Renee Shaw and a panel of experts discuss public health and policy solutions for reducing the burden of lung disease in Kentucky. Topics include increasing access to low dose CT scans for early lung cancer detection; developing a comprehensive approach to radon testing and mitigation; smoking and vaping prevention among youth; and addressing indoor and outdoor air pollution in vulnerable communities.
Making Lung Health Funding a Priority in Kentucky
Kentucky leads the nation in lung cancer cases and mortality rate, and chronic lower respiratory disease is the fourth leading cause of death in the commonwealth. Despite those sobering statistics, the state does not devote a lot of resources toward driving down rates of respiratory illness, says Ellen Hahn, PhD, RN, FAAN, professor at the University of Kentucky College of Nursing and director of BREATHE.
“We don’t talk about (lung disease) because we don’t invest in tobacco control and in lung health,” Hahn says. “We need tobacco control funding so we can give the right messages. The industry spends so much marketing their products and we are running to keep up behind them in public health. We don’t have the funding to put up powerful ads on TV or social media or radio so children and young adults get the message.”
“Our funding is low,” agrees Connie White, MD, the deputy commissioner for clinical services at the Kentucky Department for Public Health. “We try to be as efficient as we have to reach as many people as we can, but the reach that other interests have vastly outdoes anything we can manage to balance against it.”
Shannon Baker, director of advocacy for the American Lung Association in Kentucky, says that her organization and other supporters have made progress in recent years but that there is still a lot of work to be done. She notes that the emergence of the coronavirus two years ago, which in its worst cases severely damages the lungs, has helped refocus policymakers’ attention toward the vital importance of ensuring respiratory health. “When you can’t breathe, nothing else matters,” says Baker.
The Centers for Disease Control recommends Kentucky invest $56.4 million per year toward tobacco prevention and cessation programs, but the state only invests $2 million per year for those programs, Baker says. Funding has been cut for 14 consecutive years, and she says that as this KET Forum airs the Kentucky legislature is considering its next biennial budget. “At a minimum, we need to go back to the pre-pandemic level of 3.3 million dollars,” she reasons. “It puts educators in schools, tobacco control coordinators in our health departments, and it helps our kids from ever initiating (smoking and/or vaping).”
Smoking is the single most preventable cause of death, Hahn says, so it makes sense to devote as much resources as possible toward educating young people about its dangers. Kentucky has an adult smoking rate of 21.4 percent compared with the national average of 15.5 percent (2020 data), and the percentage of high school students who smoke (8.4%) and who use electronic cigarettes (26.4%) are well above national averages. According to Hahn, about 10,000 people die prematurely in Kentucky each year due to tobacco use, and medical costs to treat diseases caused by smoking are in the billions.
“Policy makes the healthy choices the easy choices,” Hahn says. This is especially true when indoor smoking bans are enacted and when taxes are increased on tobacco products. Hahn notes that there has been a positive trend in recent years where local communities in Kentucky have enacted indoor bans on smoking and vaping. That number now totals 41 towns and/or counties.
White says that most people start smoking before the age of 18, so the Kentucky Department of Public Health devotes a lot of its scarce resources toward reaching high schoolers – and younger kids – and informing them about the myriad health dangers of smoking and e-cigarette use. She also says that the department wants to expand its services to help current smokers quit their habit. Anyone who is ready to give up tobacco and transition toward better lung health can call 1-800-QUIT-NOW or visit www.QuitNowKentucky.org to contact a counselor.
The Value of Early Lung Cancer Screening
One area where Kentucky has made some inroads over the past decades is in implementing early detection screening programs for lung cancer. These low dose CT scans are given to qualifying patients and can identify very small nodules in the lung, which are then examined by oncologists and possibly recommended for biopsy. Early screening for lung cancer has proven beneficial in detecting the disease at beginning stage before it spreads to other parts of the lungs, to the lymph nodes, and to distant organs.
“In terms of who is eligible, it’s those ages 50 to 77 or 80 depending upon the guidelines who have what’s called a 20 pack-year smoking history – you’ve smoked a pack a day for 20 years,” says Jennifer Redmond Knight, DrPH, an assistant professor of health management and policy at the University of Kentucky College of Public Health. That group includes both current smokers and those who have quit smoking within the past 15 years but had a 20 pack-year history before then.
In Kentucky, 17% of smokers in the recommended age group and with a 20 pack-year history have received low dose CT scan screening. That puts the state second nationwide – a success story according to Knight, although there’s much more work to be done in spreading the word about the benefits of this procedure.
“We’ve had multi-level, coordinated engagement and partnerships around lung cancer screening really since 2013,” she says. “We actually have people looking to Kentucky and saying, ‘What did you guys do? This is incredible, and how can we do it too?’”
Knight says that in order to boost lung cancer screening rates to the level of mammographies or colonoscopies, this collaborative effort must continue and expand to include more health systems throughout Kentucky. And Knight believes that continuing to educate folks about lung cancer will help to reduce the stigma surrounding lung cancer as a smokers’ disease.
“Rather than saying ‘You deserve it,’ or blame or shame, we need to say, ‘Hey, these are our community members, brothers, sisters, friends and neighbors, being compassionate and empathetic,” she says. “Engaging folks in a positive way and a way that brings hope.”
Glenna Courtney benefited from a low dose CT scan that detected a small nodule, and her physicians at St. Elizabeth Healthcare in northern Kentucky were able to remove it and prevent her lung cancer from spreading. Learn more about her story and lung cancer screening in this episode from KET’s Fighting to Breathe series.
Radon: Kentucky’s Hidden Cancer Threat
“Radon is a colorless, odorless, tasteless gas – it’s the invisible enemy, that’s what we call it,” Ellen Hahn says. “It’s nobody’s fault, it’s in the ground, in the rock and soil under our buildings… so this radioactive gas gets in our home and we breathe it, but we don’t know it.”
Radon is the second leading cause of lung cancer behind tobacco smoke (first- and secondhand smoke), and testing for the gas is offered free in Kentucky through public health departments and some libraries. Connie White says the state has a website where citizens can learn more about radon exposure and obtain testing kits. Hahn says that only 13 out of every 10,000 homes in Kentucky have been tested for radon despite much of the state existing within a high-risk region for rock and soil contamination.
Hahn and colleagues at the UK College of Nursing are conducting a research study called Radon on the Radar that enlists homeowners in four Kentucky counties with high radon levels to get their dwellings tested. If test results for a property are high for radon, the program provides financial assistance to help with costs for installing a radon mitigation system, which circumvents the air from below the dwelling, bypassing the residence and releasing it into the outdoor air. Mitigation costs range from $800 to $2,500 depending on the property, Hahn says.
Natalie Davenport in Logan County participated in the Radon on the Radar program after she and her husband initially decided to forego having a radon mitigation system installed when they built their home. After testing, the Davenports found that radon levels were exceedingly high, and the family took the necessary steps to get a mitigation system built.
Now, Davenport does outreach to neighbors about the program; learn more about their story in this episode from KET’s Fighting to Breathe series.
Asthma and Air Pollution
“The state of Kentucky has a higher asthma rate than the United States does – 11.5% versus 8% in the U.S., and it’s different in different parts of the state,” Connie White says. “Central Kentucky actually has a higher asthma rate than the rest of the state.”
White notes that people living in a household with an annual income of less than $25,000 have an asthma rate of around 18.5% as opposed to those with a household income of over $50,000 who have a rate of 6.5%. People with lower incomes are more likely to live in homes that have mold, insect infestation, or other air irritants.
“We know that people with asthma have more emergency department visits, they have more hospitalizations, more diabetes,” she says. “Forty-nine percent are obese, 40% have depression, and 17.5% of persons who have been diagnosed with asthma report at least one disability.”
Ellen Hahn says that people with asthma have been especially vulnerable during the COVID-19 outbreak. She also points out that many low-income people with asthma are renters and often are not able to make the necessary improvements to their living spaces in order to reduce triggers for the disease. On the positive side, Hahn says that after Lexington passed a smoke-free ordinance, a study found that the community reported reduced emergency room visits for asthma patients, both adults and children.
Air pollutants also trigger asthma, and researchers with a current project supervised by the University of Louisville’s Christina Lee Brown Envirome Institute are planting trees and bushes in specified neighborhoods in south Louisville with high air pollution levels. The study, called the Green Heart Louisville project, aims to determine whether introducing more foliage can lead to improved health metrics over time.
“The strongest predictor of longevity is lung capacity,” says Aruni Bhatnagar, PhD, FAHA, director of the Envirome Institute. “Having healthy lungs is very critical to having healthy everything else, including a healthy heart, healthy blood vessels. … Most of the people who are exposed to air pollution and breathe little particles through their nose and lungs die from heart disease. There is this cardio-respiratory axis that is one of the principal determinants of health.”
Learn more about the Green Heart Louisville study in this episode from Fighting to Breathe.
Policy Goals – Current and Long-Term
Shannon Baker says that a current bill proposed in the 2022 General Assembly by Sen. Wil Schroder (R-Wilder) will reverse an earlier law that prohibited local towns and/or counties from enacting any tobacco control laws other than smoke-free ordinances. If it is passed and signed into law by Gov. Andy Beshear, Baker says local leaders can expand their efforts to reduce smoking rates by restricting e-cigarette advertisements near schools, increasing youth education outreach, or starting other anti-tobacco initiatives.
According to Ellen Hahn, emerging research has shown e-cigarette use to be damaging to respiratory health, countering the message from many of the products’ manufacturers that switching to e-cigarettes is a safe alternative to smoking tobacco.
“A few years ago, we did raise the tax a little bit on e-cigarettes,” she says, but notes that the products are taxed based on their design, making some of them less expensive for kids to purchase.
Ultimately, Hahn would like to see taxes raised on all nicotine delivery products. Kentucky’s current $1.10 per pack tax on traditional cigarettes is ranked 36th in the U.S.
Kentuckians also need to become educated about radon exposure, Hahn says. For example, she points out that folks need to know combining radon exposure with the presence of tobacco smoke increases one’s lung cancer risk tenfold. Hahn recommends the state enact laws that require radon mitigation system installation when new homes are built, but does note that the state already does require any mitigation system to be constructed by a certified professional (check this website for a list).
“This is a place where we can talk about some policy success and some policy opportunity,” Baker says. A few years ago, Kentucky amended the seller’s form in a real estate transaction to require information about radon levels, she explains, mandating that the seller either disclose testing results if the dwelling has been tested or inform the buyer that no testing has been done.
“Now, the Lung Association with the help of a grant from the Environmental Protection Agency has launched an extensive and coordinated education campaign to reach realtors and explain to them the risks associated with radon, the importance of testing, and the importance of fixing your home,” she says. “What more could we do? We should be testing K-12 schools, we should be testing day care centers, because radioactive radon exposure is cumulative.”
Another recent legislative success involves asthma, Baker says. A bill sponsored by Sen. Max Wise (R-Campbellsville) and then passed in 2021 allows schools to supply and administer rescue medication to students experiencing respiratory distress. “That’s an enormous lifesaver, and we’re thrilled about that success here in Kentucky,” she says.