Publication of the Division of Public Health Services

March/April 2004, Vol. 18, No. 2

Your Role in Preventing Smoking Related Diseases
by Will Humble

Cigarette smoking is the leading
cause of preventable death in
Arizona. Each year, cigarette smoking
causes serious illnesses among an estimated 172,000 Arizonans, including
approximately 8,800 deaths. Annual
health-related economic costs from
cigarette smoking in Arizona are
approximately $3 billion.
A recent survey conducted by the
Arizona Department of Health
Services and the Centers for Disease
Control and Prevention’s Behavioral
Risk Factor Surveillance System found
that approximately 27 percent of men
and 20 percent of women in Arizona
reported that they smoke tobacco.
These values were very close to the
U.S. Median of 26 percent for men
and 21 percent for women.
Clearly, we can all do better. As
front-line health care professionals,
you are a critical part of our overall
plan to reduce smoking
in Arizona. Research
shows that
healthcare
providers
can make a
big difference in
their
patients’
decisions to
quit smoking.

Arizona Smokers’ Helpline,
1.800.556.6222
Ashline: www.ashline.org
Overwhelming evidence suggests
that smoking cessation interventions,
if delivered in a timely and effective
manner, greatly reduce the smoker’s
risk of suffering from smoking-related
diseases. The following Five “A’s” for
smoking cessation intervention guidelines are effective when talking to
patients that use tobacco:
• Ask about tobacco use at every
visit.
• Advise the patient that quitting
smoking would improve their
long-term health.
• Assess the patient’s willingness to
quit.
• Assist the patient in finding
cessation services.
• Arrange for follow-up.
Arizona physicians have multiple
options when referring patients to
cessation services. The Arizona
Department of Health Services’
Tobacco Education and Prevention
Program funds telephone-based
cessation counseling provided by the
Arizona Smokers’ Helpline,
1.800.556.6222 and group classes
offered by county health departments.

The Helpline offers a menu of
bilingual services including multi-session telephone counseling, telephone
information, referrals to community
based classes, and self-help publications. The Helpline not only provides
cessation services, it also acts as an
information hub for tobacco users
who want to learn about class offerings. The Arizona Smokers’ Helpline
maintains a separate website, called
the Ashline, www.ashline.org, which
offers a wide range of cessation information.
For most of your patients who
smoke, helping them to quit will be
the single most important intervention
you can provide. But, it doesn’t end
there. Research suggests that it makes
good business sense. Patients’ overall
satisfaction with office visits is
improved when tobacco use is
addressed (Preventive Medicine,
December 2001). Patients who were
asked about their tobacco use or
counseled about quitting were more
likely to be very satisfied with the
physician. And, patient satisfaction
increased with the intensity of service
offered.
Will Humble is the Bureau Chief for
Epidemiology & Disease Control and can be
reached at 602.364.3855 or
whumble@hs.state.az.us

Visit the ADHS Web site at www.hs.state.az.us
Smoke Free
Environments
in Arizona
Page 2
March/April 2004

Identifying
Depression
Page 3

Depression
Resources
Page 4

World TB Day
in Arizona
Page 5

Communicable
Disease
Summary
Page 6

Top Ten Public
Health
Improvements
Page 7
Prevention Bulletin

1

Smoke-Free Environments
Building Momentum in Arizona
More and more cities, towns and
counties in Arizona are passing
ordinances that ensure smoke-free
environments. Statewide support
for smoke-free environments is
particularly strong.
In a poll conducted in December
2003 by the Arizona Republic, 42
percent of Arizonans supported a
statewide ban on public indoor smoking compared to 36 percent polled in
December 2002. Overall, 73 percent
are in favor of “some sort of” smoking
limitation, compared to 65 percent in
2002.
The tumblers are falling into place
to ensure smoke-free environments
statewide, in part because several
municipalities have implemented a
wide variety of limitations on public
smoking. Bar and restaurant owners
in cities with strict, anti-smoking ordinances claim to be losing business as
patrons flee to more smoking-friendly
cities. Some of these business owners
are among those pushing for
statewide smoke-free environments.
•

•

•

2

Tempe and Guadalupe have
restrictions that have strict limitations on smoking in all public
places, including bars and restaurants. Mesa allows smoking in
bars and small bars that are part
of restaurants when they have
separate ventilation. Chandler
recently implemented a smoking
ordinance similar to the one in
Mesa.
Peoria recently passed an ordinance that bans smoking in all
new bars and restaurants, but
allows smoking in existing bars
if they are separated by a floor-toceiling barrier and are independently ventilated. Prescott voters
passed a workplace ban in
November; however, bars are
exempt from enforcement until
2005.
Coconino County has implemented an ordinance that prohibits
smoking in all indoor places of

Prevention Bulletin

employment including
restaurants; but there is an
exemption for stand-alone
bars. The City of Tucson
prohibits smoking in any
public vehicle (including
taxicabs), enclosed
structures such as lobbies,
hallways, restrooms,
shopping malls, stores,
restaurants, theaters,
lockers and conference
rooms.
The public health justification for ensuring smokefree environments is solid.
Secondhand smoke contains several
hundred recognized toxic substances,
including numerous carcinogens. The
U.S. Environmental Protection Agency
has classified secondhand smoke as a
known cause of cancer in humans.
Employees of bars and restaurants are
exposed to the greatest amount of
secondhand smoke, creating an occupational health risk so great that it
would not be tolerated if the source
were anything except tobacco smoke.
Children exposed to secondhand
tobacco smoke are at increased risk
of lower respiratory tract infections
such as pneumonia and bronchitis.
Secondhand smoke also increases the
number of episodes and severity of

by Will Humble

symptoms in thousands of asthmatic
children in Arizona. Children
exposed to secondhand smoke are
also more likely to have reduced lung
function and symptoms of respiratory
irritation like cough, excess phlegm,
and sneezing. Secondhand smoke
may also increase the risk for sudden
infant death syndrome.
Clinicians play a unique role in
health-related public policy debates –
especially this one. If you would
like to play your part, you can contact
Arizonans Concerned About Smoking
at 623.465.2227 or
http://members.aol.com/acasinc.
Will Humble is the Bureau Chief for Epidemiology
& Disease Control and can be reached at
602.364.3855 or whumble@hs.state.az.us

Arizona Municipalities with 100% Smoke-free Environments
Municipality
Chandler
Coconino County
Gilbert
Goodyear
Guadalupe
Nogales
Prescott
Santa Cruz County
Surprise
Tempe

100 % Smoke-free
Workplaces

✔
✔
✔
✔
✔
✔
✔
✔
✔
✔

100% Smoke-free
Restaurants

100% Smoke-free
Bars

✔

✔

✔

✔

✔
March/April 2004

Identifying Depression

By Lisa Shumaker

• Depression is the leading cause of disability and is a risk factor for heart disease and high blood
pressure.
• Nearly 5% of all adults suffer from depression and it is more prevalent in women.
• White men over the age of 85 have the highest suicide rate in the nation.
• 75% of seniors have visited a doctor within one month of committing suicide.
• People suffering from depression can be helped with medication and/or psychotherapy.

Signs and Symptoms

Risk Factors for
Developing Depression

• Persistent sadness or irritability.

General risk factors for all people

• Loss of interest or pleasure in almost all
activities of the day, every day.

• Family conflict and divorce.

• Unplanned weight loss or gain.

• Death of friend, family, or partner.

• Poor appetite or overeating.

• Family history of depression.

• Trouble sleeping or excessive sleeping.

• Breakup of a romantic relationship.

• Being unusually restless or slow
moving.

• Disability, chronic illness, or pain.

• Fatigue or loss of energy.
• Feeling worthless, guilty, or hopeless.

• Financial problems and unemployment.
• Loneliness.
• Exposure to trauma or stress.

• Difficulty controlling emotions.
• Trouble concentrating or solving
problems.

Additional Risk Factors for Youth

• Thoughts of suicide or suicide attempts.

• Being gay, lesbian, bisexual,
intersexual, or transgendered.

• Poor self-esteem.

• Unplanned pregnancy and parenting.

• Use of alcohol or illegal drugs.

• Poor bonding with parent.

• Chronic headaches or fatigue.

• Parent depression or use of substances.

• Poor personal hygiene.

• Abuse, neglect, or rejection by
parents.

Additional Symptoms for Youth

• Malnutrition.

• Increased anger or hostility.

• Attention, conduct, or learning
disorders.

• Failure to gain expected weight.
• Problems in school, frequent absences
• Impulsivity.
• Extreme sensitivity to failure or
rejection.

March/April 2004

See page 4 for resource information

Prevention Bulletin

3

Depression Resources
IMPORTANT CRISIS &
BEHAVIORAL HEALTH NUMBERS

REGIONAL BEHAVIORAL
HEALTH AUTHORITIES

Dial 911 for life threatening situations

EMPACT-SPC
1.866.205.5229
Services to victims of sexual assault, abuse,
or family violence, or individuals and
families needing crisis or suicide
intervention or critical incident debriefing.
Southern Arizona Center Against
Sexual Assault
1.800.400.1001
Crisis intervention, specialized therapy, and
advocacy for victims of sexual assault.
Teen Life Line
1.800.248.8336
Peer and crisis counseling for teens.
Wingspan
1.800.553.WDVP
Crisis intervention and other services for
lesbian, gay, bisexual, and transgender
persons in southern Arizona.

Community Partnership of
Southern Arizona
(Pima, Graham, Greenlee, Cochise,
and Santa Cruz Counties)
1.800.771.9889
Value Options
(Maricopa County)
1.800.631.1314
Pinal Gila Behavioral
Health Association
(Pinal and Gila Counties)
1.800.982.1317
Gila River Health Care Corporation
Gila River Indian Community)
1.800.259.3449
The Excel Group
(Yuma & La Paz Counties)
1.800.880.8901
Northern Arizona Regional

Arizona Department of Health Services
Division of Behavioral Health Services
602.364.4558

4

Prevention Bulletin

Behavioral Health Authority
1.800.640.2123

March/April 2004

SARS, Avian
Influenza, and
Guidelines Aplenty
By Bob England MD

World TB Day and Arizona
By Cheryl McRill, MD

March 24 is World TB Day. Arizona
has a long association with tuberculosis
(TB). Many of our current hospitals
began as TB sanatoriums in the days
before the development of drugs to treat
TB. Doctors from all over the country
sent their patients here to heal (or die)
in our beautiful, dry, desert climate.
How ironic that we should now be one
of the few states to not share the national experience of a decade of decline in
this still devastating disease.
The year 1992 marked the end of
the well-known resurgence of TB in the
United States, which was attributed to
the increase in HIV, immigration from
high-risk countries, and neglect of public health infrastructure. Between 1992
and 2002 (the last year for which
national statistics are available), the
national TB case rate declined 51%,
from 10.5/100,000 population to
5.2/100,000, and the total number of
cases declined 43%. During that same
period in Arizona, our state case rate
only declined 28%, from 6.7/100,000 to
4.8/100,000, and our annual number of
cases was essentially unchanged. In
2003, our total cases increased 12.2%
to 295. Our TB case rate for 2003
increased to 5.2/100,000, which will
likely exceed the national average for
the first time in our state history (national figures are not yet available for 2003).
(See Figure 1).

Many of you have recently
received multiple alerts and advisories about SARS and avian
influenza. As the situation changes
anywhere in the world, modifications may be made.
We know that it is unrealistic to
expect clinicians to keep up with
all of these. So please remember
just the following three principles.
If we adhere to these well, we’ll do
fine:
• Promote respiratory hygiene
guidelines previously distributed: www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm (i.e. droplet precautions for patients with respiratory symptoms).
• Ask all of your patients with respiratory symptoms for a travel
history in the past 10 days.
• If you suspect possible avian
influenza or SARS-CoV, call
your local health department.
The local health department will
walk you through current
recommendations, help you
assess risk, and arrange for
appropriate testing when needed.
The single change that will be
most noticeable to most healthcare
workers and patients is the implementation of respiratory hygiene
guidelines. This means a lot of
masks, a lot of hand sanitizer, and
a lot of encouraging patients to use
them. We may feel like we’re nag- 12
ging. It may seem like overkill. It
will work, however, and our wait- 10
ing rooms will stop transmitting so
8
much colds and flu to boot.
6
As always, you may most easily
keep up with events regarding
4
SARS, avian influenza, or any other
2
emerging infectious disease at the
Centers for Disease Control and
0
Prevention website, www.cdc.gov.
Bob England MD, is the State Epidemiologist
and can be reached at 602.364.3582 or
benglan@hs.state.az.us
March/April 2004

Why are we so out of synch with
the declining TB trend seen nationally?
While it is tempting to blame our proximity to the border, the truth is that in
2002, 52% of the TB cases in Arizona
were born in other countries, not significantly different than the 51% observed
nationally. Arizona does exceed the
national average for proportion of cases
among the homeless (12% Arizona vs.
6% U.S.) and in correctional facilities
(7% vs. 3%). However, we have fewer
TB cases who are also HIV infected (4%
vs. 8%). Arizona is similar to the rest of
the nation in that all of these groups are
significantly at risk for tuberculosis.
The challenge for public health is to
devise intervention strategies to reduce
disease in at-risk populations, but we
need your help. The Arizona
Department of Health Services urges
physicians to think TB when evaluating
patients with symptoms suggestive of
tuberculosis, especially if the patient is
foreign-born, has a history of homelessness or incarceration, or has risk factors
for HIV infection. Early detection and
treatment of disease reduces transmission and is the best prevention of future
TB cases.
For more information on TB in
Arizona visit our website at
www.hs.state.az.us/phs/oids/tuberculosis/index.htm or call the Arizona
Department of Health Services’ TB
Control Program at 602.364.4750.
Figure 1

Tuberculosis Case Rates per 100,000 Population,
Arizona and United States, 1992-2003

92

19

93 994 995 996 997 998 999 000 001 002 003
2
2
2
2
1
1
1
1
1
1

19

United States

Arizona
Prevention Bulletin

5

SUMMARY OF SELECTED REPORTABLE DISEASES
Year to Date (January - December, 2003)1, 2
Jan - Dec
2003

Jan - Dec
2002

5 Year Median
Jan - Dec

VACCINE PREVENTABLE DISEASES:
Haemophilus influenzae, serotype b invasive disease (<5 years of age)
Measles
Mumps
Pertussis (<12 years of age)
Rubella (Congenital Rubella Syndrome)
FOODBORNE DISEASES:
Campylobacteriosis
E.coli O157:H7
Listeriosis
Salmonellosis
Shigellosis

8 (3)
1
0
101 (69)
0 (0)

7 (5)
0
1
280 (131)
0 (0)

6 (4)
1
2
238 (131)
1 (0)

835
42
10
802
593

733
40
18
825
668

619
40
19
825
598

288
318
978
7
9,350 (3,480)

305
252
1,125
6
10,262 (5,129)

466
178
1,026
14
6,085 (2,300)

504
146
21
14

789
314
27
32

783
214
42
33

12,817
3,581
187 (19)

14,904
3,772
201 (19)

12,492
4,100
185 (26)

14 (2)
713

11 (1)
1,031

11 (2)
939

0
0
75

1
0
143

3
0
102

2,665
295
538
480
273 (246)

3,118
263
503
457
223 (200)

1,917
262
503
504
259 (200)

VIRAL HEPATITIDES:
Hepatitis A
Hepatitis B: acute
Hepatitis B: non-acute3
Hepatitis C: acute
Hepatitis C: non-acute3 (confirmed to date)
INVASIVE DISEASES:
Streptococcus pneumoniae
Streptococcus Group A
Streptococcus Group B in infants <30 days of age
Meningococcal Infection
SEXUALLY TRANSMITTED DISEASES:
Chlamydia
Gonorrhea
P/S Syphilis (Congenital Syphilis)
DRUG-RESISTANT BACTERIA:
TB isolates resistant to at least INH (resistant to at least INH & Rifampin)
Vancomycin resistant Enterococci isolates
VECTOR-BORNE & ZOONOTIC DISEASES:
Hantavirus Pulmonary Syndrome
Plague
Animals with Rabies4
ALSO OF INTEREST IN ARIZONA:
Coccidioidomycosis
Tuberculosis
HIV
AIDS
Lead Poisoning (<16 years of age)
1
2
3
4

6

Data are provisional and reflect case reports during this period except Lead Poisoning which is by date of diagnosis.
These counts reflect the year reported or tested and not the date infected.
Case counts for non-acute Hepatitis B and C are not available before 1998.
Based on animals submitted for rabies testing.

Prevention Bulletin

March/April 2004

Top 10 Public Health Improvements
of the 20th Century
During the 20th Century, the
health and life expectancy of persons
residing in the United States improved
dramatically. The average lifespan has
lengthened by greater than 30 years
in the last century. While advances
in diagnosis and treatment of disease
has played a significant role in
increasing life expectancy, most of
this gain is attributable to advances in
public health.

8.

The top 10 advances in public health
were highlighted recently by the
Centers for Disease Control and
Prevention.
10. Fluoridation of drinking water.
Fluoridation of drinking water
began in 1945. Nearly half of all
Americans now have fluoridated
water. Fluoridation has played an
important role in the reduction in
tooth decay (40 percent to 70 percent in children) and of tooth loss
in adults (40 percent to 60 percent).
9. Eliminating lead in gasoline,
paint, and food containers. The
removal of lead from gasoline,
paint, and food cans has led to a
precipitous drop in the blood lead
levels in Americans. The removal

7.

6.

5.

March/April 2004

of these lead sources from the
environment has probably been
the single most effective environmental health intervention of the
last 100 years.
Family planning. Access to family
planning and contraceptive services has altered social and economic roles of women. Family
planning has provided health
benefits such as smaller family
size and longer intervals between
the birth of children; increased
opportunities for preconception
counseling and screening; fewer
infant, child and maternal deaths.
Healthier mothers and babies.
Thanks to better hygiene and
nutrition, availability of antibiotics, greater access to health care
and technologic advances in
maternal and neonatal medicine,
the world has healthier mothers
and babies. Since 1900, infant
mortality has decreased 90 percent, and maternal mortality has
decreased 99 percent.
Safer and healthier foods. Since
1900, safer and healthier foods
have resulted from decreases in
microbial contamination and
increases in nutritional content.
Identifying essential micronutrients and establishing food-fortification programs have almost
eliminated major, nutritional deficiency diseases such as rickets,
goiter and pellagra in the United
States.
Identification of tobacco as a
health hazard. Since the 1964
Surgeon General’s report on the
health risks of smoking, the prevalence of smoking among adults
has decreased, and millions of
smoking-related deaths have been
prevented. Better public awareness has resulted in smoking cessation. Since 1972, death rates
for coronary heart disease have
decreased 51 percent.

by Will Humble

4. Control of infectious diseases.
Control of infectious diseases has
resulted from clean water and
improved sanitation. Infections
such as typhoid and cholera transmitted by contaminated water, a
major cause of illness and death
early in the 20th Century, have
been reduced dramatically by
improved sanitation.
3. Safer workplaces. Work-related
health problems, such as coal
workers’ pneumoconiosis (black
lung) and silicosis — common at
the beginning of the century —
have come under better control.
Severe injuries and deaths related
to mining, manufacturing, construction and transportation have
also decreased.
2. Motor vehicle safety.
Improvements in motor vehicle
safety have resulted from engineering efforts to make both vehicles and highways safer and from
successful efforts to change personal behavior, such as increased
use of safety belts, child safety
seats and motorcycle helmets,
and decreased drinking and driving. These efforts have contributed
to large reductions in motor vehicle related deaths.
1. Vaccination. This century, vaccines have been developed or
licensed against 21 diseases,
11 of which are recommended for
all U.S. children. Substantial
achievements have been made in
the control of many vaccine-preventable diseases. Smallpox has
been eradicated, polio is nearly
eradicated worldwide, and rates
for nine vaccine-preventable diseases and their complications are
much lower.
Will Humble is the Bureau Chief for
Epidemiology & Disease Control and can be
reached at 602.364.3855 or
whumble@hs.state.az.us

Prevention Bulletin

7

❍ Change of Address/Name
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Arizona Department of Health Services
Public Information Office
150 North 18th Avenue
Phoenix, AZ 85007

Please include your mailing label with all
requests for changes. Fax changes to
602.542.1265 or call 602.364.2401

PRSRT STD
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PAID
Phoenix, AZ
Permit No. 957

Janet Napolitano, Governor
Catherine R. Eden, Ph.D., Director ADHS
Rose Conner, Assistant Director, Public Health Services
Editorial Board
Bob England, M.D., M.P.H., State Epidemiologist
Victorio Vaz, D.V.M., Ph.D.
Tim Flood, M.D.
Kathy Fredrickson, M.P.H.
Will Humble, M.P.H.
Karen Lewis, M.D.
Ken Komatsu, M.P.H.
Cheryl McRill, M.D.
Wesley Press, M.S.
Lisa Shumaker, M.A.
Emma N. Viera, M.P.H.
Managing Editor: Courtney Casillas
e-mail: ccasill@hs.state.az.us
Contributors: Bob England, Will Humble,
Cheryl McRill, Lisa Shumaker
This publication is supported by the Preventive Health and Health Services Block
Grant from the Centers for Disease Control and Prevention (CDC).
Its contents do not necessarily represent the views of the CDC.
If you need this publication in alternative format, please contact the ADHS Public
Information Office at 602.364.1201 or 1.800.367.8939 (State TDD/TTY Relay).

Arizona’s Children & the Environment
The Arizona Department of
In addition to the environmental
Health Services, Office of
health assessment report published by
Environmental Health, has recently
the Arizona Department of Health
published a report that assesses the
Services, the Arizona Department of
environmental exposures facing
Environmental Quality has developed
Arizona’s children. The full report,
an action plan to improve environentitled “Arizona’s Children and the
mental conditions that affect the
Environment,” examines in detail the
health of children in Arizona. The
primary environmental exposures that
Arizona Department of Environmental
affect Arizona’s children. The full
Quality’s action plan is published on
report is posted on the Arizona
their website at: www.adeq.state.az.
Department of Health Services’ webus/function/news/2004/action.pdf
site at: www.hs.state.az.us/phs/oeh/
index.htm
Figure 1
The report examines the public
Environmental Exposures Significantly
health impact of the environmental
Affecting Children In Arizona
exposures, shown in figure 1, that
affect Arizona children:
Ambient Air Pollutants
The report also includes a numAirborne Allergens
ber of specific strategies and objecSecondhand Tobacco Smoke
tives for public health and environCoccidioidomycosis (Valley Fever)
mental interventions to reduce the
Lead Poisoning
types and amounts of contaminants
Sun Exposure (UV Radiation)
that adversely affect the health of
Methyl Mercury in Fish
Arizona’s children.
Pesticide Exposure
8

Prevention Bulletin

by Will Humble

The plan outlines the Arizona
Department of Environmental
Quality’s efforts during the next year
to confront a growing number of environmental concerns identified by the
Arizona Department of Health
Services’ report ranging from environmental triggers for childhood asthma
to children’s exposure to idling school
bus exhaust and pesticides in schools
to air quality along the U.S.-Mexico
border.
There is a clear need to better
coordinate efforts and maximize
resources to protect children’s environmental health in Arizona. By
improving the types and quality of
health and environmental data that
we collect, we can collaborate to
develop public health, environmental
and public policy interventions to
improve children’s health in Arizona.
Will Humble is the Bureau Chief for Epidemiology
& Disease Control and can be reached at
602.364.3855 or whumble@hs.state.az.us
March/April 2004