White infant mortality in Appalachian states, 1976-1980 and 1996-2000: changing patterns and persistent disparities

Purpose: Appalachian counties have historically had elevated infant mortality rates. Changes in infant mortality disparities over time in Appalachia are not well‐understood. This study explores spatial inequalities in white infant mortality rates over time in the 13 Appalachian states, comparing counties in Appalachia with non‐Appalachian counties. Methods: Data are analyzed for 1,100 counties in 13 Appalachian states that include 420 counties designated as Appalachian by the Appalachian Regional Commission. Area Resource File data for 1976‐1980 and 1996‐2000 provide county‐ and city‐level infant mortality rates, poverty rates, rural‐urban continuum codes, and numbers of physicians per 1,000 residents. Multiple regression analyses evaluate whether Appalachian counties are significantly associated with elevated white infant mortality in each time period, accounting for covariates. Findings: White infant mortality rates decreased substantially in all sub‐regions over the last 2 decades; however, disparities in infant mortality did not diminish in Appalachian counties compared to non‐Appalachian counties. After accounting for poverty, rural/urban status, and health care resources, Appalachian counties were significantly associated with comparatively higher infant mortality during the late 1970s but not in the late 1990s. At the more recent time point, higher poverty rates, residence in more rural areas, and lower physician density were associated with greater infant mortality risk. Conclusion: Appalachian counties continue to experience relatively elevated infant mortality rates. Poverty and rurality remain important dimensions of health service need in Appalachia.     

Cancer Mortality Rates in Appalachia: Descriptive Epidemiology and an Approach to Explaining Differences in Outcomes

Cancer is a leading cause of death in the Appalachian region of the United States. Existing studies compare regional mortality rates to those of the entire nation. We compare cancer mortality rates in Appalachia to those of the nation, with additional comparisons of Appalachian and non-Appalachian counties within the 13 states that contain the Appalachian region. Lung/bronchus, colorectal, female breast and cervical cancers, as well as all cancers combined, are included in analysis. Linear regression is used to identify independent associations between ecological socioeconomic and demographic variables and county-level cancer mortality outcomes. There is a pattern of high cancer mortality rates in the 13 states containing Appalachia compared to the rest of the United States. Mortality rate differences exist between Appalachian and non-Appalachian counties within the 13 states, but these are not consistent. Lung cancer is a major problem in Appalachia; most Appalachian counties within the 13 states have significantly higher mortality rates than in-state, non-Appalachian counterparts. Mortality rates from all cancers combined also appear to be worse overall within Appalachia, but part of this disparity is likely driven by lung cancer. Education and income are generally associated with cancer mortality, but differences in the strength and direction of these associations exist depending on location and cancer type. Improving high school graduation rates in Appalachia could result in a meaningful long term reduction in lung cancer mortality. The relative importance of household income level to cancer outcomes may be greater outside the Appalachian regions within these states.     

Compliance rates and predictors of cancer screening recommendations among Appalachian women

High rates of morbidity and mortality in the Appalachian region of the country warrant examination of the preventive care behavior of its residents. This study determined compliance rates for breast and cervical cancer screening recommendations for women residing in Appalachian states and identified predictors of such compliance using the Behavioral Risk Factor Surveillance System data (1995-97). Healthy People 2000 goals were used as benchmarks for progress. Appalachian women have made good progress toward goals pertaining to breast and cervical cancer screening. Compliance with other preventive services, having insurance coverage, residing in urban areas, better self-reported health, and higher education were independently associated with increased odds of compliance with annual-screening recommendations. Risk factors of obesity and smoking were associated with decreased odds of compliance. Findings should be useful to health care providers, policy makers, and researchers in their efforts to educate, encourage, and promote preventive care behavior among residents of Appalachia.     

Cancer‐Related Beliefs and Perceptions in Appalachia: Findings from 3 States

Background : Appalachians experience increased rates of cancer incidence and mortality compared to non‐Appalachians. Many factors may contribute to the elevated cancer burden, including lack of knowledge and negative beliefs about the disease. Methods : Three National Cancer Institute (NCI)‐designated cancer centers with Appalachian counties in their respective population‐based geographic service areas—Kentucky, Ohio, and Pennsylvania—surveyed their communities to better understand their health profiles, including 5 items assessing cancer beliefs. Weighted univariate and bivariate statistics were calculated for each of the 3 state's Appalachian population and for a combined Appalachian sample. Weighted multiple linear regression was used to identify factors associated with a cancer beliefs composite score. Data from the combined Appalachian sample were compared to NCI's Health Information National Trends Survey (HINTS). Results : Data from 1,891 Appalachian respondents were included in the analysis (Kentucky = 798, Ohio = 112, Pennsylvania = 981). Significant differences were observed across the 3 Appalachian populations related to income, education, marital status, rurality, perceptions of present income, and body mass index (BMI). Four of 5 cancer beliefs were significantly different across the 3 states. Education, BMI, perceptions of financial security, and Kentucky residence were significantly associated with a lower composite score of cancer beliefs. When comparing the combined Appalachian population to HINTS, 3 of 5 cancer belief measures were significantly different. Conclusions : Variations in cancer beliefs were observed across the 3 states’ Appalachian populations. Interventions should be tailored to specific communities to improve cancer knowledge and beliefs and, ultimately, prevention and screening behaviors.     

Chronic cardiovascular disease mortality in mountaintop mining areas of central Appalachian states

Purpose: To determine if chronic cardiovascular disease (CVD) mortality rates are higher among residents of mountaintop mining (MTM) areas compared to mining and nonmining areas, and to examine the association between greater levels of MTM surface mining and CVD mortality. Methods: Age‐adjusted chronic CVD mortality rates from 1999 to 2006 for counties in 4 Appalachian states where MTM occurs (N = 404) were linked with county coal mining data. Three groups of counties were compared: MTM, coal mining but not MTM, and nonmining. Covariates included smoking rate, rural‐urban status, percent male population, primary care physician supply, obesity rate, diabetes rate, poverty rate, race/ethnicity rates, high school and college education rates, and Appalachian county. Linear regression analyses examined the association of mortality rates with mining in MTM areas and non‐MTM areas and the association of mortality with quantity of surface coal mined in MTM areas. Findings: Prior to covariate adjustment, chronic CVD mortality rates were significantly higher in both mining areas compared to nonmining areas and significantly highest in MTM areas. After adjustment, mortality rates in MTM areas remained significantly higher and increased as a function of greater levels of surface mining. Higher obesity and poverty rates and lower college education rates also significantly predicted CVD mortality overall and in rural counties. Conclusions: MTM activity is significantly associated with elevated chronic CVD mortality rates. Future research is necessary to examine the socioeconomic and environmental impacts of MTM on health to reduce health disparities in rural coal mining areas.     

Mortality from heart,respiratory, and kidney disease in coal mining areas of Appalachia

Purpose  The purpose of this study was to test whether population mortality rates from heart, respiratory and kidney disease were higher as a function of levels of Appalachian coal mining after control for other disease risk factors. Methods  The study investigated county-level, age-adjusted mortality rates for the years 2000–2004 for heart, respiratory and kidney disease in relation to tons of coal mined. Four groups of counties were compared: Appalachian counties with more than 4 million tons of coal mined from 2000 to 2004; Appalachian counties with mining at less than 4 million tons, non-Appalachian counties with coal mining, and other non-coal mining counties across the nation. Forms of chronic illness were contrasted with acute illness. Poisson regression models were analyzed separately for male and female mortality rates. Covariates included percent male population, college and high school education rates, poverty rates, race/ethnicity rates, primary care physician supply, rural-urban status, smoking rates and a Southern regional variable. Results  For both males and females, mortality rates in Appalachian counties with the highest level of coal mining were significantly higher relative to non-mining areas for chronic heart, respiratory and kidney disease, but were not higher for acute forms of illness. Higher rates of acute heart and respiratory mortality were found for non-Appalachian coal mining counties. Conclusions  Higher chronic heart, respiratory and kidney disease mortality in coal mining areas may partially reflect environmental exposure to particulate matter or toxic agents present in coal and released in its mining and processing. Differences between Appalachian and non-Appalachian areas may reflect different mining practices, population demographics, or mortality coding variability.     

Female reproductive organs and breast cancer mortality in New Jersey counties and the relationship with certain environmental variables

Age-adjusted female reproductive organs and breast cancer mortality rates (all sites combined) were higher in 19 of 21 New Jersey counties than the U.S. national rates. Compared with national trends, New Jersey cervical cancer and corpus uteri rates have declined less than the national rate among all races. Ovarian and breast cancer rates have not changed over the years, a pattern similar to that of the nation. New Jersey cancer mortality rates during the period 1968-1977 that highly significantly (P less than 0.0005) exceeded national rates were cancers of the cervix in 2 counties among whites and in one county among nonwhites; of the corpus uteri and uterus not specified in 3 counties among whites; of the ovaries in 3 counties among whites; and of the breast in 10 counties among whites. The overall New Jersey cancer mortality significantly (P less than 0.0005) exceeded national rates for ovarian cancer among whites and nonwhites and for breast cancer among whites. Statistically significant and positive correlations were found between breast cancer mortality and chemical toxic waste disposal sites, annual per capita income, urbanization index, and population density among whites in 21 New Jersey counties. Ovarian cancer mortality was also significantly and positively correlated with annual per capita income, and negatively with birth defects. Cervical cancer mortality showed a significant negative correlation with annual per capita income and a significant positive correlation with birth defects and low birth weight among nonwhites in 21 New Jersey counties.     

Cancer screening - United States, 2010

Each year, approximately 350,000 persons are diagnosed with breast, cervical, or colorectal cancer in the United States, and nearly 100,000 die from these diseases. The U.S. Preventive Services Task Force (USPSTF) recommends screening tests for each of these cancers to reduce morbidity and mortality. Healthy People 2020 sets national objectives for use of the recommended cancer screening tests and identifies the National Health Interview Survey (NHIS) as the means to measure progress. Data from the 2010 NHIS were analyzed to assess use of the recommended tests by age, race, ethnicity, education, length of U.S. residence, and source and financing of health care to identify groups not receiving the full benefits of screening and to target specific interventions to increase screening rates. Overall, the breast cancer screening rate was 72.4% (below the Healthy People 2020 target of 81.1%), cervical cancer screening was 83.0% (below the target of 93.0%), and colorectal cancer screening was 58.6% (below the target of 70.5%). Screening rates for all three cancer screening tests were significantly lower among Asians than among whites and blacks. Hispanics were less likely to be screened for cervical and colorectal cancer. Higher screening rates were positively associated with education, availability and use of health care, and length of U.S. residence. Continued monitoring of screening rates helps to assess progress toward meeting Healthy People 2020 targets and to develop strategies to reach those targets.     

Preconception Health Indicators: A Comparison Between Non-Appalachian and Appalachian Women

To compare preconception health indicators (PCHIs) among non-pregnant women aged 18–44 years residing in Appalachian and non-Appalachian counties in 13 U.S. states. Data from the 1997–2005 Behavioral Risk Factor Surveillance System were used to estimate the prevalence of PCHIs among women in states with ≥1 Appalachian county. Counties were classified as Appalachian (n = 36,496 women) or non-Appalachian (n = 88,312 women) and Appalachian counties were categorized according to economic status. Bivariate and multivariable logistic regression models examined differences in PCHIs among women by (1) Appalachian residence, and (2) economic classification. Appalachian women were younger, lower income, and more often white and married compared to women in non-Appalachia. Appalachian women had significantly higher odds of reporting <high school education (adjusted odds ratio (AOR) 1.19, 95 % confidence interval (CI) 1.10–1.29), fair/poor health (AOR 1.14, 95 % CI 1.06–1.22), no health insurance (AOR 1.12, 95 % CI 1.05–1.19), no annual checkup (AOR 1.12, 95 % CI 1.04–1.20), no recent Pap test (AOR 1.20, 95 % CI 1.08–1.33), smoking (AOR 1.08, 95 % CI 1.03–1.14), <5 daily fruits/vegetables (AOR 1.11, 95 % CI 1.02–1.21), and overweight/obesity (AOR 1.05, 95 % CI 1.01–1.09). Appalachian women in counties with weaker economies had significantly higher odds of reporting less education, no health insurance, <5 daily fruits/vegetables, overweight/obesity, and poor mental health compared to Appalachian women in counties with the strongest economies. For many PCHIs, Appalachian women did not fare as well as non-Appalachians. Interventions sensitive to Appalachian culture to improve preconception health may be warranted for this population.     

Identifying Sociocultural Barriers to Mammography Adherence Among Appalachian Kentucky Women

Despite lower breast cancer incidence rates, Appalachian women evidence lower frequency of screening mammography and higher mortality risk for breast cancer compared to non-Appalachian women in Kentucky, and in the United States, overall. Utilizing data from 27 in-depth interviews from women in seven Appalachian Kentucky counties, this study examines how Appalachian women explain sociocultural barriers and facilitators to timely screening mammography, and explores their common narratives about their mammography experiences. The women describe how pain and embarrassment, less personal and less professional mammography experiences, cancer fears, and poor provider communication pose barriers to timely and appropriate mammography schedule adherence and follow-up care. The study also identifies how improving communication strategies in the mammography encounter may improve mammography experiences and adherence to screening guidelines.     

Risk factors for fatal breast cancer in African-American women and White women in a large US prospective cohort

African-American women have a higher lifetime risk of fatal breast cancer than do White women. Recent studies suggest that breast cancer risk factors may vary by race. The authors examined risk factors for fatal breast cancer in postmenopausal African-American women and White women in a large US prospective cohort. In 1982, 21,143 African-American women and 409,093 White women in the Cancer Prevention Study II completed a questionnaire on reproductive, medical, anthropometric, and demographic factors. During a 20-year follow-up, 257 deaths from breast cancer occurred among African-American women and 4,265 among Whites. Cox proportional hazards modeling was used to calculate multivariate-adjusted rate ratios, stratified by race. Higher body mass index, taller height, and physical inactivity were associated with increased breast cancer mortality rates in both groups. A college education was associated with higher mortality from breast cancer only in Africa-American women (hazard ratio = 1.62, 95% confidence interval: 1.13, 2.30; p(trend) = 0.01, vs. less than a high school education). Most other risk factors were associated with breast cancer rates similarly in both groups. With few exceptions, established breast cancer risk factors were similarly associated with risk of death from breast cancer among African-American women and White women.     

Metropolitan and non-metropolitan trends in coronary heart disease mortality within Appalachia, 1980-1997

OBJECTIVES: In this article, we report on metropolitan and non-metropolitan trends in coronary heart disease (CHD) mortality within the Appalachian Region for the period 1980 to 1997. We hypothesized that trends in CHD mortality would be less favorable in non-metropolitan populations with diminished access to social, economic, and medical care resources at the community level. METHODS: Our study population consisted of adults aged 35 years and older who resided within the 399 counties of the Appalachian Region between 1980 and 1997. We examined mortality trends for sixteen geo-demographic groups, defined by gender, age, race, and metropolitan status of county of residence. For each geo-demographic group, we calculated annual age-adjusted CHD mortality rates. Line graphs of these temporal trends were created, and log-linear regression models provided estimates of the average annual percent change in CHD mortality from 1980 to 1997. Data on social, economic, and medical care resources for metropolitan vs. non-metropolitan counties were also analyzed. RESULTS: Rates of CHD mortality were consistently higher in non-metropolitan areas compared with metropolitan areas for blacks of all ages and for younger whites. CHD mortality declined among almost all geo-demographic groups, but rates of decline were slower among non-metropolitan vs. metropolitan residents, blacks vs. whites, women vs. men, and older vs. younger adults. Non-metropolitan areas had fewer socioeconomic and medical care resources than metropolitan areas in 1990. CONCLUSIONS: Appalachia, particularly non-metropolitan Appalachia, needs policies and programs that will enhance both primary and secondary prevention of CHD, and help diminish racial inequalities in CHD mortality trends.     

Mental health professional shortage areas in rural Appalachia

CONTEXT: Research on health disparities in Appalachia has rarely compared Appalachia to other geographic areas in such a way as to isolate possible Appalachian effects. PURPOSE: This study tests hypotheses that nonmetropolitan Appalachia will have higher levels of mental health professional shortage areas than other nonmetropolitan areas of the same states, but that these disparities will dissipate when accounting for social and economic differences. METHODS: The study analyzed secondary data for nonmetropolitan counties (N = 618) in the 13 Appalachian states. Appalachian counties were identified from the Appalachian Regional Commission designations. Mental health professional shortages were identified from Health Resources and Services Administration data. Area Resource File data were used to measure county-level income, education, uninsurance, unemployment, race/ethnicity percentages, and urban influence codes. Logistic regression models tested whether Appalachia was significantly associated with shortage areas, and whether the Appalachian effect persisted after accounting for social and economic covariates. FINDINGS: Seventy percent of Appalachian nonmetropolitan counties were mental health professional shortage areas, significantly higher than non-Appalachian, nonmetropolitan counties in the same states. The Appalachian effect did not persist after controlling for the full set of other variables; education and race/ethnicity emerged as significant predictors. CONCLUSIONS: Appalachia location is associated with mental health professional shortages, but this effect is driven by underlying social differences, in particular by lower education. This method of identifying Appalachia for comparative purposes may be applied to many other health services research questions and to other defined geographic regions.     

Ohio drinking water source and cancer rates.

The 88 counties of Ohio were classified as either ground water or surface water counties based on the source of the drinking water used by a majority of the county residents included in the 1963 U.S. Public Health Service Inventory of Municipal Water Facilities. Average cancer mortality rates for surface and ground water counties were compared using analysis of covariance. Mortality rates for stomach, bladder, and all malignant neoplasms were higher for white males in counties served by surface water supplies than in counties served by ground water supplies. Mortality rates for stomach neoplasms were higher for white females in surface water counties. These differences in mortality rates were not attributable to other factors known to be associated with cancer death rates including urbanization, median income, population size, manufacturing activity, and agriculture-forestry-fishery activity.     

The geographic distribution of mammography resources in Mississippi

OBJECTIVE: To determine whether the availability of mammography resources affected breast cancer incidence rates, stage of disease at initial diagnosis, mortality rates and/or mortality-to-incidence ratios throughout Mississippi. METHODS: Mammography facilities were geocoded and the numbers of residents residing within a thirty minute drive of a mammography facility were calculated. Other data were extracted from the Mississippi Cancer Registry, the U.S. Census, and the Mississippi Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS & DISCUSSION: There were no statistically-significant differences between breast cancer incidence rates in Black versus White females in Mississippi; however, there were significant differences in the use of mammography, percentages of advanced-stage initial diagnoses, mortality rates, and mortality-to-incidence ratios, where Black females fared worse in each category. No statistically-significant correlations were observed between breast cancer outcomes and the availability of mammography facilities. The use of mammography was negatively correlated with advanced stage of disease at initial diagnosis. By combining Black and White subsets, a correlation between mammography use and improved survival was detected; this was not apparent in either subset alone. There was also a correlation between breast cancer mortality-to-incidence ratios and the percentage of the population living below the poverty level. CONCLUSIONS: The accessibility and use of mammography resources has a greater impact on breast cancer in Mississippi than does the geographic resource distribution per se. Therefore, intensified mammography campaigns to reduce the percentage of advanced-stage breast cancers initially diagnosed in Black women, especially in communities with high levels of poverty, are warranted in Mississippi.KEY WORDS: Breast Cancer, Mammography, Health Disparities, Geographic Information System (GIS)     

Black-white disparities in elderly breast cancer mortality before and after implementation of Medicare benefits for screening mammography

BACKGROUND: Medicare implemented reimbursement for screening mammography in 1991. MAIN FINDINGS: Post-implementation, breast cancer mortality declined faster (p< .0001) among White than among Black elderly women (65+ years). No excess breast cancer deaths occurred among Black elderly compared with White elderly through 1990; over 2,459 have occurred since. Contextual socioeconomic status does not explain differences between counties with lowest Black breast cancer mortality/post-implementation declines in disparity and counties with highest Black breast cancer mortality/widened disparity post-implementation. CONCLUSIONS: The results lead to these hypotheses: (a) Medicare mammography reimbursement was causally associated with declines in elderly mortality and widened elderly Black:White disparity from breast cancer; (b) the latter reflects inherent Black-White differences in risk of breast cancer death; place-specific, unaddressed inequalities in capacity to use Medicare benefits; and/or other factors; (c) previous observations linking poverty with disparities in breast cancer mortality are partly confounded by factors explained by theories of human capability and diffusion of innovation.     

Respiratory organs cancer mortality in New Jersey counties and the relationship with selected demographic and environmental variables

The state of New Jersey (N.J.) has been thought to have an unusually high overall cancer mortality rate; this assumption has been based on national 1950–1969 mortality data for N.J. counties. This study presents an analysis of more recent rates of respiratory cancer mortality in 21 N.J. counties during 1968–1977, a comparison with the 1950–1969 rates, and associations between current respiratory cancer mortality rates and selected demographic and environmental variables. Age-adjusted mortality rates for cancer of respiratory organs were calculated for the N.J. counties during the period 1968–1977 and compared with the period 1950–1969, with the Surveillance, Epidemiology, and End Results (SEER) survey, and with cancer mortality in the United States, 1973–1977. The county rates were also correlated with chemical toxic-waste disposal sites (CTWDS), annual per capita income, percentage of the population employed in chemical industries, the density of population, and the urbanization index of each of 21 N.J. counties. The lung, bronchus, trachea, and pleura cancer mortality rates among white and nonwhite males and females in N.J. were substantially higher than the national rates during the period 1950–1969. In more recent years, the increases in U.S. mortality rates for lung, bronchus, trachea, and pleura cancers were significantly greater (P < 0.01) than those found in most of the 21 N.J. counties. As a consequence, the national rates are now more comparable to N.J. rates. Although the gaps between N.J. and the United States in these rates have narrowed, the observed number of laryngeal and lung cancer deaths remained significantly higher (P < 0.01 to P < 0.0001) than expected cancer deaths, based on U.S. rates, among one or more subgroup populations (white and nonwhite males and females) in several N.J. counties. Among white men in Middlesex, Camden, Burlington, and Ocean counties, the observed number of deaths for lung cancer was found to be significantly (P < 0.0001) greater than the expected number of deaths. In Hudson county observed deaths from both laryngeal and lung cancer among white men were significantly greater than the expected number of deaths from these cancers (P < 0.0001). Statistically significant and positive correlations were found between laryngeal cancer mortality and CTWDS, urbanization index, and population density. Lung cancer mortality also correlated significantly with CTWDS in N.J. Both larynx and lung cancer mortality showed significant and consistent negative correlations with annual per capita-income in N.J. Some of the implications of the study findings are discussed and recommendations made for future investigations.     

Primary care, social inequalities and all-cause, heart disease and cancer mortality in US counties: a comparison between urban and non-urban areas

OBJECTIVE: The objective of this study was to test whether the association between primary care and income inequality on all-cause, heart disease and cancer mortality at county level differs in urban (Metropolitan Statistical Area-MSA) compared with non-urban (non-MSA) areas. STUDY DESIGN: The study consisted of a cross-sectional analysis of county-level data stratified by MSA and non-MSA areas in 1990. Dependent variables included age and sex-standardized (per 100,000) all-cause, heart disease and cancer mortality. Independent variables included primary care resources, income inequality, education levels, unemployment, racial/ethnic composition and income levels. METHODS: One-way analysis of variance and multivariate ordinary least squares regression were employed for each health outcome. RESULTS: Among non-MSA counties, those in the highest income inequality category experienced 11% higher all-cause mortality, 9% higher heart disease mortality, and 9% higher cancer mortality than counties in the lowest income inequality quartile, while controlling for other health determinants. Non-MSA counties with higher primary care experienced 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than non-MSA counties with lower primary care. MSA counties with median levels of income inequality experienced approximately 6% higher all-cause mortality, 7% higher heart disease mortality, and 7% higher cancer mortality than counties in the lowest income inequality quartile. MSA counties with low primary care (less than 75th percentile) had significantly lower levels of all-cause, heart disease and cancer mortality than those counties with high primary care. CONCLUSIONS: In non-MSA counties, increasing primary physician supply could be one way to address the health needs of rural populations. In MSA counties, the association between primary care and health outcomes appears to be more complex and is likely to require intervention that focuses on multiple fronts.     

The residential radon-lung cancer association in U.S. counties: a commentary

There is little doubt that underground miners exposed to radon and its progeny have increased rates of lung cancer. Residential radon exposures should carry a possibly smaller risk of increased cancer. When it became possible to collect radon data in a large number of U.S. homes and the data were aggregated by counties, the apparent association with lung cancer was a negative one, even when many other variables were taken into account. Residential radon levels are higher in suburban residences leading to a negative association with population density. Population density is strongly positively associated with lung cancer. It follows that aggregate residential radon and lung cancer rates should be negatively associated for reasons having nothing to do with the possibility of radon being carcinogenic to the lung. A second problem presented by the data is the one of sampling bias since the county lung cancer data are from the whole county population, but only a few residences are tested. Examples of other inherent associations in environmental epidemiology are cited. One strategy is to study areas of the same population density but with radon exposure gradients. This is approximated by choice of rural high radon states. Counties in such states have weak and inconsistent associations between radon and lung cancer, some of which are positive. I conclude that counties are generally inappropriate units for study of radon and lung cancer associations.     

Women and smoking: issues and opportunities

In March 2001, the U.S. Surgeon General released Women and Smoking, the second Surgeon General's report to focus on tobacco use among women, compelling the nation to make reducing tobacco use among women one of the highest priorities for women's health. Since 1980, 3 million women have died prematurely from smoking-related diseases and injuries. Lung cancer mortality rates among U.S. women have increased about 600% since 1950, and now lung cancer is the leading cause of cancer death among U.S. women, having surpassed breast cancer in 1987. Although the report documents the devastating impact of the tobacco epidemic among women, a growing arsenal of science-based recommendations for implementing comprehensive tobacco control programs suggests that achieving the nation's ambitious Healthy People 2010 objectives, including cutting in half the rates of smoking among women and girls, is within our reach. While states continue to debate the use of tobacco settlement funds, it is important to note that when significant resources have been devoted to the implementation of evidence-based strategies, the results have been dramatic for the population overall and for women in particular. For example, in California, which has had a comprehensive tobacco control program for 11 years, smoking prevalence has declined throughout the 1990s at rates two or three times faster than in the rest of the country, and while lung cancer incidence rates increased by 13% among women in other parts of the United States, they decreased by 4.8% among women in California. These promising findings indicate that although tobacco-related diseases have become a women's health issue of epidemic proportions, we have the ability to reverse these trends.