tobacco 101 lesson two - emory universitytobacco 101 is a self-guided tutorial that provides the...

Tobacco101PartOne,Lesson2

2016

ASELF-GUIDEDE-BOOKINTWOPARTS

©2016EmoryCentersforTrainingandTechnicalAssistance2

IntroductiontoTobacco101WelcometoTTAC’sTobacco101!Tobacco101isaself-guidedtutorialthatprovidestheinformationandresourcesnecessarytounderstandwhytobaccouseisconsideredthe#1preventablecauseofdeathintheUS,aswellastheevidence-basedandpromisingstrategiesthatcanreducetobacco’stoll.Youcanbenefitfromthiscoursewhetheryouarenewtotobaccocontrolandneedanintroductiontokeytopics,orareanexperiencedprofessionallookingtorefreshandupdateyourknowledge.

Tobacco101wasrevisedinthespringof2013tocontainthelatestinformation,resources,andtoolsavailable.Theuser-friendlyself-guidedformatallowsyoutocompletethetutorialatyourownpaceandexplorethevariousexternalresourcesandtoolsasneeded.Tobacco101isorganizedintotwopartscomprisedoffourlessonseach.Optionalreviewquestionsareofferedattheendofeachlessontoallowyoutocheckyourunderstandingofthecontent,trysomeoftheresources,andreflectonhowtheinformationappliestoyourroleintobaccocontrol.

Youcanstartatthebeginningandreadthroughthecoursefrombeginningtoendorsimplyselectthosesectionsthatareofgreatestinterest.

Part1:IntroductiontoPreventionandControlofTobaccoUse• Lesson1:TheEvolutionofTobaccoControl• Lesson2:TobaccoUseintheUnitedStates• Lesson3:ImpactofTobaccoUse• Lesson4:FactorsthatDetermineTobaccoUse

Part2:ReducingtheProblemofTobaccoUse• Lesson1:CredibleTobaccoControlResourcesandKeyPartners• Lesson2:TobaccoControlModels• Lesson3:EffectiveTobaccoControlPolicies• Lesson4:StrategiesforSuccess

TTACalsoprovidestailored,on-siteTobacco101trainingsfororganizationswhowanttoincludeitinconferencesandworkshops.Tolearnmore,visitourwebsitewww.tacenters.emory.eduorcontactusattacenters@emory.edu.


TableofContentsPART1: INTRODUCTIONTOPREVENTIONANDCONTROLOFTOBACCOUSELESSONTWO

TobaccoUseintheUnitedStates Page4

CheckforUnderstanding Page19

Sources Page21


Tobacco101PartOne,LessonTwoTobaccoUseintheUnitedStates

LessonTwoLearningObjectivesInLessonTwo,wewilldiscussthetrendsintobaccouseamongadults,youngpeople,andotherspecificpopulationsintheUnitedStates.Attheendofthelessonyoushouldbeableto:

1. Explainwhyexaminingtobaccousedataisimportant.Localandnationaldataarevitaltounderstandingtheproblemoftobaccouseandwhichsolutionsworkbest.

2. DescribetrendsintobaccouseintheUnitedStates.Ournation’stobaccouseprevalencehasdeclined

duringthelast20years.However,thecurrentprevalenceestimateofslightlybelow20%isstillextremelydetrimentaltooursociety.

3. Usecredibledatasourcestofindinformationontheprevalenceandeffectsoftobaccouse.Knowingwhere

tofindreliabledataisimportant.Wecountonnational,state,andlocalorganizationstosupplyuswithup-to-datedata.


DefinitionsofKeyTermsBeforebeginningthislesson,let’stakeamomenttodefineafewkeywords:

• CurrentUser:Apersonwhohasusedthetobaccoproduct(s)inquestionatleastoncewithin30daysofbeingsurveyed.Thisincludesdailyusers,aswellasoccasionalusers.

• Prevalence:Theproportionofcurrentusersinagivenpopulation:

Prevalence=Numberofcurrentusers

Totalnumberinpopulationstudied

• TobaccoSmokingPrevalence:includesdataonsmokingcigarettes,cigars,pipes,andanyothersmoked

tobaccoproducts.Itdoesnotincludedataontheuseofsmokelessproductslikespittobaccoandsnuff.InLessonTwo,we’llbetalkingaboutprevalenceandthetrendsintobaccousebyadults,youngpeople,andotherspecificpopulationsintheUnitedStates.


WhyTrackingTobaccoUseisImportant Thislessonwilldescribeseveraltrendsintobaccouse,andwillincludedatacollectedusingreliablemethods.Itisimportanttounderstandhealthdataanditsquality,asitisthefoundationanddriverofhealthplanninganddecisionmaking.Stakeholders,electedofficialsandthemediaoftenturntostatetobaccoprogramsasasourceofinformationaboutadultandyouthtobaccousewhichmakesitimperativethatthedataprovidedtothemisaccurateandreliable.Knowingprevalencedataalsoimprovesyourabilitytobetterunderstandtheneedforandimpactoftobaccocontrol.Thisislargelybecausetheprevalenceoftobaccosmokingamongadultsisanimportantmeasureofthehealthandeconomiceffectsoftobaccouse.Itservesasabaselinemeasureforevaluatingtheeffectivenessoftobaccocontrolprogramsovertimeandisanimportantandchallengingfirststepinplanningfortheneedsofyourcommunity.Tobaccousedataareusefulbecausethey:

• Helptoaccuratelydescribethetobaccouseproblem.• Informhowprogramresourcesshouldbetargetedtoaddresstheproblem.• Canbeusedtoeducatecommunitiesandstakeholdersabouttobaccouseandtheimportanceofprevention

andcessationefforts.• Helpevaluateprogramstrategiesandoverallprogrameffects.Inturn,programevaluationcontributestothe

researchleadingtobestpracticesfortobaccocontrolprograms.


SmokingPrevalenceintheUnitedStates CDCdatafrom2010showthat45.3millionadultsintheUnitedStatesarecurrentsmokers,makingthesmokingprevalencerate19.3%.Thenationalprevalenceratedroppedbelow20%in2009,whichwasamajormilestoneintobaccocontrol.Cigarettesmokingisslightlymorecommonamongmen-anestimated21.5%ofadultmensmoke,comparedto17.3%ofwomen.Asyoucanseefromthemapbelow,prevalenceratesvarysignificantlybetweenstates.ThestateswiththemostsmokersareintheMidwestandSoutheastregions.WestVirginia(26.8%)andKentucky(24.8%)havethehighestrates,whileUtah(9.1%)andCalifornia(12.1%)havethelowest.Wewilldiscusssomeofthefactorsthatdeterminethosedifferenceslaterlessons.PrevalenceRatesbyState


SmokingPrevalenceVariesbyEducationLevel

TrendsinCigaretteSmokingAmongAdultsaged≥25Years,byYearsofEducationUnitedStates,1970-2006

Percentageofadultswhowerecurrentsmokersin2010,bylevelofeducation

EducationLevel %CurrentSmokers

GEDdiploma 45.2%

9-11yearsofeducation 33.8%

Highschooldiploma 23.8%

Undergraduatecollegedegree 9.9%

Postgraduatecollegedegree 6.3%

Thechartsaboveshowthatsmokingprevalencediffersconsiderablybyeducationlevel.Generally,asyearsofeducationincrease,prevalenceratesdecrease.Inotherwords,smokingprevalenceisloweramongadultswithmoreeducation,andhigheramongadultswithlowerlevelsofeducation.Thetopchartshowsthatthedisparitieshaveremainedforoverfortyyears,eventhoughsmokingprevalencehasdeclinedinallgroupsovertime.Note:Thelowprevalenceofsmokerswithlessthaneightyearsofeducationmaybeattributabletoindividualswhoemigratedasadultsfromcountrieswheresmokingratesarelow.FewadultsbornintheUShavelessthananeighthgradeeducation.


SmokingPrevalenceVariesbyRaceandEthnicity

TrendsinCigaretteSmokingAmongAdultsaged≥18Years,byRace/EthnicityUnitedStates,1978-2006

Percentageofadultswhowerecurrentsmokersin2010,byrace/ethnicity

Race/Ethnicity %CurrentSmokers

AmericanIndians/AlaskaNatives 31.4%

Whites 21.0%

Blacks 20.6%

Hispanics 12.5%

Asians 9.2%

Thechartsaboveshowthatsomeracialorethnicgroupstendtohaveahigherprevalenceoftobaccousethanothersdo.Whilesmokingprevalencehasdeclinedovertimeinallracialandethnicgroups,disparitiesclearlyexist.Inparticular,AmericanIndiansandAlaskaNativeshavenearlydoubletheprevalenceofsmokingcomparedtothelowestgroups.Futuresuccessatreducingtobaccousewillbefacilitatedbybetterunderstandingofspecificneedsofthosepopulationswiththehighestprevalenceoftobaccouse.


SmokingPrevalenceVariesbyAge

PercentageofCigaretteSmokingAmongAdultsaged≥18Years,byageUnitedStates,2010

Thisgraphshowsthatthepercentageofcurrentsmokingadults(menandwomen)isfairlyconsistentacrossadultagegroups,withtheexceptionofthoseoverage65.Theprevalencerateismuchlowerforthoseaged65yearsorolder(9.5%).Thisisbelievedtobebecausemanysmokershavediedbythisageorhavebeenmotivatedbyserioushealthproblemstoquit.

20.1% 22.0% 21.1%

9.5%

0%

5%

10%

15%

20%

25%

18-24 25-4445-64Over65


SmokingPrevalenceVariesbyPovertyStatus

PercentageofCigaretteSmokingAmongAdultsaged≥18Years,byIncomeUnitedStates,1983-2007

Thischartdemonstratesthehighertobaccoprevalenceforpeopleatlowerincomelevels(“below”thepovertyline)comparedtothosewithahigherincome(“at/above”thepovertyline).Estimatesfrom2010showthisgaphaswidenedevenfurther,with28.9%ofadultslivingbelowthepovertylevelsmokingcomparedto18.3%wholiveatorabovepoverty.Peoplebelowthepovertyleveltendtobelesseducatedandareoftentargetedheavilybythetobaccoindustrymarketingcampaigns.Becausethoselivingbelowthepovertylineareoftenmoreexposedtotobaccoadvertisingtactics,theyaremorelikelytobegintosmoke.ThiswillbediscussedfurtherinLesson4.


SmokingPrevalenceintheLGBTCommunityAvailablecurrentdatashowthattheLGBTpopulationsmokesatratesnearly50%to200%higherthantherestofthepopulation.Gay,bisexual,andtransgendermenare2.0to2.5timesmorelikelytosmokethanheterosexualmen.Lesbian,bisexualandtransgenderwomenare1.5to2.0timesmorelikelytosmokethanheterosexualwomen.Amongyouth,bisexualboysandgirlshavesomeofthehighestsmokingrateswhencomparedwithboththeirheterosexualandhomosexualpeers.Currently,moststateandnationalhealthsurveysdonotcollectinformationonsexualorientationandgenderidentity.MoredatawillneedtobecapturedtobeabletomoreaccuratelydescribetheuseoftobaccoamongtheLGBTcommunity.

ForFurtherInformation…aboutsmokingintheLGBTcommunity,takealookat:

• SmokingOutaDeadlyThreat:TobaccoUseintheLGBTCommunityhttp://www.lung.org/assets/documents/publications/lung-disease-data/lgbt-report.pdf

• LGBTPeopleandTobaccoFactSheet

http://www.lgbttobacco.org/files/20080701LGBTs_and_Tobacco.pdf


SmokingPrevalenceamongPregnantWomen

Prevalenceofsmokingbeforepregnancy,duringpregnancy,andafterdeliverybyyear---PregnancyRiskAssessmentMonitoringSystem(PRAMS),UnitedStates,16sites,2000--2005

Womenofreproductiveage(18-44years)whosmokeareatgreaterriskofadversepregnancyoutcomesandadversehealthconsequencesforthemselves.Thechartaboveshowsestimatedsmokingprevalenceamongwomenbefore,during,andafterpregnancyfrom2000to2005.In2005,approximately14%ofwomengivingbirthreportedsmokingatsomepointduringpregnancy.

Pregnancyisanopportunetimetoencourage womentoquitsmokingfortheirlifetime.Thisgraphshowsthataboutathirdofwomenquitsmokingduringpregnancy,butthatnearly40%relapsewithinfourmonthsfollowingdelivery.Researchersalsofoundthatthewomenwhoweremorelikelytorelapsetosmokingafterdeliverywereyoungerandhadalowerannualincome.

ForFurtherInformation…aboutsmokingamongpregnantwomen,checkout:

• SmokingPrevalenceAmongWomenofReproductiveAge---UnitedStates,2006http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5731a2.htm#tab1

• TobaccoUseandPregnancyhttp://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/


YouthSmokingPrevalence

TrendsinCurrentCigaretteSmokingbyHighSchoolStudentsandAdults,UnitedStates1965-2012

Tobaccouseisalsoaproblemamongyouth.Thisgraphshowsasharpdeclineincigarettesmokingamonghighschoolstudentsfrom36.4%in1997to21.9%in2003.Sincethen,thetrendhasslowedbutisstillcontinuingtogodown.The2011YouthRiskBehaviorSurveillanceSurveyreportsacurrentcigarettesmokingprevalenceof18.1%amonghighschoolstudents.Ifteensmokingprevalencecontinuesthisrateofdecline,theUnitedStatescouldachievetheHealthyPeople2020objectiveofreducingcurrentsmokingratesamonghighschoolstudentsto16%.Rememberthatcurrentsmokingforyouthisdefinedashavingsmokedononeormoredaysofthe30daysprecedingthesurvey.


TobaccoUseAmongYouthandYoungAdultsThe2012SurgeonGeneral’sReportPreventingTobacco UsAmongYouthandYoungAdultsstatesthattobaccouseisa pediatricepidemicaroundtheworld,aswellasintheUnited States.HerearesomefactsaboutteentobaccouseintheUnited States:

1. Oneinfourhighschoolseniorsandoneinthree youngadultsarecurrentsmokers.

2. EachdayintheUSover3,800youthunder18 startsmoking.

3. About1in8highschoolmalesarecurrent smokelesstobaccousers.

4. Nearlyoneofthreehighschoolseniorshastriedacigar.5. Themajorityofhighschoolmaleswhocurrentlyusetobaccousemorethanoneproduct.6. Tobaccouseishigheramonglowsocioeconomicstatusyouth.7. Afteryearsofsteadyprogress,declinesintheuseoftobaccobyyouthandyoungadultshasslowedfor

cigarettesmokingandstalledforsmokelesstobaccouse.8. Mostadultsmokers–about80%-startedsmokingbeforetheywere18yearsold.

ForFurtherInformation…abouttobaccouseamongyouthandyoungadults,checkout:

• The2012SurgeonGeneral’sReport.Thefullreport,summaries,factsheets,andmorecanbefoundathttp://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html

• YouthandTobaccoUseFactSheetfromtheCDC:http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm


TobaccoDataSourcesThetobaccodatapresentedinreports,factsheets,websites,andotherresourcesarecollectedthroughtheuseofhealthsurveys.Someofthesurveyscommonlyusedtocollectstate,national,andglobalare:YouthTobaccoSurvey(YTS)TheCDCbegantheYTStohelpstatesdesign,implement,andevaluatecomprehensivetobaccocontrolprograms.Theschool-baseddatameasurecontainscomponentsofCDC’sbestpracticesfortobaccocontrolprogramsandassessestheprevalenceofsmokingamongadolescentsandteenagersaswellassmokingbehavior.GlobalAdultTobaccoSurvey(GATS)TheGlobalAdultTobaccoSurvey(GATS),launchedinFebruary2007,isdesignedtoproducenationalandsub-nationalestimatesontobaccouse,exposuretosecondhandsmoke,quitattemptsamongadultsacrosscountries,andindirectlymeasuretheimpactoftobaccocontrolandpreventioninitiativesusingastandardprotocol.StateTobaccoActivitiesTrackingandEvaluation(STATE)SystemTheSTATESystemisanelectronicdatawarehousecontainingup-to-dateandhistoricalstatedataontobaccousepreventionandcontrol.TheSTATESystemallowsresearcherstobuildreportsforbehaviors,demographics,economics,environment,funding,healthconsequences,costsandpolicyproposals.BehavioralRiskFactorSurveillanceSystem(BRFSS)BRFSSisastate-basedsystemofhealthsurveysthatcollectsinformationonhealthriskbehaviors,includingsmoking.Formanystates,BRFSSistheonlysourceoftimely,accuratedataonhealth-relatedbehaviors.


FindingDataaboutYourState

Wehavefocusedmainlyonnationalleveltobaccousedatasofar,butstateleveldataisequallyimportantintobaccocontrolefforts.Eachyear,theCDCpublishesstatehighlightsontheeffectsoftobaccouseandincludesabreakdownofprevalencedatabyrace/ethnicity,educationlevel,andage.Thesehighlightsalsoshowhoweachstatecomparestootherstatesandthenationalaverageonkeyprevalenceandpolicymeasures.

Clickheretoaccessaninteractivemapthatallowsyoutoviewhighlightsforeachstate.Youcanalsodownloadafullreportofthesehighlights,TobaccoControlStateHighlights2010.


TobaccoUseintheUnitedStatesLessonTwoexplainedwhytobaccousedataisexamined,andhowitisused.ThelessonillustratedsomeofthetrendsintobaccouseintheUnitedStates,showingusthateventhoughtobaccousehasdeclinedovertime,thereisstillworktobedone,particularlyinreducingtobaccouseincertainpopulations.Thislessonalsoprovidedinformationaboutthesurveysthatgiveusinformationabouttobaccouse,andwheretofindinformationabouttobaccouseinyourstate.Inthenextlessonwewilldiscusstheeffectsoftobaccouse,includingeffectsonthebody,frombothdirecttobaccouseandsecondhandsmoke.ThelessonwillalsodiscusstheeffectsoftobaccouseontheUSeconomy,productivity,andthehealthcaresystem.


LessonTwoCheckforUnderstanding

1. Trueorfalse:Theequationusedtocalculatetheprevalenceofsmokersis:

Prevalence=Numberofcurrentsmokers


a. Trueb. False

2. Whichofthefollowingtrendshasbeenobservedintobaccoprevalencedata:

a. Aseducationleveldecreases,smokingprevalenceincreasesb. Mensmokeatahigherratethanwomenc. Asincomedecreases,smokingprevalenceincreasesd. AmericanIndianshavethehighestsmokingratesacrossracial/ethnicpopulationse. Alloftheabovetrendshavebeenobservedintobaccoprevalencedata

3. Thinkaboutit:GototheHighlightsbyStatewebsite.Clickonyourstatetobringupthestatehighlights,and

thenwritedowntheanswersthefollowingquestions.Inyourstate:a. Whatistheoveralladultsmokingprevalence?b. Whichracialorethnicgrouphasthehighestsmokingprevalence?Thelowest?c. Whatpercentageofyouth12-17smokeinyourstate?Howdoesyourstaterank?

4. WhichofthefollowingstatementsisNOTareasonwhyexaminingtobaccodataisimportant?

a. Ithelpstoaccuratelydescribethetobaccouseproblem.b. Itinformshowprogramresourcesshouldbetargetedtoaddresstheproblem.c. Itisafederallegalrequirement.d. Itisusedtoeducatecommunitiesandstakeholdersabouttobaccouseandtheimportanceofprevention

andcessationefforts.e. Itisusedtoevaluateprogramstrategiesandoverallprogrameffects.

5. Thinkaboutit:Fromreadingaboutthecurrenttrendsintobaccouse,whatdoyouthinkneedstobeafocus

ofcurrenttobaccocontrolefforts?


LessonTwoCheckforUnderstandingAnswerKey

1. Trueorfalse:Theequationusedtocalculatetheprevalenceofsmokersis:

Prevalence=Numberofcurrentsmokers


a. Trueb. False

CorrectAnswer:True.“Needtoreview?Gobacktothe“DefinitionsofKeyTerms”page.”2. Whichofthefollowingtrendshasbeenobservedintobaccoprevalencedata:

a. Aseducationleveldecreases,smokingprevalenceincreasesb. Mensmokeatahigherratethanwomenc. Asincomedecreases,smokingprevalenceincreasesd. AmericanIndianshavethehighestsmokingratesacrossracial/ethnicpopulationse. Alloftheabovetrendshavebeenobservedintobaccoprevalencedata

CorrectAnswer:e.“Needtoreview?Gobacktothe“SmokingPrevalence”pages.”

3. Thinkaboutit:GototheHighlightsbyStatewebsite.Clickonyourstatetobringupthestatehighlights,and

thenwritedowntheanswersthefollowingquestions.Inyourstate:a. Whatistheoveralladultsmokingprevalence?b. Whichracialorethnicgrouphasthehighestsmokingprevalence?Thelowest?c. Whatpercentageofyouth12-17smokeinyourstate?Howdoesyourstaterank?

CorrectAnswer:Answerswillvary.4. WhichofthefollowingstatementsisNOTareasonwhyexaminingtobaccodataisimportant?

a. Ithelpstoaccuratelydescribethetobaccouseproblem.b. Itinformshowprogramresourcesshouldbetargetedtoaddresstheproblem.c. Itisafederallegalrequirement.d. Itisusedtoeducatecommunitiesandstakeholdersabouttobaccouseandtheimportanceofprevention

andcessationefforts.e. Itisusedtoevaluateprogramstrategiesandoverallprogrameffects.

CorrectAnswer:c.“Needtoreview?Gobacktothe“WhyTrackingTobaccoUseisImportant”page.”5. Thinkaboutit:Fromreadingaboutthecurrenttrendsintobaccouse,whatdoyouthinkneedstobeafocus

ofcurrenttobaccocontrolefforts?CorrectAnswer:Answerswillvary.


LessonTwoSourcesResourcesUsed

1. Slides:4,5,6,7,8:AdultCigaretteSmokingintheUnitedStates:CurrentEstimate.Available:http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Slide4:VitalSigns:CurrentCigaretteSmokingAmongAdultsAged≥18Years-UnitedStates,2005-2010.Available:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm?s_cid=mm6035a5_w

3. Slides5,6,8:GiovinoGA,ChaloupkaFJ,HartmanAMetal.CigaretteSmokingPrevalenceandPoliciesinthe50States:AnEraofChange-RobertWoodJohnsonFoundationImpacTeenTobaccoChartBook.Buffalo,NY:UniversityatBuffalo,StateUniversityofNewYork,2009.Available:http://www.impacteen.org/generalarea_PDFs/NCTOH2009_CBtalk-6-10-09-Giovino-FINAL.pdf

4. Slide8:TrendsinCigaretteSmokingAmongAdultsAged≥18Years,byPovertyStatus–UnitedStates1983-2007,NationalHealthInterviewSurveys1983-2007Available:http://www.cdc.gov/nchs/data/hus/hus11.pdf

5. Slide9:AmericanLungAssociationHighlightsHealthDisparityinNewReportonTobaccoPrevalenceinLesbian,Gay,BisexualandTransgender(LGBT)Community. Available:http://www.lung.org/press-room/press-releases/LGBT.html

6. Slide10:TrendsinSmokingBefore,During,andAfterPregnancy---PregnancyRiskAssessmentMonitoringSystem(PRAMS),UnitedStates,31Sites,2000—2005.Available:http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5804a1.htm

7. Slide11:SmokingandTobaccoUse.Available:http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/index.htm

ImagesUsed

1. Slide4:VitalSigns-TobaccoUse:Smoking.Available:http://www.cdc.gov/vitalsigns/TobaccoUse/Smoking/StateInfo-large.html.

2. Slides5,6,&8:GiovinoGA,ChaloupkaFJ,HartmanAMetal.CigaretteSmokingPrevalenceandPoliciesinthe50States:AnEraofChange-RobertWoodJohnsonFoundationImpacTeenTobaccoChartBook.Buffalo,NY:UniversityatBuffalo,StateUniversityofNewYork,2009.Available:http://www.impacteen.org/generalarea_PDFs/NCTOH2009_CBtalk-6-10-09-Giovino-FINAL.pdf

3. Slide9:SmokingOutaDeadlyThreat:TobaccoUseintheLGBTCommunity.Available:http://www.lung.org/assets/documents/publications/lung-disease-data/lgbt-report.pdf

4. Slide10:TrendsinSmokingBefore,During,andAfterPregnancy---PregnancyRiskAssessmentMonitoringSystem(PRAMS),UnitedStates,31Sites,2000—2005.Available:http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5804a1.htm

5. Slide11:SmokingandTobaccoUse.Available:http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/index.htm

6. Slide12:SurgeonGeneral’sReportButtons.Available:http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html.

7. Slide14:TobaccoControlStateHighlights2010.Available:http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2010/index.htm

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