysis corrected for misclassification of smoking/ENDS use status.RESULTSThe prevalence of current ENDS use among pregnant women was 6.8% (95% CI: 4.4–10.2%); most of these (75%) were concurrent smokers. Using self-reports, the estimated risk ratio of SGA for ENDS users was nearly two times the risk in the unexposed (RR=1.9, 95% CI: 0.6–5.5), and over three times that for ENDS-only users versus the unexposed (RR=3.1, 95% CI: 0.8–11.7). Excluding from the referent group smokers who did not disclose their smoking status, the risk of SGA for ENDS-only use was 5 times the risk in the unexposed (RR=5.1, 95% CI: 1.1– 22.2), and almost four times for all types of ENDS users (RR=3.8, 95% CI: 1.3–11.2). SGA risk ratios for ENDS users, corrected for misclassification due to self-report, were 6.5–8.5 times that of the unexposed.CONCLUSIONSOur data suggest that ENDS use is associated with an increased risk of SGA.

E-Cigarettes and Similar Devices.

Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among youth. The 2016 US Surgeon General's Report on e-cigarette use among youth and young adults concluded that e-cigarettes are unsafe for children and adolescents. Furthermore, strong and consistent evidence finds that children and adolescents who use e-cigarettes are significantly more likely to go on to use traditional cigarettes-a product that kills half its long-term users. E-cigarette manufacturers target children with enticing candy and fruit flavors and use marketing strategies that have been previously successful with traditional cigarettes to attract youth to these products. Numerous toxicants and carcinogens have been found in e-cigarette solutions. Nonusers are involuntarily exposed to the emissions of these devices with secondhand and thirdhand aerosol. To prevent children, adolescents, and young adults from transitioning from e-cigarettes to traditional cigarettes and minimize the potential public health harm from e-cigarette use, there is a critical need for e-cigarette regulation, legislative action, and counterpromotion to protect youth.

Do socio-cultural traits and other demographics affect outdoor recreation constraints? The case for Mesa County, Colorado

Physical activity from outdoor recreational pursuits is well known to be beneficial and has been encouraged by the US Surgeon General. Specific constraints, often reflected in sociocultural issues, can be impediments to individuals participating in outdoor recreational activities. Data were collected in conjunction with the Bureau of Land Management and the Mesa County Health Department in Colorado via surveys involving 580 residents of Mesa County regarding access to outdoor recreation. Ordinal logistic regression was used to test whether ten different constraints to outdoor recreation were important to the respondents, given their age, sex, education, race/ethnicity, native language, and residential density. The results indicated that the probability of experiencing outdoor constraints increased with lower education, Hispanic ethnicity, native Spanish speaking, and young age. A second model, albeit with fewer respondents, was tested to include income. The results of the second model were similar to the first model and also showed that lower incomes were associated with a higher probability of outdoor constraints. The results of the two models indicated that socioeconomic status was a driving factor behind constraints to outdoor recreation.

Using graphic warning labels to counter effects of social cues and brand imagery in cigarette advertising.

Exposure to cigarette advertising can increase the likelihood of youth smoking initiation and may encourage people who already smoke to continue. Requiring prominent, graphic warning labels could reduce these effects. We test whether graphic versus text-only warning labels in cigarette advertisements influence cognitive and emotional factors associated with youth susceptibility to smoking and adult intentions to quit. We conducted two randomized, between-subjects experiments with middle-school youth (n = 474) and adult smokers (n = 451). Both studies employed a two (graphic or text-only warnings) by two (advertisements with social cues or brand imagery) factorial design with a fifth, offset control group (social cue advertisements with the current US Surgeon General's Warning). Graphic warnings outperformed text-only warnings in reducing visual attention to the advertisement, generating visual attention to the warning and arousing more negative affect. Graphic warnings also reduced the appeal of cigarette brands among youth relative to social cue advertisements with the Surgeon General's warnings. None of the warnings (graphic or textual) influenced health risk beliefs. Graphic warning labels on cigarette advertisements appear to have effects similar to those observed on cigarette packs in previous work, with an added benefit of reducing cigarette brand appeal among youth.

Twenty-first century emergency response efforts of the Commissioned Corps of the US Public Health Service.

The impact of the Commissioned Corps of the US Public Health Service (Commissioned Corps) on the health and safety of the nation spans more than two centuries. The public health efforts of the highly qualified health professionals of this often-underreported uniformed service include fighting threats like the great flu pandemic of 1918, the anthrax attacks, Ebola, and natural disasters such as Hurricanes Maria, Irma, and Katrina. As we near the first quarter of the twenty-first century, it is important to take a snapshot of the critical contributions and response efforts the Commissioned Corps has made in the first 18 years of the twenty-first century. Today, the Commissioned Corps faces new challenges in the form of emerging diseases and a rapidly growing opioid epidemic, but under the guidance of the US Surgeon General, it remains vigilant and fully capable of minimizing any public health threat it encounters.

Proportion of Adults Who Identified Walking As a US Surgeon General Priority

In September 2015, Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities (Call to Action) was released. This descriptive study reports the proportion of adults who responded to the 2016 Summer ConsumerStyles survey (N = 4,114) who identified walking as the activity the US Surgeon General recently promoted in the Call to Action to help Americans be more physically active. Less than half of adults (44%) correctly identified walking. Adults who were aged 18 to 24 years (35%), were male (43%), were non-Hispanic white (42%), or were physically inactive (36%) were less likely to identify walking than their counterparts. This study highlights an opportunity to raise awareness and promote the Call to Action, especially among certain populations.

ED visits for AMI, Stroke, ACS & COPD after the Statewide Smoking Ban in Cook Co., IL

ObjectiveTo utilize ED chief complaint data obtained from syndromic surveillance to quantify the effect of the Illinois smoking ban on acute myocardial infarction (AMI), acute coronary syndrome (ACS), stroke, and chronic obstructive pulmonary disease (COPD) related ED visits in adults in Cook County, IL.IntroductionTobacco use is the leading global cause of preventable death, killing more than five million people per year [1]. In addition, exposure to secondhand smoke is estimated to kill an additional 600,000 people globally each year [1]. In 1986, the US Surgeon General’s Report declared secondhand smoke to be a cause of lung cancer in healthy nonsmokers [2].The first law restricting smoking in public places was enacted in 1973 in Arizona that followed the 1972 Surgeon General’s Report providing awareness of the negative health effects associated with the exposure to air pollution from tobacco smoke [3]. Smoke-free laws were slowly enacted after this time point with most occurring after the year 2000 [4].In July 2007, the Smoke Free Illinois Act (SB0500, Public Act 095-0017) was passed in IL [5]. The ban went into effect on Jan 1, 2008 and Illinois joined 22 other states in prohibiting smoking in virtually all public places and workplaces including offices, theaters, museums, libraries, schools, commercial establishments, retail stores, bars, private clubs, and gaming facilities [5-6].While many studies have examined the effect of smoking bans on hospitalizations, this study would be the first to examine the effect of the comprehensive smoking ban in IL on ED visits by utilizing chronic disease categories created with ED chief complaint data captured by syndromic surveillance [7]. The author hypothesizes that the comprehensive smoking ban in IL significantly reduced the ED visits associated with AMI, ACS, stroke, and COPD in adults in Cook County, IL.MethodsED visits with chief complaints consistent with categories for AMI, ACS, stroke and COPD captured by the Cook Co. Dept. of Public Health local instance of ESSENCE from Jan 1, 2006 – Dec 31, 2013 were included in the analysis. Proc Genmod with a log link and negative binomial distribution was utilized for the analysis. All data was aggregated at the monthly level. The total number of ED visits of the health effect of interest was the dependent variable. The total ED visits during the same period of time, was used as the offset variable, sub-grouped by age and gender where appropriate. A binary variable was utilized to capture the effect of the time period after the implementation of the statewide smoking ban; 0 for before the ban and 1 for after the ban. When examining the effect of the statewide ban, Cook Co. as an entirety was examined as well as ED visits stratified by zip codes that already had a smoking ban in place at that time point and those that did not, and stratifying by urban (Chicago) vs. suburban Cook Co. Seasonality was addressed by including month, month squared and month cubed in the model. Influenza was addressed by including a binary variable to indicate when influenza was occurring in the area based on percent influenza-like-illness ED visits that were occurring above the threshold for the area during that time period. Age and gender were also evaluated as confounders and effect modifiers. SAS 9.4 was utilized to perform the analyses.ResultsResults are presented in Table 1. Reductions of ED visits after the smoking ban implementation were seen in AMI and ACS disease categories for the overall adjusted model, at 3% and 3.5% respectively. Stroke associated ED visits were not affected by the smoking ban. COPD associated ED visits were not reduced immediately by the smoking ban, but did have a significant reduction 6 months after implementation of the ban at 3.6%. Stronger effects were seen in individuals 70 years and older, females, the urban population, and zip codes without a prior ban for AMI, ACS, and COPD.ConclusionsAn immediate, significant reduction in ED visits associated with AMI and ACS was associated with the IL statewide smoking ban in Cook Co., IL. COPD associated ED visits were significantly reduced 6 months after the ban implementation. The effect was greater in individuals 70 years and older, females, the urban population, and zip codes without a prior ban.

Current Scope of Practice for Newborn Care in Non-Intensive Hospital Settings.

The scope of practice for newborn care in nonintensive hospital settings is ever changing, with obstetric care advances, shorter length of stay (LOS), and increased family-centered care.[1][1] In response to the US Surgeon General’s call to support breastfeeding and Baby Friendly USA, more infants

Emerging Data Show E-Cigarettes May Pose Heart Risk.

The use of e-cigarettes likely poses a risk to heart health based on emerging data that suggest it increases cardiovascular risk factors. E-cigarettes are often promoted as a safer alternative to traditional tobacco cigarettes or even as a cessation tool. The perception that these devices are safer than cigarettes has led to a surge in their use. A 2016 report from the US Surgeon General, for example, noted that 1 in 6 teens now uses e-cigarettes, even as use of traditional cigarettes has dropped in this age group. This has canceled out some of the gains in reducing youth use of nicotine-containing products, explained Holly R. Middlekauff, MD, a cardiologist and professor of medicine at the University of California-Los Angeles. > “People who wouldn’t have used tobacco products in the past are using e-cigarettes now probably because they think they are harmless,” she said. However, limited data are available on the health effects of e-cigarettes, particularly the long-term effects of exposure, which could take decades to fully understand. Preliminary studies, however, have suggested that e-cigarette use may cause cardiovascular system changes that have been linked to increased cardiovascular risk. > “The main message is they are not harmless,” Middlekauf said. Preliminary studies suggest that e-cigarettes may be associated with heart risks. In an e-cigarette, nicotine is heated …

The opioid epidemic is an historic opportunity to improve both prevention and treatment

The current narrative describing the national opioid epidemic as the result of overprescribing opioid pain medicines fails to capture the full dimensions of the problem and leads to inadequate and even confounding solutions. Overlooked is the fact that polysubstance use is nearly ubiquitous among overdose deaths, demonstrating that the opioid overdose death problem is bigger than opioids. The foundation of the nation’s opioid overdose crisis – and the totality of the nation’s drug epidemic – is widespread recreational pharmacology, the use of drugs for fun or “self-medication.” The national focus on opioid overdose deaths provides important new opportunities in both prevention and treatment to make fundamental changes to the way that substance use disorders and related problems are understood and managed.The first-ever US Surgeon General’s report on addiction provides a starting point for systemic changes in the nation’s approach to preventing, treating and managing substance use disorders as serious, chronic diseases. New prevention efforts need to encourage youth to grow to adulthood not using alcohol, nicotine, marijuana or other drugs for reasons of health. New addiction treatment efforts need to focus on achieving long-term recovery including no use of alcohol, marijuana and other drugs.

More Evidence Linking Smoke-Free Legislation and Lower Risk of Prematurity and Low Birth Weight.

Premature and low birth weight infants have increased mortality and morbidities including chronic respiratory symptoms, neurocognitive deficits, feeding difficulties, and retinopathy of prematurity. These sequelae often result in prolonged hospitalizations, frequent readmissions, and need for subspecialty care. Direct and indirect costs for the care of these children can be significant. Reduction of maternal secondhand smoke exposure during pregnancy has been identified as a modifiable risk factor for both preterm and low birth weight infants. The most recent US Surgeon General’s report on secondhand smoke noted a causal relationship between maternal exposure to secondhand smoke and a reduction in birth weight as well as a suggestive relationship between the same exposure and preterm delivery,1 underscoring the … Address correspondence to Karen M. Wilson, MD, MPH, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029. E-mail: karen.wilson{at}mssm.edu

Perceptions of Harm to Children Exposed to Secondhand Aerosol From Electronic Vapor Products, Styles Survey, 2015.

IntroductionThe US Surgeon General has concluded that e-cigarette aerosol is not harmless and can contain harmful and potentially harmful chemicals, including nicotine. We assessed factors associated with adults’ perceptions of harm related to children’s exposure to secondhand aerosol from electronic vapor products (EVPs).MethodsData came from the 2015 Styles, an Internet panel survey of US adults aged 18 years or older (n = 4,127). Respondents were asked whether they believe aerosol from other people’s EVPs causes children harm. Harm perceptions were assessed overall and by cigarette smoking, EVP use, and sociodemographic characteristics. Multinomial logistic regression was used to assess odds of perceived harm.ResultsOverall, 5.3% of adults responded that secondhand EVP exposure caused “no harm” to children, 39.9% responded “little harm” or “some harm,” 21.5% responded “a lot of harm,” and 33.3% responded “don’t know.” Odds of “no harm” response were greater among men than among women, current and former cigarette smokers than among never smokers, and current and former EVP users than among never users; odds were lower among non-Hispanic blacks, Hispanics, and non-Hispanic other races than among non-Hispanic whites. Odds of responding “don’t know” were greater among men, current cigarette smokers, and current and former EVP users; odds were lower among those aged 45 to 64 years than those aged 18 to 24 years and lower among non-Hispanic other races and Hispanics than non-Hispanic whites.ConclusionTwo-fifths of US adults believe that children’s exposure to secondhand EVP aerosol causes some or little harm, while one-third do not know whether it causes harm. Efforts are warranted to educate the public about the health risks of secondhand EVP aerosol, particularly for children.

An Osteopathic Approach to Chronic Pain Management.

Chronic pain reduces quality of life and productivity, costing billions in health care dollars and lost revenue. Physicians routinely prescribe opioids, which has led to opioid addiction and overdose. The US surgeon general recommends nonpharmacologic treatment for patients with chronic pain. A paradigm shift is necessary for patients to partner with physicians to take control of their own health. This article outlines the cognitive behavioral approaches, nonopioid therapies, and nonpharmacologic therapies that osteopathic physicians can integrate in their treatment of patients with chronic pain.

US surgeon general: doctors have central role in solving opioid epidemic

Vivek Murthy, the US surgeon general, has highlighted prescription opioid misuse as a serious public health problem. Richard Hurley spoke to him about what he thinks needs to be done

The Role of Pharmacy Through Collaborative Practice in an Ambulatory Care Clinic.

Pharmacists have been practicing in ambulatory care environments managing patients with chronic illnesses since the 1970s. The US Surgeon General and the Centers for Disease Control and Prevention support pharmacists working in collaboration with physicians to optimize medication outcomes, improve patient satisfaction, and lower health care costs. Through collaborative practice agreements, pharmacists are able to work as part of a health care team with access to electronic health records, and they assist busy physicians manage patients with chronic diseases such as diabetes. This article will review the different types of ambulatory care practice settings, what is included in a collaborative practice agreement, the credentialing and privileging of pharmacists working in such environments, the qualifications of pharmacists, the scope of practice, and some challenges for reimbursement.

ED12.05 Tobacco Control Policies in Japan

ED12.05 Tobacco Control Policies in Japan

Pooled analysis of active cigarette smoking and invasive breast cancer risk in 14 cohort studies.

The 2014 US Surgeon General's report noted research gaps necessary to determine a causal relationship between active cigarette smoking and invasive breast cancer risk, including the role of alcohol consumption, timing of exposure, modification by menopausal status and heterogeneity by oestrogen receptor (ER) status. To address these issues, we pooled data from 14 cohort studies contributing 934 681 participants (36 060 invasive breast cancer cases). Cox proportional hazard regression models were used to calculate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Smoking duration before first birth was positively associated with risk ( P -value for trend = 2 × 10 -7 ) with the highest HR for initiation >10 years before first birth (HR = 1.18, CI 1.12-1.24). Effect modification by current alcohol consumption was evident for the association with smoking duration before first birth ( P -value=2×10 -4 ); compared with never-smoking non-drinkers, initiation >10 years before first birth was associated with risk in every category of alcohol intake, including non-drinkers (HR = 1.15, CI 1.04-1.28) and those who consumed at least three drinks per day (1.85, 1.55-2.21). Associations with smoking before first birth were limited to risk of ER+ breast cancer ( P -value for homogeneity=3×10 -3 ). Other smoking timing and duration characteristics were associated with risk even after controlling for alcohol, but were not associated with risk in non-drinkers. Effect modification by menopause was not evident. Smoking, particularly if initiated before first birth, was modestly associated with ER+ breast cancer risk that was not confounded by amount of adult alcohol intake. Possible links with breast cancer provide additional motivation for young women to not initiate smoking.

Exposure to secondhand smoke and risk of peripheral arterial disease in southern Chinese non-smokers: The Guangzhou Biobank Cohort Study-Cardiovascular Disease Sub-cohort.

Objectives We studied the association between secondhand smoke (SHS) exposure and peripheral arterial disease (PAD) in Chinese non-smokers. Methods We conducted a cross-sectional study using baseline data from the Guangzhou Biobank Cohort Study: Cardiovascular Disease Sub-cohort Study (GBCS-CVD). Guangzhou residents aged ≥ 50 years were recruited between 2003 and 2008. Baseline data included measurement of ankle brachial pressure index (ABPI) and self-reported smoking status and SHS exposure. Univariate and multivariate logistic regression analyses were used to analyze the association between SHS and PAD (defined as ABPI < 0.9). Results Of the 1507 non-smokers, 24 (1.6%) had PAD. Of these, 12 were men and 12 were women. Exposure to SHS at home of ≥25 h per week was reported by 16.7% of PAD cases compared with 3.8% of those without PAD (χ2 test, p = 0.003). After adjustment for potential confounders, exposure to ≥25 h per week at home was still associated with PAD (adjusted OR 7.86, 95% CI 2.00-30.95, p = 0.003), with suggestion of a dose-response relationship. Conclusions Our results extend the US Surgeon General's 2006 report that SHS exposure is an independent risk factor for PAD. National smoke-free legislation is needed to protect all people from exposure.

Management of screening-detected stage I lung cancer.

Easily the biggest development in the fight against lung cancer since the 1964 US Surgeon General’s report directly linked tobacco use to lung cancer, is the emergence of high-quality data clearly establishing the efficacy and cost-effectiveness of computed tomographic (CT)-screening as a means of improving lung cancer survival (1-4). Only tobacco control for primary prevention can have greater population-level impact on lung cancer mortality and survival statistics (5). Given the tight link between stage at treatment and survival, CT screening, by allowing early identification, leads to high lung cancer cure rates (3). Participation in screening is also a tremendous teachable moment that can potentially enhance smoking cessation, thereby contributing to primary (and secondary) prevention.

C. Everett Koop: Pioneer in Pediatric Surgery, US Surgeon General, and Early Contributor to Pediatric Urology

C. Everett Koop: Pioneer in Pediatric Surgery, US Surgeon General, and Early Contributor to Pediatric Urology