This monograph is the first major update of adolescent smoking behavior since the groundbreaking reports of the Surgeon General and the Institute of Medicine in 1994. The authors of this National Cancer Institute (NCI) Monograph report some progress toward reducing tobacco use among adolescents but also highlight areas in which more efforts need to be made. Several chapters examine trends in adolescent smoking behavior, among all adolescents nationally, different racial/ethnic groups, and among adolescents residing in specific States. Other chapters examine these trends using different national surveys as data sources and different analytical methods. Finally, the remaining chapters present data on macro-level policies and factors that influence the initiation and maintenance of smoking behavior among adolescents. While this Monograph documents some successes in the reduction of youth smoking initiation in some States and localities, there remains a need for an ongoing and exhaustive search for solutions, followed by committed and successful application to enable the country to reach its goals in the area of adolescent smoking.

The decline in U.S. smoking prevalence since the publication of the first Surgeon General's Report in 1964 has been hailed as one of the greatest public health accomplishments of the past century. Forty four million Americans-almost half of those who ever smoked-have quit, and lung cancer death rates have decreased greatly as a result. As a nation, we've launched wide-reaching tobacco control programs in worksites, schools, communities, and all 50 states, and we've witnessed enormous shifts in social norms, policies, and public attitudes. Growth in clean indoor-air laws and smoking restrictions have made quit-smoking cues "persistent and inescapable," and new data shows that tobacco price increases and mass media cessation campaigns can significantly increase population quit rates. Over the last three decades, we have developed effective clinical treatments-psychosocial and pharmacological-and seen the publication and update of authoritative practice guidelines recommending evidence based treatments that, if universally applied, could double our national annual quit rate in a highly cost-effective way. Prospects for preventing and treating tobacco use and addiction have never been better. Yet the papers in this monograph, Those Who Continue to Smoke: Is Achieving Abstinence Harder and Do We Need to Change Our Interventions?, raise important questions about what it will take to build on the successes of the last century and, in particular, on the last few decades of research and practice. While efforts to promote tobacco cessation need to be part of a much broader national tobacco control strategy that emphasizes prevention, it is clear that the greatest gains in reducing tobacco-caused morbidity, mortality, and health care costs in the next 30 to 40 years will come from helping addicted smokers quit. Further declines in adult smoking are likely to strengthen prevention efforts as well, since adult smoking is a critical determinant of social norms and a vector for youth initiation. In this context, the findings presented in this monograph have important implications for the next generation of research and practice to help addicted smokers quit. Specifically, these papers and the findings they present indicate that helping more smokers quit will require: (1) developing more powerful treatments that can break through the 25% to 30% quit-rate ceiling achieved with our best existing treatments; (2) refining, targeting and tailoring treatments for high-risk populations; (3) greatly improving surveillance of quitting patterns and determinants; (4) developing combined clinical-public health approaches that harness synergies between evidence based clinical treatments, and macro-level policy and environmental cessation strategies; and (5) improving the use of and demand for treatments that work.

In the months immediately after January 1964, when Surgeon General Luther Terry released the first official Government report on smoking and health, cigarette consumption in the United States declined significantly. It was only the second time since the turn of the century that publicity about the hazards of smoking had produced a reduction in cigarette use. At that time, many leaders in the medical and public health arena assumed that, by providing the public with straightforward information about the dangers of smoking, they could discourage large numbers of people from using cigarettes. While the expected change in behavior did occur, it was far more limited than had been hoped-a reflection of the difficulty that individuals often experience when they attempt to alter a complex behavior such as smoking, especially one we now know to be addictive. The recognition that information alone would not eliminate tobacco use shifted the focus to strategies directed to the individual. This focus presumed, erroneously as it turned out, that the major determinants of smoking behavior were centered within the individual rather than sociologic in nature. Subsequent research and natural observation clearly demonstrated that behavior change correlated with changes occurring in the smoker's social and economic environment. This recognition has led to the adoption of public health strategies that now address the smoker's larger social environment while simultaneously offering programs of assistance for the individual. This volume provides a summary of what we have learned over nearly 40 years of the public health effort against smoking-from the early trial-and-error health information campaigns of the 1960'sto the NCI's science-based ASSIST project (the American Stop Smoking Intervention Study for Cancer Prevention), which began in the fall of 1991. Strategies To Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990's presents a historical accounting of these efforts as well as the reasons why comprehensive smoking control strategies are now needed to address the smoker's total environment and reduce smoking prevalence significantly over the next decade.

Just as the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) was a major shift in the National Cancer Institute's (NCI's) tobacco prevention and control research and dissemination efforts, this monograph is a significant departure from NCI's previous tobacco control monographs. For many, the ASSIST project represented a logical progression of NCI's phased-research approach to reducing tobacco use. For others, it represented a controversial and overly ambitious leap in a new direction. Similarly, this monograph departs from the traditional quantitative evidence review format to emphasize instead the practical, hands-on experience of program implementation. Traditional research investigators who defend the sanctity of the randomized clinical trial, many of whom were uncomfortable with ASSIST at its outset, will also be uncomfortable with the personal and anecdotal flavor of this monograph. Public health practitioners, on the other hand, as well as those investigators who have immersed themselves in the untidy world of implementation research, will appreciate the detailed historical accounts of the complexities, politics, and outright opposition encountered by the ASSIST team. The collective experiences described in this monograph provide a rich understanding of the gritty struggle against the powerful forces of the tobacco industry and its allies. For students in public health training programs, this work also provides a unique view of the world outside of academia, where commercial, political, and public health interests collide in a struggle to define the policies, norms, and practices that will affect the health of generations. Monograph 16 begins with the historical context of ASSIST and the scientific base that informed the design of the project. The conceptual framework and the development of organizational infrastructures for implementation and evaluation are then described. The heart of this monograph is the in-depth descriptions of ASSIST's media advocacy and policy development interventions and the challenges posed by the tobacco industry. The monograph concludes by describing ASSIST's contributions to tobacco control and other behavioral health interventions and the significant challenges that remain.

Exposure to environmental tobacco smoke (ETS) has been linked to a variety of adverse health outcomes. Many Californians are exposed at home, at work, and in public places. In the comprehensive reviews published as Reports of the Surgeon General and by the U.S. Environmental Protection Agency (U.S. EPA) and the National Research Council (NRC), ETS exposure has been found to be causally associated with respiratory illnesses-including lung cancer, childhood asthma, and lower respiratory tract infections. Scientific knowledge about ETS-related effects has expanded considerably since the release of the above-mentioned reviews. The state of California has therefore undertaken a broad review of ETS covering the major health endpoints potentially associated with ETS exposure: perinatal and postnatal manifestations of developmental toxicity, adverse impacts on male and female reproduction, respiratory disease, cancer, and cardiovascular disease. A "weight of evidence" approach has been used, in which the body of evidence is examined to determine whether or not it can be concluded that ETS exposure is causally associated with a particular effect. Because the epidemiological data are extensive, they serve as the primary basis for assessment of ETS-related effects in humans. The report also presents an overview on measurements of ETS exposure (particularly as they relate to characterizations of exposure in epidemiological investigations) and on the prevalence of ETS exposure in California and nationally. ETS, or "secondhand smoke," is the complex mixture formed from the escaping smoke of a burning tobacco product and smoke exhaled by the smoker. The characteristics of ETS change as it ages and combines with other constituents in the ambient air. Exposure to ETS is also frequently referred to as "passive smoking," or "involuntary tobacco smoke" exposure. Although all exposures of the fetus are "passive" and "involuntary," for the purposes of this review, in utero exposure resulting from maternal smoking during pregnancy is not considered to be ETS exposure.

Smoking cessation is the principal means by which a current cigarette smoker can alter his or her future risk of disease. Prevention of smoking initiation among adolescents can reduce smoking prevalence, but adolescents contribute little to rates of smoking-related illness until they have been smoking for 30 or more years. Cessation is often examined at the individual level in order to deter-mine the effects of cessation interventions or to define individual predictors of who will or will not be successful in their cessation attempts. However, for these individual effects to create a substantive public health benefit, they must sum to create a significant change at the population level. Powerful interventions that affect only a few individuals will have little impact on disease rates, whereas weaker interventions that impact large numbers of smokers will have important and cumulative effects on disease rates. In addition, many interventions (e.g., price increases, changes in social norms, etc.) are delivered to the population as a whole rather than to individual smokers one at a time, and it is these population-based interventions that have formed the core of the tobacco control efforts currently underway in California, Massachusetts, and several other states. This volume examines cessation at the population level. By population level, we mean that all segments of society form the denominator for evaluation of the effectiveness of tobacco control interventions. Therefore, this volume relies heavily on representative surveys of smoking behaviors in state and national populations. By doing so, it defines measures of cessation that can be used to assess the effects of tobacco control programs or public policy changes on smoking behavior. It then uses those measures to identify who is quitting, who is being successful, who is being exposed to various tobacco control interventions, and which tobacco control interventions are proving effective.

The world of tobacco control has become increasingly complex over the past several decades. It involves more extensive collaborations; new structures and configurations for coordinating efforts; and multilevel social, professional, and knowledge networks to improve information sharing for public health. Given such complexity, there has been a corresponding increased need to address tobacco control issues using a systems perspective that enables one to better understand and navigate the dynamic and evolving nature of the terrain to achieve the next generation of improved health outcomes. This monograph describes the results of the initial two years of the Initiative on the Study and Implementation of Systems (ISIS), a four-year project. This initiative is one of the first major coordinated efforts to study and implement a systems thinking perspective using several systems approaches and methodologies that appeared to be promising for tobacco control in itself and as an exemplar for other complex issues in today's public health environment. In the ancient, revered Egyptian myth, the goddess Isis breathed clean air into her late husband Osiris to restore him to life. In analogous fashion, the ISIS project hopes to contemporize the myth in a tobacco control context and encourage systems perspectives that have the potential to help people breathe cleaner air and be restored to a smoke-free life. Although this work is aimed at the efforts of the tobacco control community, the word "tobacco" intentionally appears only in the subtitle of this monograph. That is because ISIS was a research effort that focused on the tobacco control environment to examine how to apply systems approaches to issues that have become endemic throughout public health, including the need for: Better understanding of outcomes, including the unintended consequences of complex interventions and events; Effective capture, dissemination, and management of knowledge throughout the multilayered public health system; More efficient organization and linkage of the efforts of multiple, diverse stakeholders; Adoption of evidence-based practices that inform practice and improve outcomes; Strengthening of collaborative networks of scientists, policy makers, government and foundation managers, practitioners, and the public. This work was undertaken to help address some of the fundamental organizational issues in tobacco control and, by corollary, much of public health. The goal was to investigate the potential of integrated, systems-based approaches to facilitate the efforts of all stakeholders to make substantive changes in public health outcomes.

Large-scale consumption of tobacco has been a significant lifestyle factor in America for centuries . Prior to the beginning of the 20th century, tobacco was consumed in the form of spitting tobacco (chewing tobacco and snuff), smoked as cigars, or loose tobacco smoked in pipes or in hand-rolled cigarettes. Consumption of machine-made cigarettes was almost nonexistent, and spitting tobacco was the dominate form of use, accounting for nearly 60 percent of all tobacco consumed on a per capita basis. Consumption of machine-manufactured cigarettes increased dramatically following World War I; by 1935, more tobacco was being consumed in the form of cigarettes than all other products combined. As the popularity of cigarettes continued to increase, consumption of noncigarette tobacco products, especially smokeless tobacco, declined. Per capita cigarette tobacco consumption peaked in the early 1950's (as did total per capita tobacco consumption), probably in response both to the first scientific studies linking cigarette smoking to lung cancer and to the introduction and aggressive promotion of filter cigarettes by the cigarette industry in response to these early scientific findings. Filter cigarettes, which had previously accounted for less than 1 percent of all cigarettes consumed in the United States in 1950, had captured 50 percent of the market by the end of the decade, and today account for over 90 percent of all cigarette sales. In comparison to their nonfilter counterparts, filter cigarettes generally contain less tobacco. For decades following the introduction of the mass-produced and mass marketed cigarettes, consumption and prevalence of smokeless tobacco had been on the decline. However, the latter part of the 1970's and the early part of the 1980's, saw major increases in ST use. This increase was the result of renewed and more aggressive advertising by the ST industry that accompanied the introduction of innovative products such as Skoal Bandits-and the use of well-known sport and entertainment personalities in ST promotions . Personalities such as football stars Walt Garrison and Terry Bradshaw; baseball greats George Brett, Sparky Lyle, Carlton Fisk, and Bobby Murcer; and country-and-western singer Charlie Daniels, obviously appealed to a very young and impressionable audience. Furthermore, use of broadcast media to promote ST was not prohibited under the existing Congressional legislation that had governed cigarettes since 1971; thus, the ST industry was free to use television to recruit a large and relatively untapped market of new users. Because the themes and images used appealed primarily to children and adolescents, increases in ST consumption that occurred during the 1980's was primarily confined to these age groups . Where previously little or no use of ST was seen among adolescents, prevalence of ST use among older teens increased between 250 and 300 percent between 1970 and 1985. Compared with cigarettes, we know much less about the factors influencing ST use. Only in the past few years have the research results elucidated the many facets of ST use and means to intervene in this process. This monograph represents the most recent major attempt to bring together the important research findings of the last few years. Previous compilations of ST research have been the U.S. Surgeon General's Report in 1986 and a monograph published by the National Cancer Institute in 1989, titled Smokeless Tobacco Use in the United States. The present monograph will use the model established by the two previous publications in presenting as broad a picture of the ST problem as possible. Sections in this monograph describe the epidemiology, clinical and pathological effects, carcinogenesis, nicotine effects and addiction, prevention, cessation, and policy research findings in the area of ST use. Finally, recommendations based on research and compiled by experts in the field is presented.

With this volume, the National Cancer Institute (NCI) presents the 17th monograph of the Tobacco Control Monograph series. This monograph documents the evaluation of a groundbreaking NCI program. The American Stop Smoking Intervention Study for Cancer Prevention, known as ASSIST, put into practice NCI's commitment to prevent and reduce tobacco use across all populations and age groups. ASSIST took evidenced-based interventions from controlled studies and implemented them in the larger community of 17 states. Its underlying rationale-that significant decreases in tobacco use could be realized only with interventions that changed the social environment such that smoking was non-normative-was a significant departure from previous tobacco control programs and in the vanguard of the "new" public health. Prior to ASSIST, few states addressed tobacco use at the population level. The ASSIST legacy remains today in the tobacco control professionals whose work continues to reduce the burden of disability and death caused by tobacco. ASSIST raised significant conceptual and practical challenges for its evaluation team. These challenges included context-dependent implementation and the diffusion of ASSIST and ASSIST-like interventions into non-ASSIST states. In addition, the evaluation did not begin until several years after ASSIST was implemented, and its budget was limited. What had been envisioned as a simple evaluation of a demonstration project became a complex evaluation effort that engaged a diverse group of scientists and practitioners and required numerous sources of data. The resulting evaluation successfully documented the effectiveness of ASSIST. It also validated the causal pathway described in NCI's 1991 Smoking and Tobacco Control Monograph 1: Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990's-that comprehensive interventions can change the social environment of tobacco use and subsequently result in decreased tobacco use. This monograph stands alone as a documentation of the ASSIST evaluation and describes the challenges met in evaluating a program that was influenced by numerous forces outside the program's control. However, this monograph may also be viewed as a companion to NCI Tobacco Control Monograph 16, which reviews the ASSIST program in detail. Together these two monographs provide a detailed history and evidence base that document the success of an NCI initiative that began with a series of research hypotheses, tested those hypotheses with community-based interventions, and ultimately fielded a demonstration program that fundamentally changed tobacco use prevention and control in the United States. This volume and several future volumes in the Tobacco Control Monograph Series have important implications for research, practice, and policy in tobacco control as well as in other areas of public health. Lessons learned from tobacco prevention and control can be applied to a variety of public health issues, including physical activity, diet and nutrition, overweight and obesity, and substance abuse. NCI is committed to disseminating this cross-cutting knowledge to the widest possible audience so that others can benefit from the experience of the tobacco prevention and control community. By so doing, NCI is increasing the evidence base for effective public health interventions and improving the translation of research to practice and policy.

The first great "public health revolution" in developed countries involved measures to control infectious disease, and now we are in the midst of the second revolution: the massive attack on chronic disease. In this revolution, the dramatic decline in cigarette smoking in the United States since 1964 stands out as the most striking success story, which is especially remarkable considering the fact that antismoking advocates play the part of David against the Goliath of the tobacco industry. Anti-tobacco forces, including public advocacy groups, have made steady advances in controlling the smoking epidemic despite the tobacco industry's greater expenditures to expand tobacco use. The industry's counterattacks continue with steadily increasing intensity; this points to a clear need to increase the scope and effectiveness of all existing educational and regulatory anti-tobacco strategies. This monograph on the Community Intervention Trial for Smoking Cessation (COMMIT) field experience meets this need extraordinarily well because organizing, activating, and empowering communities to take action against smoking surely stands as the most important strategy for use in public health campaigns that emphasize control of tobacco use. This monograph, Community-Based Interventions for Smokers: The COMMIT Field Experience, is one of an excellent series on various aspects of tobacco and health published since 1991 by the National Cancer Institute and the first to deal with community-based approaches. It reports exciting victories: (1) a modest decrease in smoking rates in light-to-moderate smokers, especially in the hard-to-reach categories of individuals of low educational attainment and (2) an impressive accomplishment in community empowerment.

The adoption of local ordinances regulating the use or sale of tobacco represents an extraordinary social trend in the United States. Although such laws were virtually unheard of just a decade ago, hundreds of cities and counties across this country have taken aggressive action to control smoking in public settings as well as making it more difficult for minors to obtain tobacco. Major Local Tobacco Control Ordinances in the United States provides clear documentation of the extent to which local com munities are enacting legislation to restrict or severely curtail tobacco use. The monograph also represents a social barometer regarding the seriousness with which communities view the smoking problem and the range of remedial actions taken to reduce tobacco use through socially responsible public policies. These ordinances are not based on social whim, however, but are based on decades of scientific research, which has increasingly documented the health consequences of tobacco for users and non-users alike. Since the early 1960's, medical science has left no doubt about the deadly nature of tobacco use, especially the practice of cigarette smoking. The scientific data base establishing a causal connection between smoking and increased death rates from various cancers, cardiovascular diseases, chronic obstructive lung diseases, fetal distress, and other chronic and debilitating conditions is truly staggering. Between 1960 and 1990, more than 60,000 scientific citations appeared in the worldwide literature linking cigarettes and other forms of tobacco use to these adverse health outcomes. Smoking is a health hazard in its own right, but smoking potentiates the risks of several environmental and occupational carcinogens. More than 400,000 premature deaths annually occur in the United States directly attributed to the effects of cigarette smoking. Of course, we should recall that even smokeless tobacco is a health hazard. Such high levels of death and disability affect us all, however, whether we smoke or not. In a comprehensive study conducted by the Congress' Office of Technology Assessment in 1985, it was estimated that cigarette smoking alone cost this Nation upwards of $95 billion annually. Given the spiraling increase in costs for both acute and long-term health care over just the last few years, such costs would be substantially greater in 1993 dollars. As a Nation, we simply cannot afford to pay for the health care costs associated with smoking. Major Local Tobacco Control Ordinances in the United States should also provide a tangible boost for local tobacco control policy development. It contains a comprehensive review of local and State tobacco control legislation, trends in tobacco control ordinances, and model laws for reducing both nonsmokers' exposure to ETS and youth access to tobacco products. It is, in short, a call to action to all who wish to improve the health of our Nation through reasonable and prudent public health policies that reduce tobacco addiction among our young and protect nonsmokers from the documented hazards of environmental tobacco smoke. Nevertheless, true prevention of smoking-related illnesses must depend on individual responsibility and action. Each of us as individuals must do our part.

This monograph, the fifth in the NCI Smoking and Tobacco Control series, provides important information for clinicians interested in reducing the tremendous burden of disease caused by cigarettes and other tobacco products. As health professionals we can and must contribute to this effort, both by assisting individual patient cessation and by contributing to broader tobacco control activities in our communities. Cigarette smoking is still this Nation's largest cause of premature death and disability and remains the only product that, when used as intended by the manufacturer, will kill the consumer. Every physician and dentist can and should become a smoking expert to counter the pervasive attempts by the tobacco industry to convince smokers and would-be smokers that smoking is desirable, sexy, or fun. We need to remind ourselves that for decades the cigarette industry blatantly used the medical profession in cigarette advertising and enticed entire generations into believing that smoking was safe. Even today, 30 years after it became known with overwhelming scientific certainty that smoking was a major health threat, cigarette advertisers still portray smoking as free from any significant health risk. Health professionals have been an integral part of the national effort to reduce smoking in the United States, and in fact, the first major smoking information campaign launched by the U.S. Public Health Service was based on changes in physicians' smoking behavior. However, we must do more.

This monograph, Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine, is the 13th report published in the National Cancer Institute's (NCI) Smoking and Tobacco Control Program Monograph Series. One feature of this monograph is that it blends the old with the new. Monograph 7, The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of U.S. Cigarettes, covered the history of that protocol and recommended changes in its procedures. Chapter 2 of this publication cites this earlier monograph, brings us up to date on the FTC method, and provides additional suggestions as to what can be done to help alert the public to the dangers of smoking. The examination of the scientific literature on low-tar and low-nicotine cigarettes is not unique to this monograph. Several of the earlier volumes devoted one or more chapters to discussions of the various health aspects of tar and nicotine levels. However, this monograph includes more than just the study of amounts of tar and nicotine. Chapter 5 includes a discussion on the continued health risks to smokers, even those who smoke a low-tar/low-nicotine cigarette, while Chapter 2 describes how changes in the cigarette design affect an individual's smoking habit. Chapter 7 points out how the tobacco companies' advertisements have changed to match the emerging public preference for low-tar/low-nicotine cigarettes. This monograph is unique in another important aspect. For the first time, the authors who prepared the various chapters have had extensive access to the information gleaned from the internal documents of the tobacco companies. The tobacco industry files now open to the public and available on the Internet constitute some 33 million pages of formal and informal memos, meeting notes, research papers, and similar corporate documents. Included are marketing strategies that express the growing concern among the various tobacco companies of the potential loss of new recruits. This concern over the potential loss of market was due to the evolving public opinion that smoking is harmful to health and that it is related to many of the illnesses that smokers experience over the course of their lives. The singular message that has been delivered to the public-smoking causes cancer-is gradually being accepted by more and more people of all ages.

The recent increase in cigar consumption began in 1993 and was dismissed by many in public health as a passing fad that would quickly dissipate. Recently released data from the U.S. Department of Agriculture (USDA) suggests that the upward trend in cigar use might not be as temporary as some had predicted. The USDA now projects a total of slightly more than 5 billion cigars were consumed last year (1997) in the United States. Sales of large cigars, which comprise about two-thirds of the total U.S. cigar market, increased 18 percent between 1996 and 1997. Consumption of premium cigars (mostly imported and hand-made) increased even more, an astounding 90 percent last year and an estimated 250 percent since 1993. In contrast, during this same time period, cigarette consumption declined 2 percent. This dramatic change in tobacco use raises a number of public health questions: Who is using cigars? What are the health risks? Are premium cigars less hazardous than regular cigars? What are the risks if you don't inhale the smoke? What are the health implications of being around a cigar smoker? In order to address these questions, the National Cancer Institute (NCI) undertook a complete review of what is known about cigar smoking and is making this information available to the American public. This monograph, number 9 in a series initiated by NCI in 1991, is the work of over 50 scientists both within and outside the Federal Government. Thirty experts participated in the multi-stage peer review process. The conclusions presented in the monograph represent the best scientific judgment, not only of the NCI, but also of the larger scientific community.

This, the eighth monograph in the Smoking and Tobacco Control series published by the National Cancer Institute (NCI), is in many respects also the most significant. Contained in this volume are new results from five of the world's largest prospective epidemiological studies defining the magnitude of disease risks caused by cigarette smoking. Thirty years ago, in January 1966, NCI published a similar monograph titled Epidemiological Approaches to the Study of Cancer and Other Chronic Diseases. The report of the Surgeon General's Advisory Committee on Smoking and Health had been released in 1964 and had relied extensively on data from prospective mortality studies to delineate the relationship between cigarette smoking and various chronic diseases. The 1966 NCI monograph provided a detailed examination of the outcomes of several of the large prospective mortality studies presented in the 1964 advisory committee report. At that time, the outcomes available from these studies were based on 3 to 6 years of follow up; with the exception of the American Cancer Society's (ACS) Cancer Prevention Study I (CPS-I), studies in the 1966 NCI monograph did not include substantial numbers of females. This monograph includes three new prospective mortality studies (CPS-II, the Nurses' Health Study, and the Kaiser Permanente Prospective Mortality study, provides the outcomes of the CPS-I study after 12 years of follow up, and provides 26 years of follow up of the study of U.S. veterans. Data from these studies provide the most comprehensive description of the disease consequences produced by smoking available to date and are accompanied by a detailed description of the changes in smoking behaviors of the U.S. population over the past century. Prospective mortality studies continue to play a critical role in quantifying the relative mortality risks of smoking for the individual as well as in estimating the overall disease burden caused by cigarette smoking in our society. The goal of this monograph is to facilitate both these tasks by providing, in one volume, comprehensive descriptions of smoking behaviors and the disease risks that result from those behaviors.

This monograph is the eleventh volume in the Smoking and Tobacco Control series released by the National Cancer Institute (NCI). The National Association of County and City Health Officials (NACCHO) and the National Association of Local Boards of Health (NALBOH) are working with NCI in disseminating findings from this important publication. NACCHO is a nonprofit membership organization that serves all of the nearly 3,000 local public health agencies (LPHAs) in the nation's cities, counties, townships, and districts. The organization provides local health departments with education, information, research, and technical assistance on a variety of topics. It also facilitates partnerships among local, state, and federal agencies in order to promote and strengthen public health. NALBOH is an organization that represents the interests of local boards of health and assists those boards in assuring the health of the community. NALBOH enhances and supports all 3,200 local health boards across the country by providing linkages, networks, education, and training. It is also committed to promoting health and effective public health policy at all levels of government and also to strengthening the ability of health boards to develop tobacco control policy efforts. NACCHO and NALBOH constituents have unique roles in tobacco prevention and control. They often represent the local government infrastructure, and as such, they can play leadership roles in local policy development, implementation, and enforcement. For years, tobacco control legislation enacted at the city and county levels were much more stringent than those enacted at the federal or state level. However, few local communities were involved in implementing and managing actual public health programs to reduce tobacco use. This was seen primarily as a national or state responsibility. Fortunately, local communities have become more involved in recent years. This trend has been supported mainly by LPHAs, and both NACCHO and NALBOH have helped local communities become more involved in the development of public health policy.

In response to the emerging scientific evidence that cigarette smoking posed a significant health risk to the user, in the early 1950's the major cigarette manufacturers began widespread promotion of filtered cigarettes to reassure smokers that, regardless of whatever unhealthy constituents were in cigarette smoke, filters were a "scientific" breakthrough. Advertisements for Viceroy's "health guard filter" stated, "DENTISTS ADVISE-Smoke VICEROYS-The Nicotine and Tars Trapped by The Viceroy Filter CAN NEVER STAIN YOUR TEETH " and "Leading N.Y. Doctor Tells His Patients What to Smoke-Filtered Cigarette Smoke Is Better For Health. The Nicotine and Tars Trapped ... Cannot Reach Mouth, Throat Or Lungs." Chesterfield was "Best for you-low in nicotine, highest in quality," while L&M's were "Just What the Doctor Ordered." Lorillard Tobacco Company stressed its science-based Kent micronite filter (the original micronite filter was made of asbestos) and claimed it removed seven times more tar and nicotine than any other cigarette, which "put Kent in a class all by itself where health protection is concerned." Of course, we know today that not only were these claims patently false, but the cigarette companies knew, it. In the early 1950's the Federal Trade Commission (FTC) challenged a variety of health claims made for cigarettes in their advertising, including claims about tar and nicotine. In 1955 FTC published advertising guidelines that, among other things, prohibited claims by cigarette manufacturers that a particular brand of cigarettes was low in tar and nicotine or lower than other brands, when it had not been established by competent scientific proof that the claim was true and the difference was significant. Cigarette manufactures, however, continued to advertise tar numbers. In the absence of a standardized test methodology, this resulted in what is referred to as a "tar derby"-a multitude of inconsistent, noncomparable claims that did not give consumers a meaningful opportunity to assess the relative tar delivery of competing brands. The tar derby ended in 1960 when discussions with FTC culminated in an industry agreement to refrain from tar and nicotine advertising. In 1966, however, the U.S. Public Health Service (PHS) prepared a technical report on "tar" and nicotine that concluded, "The preponderance of scientific evidence strongly suggests that the lower the 'tar' and nicotine content of cigarette smoke, the less harmful would be the effect." In reaching this conclusion, the report noted the clear relationship between dose of cigarette smoke received by the smoker and disease risk. Regardless of how dose was calculated-by number of cigarettes smoked per day, age of initiation, total number of years one smoked, or depth of inhalation, mortality rates among smokers increased. When smokers quit smoking, their risk was reduced in proportion to the length of time off cigarettes.

This National Cancer Institute (NCI) booklet is for people diagnosed with the most common types of skin cancer:* * Melanoma * Basal cell skin cancer * Squamous cell skin cancer Skin cancer is the most common type of cancer in the United States. Each year, more than 68,000 Americans are diagnosed with melanoma, and another 48,000 are diagnosed with an early form of the disease that involves only the top layer of skin. Also, more than 2 million people are treated for basal cell or squamous cell skin cancer each year. Basal cell skin cancer is several times more common than squamous cell skin cancer. Learning about medical care for skin cancer can help you take an active part in making choices about your care. This booklet tells about: * Diagnosis and staging * Treatment * Follow-up care * How to prevent another skin cancer from forming * How to do a skin self-exam

The National Institutes of Health Publication 10-6287, Pain Control: Support for People With Cancer, discusses pain control medicines and other methods to help manage pain, and addresses the physical and emotional effects of pain. Having cancer doesn't mean that you will have pain. But if you do, you can manage most of your pain with medicine and other treatments. This book discusses how to work with your health care team and others to find the best way to control your pain.

Describes key lessons from the first 2 years of the Initiative on the Study and Implementation of Systems, one of the first major coordinated efforts to explore the application of systems thinking approaches and methodologies to public health.

Reports some progress toward reducing tobacco use among adolescents, and also highlights areas in which more efforts are needed. The first major update of adolescent smoking behavior since the reports of the Surgeon General and the Institute of Medicine in 1994.

The National Institutes of Health Publication 12-5726 When Someone You Love is Being Treated for Cancer: Support for Caregivers provides caregivers with coping strategies to help them deal with the stress and anxiety associated with caring for cancer patients. It discusses communication skills, ways to get support, feelings, and the need for self-care. This is for you if you're helping your loved one get through cancer treatment. You are a "caregiver." You may not think of yourself as a caregiver. You may see what you're doing as something natural-taking care of someone you love. There are different types of caregivers. Some are family members, while others are friends. Every situation is different. So there are different ways to give care. There isn't one way that works best. Caregiving can mean helping with day-to-day activities such as doctor visits or preparing food. But it can also be long-distance, coordinating care and services for your loved one by phone or email. Caregiving can also mean giving emotional and spiritual support. You may be helping your loved one cope and work through the many feelings that come up at this time. Talking, listening, and just being there are some of the most important things you can do. Giving care and support during this challenging time isn't always easy. The natural response of most caregivers is to put their own feelings and needs aside. They try to focus on the person with cancer and the many tasks of caregiving. This may be fine for a short time. But it can be hard to keep up for a long time. And it's not good for your health. If you don't take care of yourself, you won't be able to take care of others.