Trends in Ischemic Heart Disease Death Rates for Blacks and Whites—United States, 1981-1995 FREE

MMWR. 1998;47:945-949

1 table, 2 figures omitted

During 1995, ischemic heart disease (IHD) caused 21% of all deaths and 65% of deaths attributed to heart disease.¹ Few reports comparing IHD mortality between blacks and whites have presented age-specific rates,^2- 3 and none have compared trends over time. This report examines the trend in age-specific IHD death rates for blacks and whites from 1981 through 1995 (the latest year for which data are available) and indicates that, in the younger age groups (35-64 years), blacks have a higher risk for IHD death than whites.

Average annual age-adjusted and age-specific IHD death rates for persons aged ≥35 years during 1981-1985, 1986-1990, and 1991-1995 were calculated from mortality data compiled by CDC and population data compiled by the Bureau of the Census. For each of the rate calculations, the numerator was the average annual number of deaths during the period and the denominator was the average of the five mid-year population estimates during the period. IHD deaths were defined as deaths for which the underlying cause was listed as codes 410.0-414.9 of the International Classification of Diseases, Ninth Revision (ICD-9). The cause of death is reported by attending physicians, medical examiners, or coroners on death certificates filed in state vital statistics offices. Age-adjusted IHD death rates for persons aged ≥35 years were calculated by the direct method using the 1970 U.S. standard population. Age-specific death rates were calculated for 10-year age groups. Black:white mortality ratios were calculated by dividing the death rate for blacks by the death rate for whites. Black:white mortality ratios for each year during 1981-1995 also were examined and indicated the same trends as the average annual mortality ratios for the 5-year periods presented here.

From 1981 through 1995, age-adjusted IHD death rates decreased for blacks and whites of both sexes. The age-adjusted IHD mortality ratios for blacks compared with whites increased from 0.9 to 1.1 overall. For each time period, the age-adjusted black:white IHD mortality ratios were <1.0 for men and greater than 1.0 for women.

The age-specific IHD death rates increased with increasing age for blacks and whites of both sexes. The age-specific IHD mortality ratios were >1.0 in younger age groups, where death rates for blacks exceeded those for whites, and were <1.0 in older age groups, where death rates for whites exceeded those for blacks. This crossover of mortality ratios occurred in different age groups for men and women. For example, during 1981-1985, the mortality ratios for men were <1.0 in the 65-74-year age group and those for women were <1.0 in the 75-84-year age group. In every age group, IHD death rates were greater for men than women, and age-specific black:white mortality ratios were greater for women than men.

From 1981 through 1995, age-specific IHD death rates decreased for blacks and whites within each sex and age group except for black women aged ≥85 years. However, these decreases were greater for whites than blacks during this period, resulting in a greater disparity of IHD death rates between blacks and whites and in increasing black:white mortality ratios. The age-specific black:white mortality ratios increased in every age group overall, and the black:white mortality ratios increased across the three 5-year periods for men and women of every age group except the 35-44-year age group. This increase in the mortality ratios resulted in a shifting of the age groups at which death rates for blacks exceeded those for whites, such that the disparity between young blacks and whites extended into older age groups. For example, during 1981-1985, the total age-specific black:white mortality ratios remained >1.0 until the 65-74-year age group, but during 1991-1995 these mortality ratios remained >1.0 until the 75-84-year age group.

SL Huston, PhD, EJ Lengerich, VMD, E Conlisk, PhD, K Passaro, PhD, Chronic Disease Epidemiology and Evaluation Section, Div of Community Health, North Carolina Dept of Health and Human Svcs. Cardiovascular Health Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

The findings in this report indicate that IHD death rates declined for all age groups during 1981-1995; however, these decreases were greater for whites than for blacks, causing an increase in the black:white IHD mortality ratios. Black: white mortality ratios were particularly high for young women; black women in the 35-44- and 45-54-year age groups experienced IHD death rates more than twice those of white women in the same age groups. Furthermore, the disparity in IHD death rates between blacks and whites in the younger age groups increased and extended into older age groups during this period. By 1991-1995, the black:white mortality ratios were <1.0 only in the 75-84 and ≥85-year age groups for men and in the ≥85-year age group for women. In addition, among the older age groups, where death rates for whites exceeded those for blacks, the gap appeared to be closing over time, with the black:white mortality ratios increasing toward 1.0.

Since the mid-1970s, whites (especially white men) have experienced greater declines than blacks in age-adjusted IHD death rates.^4- 6 Although this report found that blacks had either similar or lower age-adjusted rates during 1981-1995, the age-specific rates for this period showed a notable race disparity for persons aged 35-64 years. Death rates for these younger age groups were considerably lower than those for older age groups. Nonetheless, the increased risk for IHD death among younger black men and women represents a substantial number of years of potential life lost.

IHD death rates are affected by changes in modifiable risk factors associated with IHD and the successful diagnostic and treatment efforts in preventing mortality. The disparities in early IHD death rates by race in this report probably reflect differing distributions of risk factors (e.g., cigarette smoking, body weight, diabetes, and hypertension) and socioeconomic status.² Other potential explanations for the increasing disparity between blacks and whites in premature IHD mortality include increasing differentials over time in the detection and treatment of IHD risk factors and in the quality of acute, in-hospital, and/or post-hospital medical care for IHD. In addition, the variation in physician, coroner, and medical examiner practices in reporting IHD on death certificates may have contributed to these differences. Compared with whites, blacks have a higher prevalence of some IHD risk factors (e.g., hypertension and diabetes),⁶ are less likely to receive certain diagnostic and therapeutic coronary procedures,^7- 8 and may have a higher proportion of sudden and out-of-hospital deaths from IHD.⁹

Public health research and intervention efforts are needed to determine and address the underlying factors associated with the greater risk for IHD death among younger (aged <65 years) blacks than among younger whites and to address the slower decline in the IHD death rates among blacks of all ages. The continued monitoring of age-specific IHD mortality by race/ethnicity, continued monitoring of the prevalence of modifiable risk factors for IHD by race/ethnicity, and collection and analysis of population-based data on IHD incidence and treatment should be conducted to monitor the success of public health efforts to reduce IHD morbidity and mortality. Setting objectives for reductions in IHD mortality among persons aged <65 years also may be useful. CDC recently awarded funds to eight states to develop programs for the prevention of cardiovascular disease, including IHD. These programs will emphasize development of policies and environmental changes to reduce and prevent cardiovascular diseases. In particular, these programs will target cardiovascular diseases in minority and low-income populations.

MMWR. 1998;47:922-926

2 tables omitted

In the United States each year, tobacco use causes approximately 400,000 deaths and is the single most preventable cause of death and disease.^1,2 Consequently, state and local public health agencies closely monitor tobacco use and its correlates.³ In 1996, the prevalence of current cigarette smoking among adults was the first health behavior and the first noninfectious condition added by the Council of State and Territorial Epidemiologists (CSTE) to the list of nationally notifiable conditions reported to CDC.⁴ In 1998, per capita sales of cigarettes (along with prevalence among youth of current cigarette smoking and current smokeless tobacco use) was added by CSTE to the list of notifiable conditions reported by states to CDC. This report summarizes state-specific findings for current cigarette and current smokeless tobacco use by adults from the Behavioral Risk Factor Surveillance System (BRFSS) and number of packs of tax-paid cigarettes sold per capita in each state from data compiled annually by The Tobacco Institute. The findings indicate that current adult cigarette smoking prevalence by state ranged from 13.7% to 30.8%, annual per capita tax-paid cigarette sales ranged from 49.1 packs to 186.8 packs, and adult smokeless tobacco use prevalence ranged from 1.4% to 8.8%.

State- and sex-specific prevalences of current cigarette smoking and current smokeless tobacco use among adults are available from the 1997 BRFSS. The BRFSS is a state-specific, random-digit-dialed telephone survey of health behaviors of the civilian, noninstitutionalized U.S. population aged ≥18 years⁵ conducted by state health departments with assistance from CDC. In 1996 and 1997, respondents were asked, "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Current cigarette smokers were defined as persons who reported having smoked at least 100 cigarettes during their lifetime and who currently smoke every day or some days. To determine current smokeless tobacco use, respondents were asked, "Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?" and "Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?" Current smokeless tobacco users were defined as persons who reported having ever used or tried any smokeless tobacco product and who currently use a smokeless tobacco product. To estimate prevalence, responses for each state were weighted to the current age, race, and sex distribution of the state's population (i.e., crude prevalence). To allow comparison of findings across states that had different age distributions, age-adjusted prevalences for each state were estimated by using direct standardization to 10-year age groups of the U.S. population in 1997 derived from U.S. census estimates.⁶ The number of packs of tax-paid cigarettes sold per capita in each state is compiled yearly by The Tobacco Institute by using information on federal, state, and local excise taxes and total population estimates.⁷

In 1997, the median state prevalence of current cigarette smoking by adults was 23.2%; prevalence was 25.5% for men and 21.3% for women (Table 1). The crude median prevalence of current cigarette smoking was similar in 1997 and in 1996 (25.5% for men, 22.0% for women, and 23.6% for both groups combined).⁴ In 1997, for every state except Florida, the crude prevalence of current cigarette smoking was within 1% of the age-adjusted prevalence for that state.

Current adult cigarette smoking prevalence differed approximately twofold across the states. In 1997, the current cigarette smoking prevalence was highest in Kentucky (30.8%), Missouri (28.7%), Arkansas (28.5%), Nevada (27.7%), and West Virginia (27.4%), and lowest in Utah (13.7%), California (18.4%), Hawaii (18.6%), the District of Columbia (18.8%), and Idaho (19.9%). The current cigarette smoking prevalence for men was highest in Kentucky (33.1%), and for women in Nevada (29.8%). For both men and women, current smoking prevalence was lowest in Utah.

Per capita tax-paid sales of cigarettes for July 1, 1996, through June 30, 1997, varied approximately fourfold across the states (Table 1). The state median tax-paid cigarette sales was 90 packs per person per year. Sales were highest in Kentucky (186.8 packs) and lowest in Hawaii (49.1 packs).

Questions about current adult smokeless tobacco use were included in the 1997 BRFSS in 17 states. The difference in prevalence was more than sixfold (from 1.4% in Arizona to 8.8% in West Virginia). Among men, the prevalence of current smokeless tobacco use was highest in West Virginia (18.4%) and Wyoming (14.7%); five states (Alabama, Alaska, Kansas, Kentucky, and Montana) reported prevalences of 9%-12%, and 10 states reported prevalences of ≤8%. For women, the prevalence of current smokeless tobacco use was ≤1.7% in all 17 states.

J Cook, Alabama, MBA; P Owen, Alaska; B Bender, MBA, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; S Hoecherl, Florida; L Martin, MS, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Feigley, PhD, Montana; M Metroka, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; P Pullen, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; T Aldrich, PhD, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

This report includes information about two CSTE-recommended indicators of tobacco use for all states (current cigarette smoking by adults and per capita tax-paid sales of cigarettes) and current smokeless tobacco use among adults for 17 states. Information on cigarette and smokeless tobacco use by youth in 1997 is available elsewhere.⁸ National surveys provide information about tobacco use and are useful for monitoring overall trends, but their effectiveness is limited for monitoring state-level year-to-year changes in tobacco consumption. National surveys also mask the twofold variation in current adult cigarette smoking prevalence among the states.

In the BRFSS, the crude and age-adjusted prevalences of current adult cigarette smoking were similar, indicating that differences in prevalence among states are related primarily to factors other than differences in adult age distributions. Although the median prevalence for current cigarette smoking among adults was nearly the same in 1996 and 1997, the twofold difference in prevalence among states, the wide variation in per capita tax-paid cigarette sales, and the wide variation in smokeless tobacco prevalence among adults suggest that further reductions in tobacco use are achievable.

The findings in this report are subject to at least three limitations. First, the BRFSS standardizes procedures among states, but the quality and completeness of the surveys can vary by state and year. Second, the changes in questions about current cigarette use in 1996 limit comparisons with previous years.⁹ Finally, estimates of per capita tax-paid cigarette sales provide populationwide rather than individual-based estimates of behaviors; because these estimates are based on tax revenues they may not accurately estimate actual consumption.¹⁰

By monitoring tobacco-related health effects, policy changes, and public attitudes at state and local levels, tobacco-related activities can be evaluated and public health programs can be tailored to local populations. CDC and state health departments are working together to improve state-specific measures of tobacco-related health outcomes, policy interventions, and related activities to improve the prevention and control of tobacco use. In 1999, CDC will provide all states with funding for tobacco-use prevention and control programs. CDC also is collaborating with states that have other sources of funding for activities related to tobacco-use prevention to develop effective public health intervention, surveillance, and evaluation activities.

References: 10 available