From: david@stat.com (David Dodell)
Subject: HICN610 Medical Newsletter Part 1/4
Reply-To: david@stat.com (David Dodell)
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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:  
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                       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





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Volume  6, Number 10                                           April 20, 1993



::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
                        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



::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
               Centers for Disease Control and Prevention - MMWR
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

                         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.










































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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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