# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 27 {#section-1 .Chapter-#}

# Tobacco Use

Lead Agency: Centers for Disease Control and Prevention

### Contents {#contents .Heading-Special}

[Goal Page 27-3](#goal)

[Overview Page 27-3](#overview)

[Issues and Trends Page 27-3](#issues-and-trends)

[Disparities Page 27-5](#disparities)

[Opportunities Page 27-6](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
27-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
27-9](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
27-10](#healthy-people-2010-objectives)

[Tobacco Use in Population Groups Page
27-10](#tobacco-use-in-population-groups)

[Cessation and Treatment Page 27-19](#cessation-and-treatment)

[Exposure to Secondhand Smoke Page 27-24](#exposure-to-secondhand-smoke)

[Social and Environmental Changes Page
27-29](#social-and-environmental-changes)

[Related Objectives From Other Focus Areas Page
27-34](#related-objectives-from-other-focus-areas)

[Terminology Page 27-35](#terminology)

[References Page 27-36](#references)

## Goal

Reduce illness, disability, and death related to tobacco use and
exposure to secondhand smoke.

## Overview

Scientific knowledge about the health effects of tobacco use has
increased greatly since the first Surgeon General's report on tobacco
was released in 1964.[^1]**^,^** [^2] Cigarette smoking causes heart
disease, several kinds of cancer (lung, larynx, esophagus, pharynx,
mouth, and bladder), and chronic lung disease. Cigarette smoking also
contributes to cancer of the pancreas, kidney, and cervix. Smoking
during pregnancy causes spontaneous abortions, low birth weight, and
sudden infant death syndrome.[^3]

Other forms of tobacco are not safe alternatives to smoking cigarettes.
Use of spit tobacco causes a number of serious oral health problems,
including cancer of the mouth and gum, periodontitis, and tooth
loss.Error: Reference source not found**^,^** [^4] Cigar use causes
cancer of the larynx, mouth, esophagus, and lung.[^5] In recent years,
reports have shown an increase in the popularity of bidis.[^6] Bidis are
small brown cigarettes, often flavored, consisting of tobacco
hand-rolled in tendu or temburni leaf and secured with a string at one
end. Research shows that bidis are a significant health hazard to users,
increasing the risk of coronary heart disease and cancer of the mouth,
pharynx and larynx, lung, esophagus, stomach, and liver.[^7]

### Issues and Trends

Tobacco use is responsible for more than 430,000 deaths per year among
adults in the United States, representing more than 5 million years of
potential life lost.[^8] If current tobacco use patterns persist in the
United States, an estimated 5 million persons under age 18 years will
die prematurely from a smoking-related disease.[^9] Direct medical costs
related to smoking total at least \$50 billion per year;[^10] direct
medical costs related to smoking during pregnancy are approximately
\$1.4 billion per year.[^11]

Evidence is accumulating that shows maternal tobacco use is associated
with mental retardation and birth defects such as oral clefts. Exposure
to secondhand smoke also has serious health effects.[^12]**^,^**
[^13]**^,^** [^14] Researchers have identified more than 4,000 chemicals
in tobacco smoke; of these, at least 43 cause cancer in humans and
animals.Error: Reference source not found Each year, because of exposure
to secondhand smoke, an estimated 3,000 nonsmokers die of lung cancer,
and 150,000 to 300,000 infants and children under age 18 months
experience lower respiratory tract infections.Error: Reference source
not found**^,\ Error:\ Reference\ source\ not\ found^** Asthma and other
respiratory conditions often are triggered or worsened by tobacco smoke.
(See Focus Area 8. Environmental Health; Focus Area 16. Maternal,
Infant, and Child Health; and Focus Area 24. Respiratory Diseases.)

Studies also have found that secondhand smoke exposure causes heart
disease among adults.[^15]**^,^** [^16] Data reported from a study of
the U.S. population aged 4 years and older indicated that among
nontobacco users, 88 percent had detectable levels of serum cotinine, a
biological marker for exposure to secondhand smoke.[^17] Both home and
workplace environments have contributed to the widespread exposure to
secondhand smoke. Data from a 1996 study indicated that 22 percent of
U.S. children and adolescents under age 18 years (approximately 15
million children and adolescents) were exposed to secondhand smoke in
their homes.[^18]

Smoking among adults declined steadily from the mid-1960s through the
1980s. However, smoking among adults appears to have leveled off in the
1990s. The rate of smoking among adults in 1997 was 25 percent.[^19]

Tobacco use and addiction usually begin in adolescence. Furthermore,
tobacco use may increase the probability that an adolescent will use
other drugs. (See Focus Area 26. Substance Abuse.) Among adults in the
United States who have ever smoked daily, 82 percent tried their first
cigarette before age 18 years, and 53 percent became daily smokers
before age 18 years.[^20] Preventing tobacco use among youth has emerged
as a major focus of tobacco control efforts.

Tobacco use among adolescents increased in the 1990s after decreasing in
the 1970s and 1980s. Data from the 1999 Monitoring the Future Study
indicated that past-month smoking among 8th, 10th, and 12th graders was
18, 26, and 35 percent, respectively. These rates represent increases of
20 to 33 percent since 1991.[^21] Data from the Youth Risk Behavior
Survey revealed that past-month smoking among 9th to 12th graders rose
from 28 percent in 1991 to 36 percent in 1997.[^22] Past-month spit
tobacco use among 9th to 12th graders was 9 percent in 1997 (2 percent
among females and 16 percent among males).Error: Reference source not
found In 1997, past-month cigar use among 9th to 12th graders was 22
percent (11 percent of females and 31 percent of males).Error: Reference
source not found

Youth are put at increased risk of initiating tobacco use by
sociodemographic, environmental, and personal factors. Sociodemographic
risk factors include coming from a family with low socioeconomic status.
Environmental risk factors include accessibility and availability of
tobacco products, cigarette advertising and promotion practices, the
price of tobacco products, perceptions that tobacco use is normal,
peers' and siblings' use and approval, and lack of parental involvement.
Personal risk factors include low self-image and low self-esteem, the
belief that tobacco use provides a benefit, and the lack of ability to
refuse offers to use tobacco.Error: Reference source not found

Overwhelming evidence indicates that nicotine found in tobacco is
addictive and that addiction occurs in most smokers during
adolescence.Error: Reference source not found**^,^** [^23] Among
students who were high school seniors during 1976--86, 44 percent of
daily smokers\
believed that in 5 years they would not be smoking. Followup studies,
however, indicated that 5 to 6 years later 73 percent of these persons
remained daily smokers.Error: Reference source not found In 1995, 68
percent of current smokers wanted to quit smoking completely, and 46
percent of the current daily smokers had stopped smoking for at least 1
day during the preceding 12 months.Error: Reference source not found
Less than 3 percent of current smokers stopped smoking permanently.[^24]

### Disparities![](media/image2.wmf){width="4.500694444444444in" height="4.805555555555555in"}

Men are more likely to smoke than women (26 percent compared to 22
percent).Error: Reference source not found Disparities in tobacco use
exist among certain racial and ethnic populations. American Indians or
Alaska Natives (35 percent) are more likely to smoke than other racial
and ethnic groups, with considerable variations in percentages by
Tribe.[^25] Hispanics (18 percent) and Asians or Pacific Islanders (13
percent) are less likely to smoke than other groups. Regional and local
data, however, reveal much higher smoking levels among specific
population groups of Hispanics and Asians or Pacific Islanders.Error:
Reference source not found Smoking levels among Vietnamese and Korean
Asian Americans are higher than previously reported, according to a 1997
multilingual survey.[^26]

Studies have found higher levels of cigarette use among gay men and
lesbians than among heterosexuals.[^27]**^,^** [^28]**^,^** [^29]**^,^**
[^30] Gay men and lesbians with higher education levels are less likely
to use cigarettes as frequently as those with lower levels of
education.Error: Reference source not found

Persons with 9 to 11 years of education (38 percent) have significantly
higher levels of smoking than individuals with 8 years or less of
education or 12 years or more. Individuals with 16 or more years of
education have the lowest smoking rates (11 percent). Individuals who
are poor are significantly more likely to smoke than individuals of
middle or high income (34 percent compared to 21 percent).Error:
Reference source not found

Data reveal high levels of tobacco use among college students. In 1995,
29 percent of college students smoked in the previous month (28 percent
of females and 30 percent of males). Five percent of college students
used spit tobacco in the previous month (0.3 percent of females and 12
percent of males).[^31]

Among adolescents, smoking rates differ between whites and African
Americans.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** By the late 1980s,
smoking rates among white teens were more than triple those of African
American teens. In recent years, smoking has started to increase among
African American male teens, but African American female teens continue
to have lower smoking rates. In 1997, 40 percent of white high school
females were smokers, compared to 17 percent of African American high
school females.**^Error:\ Reference\ source\ not\ found^**

Spit tobacco use among adolescents also differs significantly by
students' gender, race, and ethnicity. In 1997, 15.8 percent of male
high school students currently used spit tobacco, compared to only 1.5
percent of female high school students. Current spit tobacco use was
12.2 percent for non-Hispanic whites, 2.2 percent for non-Hispanic
African Americans, and 5.1 percent for Hispanics.Error: Reference source
not found

### Opportunities

Efforts to reduce tobacco use in the United States have shifted from
focusing primarily on smoking cessation for individuals to more
population-based interventions. Such interventions emphasize prevention
of initiation, reduction of exposure to environmental tobacco smoke, and
policy changes in health care systems to promote smoking
cessation.Error: Reference source not found**^,^** [^32]**^,^**
[^33]**^,^** [^34]**^,^** [^35]**^,^** [^36]**^,^** [^37] Federal,
State, and local government agencies and numerous health organizations
have joined together to develop and implement population-based
approaches.

Community research studies and evidence from California, Florida,
Massachusetts, and Oregon have shown that comprehensive programs can be
effective in reducing average cigarette consumption per person. Both
California and Massachusetts increased cigarette excise taxes and
designated a portion of the revenues for comprehensive tobacco control
programs. Data from these States indicate that (1) increasing excise
taxes on cigarettes is one of the most cost-effective short-term
strategies to reduce tobacco consumption among adults and to prevent
initiation among youth and (2) the ability to sustain lower consumption
increases when the tax increase is combined with an antismoking
campaign.[^38] In addition, recent data from Florida indicate that
past-month smoking decreased significantly among public middle school
students (19 percent to 15 percent) and high school students (27 percent
to 25 percent) from 1998 to 1999 following implementation of a
comprehensive program to prevent and reduce tobacco use among youth in
that State.[^39]

As education programs for school-aged youth are developed and proven
effective in preventing initiation and in cessation, these programs
should be included in quality health education curricula at the grade
level. Education should aim to prevent initiation among youth, provide
knowledge about effective cessation methods, and increase understanding
of the health effects of tobacco use. (See Focus Area 7. Educational and
Community-Based Programs.)

The goals of comprehensive tobacco prevention and reduction efforts
include preventing people from starting to use tobacco, helping people
quit using tobacco, reducing exposure to secondhand smoke, and
identifying and eliminating disparities in tobacco use among population
groups. To address these goals, community programs, media interventions,
policy and regulatory activities, and surveillance and evaluation
programs are being implemented. Specifically, the following elements are
used to build capacity to implement and support tobacco use prevention
and control interventions: a focus on change in social norms and
environments that support tobacco use, policy and regulatory strategies,
community participation, establishment of public and private
partnerships, strategic use of media, development of local programs,
coordination of statewide and local activities, linkage of school-based
activities to community activities, and use of data collection and
evaluation techniques to monitor program impact.

The importance of these various strategic elements has been demonstrated
in a number of States, such as Arizona, California, Florida,
Massachusetts, and Oregon.[^40] In these and other States, tobacco
control programs are supported through funding from the Federal
Government, private foundations, State tobacco taxes, State lawsuit
settlements, and other sources. These programs address issues such as
reducing exposure to secondhand smoke, restricting minors' access to
tobacco, treating nicotine addiction, limiting the impact of tobacco
advertising, increasing the price of tobacco products, and directly
regulating the product (for example, requiring product ingredient
reporting). Tobacco control programs and materials should be culturally
and linguistically appropriate.

## Interim Progress Toward Year 2000 Objectives

Of the 26 tobacco-related objectives, 3 have been met: reducing the rate
of lung cancer deaths, reducing the rate of oral cancer deaths, and
increasing the number of States that have tobacco control plans.

Sixteen additional objectives are showing progress. These include
reducing cigarette smoking among adults, which declined in the early
part of the 1990s and then leveled off, and reducing children's exposure
to secondhand smoke, which also declined. Some objectives, though
showing progress, are far from their targets. For example, although 13
States have laws limiting smoking in public places and worksites, few
ban smoking or limit it to separately ventilated areas in private
workplaces or restaurants. As of December 31, 1998, only one State had
met the objective for private worksites, and three had met it for
restaurants. All 50 States and the District of Columbia have laws
prohibiting the sale of tobacco to minors. However, the objective on
enforcement of minors' access laws to achieve illegal buy rates of no
more than 20 percent is far from being met: in fiscal year 1998, only 12
States had met this target. Although Healthy People 2000 data indicate
that smoking among adolescents is declining somewhat, other surveys
indicate that smoking among youth increased through 1997 and remained
unchanged or declined somewhat in 1998 and 1999. Two additional
objectives that include the use of and perception of harm from using
drugs, alcohol, and cigarettes by high school seniors show mixed
progress; for cigarettes there is slight progress.

Three objectives (perception of social disapproval of cigarette smoking
among adolescents, States with preemptive clean indoor air laws, and
smoking cessation during pregnancy) are moving away from the targets.

Data beyond baseline were not available for two objectives (tobacco
product advertising and promotion to youth, and health plans offering
treatment for nicotine addiction).

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Tobacco Use {#tobacco-use-1 .Heading-Special-Sub}

**Goal:** Reduce illness, disability, and death related to tobacco use
and exposure to secondhand smoke.

  --------------- --------------------------------------------------------------
  **Number**      **Objective Short Title**

  **Tobacco Use   
  in Population   
  Groups**        

  27-1            Adult tobacco use

  27-2            Adolescent tobacco use

  27-3            Initiation of tobacco use

  27-4            Age at first tobacco use

  **Cessation and 
  Treatment**     

  27-5            Smoking cessation by adults

  27-6            Smoking cessation during pregnancy

  27-7            Smoking cessation by adolescents

  27-8            Insurance coverage of cessation treatment

  **Exposure to   
  Secondhand      
  Smoke**         

  27-9            Exposure to tobacco smoke at home among children

  27-10           Exposure to environmental tobacco smoke

  27-11           Smoke-free and tobacco-free schools

  27-12           Worksite smoking policies

  27-13           Smoke-free indoor air laws

  **Social and    
  Environmental   
  Changes**       

  27-14           Enforcement of illegal tobacco sales to minors laws

  27-15           Retail license suspension for sales to minors

  27-16           Tobacco advertising and promotion targeting adolescents and
                  young adults

  27-17           Adolescent disapproval of smoking

  27-18           Tobacco control programs

  27-19           Preemptive tobacco control laws

  27-20           Tobacco product regulation

  27-21           Tobacco tax
  --------------- --------------------------------------------------------------

## Healthy People 2010 Objectives 

### Tobacco Use in Population Groups

27-1. Reduce tobacco use by adults.

Target and baseline:

+---------+--------------------------------+------------+-------------+
| Ob      | Reduction in Tobacco Use by    | 1998\      | 2010\       |
| jective | Adults Aged 18 Years and Older | Baseline\* | Target      |
+---------+--------------------------------+------------+-------------+
|         |                                | #####      |             |
|         |                                | ## Percent |             |
+---------+--------------------------------+------------+-------------+
| **2     | Cigarette smoking              | 24         | 12          |
| 7-1a.** |                                |            |             |
+---------+--------------------------------+------------+-------------+
| **2     | Spit tobacco                   | 2.6        | 0.4         |
| 7-1b.** |                                |            |             |
+---------+--------------------------------+------------+-------------+
| **2     | Cigars                         | 2.5        | 1.2         |
| 7-1c.** |                                |            |             |
+---------+--------------------------------+------------+-------------+
| **2     | Other products                 | Dev        |             |
| 7-1d.** |                                | elopmental |             |
+---------+--------------------------------+------------+-------------+

\*Age adjusted to the year 2000 standard population.

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+---------------------------+-------------+-------------+-------------+
| **Adults Aged 18 Years    | **27-1a.\   | **27-1b.\   | **27-1c.\   |
| and Older, 1998 (unless   | Cigarette   | Spit        | Cigars**    |
| noted)**                  | Smoking**   | Tobacco**   |             |
+===========================+=============+=============+=============+
|                           | Percent     |             |             |
+---------------------------+-------------+-------------+-------------+
| > **TOTAL**               | 24          | 2.6         | 2.5         |
+---------------------------+-------------+-------------+-------------+
| **Race and ethnicity**    |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > American Indian or      | 35          | DSU         | DSU         |
| > Alaska Native           |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Asian or Pacific        | 13          | DSU         | DSU         |
| > Islander                |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Asian                   | 13          | DSU         | DSU         |
+---------------------------+-------------+-------------+-------------+
| > Native Hawaiian and     | 17          | DSU         | DSU         |
| > other Pacific Islander  |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Black or African        | 25          | 1.1         | 1.9         |
| > American                |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > White                   | 25          | 2.9         | 2.6         |
+---------------------------+-------------+-------------+-------------+
|                           |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Hispanic or Latino      | 19          | 0.5         | 1.3         |
+---------------------------+-------------+-------------+-------------+
| > Not Hispanic or Latino  | 25          | 2.8         | 2.6         |
+---------------------------+-------------+-------------+-------------+
| > Black or African        | 25          | 1.1         | 1.9         |
| > American                |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > White                   | 25          | 3.2         | 2.8         |
+---------------------------+-------------+-------------+-------------+
| **Gender**                |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Female                  | 22          | 0.3         | 0.2         |
+---------------------------+-------------+-------------+-------------+
| > Male                    | 26          | 4.9         | 4.9         |
+---------------------------+-------------+-------------+-------------+
| **Family income level**   |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Poor                    | 34          | 3.0         | 2.2         |
+---------------------------+-------------+-------------+-------------+
| > Near poor               | 31          | 3.0         | 2.7         |
+---------------------------+-------------+-------------+-------------+
| > Middle/high income      | 21          | 2.6         | 2.6         |
+---------------------------+-------------+-------------+-------------+
| **Education level** (aged |             |             |             |
| 25 years and older)       |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Less than high school   | 34          | 4.1         | 2.4         |
+---------------------------+-------------+-------------+-------------+
| > Less than 9 years       | 27          | 3.8         | 2.5         |
+---------------------------+-------------+-------------+-------------+
| > 9 to 11 years           | 38          | 3.9         | 2.3         |
+---------------------------+-------------+-------------+-------------+
| > High school graduate    | 29          | 2.6         | 2.4         |
+---------------------------+-------------+-------------+-------------+
| > At least some college   | 17          | 1.7         | 2.7         |
+---------------------------+-------------+-------------+-------------+
| > 13 to 15 years          | 24          | 2.2         | 2.7         |
+---------------------------+-------------+-------------+-------------+
| > 16 years or more        | 11          | 1.2         | 2.6         |
+---------------------------+-------------+-------------+-------------+
| **Disability status**     |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Persons with            | 33 (1997)   | DNA         | DNA         |
| > disabilities            |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > Persons without         | 23 (1997)   | DNA         | DNA         |
| > disabilities            |             |             |             |
+---------------------------+-------------+-------------+-------------+
| ###### Sexual orientation | DNC         | DNC         | DNC         |
+---------------------------+-------------+-------------+-------------+
| ##                        |             |             |             |
| ###### Select populations |             |             |             |
+---------------------------+-------------+-------------+-------------+
| Age groups (not age       |             |             |             |
| adjusted)                 |             |             |             |
+---------------------------+-------------+-------------+-------------+
| > 18 to 24 years          | 28 (1997)   | 3.5 (1997)  | 2.2 (1997)  |
+---------------------------+-------------+-------------+-------------+
| > 25 to 44 years          | 27 (1997)   | 3.2 (1997)  | 2.8 (1997)  |
+---------------------------+-------------+-------------+-------------+
| > 45 to 64 years          | 25 (1997)   | 1.7 (1997)  | 3.0 (1997)  |
+---------------------------+-------------+-------------+-------------+
| > 65 years and older      | 11 (1997)   | 1.8 (1997)  | 0.9 (1997)  |
+---------------------------+-------------+-------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

27-2. Reduce tobacco use by adolescents.

Target and baseline:

+---------+-----------------------------+--------------+--------------+
| Ob      | Reduction in Tobacco Use    | 1999\        | 2010\        |
| jective | by\                         | Baseline     | Target       |
|         | Students in Grades 9        |              |              |
|         | Through 12                  |              |              |
+---------+-----------------------------+--------------+--------------+
|         |                             | ###          |              |
|         |                             | #### Percent |              |
+---------+-----------------------------+--------------+--------------+
| **2     | Tobacco products (past      | 40           | 21           |
| 7-2a.** | month)                      |              |              |
+---------+-----------------------------+--------------+--------------+
| **2     | Cigarettes (past month)     | 35           | 16           |
| 7-2b.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
| **2     | Spit tobacco (past month)   | 8            | 1            |
| 7-2c.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
| **2     | Cigars (past month)         | 18           | 8            |
| 7-2d.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+

**Target setting method:** Better than the best.

**Data source:** Youth Risk Behavior Surveillance System (YRBSS), CDC,
NCCDPHP.

Note: The table below may continue to the following page.

+------------------------------+-------------+---+------------+-----------+
| **Students in Grades 9\      | **Current   |   |            |           |
| Through 12, 1999 (unless     | Tobacco     |   |            |           |
| noted)**                     | Use\        |   |            |           |
|                              | **(used     |   |            |           |
|                              | cigarettes, |   |            |           |
|                              | spit        |   |            |           |
|                              | tobacco, or |   |            |           |
|                              | cigars\     |   |            |           |
|                              | on 1 or     |   |            |           |
|                              | more of the |   |            |           |
|                              | 30 days     |   |            |           |
|                              | preceding   |   |            |           |
|                              | the survey) |   |            |           |
+==============================+=============+===+============+===========+
|                              | **27-2a.\   | * |            | **        |
|                              | Both\       | * |            | Males\*** |
|                              | Genders**   | F |            |           |
|                              |             | e |            |           |
|                              |             | m |            |           |
|                              |             | a |            |           |
|                              |             | l |            |           |
|                              |             | e |            |           |
|                              |             | s |            |           |
|                              |             | \ |            |           |
|                              |             | * |            |           |
|                              |             | * |            |           |
|                              |             | * |            |           |
+------------------------------+-------------+---+------------+-----------+
|                              | Percent     |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| > **TOTAL**                  | 40          | 3 |            | 44        |
|                              |             | 7 |            |           |
+------------------------------+-------------+---+------------+-----------+
| **Race and ethnicity**       |             |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| > American Indian or Alaska  | DSU         | D |            | DSU       |
| > Native                     |             | S |            |           |
|                              |             | U |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Asian or Pacific Islander  | DSU         | D |            | DSU       |
|                              |             | S |            |           |
|                              |             | U |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Asian                      | DSU         | D |            | DSU       |
|                              |             | S |            |           |
|                              |             | U |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Native Hawaiian and other\ | DSU         | D |            | DSU       |
| > Pacific Islander           |             | S |            |           |
|                              |             | U |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Black or African American  | 34          | 2 |            | 28        |
|                              |             | 3 |            |           |
+------------------------------+-------------+---+------------+-----------+
| > White                      | 33          | 4 |            | 49        |
|                              |             | 1 |            |           |
+------------------------------+-------------+---+------------+-----------+
|                              |             |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Hispanic or Latino         | 35          | 3 |            | 38        |
|                              |             | 3 |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Not Hispanic or Latino     | 41          | 3 |            | 44        |
|                              |             | 7 |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Black or African American  | 25          | 2 |            | 29        |
|                              |             | 2 |            |           |
+------------------------------+-------------+---+------------+-----------+
| > White                      | 45          | 4 |            | 49        |
|                              |             | 0 |            |           |
+------------------------------+-------------+---+------------+-----------+
| **Parents' education level** |             |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| > Less than high school      | 41 (1997)   |   | 36 (1997)  | 48 (1997) |
+------------------------------+-------------+---+------------+-----------+
| > High school graduate       | 46 (1997)   |   | 41 (1997)  | 51 (1997) |
+------------------------------+-------------+---+------------+-----------+
| > At least some college      | 43 (1997)   |   | 35 (1997)  | 48 (1997) |
+------------------------------+-------------+---+------------+-----------+
| ###### Sexual orientation    | DNC         |   | DNC        | DNC       |
+------------------------------+-------------+---+------------+-----------+
| ######## Select populations  |             |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| Grade                        |             |   |            |           |
+------------------------------+-------------+---+------------+-----------+
| > 9th grade                  | 32          |   | 30         | 33        |
+------------------------------+-------------+---+------------+-----------+
| > 10th grade                 | 40          |   | 38         | 42        |
+------------------------------+-------------+---+------------+-----------+
| > 11th grade                 | 42          |   | 37         | 47        |
+------------------------------+-------------+---+------------+-----------+
| > 12th grade                 | 50          |   | 43         | 57        |
+------------------------------+-------------+---+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

Note: The table below may continue to the following page.

+------------------------------+--------------+------------+-----------+
| **Students in Grades 9\      | **Current    |            |           |
| Through 12, 1999 (unless     | Cigarette    |            |           |
| noted)**                     | Smoking\     |            |           |
|                              | **(smoked    |            |           |
|                              | cigarettes   |            |           |
|                              | on 1 or more |            |           |
|                              | of the\      |            |           |
|                              | 30 days      |            |           |
|                              | preceding    |            |           |
|                              | the survey)  |            |           |
+==============================+==============+============+===========+
|                              | **27-2b.\    | **F        | **        |
|                              | Both\        | emales\*** | Males\*** |
|                              | Genders**    |            |           |
+------------------------------+--------------+------------+-----------+
|                              | Percent      |            |           |
+------------------------------+--------------+------------+-----------+
| > **TOTAL**                  | 35           | 35         | 35        |
+------------------------------+--------------+------------+-----------+
| **Race and ethnicity**       |              |            |           |
+------------------------------+--------------+------------+-----------+
| > American Indian or Alaska  | DSU          | DSU        | DSU       |
| > Native                     |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Asian or Pacific Islander  | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Asian                      | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Native Hawaiian and other\ | DSU          | DSU        | DSU       |
| > Pacific Islander           |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 20           | 19         | 22        |
+------------------------------+--------------+------------+-----------+
| > White                      | 39           | 40         | 38        |
+------------------------------+--------------+------------+-----------+
|                              |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Hispanic or Latino         | 33           | 32         | 34        |
+------------------------------+--------------+------------+-----------+
| > Not Hispanic or Latino     | 35           | 35         | 35        |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 20           | 18         | 22        |
+------------------------------+--------------+------------+-----------+
| > White                      | 39           | 39         | 38        |
+------------------------------+--------------+------------+-----------+
| **Parents' education level** |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Less than high school      | 39 (1997)    | 37 (1997)  | 43 (1997) |
+------------------------------+--------------+------------+-----------+
| > High school graduate       | 40 (1997)    | 39 (1997)  | 41 (1997) |
+------------------------------+--------------+------------+-----------+
| > At least some college      | 35 (1997)    | 33 (1997)  | 37 (1997) |
+------------------------------+--------------+------------+-----------+
| ###### Sexual orientation    | DNC          | DNC        | DNC       |
+------------------------------+--------------+------------+-----------+
| ###### Selection populations |              |            |           |
+------------------------------+--------------+------------+-----------+
| Grade                        |              |            |           |
+------------------------------+--------------+------------+-----------+
| > 9th grade                  | 28           | 29         | 26        |
+------------------------------+--------------+------------+-----------+
| > 10th grade                 | 35           | 36         | 34        |
+------------------------------+--------------+------------+-----------+
| > 11th grade                 | 36           | 36         | 36        |
+------------------------------+--------------+------------+-----------+
| > 12th grade                 | 43           | 41         | 46        |
+------------------------------+--------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

Note: The table below may continue to the following page.

+------------------------------+--------------+------------+-----------+
| **Students in Grades 9\      | **Current    |            |           |
| Through 12, 1999 (unless     | Spit Tobacco |            |           |
| noted)**                     | Use\         |            |           |
|                              | **(used spit |            |           |
|                              | tobacco on 1 |            |           |
|                              | or more of   |            |           |
|                              | the\         |            |           |
|                              | 30 days      |            |           |
|                              | preceding    |            |           |
|                              | the survey)  |            |           |
+==============================+==============+============+===========+
|                              | **27-2c.\    | **F        | **        |
|                              | Both\        | emales\*** | Males\*** |
|                              | Genders**    |            |           |
+------------------------------+--------------+------------+-----------+
|                              | Percent      |            |           |
+------------------------------+--------------+------------+-----------+
| > **TOTAL**                  | 8            | 1          | 14        |
+------------------------------+--------------+------------+-----------+
| **Race and ethnicity**       |              |            |           |
+------------------------------+--------------+------------+-----------+
| > American Indian or Alaska  | DSU          | DSU        | DSU       |
| > Native                     |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Asian or Pacific Islander  | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Asian                      | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Native Hawaiian and other\ | DSU          | DSU        | DSU       |
| > Pacific Islander           |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 1            | 1          | 2         |
+------------------------------+--------------+------------+-----------+
| > White                      | 10           | 2          | 18        |
+------------------------------+--------------+------------+-----------+
|                              |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Hispanic or Latino         | 4            | 2          | 6         |
+------------------------------+--------------+------------+-----------+
| > Not Hispanic or Latino     | 8            | 1          | 15        |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 1            | 0          | 3         |
+------------------------------+--------------+------------+-----------+
| > White                      | 10           | 2          | 19        |
+------------------------------+--------------+------------+-----------+
| **Parents' education level** |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Less than high school      | 8 (1997)     | 1 (1997)   | 18 (1997) |
+------------------------------+--------------+------------+-----------+
| > High school graduate       | 9 (1997)     | 1 (1997)   | 17 (1997) |
+------------------------------+--------------+------------+-----------+
| > At least some college      | 10 (1997)    | 2 (1997)   | 16 (1997) |
+------------------------------+--------------+------------+-----------+
| ###### Sexual orientation    | DNC          | DNC        | DNC       |
+------------------------------+--------------+------------+-----------+
| ###### Select populations    |              |            |           |
+------------------------------+--------------+------------+-----------+
| Grade                        |              |            |           |
+------------------------------+--------------+------------+-----------+
| > 9th grade                  | 7            | 2          | 12        |
+------------------------------+--------------+------------+-----------+
| > 10th grade                 | 7            | 1          | 13        |
+------------------------------+--------------+------------+-----------+
| > 11th grade                 | 8            | 2          | 15        |
+------------------------------+--------------+------------+-----------+
| > 12th grade                 | 9            | 1          | 17        |
+------------------------------+--------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

Note: The table **b**elow may continue to the following page.

+------------------------------+--------------+------------+-----------+
| **Students in Grades 9\      | **Current    |            |           |
| Through 12, 1999 (unless     | Cigar Use\   |            |           |
| noted)**                     | **(smoked    |            |           |
|                              | cigars on 1  |            |           |
|                              | or more of   |            |           |
|                              | the 30 days  |            |           |
|                              | preceding    |            |           |
|                              | the survey)  |            |           |
+==============================+==============+============+===========+
|                              | **27-2d.\    | **F        | **        |
|                              | Both\        | emales\*** | Males\*** |
|                              | Genders**    |            |           |
+------------------------------+--------------+------------+-----------+
|                              | Percent      |            |           |
+------------------------------+--------------+------------+-----------+
| > **TOTAL**                  | 18           | 10         | 25        |
+------------------------------+--------------+------------+-----------+
| **Race and ethnicity**       |              |            |           |
+------------------------------+--------------+------------+-----------+
| > American Indian or Alaska  | DSU          | DSU        | DSU       |
| > Native                     |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Asian or Pacific Islander  | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Asian                      | DSU          | DSU        | DSU       |
+------------------------------+--------------+------------+-----------+
| > Native Hawaiian and other\ | DSU          | DSU        | DSU       |
| > Pacific Islander           |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 14           | 13         | 16        |
+------------------------------+--------------+------------+-----------+
| > White                      | 19           | 9          | 29        |
+------------------------------+--------------+------------+-----------+
|                              |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Hispanic or Latino         | 17           | 12         | 22        |
+------------------------------+--------------+------------+-----------+
| > Not Hispanic or Latino     | 18           | 10         | 26        |
+------------------------------+--------------+------------+-----------+
| > Black or African American  | 14           | 12         | 16        |
+------------------------------+--------------+------------+-----------+
| > White                      | 19           | 9          | 28        |
+------------------------------+--------------+------------+-----------+
| **Parents' education level** |              |            |           |
+------------------------------+--------------+------------+-----------+
| > Less than high school      | 19 (1997)    | 11 (1997)  | 29 (1997) |
+------------------------------+--------------+------------+-----------+
| > High school graduate       | 21 (1997)    | 11 (1997)  | 32 (1997) |
+------------------------------+--------------+------------+-----------+
| > At least some college      | 23 (1997)    | 11 (1997)  | 32 (1997) |
+------------------------------+--------------+------------+-----------+
| ###### Sexual orientation    | DNC          | DNC        | DNC       |
+------------------------------+--------------+------------+-----------+
| **Select populations**       |              |            |           |
+------------------------------+--------------+------------+-----------+
| ###### Grade                 |              |            |           |
+------------------------------+--------------+------------+-----------+
| > 9th grade                  | 14           | 9          | 18        |
+------------------------------+--------------+------------+-----------+
| > 10th grade                 | 18           | 11         | 25        |
+------------------------------+--------------+------------+-----------+
| > 11th grade                 | 18           | 9          | 27        |
+------------------------------+--------------+------------+-----------+
| > 12th grade                 | 22           | 11         | 34        |
+------------------------------+--------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

Effective prevention approaches for reducing tobacco use among
adolescents include school-based prevention programs as an integral part
of communitywide strategies that address the overall social context of
tobacco use.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** School-based tobacco
prevention programs identify the social influences that promote tobacco
use among youth and teach skills to resist these influences. Such
programs have demonstrated consistent and significant reductions or
delays in adolescent smoking.Error: Reference source not found**^,^**
[^41] The effects dissipate over time if they are not followed by
additional educational interventions or linkages to community programs.
Studies have shown that the effectiveness of school-based tobacco
prevention programs appears to be strengthened by (1) booster sessions
or further application of the programs and (2) communitywide programs
involving parents, school policies, mass media, youth access, and
community organizations.[^42]**^,^** [^43]**^,^** [^44]**^,^**
[^45]**^,^** [^46]**^,^** [^47] A multicomponent approach to
school-based tobacco use prevention[^48] also may increase the long-term
effectiveness of prevention efforts. (See Focus Area 7. Educational and
Community-Based Programs.)

27-3. (Developmental) Reduce the initiation of tobacco use among
children and adolescents.

**Potential data source:** National Household Survey on Drug Abuse
(NHSDA), SAMHSA.

27-4. Increase the average age of first use of tobacco products by
adolescents and young adults.

**Target and base**line:

  ------------ ----------------------------- ---------------- ---------------
  Objective    Increase in Average Age of    1997\            2010\
               First Tobacco Use             Baseline         Target

                                             Average Age of   
                                             First Cigarette  
                                             Use, in Years    

  **27-4a.**   Adolescents aged 12 to 17     12               14
               years                                          

  **27-4b.**   Young adults aged 18 to 25    15               17
               years                                          
  ------------ ----------------------------- ---------------- ---------------

**Target setting method:** Better than the best.

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

Note: The table below may continue to the following page.

+-----------------------------------------+-------------+-------------+
| **Adolescents and Young Adults, 1997**  | **First     |             |
|                                         | Cigarette   |             |
|                                         | Use**       |             |
+=========================================+=============+=============+
|                                         | **27-4a.\   | **27-4b.\   |
|                                         | Aged 12 to  | Aged 18 to  |
|                                         | 17\         | 25\         |
|                                         | Years**     | Years**     |
+-----------------------------------------+-------------+-------------+
|                                         | Average Age |             |
|                                         | in Years    |             |
+-----------------------------------------+-------------+-------------+
| > **TOTAL**\*                           | 12          | 15          |
+-----------------------------------------+-------------+-------------+
| **Race and ethnicity**                  |             |             |
+-----------------------------------------+-------------+-------------+
| > American Indian or Alaska Native      | 12          | 14          |
+-----------------------------------------+-------------+-------------+
| > Asian or Pacific Islander             | 13          | 15          |
+-----------------------------------------+-------------+-------------+
| > Black or African American             | 13          | 16          |
+-----------------------------------------+-------------+-------------+
| > White                                 | 12          | 15          |
+-----------------------------------------+-------------+-------------+
|                                         |             |             |
+-----------------------------------------+-------------+-------------+
| > Hispanic or Latino                    | 13          | 15          |
+-----------------------------------------+-------------+-------------+
| > Not Hispanic or Latino\*              | 12          | 15          |
+-----------------------------------------+-------------+-------------+
| > Black or African American             | 12          | 15          |
+-----------------------------------------+-------------+-------------+
| > White                                 | 13          | 16          |
+-----------------------------------------+-------------+-------------+
| ###### Gender                           |             |             |
+-----------------------------------------+-------------+-------------+
| > Female                                | 13          | 15          |
+-----------------------------------------+-------------+-------------+
| > Male                                  | 12          | 15          |
+-----------------------------------------+-------------+-------------+
| ###### Family income level              |             |             |
+-----------------------------------------+-------------+-------------+
| > Poor                                  | DNA         | DNA         |
+-----------------------------------------+-------------+-------------+
| > Near poor                             | DNA         | DNA         |
+-----------------------------------------+-------------+-------------+
| > Middle/high income                    | DNA         | DNA         |
+-----------------------------------------+-------------+-------------+
| ###### Sexual orientation               | DNC         | DNC         |
+-----------------------------------------+-------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Total for not Hispanic or Latino excludes all race categories other
than black and white.

Note: The table above may have continued from the previous page.

Because tobacco use is linked with numerous adverse health outcomes,
reducing tobacco use will reduce illness, disability, and death across a
spectrum of conditions, including heart disease, cancer, and chronic
lung disease. (See Related Objectives From Other Focus Areas section.)

Assessing the number of cases of tobacco use among both adults and
adolescents is a critical element of public health surveillance. Indeed,
in 1996 the Council of State and Territorial Epidemiologists added adult
cigarette smoking as a notifiable condition, the first time that a
behavior rather than a disease was designated a notifiable
condition.[^49]

Because the majority of initiation of tobacco use occurs in
adolescence,Error: Reference source not found direct measures of tobacco
use in adolescence are important health indicators. Measures of use in
adulthood provide an assessment of use that has extended beyond
experimentation and initiation. Evidence indicates substitution of
tobacco products among both adults and youth, so measuring the use of
multiple products (cigarettes, spit tobacco, and cigars at a minimum) is
important.

### Cessation and Treatment

27-5. Increase smoking cessation attempts by adult smokers.

**Target:** 75 percent.

**Baseline:** 41 percent of adult smokers aged 18 years and older
stopped smoking for 1 day or longer because they were trying to quit in
1998 (age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older, 1998 (unless | **Stopped Smoking\  |
| noted)**                                       | 1 Day or Longer     |
|                                                | Because They Were   |
|                                                | Trying To Quit**    |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 41                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 42                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 44                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 38                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 45                  |
+------------------------------------------------+---------------------+
| > White                                        | 40                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 38                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 41                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 45                  |
+------------------------------------------------+---------------------+
| > White                                        | 40                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 42                  |
+------------------------------------------------+---------------------+
| > Male                                         | 39                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 40                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 42                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 43                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 38                  |
+------------------------------------------------+---------------------+
| > Under 9 years                                | 36                  |
+------------------------------------------------+---------------------+
| > 9 to 11 years                                | 39                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 36                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 42                  |
+------------------------------------------------+---------------------+
| > 13 to 15 years                               | 42                  |
+------------------------------------------------+---------------------+
| > 16 years or more                             | 43                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | 44 (1997)           |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | 42 (1997)           |
+------------------------------------------------+---------------------+
| ###### Sexual orientation                      | DNC                 |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| Age groups (not age adjusted)                  |                     |
+------------------------------------------------+---------------------+
| > 18 to 24 years                               | 52                  |
+------------------------------------------------+---------------------+
| > 25 to 44 years                               | 42                  |
+------------------------------------------------+---------------------+
| > 45 to 64 years                               | 37                  |
+------------------------------------------------+---------------------+
| > 65 years and older                           | 35                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

27-6. Increase smoking cessation during pregnancy.

**Target:** 30 percent.

**Baseline:** 14 percent of females aged 18 to 49 years stopped smoking
during the first trimester of their pregnancy in 1998.

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Pregnant Females Aged 18 to 49 Years, 1998   | **Stopped Smoking** |
| (unless noted)**                               |                     |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 14                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | 14                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 14                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | 14                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DSU                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 12                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 22                  |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than 12 years                           | DSU                 |
+------------------------------------------------+---------------------+
| Less than 9 years                              | DSU                 |
+------------------------------------------------+---------------------+
| 9 to 11 years                                  | DSU                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | 14                  |
+------------------------------------------------+---------------------+
| > 13 years or more                             | 12                  |
+------------------------------------------------+---------------------+
| 13 to 15 years                                 | 10                  |
+------------------------------------------------+---------------------+
| 16 years or more                               | DSU                 |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with activity limitations            | DSU (1991)          |
+------------------------------------------------+---------------------+
| > Persons without activity limitations         | 12 (1991)           |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

27-7. Increase tobacco use cessation attempts by adolescent smokers.

**Target:** 84 percent.

**Baseline:** 76 percent of ever-daily smokers in grades 9 through 12
had tried to quit smoking in 1999.

**Target setting method:** Better than the best.

**Data source:** Youth Risk Behavior Surveillance System (YRBSS), CDC,
NCCDPHP.

+--------------------------------+------------+------------+-----------+
| **Students in Grades 9 Through | **Tried To |            |           |
| 12 Who Were Ever Daily Smokers | Quit**     |            |           |
| (Ever Smoked Every Day for 30  |            |            |           |
| Days), 1999 (unless noted)**   |            |            |           |
+================================+============+============+===========+
|                                | **27-7.\   | **F        | **        |
|                                | Both\      | emales\*** | Males\*** |
|                                | Genders**  |            |           |
+--------------------------------+------------+------------+-----------+
|                                | Percent    |            |           |
+--------------------------------+------------+------------+-----------+
| > **TOTAL**                    | 76         | 81         | 71        |
+--------------------------------+------------+------------+-----------+
| **Race and ethnicity**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > American Indian or Alaska    | DSU        | DSU        | DSU       |
| > Native                       |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Asian or Pacific Islander    | DSU        | DSU        | DSU       |
+--------------------------------+------------+------------+-----------+
| > Asian                        | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Native Hawaiian and other\   | DNC        | DNC        | DNC       |
| > Pacific Islander             |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 81         | 82         | 80        |
+--------------------------------+------------+------------+-----------+
| > White                        | 76         | 80         | 72        |
+--------------------------------+------------+------------+-----------+
|                                |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Hispanic or Latino           | 72         | 75         | 69        |
+--------------------------------+------------+------------+-----------+
| > Not Hispanic or Latino       | 76         | 81         | 72        |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 80         | 80         | 79        |
+--------------------------------+------------+------------+-----------+
| > White                        | 76         | 79         | 73        |
+--------------------------------+------------+------------+-----------+
| **Parents' education level**   |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Less than high school        | 69 (1997)  | 81 (1997)  | 57 (1997) |
+--------------------------------+------------+------------+-----------+
| > High school graduate         | 79 (1997)  | 82 (1997)  | 76 (1997) |
+--------------------------------+------------+------------+-----------+
| > At least some college        | 72 (1997)  | 76 (1997)  | 69 (1997) |
+--------------------------------+------------+------------+-----------+
| ###### Sexual orientation      | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| ###### Select populations      |            |            |           |
+--------------------------------+------------+------------+-----------+
| Grade                          |            |            |           |
+--------------------------------+------------+------------+-----------+
| > 9th grade                    | 72         | 74         | 69        |
+--------------------------------+------------+------------+-----------+
| > 10th grade                   | 81         | 84         | 78        |
+--------------------------------+------------+------------+-----------+
| > 11th grade                   | 74         | 79         | 67        |
+--------------------------------+------------+------------+-----------+
| > 12th grade                   | 78         | 85         | 73        |
+--------------------------------+------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

27-8. Increase insurance coverage of evidence-based treatment for
nicotine dependency.

+---------+-------------------------------+-------------+-------------+
| *       |                               |             |             |
| *Target |                               |             |             |
| and     |                               |             |             |
| base    |                               |             |             |
| line:** |                               |             |             |
+---------+-------------------------------+-------------+-------------+
| Ob      | Increase in Insurance         | 1998\       | 2010\       |
| jective | Coverage\                     | Baseline\   | Target      |
|         | of Evidence-Based Treatment\  | (unless     |             |
|         | for Nicotine Dependency       | noted)      |             |
+---------+-------------------------------+-------------+-------------+
|         |                               | ####        |             |
|         |                               | ### Percent |             |
+---------+-------------------------------+-------------+-------------+
| **2     | Managed care organizations    | 75          | 100         |
| 7-8a.** |                               | (1997--98)  |             |
+---------+-------------------------------+-------------+-------------+
|         |                               | ###         |             |
|         |                               | #### Number |             |
+---------+-------------------------------+-------------+-------------+
| **2     | Medicaid programs in States   | 24          | 51          |
| 7-8b.** | and the District of Columbia  |             |             |
+---------+-------------------------------+-------------+-------------+
| **2     | All insurance                 | De          |             |
| 7-8c.** |                               | velopmental |             |
+---------+-------------------------------+-------------+-------------+

**Target setting method:** Total coverage of FDA-approved
pharmacotherapies and behavioral therapies.

**Data sources:** Addressing Tobacco in Managed Care Survey, Robert Wood
Johnson Foundation; (Medicaid data) Health Policy Tracking Service,
National Conference of State Legislators.

Nearly 70 percent of current smokers want to quit smoking, and
approximately 45 percent have quit smoking for at least 1 day because
they were trying to quit.Error: Reference source not found However, only
about 2.5 percent of current smokers stop smoking permanently each
year.Error: Reference source not found Smoking cessation has major and
immediate health benefits for men and women of all ages. For example,
people who quit smoking before age 50 years have half the risk of dying
in the next 15 years compared with people who continue to smoke.Error:
Reference source not found

In 1996, the Agency for Health Care Policy and Research (AHCPR, now the
Agency for Healthcare Research and Quality) sponsored an expert panel
that produced an evidence-based guideline that evaluated smoking
cessation interventions available at the time and concluded that the
efficacy of intervention increases with intensity.[^50] The results
clearly showed that a variety of smoking cessation interventions are
effective: (1) simple advice to quit by a clinician (30 percent increase
in cessation), (2) individual and group counseling (doubles cessation
rates), (3) telephone hotlines and helplines (40 percent increase in
cessation), and (4) nicotine replacement therapy (up to double the
cessation rates). This guideline will be updated in 2000.

AHCPR's guideline recommended that smoking cessation treatments (both
pharmacotherapy and counseling) be provided as paid services and that
providers be reimbursed for delivering effective smoking cessation
interventions. AHCPR concluded that effective reduction of tobacco use
will require health care systems to make institutional changes resulting
in systematic identification of, and intervention with, all tobacco
users at every visit.Error: Reference source not found

Almost 44 percent of high school seniors who smoke report that they
would like to stop smoking. About 30 percent of high school seniors who
smoke report that they have tried to stop smoking but failed to do
so.[^51] Although many teen smokers want to quit or have tried to quit
smoking, almost no proven interventions exist for tobacco use cessation
among teenagers. Research is under way to assess effective cessation
methods for young persons, but expanded research efforts are needed.

Data reported from a study of managed care organizations indicated that
75 percent of plans either partially or fully covered one or more
smoking cessation interventions. Full coverage was provided most often
for self-help materials and smoking cessation classes, whereas more
costly interventions, such as pharmaceutical treatments for nicotine
addiction, were less frequently covered in full.[^52] According to other
data, Medicaid coverage of smoking cessation services, including
counseling and nicotine replacement therapies, varied by State.[^53]
(See Focus\
Area 1. Access to Quality Health Services.)

### Exposure to Secondhand Smoke

27-9. Reduce the proportion of children who are regularly\
exposed to tobacco smoke at home.

**Target:** 10 percent.

**Baseline:** 27 percent of children aged 6 years and under lived in a
household where someone smoked inside the house at least 4 days per week
in 1994.

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+-------------------------------------------+--------------------------+
| **Children Aged 6 Years and Under, 1994** | **Lived in Household     |
|                                           | Where Someone Smoked\    |
|                                           | Inside the House at      |
|                                           | Least\                   |
|                                           | 4 Days a Week**          |
+===========================================+==========================+
|                                           | Percent                  |
+-------------------------------------------+--------------------------+
| > **TOTAL**                               | 27                       |
+-------------------------------------------+--------------------------+
| **Race and ethnicity**                    |                          |
+-------------------------------------------+--------------------------+
| > American Indian or Alaska Native        | DSU                      |
+-------------------------------------------+--------------------------+
| > Asian or Pacific Islander               | 23                       |
+-------------------------------------------+--------------------------+
| > Asian                                   | DSU                      |
+-------------------------------------------+--------------------------+
| > Native Hawaiian and other Pacific       | DSU                      |
| > Islander                                |                          |
+-------------------------------------------+--------------------------+
| > Black or African American               | 28                       |
+-------------------------------------------+--------------------------+
| > White                                   | 27                       |
+-------------------------------------------+--------------------------+
|                                           |                          |
+-------------------------------------------+--------------------------+
| > Hispanic or Latino                      | 20                       |
+-------------------------------------------+--------------------------+
| > Not Hispanic or Latino                  | 29                       |
+-------------------------------------------+--------------------------+
| > Black or African American               | 28                       |
+-------------------------------------------+--------------------------+
| > White                                   | 29                       |
+-------------------------------------------+--------------------------+
| **Gender**                                |                          |
+-------------------------------------------+--------------------------+
| > Female                                  | 28                       |
+-------------------------------------------+--------------------------+
| > Male                                    | 27                       |
+-------------------------------------------+--------------------------+
| **Family income**                         |                          |
+-------------------------------------------+--------------------------+
| > Poor                                    | 38                       |
+-------------------------------------------+--------------------------+
| > Near poor                               | 33                       |
+-------------------------------------------+--------------------------+
| > Middle/high income                      | 19                       |
+-------------------------------------------+--------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

27-10. Reduce the proportion of nonsmokers exposed\
to environmental tobacco smoke.

**Target:** 45 percent.

**Baseline:** 65 percent of nonsmokers aged 4 years and older had a
serum\
cotinine level above 0.10 ng/mL in 1988--94 (age adjusted to the year
2000\
standard population).

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

+-----------------------------------------------+----------------------+
| **Nonsmokers Aged 4 Years and Older,\         | **Serum Cotinine\    |
| 1988--94**                                    | Levels \>0.10        |
|                                               | ng/mL**              |
+===============================================+======================+
|                                               | Percent              |
+-----------------------------------------------+----------------------+
| > **TOTAL**                                   | 65                   |
+-----------------------------------------------+----------------------+
| **Race and ethnicity**                        |                      |
+-----------------------------------------------+----------------------+
| > American Indian or Alaska Native            | DSU                  |
+-----------------------------------------------+----------------------+
| > Asian or Pacific Islander                   | DSU                  |
+-----------------------------------------------+----------------------+
| > Asian                                       | DNC                  |
+-----------------------------------------------+----------------------+
| > Native Hawaiian and other Pacific\          | DNC                  |
| > Islander                                    |                      |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 81                   |
+-----------------------------------------------+----------------------+
| > White                                       | 63                   |
+-----------------------------------------------+----------------------+
|                                               |                      |
+-----------------------------------------------+----------------------+
| > Hispanic or Latino                          | DSU                  |
+-----------------------------------------------+----------------------+
| > Mexican American                            | 53                   |
+-----------------------------------------------+----------------------+
| > Not Hispanic or Latino                      | 66                   |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 81                   |
+-----------------------------------------------+----------------------+
| > White                                       | 63                   |
+-----------------------------------------------+----------------------+
| **Gender**                                    |                      |
+-----------------------------------------------+----------------------+
| > Female                                      | 61                   |
+-----------------------------------------------+----------------------+
| > Male                                        | 69                   |
+-----------------------------------------------+----------------------+
| **Education level** (aged 25 years and older) |                      |
+-----------------------------------------------+----------------------+
| > Less than high school                       | 71                   |
+-----------------------------------------------+----------------------+
| > High school graduate                        | 67                   |
+-----------------------------------------------+----------------------+
| > At least some college                       | 55                   |
+-----------------------------------------------+----------------------+
| ###### Sexual orientation                     | DNC                  |
+-----------------------------------------------+----------------------+
| ###### Select populations                     |                      |
+-----------------------------------------------+----------------------+
| Age groups (not age adjusted)                 |                      |
+-----------------------------------------------+----------------------+
| > 4 to 11 years                               | 68                   |
+-----------------------------------------------+----------------------+
| > 12 to 19 years                              | 69                   |
+-----------------------------------------------+----------------------+
| > 20 to 44 years                              | 67                   |
+-----------------------------------------------+----------------------+
| > 45 to 64 years                              | 65                   |
+-----------------------------------------------+----------------------+
| > 65 years and older                          | 51                   |
+-----------------------------------------------+----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

27-11. Increase smoke-free and tobacco-free environments in schools,
including all school facilities, property, vehicles, and school events.

**Target:** 100 percent.

**Baseline:** 37 percent of middle, junior high, and senior high schools
were smoke-free and tobacco-free in 1994.

**Target setting method:** Retain year 2000 target.

**Data source:** School Health Policies and Programs Study (SHPPS), CDC,
NCCDPHP.

27-12. Increase the proportion of worksites with formal smoking policies
that prohibit smoking or limit it to separately\
ventilated areas.

**Target:** 100 percent.

**Baseline:** 79 percent of worksites with 50 or more employees had
formal smoking policies that prohibited or limited smoking to separately
ventilated areas in 1998--99.

**Target setting method:** Retain year 2000 target.

**Data source:** National Worksite Health Promotion Survey, Association
for Worksite Health Promotion (AWHP).

27-13. Establish laws on smoke-free indoor air that prohibit smoking or
limit it to separately ventilated areas in public places and worksites.

Target and baseline:

+-----------+-------------------------+-----------------+-------------+
| Objective | Jurisdictions With      | 1998\           | 2010\       |
|           | Laws\                   | Baseline        | Target      |
|           | on Smoke-Free Air       |                 |             |
+-----------+-------------------------+-----------------+-------------+
|           |                         | ####### Number  |             |
+-----------+-------------------------+-----------------+-------------+
|           | **States and the        |                 |             |
|           | District\               |                 |             |
|           | of Columbia**           |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Private workplaces      | 1               | 51          |
| 27-13a.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Public workplaces       | 13              | 51          |
| 27-13b.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Restaurants             | 3               | 51          |
| 27-13c.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Public transportation   | 16              | 51          |
| 27-13d.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Day care centers        | 22              | 51          |
| 27-13e.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | Retail stores           | 4               | 51          |
| 27-13f.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | **Tribes**              | Developmental   |             |
| 27-13g.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+
| **        | **Territories**         | Developmental   |             |
| 27-13h.** |                         |                 |             |
+-----------+-------------------------+-----------------+-------------+

**Target setting method:** Retain year 2000 target.

**Data source:** State Tobacco Activities Tracking and Evaluation System
(STATE System), CDC, NCCDPHP, OSH.

In 1996, only 37 percent of adult nontobacco users were aware enough of
their exposure to report having been exposed to secondhand smoke either
at home or at work.Error: Reference source not found Both home and
workplace environments contributed significantly to widespread exposure
to secondhand smoke in the United States.Error: Reference source not
found An alarming level of secondhand smoke exposure at home was
reported. Exposure ranged from 12 percent of children aged 17 years and
under in Utah to 34 percent of children in Kentucky.Error: Reference
source not found

A 1992--93 National Cancer Institute survey found that significant
numbers of workers, especially those in blue-collar and service
occupations, reported smoke-free workplace policy rates considerably
lower than the overall rate of 46 percent.[^54] Least likely to have a
smoke-free policy were food service workers---waiters, waitresses,
cooks, bartenders, and counter help. Of these 5.5 million workers, 22
percent were teenagers. In a 1993 study, food service workers were
estimated to have a 50 percent increased risk of dying from lung cancer
compared to the general population, with the higher risk attributed in
part to their workplace exposure to secondhand smoke.[^55]

Policy, educational, and clinical interventions can reduce secondhand
smoke exposure among the population. Policy approaches include the
voluntary adoption of worksite restrictions, enactment of clean indoor
air laws, and enforcement of restrictions. Public education campaigns
and local community efforts to limit smoking in public places in
California and Massachusetts have been associated with reported
reductions in the exposure of both adults and children to secondhand
smoke.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

A study published in 1996 concluded that a portion of children's
respiratory diseases and their associated illness may be prevented by
decreasing or eliminating their exposure to secondhand smoke.[^56]

Another study concluded that secondhand smoke exposure worsens asthma
and each year leads to 500,000 visits to physicians by children.[^57]
The American Academy of Pediatrics has recommended that pediatricians
inform parents about the health hazards of secondhand smoke and provide
guidance on smoking cessation.[^58] (See Focus Area 8. Environmental
Health and Focus Area 24. Respiratory Diseases.)

### Social and Environmental Changes

27-14. Reduce the illegal sales rate to minors through\
enforcement of laws prohibiting the sale of tobacco\
products to minors.

Target and baseline:

+-----------+---------------------------+--------------+--------------+
| Objective | Jurisdictions With a 5    | 1998\        | 2010\        |
|           | Percent or Less Illegal   | Baseline     | Target       |
|           | Sales Rate to Minors      |              |              |
+-----------+---------------------------+--------------+--------------+
|           |                           | ##           |              |
|           |                           | ##### Number |              |
+-----------+---------------------------+--------------+--------------+
| **        | States and the District\  | 0            | 51           |
| 27-14a.** | of Columbia               |              |              |
+-----------+---------------------------+--------------+--------------+
| **        | Territories               | 0            | All          |
| 27-14b.** |                           |              |              |
+-----------+---------------------------+--------------+--------------+

**Target setting method:** Based on published literature and expert
opinion.

**Data source:** State Synar Enforcement Reporting, SAMHSA, CSAP.

27-15. Increase the number of States and the District of Columbia that
suspend or revoke State retail licenses for violations of laws
prohibiting the sale of tobacco to minors.

**Target:** All States and the District of Columbia.

**Baseline:** 34 States with some form of retail licensure could suspend
or revoke the license for violation of minors' access laws in 1998.

**Target setting method:** Total coverage.

**Data source:** State Tobacco Activities Tracking and Evaluation System
(STATE System), CDC, NCCDPHP, OSH.

Restricting minors' access to tobacco products is one core element in a
comprehensive approach to tobacco use prevention. In 1997, of the 30
percent of students who purchased their cigarettes from a gas station or
store in the month preceding a survey, 67 percent of them were not asked
for proof of age.[^59] Earlier data indicated that only about half of
smokers aged 12 to 17 years were ever asked to show proof of age when
they tried to purchase cigarettes.[^60] Data revealed that self-service
tobacco displays make it easier for minors to purchase or steal tobacco
products. In a 1995 survey, stores with self-service displays were 61
percent more likely to sell tobacco to minors than stores without
self-service displays.[^61]

Although all States prohibit the sale of tobacco products to minors,
enforcement of laws has been limited until recent years. States and
localities have undertaken a number of measures to reduce minors'
access, including policy establishment, retail licensure, enforcement
activities, compliance checks, retailer education, and youth
involvement. State restrictions on tobacco vending machines vary, with
the most stringent restrictions banning vending machines except in areas
inaccessible to minors. Not all States have retail licensure systems.
Among those that do, not all will suspend or revoke licenses for
violation of State minors' access laws. Federal policy initiatives
require the active participation of State and local communities to
ensure effective implementation.Error: Reference source not found**^,^**
[^62] In addition to efforts to address the purchase of tobacco products
by minors, tobacco control initiatives also must target social sources
of tobacco for young people, including friends, siblings, and parents.

27-16. (Developmental) Eliminate tobacco advertising and\
promotions that influence adolescents and young adults.

**Potential data source:** American Legacy Foundation and National
Association of Attorneys General.

27-17. Increase adolescents' disapproval of smoking.

Target and baseline:

+---------+----------------------+-----------------+-----------------+
| Ob      | Increase in          | 1998\           | 2010\           |
| jective | Adolescents'         | Baseline        | Target          |
|         | Disapproval of       |                 |                 |
|         | Smoking              |                 |                 |
+---------+----------------------+-----------------+-----------------+
|         |                      | ####### Percent |                 |
+---------+----------------------+-----------------+-----------------+
| **27    | 8th grade            | 80              | 95              |
| -17a.** |                      |                 |                 |
+---------+----------------------+-----------------+-----------------+
| **27    | 10th grade           | 75              | 95              |
| -17b.** |                      |                 |                 |
+---------+----------------------+-----------------+-----------------+
| **27    | 12th grade           | 69              | 95              |
| -17c.** |                      |                 |                 |
+---------+----------------------+-----------------+-----------------+

**Target setting method:** Retain year 2000 target.

**Data source:** Monitoring the Future Study (MTF), NIH, NIDA.

Note: The table below may continue to the following page.

+----------------------------+-------------+-------------+-------------+
| **Adolescents, 1998**      | **          |             |             |
|                            | Disapproval |             |             |
|                            | of Smoking  |             |             |
|                            | One or More |             |             |
|                            | Packs of    |             |             |
|                            | Cigarettes  |             |             |
|                            | Daily**     |             |             |
+============================+=============+=============+=============+
|                            | **27-17a.\  | **27-17b.\  | **27-17c.\  |
|                            | 8th         | 10th        | 12th        |
|                            | Graders**   | Graders**   | Graders**   |
+----------------------------+-------------+-------------+-------------+
|                            | Percent     |             |             |
+----------------------------+-------------+-------------+-------------+
| > **TOTAL**                | 80          | 75          | 69          |
+----------------------------+-------------+-------------+-------------+
| **Race and ethnicity**     |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > American Indian or       | DSU         | DSU         | DSU         |
| > Alaska\                  |             |             |             |
| > Native                   |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Asian or Pacific         | DNC         | DNC         | DNC         |
| > Islander                 |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Asian                    | DSU         | DSU         | DSU         |
+----------------------------+-------------+-------------+-------------+
| > Native Hawaiian and      | DNC         | DNC         | DNC         |
| > other Pacific Islander   |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Black or African         | DNC         | DNC         | DNC         |
| > American                 |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > White                    | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+
|                            |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Hispanic or Latino       | 76          | 81          | 76          |
+----------------------------+-------------+-------------+-------------+
| > Not Hispanic or Latino   | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+
| > Black or African         | 82          | 83          | 82          |
| > American                 |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > White                    | 81          | 72          | 64          |
+----------------------------+-------------+-------------+-------------+
| **Gender**                 |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Female                   | 83          | 79          | 73          |
+----------------------------+-------------+-------------+-------------+
| > Male                     | 77          | 72          | 64          |
+----------------------------+-------------+-------------+-------------+
| **Parents' education       |             |             |             |
| level**                    |             |             |             |
+----------------------------+-------------+-------------+-------------+
| > Less than high school    | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+
| > High school graduate     | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+
| > At least some college    | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+
| ###### Sexual orientation  | DNC         | DNC         | DNC         |
+----------------------------+-------------+-------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Attitudes of adolescents regarding the acceptability of tobacco use
provide an indication of their susceptibility to tobacco use.Error:
Reference source not found The 1994 Surgeon General's report on tobacco
concluded that the following are all risk factors for tobacco use among
adolescents: adolescents' perceptions that tobacco use is the norm,
peers' and siblings' approval of tobacco use, and the belief that
tobacco use provides benefits. The report further concluded that for
spit tobacco use, insufficient knowledge among youth of the health
effects also is a factor.Error: Reference source not found

27-18. (Developmental) Increase the number of Tribes,\
Territories, and States and the District of Columbia with comprehensive,
evidence-based tobacco control\
programs.

**Potential data sources:** State Tobacco Activities Tracking and
Evaluation\
System (STATE System), CDC, NCCDPHP, OSH; IHS.

Evidence indicates that comprehensive tobacco control programs are
effective. Investments in such programs to date, however, have been
seriously limited. Data from California and Massachusetts indicate that
the ability to sustain reductions in per capita consumption due to
excise tax increases is greater when the tax increase is combined with a
comprehensive tobacco control program. Per capita cigarette consumption
in California and Massachusetts, two States with such programs, has
declined two to three times faster than in the rest of the Nation. In
addition, the rapid rise in youth smoking rates experienced nationwide
was slowed in both California and Massachusetts as a result of the
combined effects of a tax increase and a strong tobacco control
program.Error: Reference source not found Other analyses suggest that
comprehensive programs, including media campaigns, have reduced the rate
of increase in youth smoking in States with programs funded by excise
taxes (such as Massachusetts), compared with the rest of the
Nation.[^63]

In the Minnesota Heart Health Program, smoking rates were reduced by
approximately 40 percent in the intervention community with a combined
school-based curriculum, community-based activities, and mass media
interventions.Error: Reference source not found Furthermore, a
preliminary report on the effectiveness of the American Stop Smoking
Intervention Study (ASSIST) indicated that in 1993--94, per capita
cigarette consumption was 7 percent less in the 17 ASSIST States than in
the remaining States (excluding California).[^64]

Limiting the appeal of tobacco products to young people involves both
restricting tobacco advertising and promotions and countering the
ability of pro-tobacco messages to reach large segments of the
population quickly and efficiently. Because of their appeal, the mass
media can serve as a powerful tool for tobacco control. Television and
radio stations, magazines, and other media can deliver information and
educational messages directly to targeted audiences, build public
support for tobacco control programs and policies, reinforce social
norms supporting the nonuse of tobacco, and counteract the pro-use
messages and images of tobacco marketing and public relations campaigns.

An essential element in programs for reducing tobacco's appeal to youth
is to change the current social environment that reinforces the
acceptability of tobacco use.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
This change requires strategies to counter the billions of dollars worth
of tobacco advertising and promotion that bombard young people with
false and misleading messages and images about tobacco.Error: Reference
source not found**^,\ Error:\ Reference\ source\ not\ found^** An
integral part of the Arizona, California, and Massachusetts tobacco
control programs has been paid counteradvertising campaigns to
deglamorize and denormalize tobacco use, especially among young people,
with unequivocal messages about the negative effects of tobacco use on
health, performance, and appearance.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
Preliminary results indicate that the media programs have reached youth,
adults, and multicultural populations in those States and have achieved
their program objectives.

27-19. Eliminate laws that preempt stronger tobacco control laws.

**Target:** Zero States.

**Baseline:** 30 States had preemptive tobacco control laws in the areas
of clean indoor air, minors' access laws, or marketing in 1998.

**Target setting method:** Retain year 2000 target.

**Data source:** State Tobacco Activities Tracking and Evaluation System
(STATE System), CDC, NCCDPHP, OSH.

Preemptive State laws limit the ability of State and local programs to
address major areas of tobacco control, in particular smoke-free indoor
air and minors' access policies. A preemptive State tobacco control law
prevents local jurisdictions from enacting restrictions that are more
restrictive than or vary from State law. The tobacco industry attempts
to promote such laws as health promotion efforts that ensure a uniform
set of restrictions for all communities. Such laws, however, usually
afford less protection and prevent local governments from adopting more
restrictive provisions in the future.[^65] Preemptive laws have led, for
example, to weaker public health standards, loss of community education
involved in the passage of local ordinances, more difficulty with
enforcement at the local level, and lower compliance with the
laws.[^66]**^,^** [^67] Several national organizations have expressed
opposition to the enactment of preemptive laws, including the American
Public Health Association, the Institute of Medicine, and a working
group of State attorneys general.

27-20. (Developmental) Reduce the toxicity of tobacco products by
establishing a regulatory structure to monitor toxicity.

**Potential data source:** FDA.

Over the past several years, new technology and the increasing
availability of alternative forms of nicotine delivery have prompted
discussion of a "harm reduction" approach to tobacco control. Part of
this discussion has focused on making tobacco products safer, while
acknowledging that there is no such thing as a "safe cigarette."
Approaches proposed and debated include the reduction of tar and
nicotine levels in tobacco products, the reduction of tobacco-specific
nitrosamines, and the reduction of specific additives in tobacco
products.

Issues raised by products or technologies that purport to reduce risk
require the establishment of an appropriate scientific and regulatory
framework within the Federal Government. Much work needs to be done
before scientific and regulatory agencies are in a position to evaluate
the issues raised by these technologies and to inform the public about
risks.

A framework also is needed to ensure that the ongoing activities of
Federal agencies, such as the collection of information about tobacco
product ingredients and the establishment of protocols for measuring tar
and nicotine yields, better serve public health needs. For example, an
inadequate method for testing tar and nicotine yields has led to
inaccurate information about the tar and nicotine smokers actually
receive and a misperception among smokers about the safety of so-called
low-tar cigarettes.[^68] In addition, information provided by tobacco
companies about additives in tobacco products is protected from release
to the public.[^69]

27-21. Increase the average Federal and State tax on tobacco products.

Target and baseline:

  ------------- --------------------------------- ------------------ -------------
  Objective     Increase in Combined Federal and\ 1998\              2010\
                Average State Tax                 Baseline           Target

  **27-21a.**   Cigarettes                        \$0.63\*           \$2

  **27-21b.**   Spit tobacco                      Developmental^†^   
  ------------- --------------------------------- ------------------ -------------

\*24 cent Federal tax; 38.9 cent average State tax in 1998.

^†^2.7 cent Federal tax in 1999; 7 States and the District of Columbia
did not tax smokeless tobacco products in 1999.

**Target setting method:** Expert opinion; comparison to international
tax rates.

**Data source:** The Tax Burden on Tobacco, The Tobacco Institute.

As with almost all consumer products, the demand for cigarettes
decreases as price increases. An increase in the excise tax on tobacco
products would reduce rates of use of both cigarettes and spit tobacco
among adults and youth. Economists agree that a 10 percent increase in
the price of cigarettes will reduce overall smoking among adults by
approximately 4 percent.Error: Reference source not found**^,^** [^70]
Data suggest that the prevention effect on youth would be at least as
large if not larger.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

Likewise, increasing the tax on smokeless tobacco products would reduce
demand. Economists have found that a 10 percent increase in the price of
spit tobacco products will decrease male youth demand by 5.9
percent.[^71]

A 1989 report predicted that for every 10 percent increase in the price
of cigarettes, there would be a 7.6 to 12 percent decrease in teen
smoking participation rates (that is, whether teens smoke at all).[^72]
The report concluded that among teens, smoking participation responds
more strongly to price than does the amount of daily cigarette
consumption. Studies conducted since the release of this report
reinforce and support these conclusions.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
Data also indicate that earmarking funds from an excise tax increase for
tobacco prevention and control programs increases both public support
for the proposed tax and the public health impact of the price
increase.Error: Reference source not found**^,^** [^73]

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

3\. Cancer

3-1. Overall cancer deaths

3-2. Lung cancer deaths

3-4. Cervical cancer deaths

3-6. Oropharyngeal cancer deaths

7\. Educational and Community-Based Programs

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

8\. Environmental Health

8-18. Homes tested for radon

8-19. Radon-resistant new home construction

8-29. Global burden of disease

12\. Heart Disease and Stroke

12-1. Coronary heart disease (CHD) deaths

12-7. Stroke deaths

16\. Maternal, Infant, and Child Health

16-1. Fetal and infant deaths

16-6. Prenatal care

16-10. Low birth weight and very low birth weight

16-11. Preterm births

16-17. Prenatal substance exposure

21\. Oral Health

21-6. Early detection of oral and pharyngeal cancers

21-7. Annual examinations for oral and pharyngeal cancers

23\. Public Health Infrastructure

23-4. Data for all population groups

23-5. Data for Leading Health Indicators, Health Status Indicators, and
Priority\
Data Needs at Tribal, State, and local levels

24\. Respiratory Diseases

24-1. Deaths from asthma

24-2. Hospitalizations for asthma

24-3. Hospital emergency department visits for asthma

26\. Substance Abuse

26-9. Substance-free youth

26-16. Peer disapproval of substance abuse

26-17. Perception of risk associated with substance abuse

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Consumption:** The amount of tobacco products consumed or used by the
population. Consumption usually is measured in units, such as the number
of cigarettes smoked or pounds of spit tobacco used over a given period
of time.

**Counteradvertising:** The placement of pro-health advertisements on
TV, on radio, in print, on billboards, on movie trailers, on the
Internet, and in other media.

**Illegal buy rate:** Rate of illegal sales to minors in compliance
checks to assess adherence to minors' tobacco access laws.

**Nicotine dependency:** Highly controlled or compulsive use, use
despite harmful effects, withdrawal upon cessation of use, and recurrent
drug craving.

**Notifiable condition:** A disease or risk factor that is reported to
the Centers for Disease Control and Prevention by the States and the
District of Columbia.

**Pharmacotherapy:** Medical treatment using pharmaceuticals or drugs.

**Preemptive laws:** Legislation prohibiting any local jurisdiction from
enacting restrictions more stringent than State law or restrictions that
may vary from State law.

**Secondhand smoke:** A mixture of the smoke exhaled by smokers and the
smoke that comes from the burning end of the tobacco product.

**Serum cotinine:** A biological marker for tobacco use and exposure to
environmental tobacco smoke measured in the blood. Cotinine is a
breakdown product of nicotine.

**Spit tobacco:** Chewing tobacco, snuff, or smokeless tobacco.

## References 

[^1]: U.S. Department of Health and Human Services (HHS). *Reducing the
    Health Consequences of Smoking: 25 Years of Progress. A Report of
    the Surgeon General*. HHS Pub. No. (CDC) 89-8411. Atlanta, GA: HHS,
    Public Health Service (PHS), Centers for Disease Control (CDC),
    National Center for Chronic Disease Prevention and Health Promotion
    (NCCDPHP), Office on Smoking and Health (OSH), 1989.

[^2]: HHS. *The Health Benefits of Smoking Cessation. A Report of the
    Surgeon General*. HHS Pub. No. (CDC) 90-8416. Atlanta, GA: HHS, PHS,
    CDC, NCCDPHP, OSH, 1990.

[^3]: DiFranza, J.R., and Lew, R.A. Effect of maternal cigarette smoking
    on pregnancy complications and sudden infant death syndrome.
    *Journal of Family Practice* 40(4):385-394, 1995.

[^4]: HHS. *The Health Consequences of Using Smokeless Tobacco. A Report
    of the Advisory Committee to the Surgeon General*. NIH Pub. No.
    86-2874. Bethesda, MD: HHS, PHS, CDC, Center for Health Promotion
    and Education (CHPE), OSH, 1986.

[^5]: HHS. *The Health Consequences of Smoking: Cancer. A Report of the
    Surgeon General*. Rockville, MD: HHS, PHS, CDC, CHPE, OSH, 1982.

[^6]: CDC. Bidi use among urban youth---Massachusetts, March-April 1999.
    *Morbidity and Mortality Weekly Report* 48(36):796-799, 1999.

[^7]: Gupta, P.C.; Hammer, III, J.E.; Murti, P.R.; eds. *Control of
    Tobacco-Related Cancers and Other Diseases; Proceedings of an
    International Symposium.* Bombay, India: Tata Institute of
    Fundamental Research, Oxford University Press, 1992.

[^8]: CDC. Cigarette smoking-attributable mortality and years of
    potential life lost---United States, 1984. *Morbidity and Mortality
    Weekly Report* 46(20):444-451, 1997.

[^9]: CDC. Projected smoking-related deaths among youth---United States.
    *Morbidity and Mortality Weekly Report* 45:971-974, 1996.

[^10]: CDC. Medical-care expenditures attributable to cigarette
    smoking---United States, 1993. *Morbidity and Mortality Weekly
    Report* 43(26):469-472, 1994.

[^11]: CDC. Medical-care expenditures attributable to cigarette smoking
    during pregnancy---United States, 1995. *Morbidity and Mortality
    Weekly Report* 46:1048-1050, 1997.

[^12]: HHS. *The Health Consequences of Involuntary Smoking. A Report of
    the Surgeon General*. Rockville, MD: HHS, PHS, CDC, CHPE, OSH, 1986.

[^13]: U.S. Environmental Protection Agency (EPA). *Respiratory Health
    Effects of Passive Smoking: Lung Cancer and Other Disorders*. EPA
    Pub. No. EPA/600/6-90/006F. Washington, DC: EPA, 1992.

[^14]: California Environmental Protection Agency. *Health Effects of
    Exposure to Environmental Tobacco Smoke*. Final Report. Sacramento,
    CA: the Agency, Office of Environmental Health Hazard Assessment,
    1997.

[^15]: Glantz, S.A., and Parmely, W.W. Passive smoking and heart
    disease: Mechanism and risk. *Journal of the American Medical
    Association* 273:1047-1053, 1995.

[^16]: Howard, G.; Wagenknech, L.E.; Burke, G.E.; et al. Cigarette
    smoking and progression of atherosclerosis. *Journal of the American
    Medical Association* 279(2):119-124, 1998.

[^17]: Pirkle, J.L.; Flegal, K.M.; Bernet, J.T.; et al. Exposure of the
    U.S. population to environmental tobacco smoke. *Journal of the
    American Medical Association* 275:1233-1240, 1996.

[^18]: CDC. State-specific prevalence of cigarette smoking among adults,
    and children's and adolescents' exposure to environmental tobacco
    smoke---United States. *Morbidity and Mortality Weekly Report*
    46:1038-1043, 1997.

[^19]: CDC, NCHS. National Health Interview Survey. Unpublished data,
    1998.

[^20]: HHS. *Preventing Tobacco Use Among Young People: A Report of the
    Surgeon General*. Atlanta, GA: HHS, PHS, CDC, NCCDPHP, OSH, 1994.

[^21]: HHS. Drug use among teenagers leveling off. *HHS News*, December
    17, 1999.

[^22]: CDC. Tobacco use among high school students---United States,
    1997. *Morbidity and Mortality Weekly Report* 47:229-233, 1998.

[^23]: HHS. *The Health Consequences of Smoking: Nicotine Addiction. A
    Report of the Surgeon General*. Washington, DC: U.S. Government
    Printing Office, 1988.

[^24]: CDC. Smoking cessation during previous year among adults---United
    States, 1990 and 1991. *Morbidity and Mortality Weekly Report*
    42:504-507, 1993.

[^25]: HHS. *Tobacco Use Among U.S. Racial/Ethnic Minority
    Groups---African Americans, American Indians, and Alaska Natives,
    Asian Americans and Pacific Islanders, and Hispanics: A Report of
    the Surgeon General*. Atlanta, GA: HHS, PHS, CDC, NCCDPHP, OSH,
    1998.

[^26]: National Asian Women's Health Organization. *Smoking Among Asian
    Americans: A National Tobacco Survey*. San Francisco, CA: the
    Organization, 1998.

[^27]: Goebel, K. Lesbians and gays face tobacco targeting. *Tobacco
    Control* 3:65-67, 1994.

[^28]: Skinner, W.F. The prevalence and demographic predictors of
    illicit and licit drug use among lesbians and gay men. *American
    Journal of Public Health* 84(8):1307-1310, 1994.

[^29]: Penkower, L.; Dew, M.A.; Kingsley, L.; et al. Behavioral, health
    and psychosocial factors and risk for HIV infection among sexually
    active homosexual men: The Multicenter AIDS Cohort Study. *American
    Journal of Public Health* 81(2):194-196, 1991.

[^30]: Arday, D.A.; Edlin, B.R.; Giovino, G.A.; et al. Smoking, HIV
    infection, and gay men in the United States. *Tobacco Control*
    2:156-158, 1993.

[^31]: CDC. Youth Risk Behavior Surveillance: National College Health
    Risk Behavior Survey---United States, 1995. *Morbidity and Mortality
    Weekly Report* 46(SS-6):1-56, 1997.

[^32]: HHS. *Strategies to Control Tobacco Use in the United States: A
    Blueprint for Public Health Action in the 1990s.* Smoking and
    Tobacco Control Monograph 1. NIH Pub. No. 92-3316. Bethesda, MD:
    HHS, PHS, National Institutes of Health (NIH), National Cancer
    Institute (NCI), 1991.

[^33]: Pierce, J.P.; Evans, N.; Farkas, A.J.; et al. *Tobacco Use in
    California: An Evaluation of the Tobacco Control Program, 1989-93.*
    La Jolla, CA: University of California, San Diego, 1994.

[^34]: Abt Associates, Inc., for the Massachusetts Department of Public
    Health. *Independent Evaluation of the Massachusetts Tobacco Control
    Program.* 2nd Annual Report. Cambridge, MA: Abt Associates, Inc.,
    1996.

[^35]: Gostin, L.O.; Arno, P.S.; and Brandt, A.M. FDA regulation of
    tobacco advertising and youth smoking. Historical, social, and
    constitutional perspectives. *Journal of the American Medical
    Association* 277:410-418, 1997.

[^36]: Tobacco Education Oversight Committee. *Toward a Tobacco-Free
    California: Exploring a New Frontier.* Report to the California
    Legislature. February 1993, 69.

[^37]: Arizona Tobacco Use Prevention Plan
    \<http://www.hs.state.az.us/aztepp\>May 12, 1999.

[^38]: CDC. Cigarette smoking before and after an excise tax increase
    and an antismoking campaign. *Morbidity and Mortality Weekly Report*
    45:966-970, 1996.

[^39]: CDC. Tobacco use among middle and high school students---Florida,
    1998 and 1999. *Morbidity and Mortality Weekly Report* 48:248-253,
    1999.

[^40]: Pechacek, T.F.; Asthma, S.; and Eriksen, M.P. Tobacco: Global
    burden and community solutions. In: Yusuf, S.; Cairns, J.A.; Camm,
    A.J.; et al.; eds. *Evidence Based Cardiology*. London, England: BMJ
    Books, 1998, 165-178.

[^41]: Glynn, T. Essential elements of school-based smoking prevention
    programs. *Journal of School Health* 59(5):181-188, 1989.

[^42]: Botvin, G.J.; Renick, N.L.; and Baker, E. The effects of
    scheduling format and booster sessions on a broad-spectrum
    psychosocial smoking prevention. *Journal of Behavioral Medicine*
    6(4):359-379, 1983.

[^43]: Perry, C.L.; Klepp, K.I.; and Sillers, C. Community-wide
    strategies for cardiovascular health: The Minnesota Heart Health
    Program youth program. *Health Education Research* 4(1):87-101,
    1989.

[^44]: Pentz, M.A.; Dwyer, J.H.; MacKinnon, D.P.; et al. A
    multicommunity trial for primary prevention of adolescent drug
    abuse. Effects on drug use prevalence. *Journal of the American
    Medical Association* 261(2):3259-3266, 1989.

[^45]: Vartianen, E.; Fallonen, U.; McAlister, A.L.; et al. Eight-year
    follow-up results of an adolescent smoking prevention program: The
    North Karelia Youth Project. *American Journal of Public Health*
    80(1):78-79, 1990.

[^46]: Perry, C.L.; Kelder, S.H.; Murray, D.M.; et al. Community-wide
    smoking prevention: Long‑term outcomes of the Minnesota Heart Health
    Program and the Class of 1989 Study. *American Journal of Public
    Health* 82(9):1210‑1216, 1992.

[^47]: Botvin, G.J.; Baker, E.; Dusenbury, L.; et al. Long-term
    follow-up results of a randomized drug abuse prevention trial in a
    white middle-class population. *Journal of the American Medical
    Association* 273(14):1106-1112, 1995.

[^48]: CDC. Guidelines for school health programs to prevent tobacco use
    and addiction. *Morbidity and Mortality Weekly Report* 43:1-18,
    1994.

[^49]: CDC. Addition of prevalence of cigarette smoking as a nationally
    notifiable condition---June 1996. *Morbidity and Mortality Weekly
    Report* 45:537, 1996.

[^50]: HHS. *Smoking Cessation: Clinical Practice Guideline*. No. 18.
    HHS Pub. No. (AHCPR) 96-0692. Washington, DC: HHS, PHS, Agency for
    Health Care Policy and Research, 1996.

[^51]: Monitoring the Future Project 1997. *Public Use Data Tapes,
    1992--95.* 1992--95 combined data. Ann Arbor, MI: University of
    Michigan, Institute for Social Research.

[^52]: McPhillips-Tangrum, C. Results from the first annual survey on
    addressing tobacco in managed care. *Tobacco Control* 7:S11-S13,
    1998.

[^53]: Zebrek, A. *Medicaid and Indigent Care: Smoking Cessation.*
    Washington, DC: Health Policy Tracking Service, 1998.

[^54]: Gerlach, K.; Shopland, D.R.; Hartman, A.M.; et al. Workplace
    smoking policies in the United States: Results from a national
    survey of more than 100,000 workers. *Tobacco Control* 6:199-206,
    1997.

[^55]: Siegel, M. Involuntary smoking in the restaurant workplace.
    *Journal of the American Medical Association* 270:490-493, 1993.

[^56]: Mannino, D.M.; Siegel, M.; Husten, C.; et al. Environmental
    tobacco smoke exposure and health effects in children: Results from
    the 1991 National Health Interview Survey. *Tobacco Control*
    5:13-18, 1996.

[^57]: DiFranza, J.R., and Lew, R.A. Morbidity and mortality in children
    associated with the use of tobacco products by other people.
    *Pediatrics* 97:560-568, 1996.

[^58]: American Academy of Pediatrics, Committee on Environmental
    Health. Environmental tobacco smoke: A hazard to children.
    *Pediatrics* 99:639-642, 1997.

[^59]: Kann, L.; Kinchen, S.A.; William, B.I.; et al. Youth risk
    behavior surveillance---United States, 1997. *Morbidity and
    Mortality Weekly Report* 47(SS-3):1-89, 1998.

[^60]: CDC. Accessibility of tobacco products to youths aged
    12-17---United States, 1989--1993. *Morbidity and Mortality Weekly
    Report* 45:125-130, 1996.

[^61]: Widley, M.B.; Woodruff, S.I.; Pamplone, S.Z.; et al. Self-service
    sale of tobacco: How it contributes to youth access. *Tobacco
    Control* 4:355-361, 1995.

[^62]: Substance Abuse and Mental Health Services Administration.
    Tobacco Regulation for Substance Abuse Prevention and Treatment
    Block Grants. Final Rule. *Federal Register* (16)13:1492-1500, 1996.

[^63]: Chaloupka, F., and Grossman, M. *National Bureau of Economic
    Research Working Paper.* No. 5740. Cambridge, MA: National Bureau of
    Economic Research, 1996.

[^64]: Manley, M.; Pierce, J.P.; Gilpin, E.A.; et al. Impact of the
    American Stop Smoking Intervention Study on cigarette consumption.
    *Tobacco Control* 6:S12-S16, 1997.

[^65]: Conlisk, E.; Siegel, M.; Lengerich, E.; et al. The status of
    local smoking regulations in North Carolina following a state
    preemption bill. *Journal of the American Medical Association*
    273:805-807, 1995.

[^66]: Jordan, J.; Pertschuk M.; and Carol, J. *Preemption in Tobacco
    Control: History, Current Issues, and Future Concerns.* No. 97-0424.
    Berkeley, CA: Americans for Nonsmokers' Rights/Western Consortium
    for Public Health, 1994.

[^67]: Fishman, J.A.; Allison, H.; Knowles, S.B.; et al. State laws on
    tobacco control---United States. *Morbidity and Mortality Weekly
    Report* 48(SS-3):21-62, 1998.

[^68]: HHS. *The FTC Cigarette Test Method for Determining Tar,
    Nicotine, and Carbon Monoxide Yields of U.S. Cigarettes: A Report of
    the NCI Expert Committee*. NIH Pub. No. 96-4028. Bethesda, MD: HHS,
    PHS, NIH, NCI, 1996.

[^69]: Public Law 99-252, Section 4. The Comprehensive Smokeless Tobacco
    and Health Education Act of 1986.

[^70]: U.S. Department of Treasury (DOT). *The Economic Costs of Smoking
    in the United States and the Benefits of Comprehensive Tobacco
    Legislation.* Department of Treasury Working Paper Series.
    Washington, DC: DOT, 1998.

[^71]: Chaloupka, F.J.; Tauras, J.A.; and Grossman, M. Public policy and
    youth smokeless tobacco use. *Southern Economic Journal*
    64(2):503-516, 1997.

[^72]: General Accounting Office. *Teen Smoking: Higher Excise Tax
    Should Significantly Reduce the Number of Smokers. A Report to the
    Honorable Michael A. Andrews, House of Representatives*. GAO/HRD
    89-119. Rockville, MD: GAO, 1989.

[^73]: CDC. Tobacco tax initiative---Oregon, 1996. *Morbidity and
    Mortality Weekly Report* 46:246-248, 1997.