27
 |
|
|
| Lead Agency: | |
Centers for Disease Control and Prevention |
Scientific knowledge about the health effects of tobacco use has increased greatly since the first Surgeon General’s report on tobacco was released in 1964.[1], [2] Cigarette smoking causes heart disease, several kinds of cancer (lung, larynx, esophagus, pharynx, mouth, and bladder), and chronic lung disease. Cigarette smoking also contributes to cancer of the pancreas, kidney, and cervix. Smoking during pregnancy causes spontaneous abortions, low birth weight, and sudden infant death syndrome.[3]
Other forms of tobacco are not safe alternatives to smoking cigarettes. Use of spit tobacco causes a number of serious oral health problems, including cancer of the mouth and gum, periodontitis, and tooth loss.1, [4] Cigar use causes cancer of the larynx, mouth, esophagus, and lung.[5] In recent years, reports have shown an increase in the popularity of bidis.[6] Bidis are small brown cigarettes, often flavored, consisting of tobacco hand-rolled in tendu or temburni leaf and secured with a string at one end. Research shows that bidis are a significant health hazard to users, increasing the risk of coronary heart disease and cancer of the mouth, pharynx and larynx, lung, esophagus, stomach, and liver.[7]
Tobacco use is responsible for more than 430,000 deaths per year among adults in the United States, representing more than 5 million years of potential life lost.[8] If current tobacco use patterns persist in the United States, an estimated 5 million persons under age 18 years will die prematurely from a smoking-related disease.[9] Direct medical costs related to smoking total at least $50 billion per year;[10] direct medical costs related to smoking during pregnancy are approximately $1.4 billion per year.[11]
Evidence is accumulating that shows maternal tobacco use is associated with mental retardation and birth defects such as oral clefts. Exposure to secondhand smoke also has serious health effects.[12], [13], [14] Researchers have identified more than 4,000 chemicals in tobacco smoke; of these, at least 43 cause cancer in humans and animals.13 Each year, because of exposure to secondhand smoke, an estimated 3,000 nonsmokers die of lung cancer, and 150,000 to 300,000 infants and children under age 18 months experience lower respiratory tract infections.13, 14 Asthma and other respiratory conditions often are triggered or worsened by tobacco smoke. (See Focus Area 8. Environmental Health; Focus Area 16. Maternal, Infant, and Child Health; and Focus Area 24. Respiratory Diseases.)
Studies also have found that secondhand smoke exposure causes heart disease among adults.[15], [16] Data reported from a study of the U.S. population aged 4 years and older indicated that among nontobacco users, 88 percent had detectable levels of serum cotinine, a biological marker for exposure to secondhand smoke.[17] Both home and workplace environments have contributed to the widespread exposure to secondhand smoke. Data from a 1996 study indicated that 22 percent of U.S. children and adolescents under age 18 years (approximately 15 million children and adolescents) were exposed to secondhand smoke in their homes.[18]
Smoking among adults declined steadily from the mid-1960s through the 1980s. However, smoking among adults appears to have leveled off in the 1990s. The rate of smoking among adults in 1997 was 25 percent.[19]
Tobacco use and addiction usually begin in adolescence. Furthermore, tobacco use may increase the probability that an adolescent will use other drugs. (See Focus Area 26. Substance Abuse.) Among adults in the United States who have ever smoked daily, 82 percent tried their first cigarette before age 18 years, and 53 percent became daily smokers before age 18 years.[20] Preventing tobacco use among youth has emerged as a major focus of tobacco control efforts.
Tobacco use among adolescents increased in the 1990s after decreasing in the 1970s and 1980s. Data from the 1999 Monitoring the Future Study indicated that past-month smoking among 8th, 10th, and 12th graders was 18, 26, and 35 percent, respectively. These rates represent increases of 20 to 33 percent since 1991.[21] Data from the Youth Risk Behavior Survey revealed that past-month smoking among 9th to 12th graders rose from 28 percent in 1991 to 36 percent in 1997.[22] Past-month spit tobacco use among 9th to 12th graders was 9 percent in 1997 (2 percent among females and 16 percent among males).22 In 1997, past-month cigar use among 9th to 12th graders was 22 percent (11 percent of females and 31 percent of males).22
Youth are put at increased risk of initiating tobacco use by sociodemographic, environmental, and personal factors. Sociodemographic risk factors include coming from a family with low socioeconomic status. Environmental risk factors include accessibility and availability of tobacco products, cigarette advertising and promotion practices, the price of tobacco products, perceptions that tobacco use is normal, peers’ and siblings’ use and approval, and lack of parental involvement. Personal risk factors include low self-image and low self-esteem, the belief that tobacco use provides a benefit, and the lack of ability to refuse offers to use tobacco.20
Overwhelming evidence indicates that nicotine found in tobacco is addictive and that addiction occurs in most smokers during adolescence.20, [23] Among students who were high school seniors during 1976–86, 44 percent of daily smokers believed that in 5 years they would not be smoking. Followup studies, however, indicated that 5 to 6 years later 73 percent of these persons remained daily smokers.20 In 1995, 68 percent of current smokers wanted to quit smoking completely, and 46 percent of the current daily smokers had stopped smoking for at least 1 day during the preceding 12 months.19 Less than 3 percent of current smokers stopped smoking permanently.[24]
Men are more likely to smoke than women (26 percent compared to 22 percent).19 Disparities in tobacco use exist among certain racial and ethnic populations.American Indians or Alaska Natives (35 percent) are more likely to smoke than other racial and ethnic groups, with considerable variations in percentages by Tribe.[25] Hispanics (18 percent) and Asians or Pacific Islanders (13 percent) are less likely to smoke than other groups. Regional and local data, however, reveal much higher smoking levels among specific population groups of Hispanics and Asians or Pacific Islanders.25 Smoking levels among Vietnamese and Korean Asian Americans are higher than previously reported, according to a 1997 multilingual survey.[26]
Studies have found higher levels of cigarette use among gay men and lesbians than among heterosexuals.[27], [28], [29], [30] Gay men and lesbians with higher education levels are less likely to use cigarettes as frequently as those with lower levels of education.28
Persons with 9 to 11 years of education (38 percent) have significantly higher levels of smoking than individuals with 8 years or less of education or 12 years or more. Individuals with 16 or more years of education have the lowest smoking rates (11 percent). Individuals who are poor are significantly more likely to smoke than individuals of middle or high income (34 percent compared to 21 percent).19
Data reveal high levels of tobacco use among college students. In 1995, 29 percent of college students smoked in the previous month (28 percent of females and 30 percent of males). Five percent of college students used spit tobacco in the previous month (0.3 percent of females and 12 percent of males).[31]
Among adolescents, smoking rates differ between whites and African Americans.21, 22 By the late 1980s, smoking rates among white teens were more than triple those of African American teens. In recent years, smoking has started to increase among African American male teens, but African American female teens continue to have lower smoking rates. In 1997, 40 percent of white high school females were smokers, compared to 17 percent of African American high school females.22
Spit tobacco use among adolescents also differs significantly by students’ gender, race, and ethnicity. In 1997, 15.8 percent of male high school students currently used spit tobacco, compared to only 1.5 percent of female high school students. Current spit tobacco use was 12.2 percent for non-Hispanic whites, 2.2 percent for non-Hispanic African Americans, and 5.1 percent for Hispanics.22
Efforts to reduce tobacco use in the United States have shifted from focusing primarily on smoking cessation for individuals to more population-based interventions. Such interventions emphasize prevention of initiation, reduction of exposure to environmental tobacco smoke, and policy changes in health care systems to promote smoking cessation.20, [32], [33], [34], [35], [36], [37] Federal, State, and local government agencies and numerous health organizations have joined together to develop and implement population-based approaches.
Community research studies and evidence from California, Florida, Massachusetts, and Oregon have shown that comprehensive programs can be effective in reducing average cigarette consumption per person. Both California and Massachusetts increased cigarette excise taxes and designated a portion of the revenues for comprehensive tobacco control programs. Data from these States indicate that (1) increasing excise taxes on cigarettes is one of the most cost-effective short-term strategies to reduce tobacco consumption among adults and to prevent initiation among youth and (2) the ability to sustain lower consumption increases when the tax increase is combined with an antismoking campaign.[38] In addition, recent data from Florida indicate that past-month smoking decreased significantly among public middle school students (19 percent to 15 percent) and high school students (27 percent to 25 percent) from 1998 to 1999 following implementation of a comprehensive program to prevent and reduce tobacco use among youth in that State.[39]
As education programs for school-aged youth are developed and proven effective in preventing initiation and in cessation, these programs should be included in quality health education curricula at the grade level. Education should aim to prevent initiation among youth, provide knowledge about effective cessation methods, and increase understanding of the health effects of tobacco use. (See Focus Area 7. Educational and Community-Based Programs.)
The goals of comprehensive tobacco prevention and reduction efforts include preventing people from starting to use tobacco, helping people quit using tobacco, reducing exposure to secondhand smoke, and identifying and eliminating disparities in tobacco use among population groups. To address these goals, community programs, media interventions, policy and regulatory activities, and surveillance and evaluation programs are being implemented. Specifically, the following elements are used to build capacity to implement and support tobacco use prevention and control interventions: a focus on change in social norms and environments that support tobacco use, policy and regulatory strategies, community participation, establishment of public and private partnerships, strategic use of media, development of local programs, coordination of statewide and local activities, linkage of school-based activities to community activities, and use of data collection and evaluation techniques to monitor program impact.
The importance of these various strategic elements has been demonstrated in a number of States, such as Arizona, California, Florida, Massachusetts, and Oregon.[40] In these and other States, tobacco control programs are supported through funding from the Federal Government, private foundations, State tobacco taxes, State lawsuit settlements, and other sources. These programs address issues such as reducing exposure to secondhand smoke, restricting minors’ access to tobacco, treating nicotine addiction, limiting the impact of tobacco advertising, increasing the price of tobacco products, and directly regulating the product (for example, requiring product ingredient reporting). Tobacco control programs and materials should be culturally and linguistically appropriate.
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Consumption: The amount of tobacco products consumed or used by the population. Consumption usually is measured in units, such as the number of cigarettes smoked or pounds of spit tobacco used over a given period of time.
Counteradvertising: The placement of pro-health advertisements on TV, on radio, in print, on billboards, on movie trailers, on the Internet, and in other media.
Illegal buy rate: Rate of illegal sales to minors in compliance checks to assess adherence to minors’ tobacco access laws.
Nicotine dependency: Highly controlled or compulsive use, use despite harmful effects, withdrawal upon cessation of use, and recurrent drug craving.
Notifiable condition: A disease or risk factor that is reported to the Centers for Disease Control and Prevention by the States and the District of Columbia.
Pharmacotherapy: Medical treatment using pharmaceuticals or drugs.
Preemptive laws: Legislation prohibiting any local jurisdiction from enacting restrictions more stringent than State law or restrictions that may vary from State law.
Secondhand smoke: A mixture of the smoke exhaled by smokers and the smoke that comes from the burning end of the tobacco product.
Serum cotinine: A biological marker for tobacco use and exposure to environmental tobacco smoke measured in the blood. Cotinine is a breakdown product of nicotine.
Spit tobacco: Chewing tobacco, snuff, or smokeless tobacco.
[1] U.S. Department of Health and Human Services (HHS). Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. HHS Pub. No. (CDC) 89-8411. Atlanta, GA: HHS, Public Health Service (PHS), Centers for Disease Control (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Office on Smoking and Health (OSH), 1989.
[2] HHS. The Health Benefits of Smoking Cessation. A Report of the Surgeon General. HHS Pub. No. (CDC) 90-8416. Atlanta, GA: HHS, PHS, CDC, NCCDPHP, OSH, 1990.
[3] DiFranza, J.R., and Lew, R.A. Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome. Journal of Family Practice 40(4):385-394, 1995.
[4] HHS. The Health Consequences of Using Smokeless Tobacco. A Report of the Advisory Committee to the Surgeon General. NIH Pub. No. 86-2874. Bethesda, MD: HHS, PHS, CDC, Center for Health Promotion and Education (CHPE), OSH, 1986.
[5] HHS. The Health Consequences of Smoking: Cancer. A Report of the Surgeon General. Rockville, MD: HHS, PHS, CDC, CHPE, OSH, 1982.
[6] CDC. Bidi use among urban youth—Massachusetts, March-April 1999. Morbidity and Mortality Weekly Report 48(36):796-799, 1999.
[7] Gupta, P.C.; Hammer, III, J.E.; Murti, P.R.; eds. Control of Tobacco-Related Cancers and Other Diseases; Proceedings of an International Symposium. Bombay, India: Tata Institute of Fundamental Research, Oxford University Press, 1992.
[8] CDC. Cigarette smoking-attributable mortality and years of potential life lost—United States, 1984. Morbidity and Mortality Weekly Report 46(20):444-451, 1997.
[9] CDC. Projected smoking-related deaths among youth—United States. Morbidity and Mortality Weekly Report 45:971-974, 1996.
[10] CDC. Medical-care expenditures attributable to cigarette smoking—United States, 1993. Morbidity and Mortality Weekly Report 43(26):469-472, 1994.
[11] CDC. Medical-care expenditures attributable to cigarette smoking during pregnancy—United States, 1995. Morbidity and Mortality Weekly Report 46:1048-1050, 1997.
[12] HHS. The Health Consequences of Involuntary Smoking. A Report of the Surgeon General. Rockville, MD: HHS, PHS, CDC, CHPE, OSH, 1986.
[13] U.S. Environmental Protection Agency (EPA). Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. EPA Pub. No. EPA/600/6-90/006F. Washington, DC: EPA, 1992.
[14] California Environmental Protection Agency. Health Effects of Exposure to Environmental Tobacco Smoke. Final Report. Sacramento, CA: the Agency, Office of Environmental Health Hazard Assessment, 1997.
[15] Glantz, S.A., and Parmely, W.W. Passive smoking and heart disease: Mechanism and risk. Journal of the American Medical Association 273:1047-1053, 1995.
[16] Howard, G.; Wagenknech, L.E.; Burke, G.E.; et al. Cigarette smoking and progression of atherosclerosis. Journal of the American Medical Association 279(2):119-124, 1998.
[17] Pirkle,J.L.; Flegal, K.M.; Bernet, J.T.; et al. Exposure of the U.S. population to environmental tobacco smoke. Journal of the American Medical Association 275:1233-1240, 1996.
[18] CDC. State-specific prevalence of cigarette smoking among adults, and children’s and adolescents’ exposure to environmental tobacco smoke—United States. Morbidity and Mortality Weekly Report 46:1038-1043, 1997.
[19] CDC, NCHS. National Health Interview Survey. Unpublished data, 1998.
[20] HHS. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: HHS, PHS, CDC, NCCDPHP, OSH, 1994.
[21] HHS. Drug use among teenagers leveling off. HHS News, December 17, 1999.
[22] CDC. Tobacco use among high school students—United States, 1997. Morbidity and Mortality Weekly Report 47:229-233, 1998.
[23] HHS. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office, 1988.
[24] CDC. Smoking cessation during previous year among adults—United States, 1990 and 1991. Morbidity and Mortality Weekly Report 42:504-507, 1993.
[25] HHS. Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians, and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, GA: HHS, PHS, CDC, NCCDPHP, OSH, 1998.
[26] National Asian Women’s Health Organization. Smoking Among Asian Americans: A National Tobacco Survey. San Francisco, CA: the Organization, 1998.
[27] Goebel, K. Lesbians and gays face tobacco targeting. Tobacco Control 3:65-67, 1994.
[28] Skinner, W.F. The prevalence and demographic predictors of illicit and licit drug use among lesbians and gay men. American Journal of Public Health 84(8):1307-1310, 1994.
[29] Penkower, L.; Dew, M.A.; Kingsley, L.; et al. Behavioral, health and psychosocial factors and risk for HIV infection among sexually active homosexual men: The Multicenter AIDS Cohort Study. American Journal of Public Health 81(2):194-196, 1991.
[30] Arday, D.A.; Edlin, B.R.; Giovino, G.A.; et al. Smoking, HIV infection, and gay men in the United States. Tobacco Control 2:156-158, 1993.
[31] CDC. Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey—United States, 1995. Morbidity and Mortality Weekly Report 46(SS-6):1-56, 1997.
[32] HHS. Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990s. Smoking and Tobacco Control Monograph 1. NIH Pub. No. 92-3316. Bethesda, MD: HHS, PHS, National Institutes of Health (NIH), National Cancer Institute (NCI), 1991.
[33] Pierce, J.P.; Evans, N.; Farkas, A.J.; et al. Tobacco Use in California: An Evaluation of the Tobacco Control Program, 1989-93. La Jolla, CA: University of California, San Diego, 1994.
[34] Abt Associates, Inc., for the Massachusetts Department of Public Health. Independent Evaluation of the Massachusetts Tobacco Control Program. 2nd Annual Report. Cambridge, MA: Abt Associates, Inc., 1996.
[35] Gostin, L.O.; Arno, P.S.; and Brandt, A.M. FDA regulation of tobacco advertising and youth smoking. Historical, social, and constitutional perspectives. Journal of the American Medical Association 277:410-418, 1997.
[36] Tobacco Education Oversight Committee. Toward a Tobacco-Free California: Exploring a New Frontier. Report to the California Legislature. February 1993, 69.
[37] Arizona Tobacco Use Prevention Plan <http://www.hs.state.az.us/aztepp>May 12, 1999.
[38] CDC. Cigarette smoking before and after an excise tax increase and an antismoking campaign. Morbidity and Mortality Weekly Report 45:966-970, 1996.
[39] CDC. Tobacco use among middle and high school students—Florida, 1998 and 1999. Morbidity and Mortality Weekly Report 48:248-253, 1999.
[40] Pechacek, T.F.; Asthma, S.; and Eriksen, M.P. Tobacco: Global burden and community solutions. In: Yusuf, S.; Cairns, J.A.; Camm, A.J.; et al.; eds. Evidence Based Cardiology. London, England: BMJ Books, 1998, 165-178.
[41] Glynn, T. Essential elements of school-based smoking prevention programs. Journal of School Health 59(5):181-188, 1989.
[42] Botvin, G.J.; Renick, N.L.; and Baker, E. The effects of scheduling format and booster sessions on a broad-spectrum psychosocial smoking prevention. Journal of Behavioral Medicine 6(4):359-379, 1983.
[43] Perry, C.L.; Klepp, K.I.; and Sillers, C. Community-wide strategies for cardiovascular health: The Minnesota Heart Health Program youth program. Health Education Research 4(1):87-101, 1989.
[44] Pentz, M.A.; Dwyer, J.H.; MacKinnon, D.P.; et al. A multicommunity trial for primary prevention of adolescent drug abuse. Effects on drug use prevalence. Journal of the American Medical Association 261(2):3259-3266, 1989.
[45] Vartianen, E.; Fallonen, U.; McAlister, A.L.; et al. Eight-year follow-up results of an adolescent smoking prevention program: The North Karelia Youth Project. American Journal of Public Health 80(1):78-79, 1990.
[46] Perry, C.L.; Kelder, S.H.; Murray, D.M.; et al. Community-wide smoking prevention: Long-term outcomes of the Minnesota Heart Health Program and the Class of 1989 Study. American Journal of Public Health 82(9):1210-1216, 1992.
[47] Botvin, G.J.; Baker, E.; Dusenbury, L.; et al. Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association 273(14):1106-1112, 1995.
[48] CDC. Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report 43:1-18, 1994.
[49] CDC. Addition of prevalence of cigarette smoking as a nationally notifiable condition—June 1996. Morbidity and Mortality Weekly Report 45:537, 1996.
[50] HHS. Smoking Cessation: Clinical Practice Guideline. No. 18. HHS Pub. No. (AHCPR) 96-0692. Washington, DC: HHS, PHS, Agency for Health Care Policy and Research, 1996.
[51] Monitoring the Future Project 1997. Public Use Data Tapes, 1992–95. 1992–95 combined data. Ann Arbor, MI: University of Michigan, Institute for Social Research.
[52] McPhillips-Tangrum, C. Results from the first annual survey on addressing tobacco in managed care. Tobacco Control 7:S11-S13, 1998.
[53] Zebrek, A. Medicaid and Indigent Care: Smoking Cessation. Washington, DC: Health Policy Tracking Service, 1998.
[54] Gerlach, K.; Shopland, D.R.; Hartman, A.M.; et al. Workplace smoking policies in the United States: Results from a national survey of more than 100,000 workers. Tobacco Control 6:199-206, 1997.
[55] Siegel, M. Involuntary smoking in the restaurant workplace. Journal of the American Medical Association 270:490-493, 1993.
[56] Mannino, D.M.; Siegel, M.; Husten, C.; et al. Environmental tobacco smoke exposure and health effects in children: Results from the 1991 National Health Interview Survey. Tobacco Control 5:13-18, 1996.
[57] DiFranza, J.R., and Lew, R.A. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 97:560-568, 1996.
[58] American Academy of Pediatrics, Committee on Environmental Health. Environmental tobacco smoke: A hazard to children. Pediatrics 99:639-642, 1997.
[59] Kann, L.; Kinchen, S.A.; William, B.I.; et al. Youth risk behavior surveillance—United States, 1997. Morbidity and Mortality Weekly Report 47(SS-3):1-89, 1998.
[60] CDC. Accessibility of tobacco products to youths aged 12-17—United States, 1989–1993. Morbidity and Mortality Weekly Report 45:125-130, 1996.
[61] Widley, M.B.; Woodruff, S.I.; Pamplone, S.Z.; et al. Self-service sale of tobacco: How it contributes to youth access. Tobacco Control 4:355-361, 1995.
[62] Substance Abuse and Mental Health Services Administration. Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants. Final Rule. Federal Register (16)13:1492-1500, 1996.
[63] Chaloupka, F., and Grossman, M. National Bureau of Economic Research Working Paper. No. 5740. Cambridge, MA: National Bureau of Economic Research, 1996.
[64] Manley, M.; Pierce, J.P.; Gilpin, E.A.; et al. Impact of the American Stop Smoking Intervention Study on cigarette consumption. Tobacco Control 6:S12-S16, 1997.
[65] Conlisk, E.;Siegel, M.; Lengerich, E.; et al. The status of local smoking regulations in North Carolina following a state preemption bill. Journal of the American Medical Association 273:805-807, 1995.
[66] Jordan, J.; Pertschuk M.; and Carol, J. Preemption in Tobacco Control: History, Current Issues, and Future Concerns. No. 97-0424. Berkeley, CA: Americans for Nonsmokers’ Rights/Western Consortium for Public Health, 1994.
[67] Fishman, J.A.; Allison, H.; Knowles, S.B.; et al. State laws on tobacco control—United States. Morbidity and Mortality Weekly Report 48(SS-3):21-62, 1998.
[68] HHS. The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of U.S. Cigarettes: A Report of the NCI Expert Committee. NIH Pub. No. 96-4028. Bethesda, MD: HHS, PHS, NIH, NCI, 1996.
[69] Public Law 99-252, Section 4. The Comprehensive Smokeless Tobacco and Health Education Act of 1986.
[70] U.S. Department of Treasury (DOT). The Economic Costs of Smoking in the United States and the Benefits of Comprehensive Tobacco Legislation. Department of Treasury Working Paper Series. Washington, DC: DOT, 1998.
[71] Chaloupka, F.J.; Tauras, J.A.; and Grossman, M. Public policy and youth smokeless tobacco use. Southern Economic Journal 64(2):503-516, 1997.
[72] General Accounting Office. Teen Smoking: Higher Excise Tax Should Significantly Reduce the Number of Smokers. A Report to the Honorable Michael A. Andrews, House of Representatives. GAO/HRD 89-119. Rockville, MD: GAO, 1989.
[73] CDC. Tobacco tax initiative—Oregon, 1996. Morbidity and Mortality Weekly Report 46:246-248, 1997.