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From: [email protected] (David Dodell)
Subject: HICN610 Medical Newsletter Part 1/4
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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: [email protected]
FidoNet = 1:114/15
Bitnet = ATW1H@ASUACAD
LISTSERV = [email protected] (or internet: [email protected])
anonymous ftp = vm1.nodak.edu
Notification List = [email protected]
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
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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
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Centers for Disease Control and Prevention - MMWR
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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.
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