Healthy People 2000 Midcourse Review and 1995 Revisions

Use of tobacco products is the leading preventable cause of death in the United States, accounting for more than 400,000 deaths each year or about one out of every five deaths.¹ Smoking substantially increases the risk of cardiovascular disease, accounts for about 30 percent of all cancer deaths,² is the leading cause of chronic lung disease, and contributes significantly to low birthweight. Furthermore, exposure to environmental tobacco smoke (ETS) is responsible for approximately 3,000 lung cancer deaths per year among nonsmokers.³

The overwhelming evidence of the addictive nature of nicotine necessitates a continued commitment to preventing tobacco use among young people through enforcement of youth access laws, effective prevention education programs in the schools and community, and media campaigns targeted at youth. With the passage of the Pro-Children Act of 1994 as part of the GOALS 2000: Educate America Act, federally funded facilities providing children’s services, including schools and libraries, must be smokefree.

The HEALTHY PEOPLE 2000 objectives, as updated by this midcourse review, cover the majority of the six core components of tobacco control: preventing tobacco use, treating nicotine addiction, protecting nonsmokers from ETS exposure, limiting the effect of tobacco advertising and promotion on young people, increasing the price of tobacco products, and regulating tobacco products. The combined efforts of the Federal Government, the States, and the private sector will help continue progress toward meeting the HEALTHY PEOPLE 2000 objectives.

Review of Progress

An August 1994 progress review with the Assistant Secretary for Health examined the comprehensive public health strategy to reduce tobacco use (the previous progress review took place April 1992). The 1993 data indicate that adult cigarette smoking prevalence has dropped to 25 percent. For certain population groups, particularly American Indians/Alaska Natives, blue-collar workers, and military personnel, the rates of smoking prevalence are considerably higher than those for the population as a whole. Limited progress has been made in reducing the proportion of people aged 20–24 who have begun to smoke cigarettes, a proxy measure of youth initiation. The rate dropped from 30 percent in 1987 to 27 percent in 1993. Among lower socioeconomic status youth the proportion declined from 40 percent in 1987 to 38 percent in 1993. Another survey, the 1994 Monitoring the Future Survey, indicated that there has been no decline in smoking prevalence among high school seniors over the last decade and an increase in smoking prevalence since 1991. The percentage of adult cigarette smokers who stopped smoking for at least 1 day during the preceding year increased from 34 percent in 1986 to 38 percent in 1993. However, among female cigarette smokers, the percentage who quit during pregnancy is moving away from the year 2000 target of 60 percent; in 1985, 39 percent quit, compared with 31 percent in 1991. Among women with less than a high school education, 28 percent quit in 1985, compared with 21 percent in 1991. For males aged 12–17, smokeless tobacco use has declined from 6.6 percent in 1988 to 3.9 percent in 1993. Among males aged 18–24, a decrease from 8.9 percent in 1987 to 7.8 percent in 1993 has occurred. For American Indian/Alaska Native males, the comparability and small sample size of the data on smokeless tobacco makes identifying trends difficult.

The number of children aged 6 and younger who are regularly exposed to tobacco smoke at home declined from 39 percent in 1986 to 27 percent in 1993. The Pro-Children Act of 1994, requiring federally funded schools to be smokefree, promotes the elimination of children’s exposure to tobacco smoke in schools. In 1994 the District of Columbia and 41 States had plans to reduce tobacco use, particularly among young people.

Data for tracking objective 3.15 regarding tobacco product advertising targeted to youth are unavailable. However, continued attention must be paid to the effects of tobacco advertising and promotions on youth, particularly due to the recent finding that youth are more likely than adults to smoke the most advertised cigarette brands.⁴

A 1992 survey of employers with 50 or more employees found that 59 percent had policies in place either prohibiting or severely restricting smoking. In 1994 the District of Columbia and 41 States had laws restricting smoking in public places; 38 States and the District of Columbia had laws and/or executive orders restricting smoking in public workplaces; and 18 States and the District of Columbia had laws regulating smoking in private worksites. All 50 States and the District of Columbia have enacted laws prohibiting the sale and distribution of tobacco to youth under age 18. Although progress has been made toward achieving the year 2000 target for tobacco on the State level, many of these laws contain preemption clauses that prohibit local governments from enacting more stringent policies.

A 1992 Primary Care Providers Survey found that 33 percent of pediatricians routinely inquired about tobacco use, while 19 percent provided cessation counseling. Among internists, 75 percent routinely inquired about tobacco use; whereas 50 percent discussed strategies for quitting.

Mortality data demonstrate the results of decreased tobacco use. The coronary heart disease death rate has been reduced from 135 per 100,000 population in 1987 to 114 in 1992. The rate for blacks declined from 168 per 100,000 population in 1987 to 151 in 1992, but this decline is not sufficient to narrow the gap with the total population. The lung cancer death rate has risen slightly from 38.5 per 100,000 population in 1987 to 39.3 in 1992. The chronic obstructive pulmonary disease death rates have increased slightly from 18.9 per 100,000 population in 1987 to 19.9 in 1992.

1995 Revisions

Among the four new objectives added to the Tobacco priority area, one seeks to increase the average (State and Federal combined) tobacco excise tax to 50 percent of the retail price. Another seeks to increase to 100 percent the proportion of health plans that cover treatment of nicotine addiction. There is a new objective to reduce the number of States with clean indoor air laws that preempt stronger clean indoor air laws on the local level. Another new objective was added to supplement objective 3.13 to increase the number of States with laws restricting youth access to tobacco vending machines.

Special population targets have been added to objective 3.2 for females and black males to address the disparity in lung cancer deaths. For objective 3.4, reducing smoking prevalence, the age range was lowered from 20 to 18 years to focus attention on smoking at an earlier age. The language in objective 3.12 has been revised to specify that smokefree indoor air laws either ban or limit smoking to separately ventilated areas. New language has been added to objective 3.13 to measure the enforcement of laws prohibiting the sale and distribution of tobacco products to youths. The District of Columbia was added to the jurisdictions in which legislative action is sought in several objectives (objectives 3.12, 3.13, and 3.14).

Several objectives from other priority areas have been added as shared objectives to the Tobacco priority area. These objectives address the average age of first use of cigarettes by adolescents aged 12–17, oral cancer deaths, and stroke deaths. Because cigarettes have been added to the list of substances in three objectives in the Substance Abuse: Alcohol and Other Drugs priority area (use in the past month, perception of social disapproval, and perception of harm), these objectives are being added as shared objectives to the Tobacco priority area.

References

1. Centers for Disease Control and Prevention. Cigarette smoking-attributable mortality and years of potential life lost—United States 1990. MMWR 42(33):645–49. 1993.

2. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion; 1989. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication (CDC) 898411.

3. Environmental Protection Agency, Office of Research and Development, Office of Air and Radiation. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. EPA/600/6-90, 1992.

4. Changes in the cigarette brand preferences of adolescent smokers—United States, 1989–1993. MMWR 43(32):577–81. 1994.

TOBACCO

Health Status Objectives

3.1 * Reduce coronary heart disease deaths to no more than 100 per 100,000 people. (Age-adjusted baseline: 135 per 100,000 in 1987)

3.2 * Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people. (Age-adjusted baseline: 38.5 per 100,000 in 1987)

3.3 Slow the rise in deaths for the total population from chronic obstructive pulmonary disease to achieve a rate of no more than 25 per 100,000 people. (Age-adjusted baseline: 18.9 per 100,000 in 1987)

Note: Deaths from chronic obstructive pulmonary disease include deaths due to chronic bronchitis, emphysema, asthma, and other chronic obstructive pulmonary diseases and allied conditions.

3.4 * Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 18 and older. (Baseline: 29 percent in 1987, 31 percent for men and 27 percent for women)

Risk Reduction Objectives

3.5 Reduce the initiation of cigarette smoking by children and youth so that no more than 15 percent have become regular cigarette smokers by age 20. (Baseline: 30 percent of youth had become regular cigarette smokers by ages 20–24 in 1987)

3.6 Increase to at least 50 percent the proportion of cigarette smokers aged 18 and older who stopped smoking cigarettes for at least 1 day during the preceding year. (Baseline: In 1986, 34 percent of people who smoked in the preceding year stopped for at least 1 day during that year)

3.7 Increase smoking cessation during pregnancy so that at least 60 percent of women who are cigarette smokers at the time they become pregnant quit smoking early in pregnancy and maintain abstinence for the remainder of their pregnancy. (Baseline: 39 percent of white women aged 20-44 quit at any time during pregnancy in 1985)

3.8* Reduce to no more than 20 percent the proportion of children aged 6 and younger who are regularly exposed to tobacco smoke at home. (Baseline: More than 39 percent in 1986, as 39 percent of households with one or more children aged 6 or younger had a cigarette smoker in the household)

Note: Regular exposure to tobacco smoke at home is defined as the occurrence of tobacco smoking anywhere in the home on more than 3 days each week.

3.9 Reduce smokeless tobacco use by males aged 12–24 to a prevalence of no more than 4 percent. (Baseline: 6.6 percent among males aged 12–17 in 1988; 8.9 percent among males aged 18–24 in 1987)

Services and Protection Objectives

3.10 Establish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferably as part of comprehensive school health education. (Baseline: 17 percent of school districts totally banned smoking on school premises or at school functions in 1988; anti-smoking education was provided by 78 percent of school districts at the high school level, 81 percent at the middle school level, and 75 percent at the elementary school level in 1988)

3.11 Increase to 100 percent the proportion of worksites with a formal smoking policy that prohibits or severely restricts smoking at the workplace. (Baseline: 27 percent of worksites with 50 or more employees in 1985; 54 percent of medium and large companies in 1987)

3.12* Enact in 50 States and the District of Columbia comprehensive laws on clean indoor air that prohibit smoking or limit it to separately ventilated areas in the workplace and enclosed public places. (Baseline: 4 States regulated private workplaces; 8 States regulated public workplaces, including those that banned smoking through Executive Orders; 2 States regulated restaurants; 14 States and the District of Columbia regulated public transportation; 9 States regulated hospitals; 21 States regulated day care centers; and 6 States regulated grocery stores with comprehensive laws as of January 1995)

3.13 Enact in 50 States and the District of Columbia laws prohibiting the sale and distribution of tobacco products to youth younger than age 18. Enforce these laws so that the buy rate in compliance checks conducted in all 50 States and the District of Columbia is no higher than 20 percent. (Baseline: 44 States and the District of Columbia had, but rarely enforced, laws regulating the sale and/or distribution of cigarettes or tobacco products to minors in 1990; only 3 set the age of majority at 19. Baseline and followup data on enforcement will be provided in State reports to the Substance Abuse and Mental Health Services Administration as a part of compliance with the Synar amendment.)

Note: In July 1992, the President signed Public Law 102-321, the reorganization of the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, which included the “Synar Amendment.” The new law requires all 50 States and the District of Columbia to ban the sale and distribution of tobacco products to everyone under the age of 18. It also required States to enforce their law “in a manner that can be reasonably be expected to reduce the extent to which tobacco products are available to underage youths” or risk the loss of a percentage of Federal Substance Abuse Prevention and Treatment Block Grants.

Although all States have enacted youth access laws, enforcement is variable. Therefore, this objective will separately report on the enactment and enforcement of youth access laws. Enforcement will be measured based on HHS regulations implementing the amendment.

Model legislation proposed by HHS recommends licensure of tobacco vendors, civil money penalties and license suspension or revocation for violations, and a ban on cigarette vending machines.

3.14 Establish in 50 States and the District of Columbia plans to reduce tobacco use, especially among youth. (Baseline: 12 States in 1989)

3.15 Eliminate or severely restrict all forms of tobacco product advertising and promotion to which youth younger than age 18 are likely to be exposed. (Baseline: Radio and television advertising of tobacco products were prohibited, but other restrictions on advertising and promotion to which youth may be exposed were minimal in 1990)

3.16 Increase to at least 75 percent the proportion of primary care and oral health care providers who routinely advise cessation and provide assistance and followup for all of their tobacco-using patients. (Baseline: About 52 percent of internists reported counseling more than 75 percent of their smoking patients about smoking cessation in 1986; about 35 percent of dentists reported counseling at least 75 percent of their smoking patients about smoking in 1986)

1995 Additions

Health Status Objectives

3.17* Reduce deaths due to cancer of the oral cavity and pharynx to no more than 10.5 per 100,000 men aged 45–74 and 4.1 per 100,000 women aged 45–74. (Baseline: 13.6 per 100,000 men and 4.8 per 100,000 women in 1987)

3.18 * Reduce stroke deaths to no more than 20 per 100,000 people (Age-adjusted baseline: 30.4 per 100,000 in 1987)

Risk Reduction Objectives

3.19 * Increase by at least 1 year the average age of first use of cigarettes, alcohol, and marijuana by adolescents aged 12–17. (Baseline: Age 11.6 for cigarettes, age 13.1 for alcohol, and age 13.4 for marijuana in 1988)

3.20 * Reduce the proportion of young people who have used alcohol, marijuana, cocaine, or cigarettes in the past month as follows:

Note: The targets of this objective are consistent with the goals established by the Office of National Drug Control Policy, Executive Office of the President.

3.21 * Increase the proportion of high school seniors who perceive social disapproval of heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine, or regular use of cigarettes, as follows:

3.22 * Increase the proportion of high school seniors who associate physical or psychological harm with heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine, or regular use of tobacco, as follows:

Services and Protection Objectives

3.23 Increase the average (State and Federal combined) tobacco excise tax to at least 50 percent of the average retail price of all cigarettes and smokeless tobacco.

Tax as a Percent of Retail Price (State and Federal)	1993 Baseline	2000 Target
Cigarettes	31.4%	50%
Smokeless Tobacco	11.8%	50%
Source: “The Tax Burden on Tobacco,” The Tobacco Institute, 1994 and CDC, Office on Smoking and Health.

Commentary:

Cigarettes Enacting increases in taxes on tobacco products is good health policy. Changes in price can have a dramatic impact on the levels of tobacco consumption and tobacco use prevalence among youth and adults. Price increases will encourage smoking cessation among current smokers and discourage smoking initiation among youth, preventing millions of premature deaths and saving millions in health care costs. A panel convened by the National Cancer Institute (NCI) in 1991 reviewed the role of excise taxes as a deterrent to smoking. In the summary report, the expert panel concluded that excise taxes may be the single most effective approach to reducing tobacco use by youth. The panel stated that youth consumption would decrease in response to increased prices at a rate of at least 3–5 percent for every 10 percent increase in the price, a rate equal to the decline in tobacco use among adults. In addition, the panel concluded that youth price sensitivity may be as high as 3 times the adult rates, although the data on this were inconclusive.¹

Tax incidence reflects the average State and Federal tax on a pack of cigarettes as a proportion of the average retail price of a pack of cigarettes. From the mid-1950s through the early 1970s the State and Federal cigarette tax incidence was over 46 percent, with a high of 51.4 percent in 1965. By 1987, the tax incidence had dropped to 28.8 percent. Furthermore, the U.S. cigarette tax incidence is considerably lower than that for many industrialized nations. The average tax incidence across 23 developed nations is 68.5 percent. By the year 2000, the United States should be taxing tobacco products consistent with historic levels in the United States.

The Federal excise tax on cigarettes is currently 24 cents per pack, having been raised from 20 to 24 cents in 1993 as part of the Budget Reconciliation Act of 1990. In addition to the Federal tax, all States, the District of Columbia, 369 towns, and 20 counties currently impose excise taxes on cigarettes. As of September 30, 1994, State excise taxes ranged from 2.5 cents per pack in Virginia to 75 cents per pack in Michigan and averaged 30.5 cents per pack.²

In real terms, the Federal excise tax on cigarettes decreased by 68 percent from 1964 to 1982, and the average State tax on cigarettes declined by more than 40 percent from 1975 to 1990. To serve as an effective deterrent over time, excise taxes on tobacco products should be restructured from unit taxes on cigarettes and other tobacco products to equivalent-yield ad valorem taxes, which would allow revenues to keep pace with inflation-induced increases in product prices.³

Excise tax increases offer the added benefit of generating public revenue with relatively low administrative costs. A portion of the funds could be earmarked for tobacco use prevention programs to further deter tobacco use by youth. In 1988 California voters passed Proposition 99, which increased the State excise tax on tobacco by 25 cents per pack. Some of the revenue derived from this increase was earmarked for tobacco use prevention and reduction programs. The combination of a tax increase and a comprehensive tobacco control program reduced per capita consumption by 17 percent from January 1989 through January 1991. ⁴ Additional economic research has demonstrated that the tax increase had an impact on the decline in consumption independent of the impact of the comprehensive tobacco control program.⁵

Most public opinion polls and surveys indicate that at least 75 percent of the American public supports an increase in the current excise tax on tobacco. A 1993 Gallup poll, which surveyed smoker and nonsmoker support, found that 40 percent of smokers and 85 percent of nonsmokers favored a tobacco excise tax increase to finance national health reform.⁶ A 1993 poll conducted by the American Cancer Society (ACS) found strong support (66 percent) for a significant tobacco tax increase (2 dollars) to support a national health plan. This support was broad-based demographically, with 64 percent of African Americans supporting a 2 dollar increase and 71 percent of Hispanic Americans supporting the increase.⁷

Smokeless Tobacco Products
Smokeless tobacco products are highly addictive and are not safe alternatives to smoking. Moist snuff (dip) and chewing tobacco (chew) are the dominant forms of smokeless tobacco. The standard unit for retail purchase for snuff is a 1.2 ounce tin; and for chew, a 3-ounce pouch. A typical dose of snuff contains two to three times the amount of nicotine in a single cigarette.

The Federal excise tax on smokeless tobacco products is 36 cents per pound for snuff and 12 cents per pound for chewing tobacco; this translates into 2.7 cents per can for snuff and 2.3 cents per package of chewing tobacco. These taxes are considerably less than the 24 cents per pack of cigarettes. State taxes on smokeless tobacco products vary greatly. As of September 30, 1994, 9 States and the District of Columbia had no tax on smokeless tobacco products.

Smokeless tobacco is taxed at about one-tenth the rate of cigarettes. The tax discrepancy between cigarettes and smokeless tobacco may encourage children to start using smokeless tobacco as an alternative to smoking or may encourage the substitution of smokeless tobacco for cigarettes among young people who already smoke.⁸

Among high school seniors who have ever used smokeless tobacco, 73 percent did so by the ninth grade.⁹

The American Public Health Association, the American Dental Association, and the Association of State and Territorial Dental Directors have recommended that taxes on smokeless tobacco products be at least equal to those on cigarettes. In addition, the Association of Public Health Dentistry has supported significant increases in excise taxes on tobacco products. Failure to equalize the tax may result in many smokers switching from cigarettes to smokeless tobacco and many youngsters who would not smoke taking up smokeless tobacco instead.

3.24 Increase to 100 percent the proportion of health plans that offer treatment of nicotine addiction (e.g., tobacco use cessation counseling by health care providers, tobacco use cessation classes, prescriptions for nicotine replacement therapies, and/or other cessation services). (Baseline: 11 percent of health plans cover treatment for nicotine addiction in 1985)

Source: Gelb, B.D. Preventive Medicine and Employee Productivity. Harvard Business Review 64 (2):12. 1985. ¹⁰

Extensive evidence suggests that treatment of nicotine addiction substantially reduces morbidity and mortality due to tobacco-related diseases. In the 1988 report, The Health Consequences of Smoking: Nicotine Addiction, the Surgeon General asserted that treatment of nicotine addiction should be more widely available and that it should be considered at least as favorably by third-party payers as treatment of alcoholism and illicit drug addiction.¹¹ Furthermore, the U.S. Preventive Services Task Force has recommended that smoking cessation counseling be reimbursed by third-party payers.¹²

This new objective seeks to ensure that no tobacco user has financial barriers to seeking effective treatment for their nicotine addiction.

More than 70 percent of U.S. smokers see their physician each year, giving physicians considerable access to smokers.¹³ In addition, dentists see over 60 percent of the U.S. population aged 5 and older within 1 year.¹⁴ Clinical trials have demonstrated that physicians and dentists can help their patients stop smoking.¹⁵ If only half of all U.S. physicians and dentists gave brief advice to their patients and were successful with only 10 percent of them, there would still be more than 2 million new nonsmokers in the United States each year.¹³ The National Cancer Institute has developed manuals for physicians and dentists to assist patients to quit smoking.^13,16 The National Heart, Lung, and Blood Institute has produced a similar manual for nurses.¹⁷

It has been estimated that cessation counseling is more cost effective than beta-adrenergic antagonist therapy after a myocardial infarction.¹⁸ Other studies have shown that physician counseling against smoking is at least as cost effective as several other preventive medical practices, including treatment of mild or moderate hypertension or high cholesterol.¹⁹

Cessation rates improve as the intensity of the intervention increases. Greater cessation rates have been achieved with counseling by health care providers compared to providing advice alone. Even higher rates have been achieved with counseling combined with nicotine replacement therapy. Support for the maintenance of cessation is critical to long-term success.

3.25 * Reduce to zero the number of States that have clean indoor air laws preempting stronger clean indoor air laws on the local level. (Baseline: 17 States had preemptive clean indoor air laws as of January 1995)

Source: Legislative Tracking System, CDC, and State Cancer Legislative Database, NCI

Preemptive State tobacco control laws prevent local jurisdictions from enacting more stringent restrictions than the State law, enacting restrictions varying from the State law, or enacting related restrictions. Although the tobacco industry attempts to promote such laws as health promotion efforts to ensure a minimum uniform set of restriction for all communities, such laws usually afford less protection and prevent local governments from adopting more restrictive provisions in the future.²⁰

Consequences of preemptive laws have included 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.²¹

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.

3.26 Enact in 50 States and the District of Columbia laws banning cigarette vending machines except in places inaccessible to minors. (Baseline: 12 States and the District of Columbia as of January 1995)

There are an estimated 3 million underage smokers in the United States. They purchase 947 million packs of cigarettes and 26 million cans of smokeless tobacco each year, resulting in $1.26 billion in tobacco sales.²² A 1992 study by the CDC concluded that more than half of underage smokers buy their own cigarettes.²³ Although studies also show that only 23 percent of smoking youth now use vending machines often or occasionally, anticipated changes in State enforcement of minors’ access laws may increase the number of underage smokers who use tobacco vending machines.

Vending machines suggest a universal availability of cigarettes in our society. They provide an easy source of tobacco for the youngest underage smokers. A study concluded that most teens (56 percent) say they use vending machines “because no one will stop me from buying cigarettes this way.”24 This same study found that 60 percent of teenage smokers who buy their own cigarettes have ever been refused when they were trying to buy them. Of these, virtually all (98 percent) had been stopped from buying cigarettes over the counter, but only about 1 in 10 had ever been stopped from buying cigarettes from a vending machine.²⁴ Furthermore, because vending machines are self-service, it is difficult to attach responsibility and liability to a particular individual for illegal sales to minors from vending machines, and sales personnel at a register cannot effectively supervise even nearby machines while serving other customers.

Selling candy and cigarettes from the same vending machine, and unrestricted accessibility to tobacco vending machines encourages and facilitates cigarette sales to minors. Although all States have enacted laws prohibiting the purchase of tobacco products under the age of 18, few States have strong vending machine restrictions.

References

1. U. S. Department of Health and Human Services, Public Health Service; National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control, Cancer Control Science Program. The Impact of Cigarette Excise Taxes on Smoking Among Children and Adults: Summary Report of a National Cancer Institute Expert Panel. August 1993.

3. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Pub. No. (PHS)91-50212. Washington, D.C.: U.S. Government Printing Office, 1991. GPO stock #: 017-001-0474-0.

4. Burns, D. and Pierce, J.P. Tobacco Use in California 1990–1991. California Department of Health Services, Tobacco Control Section. University of California, San Diego. Westat, Inc. Los Angeles County Department of Health Services. 1992.

5. Hu, T., et al. Impact of California’s Proposition 99, a major anti-smoking law, on cigarette consumption. Journal of Public Health Policy 15(1): 23–36. 1994.

6. The Gallup Organization. The Public’s Attitudes Toward Cigarette Advertising and Cigarette Tax Increase. Princeton, N.J. April 1993.

7. American Cancer Society. American Cancer Society Survey of U.S. Voter Attitudes Toward Cigarette Smoking. Martilla and Kiley, Inc. September 1993.

8. Institute of Medicine. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, D.C. National Academy Press. 1994.

9. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Preventing Tobacco Use Among People: A Report of the Surgeon General. 1994.

10. Gelb, B.D. Preventive medicine and employee productivity. Harvard Business Review 64(2):12. 1985.

11. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health; 1988. DHHS Publication No: (CDC) 88-8406.

12. Lawrence, R.S. Diffusion of the U.S. Preventive Services Task Force recommendations into practice. Journal of General Internal Medicine 5(Suppl): S99-103. 1990.

13. Glynn, T.J. and Manley, M.W. How to help your patients stop smoking: a National Cancer Institute manual for physicians. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control, Smoking and Tobacco Control Program; November 1991. NIH Publication No. 92-3064.

14. Hayward, R.A., et al. Utilization of dental services; 1986 patterns and trends. Journal of Public Health Dentistry 49:147–152. 1989.

15. Cohen, S.J.; Stookey, G.K.; and Kelly, S.A. Physician and dentist intervention for smoking cessation. Tobacco and the Clinician. U.S. Department of Health and Human Services. 1994. NIH Publication No. 94-3693.

16. Mecklenburg, R.E.; Christen, A.G.; Gerbert, B.; et al. How to help your patients stop using tobacco: a National Cancer Institute manual for the oral health team. Bethesda, MD: U.S. Department of Health and Human Services. September 1991. NIH Publication No. 91-3191.

17. Nurses: Help your patients stop smoking. Bethesda, MD: U.S. Department of Health and Human Services. January 1993. NIH Publication No. 92-2962.

18. Krumholz, H.M., et al. Cost-effectiveness of a smoking cessation program after myocardial infarction. Journal of the American College of Cardiologists 22:1697–1702. 1993.

19. Cummings, S.R.; Rubin, S.M.; and Oster, G. The cost-effectiveness of counseling smokers to quit. Journal of the American Medical Association 262(1): 75–79. 1989.

20. Conlisk, E., et al. The status of local smoking regulations in North Carolina following a state preemption bill. Journal of the American Medical Association 273(10):805–07. 1995.

21. Jordan, J., Pertschuk, M., Carol, J. Preemption in tobacco control: history, current issues, and future concerns. The California Preemption Project. 1995.

22. Difranza, J.R. and Tye, J.B. Who profits from tobacco sales to children? Journal of the American Medical Association 263(20): 2784–87. 1990.

23. Allen, K., et al. Teenage tobacco use: data estimates from the teenage attitudes and practices survey, United States, 1989. Advance Data 224:1–20. 1993.

24. Response Research, Inc. Findings for the study of teenage cigarette smoking and purchasing behavior. NB 6246. June/July 1989.