tobacco 101 lesson two - emory universitytobacco 101 is a self-guided tutorial that provides the...
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Tobacco101PartOne,Lesson2
2016
ASELF-GUIDEDE-BOOKINTWOPARTS
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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.
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TableofContentsPART1: INTRODUCTIONTOPREVENTIONANDCONTROLOFTOBACCOUSELESSONTWO
TobaccoUseintheUnitedStates Page4
CheckforUnderstanding Page19
Sources Page21
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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.
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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.
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WhyTrackingTobaccoUseisImportant Thislessonwilldescribeseveraltrendsintobaccouse,andwillincludedatacollectedusingreliablemethods.Itisimportanttounderstandhealthdataanditsquality,asitisthefoundationanddriverofhealthplanninganddecisionmaking.Stakeholders,electedofficialsandthemediaoftenturntostatetobaccoprogramsasasourceofinformationaboutadultandyouthtobaccousewhichmakesitimperativethatthedataprovidedtothemisaccurateandreliable.Knowingprevalencedataalsoimprovesyourabilitytobetterunderstandtheneedforandimpactoftobaccocontrol.Thisislargelybecausetheprevalenceoftobaccosmokingamongadultsisanimportantmeasureofthehealthandeconomiceffectsoftobaccouse.Itservesasabaselinemeasureforevaluatingtheeffectivenessoftobaccocontrolprogramsovertimeandisanimportantandchallengingfirststepinplanningfortheneedsofyourcommunity.Tobaccousedataareusefulbecausethey:
• Helptoaccuratelydescribethetobaccouseproblem.• Informhowprogramresourcesshouldbetargetedtoaddresstheproblem.• Canbeusedtoeducatecommunitiesandstakeholdersabouttobaccouseandtheimportanceofprevention
andcessationefforts.• Helpevaluateprogramstrategiesandoverallprogrameffects.Inturn,programevaluationcontributestothe
researchleadingtobestpracticesfortobaccocontrolprograms.
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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
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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.
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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.
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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
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SmokingPrevalenceVariesbyPovertyStatus
PercentageofCigaretteSmokingAmongAdultsaged≥18Years,byIncomeUnitedStates,1983-2007
Thischartdemonstratesthehighertobaccoprevalenceforpeopleatlowerincomelevels(“below”thepovertyline)comparedtothosewithahigherincome(“at/above”thepovertyline).Estimatesfrom2010showthisgaphaswidenedevenfurther,with28.9%ofadultslivingbelowthepovertylevelsmokingcomparedto18.3%wholiveatorabovepoverty.Peoplebelowthepovertyleveltendtobelesseducatedandareoftentargetedheavilybythetobaccoindustrymarketingcampaigns.Becausethoselivingbelowthepovertylineareoftenmoreexposedtotobaccoadvertisingtactics,theyaremorelikelytobegintosmoke.ThiswillbediscussedfurtherinLesson4.
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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
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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/
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YouthSmokingPrevalence
TrendsinCurrentCigaretteSmokingbyHighSchoolStudentsandAdults,UnitedStates1965-2012
Tobaccouseisalsoaproblemamongyouth.Thisgraphshowsasharpdeclineincigarettesmokingamonghighschoolstudentsfrom36.4%in1997to21.9%in2003.Sincethen,thetrendhasslowedbutisstillcontinuingtogodown.The2011YouthRiskBehaviorSurveillanceSurveyreportsacurrentcigarettesmokingprevalenceof18.1%amonghighschoolstudents.Ifteensmokingprevalencecontinuesthisrateofdecline,theUnitedStatescouldachievetheHealthyPeople2020objectiveofreducingcurrentsmokingratesamonghighschoolstudentsto16%.Rememberthatcurrentsmokingforyouthisdefinedashavingsmokedononeormoredaysofthe30daysprecedingthesurvey.
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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
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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.
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FindingDataaboutYourState
Wehavefocusedmainlyonnationalleveltobaccousedatasofar,butstateleveldataisequallyimportantintobaccocontrolefforts.Eachyear,theCDCpublishesstatehighlightsontheeffectsoftobaccouseandincludesabreakdownofprevalencedatabyrace/ethnicity,educationlevel,andage.Thesehighlightsalsoshowhoweachstatecomparestootherstatesandthenationalaverageonkeyprevalenceandpolicymeasures.
Clickheretoaccessaninteractivemapthatallowsyoutoviewhighlightsforeachstate.Youcanalsodownloadafullreportofthesehighlights,TobaccoControlStateHighlights2010.
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TobaccoUseintheUnitedStatesLessonTwoexplainedwhytobaccousedataisexamined,andhowitisused.ThelessonillustratedsomeofthetrendsintobaccouseintheUnitedStates,showingusthateventhoughtobaccousehasdeclinedovertime,thereisstillworktobedone,particularlyinreducingtobaccouseincertainpopulations.Thislessonalsoprovidedinformationaboutthesurveysthatgiveusinformationabouttobaccouse,andwheretofindinformationabouttobaccouseinyourstate.Inthenextlessonwewilldiscusstheeffectsoftobaccouse,includingeffectsonthebody,frombothdirecttobaccouseandsecondhandsmoke.ThelessonwillalsodiscusstheeffectsoftobaccouseontheUSeconomy,productivity,andthehealthcaresystem.
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LessonTwoCheckforUnderstanding
1. Trueorfalse:Theequationusedtocalculatetheprevalenceofsmokersis:
Prevalence=Numberofcurrentsmokers
Totalnumberinpopulationstudied
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?
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LessonTwoCheckforUnderstandingAnswerKey
1. Trueorfalse:Theequationusedtocalculatetheprevalenceofsmokersis:
Prevalence=Numberofcurrentsmokers
Totalnumberinpopulationstudied
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.
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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