The following are pre-publication drafts of articles from the
Morbidity and Mortality Weekly Report dated July 7, 1995. Late-breaking articles, and final editorial revisions are not included;
therefore, these articles should be considered preliminary, and not
to be released to the public. --CDC
--------------------------------------------------------------
Farm-Tractor-Related Fatalities -- Kentucky, 1994
     Fatalities associated with farm tractors are the most common
cause of work-related death in the U.S. agricultural industry (1).
To characterize farm-tractor-related fatalities in Kentucky, the
Kentucky Fatality Assessment and Control Evaluation (KY FACE)
Project studied all fatal farm injuries occurring among persons in
that state during 1994, the initial year of operation for FACE in
Kentucky. This report summarizes the results of that study.
     KY FACE is part of a 14-state surveillance and investigation
program coordinated by CDC's National Institute for Occupational
Safety and Health (NIOSH) and is designed both to evaluate the
circumstances of fatal occupational injuries and to develop
prevention strategies. KY FACE employs multiple reporting sources*
to identify occupational fatalities throughout the state and
conducts follow-up investigations. A farm-tractor-related fatality
was defined as a death caused by operating or working on or near a
farm tractor. A farm tractor was defined as a two- or four-wheel-drive vehicle or track vehicle with a greater than 20-horsepower
engine designed to furnish the power to pull, carry, propel, or
drive implements designed for agricultural activities (2).
     During 1994, the KY FACE surveillance system identified 28
tractor-related fatalities in Kentucky; 14 (50%) of these incidents
occurred during June-August. Tractor-related fatalities accounted
for 16% of the 176 occupational fatalities recorded in Kentucky
during 1994.
     The most common cause of tractor-related fatalities was
rollover (23 [82%]), followed by runover (five [18%]). The most
common activity at the time of injury was mowing with a rotary
mower trailing a tractor (i.e., bush-hogging) on private farms
(32%). Other activities included transporting equipment or farm
products (21%); checking livestock or property (14%); pulling logs
(11%); and planting, plowing, or cutting hay (11%). Of the 28
deaths, 23 (82%) occurred on farms, and five (18%) occurred on
public roadways. Four of those occurring on roadways were
attributed to loss of control; one tractor was struck by a truck in
a rear-end collision.
     All decedents were males who ranged in age from 15 to 86 years
(median: 46 years); one was aged less than 18 years, and 15 (54%),
greater than or equal to 60 years. One death occurred in a
15-year-old student who was killed in a tractor rollover incident
while working a summer job plowing tobacco. Farming was listed as
the usual occupation on 11 (39%) of the 28 death certificates. Ten
(36%) of those fatally injured also held jobs off the farm, and 12
(43%) were retired from nonfarming occupations. Most (53%)
fatalities occurred from 12:01 to 6 p.m.; 32% occurred from 7 a.m.
and noon, and 14% after 6 p.m.
     An industrial hygienist conducted on-site investigations of 16
of the incidents. Tractors involved in these 16 incidents ranged in
age from 2 to 41 years (median: 23 years). In three of the cases,
the operators were driving directly up or down steep slopes (of 8,
14, and 30 degrees); in two of these incidents, the operator lost
control while descending, and in the third, the operator rolled
over backward while ascending a hill. In eight of the 16 incidents,
one or both wheels on one side of the tractor slid down an
embankment, causing a rollover. In one case, the operator backed
the tractor over an embankment, causing the tractor to roll over
backwards. In eight of the incidents, tires were air-filled rather
than fluid-filled; fluid-filled tires lower the center of gravity,
improve traction, and can prevent skidding, loss of control, and
rollover. Only two of the tractors were equipped with front-end
counterweights, which improve traction and stability. In eight
cases, poor equipment condition (e.g., minimally operable brakes),
was a contributing factor.
     Only one of the tractors involved in a rollover fatality was
fitted with a rollover-protective structure (ROPS); in this
incident, a tractor manufactured in 1962 had been retrofitted with
a ROPS but not equipped with seatbelts.
Reported by: TW Struttmann, MSPH, C Spurlock, PhD, SH Pollack, MD,
E Moon-Hampton, Kentucky Injury Prevention and Research Center; SR
Browning, PhD, R McKnight, ScD, Southeast Center for Agricultural
Health and Injury Prevention, Univ of Kentucky, Lexington. R
Finger, MD, State Epidemiologist, Dept for Health Svcs, Kentucky
Cabinet for Human Resources. Div of Safety Research, National
Institute for Occupational Safety and Health, CDC.
Editorial Note: During 1994, the fatality rate for civilian workers
in the agriculture/forestry/fishing industry in Kentucky was 85 per
100,000 workers, a rate more than three times greater than that for
the industry in the United States (26 per 100,000 workers in 1993)
(3). Operating tractors is a particularly hazardous activity for
older workers and adolescents. The proportion of Kentucky
tractor-related fatalities among workers aged greater than 60 years
(54%) was greater than that reported in the NIOSH National
Traumatic Occupational Fatalities surveillance system (44%) (4).
Operating tractors with a greater than 20-horsepower engine is
extremely hazardous to youth, and federal Child Labor Laws prohibit
this activity for employees aged less than 16 years; however,
children working on their family farm are exempt from Child Labor
Laws.
     In 1994, tractor rollovers and runovers accounted for 62% of
agricultural fatalities in Kentucky. The findings of the KY FACE
investigations indicated that in most of the incidents rollover
fatalities could have been prevented if the tractors had been
equipped with ROPS (Figure 1) and the operators secured with
seatbelts, which ensure that the operator remains within the
ROPS-protected zone during a rollover.
     ROPS first became available as optional equipment on farm
tractors in 1971 (tractors manufactured before 1971 were not
designed to accommodate ROPS devices). However, ROPS were not
required for new tractors until 1976, when a standard promulgated
by the Occupational Safety and Health Administration (OSHA)
required employers to provide ROPS and seatbelts for all
employee-operated tractors** manufactured after October 25, 1976
(2). Although virtually all tractors sold after 1985 have been
equipped with ROPS, farms with less than 11 employees are not
subject to OSHA inspection or enforcement, and farms managed by
family members with no other employees are not required to comply
with OSHA standards; in Kentucky, 94% of the farms are family-owned
businesses with less than 11 employees (5). The median age of
tractors investigated in this report was 23 years. One fatal
tractor rollover in this study involved a 1979 tractor manufactured
without ROPS. Because it was purchased for use on a family farm
without employees, it was not subject to the ROPS standard. The
cost to retrofit tractors manufactured before 1975 ranges from $400
to $1800, and economic constraints associated with farms in
Kentucky limit the feasibility of appropriately modifying all
tractors.
     The findings of KY FACE suggest that installation of ROPS and
seatbelts on farm tractors could have prevented the 23 tractor
rollover deaths. These findings and previous reports (1) underscore
the need for economically feasible ROPS retrofit programs. In
Kentucky, the FACE program disseminates reports containing
investigative findings and recommends intervention strategies to
county extension agents, the Kentucky Labor Cabinet Division of
Education and Training, the Kentucky Farm Bureau, and the National
Safety Council. News media releases assist in disseminating this
information further to the agriculture community and the general
public.
References
1. CDC. Public health focus: effectiveness of rollover protective
structures for preventing injuries associated with agricultural
tractors. MMWR 1993;42:57-9.
2. Office of the Federal Register. Code of federal regulations:
occupational safety and health standards. Subpart C: roll-over
protective structures (ROPS) for tractors in agricultural
operations. Washington DC: Office of the Federal Register, National
Archives and Records Administration, 1994 (29 CFR *** 1928.51).
3. Toscano G, Windau J. The changing character of fatal work
injuries. Monthly Labor Review 1994;117(10):17-28.
4. Etherton JR, Myers JR, Jensen RC, Russell JC, Braddee RW.
Agricultural machine-related deaths. Am J Public Health
1991;81:766-8.
5. Bureau of the Census. 1992 Census of agriculture: Vol 1,
Geographic Area Series, Part 17, Kentucky State and County Data.
Washington, DC: US Department of Commerce, Economics and Statistics
Administration, 1992 (AC92-A-17).

* Notification sources include newspapers, county coroners,
emergency medical personnel, Kentucky Labor Cabinet, U.S. Bureau of
Labor Statistics Census of Fatal Occupational Injuries, Kentucky
Department of Motor Vehicles' Fatal Accident Reporting System,
Southeast Center for Agricultural Health and Injury Prevention,
Occupational Health Nurses in Agricultural Communities, and
Kentucky Vital Statistics.
** The standard provides exemptions for tractors used in special
circumstances where vertical clearances may be limited (e.g., in
orchards or inside buildings).

Mass Treatment of Humans Exposed to Rabies -- New Hampshire, 1994
     On October 22, 1994, the laboratory of the New Hampshire
Division of Public Health Services (NHDPHS) diagnosed rabies in a
kitten that had been purchased from a pet store in Concord, New
Hampshire. On October 19, the animal had developed seizures, then
died of unknown causes during the night of October 20-21.
Approximately 665 persons received rabies postexposure prophylaxis
because of exposure to this kitten and other cats from the same pet
store. This report summarizes the epidemiologic investigation of
the source of the infection and follow-up care of humans and
animals potentially exposed to rabies.
     Because the pet store did not keep records for kittens
acquired for sale, the kitten's origin and date of arrival were
unknown. However, on September 26, a group of kittens reported to
have included the rabid kitten was examined by a veterinarian and
given health certificates, in accordance with state law, before
being offered for sale by the pet store. The kitten was sold on
October 5 and kept by its owners until its death. On October 22,
rabies was diagnosed in the kitten by fluorescent antibody testing
at the NHDPHS laboratory. At CDC, genetic typing of the rabies
virus isolated from the kitten indicated that it was a variant
associated with raccoons. The investigation could not determine
whether the kitten was infected with rabies before, during, or
after its stay in the pet store; two other kittens sold by the pet
store during the same period as the infected kitten died of unknown
causes at their new homes but were unavailable for testing for
rabies.
     On October 12, a raccoon captured in Henniker (a suburb of
Concord), where the kitten was suspected to have originated, tested
positive for rabies. Subsequent investigation indicated that the
raccoon may have had direct contact with three feral kittens
acquired by the pet store on September 20. All three feral kittens
developed signs of respiratory illness and died during
approximately October 4-October 6--a period overlapping that during
which the rabid kitten was in the store. None of these three
kittens were available for testing for rabies and all were younger
than the minimum age (3 months) recommended for rabies vaccination.
     From September 19 through October 23 (the last date any
potentially exposed kittens were in the pet store), a minimum of 34
kittens had been offered for sale by the store. In addition to the
infected kitten, 33 other kittens were included in the
investigation: 27 were located and tested negative for rabies, and
five died of unknown causes but were unavailable for testing
(including the three feral kittens); one kitten was quarantined at
the owner's request, and its status is unknown.
     Because of limitations in the store's records regarding the
origins and sale destinations of the kittens, local news media
assisted in alerting community residents about the potential
exposures to rabies at the store. The kittens had been allowed to
roam freely throughout the store, which was frequented by children
from child-care centers and a nearby school. As a result, NHDPHS
and two major health-care facilities screened approximately 1000
persons who responded to media alerts and referred to private
sector health-care providers for definitive evaluation of those
persons who might need rabies postexposure treatment. NHDPHS gave
medical providers an algorithm to determine the necessity for
recommending rabies postexposure treatment. Rabies postexposure
treatment, consisting of one dose of rabies immune globulin and
five doses of rabies vaccine, was initiated for approximately 665
persons (1).
Reported by: M Klauber, Dartmouth-Hitchcock Medical Center,
Concord; C McGinnis, DVM, New Hampshire Dept of Agriculture; RT
DiPentima, MPH, AE Burns, MS, VC Malmberg, MS, JS Finnigan, MJ
Walsh, JE Whitcomb, CE Danielson, MD, MG Smith, MD, State
Epidemiologist, Div of Public Health Svcs, New Hampshire Dept of
Health and Human Svcs. Viral and Rickettsial Zoonoses Br, Div of
Viral and Rickettsial Diseases, National Center for Infectious
Diseases, CDC.
Editorial Note: This incident of rabies associated with a pet store
resulted in the largest number of persons ever reported to have
received rabies postexposure treatment as a result of potential
contact with a point source in the United States.* At least three
factors accounted for the large number of persons requiring
treatment. First, the absence of pet store records regarding the
source and destination of animals precluded an accurate estimation
of the exposure period. Second, the store's popularity and its
practice of allowing kittens to roam freely throughout the
establishment increased contacts between humans and kittens.
Finally, because many children were potentially exposed, accurate
exposure histories could not be elicited; as a consequence, many
rabies postexposure treatments were administered on the basis of
incomplete information or unknown likelihood of exposure.
     The costs associated with the public health response to
exposures to the rabid kitten in New Hampshire are unprecedented in
the United States. The overall estimated cost was $1.5 million,
including expenditures for rabies immune globulin and vaccine ($1.1
million), laboratory testing of animals ($4200), and investigation
by NHDPHS and CDC personnel ($15,000). This cost is nearly 15-fold
higher than that ($105,790) associated with rabies postexposure
treatment of 70 persons after a single case of rabies occurred in
a domestic dog in California in 1981 (2).
     CDC recommends implementation of four measures to minimize the
number of exposed persons and the costs associated with exposures
to persons. First, to facilitate efforts to investigate such
exposures, pet stores should keep adequate records (e.g., health
certificates, animal source identification, and complete sales
receipts). Second, to prevent the exposure to, or the transmission
of, rabies and other zoonotic diseases--as well as injuries such as
bites and scratches--animals should be kept and displayed separate
from customers or at least confined to a discrete area within the
store. Third, because feral animals are less likely to have been
vaccinated and more likely to have been in contact with wildlife
disease reservoirs, acquisition and sale of these animals should be
monitored closely. Finally, prompt and standardized assessment of
exposure by public health officials should help minimize the number
of persons who unnecessarily receive rabies postexposure treatment.
The rabies virus is transmitted only when introduced into open
wounds or mucous membranes through a bite or direct saliva contact.
Other forms of contact (e.g., petting a rabid animal or contact
with blood, urine, or feces of a rabid animal) do not constitute an
exposure and are not indications for prophylaxis (1). Skillful
interviewing is essential to assess individual exposures,
especially when the potential exposure occurred some time ago or in
another family member (e.g., a young child).
     The rabid kitten involved in this incident had been infected
with a rabies virus variant usually associated with raccoons. Since
1977, a raccoon rabies epizootic has spread from a focus in West
Virginia to involve all eastern region states (3). During 1993,
nearly 6000 raccoons were confirmed with rabies in this region.
Although no human rabies cases have been associated with this
epizootic, the economic burden related to postexposure prophylaxis
has been high. This epizootic and case described in this report
underscore the need for intensification of rabies-control measures,
including vaccination of all household pets.
References
1. ACIP. Rabies prevention--United States, 1991: recommendations of
the Immunization Practices Advisory Committee (ACIP). MMWR
1991;40(no. RR-3).
2. CDC. The cost of one rabid dog--California. MMWR 1981;30:527.
3. Krebs JW, Strine TW, Smith JS, Rupprecht CE, Childs JE. Rabies
surveillance in the United States during 1993. J Am Vet Med Assoc
1994;205:1695-1709.

* On June 22, a second episode of rabies in a kitten associated
with a pet store was reported by the Delaware Department of Health
and Social Services. Through June 30, approximately 18 persons had
received postexposure prophylaxis for potential rabies exposure. An
investigation of this incident is ongoing.

Measles -- United States, 1994
     As of June 13, 1995, local and state health departments in 39
states had reported 958 measles cases to CDC for 1994. This
represents the second lowest number of cases ever reported, after
the historic low of 312 cases in 1993 (1). In addition, 303 cases
were reported for the U.S. territory of Guam (228) and the
commonwealths of the Northern Mariana Islands (29) and Puerto Rico
(46). This report summarizes the epidemiologic characteristics of
measles cases and outbreaks reported in the United States during
1994.
     Age distribution, complications, and hospitalizations. Of the
954 measles patients for whom age was known, 247 (26%) were aged
less than 5 years, including 73 (8%) who were aged less than 12
months and 69 (7%) who were aged 12-15 months. Nearly one half
(475) of all measles patients were aged 5-19 years, and 232 (24%)
were aged greater than or equal to 20 years. Among the 537 measles
patients for whom information was available, 45 (8%) were reported
to have been hospitalized; the median duration of hospitalization
was 4 days (range: 1-22 days). Among 338 (35%) measles cases for
which information on laboratory testing was provided, 229 (68%)
were serologically confirmed.
Vaccination status. Vaccination status was reported for 848 (89%)
measles patients. Among 762 vaccine-eligible persons,* 171 (22%)
were reported to have documented receipt of at least one dose of
measles-containing vaccine, and 539 (71%) were unvaccinated.
Fifty-two (7%) persons with reported unknown vaccination status
were considered to be unvaccinated. Four cases occurred among
persons with documentation of two appropriately spaced doses of
measles vaccine greater than 14 days before onset of symptoms.
Among 301 unvaccinated measles patients who were eligible for
vaccination and for whom a reason for nonvaccination was reported,
294 (98%) cited a religious (154 [51%]) or philosophic (140 [47%])
exemption to vaccination. Almost all (92% [277]) of these cases
occurred in outbreaks in Illinois, Missouri (2), Nevada, and Utah.
Cases among persons claiming religious or philosophic exemption to
vaccination accounted for 36% of all reported cases in 1994.
Case classification. Among 949 reported cases for which the
epidemiologic classification is known, 874 (92%) were indigenous to
the United States, including 719 (76%) acquired in the state
reporting the case and 155 (16%) resulting from spread from known
importation from another state. International importations and
cases occurring within two generations of these importations
accounted for 75 (8%) measles cases in 1994. These cases were
reported from 24 states and, for those for whom the country of
origin was reported, occurred most frequently among persons
arriving from Europe (26 cases) and East Asia (18). Cases resulted
from importations from the Americas (eight), the Middle East (six),
and Africa (two). Among the 75 persons with internationally
imported measles, 23 (31%) were aged less than 5 years; 32 (43%),
5-19 years; and 20 (27%), greater than or equal to 20 years.
Outbreaks. Twenty-two outbreaks (clusters of five or more
epidemiologically linked cases) were reported by 15 states during
1994 and accounted for 74% (705) of all reported cases. Two of
these outbreaks began in 1994 and continued into 1995 (only cases
that occurred during 1994 are reported here). Eight outbreaks,
which included 12-156 cases, occurred in schools (six outbreaks) or
colleges (two), five outbreaks (range: five-22 cases) involved
predominantly preschool-aged children, and nine (range: six-134
cases) occurred in other settings and primarily involved young
adults. The largest college outbreak (94 cases) resulted from
spread from an importation, and two other outbreaks followed known
importations. A total of 176 cases (18% of all reported cases) were
related to international importations in 1994.
     A single chain of transmission that was first recognized in a
Colorado ski resort (3) extended into nine additional states and
resulted in the largest outbreak of 1994 (247 cases); this outbreak
involved students who were unvaccinated because of religious
exemptions and who attended a college in Illinois or a school in
Missouri (2). Two other outbreaks involving persons with
philosophic exemption to vaccination occurred in Salt Lake City,
Utah (134 cases), and White Pine County, Nevada (12 cases). In
outbreaks among persons with religious or philosophic exemption to
vaccination, school-aged children accounted for 73% of all cases,
and represented 56% of all measles cases among 5-19-year-olds in
1994.
     Intensive surveillance and case investigation resulted in
identification of three large multistate outbreaks during 1994.
Epidemiologic linkages were established among 247 cases in 10
states from the outbreak that began in Colorado, among 57 cases in
six states resulting from exposures in Las Vegas, and among 146
cases from an outbreak that began in Utah and spread to Nevada.
     The genomic sequences of viruses isolated from the outbreak in
Illinois and Missouri was similar to that of a virus isolated from
an earlier outbreak in Memphis, Tennessee. These viruses probably
were recently imported into the United States because they were
closely related to measles virus strains that had previously
circulated in Europe. Four distinct genotypes were identified by
genomic sequencing among 10 isolates from four outbreaks and three
single measles cases in the United States in 1994. None of these
was related to the genotype circulating during the resurgence of
1989-1991, suggesting that all of these viruses were introduced
into the United States as a result of importation.
Reported by: State and local health depts. Measles Virus Section,
Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial
Diseases, National Center for Infectious Diseases; National
Immunization Program, CDC.
Editorial Note: Although measles incidence has increased since the
historic low reported in 1993, the number of cases reported during
1994 is the second fewest in the United States since measles
reporting began in 1912. Important characteristics of current
epidemiologic trends are the shift in age distribution of cases to
older persons, the large proportion of cases in groups whose
members do not routinely accept vaccination, and the increasing
numbers of cases linked to international importations.
     Since the measles resurgence of 1989-1991, increasing
proportions of cases have occurred among school-aged children and
adults, and proportionately fewer in preschool-aged children--a
substantial change from 1989-1991, when incidence was highest among
preschool-aged children, of whom as many as 80% were unvaccinated
(4,5). The shift in age distribution probably resulted from
record-high measles vaccination coverage levels among
preschool-aged children, which reached 90% in the first quarter of
1994 (6). More than half of the cases in persons aged 5-19 years
were associated with outbreaks among persons with a religious or
philosophic exemption to vaccination. Additional efforts will be
necessary to reduce transmission among persons with objections to
vaccination.
     Laboratory and epidemiologic data suggest that measles
transmission was interrupted in the United States during late 1993
(7). Because of the effective implementation of a strategy of mass
vaccination of children in all countries in Central and South
America, importations from the Americas have decreased
substantially since 1991 and now represent a small percentage of
all importations. However, the continued risk for international
importations and spread from importations from other locations
represent a challenge to the goal of measles elimination in the
United States; known international importations or spread from
international importations accounted for almost one fifth of
reported measles cases in 1994.
     The strategy for achieving the Childhood Immunization
Initiative goal of eliminating indigenous measles transmission in
the United States (8) is based on four components: 1) maintaining
high coverage with a single dose of measles-mumps- rubella vaccine
(MMR) among preschool-aged children, 2) achieving coverage with two
doses of MMR for all school and college attendees, 3) enhancing
surveillance and outbreak response, and 4) increasing efforts to
develop and implement strategies for global measles elimination.
CDC will continue to work with state and local health departments
to implement recommendations to achieve high levels of population
immunity, rapidly report and investigate all suspected measles
cases, and enhance surveillance to facilitate rapid identification
and confirmation of cases and implementation of appropriate control
measures.
References
1. CDC. Table II. Cases of selected notifiable diseases, United
States, weeks ending December 31, 1994 and January 1, 1994 (52nd
week). MMWR 1995;43:969.
2. CDC. Outbreak of measles among Christian Science students--Missouri and Illinois, 1994. MMWR 1994;43:463-5.
3. CDC. Interstate measles transmission from a ski resort--Colorado, 1994. MMWR 1994;43:627-9.
4. Gindler JS, Atkinson WL, Markowitz LE, Hutchins SS. Epidemiology
of measles in the United states in 1989 and 1990. Pediatr Infect
Dis J 1992;11:841-6.
5. CDC. Measles surveillance--United States, 1991. MMWR 1992;41(no.
SS-6):1-12.
6. CDC. Vaccination coverage of 2-year-old children--United States,
January-March 1994. MMWR 1995;44:142-3,149-50.
7. CDC. Absence of reported measles--United States, November 1993.
MMWR 1993;42:925-6.
8. CDC. Reported vaccine-preventable diseases--United States, 1993,
and the Childhood Immunization Initiative. MMWR 1994;43:57-60.

* Persons aged greater than or equal to 12 months who were born
after 1957. Persons born in or before 1957 are considered to be
immune based on the likelihood of their having had measles before
licensure of measles vaccine in 1963.

Prevalence of Smoking by Area of Residence -- Missouri, 1989-1991
     Variation in smoking prevalence by area of residence may be an
important consideration in the development, implementation, and
management of programs that promote nonsmoking. In general, the
prevalence of cigarette smoking is highest among persons at
economic, educational, and social disadvantage (1,2), and the
proportion of persons who are disadvantaged is greater in urban and
nonmetropolitan areas. Because smoking prevalence varies by area of
residence and characterization of these differences can assist in
directing efforts to promote nonsmoking, the Missouri Department of
Health compared urban, suburban, and nonmetropolitan areas using
data from two sources: the Behavioral Risk Factor Surveillance
System (BRFSS) for Missouri from 1989 through 1991 (suburban and
nonmetropolitan areas) and a survey specially commissioned in 1990
(Smoking Cessation in Black Americans [SCBA]) of persons living in
low-income census tracts in north St. Louis and central Kansas City
(urban areas). This report summarizes the results of this analysis.
     BRFSS is a population-based, random-digit-dialed telephone
survey of the civilian, noninstitutionalized population aged
greater than or equal to 18 years (3). For this analysis,
respondents' suburban or nonmetropolitan residence was determined
by county of residence: respondents not living in counties
composing a metropolitan statistical area (MSA) were categorized as
residing in nonmetropolitan areas; respondents living in counties
composing MSAs were categorized as residing in suburban areas.
Persons living in the urban areas of St. Louis or Kansas City
(Jackson County) were excluded from the BRFSS data. However, the
SCBA survey was conducted in 60 low-income census tracts to
determine smoking prevalence and attitudes among residents of these
areas (4). To estimate prevalences, BRFSS data were weighted to
reflect the total population in each area (based on the 1990
census) and for respondent probability of selection. Based on the
1990 census, 46% of persons resided in suburban areas, 34% in
nonmetropolitan areas, and 20% in St. Louis and Kansas City. BRFSS
data were aggregated for 3 survey years to increase the number of
respondents in the demographic categories* for the suburban and
nonmetropolitan areas, and SUDAAN was used to calculate the
variance (5). For both the BRFSS and SCBA, current smokers were
defined as persons who had smoked greater than or equal to 100
cigarettes and who reported being a smoker at the time of the
interview. The prevalence of cessation was obtained by dividing the
number of former smokers by the number of ever smokers (respondents
who have ever smoked greater than or equal to 100 cigarettes during
their lifetime) and multiplying by 100. Differences in
group-specific prevalence rates in this report reflect
nonoverlapping confidence intervals.
     Overall, the prevalence of current smoking was higher among
persons residing in the urban areas (32.4%) than in the suburban
(24.8%) and nonmetropolitan areas (26.5%) (Table 1). This pattern
was consistent across all sex and education subgroups. The
prevalence of current smoking also was higher in the urban areas
for adults aged 35-54 years and greater than or equal to 55 years.
For the 18-34-year age group, the prevalence of current smoking in
the urban areas (31.3%) was comparable to that in the suburban
(27.8%) and nonmetropolitan (33.5%) areas. For whites, the
prevalence of current smoking was higher for those living in the
urban areas (34.8%) than in suburban (24.9%) or nonmetropolitan
(26.0%) areas. For blacks, the prevalence of current smoking was
similar in urban areas (32.0%) and nonmetropolitan areas (32.1%)
but higher than in suburban areas (24.0%).
     Among current smokers, the mean number of cigarettes smoked
per day was highest in the nonmetropolitan areas (22.8), lowest in
the urban areas (15.0), and intermediate in suburban areas (19.9).
The prevalence of cessation was lower in the urban areas (37.4%)
than in the suburban (50.0%) or nonmetropolitan areas (47.6%).
Reported by: CL Arfken, PhD, W Auslander, PhD, EB Fisher, Jr, PhD,
Center for Health Behavior Research, Washington Univ School of
Medicine, St. Louis; RC Brownson, PhD, School of Public Health, St.
Louis Univ; J Jackson-Thompson, PhD, B Malone, MPA, Div of Chronic
Disease Prevention and Health Promotion, Missouri Dept of Health.
Office on Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, CDC.
Editorial Note: In Missouri during 1989-1991, the prevalence of
smoking generally was highest in urban areas regardless of sex,
education, age, and race. These findings are consistent with those
of previous reports describing the relation between urban area of
residence and smoking status (6,7). The persistence of the
association between urban residence and smoking status, despite
controlling for demographic characteristics, suggests that other
factors contribute to the higher prevalence of smoking in urban
areas. Such factors may include cultural norms, the burden and
management of stress (8), relative effectiveness of risk-reduction
messages (9), and exposure to tobacco advertisement and promotions.
Differences in prevalences among racial/ethnic groups may be
influenced by differences in educational levels, socioeconomic
status, and social and cultural phenomena that require further
explanation.
     The findings in this report are subject to at least three
limitations. First, because these estimates are based on
self-reported data, prevalences may be underestimated (10). Second,
a stratified analysis was conducted to control for each demographic
variable individually because combining data from separate surveys
with differing sampling designs precluded use of multivariate
techniques to control for each variable simultaneously. Third,
grouping areas at the urban, suburban, and nonmetropolitan levels
may mask important community differences within each of these
areas.
     The findings in Missouri suggest that urban areas are an
important target for nonsmoking promotion efforts. In general,
local survey data can provide useful information to assist state
and local health departments in identifying populations for
risk-reduction programs. In Missouri, state and local health
departments and community organizations are using these findings to
develop programs and activities to reduce the prevalence of smoking
among urban residents. For example, in Kansas City, intensive
education efforts have been initiated to change social and
community norms about smoking through activities such as rallies
and town hall meetings and the promulgation of nonsmoking
regulations. In St. Louis, activities have included
counter-advertising, public service announcements, tobacco
education in schools, and training of health-care providers about
tobacco-use prevention.
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