CDC's official MMWR electronic copy of record is the MMWR in Adobe Acrobat portable document format (.pdf). The .pdf MMWR is identical in content to the paper copy of record. The MMWR text that follows is in ASCII text file format and has not been proofread. An adequate ASCII translation does not exist for each character possibly present in the .pdf file, and there may be other significant character translation errors. Also, the ASCII text that follows lacks the figures and tables of the electronic .pdf and paper format of MMWR. Therefore, CDC does not consider this ASCII text file to represent a copy of record of the MMWR. -------------------------------------------------------------- The Great American Smokeout, November 16, 1995 Since 1977, the American Cancer Society has sponsored the Great American Smokeout to foster community-based activities that encourage cigarette smokers to stop smoking. This year, the Great American Smokeout will be on Thursday, November 16. The primary goal of this year's event is to prevent initiation of tobacco use among adolescents. From 1965 through 1993, the annual prevalence of cigarette smoking among adults in the United States declined 40% (1). However, the prevalence of smoking among adolescents remained steady since the mid-1980s (2), and the most recent data suggest it is increasing (3). Events this year will include a week of classroom activities intended to raise awareness among teenagers about the social and physical benefits of never starting to smoke. In addition, American Cancer Society volunteers will conduct activities for smokers and their nonsmoking partners at shopping malls, worksites, hospitals, military installations, and other locations. Additional information is available from the American Cancer Society, telephone (800) 227-2345 or (404) 320-3333; and from CDC, telephone (800) 232-1311 or (770) 488-5705. Reported by: American Cancer Society, Atlanta. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. References 1. CDC. Cigarette smoking among adults--United States, 1993. MMWR 1994;43:925-9. 2. Nelson DE, Giovino GA, Shopland DR, et al. Trends in cigarette smoking among U.S. adolescents, 1974 through 1991. Am J Public Health 1995;85:35-40. 3. NCHS. Health, United States, 1994. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1995; DHHS publication no. (PHS)95-1232. Health-Care Provider Advice on Tobacco Use to Persons Aged 10-22 Years -- United States, 1993 Health-Care Provider Advice on Tobacco Use to Persons Aged 10 22 Years United States, 1993 Among U.S. adults who have ever smoked daily, 91% tried their first cigarette and 77% became daily smokers before age 20 years (1). Among high school seniors who had ever tried smokeless tobacco (SLT), 73% did so by the ninth grade (1). Despite the widely publicized risks of tobacco use, in 1993, 61% of high school sophomores believed that the risk from cigarette smoking was "great," and 44% believed the risk from SLT use was "great" (2). The low levels of understanding about the harmfulness of tobacco products underscore the need for health-care providers and others to provide adolescents and young adults with information to counter the allure of tobacco use created by marketing efforts. This report summarizes an analysis of data from the 1993 Teenage Attitudes and Practices Survey (TAPS II) regarding the provision of information about tobacco use by health-care providers to persons aged 10-22 years. Data about knowledge of, attitudes toward, and practices regarding tobacco use among persons aged 10-22 years were collected by TAPS II by telephone interviews and by personal interviews among respondents not available by telephone. The sample for this analysis comprised 7960 respondents who had participated in the 1989 TAPS interview and who subsequently responded to TAPS II (aged 15-22 years at the time of the second interview), and an additional 4992 persons from a new probability sample in 1993 of 5590 persons aged 10-15 years (89.3% response rate). Data were weighted to provide national estimates. Adjusted odds ratios were computed by multiple logistical regression simultaneously adjusting for all other variables, and 95% confidence intervals were calculated using SUDAAN (3). Questions included: "Has a doctor, dentist, or nurse ever said anything to you about cigarette smoking?" and "Has a doctor, dentist, or nurse ever said anything to you about using chewing tobacco or snuff?" Correlations with affirmative responses were analyzed in relation to five categories of smoking and SLT use: Never smoked/used (never), tried but never smoked/used on daily basis or during the month preceding the interview (tried), smoked/used daily for at least 1 month but no smoking/use during the month preceding the interview (past daily), smoked/used during the month preceding the interview but never smoked/used daily for at least 1 month (current, never daily), and smoked/ used daily for at least 1 month and on greater than or equal to 1 day during the month preceding the interview (current, ever daily). One fourth (25%) of respondents reported that a health-care provider had said something to them about cigarette smoking, and 12% said the same about SLT. More females (27%) than males (24%) answered "yes" to the question about cigarettes, and more males (14%) than females (9%) answered "yes" about SLT (Tables 1 and 2). The proportion of respondents who answered "yes" increased significantly with age for cigarette smoking but not for SLT. Affirmative responses were most strongly correlated with having a history of tobacco use (Tables 1 and 2). Young persons who reported current or previous smoking or SLT use on a daily basis for at least 1 month (current or past daily) were significantly more likely than persons who had never smoked/used to answer "yes." Among current, ever daily users, 50% of smokers and 48% of SLT users answered "yes" compared with 21% of never smokers and 10% of never SLT users. Reported by: LS Baker, MPH, Center for the Future of Children, The David and Lucile Packard Foundation, Los Altos, California. GE Morley, The Robert Wood Johnson Foundation, Princeton, New Jersey. DC Barker, MHS, The California Wellness Foundation, Woodland Hills, California. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: One of the national health objectives for the year 2000 is to increase to at least 75% the proportion of primary-care physicians who routinely provide smoking-cessation advice to their patients (objective 3.16) (4). In addition, the American Medical Association has recommended that primary-care physicians and other health-care providers ask adolescents annually about their use of tobacco products and patterns of use and provide a cessation plan to adolescents who use tobacco products (5). The findings in this report indicate that only approximately half of those persons aged 10-22 years who had ever smoked or used SLT daily and were current cigarette smokers or users of SLT recall ever receiving any communication about the use of cigarettes or SLT from physicians, dentists, or nurses. The analysis of the TAPS II data is subject to at least two limitations. First, because these self-reported data are based on respondents' recollection of their communication with a health-care provider, they probably underestimate the interactions between patients and their health-care providers. Second, TAPS and TAPS II do not contain information about the number of visits to health-care providers. However, the likelihood that health-care providers will advise against tobacco use is directly related to the number of visits, and the average annual number of physician contacts varies by age, sex, race/ethnicity, and income level (6). The analysis of TAPS is consistent with other reports documenting missed opportunities to provide information before adolescents begin to use tobacco (1,7,8). Although use of cigarettes and SLT begins early in adolescence (1), the TAPS findings indicate that only 24% of respondents who had tried a cigarette and only 13% of those who had tried SLT recalled hearing about tobacco use from a health-care provider. In addition, health-care providers were more likely to say something about tobacco use to patients who were current or heavy users, a pattern consistent with that for adults (9). Basic strategies to prevent nicotine addiction in adolescents and young adults include tobacco tax increases, enforcement of laws preventing the access of minors to tobacco, youth-oriented mass media campaigns, and school-based tobacco-use prevention programs (1). In addition, the role of health-care providers is critical in preventing patients from initiating tobacco use or quitting if they become addicted to nicotine: patients who are told to quit smoking by their physician are nearly twice as likely to be preparing to quit than were those who had never been so advised (10). The National Cancer Institute and the American Medical Association have developed guidelines and national training programs to assist health-care providers in discussing both cigarette and SLT use with young patients (5,7,8). In addition, CDC, in conjunction with the American Medical Association, is funding new initiatives to foster development of innovative cessation services for adolescents. References 1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 2. Johnston LD, O'Mally PM, Bachman JG. National survey results on drug use from the Monitoring the Future study, 1975-1993. Volume 1: secondary school students. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, 1994; NIH publication no. 94-3809. 3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for survey data analysis (SUDAAN) version 5.5 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1991. 4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 5. American Medical Association. Guidelines for adolescent preventive health services. Chicago: American Medical Association, 1993. 6. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Vital and health statistics; series 10, no. 190). 7. Epps RP, Manley MW. Prevention of tobacco use during childhood and adolescence: five steps to prevent the onset of smoking. Cancer 1993;72:1002-4. 8. Mecklenberg RE, Christen AG, Gerbert B, et al. How to help your patients stop using tobacco: a manual for the oral health team. Bethesda, Maryland: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1993; NIH publication no. 93-3191. 9. Frank E, Winkleby MS, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians' smoking cessation advice. JAMA 1991;266:3139-44. 10. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549-53. Symptoms of Substance Dependence Associated with Use of Cigarettes, Alcohol, and Illicit Drugs -- United States, 1991-1992 Each year in the United States, approximately 400,000 deaths result from cigarette smoking, 100,000 from misuse of alcohol, and 20,000 from use of illicit drugs (1). Many of the adverse health effects associated with the use of tobacco, alcohol, and illicit drugs result from long-term use caused by substance dependence (i.e., addiction) (2,3)--a cluster of cognitive, behavioral, and physiological symptoms indicating sustained psychoactive substance use despite substance-related problems (4). In addition, substance dependence is characterized by repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior. Nicotine is the psychoactive substance in cigarettes and other forms of tobacco that accounts for the addictive properties of tobacco (2). In addition to tobacco, other potentially addictive substances include alcohol, marijuana, and cocaine (3). To assess the prevalence of selected indicators of substance dependence among the U.S. population, CDC and the National Institute on Drug Abuse analyzed data from the National Household Survey on Drug Abuse (NHSDA) (5) for 1991-1992. The findings in this report suggest that a symptom of substance dependence is more likely to be reported by persons who smoke cigarettes and persons who use cocaine than by persons who use alcohol or marijuana. NHSDA is a household survey of a nationally representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 12 years. Data from the 1991 and 1992 surveys were combined (n=61,426) to estimate the prevalence of daily use of cigarettes, alcohol, marijuana, and cocaine for greater than or equal to 2 consecutive weeks during the preceding 12 months; attempts to reduce use; and four indicators of substance dependence among persons aged greater than or equal to 12 years who reported having used one of the four substances one or more times during the 30 days preceding the survey. Indicators of dependence for other substances (including heroin, tranquilizers, sedatives, analgesics, and inhalants) were not analyzed because the numbers of persons who reported use were too small to calculate reliable estimates. Information about the indicators of dependence was based on responses to four questions; persons who reported current use* of cigarettes, alcohol, marijuana, or cocaine were asked whether, during the 12 months preceding the survey, they 1) "felt [they] needed or were dependent on [the substance]," 2) "needed larger amounts to get the same effect," 3) "felt unable to cut down on [their] use even though [they] tried," and 4) "had withdrawal symptoms, that is, felt sick because [they] stopped or cut down on [their] use." The analysis of "unable to cut down" and "felt sick" was restricted to persons who reported trying to reduce their substance use during the preceding 12 months. Data were adjusted for nonresponse and weighted to provide national estimates. Standard errors were calculated by using SUDAAN (6). Of the 61,426 total NHDSA participants during 1991-1992, use of cigarettes, alcohol, marijuana, or cocaine during the 30 days preceding the survey was reported by 14,688 (26.6%), 27,814 (49.4%), 3904 (4.6%), and 821 (0.8%) persons, respectively (Table 1, page 837). Daily use of these substances for greater than or equal to 2 consecutive weeks during the 12 months preceding the survey was reported by 78.4% of persons who smoked cigarettes, and by 22.6%, 13.8%, and 12.4% of those who used marijuana, alcohol, and cocaine, respectively. Cigarette smokers were more likely than persons who used the other substances to report having tried to cut down, and were approximately twice as likely as persons who used alcohol, marijuana, or cocaine to report having been unable to cut down (Table 1, page 837). Cigarette smokers were more likely than users of the other substances to report feeling dependent on the substance or feeling sick when they stopped or cut down on its use. Cigarette smokers (75.2%) were more likely to report one of the four symptoms of dependence than were persons who used cocaine (29.1%), marijuana (22.6%), or alcohol (14.1%). To compare data for more frequent users, the analysis was restricted to persons who had used these substances daily for greater than or equal to 2 consecutive weeks during the 12 months preceding the survey. Of the 47,227 current substance users, 14,615 (30.9%) reported daily use. Among these persons, those who smoked cigarettes were more likely than those who used alcohol or marijuana to report having been unable to cut down (Table 1, page 837). Persons who had used cocaine daily were more likely than persons who had used cigarettes, alcohol, or marijuana to report feeling a need for more of the substance to get the same effect. Persons who were daily cigarette smokers were more likely than persons who used alcohol, marijuana, or cocaine daily to report feeling dependent on the substance and were more likely than daily users of alcohol or marijuana to report feeling sick when they stopped or cut down. Among persons who had used any of the four substances every day for greater than or equal to 2 consecutive weeks, those who smoked cigarettes (90.9%) and those who used cocaine (78.9%) were more likely to report a symptom of addiction than were persons who used alcohol (48.1%) or marijuana (58.8%). To determine whether the prevalence of reported symptoms varied for different measures of frequency of use, the analysis was further restricted to persons who reported that, on average, they used each substance on a daily or weekly basis during the 12 months preceding the survey. Although the prevalance estimates varied within each category of substance use, the relative ranking of the substances by frequency of symptoms of dependency remained constant. Reported by: J Henningfield, Clinical Pharmacology Research Br, Addiction Research Center, National Institute on Drug Abuse. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report suggest that persons who smoked cigarettes and persons who used cocaine were more likely than those who used alcohol or marijuana to report a symptom of substance dependence after controlling for frequency of use. The high level of dependency associated with cigarette smoking may account, in part, for the low success rate for attempts to quit smoking (only 2.5% of smokers successfully quit each year) even though most smokers report wanting to quit smoking (7). In addition, a high proportion (73%) of adolescents who smoke but who intended to quit smoking in 5-6 years were still smoking 5 years later (8). The findings in this report are subject to at least three limitations. First, the four NHSDA indicators do not provide a comprehensive measure of substance dependence because not all symptoms of the withdrawal syndromes characteristic of each substance were included. As a result, the proportion of persons who reported at least one indicator of substance dependence may be underestimated. Second, the categories of substance use were not mutually exclusive, and possible interactions experienced by users of multiple substances were not examined. Finally, these findings are based on self-reported data, and self-perception of substance dependence was not validated; however, self-reported symptoms of nicotine dependence have been confirmed previously by observer rating (2). Although the severity of dependence can be estimated by the number of symptoms reported for persons using a particular psychoactive substance (4), criteria have not been developed to enable comparisons of the severity of dependence of different substances (9). Therefore, the findings in this report cannot be interpreted to indicate that nicotine produces more severe addiction than cocaine, marijuana, or alcohol. In addition, differences in the patterns of use of these substances and in the development of dependency may reflect their availability and accessibility: because cigarettes and alcohol are legal for adults, they are more available and accessible than marijuana and cocaine. Other factors that may account for some of these differences include price, advertising and promotion, social pressure, regulations, sanctions, and pharmacologic characteristics (9). The use of cigarettes, alcohol, and illicit drugs all result in excess dependence, morbidity, and mortality and in substantial economic costs (1,3,10). Public health interventions that decrease the availability and social acceptability of tobacco use assist in reducing the initiation of use and the development of nicotine addiction (8). These approaches include reducing illegal sales of tobacco to minors, increasing the real price of tobacco products, restricting tobacco advertising and promotion targeted toward minors, and conducting educational and advertising campaigns that "deglamorize" tobacco use. School- and community-based educational interventions can help prevent tobacco initiation (8) and the use of alcohol and other substances (10). In addition, improved access to substance-dependence treatment programs may help reduce the health burden resulting from the use of tobacco, alcohol, and illicit drugs (10). References 1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12. 2. CDC. The health consequences of smoking: nicotine addiction--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (CDC)88-8406. 3. Schuster CR, Kilbey MM. Prevention of drug abuse. In: Maxcy KF, Rosenau MJ, Last JM, (eds). Maxcy-Rosenau-Last public health and preventive medicine. 13th ed. East Norwalk, Connecticut: Appleton and Lange, 1992. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. 5. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: population estimates, 1992. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1993; DHHS publication no. (SMA)93-2053. 6. Shah BV. Software for survey data analysis (SUDAAN), version 5.5 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1991. 7. CDC. Smoking cessation during previous year among adults--United States, 1990 and 1991. MMWR 1993;42:504-7. 8. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 9. Henningfield JE, Cohen C, Slade JD. Is nicotine more addictive than cocaine? Br J Addict 1991;86:565-9. 10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. *Used one or more times during the 30 days preceding the survey. Minors' Access to Smokeless Tobacco -- Florida, 1994 Laws enacted by the legislature in Florida to restrict access of minors to tobacco (Florida Revised Statutes 859.06-859.061) went into effect October 1, 1992, and May 20, 1994; these laws prohibit the sale of tobacco products to persons aged less than 18 years and require the posting of a warning sign indicating that such sales to minors are illegal. Merchants convicted for such violations can be fined up to $500 and imprisoned up to 60 days. Florida and Vermont are the only states that enforce access laws restricting the sale of tobacco to minors statewide (1). Although minors' access to cigarettes is well documented, the extent to which minors have access to smokeless tobacco (SLT) has not been well characterized. To assess the effectiveness of the Florida laws in preventing minors from gaining over-the-counter access to SLT and in ensuring that tobacco vendors comply with the sign statute, in November 1994, the Department of Exercise Science/Wellness Education of Florida Atlantic University conducted a study of minors' attempts to access SLT in Palm Beach County (1990 population: 863,518). The findings in this report indicate that, despite the enactment of laws prohibiting the sale of tobacco products to persons aged less than 18 years, some minors still were successful at purchasing SLT. The 1994-95 Florida Business Directory was used to identify four categories of retail outlets in Palm Beach County: convenience stores, grocery stores, pharmacies, and gasoline stations (n=722). A map of the county was divided into 12 equally sized areas; within each of these areas, 11 sample retail sites were randomly selected to produce a total sample of 132 retail sites. Of the 132 sites, 44 were excluded from the assessment because they had closed, had moved, no longer sold tobacco products, or were considered by the adult team member at the time of the purchase attempt to be in unsafe areas. The remaining 88 stores represented 12% of the 722 retail sites in the county, and comprised 25 (17%) of 149 pharmacies, 10 (8%) of 125 grocery stores, 39 (16%) of 246 gas stations, and 14 (7%) of 202 convenience stores. Four teams of volunteers, each comprising one minor (from among four minors aged 11-17 years) and one adult, were used for the assessment; three of the minors were female, aged 11, 14, and 17 years, and one was a 14-year-old male. One purchase attempt was made at each of the 88 stores. Purchase attempts followed a standard procedure: the adult member of the team entered the store first to note the presence of any clearly displayed signs stating that tobacco products would not be sold to minors. The adult then observed while the minor entered the retail site, selected a SLT (i.e., snuff or loose-leaf or fine-cut chewing tobacco) and attempted to purchase the product. If a sale was recorded on the cash register or the vendor placed the SLT on the counter for purchase by the minor, the attempt was considered successful; the minor would then state that he or she had insufficient money for purchase and would immediately leave the store. The attempt also was considered successful if the vendor asked the minor's age but was prepared to sell the SLT.* If the minor was denied purchase outright or was asked for age verification and denied purchase, the attempt was considered unsuccessful. The adult member recorded reasons for refusal as stated by the vendor at the time of attempted purchase; when no refusal reason was provided to the minor, the adult team member waited until the minor had departed and then asked the vendor about the reason for refusal. Significance testing was performed using Pearson chi-square tests. Overall, attempts by minors to purchase SLT were successful in 31 (35%) of the 88 retail sites. The likelihood of a successful attempt was greater for the 17-year-old female (24 [77%] of 31 attempts) (p less than 0.01). The likelihood of a successful attempt was similar for each of the four categories of stores: attempts were successful at 15 (39%) of the 39 gas stations; five (36%) of the 14 convenience stores; eight (32%) of the 25 pharmacies; and three (30%) of the 10 grocery stores. Of the 65 stores for which data were available, warning signs provided by the Florida Department of Business and Professional Regulation were posted in 27 (42%); purchase attempts were more successful in stores without signs than in those with signs (20 [57%] of 35 versus seven [23%] of 30, respectively [p less than 0.01]). Reasons specified by the vendors for the 57 unsuccessful attempts were that the minors looked too young (34 [60%] attempts), that the sale of tobacco products to minors was illegal (11 [19%] attempts), and that the store had a policy prohibiting sales to minors (eight [14%] attempts); in four (7%) attempts, either no product was offered when a minor requested it or no refusal explanation was offered. Reported by: FS Bridges, EdD, RL Welsh, PhD, Dept of Exercise Science/Wellness Education, Florida Atlantic Univ, Davie; JM Malecki, MD, HRS/Palm Beach County Public Health Unit, West Palm Beach, Florida. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The assessment in Palm Beach County indicates that, despite the enactment of state laws prohibiting the sale of tobacco to persons aged less than 18 years, 35% of minors were successful in making attempts to purchase SLT. Previous assessments in Kansas and Texas documented successful attempt rates by minors of 15% and 59%, respectively (2,3). The differences in successful attempt rates in the three assessments may reflect, in part, variations related to the ages of the minors making the purchase attempts. For example, in Palm Beach County, the 17-year-old female was more likely to be successful than those minors aged less than 14 years, possibly because some vendors may have presumed that the SLT was not for her use (S. Bridges, Florida Atlantic University, personal communication, 1995). As a result of the assessment in Palm Beach County, measures to reduce the sale and use of tobacco products among minors in the county will be implemented and will include educating the public and the business community about this problem, and encouraging businesses that sell SLT to comply with the state laws prohibiting the sale of tobacco to minors and to post warning signs about those laws. In addition, other strategies policy makers and school and public health officials can use to prevent the use of tobacco by minors include 1) the designation of state agencies to be primarily responsible for investigation and enforcement of sales to minors, 2) increasing the severity of penalties for repeat illegal sales, 3) levying separate fines for failure to post warning signs stating the legal age of purchase, 4) requiring retailers to ask all purchasers of tobacco products to show proof of age, 5) restricting tobacco-product advertising targeted toward minors, 6) ensuring that health education curricula in grades kindergarten through 12 include a tobacco-education component; and 7) banning the use of vending machines (3,4). References 1. Office of Evaluations and Inspections. Youth access to tobacco. Washington, DC: US Department of Health and Human Services, Office of the Inspector General, 1992; DHHS publication no. (OEI)02-91-00880. 2. Hoppock KC, Houston TP. Availability of tobacco products to minors. J Fam Pract 1990;30:174-6. 3. CDC. Minors' access to tobacco--Missouri, 1992, and Texas, 1993. MMWR 1993;42:125-8. 4. Public Health Service. Model Sale of Tobacco Products to Minors Control Act. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990. *During one successful purchase attempt, the adult/minor team determined that the vendor was prepared to sell based on the vendor's tone of voice during the attempted transaction and the vendor's movement of the SLT toward the minor at the sales counter. Outbreak of Acute Febrile Illness and Pulmonary Hemorrhage -- Nicaragua, 1995 During the week of October 15, three persons died after presenting to the Achuapa Health Center in Leon state (1995 population: 330,168), Nicaragua, with an acute febrile illness. During the next 2 weeks, at least 400 persons were evaluated at clinics in Achuapa (1995 population: 12,741) and nearby El Sauce (1995 population: 24,289) for acute illnesses characterized by fever, chills, headache, and musculoskeletal pain. As of November 7, approximately 150 of these patients and 150 persons from nearby areas had been hospitalized in the regional medical center in Leon because of more severe manifestations, including intense abdominal pain, hypotension, and/or respiratory distress. At least 13 of the patients have died from respiratory distress and pulmonary hemorrhage. This report summarizes the preliminary findings of the ongoing investigation of this outbreak by the Nicaraguan Ministry of Health, the Pan American Health Organization, and CDC. Dengue and dengue hemorrhagic fever were initially suspected as the cause of the outbreak but were ruled out in Nicaragua and at CDC by serologic tests and polymerase chain reaction assays of serum specimens. Additional serologic tests found no significant reactions to other arthropodborne and zoonotic pathogens, including New World arenaviruses, lymphocytic choriomeningitis virus, hantaviruses, other Bunyaviridae, Filoviridae, Flaviviridae, Rhabdoviridae, Togaviridae, spotted-fever-group and typhus-group rickettsia, Ehrlichia chaffeensis, and Coxiella burnetii. Preliminary histopathologic examination at CDC of multiple tissues from four decedents indicates features consistent with leptospirosis. Specifically, silver impregnation staining of autopsy specimens from two patients identified organisms with typical leptospiral morphology in kidney and liver tissue; in a third patient, leptospiral morphology was less typical. These findings were confirmed by immunohistochemical staining using rabbit polyclonal reference antiserum reactive with 16 different leptospiral strains. Leptospiral antigens were seen as intact leptospira, thread-like filaments, and granular forms in liver and kidney tissue from three patients. Immunohistochemical tests of these tissues with polyclonal antibodies were negative for dengue virus, yellow fever virus, hantaviruses, arenaviruses and Ebola virus. Reported by: F Munoz, MD, C Jarquin, MD, A Gonzalez, MD, J Amador, MD, J de los Reyes, MD, R Jimenez, MD, Ministry of Health, Nicaragua. F Lamy, MD, N Jiron, MD, Pan American Health Organization, Nicaragua. F Pinheiro, Pan American Health Organization, Washington, DC. US Agency for International Development, Managua, Nicaragua. Div of Vector-Borne Infectious Diseases, Div of Bacterial and Mycotic Diseases, and Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The preliminary findings of this investigation indicate that leptospirosis was the most likely cause of fatal pulmonary hemorrhage in four hospitalized patients in Nicaragua. Additional studies are under way to confirm the role of leptospiral infection in the outbreak of acute febrile illness, establish animal reservoirs of infection, and identify potentially modifiable risk factors for disease. The investigation has thus far ruled out the potential role of dengue virus and other arthropodborne and rodentborne pathogens; in Central and South America, mosquitoborne dengue is a leading cause of febrile illness, and the increasing circulation of multiple dengue serotypes, including dengue type 3, has been associated with an increase in reported hemorrhagic manifestations of dengue (1,2). Leptospirosis is a zoonotic disease of worldwide distribution, involving many wild and domestic animals (3). Human infection may result from indirect or direct exposure to infected urine, often through contaminated water or soil. The investigation in Nicaragua is examining the possibility that infection in humans resulted from exposure to water and soil contaminated by animal urine following recent heavy rainfall and flooding in that region. The spectrum of leptospiral disease is broad and may include fever, headache, chills, myalgia, abdominal pain, and conjunctival suffusion; more severe manifestations include renal failure, jaundice, meningitis, hypotension, hemorrhage, and/or hemorrhagic pneumonitis (4). Severe pulmonary symptoms and pulmonary hemorrhage have not been characteristic of leptospirosis in the Western Hemisphere but have been associated with large outbreaks in Korea and China (5,6). Clinical features of leptospirosis are similar to many other febrile illnesses; in the tropics, the differential diagnosis of such illnesses also may include dengue and malaria. Leptospirosis is diagnosed by isolation of leptospires from blood or cerebrospinal fluid during the acute illness and from urine greater than or equal to 10 days after the onset of symptoms or by documenting rising titers in serologic tests, such as the microagglutination test. Penicillin is the antibiotic of choice for leptospirosis, and treatment should be initiated early in the course of illness (7). Alternatives are amoxicillin, ampicillin, doxycycline, and tetracycline. Supportive therapy is essential for managing dehydration, hypotension, hemorrhage, renal failure, and pulmonary involvement. For adults with short-term, high-risk exposure to leptospirosis, doxycycline provides effective prophylaxis when administered weekly in a single oral dose of 200 mg (8). Public health measures include controlling rodents, preventing contact with animal urine, wearing protective clothing (e.g., water-resistant boots) when exposure is likely, and avoiding swimming or wading in potentially contaminated water (i.e., with urine of infected animals). Additional information is available from the CDC Fax Information Service, telephone (404) 332-4565; enter document number 221013# at the prompt. References 1. Gubler DJ, Clark GG. Dengue/dengue hemorrhagic fever: the emergence of a global health problem. Emerging Infectious Diseases 1995;1:55-7. 2. CDC. Dengue type 3 infection--Nicaragua and Panama, October-November 1994. MMWR 1995;44:21-4. 3. Torten M, Marshall RB. Leptospirosis. In: Beran GW, ed. Handbook of zoonoses. Section A: bacterial, rickettsial, chlamydial, and mycotic. Boca Raton, Florida: CRC Press, 1994:245-64. 4. Farr RW. Leptospirosis. Clin Infect Dis 1995;21:1-8. 5. Wang CN, Liu J, Chang TF, Cheng WJ, Luo MY, Hung AT. Studies on anicteric leptospirosis: I. Clinical manifestations and antibiotic therapy. Chinese Med J 1965;84:283-391. 6. Park SK, Lee SH, Rhee YK, et al. Leptospirosis in Chonbuk Province of Korea in 1987: a study of 93 patients. Am J Trop Med Hyg 1989;41:345-51. 7. Farrar WE. Leptospira species (Leptospirosis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. New York: Churchill Livingstone, 1995:2137-41. 8. Takafuji ET, Kirkpatrick JW, Miller RN, et al. An efficacy trial of doxycycline chemoprophylaxis against leptospirosis. N Engl J Med 1984;310:497-500.