------------- cut here ----------------- Volume  6, Number 10                                           April 20, 1993                +------------------------------------------------+               !                                                !               !              Health Info-Com Network           !               !                Medical Newsletter              !               +------------------------------------------------+                          Editor: David Dodell, D.M.D.     10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA                           Telephone +1 (602) 860-1121                               FAX +1 (602) 451-1165  Compilation Copyright 1993 by David Dodell,  D.M.D.  All  rights  Reserved.   License  is  hereby  granted  to republish on electronic media for which no  fees are charged,  so long as the text of this copyright notice and license  are attached intact to any and all republished portion or portions.    The Health Info-Com Network Newsletter is  distributed  biweekly.  Articles  on  a medical nature are welcomed.  If you have an article,  please contact  the editor for information on how to submit it.  If you are  interested  in  joining the automated distribution system, please contact the editor.    E-Mail Address:                                     Editor:                             Internet: david@stat.com                               FidoNet = 1:114/15                            Bitnet = ATW1H@ASUACAD  LISTSERV = MEDNEWS@ASUACAD.BITNET (or internet: mednews@asuvm.inre.asu.edu)                           anonymous ftp = vm1.nodak.edu                Notification List = hicn-notify-request@stat.com                  FAX Delivery = Contact Editor for information   ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                         T A B L E   O F   C O N T E N T S   1.  Comments & News from the Editor      OCR / Scanner News ...................................................  1  2.  Centers for Disease Control and Prevention - MMWR      [16 April 1993] Emerging Infectious Diseases .........................  3      Outbreak of E. coli Infections from Hamburgers .......................  5      Use of Smokeless Tobacoo Among Adults ................................ 10      Gonorrhea ............................................................ 14      Impact of Adult Safety-Belt Use on Children less than 11 years Age ... 17      Publication of CDC Surveillance Summaries ............................ 21  3.  Clinical Research News      High Tech Assisted Reproductive Technologies ......................... 24  4.  Articles      Low Levels Airborne Particles Linked to Serious Asthma Attacks ....... 29      NIH Consensus Development Conference on Melanoma ..................... 31      National Cancer Insitute Designated Cancer Centers ................... 32  5.  General Announcments      UCI Medical Education Software Repository ............................ 40  6.  AIDS News Summaries      AIDS Daily Summary April 12 to April 15, 1993 ........................ 41  7.  AIDS/HIV Articles      First HIV Vaccine Trial Begins in HIV-Infected Children .............. 47      New Evidence that the HIV Can Cause Disease Independently ............ 50      Clinical Consultation Telephone Service for AIDS ..................... 52      HICNet Medical Newsletter                                            Page    i Volume  6, Number 10                                           April 20, 1993    ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                         Comments & News from the Editor ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::  I would like to continue to thank everyone who has sent in a donation for the  Mednews OCR/Scanner Fund.  We have reached our goal!  A Hewlett Packard Scanjet IIp was purchased this week.  Thank you to the following individuals whose contributions I just received:  John Sorenson Carol Sigelman Carla Moore Barbara Moose Judith Schrier  Again, thank you to all who gave!  I have been using Wordscan Plus for the past couple of weeks and would like to  review the product.  Wordscan Plus is a product of Calera Recognition Systems.   It runs under Windows 3.1 and supports that Accufont Technology of the Hewlett  Packard Scanners.    When initially bringing up the software, it lets you select several options;  (1) text / graphics (2) input source ie scanner, fax file, disk file (3)  automatic versus manual decomposition of the scanned image.   I like manual decomposition since the software then lets me select which  parts of the document I would like scanned, and in what order.  Once an image is scanned, you can bring up the Pop-Up image verification.  The  software gives you two "errors" at this point.  Blue which are words that were  converted reliability, but do not match anything in the built-in dictionary.   Yellow shade, which are words that Wordscan Plus doesn't think it converted  correctly at all.  I have found that the software should give itself more  credit.  It is usually correct, instead of wrong.  If a word is shaded blue,  you can add it to your personal dictionary.  The only problem is the personal  dictionary will only handle about 200 words.  I find this to be very limited,  considering how many medical terms are not in a normal dictionary.   After a document is converted, you can save it in a multitude of word  processor formats.  Also any images that were captured can be stored in a  seperate TIFF or PCX file format.  I was extremely impressed on the percent accuracy for fax files.  I use   HICNet Medical Newsletter                                              Page  1 Volume  6, Number 10                                           April 20, 1993  an Intel Satisfaxtion card, which stores incoming faxs in a PCX/DCX format.   While most of my faxes were received in "standard" mode (200x100 dpi), the  accuracy of Wordscan Plus was excellent.   Overall, a very impressive product.  The only fault I could find is the  limitations of the size of the user dictionary.  200 specialized words is just  too small.   If anyone has any specific questions, please do not hesitate to send me email.                                     HICNet Medical Newsletter                                              Page  2 Volume  6, Number 10                                           April 20, 1993    ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                Centers for Disease Control and Prevention - MMWR ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                           Emerging Infectious Diseases                          ============================                    SOURCE: MMWR 42(14)   DATE: Apr 16, 1993                                   Introduction       Despite predictions earlier this century that infectious diseases would  soon be eliminated as a public health problem (1), infectious diseases remain  the major cause of death worldwide and a leading cause of illness and death in  the United States. Since the early 1970s, the U.S. public health system has  been challenged by a myriad of newly identified pathogens and syndromes (e.g.,  Escherichia coli O157:H7, hepatitis C virus, human immunodeficiency virus,  Legionnaires disease, Lyme disease, and toxic shock syndrome). The incidences  of many diseases widely presumed to be under control, such as cholera,  malaria, and tuberculosis (TB), have increased in many areas. Furthermore,  control and prevention of infectious diseases are undermined by drug  resistance in conditions such as gonorrhea, malaria, pneumococcal disease,  salmonellosis, shigellosis, TB, and staphylococcal infections (2). Emerging  infections place a disproportionate burden on immunocompromised persons, those  in institutional settings (e.g., hospitals and child day care centers), and  minority and underserved populations. The substantial economic burden of  emerging infections on the U.S. health-care system could be reduced by more  effective surveillance systems and targeted control and prevention programs  (3).       This issue of MMWR introduces a new series, "Emerging Infectious  Diseases." Future articles will address these diseases, as well as  surveillance, control, and prevention efforts by health-care providers and  public health officials. This first article updates the ongoing investigation  of an outbreak of E. coli O157:H7 in the western United States (4).   References  1. Burnet M. Natural history of infectious disease. Cambridge, England:  Cambridge University Press, 1963.   2. Kunin CM. Resistance to antimicrobial drugs -- a worldwide calamity. Ann  Intern Med 1993;118:557-61.   3. Lederberg J, Shope RE, Oaks SC Jr, eds. Emerging infections: microbial  threats to health in the United States. Washington, DC: National Academy  Press, 1992.   HICNet Medical Newsletter                                              Page  3 Volume  6, Number 10                                           April 20, 1993   4. CDC. Preliminary report: foodborne outbreak of Escherichia coli O157:H7  infections from hamburgers --western United States, 1993. MMWR 1993;42:85-6.                                           HICNet Medical Newsletter                                              Page  4 Volume  6, Number 10                                           April 20, 1993              Update: Multistate Outbreak of Escherichia coli O157:H7              Infections from Hamburgers -- Western United States,                                    1992-1993             =======================================================                    SOURCE: MMWR 42(14)   DATE: Apr 16, 1993       From November 15, 1992, through February 28, 1993, more than 500  laboratory-confirmed infections with E. coli O157:H7 and four associated  deaths occurred in four states -- Washington, Idaho, California, and Nevada.  This report summarizes the findings from an ongoing investigation (1) that  identified a multistate outbreak resulting from consumption of hamburgers from  one restaurant chain. Washington       On January 13, 1993, a physician reported to the Washington Department of  Health a cluster of children with hemolytic uremic syndrome (HUS) and an  increase in emergency room visits for bloody diarrhea. During January 16-17, a  case-control study comparing 16 of the first cases of bloody diarrhea or  postdiarrheal HUS identified with age- and neighborhood-matched controls  implicated eating at chain A restaurants during the week before symptom onset  (matched odds ratio OR=undefined; lower confidence limit=3.5). On January  18, a multistate recall of unused hamburger patties from chain A restaurants  was initiated.       As a result of publicity and case-finding efforts, during January- February 1993, 602 patients with bloody diarrhea or HUS were reported to the  state health department. A total of 477 persons had illnesses meeting the case  definition of culture-confirmed E. coli O157:H7 infection or postdiarrheal HUS  (Figure 1). Of the 477 persons, 52 (11%) had close contact with a person with  confirmed E. coli O157:H7 infection during the week preceding onset of  symptoms. Of the remaining 425 persons, 372 (88%) reported eating in a chain A  restaurant during the 9 days preceding onset of symptoms. Of the 338 patients  who recalled what they ate in a chain A restaurant, 312 (92%) reported eating  a regular-sized hamburger patty. Onsets of illness peaked from January 17  through January 20. Of the 477 casepatients, 144 (30%) were hospitalized; 30  developed HUS, and three died. The median age of patients was 7.5 years  (range: 0-74 years). Idaho       Following the outbreak report from Washington, the Division of Health,  Idaho Department of Health and Welfare, identified 14 persons with culture- confirmed E. coli O157:H7 infection, with illness onset dates from December  11, 1992, through February 16, 1993 (Figure 2A). Four persons were  hospitalized; one developed HUS. During the week preceding illness onset, 13  (93%) had eaten at a chain A restaurant. California       In late December, the San Diego County Department of Health Services was  notified of a child with E. coli O157:H7 infection who subsequently died.  Active surveillance and record review then identified eight other persons with  E. coli O157:H7 infections or HUS from mid-November through mid-January 1993.  Four of the nine reportedly had recently eaten at a chain A restaurant and   HICNet Medical Newsletter                                              Page  5 Volume  6, Number 10                                           April 20, 1993  four at a chain B restaurant in San Diego. After the Washington outbreak was  reported, reviews of medical records at five hospitals revealed an overall 27%  increase in visits or admissions for diarrhea during December 1992 and January  1993 compared with the same period 1 year earlier. A case was defined as  postdiarrheal HUS, bloody diarrhea that was culture negative or not cultured,  or any diarrheal illness in which stool culture yielded E. coli O157:H7, with  onset from November 15, 1992, through January 31, 1993.       Illnesses of 34 patients met the case definition (Figure 2B). The  outbreak strain was identified in stool specimens of six patients. Fourteen  persons were hospitalized, seven developed HUS, and one child died. The median  age of case-patients was 10 years (range: 1-58 years). A case-control study of  the first 25 case-patients identified and age- and sex-matched community  controls implicated eating at a chain A restaurant in San Diego (matched  OR=13; 95% confidence interval CI=1.7-99). A study comparing case-patients  who ate at chain A restaurants with well meal companions implicated regular- sized hamburger patties (matched OR=undefined; lower confidence limit=1.3).  Chain B was not statistically associated with illness. Nevada       On January 22, after receiving a report of a child with HUS who had eaten  at a local chain A restaurant, the Clark County (Las Vegas) Health District  issued a press release requesting that persons with recent bloody diarrhea  contact the health department. A case was defined as postdiarrheal HUS, bloody  diarrhea that was culture negative or not cultured, or any diarrheal illness  with a stool culture yielding the Washington strain of E. coli O157:H7, with  onset from December 1, 1992, through February 7, 1993. Because local  laboratories were not using sorbitol MacConkey (SMAC) medium to screen stools  for E. coli O157:H7, this organism was not identified in any patient. After  SMAC medium was distributed, the outbreak strain was detected in the stool of  one patient 38 days after illness onset.       Of 58 persons whose illnesses met the case definition (Figure 2C), nine  were hospitalized; three developed HUS. The median age was 30.5 years (range:  0-83 years). Analysis of the first 21 patients identified and age- and sex- matched community controls implicated eating at a chain A restaurant during  the week preceding illness onset (matched OR=undefined; lower confidence  limit=4.9). A case-control study using well meal companions of case-patients  also implicated eating hamburgers at chain A (matched OR=6.0; 95% CI=0.7- 49.8). Other Investigation Findings       During the outbreak, chain A restaurants in Washington linked with cases  primarily were serving regular-sized hamburger patties produced on November  19, 1992; some of the same meat was used in "jumbo" patties produced on  November 20, 1992. The outbreak strain of E. coli O157:H7 was isolated from 11  lots of patties produced on those two dates; these lots had been distributed  to restaurants in all states where illness occurred. Approximately 272,672  (20%) of the implicated patties were recovered by the recall.       A meat traceback by a CDC team identified five slaughter plants in the  United States and one in Canada as the likely sources of carcasses used in the   HICNet Medical Newsletter                                              Page  6 Volume  6, Number 10                                           April 20, 1993  contaminated lots of meat and identified potential control points for reducing  the likelihood of contamination. The animals slaughtered in domestic slaughter  plants were traced to farms and auctions in six western states. No one  slaughter plant or farm was identified as the source.       Further investigation of cases related to secondary transmission in  families and child day care settings is ongoing.   Reported by: M Davis, DVM, C Osaki, MSPH, Seattle-King County Dept of Public  Health; D Gordon, MS, MW Hinds, MD, Snohomish Health District, Everett; K  Mottram, C Winegar, MPH, Tacoma-Pierce County Health Dept; ED Avner, MD, PI  Tarr, MD, Dept of Pediatrics, D Jardine, MD, Depts of Anesthesiology and  Pediatrics, Univ of Washington School of Medicine and Children's Hospital and  Medical Center, Seattle; M Goldoft, MD, B Bartleson, MPH; J Lewis, JM  Kobayashi, MD, State Epidemiologist, Washington Dept of Health. G Billman, MD,  J Bradley, MD, Children's Hospital, San Diego; S Hunt, P Tanner, RES, M  Ginsberg, MD, San Diego County Dept of Health Svcs; L Barrett, DVM, SB Werner,  MD, GW Rutherford, III, MD, State Epidemiologist, California Dept of Health  Svcs. RW Jue, Central District Health Dept, Boise; H Root, Southwest District  Health Dept, Caldwell; D Brothers, MA, RL Chehey, MS, RH Hudson, PhD, Div of  Health, Idaho State Public Health Laboratory, FR Dixon, MD, State  Epidemiologist, Div of Health, Idaho Dept of Health and Welfare. DJ Maxson,  Environmental Epidemiology Program, L Empey, PA, O Ravenholt, MD, VH Ueckart,  DVM, Clark County Health District, Las Vegas; A DiSalvo, MD, Nevada State  Public Health Laboratory; DS Kwalick, MD, R Salcido, MPH, D Brus, DVM, State  Epidemiologist, Div of Health, Nevada State Dept of Human Resources. Center  for Food Safety and Applied Nutrition, Food and Drug Administration. Food  Safety Inspection Svc, Animal and Plant Health Inspection Svc, US Dept of  Agriculture. Div of Field Epidemiology, Epidemiology Program Office; Enteric  Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for  Infectious Diseases, CDC.   Editorial Note: E. coli O157:H7 is a pathogenic gram-negative bacterium first  identified as a cause of illness in 1982 during an outbreak of severe bloody  diarrhea traced to contaminated hamburgers (2). This pathogen has since  emerged as an important cause of both bloody diarrhea and HUS, the most common  cause of acute renal failure in children. Outbreak investigations have linked  most cases with the consumption of undercooked ground beef, although other  food vehicles, including roast beef, raw milk, and apple cider, also have been  implicated (3). Preliminary data from a CDC 2-year, nationwide, multicenter  study revealed that when stools were routinely cultured for E. coli O157:H7  that organism was isolated more frequently than Shigella in four of 10  participating hospitals and was isolated from 7.8% of all bloody stools, a  higher rate than for any other pathogen.       Infection with E. coli O157:H7 often is not recognized because most  clinical laboratories do not routinely culture stools for this organism on   HICNet Medical Newsletter                                              Page  7 Volume  6, Number 10                                           April 20, 1993  SMAC medium, and many clinicians are unaware of the spectrum of illnesses  associated with infection (4). The usual clinical manifestations are diarrhea  (often bloody) and abdominal cramps; fever is infrequent. Younger age groups  and the elderly are at highest risk for clinical manifestations and  complications. Illness usually resolves after 6-8 days, but 2%-7% of patients  develop HUS, which is characterized by hemolytic anemia, thrombocytopenia,  renal failure, and a death rate of 3%-5%.       This report illustrates the difficulties in recognizing community  outbreaks of E. coli O157:H7 in the absence of routine surveillance. Despite  the magnitude of this outbreak, the problem may not have been recognized in  three states if the epidemiologic link had not been established in Washington  (1). Clinical laboratories should routinely culture stool specimens from  persons with bloody diarrhea or HUS for E. coli O157:H7 using SMAC agar (5).  When infections with E. coli O157:H7 are identified, they should be reported  to local health departments for further evaluation and, if necessary, public  health action to prevent further cases.       E. coli O157:H7 lives in the intestines of healthy cattle, and can  contaminate meat during slaughter. CDC is collaborating with the U.S.  Department of Agriculture's Food Safety Inspection Service to identify  critical control points in processing as a component of a program to reduce  the likelihood of pathogens such as E. coli O157:H7 entering the meat supply.  Because slaughtering practices can result in contamination of raw meat with  pathogens, and because the process of grinding beef may transfer pathogens  from the surface of the meat to the interior, ground beef is likely to be  internally contaminated. The optimal food protection practice is to cook  ground beef thoroughly until the interior is no longer pink, and the juices  are clear. In this outbreak, undercooking of hamburger patties likely played  an important role. The Food and Drug Administration (FDA) has issued interim  recommendations to increase the internal temperature for cooked hamburgers to  155 F (86.1 C) (FDA, personal communication, 1993).       Regulatory actions stimulated by the outbreak described in this report  and the recovery of thousands of contaminated patties before they could be  consumed emphasize the value of rapid public health investigations of  outbreaks. The public health impact and increasing frequency of isolation of  this pathogen underscore the need for improved surveillance for infections  caused by E. coli O157:H7 and for HUS to better define the epidemiology of E.  coli O157:H7.   References  1. CDC. Preliminary report: foodborne outbreak of Escherichia coli O157:H7  infections from hamburgers --western United States, 1993. MMWR 1993;42:85-6.   2. Riley LW, Remis RS, Helgerson SD, et al. Hemorrhagic colitis associated  with a rare Escherichia coli serotype. N Engl J Med 1983;308:681-5.   HICNet Medical Newsletter                                              Page  8 Volume  6, Number 10                                           April 20, 1993   3. Griffin PM, Tauxe RV. The epidemiology of infections caused by Escherichia  coli O157:H7, other enterohemorrhagic E. coli, and the associated hemolytic  uremic syndrome. Epidemiol Rev 1991;13:60-98.   4. Griffin PM, Ostroff SM, Tauxe RV, et al. Illnesses associated with  Escherichia coli O157:H7 infections: a broad clinical spectrum. Ann Intern Med  1988;109:705-12.   5. March SB, Ratnam S. Latex agglutination test                                    HICNet Medical Newsletter                                              Page  9 Volume  6, Number 10                                           April 20, 1993              Use of Smokeless Tobacco Among Adults -- United States,                                      1991             =======================================================                    SOURCE: MMWR 42(14)   DATE: Apr 16, 1993       Consumption of moist snuff and other smokeless tobacco products in the  United States almost tripled from 1972 through 1991 (1). Long-term use of  smokeless tobacco is associated with nicotine addiction and increased risk of  oral cancer (2) -- the incidence of which could increase if young persons who  currently use smokeless tobacco continue to use these products frequently (1).  To monitor trends in the prevalence of use of smokeless tobacco products,  CDC's 1991 National Health Interview Survey-Health Promotion and Disease  Prevention supplement (NHIS-HPDP) collected information on snuff and chewing  tobacco use and smoking from a representative sample of the U.S. civilian,  noninstitutionalized population aged greater than or equal to 18 years. This  report summarizes findings from this survey.       The 1991 NHIS-HPDP supplement asked "Have you used snuff at least 20  times in your entire life?" and "Do you use snuff now?" Similar questions were  asked about chewing tobacco use and cigarette smoking. Current users of  smokeless tobacco were defined as those who reported snuff or chewing tobacco  use at least 20 times and who reported using snuff or chewing tobacco at the  time of the interview; former users were defined as those who reported having  used snuff or chewing tobacco at least 20 times and not using either at the  time of the interview. Ever users of smokeless tobacco included current and  former users. Current smokers were defined as those who reported smoking at  least 100 cigarettes and who were currently smoking and former smokers as  those who reported having smoked at least 100 cigarettes and who were not  smoking now. Ever smokers included current and former smokers. Data on  smokeless tobacco use were available for 43,732 persons aged greater than or  equal to 18 years and were adjusted for nonresponse and weighted to provide  national estimates. Confidence intervals (CIs) were calculated by using  standard errors generated by the Software for Survey Data Analysis (SUDAAN)  (3).       In 1991, an estimated 5.3 million (2.9%) U.S. adults were current users  of smokeless tobacco, including 4.8 million (5.6%) men and 533,000 (0.6%)  women. For all categories of comparison, the prevalence of smokeless tobacco  use was substantially higher among men. For men, the prevalence of use was  highest among those aged 18-24 years (Table 1); for women, the prevalence was  highest among those aged greater than or equal to 75 years. The prevalence of  smokeless tobacco use among men was highest among American Indians/Alaskan  Natives and whites; the prevalence among women was highest among American  Indians/Alaskan Natives and blacks. Among both men and women, prevalence of  smokeless tobacco use declined with increasing education. Prevalence was  substantially higher among residents of the southern United States and in  rural areas. Although the prevalence of smokeless tobacco use was higher among   HICNet Medical Newsletter                                              Page 10 Volume  6, Number 10                                           April 20, 1993  men and women below the poverty level, * this difference was significant only  for women (p less than 0.05) (Table 1).       Among men, the prevalence of current use of snuff was highest among those  aged 18-44 years but varied considerably by age; the prevalence of use of  chewing tobacco was more evenly distributed by age group (Table 2). Although  women rarely used smokeless tobacco, the prevalence of snuff use was highest  among those aged greater than or equal to 75 years.       An estimated 7.9 million (4.4% 95% CI=4.1-4.6) adults reported being  former smokeless tobacco users. Among ever users, the proportion who were  former smokeless tobacco users was 59.9% (95% CI=57.7-62.1). Among persons  aged 18-24 years, the proportion of former users was lower among snuff users  (56.2% 95% CI=49.4-63.0) than among chewing tobacco users (70.4% 95%  CI=64.2-76.6). Among persons aged 45-64 years, the proportion of former users  was similar for snuff (68.9% 95% CI=63.1-74.7) and chewing tobacco (73.5%  95% CI=68.9-78.1).       Among current users of smokeless tobacco, 22.9% (95% CI=19.9-26.0)  currently smoked, 33.3% (95% CI=30.0-36.5) formerly smoked, and 43.8% (95%  CI=39.9-47.7) never smoked. In comparison, among current smokers, 2.6% (95%  CI=2.3-3.0) were current users of smokeless tobacco.       Daily use of smokeless tobacco was more common among snuff users (67.3%  95% CI=63.2-71.4) than among chewing tobacco users (45.1% 95% CI=40.6- 49.6).   Reported by: Office on Smoking and Health, National Center for Chronic Disease  Prevention and Health Promotion; Div of Health Interview Statistics, National  Center for Health Statistics, CDC.   Editorial Note: The findings in this report indicate that the use of smokeless  tobacco was highest among young males. Adolescent and young adult males, in  particular, are the target of marketing strategies by tobacco companies that  link smokeless tobacco with athletic performance and virility. Use of oral  snuff has risen markedly among professional baseball players, encouraging this  behavior among adolescent and young adult males and increasing their risk for  nicotine addiction, oral cancer, and other mouth disorders (4).       Differences in the prevalence of smokeless tobacco use among  racial/ethnic groups may be influenced by differences in educational levels  and socioeconomic status as well as social and cultural phenomena that require  further explanation. For example, targeted marketing practices may play a role  in maintaining or increasing prevalence among some groups, and affecting the  differential initiation of smokeless tobacco use by young persons (5,6).       In this report, one concern is that nearly one fourth of current  smokeless tobacco users also smoke cigarettes. In the 1991 NHIS-HPDP, the  prevalence of cigarette smoking was higher among former smokeless tobacco  users than among current and never smokeless tobacco users. In a previous  study among college students, 18% of current smokeless tobacco users smoked   HICNet Medical Newsletter                                              Page 11 Volume  6, Number 10                                           April 20, 1993  occasionally (7). In addition, approximately 7% of adults who formerly smoked  reported substituting other tobacco products for cigarettes in an effort to  stop smoking (8). Health-care providers should recognize the potential health  implications of concurrent smokeless tobacco and cigarette use.       The national health objectives for the year 2000 have established special  population target groups for the reduction of the prevalence of smokeless  tobacco use, including males aged 12-24 years (to no more than 4% by the year  2000 objective 3.9) and American Indian/Alaskan Native youth (to no more  than 10% by the year 2000 objective 3.9a) (9). Strategies to lower the  prevalence of smokeless tobacco use include continued monitoring of smokeless  tobacco use, integrating smoking and smokeless tobacco-control efforts,  enforcing laws that restrict minors' access to tobacco, making excise taxes  commensurate with those on cigarettes, encouraging health-care providers to  routinely provide cessation advice and follow-up, providing school-based  prevention and cessation interventions, and adopting policies that prohibit  tobacco use on school property and at school-sponsored events (5).   References  1. Office of Evaluations and Inspections. Spit tobacco and youth. Washington,  DC: US Department of Health and Human Services, Office of the Inspector  General, 1992; DHHS publication no. (OEI-06)92-00500.   2. National Institutes of Health. The health consequences of using smokeless  tobacco: a report of the Advisory Committee to the Surgeon General. Bethesda,  Maryland: US Department of Health and Human Services, Public Health Service,  1986; DHHS publication no. (NIH)86-2874.   3. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 Software  documentation. Research Triangle Park, North Carolina: Research Triangle  Institute, 1989.   4. Connolly GN, Orleans CT, Blum A. Snuffing tobacco out of sport. Am J Public  Health 1992;82:351-3.   5. National Cancer Institute. Smokeless tobacco or health: an international  perspective. Bethesda, Maryland: US Department of Health and Human Services,  Public Health Service, National Institutes of Health, 1992; DHHS publication  no. (NIH)92-3461.   6. Foreyt JP, Jackson AS, Squires WG, Hartung GH, Murray TD, Gotto AM.  Psychological profile of college students who use smokeless tobacco. Addict  Behav 1993;18:107-16.   7. Glover ED, Laflin M, Edwards SW. Age of initiation and switching patterns   HICNet Medical Newsletter                                              Page 12 Volume  6, Number 10                                           April 20, 1993  between smokeless tobacco and cigarettes among college students in the United  States. Am J Public Health 1989;79:207-8.   8. CDC. Tobacco use in 1986: methods and tabulations from Adult Use of Tobacco  Survey. Rockville, Maryland: US Department of Health and Human Services,  Public Health Service, CDC, 1990; DHHS publication no. (OM)90-2004.   9. Public Health Service. Healthy people 2000: national health promotion and  disease prevention objectives. Washington, DC: US Department of Health and  Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91- 50213.                          --------- end of part 1 ------------