Wednesday, December 13, 2017

States use only 3 percent of tobacco revenue for tobacco prevention, and Kentucky spends even less: 0.7 percent

When cigarette manufacturers agreed in 1998 to pay billions of dollars to settle a lawsuit by states seeking reimbursement of health costs related to smoking, the presumption was that the states would spend a large part of the money on tobacco prevention. Few have, and Kentucky is among the low spenders, though it is a national leader in smoking and tobacco-related health costs.

Those points are made annually in reports by the Campaign for Tobacco-Free Kids, the American Cancer Society Cancer Action Network, the American Heart Association, the American Lung Association, the Robert Wood Johnson Foundation and the Americans for Nonsmokers' Rights and Truth Initiative.

The latest report, "Broken Promises to Our Children: A State-by-State Look at the 1998 Tobacco Settlement 19 Years Later," says states will spend less than 3 percent of this fiscal year's settlement funds and tobacco taxes – $27.5 billion out of $721.6 million – "on programs to prevent kids from smoking and help smokers quit."

The report says Kentucky will get $371 million this fiscal year from the settlement and tobacco taxes, but will spend only $2.6 million on tobacco prevention, a meager 0.7 percent. The spending is less than 5 percent of the $56 million that the federal Centers for Disease Control and Prevention says the state should spend.

Meanwhile, tobacco companies spend $250 million a year on marketing in Kentucky, and $8.9 billion nationally – "$1 million every hour – to market their deadly and addictive products," the report says.

That's way out of whack, said Charlie Ross of Mayfield, board chair of the Foundation for a Healthy Kentucky. "Health care expenses and productivity losses tied to smoking total more than $19 per pack, yet the state gets just 60 cents per pack in tobacco taxes," Ross said in a release. "It seems pretty straightforward that we need to focus more resources on preventing what's behind these costs. We'll not only reduce health-care expenditures, we'll save lives and draw more jobs to the Commonwealth from companies that need a healthy workforce to grow their business."

Ben Chandler, president and CEO of the foundation, said "Kentucky continues to make small strides in reducing smoking rates among both adults and youth, but we remain substantially higher than the national average and almost every other state. That's particularly true in Appalachian counties, where the rate hovers around 30 percent, double the national average. The single most effective way to reduce these rates is to raise the price of cigarettes through a substantial state tax increase of at least $1 per pack."

Tuesday, December 12, 2017

Kentucky ranked 42nd in America's Health Rankings this year, up from 45th last year, but there's little to celebrate

Kentucky moved up three notches in the latest America's Health Rankings, from 45th to 42nd, but its improvement stemmed mainly from gains in the factors that determine health, not the actual health outcomes. The state was 39th in health determinants (clinical care, policy, community and environment) but 46th in outcomes, such as the death rate from cancer, which is the nation's worst.

That was reflected in the rankings of behaviors, such as the smoking rate and the rate of drug deaths, both second largest in the nation, as well as obesity and physical inactivity. But the behavior score was helped by a high rate of high-school graduation and a low rate of excessive drinking.

The state's highest rankings came in health policy. It was ninth in the nation in the percentage of residents covered by health insurance, thanks to its expansion of Medicaid under the Patient Protection and Affordable Care Act. It also ranked better than average in some measures of community and environment, such as infectious diseases.

"Kentucky made progress in some areas, including expanding the number of residents with health insurance, but drug deaths are up dramatically, and our high rate of obesity remains a challenge," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky. "Our high smoking rate is a plague we know how to address, however. It's a huge contributing factor to our ranking as the cancer capital of the nation and our inability to reduce low birth-weight babies, heart disease and premature death. Smoking rates declined 2 percent nationally since last year, but only 1.4 percentage points in Kentucky. Raising the tobacco tax by at least $1 and enacting more smoke-free laws in counties and cities across the Commonwealth are two measures that will kick-start a greater decline in smoking rates and better health."

Since the rankings were first released in 1990, with the exception of 2008 when it ranked 39th, Kentucky has ranked in the bottom 10 states for health. It was 44th in 2010, 43rd in 2011, 44th in 2012, 45th in 2013, 47th in 2014, 44th in 2015, and 45th in 2016. Here are this year's figures:

Sunday, December 10, 2017

We're in the final few days of open enrollment for insurance on; automatic re-enrollment might not be the best way

Updated Dec. 11, 2017: This article has been edited to reflect that CareSource's marketplace products are not part of Humana.  

By Melissa Patrick
Kentucky Health News

You have just a few days to enroll in a 2018 health-insurance plan on Open enrollment under the Patient Protection and Affordable Care Act ends Friday, Dec. 15.

"The clock is ticking," Whitney Allen, the outreach and enrollment coordinator for the Kentucky Primary Care Association, said in an e-mail. " We encourage anyone that has questions about enrolling in a 2018 health insurance plan to contact their local application assister before Dec. 15!"

And even if you don't need marketplace coverage, Allen says you should remind others, because that seems to be the way most people are hearing about government-subsidized insurance this year.

"It seems word of mouth has been the best advertising, this open enrollment," Allen said.

The state health agency has said it is using direct mail, text messages, phone calls and e-mails to communicate with current policyholders and potential new enrollees about open enrollment because it no longer gets federal funds for outreach.

Allen said most people in southeastern Kentucky who have called for application assistance say they heard about the service from family members and friends who have used it.

Who needs coverage?

Anyone who doesn't have health coverage through a job, Medicare, Medicaid, the Children's Health Insurance Program, or other coverage that meets federal standards, needs to sign up for marketplace coverage or risk paying a penalty.

The penalty for not having health insurance in 2018 is $695 per adult and $347.50 per child, with a maximum of $2,085 per family, or 2.5 percent of the household's income, whichever is larger.

If you miss the deadline, and don't qualify for a special enrollment period, you will have to wait another year to sign up, says the website.

Health advocates have encouraged consumers to actively pick a plan to make sure they are getting the best coverage for the best cost, even if they will be automatically re-enrolled, as around 80,000 Kentuckians could be if they don't pick their own plan.

Stan Dorn, a senior fellow at Families USA, an advocacy group, told Kaiser Health News that auto-enrollment doesn't take premiums or benchmark plan changes into account, which means that even if you are assigned to the same plan, your cost could be different next year.

Kaiser Health News has also reported that it's important to actively choose a plan because "if you don't like the plan you're auto-enrollled in this year you may be stuck with it in 2018, unlike previous years when people could generally switch."

In general, the federal exchange plans are more attractive to individuals and families who earn less than 400 percent of the federal poverty level because they will qualify for subsidized coverage. And those who make too much to qualify for a subsidy are encouraged to connect with a certified health insurance agent or a broker to determine whether an exchange or off-exchange plan is best for them.

CareSource, which is offering exchange plans in 61 Kentucky counties, encouraged consumers to also check to see if their doctors are on their plans network.

"Even if a plan did not include your doctor last year, check again for 2018. Some plans, like CareSource, have recently signed agreements with new provider groups. This means more doctors may be in network beginning on January 1, 2018," CareSource said in a news release.

Anthem Blue Cross Blue Shield is selling plans in the other 59 counties. Here's a checklist of the information that you need to have available when you sign up for coverage:

Where can I get help?

Application assisters are available in every Kentucky county to help people sign up for coverage, and their services are free. There are also sign-up events throughout the state. To find an event in your county or an assister, go to

Help is also available through the state call center at 855-459-6328 and the customer center at 800-318-2596, which is available 24 hours a day, seven days a week.

Click here for a livestream open enrollment information session that aired Friday, Dec. 8 on the Kentuckians for The Commonwealth Facebook page. The video features application assisters from the Primary Care Association.

Friday, December 8, 2017

Flu and pneumonia, which can result from flu, are 8th largest U.S. cause of death; officials urge all over 6 months to get flu shot

Flu season is here and will last through February or longer, prompting state health officials to encourage Kentuckians to get their flu vaccinations.

“During the holidays families and friends will gather, which increases the potential for exposure to the flu virus," Dr. Jeffrey Howard, the state's acting health commissioner, said in a news release. "We urge everyone who hasn’t received the flu vaccine, particularly those at high risk for complications related to the flu, to check with their regular health care professional, local health departments or other vaccine providers.”

Flu is a "very contagious" disease caused by a virus that spreads from person to person. Symptoms include fever, headache, cough, sore throat, runny nose, sneezing and body aches.

It can also be deadly. Flu and pneumonia are the eighth leading causes of death in the United States, according to the federal Centers for Disease Control and Prevention.

Just this week, Jennifer Earl of CBS News reported that a 20-year-old mother of two in Arizona died unexpectedly and quickly from flu.

Alani "Joie" Murrieta of Phoenix was being treated for the flu with an anti-viral medication called Tamiflu, but her health took a turn for the worse the day after her diagnosis. She was then rushed to the hospital, diagnosed with pneumonia and started treatment, but within two days of when she started feeling ill she was dead.

Murrieta's aunt, Stephanie Gonzales, warned the public to take the flu seriously.

"Don't take life for granted. If you feel sick, go to the doctor. Don't wait until your symptoms are so bad there is no turning back," she told CBS.

Kentucky's flu level as of Friday was classified as "regional," with 104 laboratory-confirmed cases, according to the state's weekly influenza surveillance report. Twelve of the state's 17 regions have had a confirmed case this flu season. As of Dec. 2, there had been no flu-related deaths reported in Kentucky.

NPR reports that the flu season could be "unusually harsh" this year because of several factors.

One is this year's early start to the season, which could make it last longer and infect more people. Another is that Australia had a severe flu season this year and the U.S. typically has a similar experience to what happens in the southern hemisphere.

Australia's bad season stemmed from a strain of the flu virus called H3N2 that tends to make people sicker than other strains, and because the flu vaccine was only about 10 percent effective against that strain this year in Australia. The U.S. is using the same vaccine as Australia, but its effectiveness in the U.S. is still unknown.

Health experts say that even an imperfect vaccine is better than no vaccine because it can help prevent or lessen the severity of the illness and also helps to promote "herd immunity" of the population.

The CDC recommends that everyone over six months of age get a flu vaccination, and especially encourages people who may be at higher risk for complications or negative consequences get one. They include:
• Children age six months through 59 months;
• Women who are or will be pregnant during the influenza season;
• Persons 50 years of age or older;
• Persons with extreme obesity (body-mass index of 40 or greater);
• Persons aged six months and older with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts (including children) and caregivers of children younger than 5, particularly contacts of such children, or of adults 50 and older;
• Household contacts and caregivers or people who live with a person at high-risk for complications from the flu; and
• Health care workers, including physicians, nurses, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

Howard added, “You should also follow the advice your parents gave you to prevent flu and other illnesses that tend to circulate at this time of year – wash your hands frequently, cover your mouth when you cough or sneeze and stay home when you’re sick.”

House conservatives oppose McConnell-endorsed efforts to resume Obamacare subsidies to moderate-income people

Wednesday, December 6, 2017

Groups pushing $1-a-pack increase in state cigarette tax make their sales pitch through an infographic

The group promoting a $1-a-pack increase in the state cigarette tax and local ordinances to ban smoking in workplaces has a new infographic to remind Kentuckians of the cost of smoking.

The graphic was created by Kentucky Voices for Health, part of the Coalition for a Smoke-Free Tomorrow, which says making the tax $1.60 per pack and raising other tobacco taxes would raise $266 million a year in revenue for the state. The average state cigarette tax is $1.71 per pack.

"Research shows that a tobacco tax increase in Kentucky must be at least $1 to achieve any health benefits," the coalition said in a news release. "Tobacco companies use coupons and other point-of-sale promotions to soften the impact of tax increases on the price of their products, so the tax increase has to be large enough to overcome those promotions."

"The current tax doesn't begin to cover the high cost of smoking in Kentucky," said KVH Executive Director Emily Beauregard. An extra dollar per pack will put a dent in those costs. More to the point of the coalition's work, it also will save lives and improve health."

Smoking's costs are measured not only in dollars, said Ben Chandler, chair of the coalition and CEO of the Foundation for a Healthy Kentucky, which staffs it. "Nearly 9,000 deaths every year in Kentucky are directly related to smoking, more than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined," Chandler said. "If we don't start reducing smoking rates in Kentucky right now, 119,000 of today's youth will die early due to tobacco use."

The release said "5,900 Kentucky babies would be born healthier over a five-year period because their moms would quit smoking if the state enacted a $1 tax increase. The Campaign for Tobacco-Free Kids estimates that a total of 29,400 adults would quit smoking, and 23,200 kids would never start." The second page of the infographic appears below.

Tuesday, December 5, 2017

Providing healthier food for students can require new equipment

Jefferson County Public Schools photo
Almost all Kentucky schools are serving meals that meet federal "standards for strong nutrition, but in order to do this, many of these same schools have to work around equipment and infrastructure challenges," Ashlie Stevens reports for WEKU-FM. A survey by the Pew Charitable Trusts found that 89 percent of the state's school districts "needed at least one piece of new equipment to better serve nutritious foods."

The average cost of that is about $50,000 per school, "which is tough considering how public school cafeterias are funded," Stevens reports. Dan Ellnor, manager of the Nutrition Service Center for Jefferson County Public Schools, told her, “No local tax dollars go to feed kids; it is a completely federal grant program. . . . If we don’t make money, we can’t reinvest in the program.”

The U.S. Department of Agriculture, which oversees the school-meals program, has grant fund to help schools buy equipment, but it is relatively small "because the need across the country is so immense," Stevens reports. Legislation in Congress would expend the program to include loans.

In Jefferson County, “Our main challenge has been refrigeration with the increased fruits and vegetables,” which require "a lot more storage space," Ellnor said. Stevens adds, "The schools also need new combination ovens to roast and steam instead of fry these foods, and sometimes they just need more physical space for food prep."

Monday, December 4, 2017

Speaker uses experiences with depression, suicide to help students in area where suicide and attempts are more prevalent

"When Drew Bergman asked students at a packed Graves County Middle School assembly on Thursday how many of them knew someone who had attempted or died from suicide, half of them raised their hands. That stark reality demonstrates how prevalent suicide is in Graves and several area counties," David B. Snow reports for The Paducah Sun.

Graves County is in the Four Rivers mental-health region, one with a significantly higher rate of 10th-grader suicide attempts (9.3 percent) than the rest of Kentucky (8.2 percent). Among adults, the county "ranked 25th among Kentucky's 120 counties with a suicide rate of 17.88 per 100,000 people," Snow notes. "Carlisle [County] led the state with 28.46, Hickman ranked fifth at 23.4, Marshall was sixth at 23.28, Ballard was 13th at 20.26, Fulton was 14th at 20, McCracken was 15th at 19.61 and Calloway was 81st at 13.94. Livingston County is 56th at 15.23."

Snow notes, "Kentucky Health News reported in November that 1 in 12 of Kentucky's high school sophomores said they had attempted suicide within the previous year. It also reported that teen suicides went from 19 in 2014 to 44 in 2016, more than doubling in a two-year period. With seven of the eight Purchase counties among the state's top 25 in suicide rate," Lourdes Hospital in Paducah invited Minding Your Mind, an organization promoting mental-health education, to send a speaker last year."

That was Bergman, who came to McCracken and Marshall counties last year. He told GCMS students that he had come "from a good family, he and his two siblings were very good students, but underneath what he called the 'country club' facade were things kept out of the public eye," Snow writes. "Bergman said his seemingly successful father was an alcoholic and his parents slept apart for most of his youth because of that. He said his father's addiction was hidden from the children until his father got in a drunken driving wreck when Bergman was in the seventh grade. That was when his parents divorced.

"This perfect childhood that I grew up living came crashing down," Bergman said. "And this is when my entire family began to deal with their own mental health issues for the first time. . . . For the first time, I began to exhibit some symptoms of depression." He attempted suicide that year, and again four years later, at age 16.

"When he was a senior, Bergman told the students at his high school about his depression," Snow writes, quoting him: "The day that I started to talk about what I had gone through is the day that I began to feel better."

Snow writes, "He encouraged the students to talk about how they feel with parents, teachers or trusted adults. He said that people need to talk about mental health issues to help remove the stigma associated with them and to help those going through them. Bergman also encouraged the students who knew someone going through problems to tell an adult, saying he would rather lose that friendship than lose that friend to suicide."

Bergman also discussed treatment for mental illness and how he has treated his depression "through medication and positive coping mechanisms, like listening to music, getting outside, relaxation, and preparing for things like tests or events to remove stress and maintain some control. He encouraged the students not to let the topic end with the assembly, to talk about mental illness with their peers, their parents and their teachers."

Sunday, December 3, 2017

Tax bill would repeal requirement to have health insurance, perhaps boosting efforts to repeal and replace Obamacare

Reporters interviewed Sen. Mitch McConnell between negotiations
on the tax bill. (Associated Press photo by J. Scott Applewhite)
The tax-reform bill the Senate passed early Saturday morning, with Majority Leader Mitch McConnell of Kentucky in the driver's seat, includes a repeal of the requirement that almost all Americans obtain health insurance.

The provision, perhaps the most important part of the 2010 Patient Protection and Affordable Care Act, appears highly likely to remain in the final version of the bill that will emerge from a House-Senate conference committee. That's because it was also in the House bill and would help make up for the budget deficits caused by tax cuts, writes Paige Winfield Cunningham of The Washington Post.

Once the mandate is repealed, Republicans may find it easier to "repeal and replace Obamacare," as they vowed for seven years but have so far failed to do, because "It disposes of a major reason previous GOP measures were projected to result in fewer Americans with coverage," Cunningham notes.

Enactment of the tax bill could also lead to cuts in Medicare. "If lawmakers don’t waive a 2010 rule known as 'paygo,' aimed at keeping government spending in check, that deficit spending would trigger automatic cuts to mandatory spending," limited to 4 percent, Cunningham writes. "Sen. Susan Collins (R-Maine), who generally opposes cuts to entitlement programs," has said that McConnell has promised that Congress will waive 'paygo', "but such a decision is beyond McConnell’s ability to control. Waiving 'paygo' requires 60 votes in the Senate, and it’s not at all clear that Democrats would be willing to help Republicans save themselves from mandatory cuts." Perhaps McConnell believes enough would.

Part of the price McConnell paid for the vote of Collins, who helped kill a repeal-and-replace-Obamacare bill in the summer, was a promise for a vote on legislation to restore the insurance subsidies that President Trump ended recently. That measure, sponsored by Sen. Lamar Alexamder (R-Tenn.) and Patty Murray (D-Wash.), "seems awfully shaky," Cunningham writes. "The Senate is focused right now on the tax overhaul; yesterday House conservatives told The Hill they wouldn't support it (they've labeled it an 'insurer bailout'); and, as conservative policy wonk Chris Jacobs writes over at The Federalist, even if the payments are included in a year-end spending bill, they might not ever get made, due to mandatory sequester cuts."

Cunningham concludes, "Here's the interesting question at play over the next few weeks: Will Congress make two changes to the ACA marketplaces that are contrary to each other? Repealing the mandate undermines the marketplaces by ultimately weakening their risk pools (some healthy people drop coverage without the mandate). Making the subsidy payments (known as cost-sharing reductions) helps lower marketplace premiums, but it's kind of moot if you've already removed the key requirement underpinning the whole ACA."

If Trump signs the individual-mandate repeal into law, health-insurance companies will have to decide whether they want to sell through the Obamacare marketplaces, notes Sarah Kliff of Vox: "Are they comfortable selling in a marketplace where they have to offer all consumers coverage but healthy people can decide not to purchase? Or are they scared off by the prospect of getting swamped with sick customers? . . . By September or October of next year, we'd have a sense of whether there are some places where nobody wants to sell Obamacare. And we'll know if there are places with really high premiums, as insurance plans only their sicker customers to stick around."

Kliff concludes, "If Obamacare does truly seem to be in collapse — insurance plans fleeing the markets, premiums spiking — that might give Republicans the pretext to once again take another shot at Obamacare repeal."

FDA approves new shingles vaccine; may be available in 2018

If you had chicken pox as a child, as 99.5 percent of Americans now over 40 did, you still have the virus, and it can cause a painful rash called shingles, which can sometimes leave victims with permanent pain after the rash disappears. About 1 million Americans get shingles each year, and the Centers for Disease Control and Prevention expect one in three adults to get it.

The good news is that there are vaccines for the virus, and the better news is that the U.S. Food and Drug Administration approved an improved vaccine called Shingrix in October. It may be available in 2018, Clark Kebodeaux, an assistant professor in the University of Kentucky Department of Pharmacy Practice and Science, writes for the Lexington Herald-Leader.

"Patients will need two vaccine shots to be fully protected with Shingrix: the first dose followed by a second dose two to six months later," Kebodeaux  writes. "Clinical trials showed that the new vaccine is effective and longer-lasting than the previous vaccines."

The CDC's American Council on Immunization Practices recently voted to recommend that all healthy adults age 50 and older get Shingrix, including patients who have received Zostavax, an earlier vaccine, Kebodeaux reports.

"The Shingrix vaccine is new and is not yet available to the public, but may will be available in 2018," Kebodeaux writes. "Once available for distribution, the vaccine will likely be available at physician’s offices and pharmacies. Talk to your health care provider or pharmacist to see if it will be appropriate for you."

Saturday, December 2, 2017

U of L opens clinic to treat hepatitis C, a disease for which Kentucky has the nation's highest rate of new cases

The University of Louisville Hospital has opened a new center to treat hepatitis C and expects to have more than 2,000 patient visits in its first year, according to a U of L news release.

“While Kentucky has the highest rate of new hep-C cases in the U.S., few places exist here for treatment,” Barbra Cave, a family nurse practitioner who leads the center, said in the release. “This is a much-needed service in the community.”

In the past, treating hepatitis C involved a year-long therapy that came with multiple side effects, and not everyone was a candidate for treatment. "Doctors found it challenging, and some patients opted to not get treated at all," says the release.

But today, treatment involves one pill, once a day for eight to 12 weeks, and has minimal side effects, according to Dr. Ashutosh Barve, the center’s medical director. The center also uses FibroScan, which allows staff to perform a non-invasive assessment of the liver without a biopsy, says the release.

“This is truly a success story of modern medicine. We went from discovering the basic science of the disease in the late ‘80s, early ‘90s, to finding a cure in 2014,” said Barve, a gastroenterologist.

The treatment is not inexpensive. It runs between $32,000 and $56,000 on most health plans, Dr. John Ward, director of the Division of Viral Hepatitis at the federal Centers for Disease Control and Prevention, said at a conference in Lexington in July.

New cases of hepatitis C are largely driven by intravenous drug use, but many "Baby Boomers" have the disease and don't know it, and both groups should be routinely screened for it. It is estimated that up to half of people with the disease don't know they are infected.

“People may carry the disease for decades before they have symptoms,” said Cave, who specializes in gastroenterology and hepatology.

Hepatitis C is a blood-borne virus that can live on a surface for weeks if not sterilized properly. It can cause major complications if left untreated, including cirrhosis of the liver or liver cancer.

The disease can be contracted from contaminated tattoo equipment, contaminated dental equipment or passed on from mother to baby. Cave says anyone who got a blood transfusion prior to 1992 or older veterans who were vaccinated with a "jet gun" are also at risk.

Friday, December 1, 2017

Two decades of data show Kentucky communities with strong smoke-free laws have 8 percent fewer cases of lung cancer

By Melissa Patrick
Kentucky Health News

Kentucky communities with strong laws against smoking in workplaces have fewer cases of lung cancer, according to a University of Kentucky study that says it's the first to show such findings.

Researchers found that residents of counties with comprehensive smoke-free laws, including those with city-only smoking bans, were 8 percent less likely to be diagnosed with lung cancer than those living in communities without smoke-free laws.

There was no difference in lung-cancer rates between places that don't have smoking bans and those that have moderate or weak laws. The study considered laws to be comprehensive if they covered all workplaces, including restaurants and bars; moderate if they covered indoor public places, but not all workplaces; and weak if they allowed for major exemptions.

The researchers say the findings could encourage more localities to pass smoking bans. Only a third of Kentuckians are covered by such ordinances.

"Local government can play a critical role in preventing lung cancer," Ellen Hahn, the lead author of the study, said in a UK news release. "Elected officials can ensure that all workers and the public are protected from secondhand smoke by passing strong smoke-free laws with few or no exceptions."

Hahn is a UK nursing professor and director of the Bridging Research Efforts and Advocacy Toward Healthy Environments initiative at UK.

The BREATHE researchers looked at 20 years of lung-cancer data for more than 80,000 Kentuckians 50 and older. (Few Kentuckians under 50 have lung cancer.) The state has more cases of lung cancer than any other state, and its death rate from the disease is 50 percent higher than the national average. And not surprisingly, at 25 percent, Kentucky leads the nation in adult smoking.

Jim Waters, president and CEO of the Bluegrass Institute for Public Policy Solutions, a libertarian, free-market think tank, said that while lower rates of lung cancer are "wonderful," correlation does not equal causation and therefore public policy should not be built around it. "You can't attribute deaths directly to a single cause such as smoking," he said, "since many factors usually are involved: hereditary issues, poor diet, lack of exercise and education."

Hahn said the study did take other causes of lung cancer into account. "We used a sound, well-known statistical method to consider the other factors that may have affected new cases of lung cancer, in addition to smoke-free laws," she said. "Even after taking sex, age, smoking rate, and income into account, comprehensive smoke-free laws were associated with fewer new cases of lung cancer."

Hahn said factors that protect Kentuckians from lung cancer were being female, being younger, and living in a county with a lower smoking rate or higher median household income in the county.

Waters said his institute supports education efforts to encourage people not to smoke "without the punitive action of denying individuals the right to participate in a legal practice on private property. . . . Where does that end? We don't believe such reasoning will end with anti-smoking policies."

Hahn replied, "Research shows that simply educating the public not to smoke does not work to lower smoking rates or to reduce disease from tobacco smoke exposure. Smoke-free laws are known to reduce disease," heart attacks and hospital visits for emphysema and asthma, as BREATHE summarizes. "Just as we have laws to prohibit drunk driving (alcohol is legal), smoke-free laws prohibit smoking (legal) indoors where the second-hand smoke can harm workers and the public."

Ben Chandler, CEO of the Foundation for a Healthy Kentucky and chair of the recently launched Coalition for a Smoke-Free Tomorrow, called on Kentuckians to use this research to pass more smoke-free laws.

"We know that the Kentucky communities with smoke-free laws covering every workplace and public building are protecting the freedom of their residents and visitors to breath air untainted by dangerous secondhand smoke," Chandler said. "We know that a secondary benefit of these laws is that they help reduce smoking. But here's solid evidence from more than 20 years of data showing a significant decline in lung cancer."

The latest Kentucky Health Issues Poll on the issue found that 71 percent supported a statewide law to ban smoking in public places and the workplace. The state House passed such a ban in 2014, when it was controlled by Democrats, but the bill died in the Republican-controlled Senate, and Republican Gov. Matt Bevin, who took office in 2015, says smoking bans should be a local issue.

The study was published in Cancer, a journal of the American Cancer Society. An editorial in the journal said the "unique and important" study "has shared an incredibly valuable insight into the impact of smoke-free ordinances on lung cancer mortality" and emphasizes "the need for statewide, not municipal, enforcement for maximum efficacy."