Study finds painkiller prescriptions for injured Ky. workers declined after state required doctors to use prescription-tracking database

After Kentucky fully implemented its prescription-monitoring database in 2012, fewer workers injured on the job received prescription painkillers, and when they did they got fewer of them, according to a new study.

The study, conducted by the Workers Compensation Research Institute, examined workers' compensation claims for more than 21,000 Kentucky workers with new injuries in 2011-13, and nearly 91,000 prescriptions associated with those claims, says the news release.

The study looked at the effects of 2012 House Bill 1, which became law in July of that year. It required use of Kentucky's All-Schedule Prescription Electronic Reporting system, or KASPER.

The study found that the share of Kentucky workers who received an opioid prescription for their injury decreased from 54 percent before the law to 44 percent after its took effect -- a drop of almost 19 percent. This measure didn't change much in neighboring states without a similar law, says the release.

Boris Ladwig of Insider Louisville reports that "the workers who did receive opioids took 15 percent less, and the share of workers who are taking opioids for chronic conditions fell by 22 percent," from 7.3 percent before the law to 5.7 percent after.

Vennela Thumula, the nonprofit’s policy analyst, told Ladwig she was surprised by the findings: “With fewer injured workers receiving opioids post-reform, we expected those receiving opioids to have relatively more severe injuries, on average. Therefore, we expected to see a higher average amount of opioids per claim in the post-reform period.”

Most of the reductions were seen in workers between 25 and 39, those who had not had surgery, and those who had sustained a back sprain or strain, as opposed to those with fractures.

The release notes that even after the law passed, there continued to be a higher rate of opioid prescriptions dispensed to workers in Eastern Kentucky, 62 percent compared to 43 percent among those living in other regions.

The Workers' Compensation Research Institute reports that as of December 2016, 20 states had adopted similar legislation.

Conferences on lung cancer and smoking cessation, pharmacy, and behavioral health in rural areas scheduled in northeastern Ky.

The Northeast Kentucky Area Health Education Center will host three health conferences this fall, one on lung cancer and smoking cessation, a fall pharmacy forum and one on behavioral health.

Lung Cancer & Smoking Cessation Symposium

The second annual Lung Cancer and Smoking Cessation Symposium will be held Friday, Sept. 22, at the Center for Health, Education & Research in Morehead. It will run from 8:30 a.m. to 2 :45 p.m. St. Claire Regional Medical Center and the University of Kentucky will co-host the event.

Dr. M. Patricia Rivera, professor in the Division of Pulmonary Diseases and Critical Care Medicine at the University of North Carolina School of Medicine, is the keynote speaker and will discus the landscape of disparities in lung cancer care.

Among other things, the symposium will discuss terminating lung cancer and the latest treatments, lung cancer survivorship and tobacco treatment and the synergistic risk of radon and tobacco smoke for lung cancer.

This event is for physicians, physician assistants, nurses, nurse practitioners and other interested health-care professionals. Attendance is free, but registration is required. Click here for more information and to register. Continuing education credits are available.

Fall Pharmacy Forum

The Fall Pharmacy Forum will be held Sept. 23 at the Carter Caves State Resort Park near Olive Hill. St. Claire Regional Medical Center will co-host the event, which will run from 7:30 a.m. to 2:10 p.m.

This forum will discuss the safe handling of hazardous drugs, diabetes self-management education, antimicrobial stewardship and will offer a legislative update, including current issues around controlled substances.

This event targets pharmacists, pharmacy technicians and other interested health care professional.

The event is free, but requires registration. Click here for more information and to register. Continuing education credits are available.

Kentucky Rural Behavioral Health Symposium

The fourth Annual Kentucky Rural Behavioral Health Symposium will be held Oct. 13 at the Center for Health, Education and Research in Morehead. It will run from 8:30 a.m. to 4 p.m.

Among other things, this symposium will discuss post-traumatic stress disorders, dementia related changes in communication and behaviors, making a differential diagnosis between PTSD and attention deficit hyperactivity disorders and transitional care.

This event targets physicians, physician assistants, nurses, social workers, therapists, mental health administrators and other interested health care professionals.

The registration fee is $30, which must be received by Sept. 29. Click here for more information and to register. Continuing education credits are available.

2017 Data! Forum, "Using Data to Foster Health Innovation," to be held Oct. 23 in Erlanger; event is free, but registration required

The Foundation for a Healthy Kentucky and Interact for Health are hosting the 2017 Data! Forum to help communities better harness data to improve health. This year's theme is "Using Data to Foster Health Innovation."

Attendance is free, but registration is required. The forum will run from 9:30 a.m. to 4 p.m. Oct. 23 at the St. Elizabeth Training and Education Center, 3861 Olympic Blvd., Erlanger. Click here to register.

"Information from claims and other health data has tremendous potential to improve community health, especially when used to design interventions at the front end, before people become chronically ill," Ben Chandler, president and CEO of the foundation, said in the news release.

The morning keynote speaker, Aaron Truchil, director of analytics and informatics at the Camden Coalition of Healthcare Providers in New Jersey, will discuss how the coalition uses data to identify "super-utilizers" of health care, and their approach to "whole-person care."

Afternoon keynote speakers include Ohio and Kentucky's medical directors of Medicaid, Barbara Sears and Dr. Gilbert C. Liu, respectively, who will share how their state's Medicaid programs use data to improve health.

The forum is intended for non-profit and philanthropic organizations, entrepreneurs, hospitals, health departments, community planners, health advocates and researchers, says the release.

For more information, contact Rachelle Seger at rseger@healthy-ky.org or call 877-326-2583.

Anti-smoking group says cigarette manufacturers purposely target military members and people with mental illness

An anti-smoking group has released two videos accusing cigarette companies of purposely targeting mentally ill people and U.S. soldiers.

“As the number of smokers drops, the industry is finding it harder and harder to find those replacement smokers,” Robin Koval, chief executive of Truth Initiative, told William Wan of The Washington Post. “So the industry is targeting people based on their challenges in life, on who they are. It’s shocking and appalling.”

The group released the advertisements on Aug 24. They are also available on their website and on social media,

One says 40 percent of cigarettes sold in the U.S. are to people with mental-health issues, including depression, anxiety and substance-use disorders. The other says 38 percent of military smokers start after enlisting.

According to the Centers for Disease Control and Prevention, 36 percent of people with a mental illness smoke, and 24 percent of all active-duty military personnel are smokers. Nationwide, only 15 percent of adults and 6 percent of teens are smokers, both rates at an all-time low. Kentucky's smoking rates have also declined, but continue to be significantly higher than the national average, at 26 percent and 17 percent respectively.

Wan writes that in addition to the military and those with mental illness, many other groups also continue to have high smoking rates, including Native Americans and minorities, people who live in rural areas and people with low incomes.

The ad that focuses on mental illness and smoking cites internal tobacco-industry documents that discuss ways to target the mentally ill population, adding that tobacco companies even distributed free cigarettes to psychiatric facilities at one point, saying they would help steady patients' nerves.

The one about the military cites a tobacco industry document that targets young military servicemen. Truth Initiative's website also refers to a series of  industry initiatives, including sending free cigarettes overseas to troops as late as the 1990s (the U.S. Department of Defense no longer allows this); sending troops Marlboro racing-team caps and playing cards, among other things; and leading a Christmas-card campaign that features cards that resembled Marlboro ads.

Wan writes that "tobacco companies for the most part have not responded to the growing accusations that they are targeting vulnerable populations," but  notes that in response to a separate Washington Post article on the socioeconomic divides in smokers, Altria, the country's largest cigarette company, told Wan it uses the same marketing approach across the nation.

He writes, "The company pointed to more than $112 billion that tobacco companies have handed over to help smokers and encourage smoking prevention as part of the 1998 Tobacco Master Settlement Agreement." Actually, states have not used most of that money for tobacco prevention; Kentucky gets about $93 million a year from the settlement but spends only $2.5 million on tobacco prevention.

Study on strip mining and health suspended, but all sides were heard at meetings already scheduled in Hazard and Lexington

Historical map shows mountaintop-removal sites in red, other
strip mines in yellow. (For a larger version, click on the image.)

By Melissa Patrick
Kentucky Health News

A study of possible health risks of living near big strip mines in Central Appalachia held what may have been its final public meetings in Kentucky last week, following suspension of the study by the Trump administration.

On Aug. 18, the Office of Surface Mining Reclamation and Enforcement told the National Academies of Sciences, Engineering and Medicine to stop all work on the study, citing a budget review of the Interior Department, OSMRE's parent agency.

"The National Academies believes this is an important study and we stand ready to resume it as soon as the Department of the Interior review is completed," the academies said in a statement, but the spokeswoman for the agency said they didn't know when that might be.

The academies created an 11-member committee to review the available research on the health effects of mountaintop removal and other forms of surface coal mining, and identify gaps in the research for study.

A number of studies have shown that surface mining is associated with higher rates of cancer, heart disease, birth defects and other health conditions in Central Appalachia, but have not established a connection, and other studies have been inconclusive or not even found correlation.

Hazard and Lexington meetings

The committee's first Kentucky meeting, Aug. 21 in Hazard, included coal-mine visits and a public meeting. The second was Aug. 22 in Lexington, where the panel heard from Kentucky environmental officials, geologists and others.

Several who spoke at Hazard said they hoped the Trump administration would restart the study and also expressed concerns that "mountaintop mining hurts air and water quality, impairs human health and destroys mountains and streams," Bill Estep of the Lexington Herald-Leader reports.

"Science isn’t going to hurt us. What we don’t know very well could," said Dee Davis of Whitesburg, president of the Center for Rural Strategies.

Coal-industry representatives said "Coal companies do a good job of reclaiming land and monitoring water quality," Estep reports. Tyler White, president of the Kentucky Coal Association, said his organization supports the decision to halt the study and the tax dollars appropriated for it would have been better spent combating health problems or drug abuse in the coalfield.

Glynis Bourd of Ohio Valley Resource reports that the effects of surface mining on health have been a concern of people in Central Appalachia for a long time. Her story includes a detailed video timeline demonstrating them.

At the Lexington meeting, Larry C. Taylor, an environmental scientist for the state Department for Environmental Protection, told the panel that a state study found there was no correlation between two metals, arsenic and chromium, in drinking water and cancer incidence and deaths in Eastern Kentucky. The metals are released by mountaintop removal and other large-scale surface mining.

Richard Wahrer of the state Department of Natural Resources said state regulators perform extensive evaluations on the impact of mining on watersheds. "Remember, water can't leave the mining site unless it is in compliance with established standards," he said. "We have not had material damage occurring outside the cumulative impact area."

Viney Aneja, a professor at North Carolina State University, reported on his study that measured the environmental exposure of residents in southwest Virginia to coal dust generated by trucks hauling coal from a nearby surface coal mine.

The study found that coarse dust particles, called PM10, often exceeded the national standards in locations both near and about one mile away from the surface mine, and on some days were three times higher than the national standards. PM10 particulates, which can be as small as 2.5 micrometers across, can easily be inhaled and pose a risk of lung damage.

Charles Snavely, secretary of the Kentucky Cabinet for Energy and the Environment and a former coal executive, said he had never heard anyone in his Eastern Kentucky community attribute a health problem to coal mining.

"I don't see how you could tell it because the problems that we have in the coalfields of Kentucky are obesity, smoking, lack of exercise, poor medical care and drug abuse," he said. "I'm sorry, I tried to stay to data . . . but I and a bunch of people who work there, grew up there, lived there our entire adult lives and I never heard that complaint once." He is a native of Prestonsburg.

Others weigh in

Luke Popovich, a spokesman for the National Mining Association, told The New York Times that the decision to halt the study may have been justified: “The National Institute of Environmental and Health Sciences concluded in July that after examining available studies, it didn’t see evidence justifying a health hazard, noting that no conclusive evidence connected mountaintop mining with health effects and that studies often failed to account for extraneous health and lifestyle effects.”

Actually, the institute said it could not reach any conclusion because the existing research had a "strong potential for bias." It called for more research and concluded: "Without such work, uncertainty will remain regarding the impact of these practices on the health of the people who breathe the air and drink the water affected by MTR mining."

The American Public Health Association said in a statement that the study's suspension shows the Trump administration's "disregard for science and evidence when it comes to the environment and safeguarding health."

U.S. Rep. John Yarmuth, D-Louisville, who has introduced legislation to block new surface-mining permits until the health risks have been determined, said in a statement: “The fact that mountaintop-removal permits have been approved when there has never been a federal study on the health effects of mountaintop-removal mining is shameful enough. To now prevent this study from being completed would be reprehensible."

Opioid epidemic meets opposition from doctors, legislators and insurance companies, and gets attention from local news media

Phillip Chang (UK photo)

To fight the opioid epidemic, Kentucky doctors, legislators and health-insurance companies are working to limit the prescription of painkillers.

At the annual convention of the Kentucky Medical Association over the weekend, a University of Kentucky trauma surgeon told other physicians how he and his colleagues got a wake-up call about the problem and "how they were able to halve the amount of opiates given to trauma patients without increasing their pain levels," the Lexington Herald-Leader reports in an editorial.

Dr. Phillip K. Chang, now UK's chief medical officer, had what he calls an “eye-opening moment” in 2013, when a young man he treated for injuries in a vehicle crash became addicted to the painkiller he had prescribed. He says many physicians have had similar epiphanies, and addiction “could happen to our family, our neighbors, ourselves.”

Author Sam Quinones was interviewed at the KMA meeting.

Topics related to the opioid epidemic dominated the KMA's weekend convention. Journalist Sam Quinones discussed his book, Dreamland, about the 30-year history of the epidemic. “We believe it is important to know the issue from a historical perspective,” KMA President Nancy Swikert said in a press release. “Knowing how we got to where we are on this issue will help us address it going forward.” She said this was the first time the annual meeting “has had breakout groups to address an important public-health issue.”

The Herald-Leader gives a capsule history: "Two developments of the 1990s spurred this crisis: Pain was added as a vital sign by the hospital accrediting commission. And the pharmaceutical industry targeted physicians with aggressive and misleading marketing of opioids, flooding Kentucky with powerful painkillers, many of which were diverted into the black market." Meanwhile, the federal Medicare and Medicaid centers began asking patients about pain control, "creating a financial incentive to over-prescribe painkillers."

Chang told Kentucky Health News and WKYT-TV last year that the UK trauma team adopted a protocol to treat acute pain (as opposed to chronic pain): Use a non-narcotic first, and only prescribe a narcotic if the non-narcotic doesn't relieve the patient's pain. "Rather than eliminating pain, Chang aims to keep pain 'tolerable' — a standard that Medicare should adopt," the Herald-leader editorial said.

Chang told the Herald-Leader last week that UK patients are “super receptive” when educated about the risk of opioids. He said the trauma team is integrating art, music and touch therapies into treating acute pain, and has achieved the same level of pain relief with half the amount of painkillers. "Such success among trauma patients certainly could be replicated in other populations," the editorial said.

The 2017 General Assembly imposed a three-day limit on most opioid prescriptions for acute pain. Change told the Herald-Leader that the law is "a game-changer," and the newspaper said the law "creates opportunities for doctors to educate their patients about non-addictive options."

Insurance companies can play a role, too. Anthem Blue Cross and Blue Shield announced last week that prescribed opioids for its members in Kentucky dropped 12 percent in the past year. The insurer said it limits to seven days its coverage of opioids for patients newly starting opioids, requires prior authorization by a health-care provider, and directs patients most at risk for opioid-use disorder to one pharmacy.

All those steps have helped reduced opioid prescriptions, the company said in a press release. "The primary goal of the quantity limits was to prevent inadvertent addiction and opioid-use disorder, and to ensure clinically appropriate use consistent with Centers for Disease Control guidelines," it said.

In March, the CDC recommended that opioid prescriptions last three to seven days, and that prescribers should avoid high doses and warn patients of the risk.

“As a health insurer, we have a responsibility to do what we can to address this health epidemic and we are committed to making a significant difference to our members,” Deb Moessner, president of Anthem Blue Cross and Blue Shield in Kentucky, said in the release. “We believe these changes in pharmacy policy, complemented by a broad set of strategies addressing the opioid epidemic, will help prevent, deter and more effectively treat opioid use disorder among our members.”

Attorney General Andy Beshear recently announced a program that will help residents in four counties safely dispose of prescription drugs at home, noting that 80 percent of heroin users begin their addiction through prescription drug abuse and that misuse often starts when a person has access to unused painkillers.

The Kentucky Opioid Disposal Program will distribute 50,000 "drug deactivation pouches," called Deterra, to residents in Floyd, Henderson, McCracken and Perry toward this effort. One pouch can dispose of  45 pills, six ounces of liquid or six opioid patches -- and altogether have the potential to dispose of more than 2 million unused opioids, says the news release.

The initiative is being partially funded with settlement funds from drug companies, along with funds from the nonprofit A Stronger Kentucky Inc., chaired by his father, former Kentucky Gov. Steve Beshear.

The CDC reported in July county-by-county figures for dispensing of opioids in 2015 and 2010. The amount in Kentucky went down, but some counties went up, and the figures are available from Kentucky Health News at www.uky.edu/comminfostudies/irjci/OpioidVitalSigns2017Kytable.xlsx.

Lisa King of The Sentinel-News in Shelbyville used the data as the basis for a story saying that opioid prescriptions declined 20 percent over the five-year period, and also looking at some other counties. But in interviews with pharmacists, she also found a possible reason that the number could now be going up. She wrote:

"Raschelle Cox at Shelbyville Pharmacy said that even though prescription numbers may be down, there are still a lot being written. 'In the two years that I’ve been here, I haven’t noticed any decrease,' she said. Cox added that . . . there are a couple of medications used to treat neuropathy from diabetic nerve pain, that people have been using instead of opiates, that have just recently been declared as narcotics. 'Now Gabapentin is controlled as of July 1,' she said. 'We sell a lot of it.' Roanya Rice, director of the North District Health Department, said a trend is also underway of using drugs other than narcotics."

FDA expected to soon decide if smokeless cigarette can be sold in U.S., rule on Philip Morris's health claims later

Washington Post illustration

Philip Morris International says it has created a heat-not-burn smoking device that will have 90 to 95 percent less toxic compounds than cigarettes, "an innovation it claims could save lives and eliminate smoking in America," William Wan reports for The Washington Post.

The process gently heats sticks of tobacco in a special battery-operated device and is sold in 25 countries under the brand HeatStick. The Food and Drug Administration is expected to decide in the next two months if it can be sold in the U.S., but won’t rule on the company's health claims until the beginning of next year, Wan reports. If the FDA approves the claims, HeatStick "would be the first tobacco product to carry the U.S. government’s stamp as a less harmful alternative to cigarettes — a marketing coup for Philip Morris."

The company's request to the FDA has caused "heated debate and worries" among health experts about "whether the new device will lower tobacco-related deaths, or if it is just substituting one harmful product for another" and "fueling such doubts is that many of America’s leading health organizations and experts remain deeply suspicious of Philip Morris," the leading U.S. cigarette manufacturer, Wan writes.

“They are masterful liars. That’s not an exaggeration — that’s a fact proven by decades of evidence,” Matthew L. Myers, longtime president of the Campaign for ­Tobacco-Free Kids, told Wan. “So the question we’re all asking ourselves is: What’s their ultimate game plan with this thing?”

The process or device is called IQOS, for "I quit ordinary smoking," according to the only independent study, of it, published this year in the journal JAMA Internal Medicine. The study found that the process produced "higher levels of several toxic compounds" than Philip Morris has claimed since it announced IQOS in 2014. Wan reports that the company's forceful response to the study has made the researchers' unwilling to talk publicly about their work.

Some health advocates say that even if the the company's health claims are true, they are concerned that the product will hook a new generation of Americans on nicotine, halting the reduction of smoking rates in America, now at an all-time low. Others are concerned about the health issues associated with nicotine and ultrafine particles.

"It probably isn't as bad as a cigarette, but that's like saying jumping out of a 10-story building isn't as bad as jumping out a 50-story building," Stanton Glantz, a tobacco researcher at the University of California at San Franscisco, told Wan.

But other health researchers support the move to a safer product: “If you have a company willing to shift to a less harmful product, is that something we should be getting in the way of?” Jonathan Foulds, a smoking cessation expert at Penn State, told Wan.

“The skepticism is not surprising for us,” Philip Morris’s chief scientist, Moira Gilchrist, told Wan. “You don’t have to trust or believe us. You don’t have to take our word for it. But what we ask is that people have an open mind. Look at the science we’ve done on this and base your decision on that.”

Philip Morris CEO André Calantzopoulos predicts smokeless products will eventually replace the production of regular cigarettes in his company.

IQOS is a big success in Japan, where Wan reports it has "grabbed 10 percent of Japan's tobacco market -- a feat that has investors salivating over its U.S. prospects," Wan reports. The demand in Japan is so large that Philip Morris has had to limit its sales there. The company has plans to "more than triple its manufacturing capacity, from 15 billion HeatSticks to 50 billion. By the end of 2018, it plans to produce 100 billion," Wan writes.

West Nile virus report for Kentucky: four cases in humans, four in horses, and in some mosquitoes in Jefferson County

Four cases of West Nile virus have been found in Kentucky this summer: two in Hopkins County and one each in Jefferson and Fayette counties, the state Department for Public Health reported Friday. All were in adults. The number is below the annual average of 10 reported from 2012 to 2016.

All but eight states have reported cases of West Nile in people, horses, birds or mosquitoes this year, the department said. The virus is transmitted by mosquito bites. The Louisville health department recently found West Nile-infected mosquitoes in four Jefferson County ZIP codes (40204, 40205, 40206, 40208, 40212 and 40214), but there have been no other positive reports of mosquitoes with the virus in Kentucky.

“It’s common for us to find mosquitoes infected with West Nile in Louisville around this time each year. What this means is people should take the appropriate precautions, Louisville Health and Wellness Director Sarah Moyer told Darla Carter of The Courier-Journal.

The state health department says four horses have tested positive for West Nile, in Bourbon, Franklin, Hart, and Russell counties. The virus can cause severe illness in horses and certain species of birds, but does not usually affect domestic animals. There is no West Nile vaccine available for people, but several are available for horses, and owners are advised to vaccinate their horses annually.

In most human cases, infected people have no symptoms or show relatively mild symptoms, such as fever, headache, body aches, joint pains, vomiting, diarrhea, or rash. They typically recover on their own, though symptoms may last several weeks. Fewer than 1 percent will develop a serious illness such as encephalitis or meningitis. People over 50 and those with certain medical conditions, such as cancer, diabetes, hypertension, kidney disease and organ transplants, are at greater risk for serious illness if they contract West Nile.

The health department advises Kentuckians to avoid mosquitoes, particularly between dusk and dawn, when the insects are most active. It recommends these precautions:

Avoid Mosquito Bites

·        Use insect repellents when you go outdoors. Repellents containing DEET, picaridin, IR3535, and some oil of lemon eucalyptus and para-menthane-diol products provide longer-lasting protection. To optimize safety and effectiveness, repellents should be used according to the label instructions. More information about insect repellents can be found at http://www.cdc.gov/westnile/faq/repellent.html.

·        When weather permits, wear long sleeves, long pants and socks when outdoors. Mosquitoes may bite through thin clothing, so spraying clothes with repellent containing permethrin or another EPA-registered repellent will give extra protection. Don't apply repellents containing permethrin directly to skin. Do not spray repellent on the skin under your clothing.

Mosquito-Proof Your Home

·        Install or repair screens on windows and doors to keep mosquitoes outside.

·        Help reduce the number of mosquitoes around your home by emptying standing water from flowerpots, gutters, buckets, pool covers, pet water dishes, discarded tires and birdbaths on a regular basis.

More information can be found online at: https://www.cdc.gov/westnile/ or http://www.chfs.ky.gov/dph/epi/westnile.htm. 

Zika cases become rare, but CDC cautions travelers to maintain vigilance when traveling in infected areas

As of mid-August, only one confirmed case of locally transmitted Zika had been recorded in the continental U.S., compared to hundreds of locally transmitted cases last year, John Cohen reports for Science.

That's because Zika cases have "plummeted" in Latin America and the Caribbean, which were hit hard by the virus, and now much of their population is immune to it, Cohen writes. And that means fewer Americans are being infected while traveling and bringing it home with them, which reduces the chances of local transmissions in the U.S.

Zika is a virus that is spread primarily through the bite of an infected mosquito. It can also spread through sexual transmission and from a mother to her child during pregnancy. Click here for more information about Zika.

Infectious disease experts told Cohen that this respite could last for years.

They had expected the Zika virus, much like dengue, West Nile and yellow fever, to initially surge through the population, then decrease as people developed immunity, but "few predicted that cases would disappear so quickly," Cohen writes.

Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, told Cohen that this "herd immunity" has reduced the number of vulnerable people to the point that the virus can't easily move between humans and mosquitoes.

But caution was advised by Lyle Petersen, head of the vector-borne disease division of the Centers for Disease Control and Prevention. "Just because cases go down, it doesn't mean we should stop worrying about it," he told Cohen. "We need to maintain our vigilance."

Peterson said the decline in Zika cases doesn't lessen the need for a vaccine against the virus, but Cohen says the sharp decline in cases will make it hard to perform clinical trials for a vaccine.

The CDC cautions that anyone living in or traveling to areas with the risk of Zika should continue to protect themselves from mosquitoes, especially if you are pregnant or going to become pregnant.

Last year in the U.S., the CDC recorded 224 cases of local transmission, all in Florida and Texas, and 4,830 travel-related cases. This year, the CDC has recorded no locally transmitted cases and 213 travel-related ones, though Cohen reports that one case of locally transmitted Zika was recorded on July 26 in Hidalgo County, Texas, which borders Mexico.

"I think it's highly unlikely we will see any resumption of significant transmission for at least a decade," Neil Ferguson, a mathematical biologist at Imperial College London, told Cohen.

Biostatistician Ira Longini of the University of Florida in Gainesville disagreed. He said his models predict Zika "will still thrive in susceptible populations that have yet to be hit by the first wave of transmission, leading to 'flare-ups here and there'," Cohen writes.

Aetna will distribute 720 doses of naloxone to first responders in N. Ky and Appalachia; at current rate of use, will last 4 months

Bevin demonstrates how to administer Narcan (State photo)

Gov. Matt Bevin demonstrated how to administer a life-saving drug that reverses opioid overdoses during the announcement of a partnership with health insurer Aetna Inc. that will distribute 720 doses of naloxone, often known by the brand name Narcan, to first responders in Northern Kentucky and Appalachia.

"We don't have the luxury of pretending there isn't a problem, and Aetna is helping us address this issue head on," Bevin said in the news release. "Every single life has value and is worth saving. It is up to all of us to work together and find real, long-lasting solutions."

The Aug. 23 announcement in Boone County and was largely attended by emergency medical technicians, firefighters and police officers from 15 different agencies, Scott Wartman reports for the Cincinnati Enquirer.

“First responders are uniquely positioned to address the terrible effects of the opioid crisis—particularly in Kentucky, were overdose deaths increased significantly from 2015 to 2016,” Dr. Hal L. Paz, Aetna's executive vice president and chief medical officer, said in the release.

Wartman reports that 720 doses of naloxone should last about four months at the rate emergency rooms in the regions are seeing overdoses. A nurse with Northern Kentucky's St. Elizabeth Hospital told Bevin that in the first seven months of 2017, their emergency rooms treated 1,300 overdoses with naloxone.

Kentucky has the third highest rate of opioid overdose deaths per person. Last year, 1,404 Kentuckians died as a result of an opioid overdose, a 7.4 percent increase from 2015, according to a report from the state Office of Drug Control Policy.

In July, the state launched an awareness campaign called "Don't Let Them Die" to focus more attention on the opioid crisis and offer information on drug treatment and naloxone. The state has also distributed almost $1 million to 28 school districts statewide this year to support programs that focus on reducing drug, alcohol and tobacco use. These programs will target preschool through fourth grade.

Study finds Appalachian health is falling farther behind the rest of the nation, and Kentucky's health falls behind Appalachia's

By Melissa Patrick
Kentucky Health News

When it comes to health, Appalachia is falling farther behind the rest of the nation, and the part of the region dominated by Kentucky has the poorest health statistics.

So says a comprehensive report from the Appalachian Regional Commission, the Robert Wood Johnson Foundation and a Kentucky foundation, looking at a range of health measures in Appalachia.

"Appalachian Kentucky is behind not only the rest of the nation, it's behind Appalachia," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the study.

The report, “Health Disparities in Appalachia,” not only paints a grim picture of the region's health status, but also shows that even in the areas of improvement, Appalachia hasn't kept up with the rest of the nation, and continues to fall behind.

The researchers found that over two decades, Appalachia and the rest of the U.S. saw improvements in seven of the eight health measures examined: deaths from heart disease, cancer and stroke; infant mortality, the supply of primary care doctors, education levels, years of potential life lost. Poverty was the only measure that increased.

But when compared to the rest of the nation, Appalachia's improvements lagged behind in all but one of those measures, the supply of primary-care physicians.

The greatest gap was in life expectancy, the most fundamental measure of a place's health. The report measured it in "years of potential life lost." Over the last two decades, the U.S. saw a 24 percent decrease in premature deaths, while the Appalachian region only saw an 8 percent decrease. The Appalachian rate was one-fourth higher than the nation as a whole.

A news release about the study noted that the nation's improvements have often outpaced those in Appalachia.

For example, in the 1990s, the cancer death rate in Appalachia was only 1 percent higher than the rest of the nation, but more recently it is 10 percent higher. The infant-mortality rates were 4 percent higher in Appalachia in the '90s, but are now 16 percent higher.

The report also analyzed 41 health indicators and how the 420 Appalachian counties compared to the rest of the nation in those measures, as well as how parts of the region compared to one another. The data is also broken down by state.

It found that Appalachia has a higher death rate than the rest of the nation - by at least 10 percent -- in seven of Americas leading causes of death, including heart disease, cancer, chronic obstructive pulmonary disease, injury, stroke, diabetes and suicide.

And Kentucky's rates for these measures were even higher, when compared to both the national and Appalachian rates: heart disease deaths were 45 percent higher in Kentucky, compared to 17 percent higher in the region; cancer deaths were 35 percent higher, compared to 10 percent higher in the region; and diabetes deaths were 32 percent higher, compared to 11 percent higher in the region.

One of the greatest differences between Appalachia and the rest of the nation is in the number of deaths caused by an injury, which are 33 percent higher in the region. Injury deaths include things like motor vehicle accidents, falls and drug overdoses.

Foundation for a Healthy Kentucky chart shows how much more common, in percentages,
health problems are in Appalachia and Appalachian Kentucky, compared to national rates.

Appalachian sub-regions are outlined in red.

These deaths were more than twice the national rate in Kentucky, at 80.1 injury deaths per 100,000 people compared to 39.5 per 100,000 nationally.

The overdose, or poisoning, deaths were a whopping 141 percent higher in Kentucky, 146 percent higher in Central Appalachia, which is dominated by Kentucky, and 79 percent higher in North Central Appalachia than in the nation as a whole.

The premature death rate in Central Appalachia was much higher than the other sub-regions, 68 percent higher than the national average. Kentucky's rate was 63 percent higher.

Click on any map to view a larger version of it.

Appalachian suicide rates were also higher than the national rates by 17 percent, and were 31 percent higher in Central Appalachia.

“In measure after measure, the Central Appalachian region—including Eastern Kentucky—faces greater health challenges, and gaps are widening at a faster rate, than in the rest of Appalachia and the nation,” Chandler said in the news release. “Appalachia’s economic livelihood is absolutely dependent on improving these health measures."

The report also notes that the Appalachian region’s rural counties have higher death rates than the region’s large metro counties for each of the mortality measures, "signifying a stark rural-urban divide in the region": in rural counties, heart disease is 27 percent higher; cancer is 15 percent higher; COPD is 55 percent higher; injury is 47 percent higher; stroke is 8 percent higher; and diabetes is 36 percent higher. Premature deaths are 40 percent higher in rural Appalachian.

Foundation graphic shows how much more common, in percentages, social
determinants of health problems are in Appalachia compared to national rates.

It comes as no surprise that many of the risk factors for poor health are also more prevalent in the Appalachian region, including fewer health care providers, higher rates of diabetes and obesity, higher rates of physical inactivity and higher smoking rates.The region also has lower incomes, higher poverty rates, more people on disability and lower shares of residents with some college education -- and all of these risk factors are higher in Kentucky.

Chandler said that with smoking rates in Kentucky 59 percent higher than the national average and 23 percent higher than the Appalachian region, reducing this rate would be a sure way to improve the health of Kentuckians.

"The single most effective policy changes that this state, Kentucky, can make to improve health are changes that will reduce our smoking rate and exposure to second-hand smoke," he said. "That ought to be low hanging fruit."

Chandler said the foundation supports smoke-free laws to decrease exposure to second-hand smoke and an increase in the tobacco tax by at least $1/pack toward this goal.

One bright spot is the Appalachian region's high rate of social associations, at 33 percent. This is a measure of the number of social organizations available and may very well end up being part of the solution to improve the region's health."Greater levels of social relationships and interaction positively affect a number of outcomes, included those associated with both mental and physical health,” says the report.

This measure could also contribute to Appalachian Kentucky's poor health as the state's rate for this measure is lower than the regions, 8.6 social organizations per 10,000 people compared to 12.5 per 10,000.

The region also has lower incidence of chlamydia, lower prevalence of HIV, higher student-teacher ratios, and better diabetes monitoring among Medicare patients than the nation as a whole.

“This report begins to identify key health challenges confronting Appalachia,” ARC Federal Co-Chair Earl F. Gohl said in the release. “Now we need to understand the implications these findings have for Appalachia’s economy so we can continue working towards a brighter future for the Region.”

This report is part of multi-part research project titled “Creating a Culture of Health in Appalachia: Disparities and Bright Spots.” The next report will explore “bright spots,” Appalachian communities that have better-than-expected health outcomes given their resources, with the goal of identifying activities, programs or policies that other struggling communities could replicate.

Where does your county rank in painkiller prescriptions per person? Here are the numbers, and possible reasons for them

Kentucky Health News reported in July about a Centers for Disease Control and Prevention report showing ranges of painkillers sold per person in each county in 2015 and whether there had been an increase or decrease since 2010. At the time, the individual county data wasn't available, but now it is.

The CDC report calculated the rate of "morphine equivalent doses" sold at retail pharmacies in 2010 and 2015 in each county and whether there had been an increase or decrease, if the change was greater than or equal to 10 percent. Counties with changes of less than 10 percent were labeled "stable."

Morphine equivalent doses, in milligrams, are determined by a calculation that allows health-care providers to understand how potent one opioid is compared to another.

The report found that painkiller prescriptions had declined statewide, but increased or remained high in many counties from 2010 to 2015.

Opioid doses per person decreased in 71 counties, increased in 19, and were considered stable in 24. Six counties didn't have enough data to show a trend. The report does not account for people who fill their prescription in one county but live in another.

On the 2015 map, the counties are shaded by quartiles, each representing one-fourth of the total range. Here's a table of the top quartile, showing the 30 Kentucky counties with the most doses per person of opioid painkillers in 2015. Click here for a spreadsheet that gives figures for all counties.

Click here to download the full data set.

The report gives partial credit for the decline to the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system, which went from voluntary to mandatory during the period.

The report says, "The substantial variation in opioid prescribing observed at the county level suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use, and demonstrates the need for better application of guidance and standards around opioid prescribing practices."

It says counties with higher amounts of opioids tended to have "a larger percentage of non-Hispanic whites; higher rates of uninsured and Medicaid enrollment, lower educational attainment; higher rates of unemployment; micropolitan status [counties with towns of 10,000 to 50,000]; more dentists and physicians per capita; a higher prevalence of diagnosed diabetes, arthritis, and disability; and higher suicide rates."

The data for the study came from the Quintiles IMS Transactional Data Warehouse. It does not include prescriptions dispensed directly by prescribers.

Frankfort Independent Schools offer programs for students at risk of attempting suicide; experts offer guidance

Frankfort Independent Schools are working to prevent teen suicide, attempts of which are probably more common than most people think.

Austin Horn reports for The State Journal in Frankfort that a 2016 survey of Kentucky high-school sophomores found that 8.2 percent said they had attempted suicide, and the rate was 8.4 percent in the Bluegrass, where Frankfort is located. The national rate is 9.4 percent.

“It’s a very serious issue,” Dr. Julie Cerel, a psychologist and professor at the University of Kentucky College of Social Work and president of the American Association of Suicidology, told Horn.

School social worker Marci Fritts told Horn that she coordinates mental-health services for at-risk students at Second Street School and Frankfort High School through a partnership with the Kentucky Counseling Center.

“We have clinical therapists working with all of our identified students that (we identified) either through talking with parents, through collaboration with teachers, through referral in school, and approaching guardians and parents about services that potentially would benefit the student,” Fritts said. “We have two full-time therapists at Second Street School, and we have a therapist on-site at the high school.”

The school system also partners with Operation Making a Change, a program designed to provide young males with mentorship, and Fritts heads her own program called “My Life, My Choice,” a prevention-based program provided to all female sophomores at Frankfort High School.

Statewide, all middle and high-school students are required to receive some form of suicide prevention education by Sept. 1, and teachers are required to receive at least two hours of training. In addition, the state is also rolling out a “Sources of Strength” peer-led prevention program this year.

The biennial “Kentucky Incentives for Prevention” survey is given to students across the state in even-numbered grades starting in the sixth grade. It has only asked about suicide since 2014, when the suicide attempt rate for Kentucky's 10th-graders was 8 percent, compared to 8.6 percent nationwide. Suicide is the second leading cause of death among Kentucky's teens and young adults.

Cerel told Horn that there is never just one factor that leads a person to attempt suicide, but one study found that teens who had attempted suicide reported that the most common reason was a recent break-up, regardless of the length of the relationship. Cerel warned parents to take these break-ups seriously.

“If a teen is stressed or feels like something has happened and they’re never going to get over it, the adult response shouldn’t be, ‘Oh, that’s nothing, you’re going to grow up and find somebody else,’” Cerel told Horn. “The response probably should be, ‘I understand that this feels like the worst thing ever; let’s figure out a way to get you some help.’”

Dr. Vicki Hayes, a psychologist in Frankfort, told Horn that sometimes there are warning signs that shouldn't be ignored.

“One of the biggest behavioral things you want to watch for as a parent is abrupt change in a child’s behavior,” Hayes said. “Pay a lot of attention to that and try to find out what’s going on. If they’re saying anything morbid or that sounds suicidal, don’t let that ride. Don’t ever call a bluff or think that they don’t mean it. It’s better to err on the side of caution.”

Bullying is often cited as a reason for youth suicide attempts in Franklin County, Hayes told Horn.

“There are very few people who have not been bullied. I think there’s a huge bullying problem in Franklin County, and I’m concerned about it — all the schools,” Hayes said. “I don’t think any of them are doing enough to stop the bullying here in this particular county.”

In the 2015-16 school year, the Frankfort schools, with an enrollment of 735, reported 47 events of harassment, a rate of 6.4 percent, while the Franklin County Public Schools, with an enrollment of 6,131, reported 312, a 5 percent rate. The county system has two high schools, Franklin County and Western Hills. "The State Journal reached out multiple times to both Franklin County public high school psychologists but did not receive a response by press time," Horn reports.

Horn notes that the recent Netflix television series "13 Reasons Why," which depicts the aftermath of a fictional teenage girl's suicide, has also exposed teens to suicide and may have "adverse effects." This series has prompted schools throughout the state to send resource letters home with guidance on how to talk to children about suicide and has also warned that "vulnerable youth" should not watch it.

"Cerel referenced a recent study that showed Google searches for suicide methods increased by as much as 28 percent in the two weeks following the release of “13 Reasons Why," Horn reports.

Trump administration wants to drop Obama rule, tied up in court, that would ban binding arbitration in nursing-home disputes

"The Trump administration is pushing to scrap a rule that would have made it easier for nursing home residents to sue nursing homes for injuries caused by substandard care, abuse or neglect," reports Robert Pear of The New York Times. "The push would undo a rule issued by the Obama administration that would have prevented nursing homes from requiring that consumers agree to resolve any disputes through arbitration rather than litigation. Nursing homes routinely require consumers to sign an arbitration agreement as a condition of admission to the home."

Many businesses are including binding-arbitration rules in their contracts with consumers, Pear notes, but nursing homes are a special kind of business, dominated by a special kind of patient. "About half of nursing home residents have Alzheimer’s disease or other dementia, according to the National Center for Health Statistics, and consumer advocates say harried family members could easily miss the arbitration clauses as they move a loved one into a home offering care," he reports.

The rules were issued in September 2016, but a lawsuit by the industry and a judge's ruling kept them from taking effect.

The Obama administration said it was “almost impossible for residents or their decision-makers to give fully informed and voluntary consent to arbitration before a dispute has arisen,” but the Trump administration makes another argument: “We believe that arbitration agreements are, in fact, advantageous to both providers and beneficiaries because they allow for the expeditious resolution of claims without the costs and expense of litigation.”

Trump-appointed officials at the Centers for Medicare and Medicaid Services have "proposed several requirements to protect nursing home residents who agree to binding arbitration," Pear reports, including “plain language” in contracts and an explanation to the consumer “in a form and manner that he or she understands.” The nursing-home industry has objected, calling the rules “hopelessly vague.”

State health department offers safety tips for Aug. 21 solar eclipse; cautions to not look directly at it without eye protection

In an eclipse, the moon shadows part of Earth.

The Kentucky Department of Public Health is warning the public to not look directly at the solar eclipse without proper eye protection.

“Looking at an eclipse without proper eye protection can cause permanent and irreversible eye damage, including blindness” Health Commissioner Hiram C. Polk Jr. said in a news release. “We encourage everyone to enjoy this special celestial event, but urge the public not to look directly at the uneclipsed or partially eclipsed sun without special-purpose solar filters such as eclipse glasses or handheld solar viewers.”

This long awaited celestial event Polk is talking about will happen Monday, Aug 21. While Hopkinsville, Paducah and the Land between the Lakes are in the 70-mile path of totality, all of Kentucky will be able to see a "deep partial eclipse." Totality will last less than three minutes, but the sun will be partially obscured for more than two hours. Online interactive maps and guides give the times; one is https://www.vox.com/science-and-health/2017/7/25/16019892/solar-eclipse-2017-interactive-map.

State officials offers tips on how to safely view a solar eclipse and avoid permanent eye damage:

• Only use eclipse glasses or handheld solar viewers that meet the International Organization for Standardization international standards.
• Homemade filters or ordinary sunglasses, even very dark ones, are not safe for looking at the sun.
• Telescopes with solar filters on the large end can be used, but older telescopes that have small solar filters that attach to the eyepiece are not safe.
• It is safe to use pinhole projectors and other projection techniques that offer indirect viewing of the eclipse. These can be made with paper or cardstock.
• Do not look at the eclipse through an unfiltered camera, telescope, binoculars or other optical device.
• Do not look at the sun through a camera, telescope, binoculars or any other optical device while using your eclipses glasses or handheld solar viewer. The concentrated solar rays will damage the filter and enter your eye(s), causing serious injury.
• Seek expert advice before using a solar filter with a camera, telescope, binoculars or any other optical device.

The state health department also offers safety tips for those who will be spending the day outdoors while waiting on the eclipse, including: stay hydrated and drink plenty of water; avoid drinking alcohol, which causes you to lose fluid; wear light colored, loose fitting clothes and a hat; apply and reapply sunscreen throughout the day with at at least a SPF 15 rating; use an Environmental Protection Agency-registered insect repellent, and keep your hands washed to avoid spreading germs.

State health officials will deploy portable medical tents at an upcoming eclipse event in Hopkinsville and all food vendors in the region will be inspected, says the release.

Click here for a link to the state released video about eclipse eye safety. Click here for one directed toward children.

Health foundation offers workshop to help businesses implement smoke-free policies; smokers cost businesses extra $5,800/year

The Foundation for a Healthy Kentucky is offering a workshop to help businesses learn how to implement smoke-free policies in their workplaces Aug. 31 in Louisville.

"More than 70 percent of Kentucky adults and 90 percent of Kentucky businesses support smoke-free, so it's never been easier for Kentucky businesses to adopt workplace policies to protect their employees from the dangers of secondhand smoke," Ben Chandler, president and CEO of the foundation, said in a news release.

The 75-minute workshop will be part of the Kentucky Society for Human Resource Management conference Aug. 29-31 at the Galt House in Louisville. It will be led by University of Kentucky Associate Professor Melinda Ickes, who is also a faculty associate with the Kentucky Center for Smoke-free Policy. The presentation will be Thursday, Aug. 31 at 10:30 a.m. Click here to register.

"Smoking costs businesses an estimated $5,800 per smoker in extra expenditures each year, including productivity losses and additional health care costs, and puts them at risk for the health consequences for all workers exposed to secondhand smoke," says the release.

The foundation will also offer information about developing and implementing smoke-free workplace policies at its exhibit booth at the conference and on its website afterward.

National panel studying surface coal mining's effects on health sets meetings Mon. night in Hazard, Tue. afternoon in Lexington

In a study of possible health risks from large-scale strip mining, the National Academies of Sciences, Engineering and Medicine will hold two public meetings in Kentucky.

The first meeting will be held from 6:30 to 9 p.m. Monday, Aug. 21, at the Perry County Library, 289 Black Gold Blvd. in Hazard.

The second meeting will be held from 12:45 to 5 p.m. Tuesday at the Marriott Griffin Gate Resort, 1800 Newtown Pike in Lexington.

The study was commissioned by the Interior Department's Office of Surface Mining Reclamation and Enforcement, citing a “growing amount of academic research that relates to possible correlations between increased health risks as a result of living near surface coal mine operations.”

Bill Estep of the Lexington Herald-Leader notes, "Several studies have concluded that mountaintop mining in Central Appalachia is associated with higher rates of cancer, heart disease and other health problems among local residents." The leading researcher has pointed to dust containing rare-earth metals as a likely cause. However, a 2012 study by a Yale University researcher and others for coal interests "did not find that mining or mining-related pollution directly contributed to health problems in Central Appalachia," Estep notes. "Rather, the results pointed to 'substantial economic and cultural disadvantages that adversely impact the health of many area residents,' the study said." The leading researcher says his work has accounted for those issues.

Information about the study can be found here. For more information, or to register to attend, email rchappetta@nas.edu or call 202-334-2766.

Cabinet for Health and Family Services promotes health and wellness at state fair, and collects duffel bags for foster kids

helpourkidsinc.org

The Kentucky State Fair is not just a great place to support Kentucky's agriculture or to spend the day on the midway; it's also a great place to learn about some of the state's health and wellness initiatives and to donate a new duffel bag or backpack to a foster child.

“Often times, when children are removed from their home and placed into state care, all their belongings are literally stuffed into a black garbage bag,” Health Secretary Vickie Yates Brown Glisson said in a news release. "This effort changes that. Donating a duffel bag or backpack is a small but meaningful way to help foster children and give them the dignity of carrying their possessions in a new bag that is all their own.”

New duffel bags and backpacks will be collected at the Cabinet for Health and Family Services' exhibit in the Health Horizons area of the South Wing B. The fair runs through Aug. 27 at the Kentucky Exposition Center in Louisville.

The cabinet's exhibit will offer daily interactive displays that features learning activities for children and adults, free health screenings and on-site health educators who can speak to individuals about wellness and prevention. It will also offer free dental screenings for children with signed consents who are entering public school kindergarten or first grade from 10 a.m. to 2 p.m. daily.

In addition to these daily health initiatives, they will also have special "focus days," including:

• Tuesday, Aug. 22: Services for Seniors, including Adult Protective Services, Aging and Independent Living/Long Term Care Ombudsman, and the Kentucky Prescription Assistance Program
• Wednesday, Aug. 23: Focus on Foster Care and Adoption, 10 a.m. to noon
• Thursday, Aug. 24: Focus on Zika Education and Mosquito Control, 10 a.m. to noon
• Friday, Aug. 25: Focus on Substance Use Disorder Strategies and Services, 10 a.m. to noon

Exhibit buildings are open daily from 9 a.m. to 9 p.m. Sunday through Thursday and until 10 p.m. Friday and Saturday. Admission at the gate is $10 for adults, seniors and children; free for children 5 years and under. Parking at the gate is $10 per car.

Foundation for a Healthy Kentucky calls for statewide smoking ban, pushing people to quit by raising tobacco tax $1 a pack

Ben Chandler

Kentucky's poor health is hurting its economy, and the state needs a smoking ban and a big increase in its cigarette tax to prevent disease, Foundation for a Healthy Kentucky President Ben Chandler told a legislative committee Wednesday.

"The poor health of the commonwealth is one of the main things that's holding our economy back," Chandler said, telling the Interim Joint Committee on Health and Welfare that among the 50 states, Kentucky's population is 26th but its economy is 45th.

"The single most effective policy changes we can make to improve the health of Kentuckians are changes that will reduce our smoking rates and exposure to secondhand smoke," Chandler said. "Passing smoke-free laws and raising the tobacco tax by $1 or more per pack will help reduce smoking, save health care costs, and won't cost the state a dime."

Kentucky has a relatively low cigarette tax, 60 cents a pack, and the highest smoking rate in the nation, 26 percent of adults, as well as the highest death rate from cancer. "If there's anything that needs dealing with, it's that," Chandler said. "Doing something about this smoking problem is absolutely critical to the future of this state . . . . Businesses are not going to locate here if they don't have a healthy workforce."

Republican Sen. Tom Buford of Nicholasville called for a larger increase than Chandler, "Even to a $1.60 a pack is probably not going to provide us the result that we would like to have," Buford said. But he added, "I don't know if the will is there." Alluding to the late-January filing deadline for legislative elections, he said, "I can tell you February the first if there's a chance for tax reform."

Critics of a tobacco-tax increase have said it would penalize lower-income people, who are more likely to smoke. Chandler told the House-Senate committee that a big increase is needed to push them into quitting.

"You have to raise the tax by $1 or more to get the health benefits," he said. "Otherwise, it's just an added tax burden on the poor." He said cigarette companies would counter an increase of 30 to 40 cents a pack with discount coupons.

Asked where he would spend the money, Chandler, a former congressman and state attorney general, said some should be spent to discourage Kentuckians from smoking.

"We have a very good, in many respects, health-care system, but it's a rescue system," he said. "And people don't want to talk about this, but . . . we spend money largely, for the most part, on health care, to rescue people who are already sick. And we ought to spend a bigger portion . . . on health, as opposed to health care."

Referring to a smoking ban, which she supports, Sen. Julie Raque Adams of Louisville, the committee co-chair, said, "It's not really a freedom issue because every one of us pays out of pocket for those costs."

Chandler told the committee, "We have to focus on promoting policy changes that lead to healthier outcomes by addressing the things that cause poor health in the first place. . . . now have a rescue system."

Appalachian Kentucky continues to be the least healthy region of the state, and the disparity is increasing, Chandler said.

"While all of Kentucky lags behind the nation as a whole, it's generally people living in more rural Eastern counties with more challenging health issues," he said. "The latest numbers show that the health disparities between Central Appalachia and the rest of the nation, or even the rest of Appalachia, are large. And they're continuing to grow."

For example, he said the national death rate from heart disease "declined nearly 58 percent from 1980 to 2014, but not in Eastern Kentucky. In Owsley County, cardiovascular disease mortality actually increased over that 34-year period."

Another big Kentucky health problem is obesity. Chandler said, "Some of the evidence-based programs that help reduce obesity include making the healthy choice the easiest choice by replacing sugary drinks and snacks in school and government vending machines with healthier options, such as fruit and water; increasing the tax on sugary drinks; passing policies that require new streets to be walkable and bikeable; building sidewalks, walking trails, playgrounds and other places where residents can safely engage in physical activity; and adopting policies that enable farmers' markets to thrive."

A video of Chandler's testimony is on the KET website.