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NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE MEETING REPORT FOR January 25-26, 1999 SUPPLEMENTAL REPORTS DEPARTMENT OF HEALTH & HUMAN SERVICES U.S. PUBLIC HEALTH SERVICE NATIONAL INSTrFUTES OF HEALTH NATIONAL CANCER INSTITUTE

NATIONAL DENTAL TOBACCO'FREE STEERING COMMITTEE MEETINGREPORT~ J ry~_25~26, 1999 .anua SUPPLEMENTAL REPORTS DEPARTMENT OF HEALTH & HUMAN SERVICES U.S. PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH NATIONAL CANCER INStlt'~T~

SUPPLEMENTAL REPORTS NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE Committee Reports January 25-26, 1999 Pace(s) 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Chairman's report ....................................... Academy of General Dentistry report ....................... American Academy of 0ral Medicine report .................. | American Association for Dental Research report .............. American Association of Community Dental Programs report .... American Association of Dental Schools report ............... American Association of Public Health Dentistry report ......... American Association of Women Dentists report ................. American Dental Assistants Association report ................... American Dental Association reports - Part A Council on Access, Prevention and Professional Relations ....... - Part B Council on Dental Practice ............................. - National Board Dental Examination letter ..................... - Foundation for Dental Health Education order form .............. American Dental Hygienists' Association report .................. American Public Health Association report ...................... Association of State and Territorial Dental Directors report ......... • National Dental Association report ............................ Oral Health America, National Spit Tobacco Education Program.report ... .. .10 .. .11 .. .13 .. .14 .. .15 ...... 16 ........ 19 ........ 21 ........ 23 ....... 25 ....... 27 ....... 29 ....... 39 ....... 40 ....... 41 16. 17. 18. 19. 20. 21. 22. 23. 24. 25." 26. 27. 28. Secondhand Smoke Facts - Repaee Associates ...................... Adolescent Smoking Cessation Dental Practices., ................... Division of Oral Health, CDC report and ~ on Oral and Pharyngeal Cancer .................................. Center for Tobacco Preventioia, Karolinska Institute, Sweden .......... Indiana University Nicot'me Dependence Program report .............. Oregon Health Sciences University drug dependence intervention program ........................................ University of Southern California report ........................... Military Health Care Provider position statement .................... Tobacco Free Delaware Coalition report .......................... Tucson, Arizona: Full Court Press Coalition report .................. New Zealand Dental Association Smoke Free Promotion report ......... Section of World Dentistry Against Tobacco, FDI meeting report ....... 11t~ World Conference on Tobacco OR Health, August 6-10, 2000 - Announcement and ~n information ......... 45 ......... 47 ......... 49 ......... 53 ......... 59 ......... 61 ......... 65 ......... 66 ......... 67 ......... 71 ......... 75

Supplement 1: Chairman's Report CHAIRMAN'S REPORT NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE January 25, 1999 This fifteenth meeting of the National Dental Tobacco-Free SteeringCommittee occurs at the dawn of a new phase of the "tobacco wars." In 1998, the industry mounted strong re~sistance against litigation that would hold it accountable for misdeeds hnd against legislation that would promote corporate responsibility. Public health objectives to prevent nicotine addiction and tobacco-related diseases and adverse conditions are diametricullyopposed to the tobacco industrfs objectives of developing markets and increasing profits. Strategies applied by public health forces constantly meet with tobacco industry efforts tO preempt individual, community, and State laws, exempt itself from justice, and weaken social controls and accountability. The first part of this meet~g will address current status of the National Cancer Iustitu~te (NcI) with respect to tobacco control. On October 6, 1998, the Tobacco Control Research Branch was established, giving increasedvi.~ibility to the!sst~ewi~'thin NC!. In November, NCI's Board of Scientificcouusellors approved t.h.e Branch's nine-po~int research plan; a comprehensive agenda that promises to bring fresh understanding of .factors that' l~ad individu.'als to avoid, !nitiate, quit, or continue tobacco nse~ The second part of this meeting will review sever~ tobacco legislative, litigation, and public education activities Of 1998, and what these mean to public health practice in '1999 and beyond. Certainly, the sum- zero result of h~ving no Congressional legislation passed in 1998 was a victory for public health, even though new public health measures were not adopted, Congress did not legislat~ the special protection and a~antages that the tobacco industry had sought. YeL the industry did gain some~ advantages when it returned ~to state Attorneys General for a ne~ settlement. Now, ~the industry is quietly returning to a new Congress in. an attempt to secure special protection and adv ~a:ntages not secur.ed ~ it~ a~eement with the States. The President and others areintioduci~ng countermeasures. The best that can be saldab0nt the 1998 tobacco wars is that the public is much ~ore aware tha~ tobacco is a major hea!th i.ssee. Also, there is some hope that a portion of Stat~.tobacco settlement funds ~ill be allocated tO. financing effective public health measures, including patient tobacco cessation programs and public education campaigns. The worst that can be said is that, in spite of new evidence of tobacco industry untruthfulness and misdeeds, the sheer magnitude of its political effort, coupled .with its huge med~a campa!gn, has been s.h0wn to be.still .quite~ capable~of misleading the public and stopping sound legislation. ~.: ~ The third part Of the : ~ ~ " :" . meeting will address re~entadvances in the science.that forms the basis of our~ understanding of tobacco effec~ on the body and ~the pubfic. Risks associated with cigars, nicotine~ addiction, human behavior, and population trends will be reviewed. The balance of the meeting will be devoted to tobacco control activifie~within t~he denta~:~mmunity in the U~$~ end abroad. Other general and dental.-specifiC activities may be addre.ssed. A few are recognized below, : In 1998, Dr. Gro Harlem " ~ , Brundtland became the Direct0r,General of the World Health Organization (WHO). She immediately pl~aced tobacco control among her three top priorities and designated Dr. Derek Yach to lead the WHO initiative. Globally, WHO expects tobacco-related deaths to triple within the next two decades. This week in Geneva, Switzerland, WHO tobacco control proposals may be clarified during the World Health Assembly, Elsewhere, national governments are beginning to file suits against tobacco ~ompanies; their suits being patterned after those sucee~fully brought in the U.S. European dental schools and dental associations are increasingly active in tobacco control, both clinically and as professional organizations. The Taiwan Dental Association is defining its tobacco control role in order to address high oral cancer rates among individuals who use tobacco and chew betel quid. 1

Supplement 1: Chairman's Report Canadian, Hew Zealander, Mexican and other dental leaders are making progress in bringing the dental profession into the community of organizatioas that are dedicated to reducing the use of tobacco and its adverse health consequences. The FDI World Dental Federation has been highlighting tobacco and/or oral cancer issues in every Congress and in most of its publications. It is planning to present and publicize special programs on oral cancer and tobacco control during its 100th anniversary Congress scheduled for Paris, November 29 - December 2, 2000. I am privileged to be involved in many of these activities. Several multidisciplinary tobacco control conferences have been held since the April 1998 NDTFSC meeting. For example, on June 15 and 16, leading tobacco-research scientists and distinguished public health program leaders met at an American Cancer Society-sponsored conference, Cigar Smoking Health Risks: State-of, the-Science. On July 27-28, Vice-President AI Gore,. leading tobacco-research scientists from the U.S. and abroad, and several key individualsrepresenting tobacco control programs, met in Bethesda, Maryland for a special conference, Addicted to Nicotine. The conference, sponsored by- the Robert' Wood Johnson Foundation and the National Institute on Drug Abuse (NIDA), identified the current state Of the science and presented a comprehensive research agenda. Program summaries, presenters' biographies, and the meeting agenda are available on NIDA's home page on the World Wide Web at" www.nida.nih.gov. The conference provided the latest information about how nicotine acts in the body, especially in the central ncrvoussystem. This knowledge is expected to lead to more" effective means Of preventing and treating nicotifie addiction. I am optimistic about allthat the health professions, i~cluding the dental profession, can and will be doing in a few more years to reduce tobacco use-a major underlying cause of many oral diseases and conditions. (Incidentally, recentlyit has been learned that the tobacco industry has for years Worked ha~'dt0 prohibit tobacco from being identified in medical and death registries as~n underlying cause Of disease and mortality.) " ~ : .... ~ ..... ~ On Sep.temberJ0~ 1998, ,the Ageney for Health care Policy and Research (AHCPR) awarded a co~.tract the Unlversity:of Wisc0fisin tO reactivate th~ exper~ panel that developed CliniCal Pr~ctic~e Guideline N~. 18: Smoking Ce~idion. Release of~the Updated Gulde~ine is pl~anned for the fall6fihis year. I represent the dentalprofession on this panel. Upon its rel~ase in 1996,the Guideline was quickly adop~ted ~s the "gold standard" for clinical practice within numerous bealthcare systems ~n the U.S: and abroad. It is helping stimulate the adoption of clinical tobacco use intervention serv.i.'ces in managed care systems and as a practice standard.~ New Clinical intervention materials and upgrades, based on the Guideline are under development for dental iextb00ks: tbeADA Guide toDental 2~er~apeutics, the NCI dental manu'al, and other dental publichtions. ~ " ~ ' Since our last meeting,, I have had several opportunities to speakabout th~ AHCPR Guideline tO non- dental clinicians. ~Thi~has helped stimulate discussions of the topic in terms0f a variety of practice settings, and conversely has increased my appreciation that the ability and opportunity to help patients in dental practices are as good, if not better, than in other clinical settings. Of course, I continue to lecture and teach .dental clinicians about tobacco intervention and welcome opportunities to do so, but willnot present a litany Of. such. , past and future-, ~ evehts,.. •:. ! ~ i . . .~ :. ' " ~ ' . .' " ' TheNational~Iustitute of Delta| ahd Cr~iniofacial Research's Office of the Director has arranged for me to monitor, assess, and advise on-tobacco issues.~ A series of familiarization meetings are in progress. In due course, the role of all drugs of dependency and abuse on oral health should be considered. Substantial documentation on the effect of tobacco on oral health has been submitted for consideration for the forthcoming Surgeon General's Report on Oral Health. It is exciting to nole how firmly tobacco preventi6n and control issues have become established in dental organizati0ns~ The stream of tobacco and tobacco-control-related journal articles, meeting agendas, featured programs, and association policies, the activity of special interest groups in various national dental organizations, and dental representation in broad coalitions are evidence of the growing engagement of the profession in controlling a serious underlying cause of numerous oral diseases and adverse condition-s. Examples have been cited in every NDTFSC member's report. I am confident that we all look forward to hearing about many more accomplishments during this meeting. Thank you for your continuing heIp and commitment. 2

Supplement 2: Academy of General Dentistry report Academy of General Dentistry ' 211 East Chicago Avenue, Suite 1200, Chicago, Illinois 60611-2670 (312) 440-4300 888-AGD-DENT Fax (312) 440-0559 Report to the National Tobacco-Free Steering Committee January 25 & 26, 1998 The Academy of General Dentistry encourages its members and all general practice dentists and members of the dental health team to promote tobacco cessation and abstinence through patient education. The Academy continues to educate the public about the adverse impact tobacco has on oral and general health through internal and external communications. AGD Impact A cover story on oral cancer was featured in the November t998 AGD Impact, and an editorial letter from Bob Krause, Oral Health America president, comments on AGD l!npact "s oral cancer cover story will appear in the March 1999 issue. Every month, the newsmagazine messages reach more than 35,000 general dentists. A Dental Health-Fact Sheet on Smoking and Periodontal Disease is scheduled for the 1999 AGD Impact editorial calendar. See attached articles. General Dentist~_ The 1999 July/August General Dentistry journal will feature tobacco and oral health studies from Drs. Karen Crews and Nancy Williams. Each hi-monthly journal mails to more than 65,000 general dentists. Public Information This year, the Academy has reached an audience of more than 223 million consumers with positive dental health messages, including anti-tobacco stories, that cite the Academy of General Dentistry in print and broadcast media. Two Dental Health Fact Sheets entitled "'Oral Cancer" and "Spit Tobacco" appeared in AGD Impact. Dentists are able to copy these fact sheets an distribute them to their patients. Both fact sheets were added to our fact sheet packet that is available to the dentist to help educate their patients. See attached articles. The Academy of General Dentistry is dedicated to this health care topic which broadens dentistry's role in comprehensive health care, and also encourages all dental offices to serve as model tobacco-free environments and to work actively within the community to promote tobacco cessation and abstinence and to educate school-age children on the hazards of tobacco use. 3

Supplement 2: Academy of General Dentistry report Fact Sheet Academy of General- Dentistry Spit Tobacco Spit tobacco affects your dental health as well a.,;the rest of your body. If you use smokeless to- bacco and have thmu.:ht about quitting, your dentist can help. In the meantime, here are a few facts that may help you decide to join the 200 million Ameri- cans who are tobacco-tree. What is spit tobacco? Spit tobacco includes snuff, a finely ground version of processed tobacco, and chewing tobacco in the form of shredded or pressed bricks and cakes. called plugs, or rope-like strands called twisls. Users "pinch" or "dip" tobacco and place a wad in their check or between their low- er tip and gums. In the United Kingdom. users often snort snuff, Isn't it safer " ' than smoking? Absolutely not. Some wrongly believe that spit Iobacco is safer than smoking cigarettes. But spit tobacco is more addictive be- cause it contains higher levels of addictive nicotine than cigarettes and can be harder to quit than cig- arettes, One can of snuff delivers as much nicotine as 6{) cigarettes. About 8.000 people die every. year from tobacco use. About 70 percent of those deaths are from oral cancer. Other cancers caused by tobacco include cancer of the pancreas, nasal cavil): urinal,. tract, esophagus, pharynx, laryn, x. intestincs and the stomach. Kids who use spit tobacco products arc 4 to 6 times more likely to devel- op oral cancer than non-users and tobacco juice-related cancers can form within five year of regular use. Among high ~hool seniors who have ever used spit tol:ratx:o. • ,2most lhr~.fourtlx~ began by lhe ninth gr,~3e, How do.es snuff and chewing tobacco harm my dental health? It causes bad breath, discolors teeth and promotes tooth decay that leads to tooth loss. Spit to- bacco users have a decreased sense of smell and taste, and they arc at. greater risk of devel- oping cavities. The grit in snuff eats away at gums. exposing IOOth roots which are sensitive to hot and cold temperatures and can be painful. Sugar in spit to- bacco causes decay. Spit tobac- co users also have a hard time getting their teeth clean. What about mouth sores? The most common sign of possi- ble ~mcer in smokeless tobacco users is leukopl',&ia. (Ioo-ko-play- key-ah) a white scaly patch or le- sion inside the mouth or lips. com- mon among many spit tobacco users. Red sore.,; are'dso a warn- ing sign of cancer. Often. signs of precancerous lesions are unde- tectahle. Demise,; can diagnose and treal SLlch cases belbre the conditiou develops into oral cancer. If a white or red sore appears and doesn't he'd. see your dentist inunediately for a ..... lnc~ous test to see I1 It sprec, . Spit tobacco users 'also should see their dentist every ~ee months, to make sure a prob- lem doesn't develop. Studies have found that 61) to 78 percenl of spit tobacco users have oral lesions. ' What are double dippers? Double dippers, who mix snuff and chewing tobacco, are more likely to develop precancerous lesions than those who use only one type of spit tobacco. Long- Icrm snuff users have a 5{} per- cent greater risk of developing troll cancer dlan non-users, imd spit lobncco users are more like- 13' to become cigarette smokers. How do you kick the habit? Your dentist can help you kick yourspit tobacco habit. Inaddi- lion to cleaning teeth and treating bad breath and pule},, swollen gums associated with tobacco use. your dentist may pres~,xibe a variety nf nicoline replacement therapies, such as the transdermai . nicotine patch or chewing gum that helps to wean addicted snuff dippers or tobacco chewers. Nicotine patches are worn for 24 hours over several week,;. supplying a steady flow of nico- tine. The four brands nf patches are Habitrol. Nicoderm. @Tl'=s =r~ormat)on wa'~ c~rnDded 1or you by the Academv ot General Den- II tistry.. Your dentist cares about long-term dental he~h fur you and .vour ~ fam~ and demonstrat~ that concern by below_ mg 1o the Academy ~ General Oenttstry. As one ot the, 35.000 general dentt~s =n the Umted Slates and Canada who ate meml:~rs c~ the Academy. ~ den~t D&'lwJgales m an ongoing pccx3r, am ol t:~es,s~o~;.I devetolxnera and congnum'g_ educat=on (o remain curren~ w~th advances ~nthe peoless=on and to ~'owde ~:luahty I:mt=enl treatrneat. V~s=t the AGD's wel:mte at w~w..a.aa.o~. You ha~e perm~s~on to photocow th~ I~ .age and ~lnl~qe ~t 1~ ~ur p al~ec~ls. Ni¢otrol aud Pmstep. Over the course of treaunent the amount of nicotine in the patch decreas- es. The nicotine patch has a 25 percent success rate. Or you may try nicotine gum therapy on your quit day. One piece of gum is slowly chewed every 1-2 hours. Each piece should be dis- carded after 20-30 minutes. Make goals Make the following go',tls to quit and never resume chewing or dip- ping: • Pick a date and taper use as the date nears. Instead of using spit tobacco, carry subFtitutes like gum. hard candy and sunflower seeds. • Cut back on when and where you dip and chew. Let friends and family know that you're quitting and solicit their support. It" they dip and chew, ask them not to do it around you. • Make a list of three situations you" re most likely to dip and they,; and make every, effort to avoid using lObtV.:co at those times. • Switch to a lower nicotine bnmd to help cut down your dose. &)ttrces: Campa~qn far Tobacco.Free Kids. Oral ltealth America. Beat the Smokeles.r Ilabit: Game Plan for Surress. Nathmal l~ti~ttes of Health and National Cancer Institute. June 1o03: llealth hnplicationx of Smo~lesx ~barro [I.~': National la~lilule.t Ilealth ~flsen.~t.¢ Development Co~nre Statement. 1986: Smo~le~¢ Tobacco: Think Befo~ You American Dental A.~rociation. 19~: ~e theman Cost o[Tobacco ~ by Carl Banerd~i. M.D. et al.. ~ New England J, mmal of Medicine. Ma¢h 31. 1~: Morb[dity and MonaliEv Wee~y Report. Cente~ for Contud and P~.ention. Ma~h 25. 1~: Nirotine ~t~ Succ¢~ Rate Set at Drily 25~. by ~n Van. Chica~ T~bune. Fehma~ 24. I~: and Ce~atmn A~g ~ Bo~r. by Fe~¢aq" 1~: ~ 173-1~. March 19~ 4

Supplement 2: Academy of General Dentistry report Fact Sheet .Academy of General Dentistry. Oral cancer How common and how serious is oral cancer? Oral cancer, the sixth most com- mon cancer, accoums for about 3.6 percent of all cance~s diag- nosed, with roughly 40.000 new cases of oral cancer reported an- nually in the United States. The vast majority of 0ral cancers oc- cur in people older than 45 years, with men being twice as likely as women to develop the disease. 2"he most f~quent oral cancer sites are the tongue, the floor of the mouth, soft palate tissues in back of the tongue, lips. and gums. If not diagnosed and treated in its early stages, oral cancer can spread, leading to chronic prin, loss of function, ir- reparable facial and oral disfig- uroment following surgery, and even death. Your general dentist can perform a thorough screen- ing for oral cancer. What causes oral cancer? Scientists aren't sure of the exact cause of oral cancer. However, the carcinogens in tobacco prod- ucts, alcohol and certain foods. as well as excessive exposure to the sun have been found to in- crease the risk of developing oral cancer. Risk factors for oral cancer may also be genetically inherited. What are the warning signs to watch out for? Oral cancer--represented by" red. white or discolored lesions. patches or lumps in or around the mouth--is typically painless in its early stages. As the malig- nant career spreads and destroys healthy oral tissue, the lesions or lumps become more painful. However. oral cancer is some- times difficult to self-diagnose. so routine dental exams are rec- ommended. See your dentist immediately if you observe: any sore that persists longer than two weeks: a swelling, growth or lump any- where in or about the mouth or neck: white or red patches in the mouth or on the lips: repeated bleeding from the mouth or throat:, difficulty swallowing or persistent hoarseness. cheeks and oral cavity, and thor- oughly examines the soft tissues in your mouth, specifically looking for any sores or discol- ored tissues. How is oral cancer treated? If your dentist suspects oral can- cer. a biopsy of the lesion is re- quired to confirm the diagnosis. SurgeD' is required to remove the minors, which may cause disfiguration. Radiation therapy may be used as part of the treatment. How does a dentist screen for oral cancer? Your dentist should screen for oral cancer during routine checkups. He or she feels for lumps or irregular tissue O ° chan=es m your neck. head. What can I do to prevent oral cancer? Oral cancer accounts for roughly 9.000 deaths annually (about 3 percent of all cancer-cansed deaths). Of all major cancers. oral cancer has the worst five- This mtormat=on was compded for you by the Acaoerny o! General Dent=stry Your dentist cares about long-term Oental health for you ~ your lamdy and ¢~.strates that cor~cem 0y belong=ng to the Aeanq~my ol General Dentistry. As ¢a'~e ot the 35.000 general dentils =n the United States and Canaaa who are members o! the Aeaoemy, you~ ~entlst oamooales in an ongoing program OI i:~:)less~tal de- velol:~nt and continuing, eOucal~on to remain ounen! w~th aOvanees =n the omles- ss:m and to 0n:n,,~Se ~.~-u¢/oat*eric u'eacaent ~hstt me AGDs ~¢~te at v,'n'w.a~.o~2. year survival rate at about 54 ~ercent. Because oral cancer is usually not dia~osed in its early stages, less than half of all oral cancer patients are cured. You can help prevent oral cancer by not smoking, using spit to- bacco and drinking excessive al- cohol. When tobacco use and al- cohol use are combined, the risk of oral cancer increases 15 times more than non-users of tobacco and alcohol products. Research suggeststhat eating plenty of fruits and vegetables may safe- guard against oral cancer. Be- cause successful treatment and rehabilitation are dependent on early detection, it is extremely important to see your dentist for an oral cancer screening and re~lar checkup at least every six months. Survival rates great- -ly increase the earlier oral can- cer is discovered and treated. During your next dental visit. ask your dentist to do an oral cancer screening. Sources: American Cancer Society: Luke E Matranga, DOS, MAGD, CBGD. past pres- ident of the AGD: "The War on Oral Cavil." and Pharyngeal Cancer." by Dr. Harold Slarkh~. JADA, April 1996; "U.S. Adult Knonqedge of Risk Factors and Signs of Oral Cancers: 1990.'" b.v Dr. Alice Horowit:, et. aL. J/IDA, January 1995: "The Early Warning Signs of Oral Cancer." by Edmund Cataldo. Dental Hygienist News. Sprine 1994. AGD IMPACT Nmmbet 1998 5

Supplement 2: Academy of General Dentistry report March 1999 COVER STORY: Evidence based care BUSINESS BUILDER: Creating a good dental team FEATURE: Why you should look into ~ Fellowship/Mastership Awazds SPECIAL TECHNOLOGY: Extraoml cameras w/ fact sheet FACT SHEET: Dental implants Editorial Calendar July 1999 COVER STORY: Nutrition and oral health making the connection BUSINESS BUILDER: Old patient records--Keep them under control FEATURE: Working with pcriodontist FEATURE: Generic drug companies leave the market FACT SHEET: Nutrition and health April 1999 COVER STORY: Legislation affecting dentistD' BUSINESS BUILDER: Y2K-Effects on the dental practice FEATURE: What's new in pain management FEATURE: Anesthesia in the dental office SPECIAL TECHNOLOGY: Intraoral cameras w/ fact sheet FACT SHEET: Dental anesthesia August/September 1999 COVER STORY: Dentistry's relationship with insurance companies--good and bad BUSINESS BUILDER: Transition planning FEATURE: Dental noise is a work hazard FEATURE: Problem-based learning FACT SHEET: Diabetes and perio disease May 1999 COVER STORY: DentistD"s response to PEW BUSINESS BUILDER: Y2K--Carriers payment options, eligibili .ty issues FEATURE: The changing physician and dentist relationship FEATURE: Consolidation among dental suppliers SPECIAL TECHNOLOGY: Curing lights w/fact sheet FACT SHEET: Women's dental health October 1999 COVER STORY: Access to car~deliwring care to patients- BUSINESS BUILDER: Bomncrs dental needs growing FEATURE: Violence in the workplace FEATURE: Caries--not as insignificant as we thought FACT SHEET: Low-birth-weight babies and perio disease June 1999 COVER STORY: Is there room for expanded function auxiliaries? BUSINESS BUILDER: Keeping your patients happy FEATURE: Annual meeting previcxv or new dental research FEATURE: Tree or false: The year 2000 will have a shortage of dentists SPECIAL TECHNOLOGY: Panoramic x-rays w/ fact sheet FACT SHEET: Sealants November 1999 COVER STORY: Dentistry. and the Media BUSINESS BUILDER: How to choose an associate FEATURE: Latest latex allergy, statistics FEATURE( Working with pediatric dentists FACT SHEET: Heart disease and pcrio disease December 1999 COVER STORY: Wellness in dental care--what dentists are doing and what they can do BUSINESS BUILDER: Cosmetic dentist~, a practice staple FEATURE: AGD helping members FEATURE: Where dentistry stands on the fluoridation battle line FACT SHEET: Smoking and perio disease Updated Dec. 30. 1998 6

Supplement 3: American Academy of Oral Medicine report REPORT TO THE NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE JANUARY 25-26, 1999 The American Academy of Oral Medicine (AAOM) had its annual meeting on 27 April-01 May 1998, and the board of directors agreed to reaffirm the commitment of the Academy to support the goals of the NDTFSC. Discussion were made on how the AAOM can continue to support of the important mission of the NDTFSC. The proposed American Academy of Oral Medicine organization statement, regarding the effects of tobacco on oral health and oral medicine related conditions, was presented to members during the general business meeting. The proposed statement, which indicates that there is no safe form of tobacco, and that all forms of tobacco including cigars, pose a significant risk to the oral health of users, was accepted by the general membership. The statement is to be published as a letter to the editor to the major English language peer- reviewed medical and dental journals. All dental health care providers were urged to become active in tobacco control. Additionally the Academy will continue support bfthe NDTFSC by: ' 1.) Including tobacco related topics such as tobacco control in the scientific program at future fiie~ings, as will be done at the May 1999 meeting. 2.) Having educational materials and information regarding tobacco use and intervention distributed at annual meetings. • ~. 3.) Publishing in the quarterly AAOM newsletter information for members regarding tobacco use and control, as was done with the most recent issue. 4.) Continuing to include in the Academy's official.publication, the Jbumal of Oral Surgery~ Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, scientific papers regarding the pathophysiology of tobacco and strategies of cessation. 5.) Actively encouraging all members, many of whom are engaged in dental education, to include tobacco related issues in their dental curriculum. The American Academy of Oral Medicine looks forward to further defining its role and contributing to the mission of the NDTFSC. Respectfully submitted, Paul J. Vankevich, D.M.D. AAOM representative to the NDTFSC 7

Supplement 3: American Academ~ of Oral Medicine report AMERICAN ACADEMY OF ORAL MEDICINE POSITION STATEMENT ON TOBACCO USE AND ORAL HEALTH The American Academy of Oral Medicine has the opinion that there is no safe form of tobacco ( 1 ). The use of any tobacco product has an associated increased risk of oral disease, systemic health problems,affecting oral health, and oral cancer ( 2 ). Smokeless ( spit ) tobacco use places the user at increased risk for oral cancer and a number of other non-cancer oral conditions ( 3 ). Cigar use has been linked with cancer ofthe upper aero-digestive tract ( 4 ). All forms of tobacco can adversely effect the periodontium and result in premature tooth loss ( 5 ). All health care providers are urged to ask patients regarding their tobacco use, advise cessation when appropriate, and arrange for follow up as necessary ( 6 ). ( 1. ) Bartecchi CE, Mackenzie TD, Schrier RW. The human costs of tobacco use. (First Of Two Parts). N Engl J of Med March 31,1994; 330 (13): 907-912 ( 2. ) Mandel I. Smoke signals: an alert for oral disease. J Am Dent Assoc 1994; 125: 872- 878 ( 3. ) U.S. Department of Health and Human Services. The health consequences of using smokeless tobacco. A report of the advisory committee to the Surgeon General. Bethesda, Maryland: Public Health Service, National Institutes of Health, 1986 (NIH Publication No 86-2874) ( 4. ) U.S. Department of Health and Human Services. Cigars: Health Effects and Trends. Bethesda, Maryland: U.S. Department of Health and Human Services, National Cancer Institute, Smoking and Tobacco Control Program; 1998. DHHS publication 98-4302 ( 5. ) Burgan S. The role of tobacco use in periodontal diseases: a literature review. Gen Dent 1997; 45 (5): 449-460 ( 6. ) Tomar SL, Husten CG, Manley MW. Do dentists and physicians advise tobacco users to quit? J Am Dent Assoc 1996; 127:259-265

Supplement 3: • American Academy of Oral Medicine report SMOKELESS ( SPIT ) TOBACCO REFERENCES AND BIBLIOGRAPHY Burgan S. The role of tobacco use in periodontal diseases: a literature review. General Dentistry 1997; 45 (5): 449-460 Cormolly GN, Wirm DM, Hecht SS, Henningfield JE, Walker B, Hoffman B. The.reemergence of smokeless tobacco. New England J of Medicine 1986; 314: 1020-1027 Djordjevic MV, Hoffmann D, Glynn T, Cormolly GN. US commercial brands of moist snuff, 1994. I. Assessment ofnicotine, moisture, and pH. Tobacco Control 1995; 4:62-66 Hermingfield JE, Fant R¥, Tomar SL. Smokeless tobacco: an addictive drug. Advances Dental Research September 1997; 11(3): 330-335 Henningfield JE, Radzins A, Cone EJ. Estimation of available nicotine content of six smokeless tobacco products. Tobacco Control 1995; 4:57-61 Hoffman D, Djordjevic MV. Chemical composition and carcin0genicity Of smokeless tobacco. Advances Dental Research September 1997; 11(3):322-329 Mandel I. Smoke signals: an alert for oral disease. JADA 1994; 125:872-878 Tomar SL, Husten CG, Manley MW. Do dentists and physicians advise tobacco users to quit? JADA 1996; 127:259-265 U S Department of Health and Human Services. The health consequences of using smokeless tobacco. A report of the advisory committee to the Surgeon General. Bethesda, Maryland: Public Health Service, National Institutes of Health, 1986 (NIH Publication No. 86-2874) ' Winn DM. Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco. Adv Dental Research September 1997; (3): 313-321 Wray A, McGuirt W F. Smokeless tobacco usage associated with oral carcinoma. Arch Otolaryngol Head Neck Surg 1993; 119:929-933 9

Supplement 4: American Association forDental Research report Report to the National Denta[ Tobacco-Free Steering Committee By John C. Greene American Association for Dental Research The American Association for Dental Research continues to emphasize its role of communicating the results of scientific research as well as facilitating and promoting the pursuit of new knowledge by its members. In the June, 1998 issue of the Journal of Dental Research, 20 papers were listed as dealing with tobacco and were presented at the AADR meeting held in Minneapolis, Minnesota. At our last meeting I called attention to two of those abstracts. They dealt with the emergence of cigar usage among professional baseball players. According to that abstract, the use of cigars has increased eighteen fold in this population and the bulk has occurred within the last three years. I also mentioned an abstract by Severson and co-workers that concluded that smokeless tobacco ~cessation advise when delivered by dental professionals in the context of a dental hygiene visit can be quite successful. I would like to call your attention to a few other abstracts of presentations made at that same meeting: Barr and co-workers at the University of Connecticut reported that, from their study, immunosuppressed individuals who smoke apparently have an increased risk of developing oral candidiasis. Payne and co-workers at the Universities of Nebraska and Iowa, reported finding deleterious histologic and clinical changes at the site of smokeless tobacco placement in as few as two to seven days, underscoring the potential hazards of even short term use of snuff. Liso and co-workers at the Tri- service General Hospital in Taiwan reported data showing an increase in dental caries in smokers compared to non-smokers. Tomar and Winn from UCSF and NIDCR found an increase of coronal and root caries in persons who used chewing tobacco. At the International Association for Dental Research in Nice, France last July their were 31 presentations that dealt with tobacco. Their are a few that I would like to bring to your attention: A study by Jones and Co-workers at the University of Texas, San Antonio reported that in their study, dental implant losses for smokers were found to be significantly higher than for non-smokers. Squire and co-workers at the University of Iowa reported finding evidence that carcinogens in tobacco penetrate the oral muco.4a more rapidly following a brief exposure to alcohol. Tomar and Marcus at UCSF reported that data from the third National Health and Nutrition Survey indicate that cigarette smoking appears to be a major risk factor for periodontitis in the United States. Researchers at the Boston University Goldman School of Dental Medicine reported finding that alveolar bone loss and tooth loss increased among cigar and pipe smokers and that the risk of tooth loss is similar to that of cigarette smokers. Biondi and co-workers from Argentina reported finding a close relation between the amount of tobacco consumed and the presence of precancerous lesions and oral cancer. Chen and Wolff at the University of Minnesota conducted a ten year study of Chinese smokers and non-smokers and found no differences in plaque, calculus or probing depth and attachment scores between the two groups but did find an increase in tooth loss among smokers. At the last meeting I also reported that the president of the IADR was planning to appoint an ad hoe committee to explore possible ways the dental research community might join forces with other international dental and related organizations to help reduce the use of tobacco in all forms in countries around the world. The IADR, following its meeting in June, asked me to form such a committee and to investigate this issue. I am still in the process of getting this task underway. I believe the international dental community could provide a very useful service, particularly if it were to link up with other international bodies with similar interests. John C. Greene, DMD, MPH 1/25/99 It

Supplement 5: American Academy of Community Dental Programs report American Association of Community Dental Programs " CDP Report to the National Dental Tobacco Free Steering Committee January 26, 1999 The Amedcan Association of Community Dental Programs (AACDP) continues to support the goal of a tobacco free society and the work of the National Dental Tobacco Free Steering Committee (NDTFSC). As the dental pmfession's representatives for public health issues at the local public health level it is essential that community dental programs accept the responsibility to press forward with and help shape the oral health communities tobacco control activities at the grass roots level. Our pos'~doning within the local public health infrastructure not only creates this responsibility but presents us with unparalleled opportunities for linkages with other paris of the public health community, private community health organizations, other powerful local organizations and local advocacy groups which are essential to tobacco control activities. In addition, the patient populations that community dental programs are responsible for and .that we have unequaled access to, are those that are most likely to have the highest risk for tobacco use. They are also most likely to experience the greatest long-term adverse health, economic and societal consequences of our nations deadliest addison, tobacco use. AACDP recognizes therefore that these factors converge to present a serious obligation, as well as a remarkable opportunity for us to move our profession's tobacco control agenda fonNard, by educating our members, by coordinating with professional organiZations atthe national, state and local levels and by serving as a critical link between the oral health community and other grass roots community groups in order to decrease our nations greatest cause of preventable death, tobacco use. In order to be effeclive in these roles AACDP must continue to develop its ability to transfer information to and from the grass roots community program members as well as to improve collaboration with appropriate state and national level organizations. A breakthrough in this regard has finally materialized in the form of an information transfer partnership grantthat will link AACDP, ASTDD and NNOHA. For the flint lime we should see a regular newsletter for AACDP and NNOHA which would also be in partnership with ASTDD along with a conjoint staff person linking the three organizations. AACDP will strive to assure that tobacco information transfer is a regular focus of the conjoint newsletter and strengthens the dental public health communities ongoing efforts in tobacco control. Since our last meeting AACDP has promoted tobacco components dudng the planning process of the upcoming National Oral Health Conference, promoted tobacco control as a part of the ADA's policy council on access and prevention (CAPIR), had a tobacco segment dudng our annual meeting associated with the last NOHC and National Sealant Conference, has a tobacco component planned for our upcoming annual conference in conjunction with the March NOHC and parlnered on a regional conference =Tobacco and Dentistnj: Who Wins and Who Loses?~ this past fall. This conference was of interest because it not only offered a wodd class set of speakers including Hal Slavkin, Sol Silverman, InNin Mandel, Greg Connolly and our own Robert Mecklenburg among others with wodd class presentations of interest to clinicians but it also developed and exciting partnering outcome. The closing panels consisted of an encouraging spectrum of the major state level dental professional organizations agreeing to place tobacco control at an enhanced level within their respective organizations and to work coilaboratively wflh both the other dental organizations present as well as with other state and community organizations involved in tobacco control. AACDP partnered with a state level component and that components linkages to market the conference and to exploit the conference marketing process to convey tailored tobacco educational messages to all of the local dental programs in the multi-state area and to component dental societies, to state dental directors in the region, to dental school faculty in the state and to the leadership of selected community level organizations. The rational of this strategy was that despite the caliber of the conference most of the leaders and decision makers within the regions dental professional organizations would not feel able to attend. However, by including a clear concise statement on why involvement in tobacco control is appropriate and important to our patients, our practices and the profession we could achieve a much greater outcome than through the conference alone. We also employed the strategy of placing the educational message on the conjoint letterhead of two organizations that the recipient audience might respect in order to increase attention to the content_ 11

Supplement 5: American Academy of Community Dental Programs report -2- As a part of t~e follow-up addvities with the dental organizations that were a part of the conference another interesting phenomenon seems to have become obvious. The older more senior leademhip of dental associations seem to be less inclined to commit their organizations and their personal efforts to'tobacco control and are more committed to regulatory, insurance/managed care, professional turf issues and what may be viewed as tradi~onal business issues of dentistry, where as younger, emerging leaders and the general membership may be more receptive to tobacco control and what they see as their professional obligations to the public's health. Consequently we will focus efforts on educa'dng and involving upcoming leaders and the rank and file memberships as an important evolutionary process in improving dental organizafion policies and commitments to tobacco control. t AACDP also sees thevalue of developing grass rools collaborate relationships between dental organizations, other health organizations and other community groups that may have a health related focus. This process can bdng comparatively enormous resources and clout to dentistry's efforts to improve govemment policy, priority, program, funding and regulatory development, Tobacco control offers an unparalleled opportunity for community dental programs to collaborate with a wide vadety of such organizations on tobacco related issues and through these rela~nshipsto develop broad based support for oral health issues. AACDP members have taken leadership roles in tobacco coal~ons.- ,We have attending vigils, been part of anti-tobacco demonstrations, wdtten to legislators, testified and arranged.testim0ny-on legislation, partnered with tobacco control groups on newsletters ~ and conferenbes and worked within other organizations to promote tobacco control. As a result of the cross fe~lizafion in these tobacco related partnerships, community dental programs have developed support for oral health issues from Such non-dental groups as Hea~y Schools C0al[ons, Academy of Pediatrics, Area Health Education Centers, Advocates for Children & Youth, nursing:0rganizations; community actionagendes, Health Coal~ons, influential program areas Within Our local health depariments, Heart Associations, CancerSocieties and the like; In one state this broadersupport helped pass • awatemhed piece oforal health legislation that requires the state health department to increase Utilizations of Medicaid dental-se!vices from 14% of children, each-year to70%, created a high profile dental policy panel by law to guide state government dental programs~ assured thatthe states CHIP program would include dental~ established the state dental ; directors.position in law, provided substantial dental program funding and in essence created one the most significant pieces of dental legislalJon to come out 0f a state since water flUoridation per a recentchief of staffto the U.S: Surgeon General. ~ -~ln addition to partnering and ,developing linkages that support tobacco and oral health interests AACDP facilitated de~velopment of a tobacco project at the National Museum of Dentistry in Baltimore which has been independently reviewed as the best museum in Baltimore, and is partnering on aninitiative to develop an Ask, Advise, ~ Assist, Arrange model that encourages health care providers to carry out the Ask and Advise Componentand then .automatically links the-patient to professional tobacco control counselors who provide thefollow-up Assistance and Arrangements for set~ng stop dates, addi~onal counseling and follow-up. We believe that this model should increase professional involve~ent~ in tobacco control in the clinioal seffing. . AACDP sees key ongoing issues that we need to focus on as including continued development of the information transfer infrastructure with ASTDD and NNOHA, and assurance that tobacco settlements as well as local tobacco tax dollars are appropriately used in tobacco prevention/cessation. We see funding-of the CDT Code for tobacco counseling in the.dental settingand training of oral health professionals as important issues in this regard. AACDP looks forward to playing an increasingly effective role in redudng our nations deadliest addison., tobacco use. Respectfully Submitted Robert D, Jones, DDS AACDP . • 205 Fey Road Chestedown, MD 21620 1-800-978-2904

Supplement 6: American Academy of Dental Schools report AMERICAN ASSOCIATION OF DENTAL SCHOOLS' REPORT TO THE NATIONAL DENTAL TOBACCO FREE STEERING COMMITTEE JANUARY 25 & 26, 1999 The American Association of Dental Schools (AADS) continues to support tobacco use prevention and cessation through a variety of activities. AADS ACITClTIES: Since the April 1998 meeting of the NDTFSC, AADS: Published an article in the Bulletin of Dental Education concerning the recent Surgeon General's Executive Summary.'.. Tobacco Use Among U.S. Racial and Minority Groups. Continues their membership and support for the Campaign for Tobacco Free-Kids. Continues their membership in the Coalition on Smoking or Health. Continues to monitor tobacco legislation at the federal level and to assist its member institutions on state and local legislative activity related to tobacco issues. Invites all interested members to attend the Special Interest Group Meeting on Tobacco- Free Initiatives. The SIGwill meet during 1999 AADS Annual Meeting. The TFI will meet on Tuesday; March 4, 1999 at 4:00 PM. The section is co-chair by Drs. Joan McGowan, University of Michigan, and Nancy Williams, University of Tennessee. This year's theme is, "The Impact of Tobacco Settlements on Dental Education," and will also include an update on tobacco issues. Speakers include: Dr. RhysJones (Cigars) ~ ~ Dr. Arden Chfisten.(Cigarettes)' Dr. Joan McGowan (Spit Tobacco) Dr. Eric Stafne (The Minnesota Tobacco Settlement) Dr. Robert Mecklenburg (Public ,Issues Update) Dr. Nancy Williams (Moderator for the TFI) Member activity: Drs. Arden Christen (Indiana University) and Nancy Williams and Marjode Woods (University of Tennessee) continue to work with Glaxo to gain funding to improve tobacco free programs at their respective dental schools. Dr. Karen Crews (University of Mississippi) has reported that she is awaiting formal notice of funding from the State of Mississippi tobacco settlement to enhance tobacco free programs at her dental school. Respectfully s~.mi_ttefl by Nancy J. Williams, RDH, EdD Professor, University of Tennessee, Memphis College of Allied Health Sciences Department of Dental Hygiene and Associate Director, UT Memphis Cancer Center University of Tennessee, Memphis 3 N. Dunlap, Room 334 Memphis, TN 38163 Substituting for Dr. Karen Crews, Liaison to NDTFSC 13

Supplement 7: American Association of Public Health Dentistry report AMERICAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY AAPHD National Office 3760 SW Lyle Court Portland, Oregon 97221-3363 Phone: (503) 242-0712 Fax: (503) 242-0721 E-marl: natoff@aol.com REBECCA S. KING. DDS. MPH HEAD OF ORAL EPIDEMIOLtY~Y DENTAL HEALTH SE~ION DHHS ~ ~X RALEIGH. NC 27626.0S~s ~: {919} 715~72 E-~uh rdmxc.t_k m~ldhl;mil.+h~+.,t at c.s;c .t + KIM McFA~ND. D[~S. MHSA DENTAL H~LTH DIRECTOR DE~. OF H~LTH & HUMAN SERVICES t01 CE~NIAL MALL ~M I. LINCOLN. NE PATRICIA A. MAIN, DI~, DDPH. REGION Of: ~IRHAM IIEALTH DEPT. 116 (.X'~MMERCIAL AVEN( AJAX ONTARIO L IS 211S CANADA K A~X WH~E. D[~. t+Pl I ~1~ PERMANENTE CE~R ~R HEALTH RES~RCH ~ N. I~R~ATE AVENUE ~R~AND, OR 97227.11 I0 • ~THRYN ATCHISON. DI~. MPH TERRA I~N, DI~, MPH CANDA~ JONES. RI~, MPH GEORGE W. TAYLOR, I~D, ~PH ~OMAR, DMI~ I~PH RO~T WE~NT, DMD. ~PH JOSEPH DC~HEW[T, I'IDS, MPH E-mad: Report to the National Dental Tobacco-Free Steering Committee National Cancer Institute January 25-26, 1999 Bethesda, MD Presented by: Rhys B. Jones, DDS,2vlS Representative of the American Association of Public Health Dentistry The American Association of Public Healtli Dentistry (AAPHD) continues to support the goal of the National Dental Tobacco-Free Steering Committee CNDTFSC) to ensure that the oral health team and dental organizations are directly, appropriately, and routinely involved in influencing patients andthepublie to avoid and discontinue the use of tobacco. NDTFSC meets under the auspices of the National Cancer Institute to: 1. Assess recent developments in tobacco use intervention strategies and activities. Define opportunities for dental involvement in tobacco use intervention activities. 3. Promote cooperation and collaboration between dental organizations and other professional and public interest organizations at the community, state, national, and global levels. Since the April 1998 NDTFSC meeting, AAPHD has promoted the goal and strategies of tobacco intervention in the following manner~ -" Publication of scientific journal articles on tobacco and oral cancer in the Journal of Public.Health Dentistry. Included in 1998 was the publication of the AAPHD Resolution on Tobacco Cessation, Prevention, and Control Relative to Cigars. (J Public Health Dent 1998; 58:169). The presentation of contributed papers and posters on tobacco interventions and oral health outcomes at the AAPHD Annual Meeting, October 21-23, 1998, San Francisco, CA. Publication of tobacco related news items in the AAPHD newsletter, Communique. These items include an update on Oral Health Objectives for Healthy People Year 201 O, an update on cigars and oral health outcomes, an announcement and highlights of the release of the MMWR Recommendations and Reports on the~Nationai Strategic Planning Conference on Preventing and Controlling Oral and Pharyngeal Cancer, and a summary of the 1998 NDTFSC meeting. AAPHD, in the official comments on the draft Healthy People Year 2010 objectives, recommended specific mention of tobacco use as a major risk factor for oral disease in the text for the chapter on oral health, and the inclusion of an objective on tobacco cessation activity by oral health professionals. Specific activities discussed for the coming year by the AAPHD oral health committee include the potential development of a tobacco and oral health brochure from AAPHD aimed at the dental professional, the development of an overview paper on model tobacco interventions for the adult and pediatric dental patients, and the presentation of an invited tobacco intervention session at the 1999 AAPHD Annual Meeting in Honolulu, HI. 14

Supplement 8: American Association of Women Dentists report Ameficaaa Association of romen Dentists 645 North Miclfig~m Avenue Suite 800 Chicago, IL 60611 January25,1999 TO:. FROM: National Dental Tobacco-Free Steering Committee Wendy S. Hupp, DMD SUB J: Association Report 1. The Board &Trustees of the AAWD met in Asheville, North Carolina in May, 1998. They voted unanimously to adopt a Tobacco Position Statement. (see reverse) This information was published in the AAWD newsletter, The Chronicle, July-August 1998 issue. 2. The "Four A's" were described in the September-December 1998 issue (see below). 3. The AAWD is constructing a website that will also have this information available: w~x~v.womendenlists.org or ~v.aawo.org. 4. The Association is planning a greater scientific and eon.tinuing educational focus to its future meetings, with Tobacco Intervention to be included. How to Help Your Patients Quit Tobacco b11 Dr. Wcnd~l Hupp, AA WD s Nm~ rcprescntan~ e and AA WD's representative to the National Dental Tobacco-Free Steering Committee The scientific journals are full of studies linking tobacco use to all types of dis- eases, from periodontitis to cancer, emphysema, heart problems and even male impo- tence! As health care providers, it is important for us to reinforce the fact that there is no safe form of tobac- co. Because more than half of current smokers seek dental treatment at least once a year, we have the opportunity to interact with our patients about tobacco on different lev- els. From the oral examina- tion, restorative, or surgical treatment by the dentist, pro- phylaxis by the dental hygien- ist, to a concerned front office staff memher, even a 30-see- ond discussion lets the patient bear the anti-tobacco message. Perhaps yours will be the motivation for him or her to finally quit! The National Cancer Institute (NCI) and the National Dental Tobacco-Free Steering Comn~ittee (NDTF- SC) have been working to dis- seminate a simple, brief method for tobacco interven- tion in the dental office. This technique is called the "Four As" and is described below. 1. ASK your patient about tobacco use. Include. ciga- rettes, cigars, pipes and spit tobacco. 2. ADVISE tobacco users to stop. You can also mention the stains on their teeth and fillings, and the gener- al/systemic effects. 3. ASSIST by setting a quit date, by providing written literature and educational materials, and by recom- mending nicotine replace- ment therapy and tobacco cessation classes. ~. ARRANGE follow-up ser- vices: a phone call of encouragement from a staff member or another prophy to remove stains. This can help prevent a relapse. It is important to tailor your approach to each individ- ual: if you sense a lack of interest, move on. You don't want to tose their attention about dental health issues. Revisit the anti-tobacco rues- sage, gently, at their nex~ visit. For more information, con- tact the following: NC1800/422-6237 How to Help Your Patie~tts Stop Usi~(q Tobacco: a matlual for the oral health team. Agency for Health Care Policy and Kesearch 800/358-9295 AHCPR Clinical Practice Guideline #I 8: Smokiuyl Cessation Centers for Disease Control and Prevention, Office of Smoking and Health $00/232-1311 or www.edc.gov/tobacco/ American Cancer Society. 's The Great American Smoke- Out 800/227-2345 15

Supplement 9: American Dental Assistants Association report ASSo C 0 N I C L E Dr. Wendy Hupp Represents AAWD on Tobacco-Free Steering Committee at National Institute of Health The AAWD has a representatzve to the National Dental Tobacco-Free Steering Committee (NDTF- SC) in the person, of Dr. Wendy Hupp of Mystic, Connecticut and the U.S. Navy. Dr. Hupp atte,nded the April meeting of NDTFSC at the National Institute of Health in Bethesda, Maryland. The committee is comprised of about 20 representatives of other dental organizations such as the ADA~AGD, NDS, ' and the American Associa- tions o~Dental Examiners," Dental Schools, Dental Research, and Public Health Dentist~,. This pasf meetihg marked the recognition of the AAWD as a full voting mem- ber of the committee. The goal of the NDTFSC is to ensure that the oral health team and ddntal organimtiohs are directly, appropriately and routinely involved in influenc- ing patients and the public to avoid or discontinue the use of tobacco. It xv~ es~blished in 1989 a~d meets approximately ev~ nine mont~. The National Cancer In~t~ (NCI) provides hnding for ~me me~ers to-auend, although Dr. Hupp has volun- teered to represent the AAWD on her own. Her interest in this area stems from her spe- cial~gaining in Oral Medicine and ~al Diagnosis that was completed at the Naval Dental ~hool in 1997. ~e ~C ~ to a~s re~nt flevelopmen~ in tobacco ~ in~enfion s~ate~es and aefi~fi~, m defin~ op~rmni- fi~ for den~ involwmenL and to promote cooperation and collaboration between fl~e member organizations and other public interest groups. At the AAWD meeting in Asbeville, Dr. Hupp proposed the following Tobac .e:9 Position Statement, which was ao_proved by the board. 1.' The AAWD should contin- • ue to educate and inform its membership and the public about ti~e many healfl~ haz- ards dttrihuted to the use of tobacco products, particu- larly cigarettes, pipes, cig- ars, and spit tobacco. 2. The AAWD prohibits smoking at al! of its meet- ings and conferences. 3. The AAWD isopposed to the advertising.of ciga- rettes, pipes, cigars, and spit tobacco products in both electronic and print media; endorses the nmn- dating of warnihg labels on all tobacco products; and supports national legisla- tion to these ends. 4. The AAWD urges its indi- vidual members and con- stituent groups to adopt anti-tobacco policies for their offices and meetings. 5~ The AAWD urges its mem- bers to become fully in- formed about tobacco cessa- tion and intervention tech- niques to effectively educate those with whom we have • contact, especmlly children. 6. The AAWD urges contin- 'fled research into the ad- verse effects of tobacco use. In future issues of the Chronicle, Dr. Hppp will pre- sent some information for educating our patients as well as resources for literature from NIHand NCI. A contin- Uing educationsession about tobacco intervention is in the planning stages for a future AAWD meeting. SAN - ' x[CISCO Amedcan Dental Association 139th Annual Session ,~ 0ctober 24 -28. t998 Pte.se~zions. Ft~ October 23.1998. Tet~ O~y. Te~m Builoln9 Conference JULY-AUGUST 1998 VOLUME 19-NUMBER 4

Supplement 9: American Dental Ass tants A ociati0n report National Dental Tobacco Free Steezing Committee Report January 25 & 26, 1999 submitted by Judith A- Andre~s, CDA American Dental'Assistants Association ]~ubl~cations : AD~A has an article on the clinician's role in spit tobacco cessation which will be use4 in 1999. The length is about two pages an~ is an abstract f~rom the Texas Dental AssDciation's Journal • 'F. A - C .T. We will also feature a Pgge from Joe Garagi. ola o'F NSTEP. It will rum at the same time as the above article. • FACT is, a n~ew program,,in~o~uced throughout Iowa. It is ,sponsored through a ,.grant from 'the Robert Wood JOhDs,o~ Foun'dat~:on. lt,. is the only ome in existence.at this time. (Attaehment) Iowa .]~as begun Public Health. regular basis into the next on 0ral Health 2010 throg~h the Irowa D4par~ment o'F There a~.e a number o~ sub-committees who meet on a to set goals and make recommendations for oral health millennium. One sub-committee,is directed to tobacco; cessation, diagnosis of diseases related to tobacco use an~ action to 'be tahen to deter teenage participation in the use of tobacco products. ADAA continues to promote cessation ofall tobacco products. We strive to conduct all business and scienti~ic meetings in tobacco free environments.~ ADAA ~eleomes any participant on the NDTFSC to submit articles o9 interest to our editor ~or consideration in future publication o~ the "Dental Assistant" 17

Supplement 9: American Dental Assistants Association report • Families Against Cigarettes And Tobacco Sign 7,000 ith an eventual goal of 25,000 families planted fimlly in mind, Tobacco Free Iowa members hit the recruiting trail hard at the Iowa State Fair and the re- sults were a resounding success. 7,000 families took a pledge to be tobacco- free and in return were in enrolled in the Families Against Cigarettes and Tobacco (EA.C.T.) Program. For their pledge, each family was provided with a credit card sized EA.C.T. Card which they can use for discounts at family retailers all across the state in the next few years. ' AccOrding to Aaron Bangsund Project Director for Tobacco Free Iowa, the goal of the program is to create an educational moment for parents every time they use the. card. "We • expect that when a parent goes to redeem the card for a free soda, slice of pizza, or anything they'll remember to talk to their children atiout the harmful effects of tobacco products. It gives them an excuse and a reminder," he said. Bangsund also said that although the discounts that existed for the card dudng the Iowa State Fair were only in the Des Moines area families, still jumped at the opportunity. "They understood that we will be expanding the coverage of the card statewide by this 'nter. So it was no t,,d~lem to sign them oh ." ".-" : Kids representing Tobacco Free Iowa help sign up families for the F.A.C.T. card at the Iowa State Fair. American Cancer Society Tobacco Con- trol Volunteers across the state are working currently to add incentives for the card in their local area. "We obviously want to make the card as valuable as possible in every area of the state." said Ann Wright, ACS Iowa Vice President nf Cancer Control. "And once we get these discounts and incentives in place, we'll spend a lot of time on promotion and getting more families signed up." A supporting Web site for the F.A.C.T. Program has been set up at www.factsia.org. The site includes all incentives available across the state as well as some fun information to keep kids interested. Interested families may also call i-877-FACTS-IA for more information. Together, we Pledge that our family will. get the facts about tobacco products. We promlse to talk to each other about the negative effects of tobacco. We promise to be good role models. We will strive to be stronger and he~lfhier. The EA.C.T. Program is the only program of its kind in the United States. It is sponsored through Tobacco Free Iowa by a grant from the Robert Wood Johnson Founda- tion. The American Can- cer Society ~rves as lead agency for administration of'the grant. ll II I iowa ..-DIvision.-.., Nbminated :- .=.-- ,. .,,. . ": • " Fo i- l t gr!ty • .... %.': ;.::'~ ." :::: ":-,-,';:,'." .:......., ." Busmess.Bur~aU,:•~¢rvmg Great~.• Iow~ mem~ ~ch ~ for ca~gon~ mc]ud- ' ~g for-p~fit ~d non-~fit ~le or- . ." .:" ~ :- • .,.,..,.. g~ons,. " .,:. .., ... , ').~: ." ~" .."~ .." • , . ~sid~nt J~ ~en w~'~at]y f~d 0~ su~s ~ or ~ ~st.of ~d~ no~ wi~o~t w~ch ~1 of O~eff~ f~l. But ~'o~ ra~ of ~ p~t few y~, it's obvig~ ~'~ow~s ~st us," says ~en ~ ~e ad w~eh ~n ~ publiea- do ~ hu~ live," 'she adds. Be~r B~e~ B~u of G~te~ Iowa A~g~ Mee~gg oa Novem~r 20. • ERlCAN 18

Supplement 10: American Dental Association report- PartA Council on Access, Prevention and Professional Relations REPORT OF THE AMERICAN DENTAL ASSOCIA TION--PART A ADA COUNCIL ON ACCESS, PREVENTION AND INTERPROFESSiONAL RELATIONS SUBMITTED TO THE NATIONAL DENTAL TOBACCO FREE STEERING COMMITTEE ON JANUARY 25, 1999 ADA Board of Trustees Action: During its December 1998 meeting, the ADA Board of Trustees discussed the tobacco settlement money coming into states and potential action on the part of.state dental societies. The following.interim policy statement was adopted, calling on the ADA: =through the appropriate agencies, to assist constituent societies in designing strategies to fund indigent dental care,~ either through existing programs or new programs created with state tobaccO settlement fH,.nds." . ~:-~ This interim policy statement will be submitted to the 1999 House of Delegates for ratification. Two Councils (the Council on Governmental Affairs and the Council on Access, Prevention and Interprofessional Relations) are discussing the interim policy and will most likely provide input and guidance on implementation of the policy if it is ratified. Staff technical assistance is available for state dental societies wishingto voice their opinion about how the settlement money should be spent in their stat?.. ADA to Apply for NCl Grant: Dr. Sol Silverman, Jr., has agreedto be the principal investigator for a National Cancer Institute R25 (Cancer Education) grant being submitted this year by the American Dental Association. The Council on Access, Prevention and Interprofessional Relations is coordinating the project for the Association in cooperation with the Council on Dental Education and Licensure, the Council.on Scientific Affairs and the Council on Dental Practice. The grant proposal endeavers to revitalize and strengthen oral cancer prevention education for dentists in the Un~ed States. Specific components of the grant proposal are under development. The overarching goal being discussed is to develop centers of excellence in oral cancer prevention within selected dental schools. These centers would field test model curriculum in the areas of prevention and early detection with the goal of integrating program MORE --7

Supplement 10: American DentalAssociation report- Part AConncil on Access, Prevention and Professional Relations ADA Part A Page 2 segments into all 55 dental schools. Key elements would include oral cancer prevention, early detection and diagnosis. A continuing education component for licensed dentists is also being considered. This project may also investigate the potential for use of model oral cancer prevention curricula within other colleges, universities and academichealth centers preparing primary care professionals such as dental hygienists, nurse practitioners, family physicians and internists. • ADA ONLINE: The ADA's tiomepage onthe World Wide Web (www.ada.or,q) has a variety of tobacco statements, policies and stories of interest to dental professionals. Search for =tobacco and nicotine" in the topical index. -. JADA Articles: Please refer to Part B the Amei~ican Dental Association'~ Report "from Dr. Arden Christen fo~" a list of recent tobacco-related articles of interest publ!shgd recently in the Journal of the Ame~can DentalAssociation. ASS0Eiation- Report on Tobacco Cessati.on--Dental Office. Strategies: ADA consultants, Drs. Arden Christen, Karen Crews and Eric. Stafne drafted a report on tobacc0~ ~cessation in 1998. It is undergoing review by the Council on Dental Practice; the Council on Access, Prevention. and Interprofessional Relations and the Council on~" ScientificAffairs. The Councils' comments will be incorporated and the i-eport Will be submitted bythe Councils for publication inthe Journal of the American Dental Associationl • .ADA Annual Session 1999: Dr. Sol Silverman; Jr. is scheduled to present a half-day course on oral cancer during the 1999.ADA Annual Session in Hawaii. This session, is sponsored by the Council on Access, Prevention and Interprofessi0nal Relations. ADA Staft Contact: Ms. Jane Forsberg Jasek, 312/440-2862, iaseki~ada.om ADA ONLINE: www.ada.oq]

Supplement 10: American Dental Association report- Part B Council on Dental Practice REPORT FROM THE ADA BY DR. ARDEN G. CHRISTEN, Consultant in Tobacco Education and Control, Council on Dental Practice and Council on Access, Prevention and Interprofessional Relations.January 25-26, 1999: PART B 1. Requests for Information by Practicin,q Dentists/Hy,qienists/Other,q (Clearinghouse Function): Since our last meeting (41 weeks) my Log indicates that I have received and answered 92 requests for information relating to tobacco education/control~ tobacco cessation (about 2.24 calls, letters, FAX's or personal contacts a week). I often receive referrals and/or questions from agencies within the American Dental Ass.ociation. In many instances, packets of material, including slide sets and reprints, were sent to individual practicing dentists and dental hygienists. About 70 inquiries (76%) were from dental hygienists, assistants or office managers. The nature of these inquiries can be broken down as follows: a. Information relating to smoking cessation activities in dental office settings (especially as concerned with-use of nicotine patches, nicotine gum, nicotine nasal spray, Zyban, Nicotrol inhaler) ........ 70 (76%) b. Smokeless tobacco issues/concerns ................... -~---,-~ ....... 8 (9%) c. Miscellaneous topics (e.g. smoker's rights; political issues; financial remuneration; availability of CE courses/training; involuntary smoking; workplace issues; etc) ....................................................... 22 (24%) Most of the individuals who contacted mewanted more detailed, how-to-do-it information for the dental office. I sent many of these requesters.our 51-page booklet, "A Smoking Cessation Pmgr, am for the Dental Office," Indiana University, 1994; and 'q'obacco and Your Mouth" (an 8-page color pamphlet illustrating actual clinical cases) which is available through The Health Connection, 55 West Oak Ridge Drive, Hagerstown, MD 21740-7390. Call 1-800-5.48-8700; internet catalog: www.healthconnection.o=:g Information requestom were frequently referred to the ADA lending library for Reference Packages of Journal Articles by Subject, ADA telephone# in Chicago: 1-800-621-8099, Extension 2654. Hot Topics: One of the hottest new areas of tobacco-related interest in dentistry i,~ that of tobacco use and its implications for understanding the causation and treatment of various forms of periodontal disease. Periodontists.must all be targeted in the months and years ahead to take advantage of this special area of-interest. ... There were noticeably fewer.requests for information during this period than the prev=ous. However, the calls being received are now more structured, specific and detailed than before. A number of calls related to the significance of nicotine gum and transdermal nicotine patches going over the counter: Some-oral. health care providers were interested to find out that the Habitrol patch is still a prescription item. I received a number of requests for info relating to the new prescription product nicotine nasal spray (Nicotrol NS-McNeill Consumer Products~ Co., P.O. Box 6767, Buffalo, New York 14240-8788)k; and the recently introduced nicotine inhalation system (Nicotrol inhalation system (also from McNeil Consumer Products) However, the most calls I received were about the new, non nicotine-containing smoking cessation product, Zyban (bupropion hydrochloride a non-sedating anxiolytic which is marketed by GlaxoWellcome, Inc.). Other topics of special interest to clinicians were similar to 21

Supplement 10: American DentalAssociation report- Part B Council on Dental Practice those desired during the last several years, i.e., prescribing information for nicotine patches; treatment planning considerations; financial remuneration for smoking cessation activities; medical contraindications for use of nicotine patches, gum; information about the new ADA CD-2 Code number for smoking cessation issued in January of 1995 (Code # 01320, "Tobacco Counseling for the Control and Prevention of Oral Disease."), Also, some dentists have successfully challenged the payment system by using Medical Codes (#99242 Initial Evaluation and #90841 Follo~w-Up- Counseling, using the DSM-IV Code 305.1 "Nicotine Dependence.") I also received about a dozen ;requests for information for dentists, hygienists and assistants who wished to give presentation to scho~)lchildren, PTA's, Health Fairs, Great American Smokeout [ACS] etc. Some of these individuals were sent our rotating slide set with script. Others were referred to the ADA or Dr. Mecklenburg for information., i also serve as a manuscript reviewer for a number of dental medical/public health journals including: JADA; American Journal of Health Behavior (formerly Health Values); Chest; Indiana, Medicine, etc. :.~. ~ .- .. . .- ~ Non-Hot Topics: A few short years ago, many of the previous "hot-topics" r~iated to the appropriateness of dental-team:member involvement in .smoking cessation • activities: However/dUring the.past 41.~eeks, i received no:ph0ne calls about the following topics: pharmacist's objection to a particular dentist who-was prescribing patches forhis-orher patient and State Board issues. Feel freeto refer dentists/ " hygienists/others tome if they~need moreinformation about-tobacco education " programs for dental practice. I frequently am in contact with: Dr. Mecklenburg to shars ideas.and information and-to coordinate programs. Call me,at my desk telephone: (317) 274-5417; or FAX: (317) 274-2419;~or E-Mail [Inte:rnet]: achr, iste@iusd:!up~iiedu 2. Tobacco Activities at the American Dental Association Meeting (Fall a1998): "-- ~ ~ . • - ~,- ~ Each year for the.past 12 years,~ members of our dentar tobacco cessation team at Indiana Universityor Dr. Mecklenburg have presented a table clinic or CE programs relating to smoking cessation at the annual ADAmeeting. Bob Mecklenburg presented a CE'Program - entitled, "How to Help Your Patients be Tobacco Free: A Practical Team Approach,'~. on .Saturday afternoon, October 24th, 1998 at the 139th Annual. Session of the ADA meeting in San Francisco. This program was held from 2- 4:30 p.m.. A number Of packets of information were given tothose who were attending. I presented a table clinic entitled, "Helping Patients Quit S~oking," at the 139th Annual Session of the ADA meeting held in San Francisco, on Sunday October 25, 1998. It was very well attended with about 150 persons visiting my table clinic. 3. Issuance of the 1998 ADA Guide to Dental Therapeutics: Information on more than 800 generic drugs and 2,200 brand-name drugs used in dentistry and medicine, are presented in this much needed new comprehensive, easy to use dental drug reference. Chapter 29 entitled "Cessation of Tobacco Use" (pages 505-516) are co-authored by Drs. Martha Somerman and Bob Mecklenburg.

Supplement 10: American Dental Association report- National Board Dental Examination letter American Dental Association 211 East Chicago Avenue • Chicago. |llinols 60611-2678 F~: (3'12) 440-7494 ~.sd~.org Da~e: January 8, 1999 To:- Fr6m: Subje~t: ~ Dr. Myron Allukian Examination content relat~tto tobacco use. In response to your realuest, I ~eviewcd our information regarding the National Board Dental Examination content in Part II that rdatcs to tobacco use. ,, . , ~ First. the Examination Specifications direct two test construction commiuees to op content that o~¢~ ~ehtes to tobacco use: Oral P~tholog~, and Dental Radio.lp_~. _ Mucosiddes and derma¢oses, iafeotions, ... Benign A. Soft tissue (23 items) Be neoplasms, Keratofic and premalignant condifions,:Malignant diseaseg,Salivary gland d~seases: "; ..... - " ~ ......., :, ,"" Hard tissue (14 items) Odontogenic (Odontogenic tumors and cysts, ...); Bone (~:., Beai~'ga and malignant neoplasms); D. H~redJtary diseases F. Chemical and physicat injuries G. Dh~nostic techt~iques and therapy Dental R~oioiogy (]0 Rem~) " B. Radiobiologic concepts (radiobi~logy) Demal Public Heahh.~nd.0.ccupafional Safety_ Evaluation of Dental Literature (3 items) Basic statistics (Inferential- including hypothesis testing). . Epidemiology (4 hems) Pdsk factors (including demographic,, behavioral, and aRkudinal); Epidemiology of oral diseases (...oral cancer). The case-based section of the examination does not spvcify cement by subj¢= matter, but by various stages in the process of diagnosing and treating patients. Tobao:o related items arc frequently found in the patient ¢~es section of the examination. In reviewing the two recent Part H Examinations, we found that one included two patient cases involving smokers. The other included three cases involving smokers. i hope this information provides the information you requested. Please feel free to conta~ n-~ if you have additkmal que~or_~.

Supplement 10: American Dental Association report- National Board Dental Examination letter 7 Tobacco-Related Articles Appearing in JADA from Jan 1998-Jan 1999. Slavkin (author). "Placing health promotion into the context of our lives." JADA 129:91- 95, January 1998. Andrews, Severson, Lichtenstein, Gordon (authors). "Relati,onship between tobacco use and self-reported oral hygiene habits." JADA 129°:313-320, March 1998. Yellowitz, Horowitz, Goodman, Canto, Farooq (authors). " Knowledge, opinions and practices of general dentists regarding oral cancer: a pilot survey." JADA 129:579-583, May, 1998. Winn, Diehl, Horowitz, Gutkind, Sandbergl Kleinman (authors). "Scientific progress in understand!ng oral and pharyngeal cancers," JADA 129:713-718, June 1998. Severson, Andrews, Lichtenstein, Gordon, Barckley (authors). "Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial, JADA 129:993-999, July 1998. Gould, Eickhoff-Shemek, Stacy, Mecklenburg(authors). "The impact of National Cancer Institute training on clinical tobacco use cessation services by oral health teams." JADA 129:1442-1459, October 1998. Krall, Gary.ey, Garcia (authors) "Alveolar boneloss and tooth loss in male cigar and pipe smolders." JADA 130-57-64, January 1999.

Supplement 10: American Dental Association report- Foundation for Dental Health Education order form THE FOUNDATION FOR DENTAL HEALTH EDUCATION ORDER FORM BASEBAll CARDS: a p= H JK" Check One Quantity Price Shippin~/Handlin~l Amount Due 1000 $50 $5.00 $55.00 2000 $100 $7.50 $107.50 3000 $150 $10.00 $160.00 5000 $200 $12.50 $212.50 6000 $300 $17.50 $317.50 10000 $350 $25.00 $375.00 POSTERS: "Br a Hom Run Hi r, Nora Tobacco Spi r, Be Smart, D 't Start" Quantity Base Cost $ 2.00 each Poster Cost $ Shippin9 & Handlin~l I to 10 posters $5.00 10 to 50 posters $10.00 each additional 50 $10.00 Call for bulk rate over 100 Poster Amount Due Poster Cost + Shipping = Bal. Due: $. Baseball Amount Due $ + Poster Amount Due $. = Total Order $ Make Check Payable to: Mail this form with your check to: FDHE The Foundation for Dental Health Education (FDHE) c/o Alliance of the ADA, 5th Floor 211 East Chicago Ave Chicago, IL 60611-25616 Questions? Call 312 440 2865 (Ask for Joan, Admin.Secretary, Alliance of the American Dental Assoc.) SHIPPING INFORMATION (PLEASE PRINT): Include both PO Box & Street Address Name: Address: Phone: _( ). City/State/Zip: Please read and sign the PURCHASE AGREEMENT, incomplete forms will delay pmcessin~ of your order:. I understar~ that the Mark McG~re posters and baseball cards are f~ educational purposes only. They are not to be sold or exchanged for profit or gairk The purpose of this project is to have an impact on children ~ youth; to help them understand the importance of not using tobacco Q-tobacco products. This product may not be reproduced or copied in any form ~thout the express written permission of the AJliarme of the Amedcan Dental Association. By signing this form I affirm that I understand the purpose of this project and agree to the terms of purchase and use of the posters and baseball cards. Signature: Title: Name (Please Print) :

Supplement 11: American Dental Hygienists' Association report AT BALTIMORE DE~ OF DENTAL HYGIENE Memorandum To: From: National Dental Tobacco Free Steering Committee Jacquelyn L. Fried, RDH., MS ~.~ American Dental Hygiemsts' Ass'~c~ation Representative Date: Subject: January 25-26, 1999 ADHA Tobacco Activity Since April, 1998 Thank you to Nancy Williams for facilitating my transition as new ADHA representative to the NDTFSC. o ADHA continues to support tobacco prevention and cessation through numerous channels. A. In the past nine months, eight publications addressing tobacqo issues appeared in the Journal of Dental Hygiene and Access. Topics included were legislative, the tobacco industry, cigars, cancer and tobacco, secondhand smoke and addiction. A book review also critiqued a tobacco publication. B. The fifth Annual Tobacco Free Networking Session met in New Orleans on June 26, 1998 at the ADHA Annual Session. Other presentations on cigars and cancer and tobacco were part of the Annual Session Program. The sixth Annual Tobacco Free Networking Session is scheduled for June 18 in San Diego. Dr. Nancy J. Williams has assumed Associate Directorship of the University of Tennessee Cancer Center, housed in the College of Medicine• The University of Tennessee also received funding through a grant from Glaxo-Wellcome to establish a tobacco cessation program run by dental and dental hygiene students. Ms. Jackie Fried continues to speak to different groups at the University of Maryland Dental School. She spoke to the General Practice Residents about tobacco issues and will soon meet with the periodontics post graduate students. She presented a continuing education course at the UM summer seminar and will be speaking to the Garrett County Maryland Health Department in May. Both dental and dental hygiene students continue to do case conferences and table clinics on tobacco related topics. 27

Supplement 11: American Dental Hygienists' Association report Activity among individual ADHA members continues via presentations, survey research and development of educational materials. Annual sessions include member poster sessions and student table clinics that highlight tobacco related topics. 1999 portends to be a great year for continued emphasis on tobacco prevention and cessation among the ADHA membership. JLF/rw

Supplement 12: American Public Health Association report AMERICAN PU~, LIC HEALTH ASSOCIATION TOBACCO ACTIVITIES MARCH 1998-JANUARY 1999 1015 Fifteenth Street, Washington, DC 20005-260. Main. : 202~-789-5600 Fax: 202-789-5661 DEFEAT OF THE McCAIN BiLL IN THE SENATE The single most important event in our efforts with Congress and the Administration to enact federal tobacco control legislation occurred in June 1998, after the submission of the last report on APHA tobacco related advocacy activities. A motion to invoke cloture in the Senate on a modified version of the McCain Bill failed~ by seven votes, and the Bill, by then heavily laden with extraneous amendments, was returned to committee.and effectively taken of the track to a floor vote. This was a devastating defeat, but the failure of the motion by so small a margin was indicative. Passage of the motion would have'meant-that debate on the Bill would be restricted, and that a vot~ would occur within a foreseeable period of time. APHA had supported the majority of the provisions in the McCain bill, arid was instrumental with other public health groups in the importation of much of the public health and tobacco-specific portions of the bill from the other pieces of Senate tobacco legislation that we had worked on with committee staff. APHA was invited to review, and did carefully review and comment upon the~e portions prior to their inclusion in the McCain Bill. Particularly gratifying was that these section wer~ incorporated by McCain into his bill directly, as opposed to being offered subsequently as possible amendments. Needless to say, the months of April and May, 1998 were filled with lobbying visits to Senate members, particularly after the tobacco industry announced that it was pulling out of any negotiations on a federal solution. In response to this, APHA sent a letter to all 535 members of Congress urging them to" continue their efforts to enact federal legislation even in the absence of the'industry. The letter included the key APHA principles, enumerated in what was then our interim tobacco policy (subsequently passed by the APHA Board at the Annual Meeting in November, 1998, and attached to this report), that'would need to be part of the most effective tobacco control bill. In ApriI,APHA staff also attended a meeting with tobacco growers to discuss the needs and concerns of tobacco growing communities in light of the potential effect of enactment of federal legislation in effectively threatening their livelihood. As the When, in May, the status of the McCain Bill became undertain, Dr. Akliter sent a letter to Senate Majority leader Trent Lott, urging him to bring the McCain Bill before the. full Senate for consideration. Key Senators were copied on this correspondence, simultaneously, we issued an action alert to our members urging them to contact their Senators to make sure that the bill progressed. We repeated this effort in the May/June issue of The Nation's Health asking our members to reinforce to their Senators that the proceeds resulting from federal legislation be targeted on tobacco prevention, cessation and research. Dr. Akhter followed up with another letter, this time hand delivered to the full Senate, urging its members to focus their deliberations on public health, and to ensure adequate funding levels for tobacco programs such as those sponsored by CDC. On June 17, 1998, after four weeks of debate on the floor of,tbe Senate, the motion to invoke cloture failed and the bill effectively died. Immediately following the demise of the McCain Bill, APHA scanned the legislative landscape in the House and Senate to see if there were any other viable tobacco vehieles to promote, and if there was any political will left in Congress to pursue them. In the Senate, the Hatch-Feinstein Bill posed hazards for the public health community in light of what were perceived to be too many concessions to the tobacco industry. In the House, the "No Tobacco For Kids Act" (I-I.IL 3868), a bill introduced by Henry Waxman (DOCA) and Marry Meehan (D-MA), was attractive as a modified version of the McCain Bill, but Speaker Gingfich had already focused the attention of the House on managed care so the likelihood that this bill would ever see the floor was remote.

Supplement 12: American Public Health Association report As the momentum (and time) for federal tobacco legislation waned in Congress, efforts among the states to revive the potential for individual settlements with the tobacco industry strengthened. This was much to the liking of the tobacco industry..In response to this, and as Congress went into its fall recess, APHA developed a grassroots strategy in anticipation of the reality of state settlements. We determined that our niche would be to approach the attorneys general of the states about to settle, to remind them that funds stemming from any such agreement must be used in significant part for smoking prevention, cessation, and research. We also determined to approach the governors of those states to encourage them to work with their attorneys general to affect this end. Dr. Akhter wrote to both parties in settling states to urge this collaboration. .. On a separate note, but during the same timeframe, .bad news ..was .received from the Fourth Circuit Court of Appeals in that it overturned a prior judicial determination.that the I~A did have jurisdiction over tobacco and cigarettes under the drag and device provisions of the FDC Act, APHA has and will continue to actively support the need for full and, unfettered FDA jurisdiction over tobacco and all tobacco products, and has .been called .upon to .review and comment upon suggested legislative langu ~age to ae~complish th~s zn the106~ Congress. . In November, a c~mprehensi~,e.t0bacco settlement became a reality, involving 46 states (excepting Florida, Mississippi, Texas, and Minn:esota, who.had earlier settled with the industry). The primary purpos~e was to resolve Mediqaid lawsuits,wherein the states had sought to recoup Medicaid monies e~pended to add.r~s tobacco-related health prgblems. APHA and dozens of other health organizations attended a summit meeting in Chicago put on By the. AMA to address the response of the health community to the state settlement, and to discuss our federal agenda for the 106th Congress. Regarding the state settlement~ APHA's action alert to our State Affiliates is attached. The:legislative agenda for APHA in the coming months will be.to work with select health organizations:and members of Congress to introduce ~i.egislation that will.address those issues that, for jurisdictional reasons, could not be addressed by the• ~ett!e~ent... In particular, FDA jurisdiction over tobaee.o .and all tobacco produets,.international tQbac~o,co, ntrol, and a funding ,mechanism for smoking prevention, cessation and research,thatincludes "!ook~aek' provisions and. 0~her effective assessment tools to measure the decline in tobacco use. Also on the international front, Dr, Akhter is actively involved in the planning of t~o international to.bacc~o conferences, one in conjunc.tion.with Key members of Congress, that will take placein 1999. .:-, -~ For further information on APHA's tobacco advocacy agenda for 1999, please contact Mary Wallace, JD, Director 0fGovernment Relations and Affiliate Affairs. Direct Diali (202) 789'-5648 E-malh mary.wallace@ apha.org Community Dental Programs Department of Public Health City of Boston MYRON ALLUKIAN, DDS, MPH Director (617) 534-4717 (6'~7) s34-s3ss (Fax) 1010 Massachusetts Ave. Boston, MA 02118

Supplement 12: American Public Health Association report MEMORANDUM To: AffiliatePresidents, Affiliate Representative to the Governing Council PLEASE CO-ORDINATE YOUR EFFORTS WITH YOUR LEGISLATIVE CHAIR From: Mary..Wallace, JD, Director of Government Relations and Affiliate Affairs Date: December 8°~, 1998 Re: State Tobacco Settlement ACTION ALERT STATE TOBACCO SETTLEMENT As you are aware, tobacco manufacturers representing over 90% of market share for the industry have entered into a settlement agreement with 46 states (all those except Florida, Mississippi, Texas and Minnesota, who had settledpreviously) that will yield a total of $206 billion dollars to the states, collectively, over the next 26 years. Amounts payable to individual states will vary according to a formula based on population and other factors. The primary purpose ofthis agreement is to resolve pending and future state litigation against the industry to recoup Medicaid health costs incurred by the states to address the illness and death of Medicaid patients due to tobacco use. The agreement includes (among other provisions) modest restrietio.ns on industry lobbying, advertising, sponsorship;and promotional activities; a forty five cent per pack increase to wholesalers (proceeds from which will help industry fund the settlemen0; the establishment of a national foundation, funded by industry, to study programs designed to reduce teen smoking and educate the public as to the risks associated with tobacco; and terms and conditions relative to the preservation of industry documents. The scope of this document is limited,, and its failure to specifically direct that funds be dedicated to tobacco control and related public.health issues is both a failu~ and an opportunity. At the direction of the Executive Board, APHA is formally on record in opposition to the process by which this settlement was negotiated in secret by tobacco attorneys and attorneys general for eight states. When that group had reached an agreement, the proposal was put before the attorneys general of the balance of the states, and less than a week was provided for them to explain the 146 page document to their governors and obtain approval. Public debate was denied, 31

Supplement 12: American Public Health Association report so that the invaluable input that should have been received from public health professionals on priorities that need to be addressed in any tobacco settlement was absent. However, it is not too late to make a difference. WE ASK THAT YOU ACT NOW TO HELP YOUR GOVERNOR AND STATE LEGISLATURE MAKE THE RIGHT DECISIONS ON HOW TO APPLY THIS MONEY TO EFFECTIVELY CURB TOBACCO USE IN YOUR STATE. Consult with members in your state of relevant APHA sections, s~ch as Alcohol, Tobacco and other Drugs (ATOD). With the~ help, craft a message, write to your Governor (as affiliate leadership on behalf of your affiliate) and visit your state legislators. Remind them that this is a tobacco settlement, the logical purpose of which is to target smoldngprevention~and cessation programs that are already in effect that would benefit from additional funding, and to identify areas where n~w programs need to bedeveloped and funded to further serve this purpose. One successful m6del for accomplishing this objective on a iong-termbasis is the establishment of a public health trust fund to ensure that the dollars last until the problem is eliminated. Please include the following concepts in your communication: ~ Remind your Governor and legislators that the substantial partof the dollars to be'received by your state must be earmarked for public health considerations, particularly those dedicated to both new and existing smokingiarevention and eessatiou programs, eounte(-advertising, etc. • Encourage your Governor to establish a State Advisory Council that would include public health representatives and others with beneficial input on health issues to decide the highest and best use, in the interest of public health, of the funds to be received. • Impress ybur Governor and legislators with the need to be prudent with these funds, as this is a one-time opportunity. Establishing a public health trust fund,0r similar mechanism to make the most of these dollars Over the long term, is essential. PLEASE ACT NOW, AND ACT ASSERTIVELY. THIS ISSUE IS CUSTOM MADE FOR APHA GRASSROOTS ACTIVISM BY OUR Ab-TILIATES AND SECTION EXPERTS. PLEASE CALL FOR ADDITIONAL. INFORMATION AND SUGGESTIONS, and forward your inquid~ to Ma/y Wallace,. Director, Government Relations and Affiliate Affairs (202) 789- 5648 Or mary.wallace @ apha.erg Meanwhile, you need to know that the fight on the federal levelis not over. President Clinton, certain members of Congress~ and major health related organizations, including APHA, have already Set in motion a revitalization, during the upcoming congressional session, of tile push for federal legislation to address, at a minimum, the following critical aspects of the fight against tobacco that are not, and cannot be, addressed at the state level: • Obtaining full FDAjurisdietion and authority over all tobacco products; • Implementing international tobacco control provisions to prevent and overcome health problems eansed by the sale of U.S. tobacco products abroad; and • Establish a ~ubstantial per pack price increase, with resulting funds dedicated to smoking prevention and cessation, and including stringent "'look-back" provisions and other assessment tools to measure progress and determine penalties. 1999 will be an active year for tobacco control efforts, and your input is essential. Please e-mail us or send us hard copy of your communications within your state, and let us know how your visits to legislators go. Thank you in advance for your interest, expertise, and time! 32

Supplement 12: American Public Health Association report 9808: National Tobacco Control Legislation The American Public Health Association, Acknowledging that the detrimental effects of tobacco use have long been known to have ~ severe, negative impact on the public's health; 1 and Recognizing that comprehensive, well-funded, sustainable national tobacco control legislation is crucial to achieving long-terrr~eductions in the prevalence of smoking by youth and adults;2 and Reaffirming the long-standing policy of the American Public Health Association in support of strong tobacco control actions to protect the public's health (APHA Public Policy Statements 1948-present, Cumulative, American Public Health Association, • Washington, DC); therefore 1. Congratulates President Clinton and the Koop-Kessler Committee on initiating tobacco control efforts in 1997 by their (a) review of the hational tobacco control proposal; (b) call for unfettered authority of the Food and Drag Administration (FDA) to regulate nicotine and all tobacco products; (c) emphasis on the importance of tax and price increases on all tobacco products to deter smoking by young people; and (d) call for a properly designed national tobacco control policy;3 2. Recommends that legislation for a national tobacco control policy be developed that meets five basic principles: (1) protection of children against inducements to use tobacco and encouragement not to use them;4 (2) aid to addicted adults and children in cessation of tobacco use;5 (3) right of every person to breathe air not contaminated by tobacco smoke;6,7 (4) the same right of parties injured by tobacco to sue for compensation as they have ~ith other products;8 and (5) require meaningful community-driven strategies for stabilizing the economies of tobacco-dependent communities; 3. Recommends that national tobacco control legislation (a) ban all advertising, promotion, and sponsorship of tobacco products;9 (b) substantially and repeatedly raise the "~. tax on cl=arettes and other tobacco products;10 (c) require the tobacco industry immediately to implement strengthened health warnings stating that tobacco is addictive, causes heart

Supplement 12: American Public Health Association report disease and cancer, and can kill you: (d) reaffima the full authority of FDA to regulate nicotine as an addictive drug and all tobacco products as a drug delivery device:l I (e) require a l~arge comprehensive sustained professionally designed anti-tobacco education program and well-designed cessation programs and quality assurance mechanisms funded, but not controlled by, the tobacco industry;12 (f) require the complete public disclosure of all tobacco industry, documents that relate to the development, promotion and sale of tobacco products and/or the health consequences of tobacco products: 13 and (g) require that all tobacco products be fire-saf~; I and 4. Specifically recommends that national tobacco 6omrol legislation neither preempt any state or local authority from further regulating tobacco nor grant the tobacco industry immunity from liability. 14 References US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411. ,Smo "king control strategies in developing countries: Report of a WHO Expert Committee. Geneva, World Health Organization; 1983. Koop CE, Kessler DA (co-chairs). Final Report of the Advisory Committee on Tobacco Policy and Public Health. Washington, DC, July 1997. Lynch BS, Bonnie R J, Editors. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Committee on Preventing Nicotine Addiction in Children and Youths. Institute of Med~ine. National Academy Press, Washington, DC. 1994. US Agency for Health Care Policy and Research. Clinical Practice Guidelines, Numl3er 18. Smoking Cessation. US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, Centers _for Disease Control and Prevention. AHCPR No. 96-0692, April 1996. US Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. US EPA, Office of Research and Development, Office of Air and Radiation. EPAI60016-90/OO6F. December 1992.

Supplement 12: American Public Health Association report l-0. 11. 12. 13. 14. California Environmental Protection Agency. Health Effecm of Exposure to Environmental Tobacco Smoke. Final Report. California Environmental Protection A~ency, Office of Environmental Health Hazards Assessment, Sacramento. CA. Koop CE, Kessler DC, Lundberg GD. Reinventing American tobacco policy, sounding the medical community's voice. JAMA. 1998;279:550-552. Roemer R. Legislative Action to Combat the World Tobacco Epklemic. Second Edition. World Health O~anization, Geneva, 1993. Grossman M, Chaloupka FJ. Cigarette Taxes. The Straw to Break the Camel's Back. Public Health Reports. July/August 1997; Volume 112; p. 291-297. Food and Drug Administration. Regulations Restricting tile Sale and Distribution of Cigarettes and Smokeless Tobacco to Protect Children and Adolescents; Final Rule. Federal Register. Wednesday, August 28, 1996. US Department of Health and Human Services. Preventing Tobacco Use Among Yout~g People: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. Glantz SA, Slade J, Bero LA, Hanauer P, Barnes DE. The Cigarette papers. University of California Press, Berkeley, CA 1996. Bloch MH, Daynard R, Roemer R. A Year of Living Dangerously. The Tobacco Control Community Meets the Global Settlement. Public Health Reports. November/December 1998. Volume 113;488-497. - 9809: An International Tobacco Control Policy The American Public Health Association, Recognizing that tobacco use is a growing threat to public health world-wide and accounts for 3 million d~aths each year; 1 and Recognizing further, that if present smoking patterns persist, 10 million people will die each year'from tobacco use by the time the children of today reach middle age, 3 million in developed countries, 7 million in developing co'untries;2 and Noting that in 1997, Congress enacted an amendment to the Commerce, State and Justice appropriations bill prohibiting the use of government funds to promote tobacco sales or exports overseas and prohibiting the Department of Commerce, State and Justice from seeking to weaken the tobacco control laws in any country;3 and 3S

Supplement 12: American Public Health Association report Noting further that legislation has been introduced in Congress but not passed that would require that American tobacco companies abide by the same rules regarding sales to minors, m~rketing, and health warning labels in their international operations as they do in the US and requiring that health warning labels be in the primary language(s) of the country in which the products are sold;4 and Noting further that on July 9, 1997 the report of the Koop-Kessler Advisory Committee on Tobacco Policy and Public Health, formed at the request of the bipartisan group of Ivlembers of Congress, including Congressperson Waxman, addressed the omission of international tobacco policy;5 and Concerned that the aggressive marketing and promotion of tobacco in developing and transitional nations by American tobacco conglomerates has an adverse impact on the health of all populations abroad~ particularly women and children; and • Concerned that the United States government has contributed to the growth of the global tobacco pandemic by promoting the transnational activities of American tobacco conglomerates;6 and Reaffirming the long-standing policies of the American Public Health Association in support of strong tobacco control actions to prot.ect the public's health;7 therefore 1. Recommends that activities and legislation for an international tobacco control policy be developed that meet four basic pdnciples:-(a) the United States should actively promote global tobacco control; (b) the United States should assure that public health c0ncems overrule trade considerations in all trade regulations and related proceedings; (c) the United States should actively .support and allocate substantial resources to fund effective international governmental and non-governmental.institutions engaging in tobacco control activities; and (d) the United States should effectively regulate the activities of American-based tobacco conglomerates to support these global tobacco control efforts; 2. Specifically recommends that tobacco control legislation should (a) remove tobacco products from Section 301 of the 1974 Trade Act, which grants broad discretionary powers to impose trade sanctions against any nation whose trade policies are "unjustifiable'~ unreasonable or discriminatory" and under which several Asian nations have been forced to open their markets to US tobacco products and tobacco advertising; (b) prohibit federal agencies from promoting American tobacco products abroad, or interfering in any efforts by international or foreign public health authorities to control tobacco use within their sovereign borders; (c) require that US tobacco exports contain the same warning labels of equal size in the local language as are required by law in the United States; (d) provide for the surveillance and prevention of international tobacco smuggling,

Supplement 12: American Public Health Association report including strict penalties for companies shown to be supporting smuggling: and (e) require that all tobacco products be fire-safe: and 3. Specifically recommends that the United States adopt legislation that requires every US tobacco company to pay at least a 2-cent fee for each package of cigarettes it sells overseas, with the money raised from such fee to be used by governmental and non-governmental entities for international tobacco control activities~ including (a) the promulgation and implementation of the World Health Organization Framework Convention on Tobacco Control;8 (b) efforts by UNICEF (United Nation's Children Fund) to promote eradication of tobacco use among children; and (c) efforts by all ,~propriate federal agencies, including Health and Human Services, to promote tobacco control internationally. References t Roemer R. Legislative Action to Control the World Tobacco Epidemic, 2nd ed. Geneva: World Health Organization, 1993. Pet9 R, Lopez AD, Boreham J, Thun H, Heath C Jr. Mortality from Smoking in Developed Countries, 1950-2000, Indirect Estimates from National Vital Statistics. New York: Oxford University Press, 1994. Pub. L. 105-119. Section 618 (enacted into law 11/26/97). S.1415, S.1638 and H.R. 3474. Final Report of the Advisory Committee on Tobacco Policy and Public Health, Co- chairs C. Everett Koop, MD, SoD and David Kessler, MD, JD, July 1997. See, e.g. Council on Scientific Affairs, The World Wide Smoking Epidemic: Tobacco Trade, Use & Control, 263 JAMA. 3312 (1990). See also Recommendations of the 10th World Conference on Tobacco or Health, held in Beijing, China, August 23-28, 1997 that "governments consider the international industry that do not contribute to an increase in the world-wide epidemic of tobacco relate.d diseases and death..." APHA Public Policy Statements, 1948-present, cumulative, American Public Health Association, Washington, DC. International Framework Convention for Tobacco Control. VCHA Res. 49.17, 49th Ass., 6th Plen, Mtg. WHO Doc. A49/VR/6 (1996). See generally Taylor A. Roemer R, International Strategy for Tobacco Control, WHO Doe. WHO/PSA/96.6 (1996~: Taylor A. An International Regulatory Strategy for Global Tobacco Control, 21 Yale Jottrnal ofhlternational Lain 257 (1996). 37

ASSOCIATION OF STATE AND TERRITORIAL DENTAL DIRECTORS Michael L. Morgan, DDS, MPA January 26, 1999 I want to bring you greetings from the Association of State and Territorial Dental Directors (ASTDD) and from my home state of Oklahoma. 1998 has proven to be very busy with a great deal of ASTDD involvement in tobacco prevention. Also, this is a very exciting time in tobacco use prevention with all of the state lawsuits against the tobacco industry and settlements going on. Severa~ state dental directors are actively involved with these efforts. Additionally, settlement states are actively seeking passage of state legislation to earmark at least part of the tobacco settlement money coming to individual states, for use for tobacco prevention programs, and state dental directors are continuing to work to keep existing tobacco prevention programs. Additional activities on the agenda for this year include: 1. Working on the preemption issue in state tobacco laws. This includes trying to prevent state preemption in states that don't have it, and trying to remove state preemption in states that do already have it. We want local communities to be able to have control and handle their own tobacco issues the way they want to. 2. Exploring additional state referendum elections for tobacco issues such as clean indoor air. 3. Implementation of the =Synar Regulations." The regulations, released by the US Dept. of Health and Human Services, Centers for Substance Abuse Prevention on January 19, 1996, require that all states achieve a compliance rate of at least 80% within the next several years or face significant reduction in federal substance abuse bloi:k grant funds. Representative Mike Synar from Oklahoma died on January 9, 1996, and we certainly miss his help in tobacco prevention efforts. 4. Working with the Tar Wars Program (sponsored by Doctors Ought to Care) - for 5~h grade. 5. Working with the High School Heroes Program (sponsored by the American Lung Association) - for high schoolers teaching 3"~ and 4= grades, r 6. Working with the Teens as Teachers Program - which is similar to the High School Heroes Program (sponsored by Americans for Non-Smokers' Rights). The ASTDD Annual Meeting and the National Oral Health Conference are scheduled for March 13-17, 1999 at the Hyatt Regency Hotel in Crystal City, Virginia. This is a joint meeting with the Association of Maternal and Child Health Programs (AMCHP), American Association of Community Dental Programs (AACDP), State Medicaid Dental Program Directors, Centers for Disease Control and Prevention (CDC), Health Care Financing-A~lministration (HCFA), and Health Resources and Services Administration (HRSA). The MCH joint session will be held at the Omni Hotel in Washington, D.C. 39

Supplement 14: National Dental Association report January 25, 1999 TO: THE NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE DEPAI~TMENT OF HEALTH AND HUMAN SERVICES NATIONAL INSTITUTE OF HEALTH NATIONAL CANCER INSTITUTE FROM: JOEL V. TURNER, D.D.S. NATIONAL DENTAL ASSOCIATION 3517 16TM STREET NW WASHINGTON, D.C. At the 85~ Annual Convention of the National Dental Association the "Special Magic' of Dentistry as a health care profession was high-lighted. Members of this Association can and do directly affect h~e health of many of the under-served and minorities in the population of the United States. The exchange of information and knowledge with the resultants of tobacco usage was Acknowledged. The awareness of multiple factor involvement in tobacco usage was addressed. Such factors are difficult to control and reduce due to the great diversity. Health problems due to tobacco usage arc present and high among Ai~o-Americans and other minotitics. Individual health professionals within the 'Special Magic' of Dentistry have an expanded capability. This includes their leadership and obligation to use their close rapport with patients to influence their actions regarding practices that directly can cause undesirable changes in their health.

Supplement 15: Oral Health America, National Spit Tobacco Education Program report THE ORAL HEALTH AMERICA APPROACH: NATIONAL sPIT TOBACCO EDUCATION PROGRAM (NSTEP) AIV[ERIC_~S. FUND FOR DENTAL HEALTI-I 410 North M,chlgan Avenue Su,te 35~ Chicago, Illinocs 60611--'211 NSTEP Program Summary and Purpose: 836. 0o Fax ,2) In 1996, Oral Health America received a major grant to increase the public's awareness about the dangers of spit tobacco and oral cancer through its National Spit Tobacco Education Program (NSTE~P). Through NSTEP, Oral Health America is bringing together Major League Baseball, the dental community, and other tobacco'~ontrol groups to drive home a strong no-use, anti-spit tobacco message to the nation's youth. By the year 2000, 75 percent of all dentists will be expected to help their patients stop smoking or using spit tobacco, according to Healthy People 2000, the federal government's agenda for the improved health of all Americans. Oral Health America is working .to help the nation achieve this goal through NSTEP, funded with major support from the Robert Wood Johnson Foundation and with additional support from the National Cancer Institute, the Centers for Disease Control and Prevention, and the National Institute of Dental Research. Conducted under the leadership of National Chairman Joe Garagiola, NSTEP is a public education anti-spit tobacco initiative dedicated to promoting oral health and educating youth, parents, and coaches about oral cancer prevention and the dangers of spit tobacco use. Through the work of six NSTEP Community Coordinators, NSTEP has developed grassroots coalitions of teachers, coaches, dentistsl and an array of volunteer groups who w.ork together to integrate spit tobacco education and cessation into the existing tobacco control agendas in their areas. The NSTEP Community Coordinators each conduct in-stadium events with the Major League Baseball franchises in their communities, including the Baltimore Odoles, the Colorado Rockies, the Texas Rangers, the Atlanta Braves, the Detroit Tigers, and the Seattle Mariners. These events have been hugely successful in educating baseball fans about the dangers of spit tobacco use. Background: Each year, anywhere from 10 to 16 million Americans put their health at risk by using smokeless or "spit'"~obacco products. Annual sales of these products nowexceed $1 billior~, or more than tdple that of1972. The most dramatic increases have been seen with "snuff," which is sold in small round tins and has become extremely popular among youngsters. Worn rings in the pockets of blue jeans, formed by the spit tobacco tins, have become a status symbol among young people in many partsof the country. " '~ ~ Today, annual moist snuff sales in the United States have grown to 6vet 60 million pounds, an 85% increase from 1981. The magnitude of this increase and the spread of the use of the products to a wider and more diverse segment of the population has alarmed the public health community. But even as the popularity of this known carcinogen reaches near epidemic proportions, spit tobacco use gets relatively little attention as a public health issue when compared to the attention given cigarettes. Some additional indications that spit tobacco is a growing public health crisis are: One out of three adolescents in the United States is using tobacco by age 18.t 41

Supplement 15: Oral Health America, National Spit Tobacco Education Program report -k In 1970, young men ages 17-19 used spit tobacco the/east of any age group. Today, usage by men of these ages is the highest of any age group, with 1 million adolescent boys currently using spit tobacco, according to HHS. One state survey indicates that neady 10% of the state's third to sixth graders admitted to having tried spit tobacco. There are even reports of usage as early as kindergarten. -k Spit tobacco use by adolescents is associated with eady indicators of periodontal degeneration and with lesions in the oral soft tissue.1 -k The risk of developing oral cancer for long-term spit tobacco users is approximately 6 times greater than for non-users. -k The U.S. Department of Health and Human Services (HHS) has stated that tobacco products are among the most heavily advertised products in the United States. In 1993, the tobacco industry spent $6.2 billion on advertising and promoting cigarettes and spit tobacco. -k Cancer of the oral cavity and pharynx accounted for about 30,500 new cases of cancer and about 8,350 deaths in 1990. Although oral cancer comprises only 3 percent of all cancers in the United States, only one-half of those individuals affe¢Jted by oral cancer will be alive 5 years after diagnosis.. About 75 percent of these cancers are attributable to tobacco and alcohol use. NSTEP 1998 Baseball Season Activities: This year for the first time the Major League Baseball Players Association voted to add an oral screening as part of the players medical .exam. This means that every player will have an,. opportunity to have ahard and soft tissue examination. NSTEP tobacco control experts have been on hand dudng Spring Training in both Arizona and Flodda to help players who want help quit the spit tobacco habit. This involved providing players with general tips such as using a substitute such as chewing gum or sunflower seeds. They also prescribed nicotine replacement patches for those players who are strongly addicted or who have tried but have not been able to quit in the past. Spit tobacco use among major league baseball players is estimated to be as high as 35 percent, which is down from about 40 pement during the past decade. (27 percent among Minor League). During a recent study 46 percent of baseball playe}s who used spit tobacco had pre- cancerous lesions in the mouth. NSTEP Partners: Believing that collaboration is the key to any program's success, Oral Health America~s National Spit Tobacco Education Program has united the baseball community, tobacco control groups, and members of the Oral Health 2000 Consortium in a unique public health alliance. Oral Health America's national partners include Major League Baseball, the Major League Baseball Players Association, the National Cancer Institute, the National Institute of Dental and Craniofacial Research, the Professional Baseball Athletic Trainers Society, the Centers for Disease Control and Prevention, the American Baseball Coaches Association, and the Robert Wood Johnson Foundation,

Supplement 15: Oral Health America, National Spit Tobaccv Education Program report About Oral Health America: Since 1955, Oral Health America, America's Fund for Dental Health, has brought together the public, private, and voluntary sectors and served as a catalyst for support and change within and through. the dental and other related communities of interest. By supporting a variety of research, services, and educational programs, Oral Health America aims to identify and prioritize the challenges and .opportunities impacting the nation's oral health. .~ ,. -- . . .. Oral Health America, an independent, pi~blici: nonprofit, 501(c)(3) national organization, has .served as the leading, oral health charity in the United States for over four decades. Oral Health Amedca currently has a multi-year memorandum of agreement with the PublicHealth~ Service that authorizes a broad,range of collaborative activities. Oral. Health Amedca has been recognized for its strong leadership in the HealtSy People 2000 initiative by the US Department of Healtha~d Human ' Services. : _ For additional, information, contact Oral Health Amedca at (312) 836-9900, orwdte us at: .. . Oral Health Amedca : " - " " Avenue Suite 352 " " ' 410 North Michigan " Chicago Illinois 60611-421 ~ : ' • " -k increase awareness amongtargeted populations of the importance of.oral heaRh to overall -k ; improve access:to carebyunderserved opulation " - : # H' a 12 ' "" " " . -k -replicate landmark local oral health programs {hat ge/ierate support at thehationa/ievel f~om ~ .all sectors of.the dental commun , ..,, ~; ,, :. .... :•i -k.•.increase i~volvement of the dental team in community-based oral health programs; i ' .: :• " -k. develop a~latabase of oral health programs that canbe accessed nationwidefor community implementation ' :..' ' : ~ ' " ' Sourcei U.S~ VepartmentofHealthand Human services. PreventingTob~=cco Use,AmongYoungPeo/de: A Reportof~e Sulgeon General Atlanta, Georgia, 1994 ..... ' ' ' Oral Health America--America's Fund for Dental Health--is a national, independent, 501(cX3)~ nonprofit charity incorporated in 1955, meets all nine standards of the National Charities Information Bureau, a national, watchdog group he~dquarterod in Now York City (most reev~fly as of Fall 1998). Oral Health America's programs motivate p~ople tO sc~k dental car~ assist the t'orsott~ m obtaining care, support dental ¢ducatmn and research, and advance the art add sc~coce of dentistry. ~

Supplement 1S: Oral Health America, National Spit Tobacco Education Program report 44

Supplement 16: Secondhand Smoke Facts-RepaceAssociates i|EPACE ASSOCIATES SECONDHAND SMOKE CONSULTANTS Secondhand Smoke Facts Secondhand Smoke kills as many as 62,000 Americans annually from heart disease, and causes nasal sinus cancer, sudden infant death syndrome and low birthweight (increasing the risk of perinatal mortality) (capt.s'A, 1997). Secondhand Smoke causes 3000 to 5000 lung cancer deaths per year in the U.S, more than all regulated hazardous air pollutants combined (u.s. EPA, 1992; Rcpace & Lowrey. 1985a;1990), Secondhand Smoke causes eye and nasal irritation, cough, phlegm, and chest discomfort in adults. In young children it causes middle ear infection and asthma, and in infants, bronchitis and pneumonia (u.s. EPA,1992; CalEPA, 1997.) Secondhand Smoke is a Class "A" or "known human carcinogen," a category including arsenic, asbestos, benzene, coke oven emissions, radioactivity, and vinyl chloride EPA, 1992). Secondhand Smoke is an overwhelming source of respirable particulate air pollution (RSP), typically exceeding EPA fine-particle clean air standards (PMzs) wherever tobacco is smoked indoors (Repace & Lowrey, 1980). • - • Secondhand Smoke can not be controlled by dilution, by ventilation, or by .air cleaning to federal "acceptable risk" levels for carcinogens in air (Repace & Lowrey, 1985b). • The U.S. Occupational Safety and Health Administration (OSHA) declared, that dilution, ventilation, or air cleaning were all unacceptable methods for the control of the lung cancer or heart disease risks of Secondhand Smoke (OSHA, 1994). Levels of Secondhand Smoke RSP, carbon monoxide, and nicotine can be accurately measured or predicted in air (Repaee, 1987; Repaee, et al., 1998; Repace et al, in press). Levels of the nicotine metabolite, cotinine can now be accurately measured or predicted in the blood, urine, and saliva of nonsmokers, and can be related to their risk of lung cancer and heart disease mortality (Repace and Lowrey, 1993; Repaee, et al., 1998). • 88% of the nonsmoking U.S. population has cotinine in their blood (Pirkle et al., 1996). • A single large cigar produces about 5 times the Secondhand Smoke RSP and 25 times the carbon monoxide as a single cigarette (Repace, Ott, and Klepeis, 1998). References: Repaee IL, and Lowrcy AH. Indoor Air Pollution, Tobacco Smoke, and Public Health. SCIENCE 208:464.474 (1980). Repace .IL, and Lowrey AH. A Quantitative Estimate of Nonsmokers' Lung Cancer Risk From Passive Smoking. I.",'r~Rr~^TION^L I 1 : 3-22 (1985). Repace JL, and Lowrey AH, An Indoor Air Quality Standard For Ambient Tobacco Smoke based on C~cinogenic risk. NY ST^T~ J MED: 85:381-383 (1985). Repace JL. Indoor concentrations of environmental tobacco smoke: models dealing with effects of ventilation and room size, Ch, 3. IARC Scientific Publications no.81. Environmental Carcinogens.- Selected Methods ofAnalysis-.Volume 9 Passive Smoking: l.K. O'Neill, K.D. Broonemann, B. Dodet & D. Hoffmann. Eds. International Agency for Research on Cancer, Lyon, France, (1987). Repace JL, and Lowrey AH. Risk Assessment Methodologies in passive smoking-induced lung cancer. RISK ANALYSIS, 10: 27-37, (1990).Repace .IL, and Lowrey AH. An enforceable indoor air quality .standard for environmental tobacco smoke in the workplace." Risk A~.,.t.Ysts, 13:463-475 (1993). Repace JL. Jinot J, Bayard S, .E.mmons K, and Hammond SK. Air nicotine and saliva cotinine as indicators of passive smoking exposure and risk RISK A.~.~LYS~S 18. 71-83 (1998). Rcpace JL, Ott WR. and Klcpois life Indoor Air Pollution from Cigar Smoke. In: The National Cp~:dcier.lnstit.ute Monograph on Cigar Smoking in the U.S. (in press). Rcpace JL, Ott WR. and Klepeis NE Mathematical Models for ctmg Time-Averaged Environmental Tobacco Smoke Concentrations. L Ex~:~.so~ ASSF.SSMmcr ~ .E~wlRO~ F~It~EMSO~_ (Paper presented, Manuscript submi~ext). U.S. Environmental Protection Agency, Washingloo. DC 20460. Respiratory. Health effects of passtre smoking: lung cancer and other disorders (I~PA 600/6-90/006F) (1992). U.S. Dept. of Labor. Oecupatiooal Safety & Health 101 Felicia Lane • Bowie, MD 20720 U.S.A. Phone: 301-262-9131 * Fax: 301-352-8457 • E-mail: <repace@erols.com>

Enhanced care: • Document chart • Brief advice ~Motivational intewiew Follow-up contacts • Parental Involvement Adolescent dental visit scheduled Letter to parent Call / questionnaire no no Smoker? At risk? Stop yes Consent to participate? yes no Do.cumen.t chart Brief advice /

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Supplement 18: Division of Oral Health, CDC report and MMW on Oral and Pharyngeal Cancer Division of Oral Health National Center for Chronic Disease Prevention and H~alth Promotion Ccntexs for Di~ Control and Pr~vantion OIL4L HEALTH: SIGNIFICANT OPPORTUNITIES TO PREVENT UNNECESSARY D.ISEASE Background Americans will make approximately 500 million dental visits this year. The Nation will spend an estimated $60 billion on dental services in the year 2000. Much of the health and economic burden associated with oral diseases and conditions could be prevented. • Dental sealants applied to children's teeth can pre~cnt most dental decay, yet less than 30% of children have had their teeth treated with sealants. • Over 100 million Americans lack the proven benefits of fluoridated water. The per capita cost of water fluoridation over a lifetime is less than the cost of one dental filling. • Over 8,000 people die from oral and pharyngeal cancers each year-about one person every hour. This year, 30,000 new cases of oral cancer will be diagnosed. CDC Program Activity CDC is the federal agency with primary responsibility to support state and community-based programs in oral disease prevention and oral health promotion and conduct oral health prevention research. CDC activities include: • Ensuring the quality of community water fluoridation, monitoring the relative risk~ and benefits, and extending this effective prevention measure nationwide. Helpingstates establish surveillance systems that provide valuable health ~rtformation to assess the effectiveness of interventions and target interventions to those at greatest risk. Assessing the risk of infectious diseases transmission (e.g., HIV, hepatitis) in the dental care setting,'updating guidelines to minimize risk, and investigating outbreaks and hazards. Expanding the science base, building state-based capacity, and expanding communication to the public to prevent and control oral diseases. P, eaehing high risk children through school-based programs supported by linkages with health care professionals and other dental partners in the community. Supporting the formation of an oral health research network within CDC's university-based Prevention Research Centers. .. E~ample of Program in Action CDC provided technical assistance to the California Department of Health Services to help implement a state law to fluoridate water supplies in communities across the state. For example, Los Angeles will begin fluoridating water for 80% of its 3.6 million residents in early 1999. Opportunity CDC, in collaboration with public and private partners, would implement proven prevention strategies for children and adults that can virtually eliminate dental decay and reduce tooth loss while producing substantial cost savings. CDC would enhance oral health surveillance to help states better target proven prevention strategies in community, school, and clinical settings. CDC would also expand its efforts to reduce the health burden fi:om oral cancers, gum disease and related health conditions with links to oral health, such as diabetes and heart disease.

Supplement 18: Division of Oral Health, CDC report and MMWR on Oral and Pharyngeal Cancer P. roposal for DOH Oral Cancer Program Activity Based on the 10 priority recommendations that emanated from the 1997 meeting of the Oral Cancer Roundtable, CDC/NCCDPHP/DOH is uniquely positioned to take the lead for three of the 10 recommendations, and contribute toward the implementation of seven others. A key area of focus for CDC would be primary prevention (reducing risk factors for oral cancer) and early detection. Increasing public awareness about oral cancer would be a key component of this effort. CDCANCCDPI-IP/DOH Lead - in collaboration with other Divisions in NCCDPHP a) establish a mechanism to implement and monitor the recommended strategies developed during the conference; f) after ~sessing local needs, develop, implement, and evaluate statewide models to educate all relevant groups; g) develop, and conduct a national promotional campaign, to raise public awareness of oral cancer and its link to tobacco use and heavy alcohol consumption. (This activity would need to be done in partnership with groups such as the American Dental Association - but could be accomp~shed through a cooperative agreement - Similar to ~the DCPC Skin Cancer Campaign). DOH Collaboratewith Outside Partners b) urge o:ral heaith professionals tO become more actively involved in community health; c) require im~aNon in prg~,enting a~d controlling tobacco and aieoho1 nsg at all levels of training in dental, medical, nm'sing, and other related health-rare disciplines; d) encourage Medicaid, Medicare, traditional insurance plans, and managed-care entities to consider malting oral, cancer examinations an integral part of comprehensive physical and oral examinations; e) designate federal funding for .a national program of oral cancer prevention, early detegtion, and control; ~ " h) develop health-care curricula that require competency in prevention, diagnosis, and multidiseiplinary management of oral and pharyngeal cancer; i) sponsor and promote continuing education for health-care professionals on the multidiseiplinary management of all phases of oral cancer and its sequelae; j) strengthen organizational approaches to reducing oral cancer by developing organized cooperative and collaborative, arrangements, funding formal centers, and involving commercial firms.

Supplement 18: Division of Oral Health, CDC report and MMWR on Oral and Pharyngeal Cancer CDC August 28, 1998/Vol. 47 / No. RR-14 MORBIDITYAND MORTALITY WEEKLY REPORT Recommendations and Reports Preventing~and Controlling Oral and Pharyngeal Cancer Recommendations from a National Strategic Planning Conference U.S. DEPARTMENT OF HEALTH AND ~IUMAN SERVICES Centers for Disease Control and Prevention (CDC) Atlanta, Georgia 30333 51

Vol. 47 / No. RR-14 MMWR Preventing and Controlling Oral and Pharyngeal Cancer Recommendations from a National CONCLUSION Strategic" -Planning Conference National efforts to reduce morbidity and mortality associated with oral cancer re.usa focus on two areas: primary prevention (i.e., reducing risk factors) and early detectton. • Sum.mary Although pers.ons at high risk for !he disease are. more likely to visit a physician than In August 1996, CDC c.onveneda national conference.to develop strategies for a dentist, phys¢cians may be less hkely than dent=sts to perfo.rm an oral cancer exami- preventing and.contmlhng oral and pharyngeal.cancer i.n. the United States. The nation on such'patients ( 17-21 ). Thus, all primary-care prov=ders must assume more conference, which was cosponsored by the Natlonal Instttute of Dental Research responsiblity for counseling patients about behaviors that put them a! risk for devel- of the National Institutes of Health and the American Dental Association, in- oping this Cancer, examining patients who are at high risk for develop=ng.the dis.ease cludad 125 experts in oral and pharyngeal cancer prevention, treat.me, nt, and because of tobacco use or excessive alcohol consumption (22), and refernng pat=ants research; both the private and public sac!ore were represented. Partlctpants at to an appropriate specialist for management o! .a suspic.ious oral lesion. Comprehen- the conference developed recommendattons concerning advocacy, collabora- siva education of medical and dental pract=t~oners ~n diagnosing and promptly t/on, and coalition bu. ilding; public health policy; public education; professional managingearly lesions could facilitate the multidisciplinary collaboration .necessary education and practice; and data collection, evaluatio, n", and research, to detect oral cancer in its e~rliest stages. Furthermore, because of the pubhc's lack of A follow-up meeting consisting of selected .p.artlczpan. ts of the 1996 confer- knowlege about the risk factors for oral can.cer and because this disease can often be ence was held in September !997. During thls meeting, changes that had detected in its. early stages (21,23), the public's awareness of oral cancer (including its occurred in the political and scientific are.nas since the 1996 conference were risk factors, s~gns, and symptoms) must also be increased. consldete..d,.and 10 reco_m, mended strategies from the conference w..e.re selected Oral cancer occurs in sites that lend themselves to early detection .by most primary for pr/onty ~mplementation. These 10 strategles were to a) estabfish a mecha- health-care providers and, to a lesser extent, by self-examination. HeCghtened aware- nlsm to implement and monitor the recommended strategies deve/ope.d, during hess in the ..general population'coul~ help with earl.y detection of this cance.r and could the conference; b) urge oral health professionals to become more actively in- stimulate d~alogue between patients and their pnmary health-care prowders about volved/n community health; c) require instruction in preventing and controlling behaviors that may increase the risk for developing oral cancer. Recent advances in tobacco and alcohol use at all levels of training in dental, medical, nursing, and understanding the molecular events involved in developing cancer might provide the other related health-care disciplines; d) encourage Medicaid, Medicare, tradi- tools needed to design novel preventive, diagnostic, prognostic, and th.erapeut!c regi- tlonal insurance plans, and managed-care entities, to con.sider maklng oral mens to combat oral cancer. Acquiring greater knowledge of the biology, =mmu- cancer examinations an integralpa~ ofcomprehen, s~ve physical and oral exami- nology, and pathology of the oral mucosa may also help to reduce the morbidity and nations; e) designate f_e. deral funding for a national .program of oral cancer mortality from this disease. prevention, early detection, and c.ontrol; f) after assessing local needs, develop, implement, and evaluate st.atew~de mo~els to educate all relevant groups; g) develop and conduct a n._atlonal promotional campaign to raise public aware- ness of oral cancer and ~ts link to tobacco use and heavy alcohol consumption; h) develop health-care curricula that require competency in prevention.., diagno- sis, and multidisciplinary management of oral and pharyngeal cancer; i) sponsor and promote continuing education for health-care professionals on the multidis- ciplinsry management of all phases of oral cancer and its sequelae; and j) strengthen organizational approaches to reducing oral cancer by developing or- ganized cooperative and collaborative arrangements, funding formal centers, and involving commercial firms. CDC will use these recommended strategies to develop programs to reduce the burden of oral and pharyngeal cancer in the United States. Through the Oral Cancer Roundtable, a group of conference and meeting participants, CDC will communicate to interested agencies, organizations, and state health depart- ments ways in which they can implement elements of the national plan. The Roundtab/e will help CDC track the efforts and progress of these groups.

Supplement 19:- Center for Tobacco Prevention, Karolinska Institute, Swede. SEPPO WICKHOLM DDS Center for Tobacco Prevention Karolinska Institute STOCKHOLM Facts about: Dentists in Sweden 3,800 in Private Practice 350 in University 4, 500 in Public Dental Service Total number of Dentists 8,650 organized by SWEDISH DENTAL ASSOCIATION Training: 5 years, 4 dental schools Facts about: Sweden 8.8 million inhabitants Capital: Stockholm (1.8 million inhabitants) Facts about: RDHs in Sweden 880 in Private Practice 1,320 in Public Dental Service Total number of RDHs 2,200 organized by SWEDISH DENTAL HYGIENISTS' ASSOCIATION Training: 2-3 years, 9 dental schools 53

Supplement 19: Ceuter for Tobacco Prevention, Karolinska Institute, Sweden /'l'he Swedish Tobacco Prevention Dental Network" NA'rzONAL h~fional a~d services |n : oga|nst Stockholm Tobacco -:, NDTFSC Dentists, RDHs, Assistants 300. 5tu~n~s 80 " " Economic su~ort I~ntal Employe=s Organizations- " Nati6nal Institute of Public - Heaffh .......... Activities L~bBy~:~m "" :• ":. r. Tobacco control octiv~tles ~e ~war=n~ss-in dentistry al and Regional pregr~ms in ~, ,! ~ Communi~ M.dicin. on ~ /e~ or e~j~ ml ry.m _cc~tcd d~ntol practice s~ttin~s o I- ~.~ ~. Center for ~ |,:Toba~o~J- ~ ., L~.. Prevention Stockholm ~t20 public clinics 1,000 private dentists 85% of the population regularly visit their ~ental team kS4

Supplement 19: Center for Tobacco Prevention, Karolinska Institute, Swede.q PHASE 1 ~ Structure and Organization ~ Clinic Policy and Office Management ~ Education 1. Dentists 2 RDHs . 13. Assistants PHASE 2 ~ Primary Prevention - Adolescents 10-19 years old 1. Office-based 2. External e Secondary Prevention 1. 4:A:s as a model 2. Smoking cessation - individually or in group PHASE 3 ~ Pilot Tobacco Free Clinics/Offices 1. Centers of exeellenc~ 2. Education - Workshops 3. Adaption to local environment, culture, size of clinic etc 4, Computer assisted smoking and snuff cessation Cent. for Tot~:co P~v~tlon Sw~en Swe~enCent~r for Tobacco Pr~v~n~on ~.~_ Community ~dicin¢ in Stockholm Centei" for/ Tobacc~p/ prevention National and r~ional I~rolinska Institute ENSP ~rk 55

Supplement 19: Center for Tobacco Prevention, Karolinska Institute, Sweden Young People's Tobacco Use. A Hultilevel Assessment of Potential Risk Factors. BRGIV S Social indexes (demographics, occupational indexes, criminality indexes) and health- promotion campaigns. Knowledge, attitude and behaviour - healths and anthropometric measures School structural characteristics and tobacco policyclass structural characteristiCs, specific pedagogic programs concerning health issues school-nurse's report on chroni~ diseases, handicaps, allergies and anthropometric measures Friends and group pressure parents~ occupation and edu~cation, parents' tobacco use (cigarette, oral snuff) • current • ~ during pregnancy (index child) Time frame Age il years1997 18years2004 Clmtersarnple Recruited Completed baselLaemsessmenc Schools 119 91 91 Pup~s 4668 3051 3027 Class~ 215 215 Design: A prospective 1 ongicudinal study" of children in Stockholm's County. Method: A large cohort of school children Lathe 5th grade (11 years old) has been recruited, fissessment of tobacco usewill be carried out yearly through senior high school by" means of a self-completed questionnaire. The assessment of explanatory factors is carried out by means of self-completed questionnaire or interviews. Institution: Cez~tre for Tobacco Prevention, Department of Community Medicine, Stockholm County Council, Sweden. Authors: Ann Post, Reg Nurse, B.Sc, Maria lq~saria Galanti, MD, PhD, Hans Gilljam, MD, PhD. Ann Post, Centre forTobacco Prevention. Novum, H~lsov~gen 7,141 57 Hucktinge, Sweden. Tel 585 850 36.Fax 08-585 8.~0 10. E-mail ann-post@smd~siLse

Supplement 19: Center for Tobacco Prevention, Karolinska Institute, Sweden Dr SmokeFree Office-based computer-tailored smoking cessation with documentation and follow up. Hans Gilljam. Tobacco Prevention Center, Karolinska Institute, Huddinge, Sweden. Smoking cessation is one of the best health investments for both individuals and society. The chance to remain smoke-free 12 months after a decision to quit on your own is about 5%. With professional help the chance of success may reach as high as 40%. However, experienced smoking cessation help is not readily available, and therefore great efforts have been made to spread smoking cessation skills to pfim~'y care. The results have often left much to be desired. In several studies, tailored messages have proved to be both efficient and cost-effective, and the results have been dose to those achieved by more elaborate interventions. A~. interactive computer program for smoking cessation has been developed. An office set up with a "patient" computer is required. Ideally the computer is placed to allow some privacy. The smoking patient may then, after identification be offered to consult with the computer. If the smoker accepts he/she may need a short introduction of 1-2 minutes but requires no further assistance. Initially, the patient will choose the appropriate language. A smoking history is taken by the computer including the smoker's fears and motives. Individual preferences concerning time frame and method for tapering down, interactions with family and friends and the health care service etc. are recorded and stored. Depending on computer skills this first session will last 10-15 minutes. The consultation ends with setting a date for next visit and to collect the tailored smoking cessation calendar which is printed out. Visit no 2 is scheduled for Quit day or the next few days. After a positive identification the patient will tell the program how he/she has sueeeded. Lapses, withdrawal symptoms etc. are recorded and evaluated. Help and advice is available on screen and after 10-15 minutes this second session will end with the printing of a new calendar stretching 4-5 weeks. Visits 3 typically lasts for 5 minutes and produces a new tailored print-out. Visits 4 and 5 last about 5 minutes each, and the last visit (5) is the 6 month follow up. The print-outs on the last two visits are not tailored. An infinite number of different calenders may be produced in response to individual preferences. All the data are recorded and stored, and available for analysis. A set of standard analyses are provided with the system offering tools for the provider to evaluate how the, smoking cessation program is working. With time for instance, the collected data will reveal whether eultural differences have to be taken into account. If so, the appropriate changes are easily made. Similarly, customization of the system for research purposes is possible. The system will be demonstrated, and preliminary results of our ongoing study with 22 computers and 110 primary care physicians eormeeted in a large smoking cessation network will be presented. The effects of this infrastructure, the reactions and experiences of the staff and the patients will be discussed. Hans Gilljam MD PhD General manager of the Division of Health Intervention and the Tobacco Prevention Center, Division of Community Health, Stockholm County Council, Sweden. tel (46)-8-58 58 50 31 fax (46)-8-58 58 50 10 e mail hans.gilljam@smd.sll.se

Supplement 19: Center for Tobacco Prevention, Karolinska Institute, Sweden The Quit Line The .Quit Line is a service available during office hours and some evenings (not on weekends). Smokers or concerned citizens may call toii-Bee for advice or smoking cessation assistance. A simple questionnaire is filled by the counsellor and the caller is asked whether he/she will be available for follow up (98% accept)., The Quit line is operated according to the principles outlined ha the transtheorefical model of stages of change. The callers get tailored information by mail and are encouraged to call back. A computerized patient record is kept to allow for evaluation and to enable the smoking cessation therapists to effectively identify a re-caller to allow for a continuation of the treatment_ Quit line may also serve as backup for the primary health care service. Primary care physicians may refer smokers to Quit line where advice, assistance and follow up can be arranged forin cooperation with the physician. A year after first contact all clients receive a mailed questionnaire assessing point prevalence abstinence, prevalence of six months centinuos abstinence (from follow-up), several personality factors and factors previously known to be related to smoking cessation: The project was developed and is executed by. the The Center for Tobacco Prevention (CTP) which is a part of the Community Medicine program at the Stockholm County Council with academic affiliation to Karolinska Insfiuate~ The' Quit Line is fi_nenced by the SWedish Cancer Society (Cancerfonden), the National I~,stittite of Public Health (Folkalsoinstirutet), the Swedish Heart and Lung Association (Hjart- Lungfonden)', and the National Cooperation of Swedish Pharmacists (Apoteket AB). At the moment there We approximately 20 smoking cessation therapists (trai~ed at the CTP) working part time with the "Quit line". The Health Line is a 24h toll-free service for those who seek basic information. Pre-recorded messages inform about how to stop, where to fred help, health benefits associated with stopping, nicotine replacement therapy etc. The information can be obtained in written form through the free fax service. Individual phone numbers can not be identified but records are kept to allow analysis of how the service is used and how it can be improved. A speech reeogmtton system will in time replace the current tone-dial system. The Health Line serves as back up for Quit Line.

Supplement 20: Indiana University Nicotine Dependence Program report Other Reports:,, Dr.Christen at the Indiana University Nicotine Dependence Program: a. Announcement of a new Journal: Nicotine and Tobacco Research: A new journal, entitled "Nicotine and Tobacco Reseamh," devoted to the scientific study bf nicotine and tobacco begins publication early in 1999: It is to be published by the Society for Research on Nicotine and Tobacco. For information, contact Gary Swan, PhD, Editor, Nicotine and Tobacco Research, SRI International, 333 Rave.nswood Avenue, Menlo Park, CA 94025. E-mail: gswan@unix.sd.com b.The Indiana University Nicotine Dependence Pro,qram has completed six years of treating outpatients for smoking cessation on campus. This fee for-service program utilizes the Mayo Clinic Model and works with smokers on a long-term individual basis. Over 450 patients have been treated. As of I April 1997, this program, was restructured with Dr. Christen and Dr. Steven S. Jay, MD (a pulmonologist) who now serve as co-directors. Ms. Debi Hudson, RRT, is full-time Clinical Coordinator. Patients are seen on campus in three locations: the VA hospital; the Dental School and at the Indiana Univ Cancer Center (Cancer Pavilion). ~ c.Upcoming Scientific Tobacco Conferences: 1.The 12th National Conference on Nicotine Dependence, sponsored by the American Society of Addiction Medicine (ASAM), wilt be held on October 14- 17, 1999 in Cleveland, Ohio..Traditionally, the ADA has been a co-sponsor of this meeting. For information about this meeting contact, the ASAM office: 4601 North Park Avenue, Suite 101, Arcade Level, Chevy Chase, MD 20815. Tel: (301) 656-3920. 2. The 5th Annual Meeting of the Society for Research on Nicotine and Tobacco will be held on March 5-7, 1999 at the Sheraton Hotel, San Diego, California. It is held in conjunction with the 20th Annual Meeting of the Society of Behavioral Medicine. For information about this meeting or the SRNT organization contact their central office: 7611 Elmwood Avenue, Middleton, WI 53562. Their website is : www.srnt.org Tel: (608) 836-3787k; FAX: (608) 831-5485; email: srntl @aol.com d. Two Upcoming Cessation Intervention Programs/Interventions for Med!ca/ and D.,.ental Professionals: Indiana University Workshop on State-of-the-Art Smoking Cessation Interventions: The Indiana University School of Medicine, Division of Continuing Medical Education and the Indiana University Nicotine Dependence Program are sponsoring a day and a half workshop on March 11-12, 1999 at the University Place Conference Center, IU Campus, Indianapolis, Indiana, The program includes lectures, case-presentations and hands-on, skill-building workshops on how to assess, diagnose, and develop treat-merit plans and optimally deliver effective tobacco cessation interventions. Accepted by the Indiana State Board of Dental examiners, dentists will receive 12.5 credit hours. For more information or a course

: Supplement 20: Indiana University Nicotine Dependence Program report brochure, contact the Registrar, Indiana University School of Medicine, Division of Continuing Medical Education, 1226 West Michigan Street, BR 156, Indianapolis, Indiana 46202-5178. Tel: (317) 274-8353. Tuition for physicians and dentists is $300 and for others $225. Residents-in-training and students are $50. Mayo Clinic Nicotine Dependence Seminar: Counselor Training and Program Development: On May 17-19, 1999, the Mayo Clinic approach to patient care for nicotine dependence will be presented in a 3-day program, in Rochester, Minnesota. It will be held at the Leighton Auditorium, Siebens Medical Education Building. The Mayo M(~del will be discussed in-depth and will focus on counseling skills, pharmacologic therapy, relapse prevention, and program compon- ents. For information call 1-800-323-2688 or write to: The Mayo School of Continuing Medical Education, 200 First Street S.W., Rochester, Minnesota 55905. You may also Fh~X a request for information to (507) 284-0532. Complete program details will be available in their course brochure, February 1999. e. "Tobacco and Your Oral Health" Recently Published Booklet for Dental Reception Room Use: Dr. Christen and Ms.Jenny Klein, RDH, MSA, have prepared a 35-page book for dental office reception rooms entitled, Tobacco and Your Oral Health. This book describes the range of problems associated With both smoking and smokeless tobacco. Explanations and detailed illustrations of the negative effects of tobacco use on periodontal and implant therapy are also emphasized. It was released in the fall of 1997 by the Quintessence Publishing Co, Inc., 551 North Kimberly Drive, Carol Stream, Illinois 60188-1881. Tel: (630) 682-3223. E-mail: quintpub@aol.com f. The Female Smoker: From Addiction to Recovery, co-authored by Joan and Arden Christen has just been published. This work -- 40 months in preparation -- was written to provide a comprehensive, current and independent literature review of this vital subject. The authors reviewed over 1,000 scientific works and used nearly 900 of these published articles as the basis for the final book. Several educational grants have funded this work which has been made available free of charge to all members of our steering committee. If you need another copy, contact Dr. Christen

Supplement 21: Oregon Health Sciences University drug dependence intervention program Screening for Signs and Symptoms of Depression Depression can cause a number of symptoms. Not everyone experiences every symptom. Some people have only a few, while others experience many. The severity of the symptoms also varies. Here are common signs of depression: (For each symptom that you are feeling, cheek the circle beside the statement) 0 a sad or empty feeling that doesn't go away 0 loss of interest or pleasure in your activities, including sex 0 restlessness 0 irritability 0 frequent crying 0 feelings of guilt 0 feeling worthless 0 feelings hopelessness; believing that things will not get better 0 less energy (feeling "slowed down" or tired) 0 poor concentration or inability to think or to make decisions 0 poor memory 0 thoughts of death or suicide; suicide attempts 0 changes in sleep: difficulty falling asleep, waking up too early in the morning, or oversleeping 0 loss or increase in appetite; weight gain or loss chronic aches and pains, such as headaches or stomach aches and other digestive problems that don't get better with treatment 0 disturbed thoughts, flaat is, thoughts not based in reality about physical disease, sinfulness or poverty If you have five or more of these symptoms and they've lasted longer than two weeks or if the symptoms are interfering with your daily functioning, get professional help. OHSU School of Dentistry Department of Pedodontology: Theresa E. Madden, DDS, PhD, Li~la D. Boyd, MS, RDH, Jolene Bauer, BS, RDH 61

• Supplement 21: Oregon Health Sciences University drug dependence intervention program Screening for Alcohol Abuse/Dependency How many drinks (1 drink=12 oz. beer=-l.5 oz. liquor=5 oz. wine) do you have in an average wcek7 How many drinks do you average on one occasion7 Does anyone in your family have an alcohol/drug problem? Has anyone ever said your drinking might be causing you problems7 How much alcohol did you drink in the last 24 hours7 Patients with positive answers on this screening and who meet the DSM-IV Criteria of alcohol abuse/dependency (see the back of this sheet) should he referred to an addiction medicine specialist. Answers suggestive of Question #1: Women >10 drira week Men>13 drinks/week Criteria for Substance Dependence & Abuse alcohol abuse/dependency: Question #2: Women >2 drinks/occasion Men > 3 drinks/occasion DSM-IV Criteria for substance dependence ~ A maladaptive pattern of substance use, leading to clinically significantimpalrment or distress, as manifested by 3 or more or the following, occurring at any time in)the same 12-month period: I) tolerance, ~ defined by either of the followihg: :., a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect b) markedly diminished effect with continued use of the same.amount of the substance 2) withdrawal, as nianifested by either of the following: a) the characteristic withdrawal syndrome for the substance... b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms 3) the substance is often taken in larger amounts or over a longer period than was intended 4) there is a persistent desire or unsuccessfuI efforts to cutdown or control substance use " 5) a great deal of time is ~pent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects 6) important social, occupational, or recreational activities are given up or reduced because of substance use 7) the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current~ cocaine use despite recognition of cocaine-induced depression, or continued drinking, despite recognition that an ulcer was made worse by alcohol consumption) DSM-IV Criteria for substance abuse A maladaptive pattern of substanceuse leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period: I) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) OHSU School of Dentistry Department of Periodontology: Theresa E. Madden, DDS, PhD, Linda D. Boyd, MS, RDH, Jolene Bauer, BS! RDH

Supplement 21: Oregon Health Sciences University drug dependence intervention program Tobacco Intervention Outcomes Student Name: Date: Patient Name: Chart #: Dental student attended tobacco cessation workshops O Yes 0 No Patient use of tobacco O current user O past user O never used > than 1 month Patient attitude toward quitting (Stage of Readiness to Quit) O Stage I O Stage 2 O Stage 3 O Stage 4 O Stage 5 Number of previous attempts to quit tobacco use O Never O 1-2 O 3-4 O 5-6 0 6+ Number of relapses following cessation of tobacco use O0 01-2 03-4 05-6 O 6+ Education materials used for the patient include: O Pamphlet: "You Can Quit Smoking" O O Fact sheet: Tobacco & Oral Health O O Handout: Local Tobacco Cessation Programs O 0 Other. Commit to Quit Stop Smoking Kit Handout: Steps to Tobacco Cessation Prevention message for non-user & previous user Patient score from Fagerstrom Test of Nicotine Dependence: O 0-3 O 4-6 O 7-11 Co-morbid conditions present: 0 Alcohol abuse/dependency O Other.substance abuse 0 depression 0 psychiatric condition other.. 0 family history of alcohol/drug/nicotine dependence This patient's contraindications for nicotine replacement therapy include: O Insulin dependent diabetes O O Hyperthyroidism O O Pregnancy or nursing O 0 Peripheral vascular disease Accelerated hypertension Peptic ulcer disease Cardiovascular disease This patient's eontraindications for Zyban include: 0 Seizure disorder 0 O MAO inhibitor O Eating disorder Other med~. wfouproprion HC1 Quit Date set? 0 Yes Follow up contacts made with Date ~rae Patient abstaining from tobacco use 0 No If no, was tobacco cessation discussed again (dates). ~atient and results (continue on the back of the page if more room is needed): Results at: O 2wk. O 3mo. O6mo. O9mo. Olyr. OOther Relapse after student's initial tobacco cessation intervention7 O Yes Describe action taken (coping strategies) at relapse by student and patient: 0 No

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• Supplement 22: University of Southern Californht ~ USC SCII()OL OF 1)I':NTISTRY AV97-1997 REPORT Tothe Nation~ Dent~ Tobacco-Free Steedng Committee January1999 The USC School of Dentistry continues to support the goals of the National Tobacco-Free Steering Comrnittee.~ A variety of activities are provided byour Tobacco Use Prevention and Cessation project (originally funded by the Tobacco Control Section, TCS, Department of • Health Services, State of California, Augu.st 1990 - December 1.994). ' Students, faculty and school staff are urged to quit tobacco use and are offered cessation strategies and referrals to classes. The school has been a non-smoking facili'tY for many years. Dental and dental hygiene students :at USCare trained to provide their patients with tobacco use information and cessation counseling, based on the NCi manual and using NCI and California TCS developed materials. Patients of the School of Dentistry clinics are questioned about tobacco use, provided with education and information, counseled to stop, and provided with resources in the community for cessation classes. Dental hygiene and dental assisting students and faculty from community colleges throughout Southern California. are trained, upon request, by our USC project director, presenting the NCI program and sharing TCS developed educational materials. Presentations sharing our education and cessation activities have been made during the last several years at annual meetings of the American Association of Dental Schools, American Association of Public Health Dentistry, American Public Health Association, and Health Professions Schools in Service to the Nation. ' University of Southern California Los Angeles. Cahforma 90089-0641 An article entitled "Office - Based Training in Tobacco Cessation for Dental Professionals~ authored by USC faculty (Wood, Nathason, Hiroshige} was published in the Journal of the American Dental Association in 1997. One intent of the article was to encourage dental professionals to participate in tobacco education and cessation programs with their patients and for the public.

Supplement 23: Military Health Care Provider position statement Paul J. Vankevich, D.M.D. CDR DC USN TOBACCO CONTROL AND INTERVENTION; THE MILITARY HEALTH CARE PROVIDER FACT SHEET Health care providers have a professional and moral obligation to practice preventive medicine and engage ifi health promotion. Tobacco used in any form has potentially significant deleterious effects on human health. Tobacco control and intervention is consistent with the mission of military readiness of the Medical Department and is a cost effective means of controlling increasing health care expenditures. There is no safe form of tobacco. All types of tobacco, smokeless and pyrolytic, contain tobacco toxins, carcinogens and the addictive agent nicotine. The objective of any tobacco use is the delivery of a dose of nicotine to the brain. Smoking is a leading cause of death in the world. It is estimated that one in five deaths in the United States is related to smoking. (435,000 deaths each year) Half 0fthe people who smoke will die of a smoking-related illness. In the United States one in four smokers will die prematurely of a tobacco-related disease, losing on average two decades of life. The 43 identified carcinogens" in tobacco smoke are the main single cause of cancer mortality in the Unites States, causing 30% of cancer.deaths. Cigarettes are the only commercially available product, when used as directed, cause cancer. The annual tobacco-related health care costs and lost productivity in the United States is estimated to $65 billion. In 1997 this equated to $2.59 cost per pack of cigarettes. DOD tobacco-related health costs exceed $I billion annually. Cigarette smokers are absent from work 6.5 days more per year than nonsmokers. They make six visits more to health facilities each year than nonsmokers, and their dependents make 4 more visits each year than those of nonsmokers. CONCLUSION Military health care providers should set a tobacco-free example, ask all patients about their tobacco use and actively engage in tobacco control activities.

Supplement 24: Tobacco Free Delaware Coalition report IMPACT Delaware Tobacco Prevention Coalition, Tobacco Free Delaware Program Lead Agency: American Lun_qAssociation of Delaware Project Director: Deb Brown Communi~ & Youlh Educator: Shed Towner Gabrelcik Communications: Pare Finkelman Tobacco Free Delaware is a project of the IMPACT Delaware Tobacco Prevention Coalition. Funded by a grant from The,Robert Wood Johnson Foundation through the Smokeless States National Program Office of the Amedcan Medical Association. Tobacco Free DeJaware is (~edicated to preventing disease and premature death from tobacco abuse in the nation's First State. In April of 1997, the IMPACT Delaware Tobacco Prevention Coalition, a group Of health agerjcies, communit~ organizations and individuals dedicated to reducing tobacco use in Delaware, received a 4-year Smokeless States grant from the Robert Wood Johnson Foundation. Thegrant is being.used to tund the operations of Tobacco Free Delaware. Program which include youth tobacco use prevention, the expansion of smoke-free areas in public and work places, tob~coo control education, public policy and coalition-building initiatives. , • The grant has helped the Coalition more than double its membe~shi_p. Member organizations worked under the Coalition umbrella to defeat five bills that would have weakened the state's youth access law and won successful passage of the Healthy Lifest~es and Tobacco-Related Disease Prevention Fund Bill. Other Coalition accomplishments include: • Winning passage of the bill prohibiting smoking on all government-related transportation,. including school bpses; -~ • Rallying support statewide for a tobacco exdse tax campaign, whic, h although unsuccessful brought new members into the Coalition; • Developlqg a training package and overseeing implementatiorl of compliance cheP,,ks; • Launching a public education media campaign on tobacco use in the state through TV and radio spots, billboards and brochurp.s; and • Training youth in advocacy through the Teens Against Tobacco Use Program. The Tobacco Free Delaware Program'spreventJon plan includes an annual youth conference. This years event will be a satellite conference enabling students from all three Delaware counties to participate in an interactive daylong evenL Wendy Schaetzel Lesko, Executive Director of Activism 2000 Project, Washington, D.C. will be the keynote/facilitator for the daylong conference. Statewide high schools, representatives of T~.T.U. programs and jr. high students will participate in a vadety of youth empowerment workshops. IMPACT Delaware Tobacco Prevention Coalition Member Organizations Total Organizations: 101 68 organizations added since becoming a Smokeless Statesgrantee 3 local and 2 county coalitions Medical Socie~, of Delaware Medical Society of Delaware Alliance American Lung Association of Delaware. 102I Gi/pin Avenue o Suite 202 • Wi/mington DE ]9806 302 555-7258 • fax 302 655-8'346 • e-a~iL super/ung@ao/.com ~7

Supplement 24: Tobacco Free Delaware Coalition report Asthma. Allergy and Immunology Society of Pulmona~ Associates Bell. ~of Delawa/~_ Boys and_Gi_'ds_Club of. _D~leiware Bravwine Coup~lina. Ino ide "no ~ u Career I~fom~on Ch.es~..pea~.e Bay Gid .~. Cguncil ¢hdsliana Care ~~ Ohfistiana Care.Health ~ysJen!, Cancer Outreach P.rqgram Concord High ~YV¢~lnes.s ~enter Dp, ,lawam A~so~io0 for Physical .E.du~aUo9 Health, Recr~e~t. ~n and~l~anc~ I~)ela~ BR~t.C_,aaq~ P~d~on Delaware C~emission ft~" Woro en. Delaware Dental Hygienists' Association " hil use Department of ,~ewk:es for Child .r~, Youth and Their Families I~skm o~ Azdr~ D~s~" _ran of Ak:~:d~_ ism. Drug Abt~s? a~nd Mental. ~Hpalth I;;~v~ AEB W~E~=s~C, enter D~er W~n~ss T~k~ome DuPont Bosj~al fo~ ChJldr~ Educa~m Against Alcohol and 0rugs, Youth Group Family and Children Services of Dela~a~'a F~i~'t State Pr~nmunity Against Substance Abuse* • First _St~t_e Orthopedics Fraim Boys and Gi_ls Club .filas=~_W_ellnass -~ent or Gover~r'_ ~ Cot/neff on Lifestyles and l=/tness Group Against Srnoldng Pollution

Supplement 24: " Tobacco Free Delaware Coalition report Hockessin ~Socc~" Club t " I h~tin Ame~an Cocnmunitv Center Middlef[own-Odess~-Townsend Community Coalil/on*" ~Hsalth ~I New Castle Count/, C, omm~nity Padner~hip Boysand Girls Club Th.e,J~no Task Fome e dlness mun" of D lawar UniveR~Y of Delaw'~'e ,UqJvers, ityx~f Delaware, C_,qllege of He~dth ~nd Social Sewic~s. Volunteers for Pzloier~cent Pregnancy Prevention • W~qness Program Oevelo~n ent VY~Jde Health Center ,Women and Wegn~ss YMCA of De]aw~'e YWCA of New Castle County Underlined organiza~ons were recruited since receiving SLS furjdlng; *local coalition; **county coalition

Supplement 25: Tucson, Arizona: Full Court Press Coalition report YEAR OBJECTIVES GOAL: To reduce teen tobacco use in Tucson by 10% by the Year 2000 By 2000, cues and messages supporting non-tobacco use .will have increased and pro-tobacco use cues and messages will have decreased. By 2000, Tucson will have increased enforcement and strengthened public support for policies that protect youth. By 2000, major community groups and organizations that represent the priority population (youth) and have broadbased reach and influence will be involved in tobacco control and prevention activities. By 2000, youth will be involved and engaged in tobacco use prevention activities and independently affect tobacco use among their peers. By 2000, all middle and high schools in Tucson will have tobacco free policies which are enforced. By 2000, all middle and high schools in Tucson will link with youth and community organizations to promote and enhance tobacco free school climates. By 2000, there will be an increase in the availability and use of youth cessation services. 71

Supplement 25: Tucson, Arizona: Full Court Press Coalition report PARTNERS American Cancer Society Full Court Press Program Office 1636 N. Swan, Suite 151 Tucson, AZ 85712 (520) 321-7989 (520)'321-7988 (fax) fcp~rtd.com (e-mail) American Lung Association Full Court Press Cessation Office 2819 E. Broadway Tucson, AZ 85716 (520) 323- I 812 (520) 323-1816 (fax) Rolling Thunder Full Court Press Policy Office 2929 E. Thomas Road Phoenix, AZ 85016 (602) 381-3089 (602) 381o3096 (fax) Pima Prevention Partnership, Inc. Full Court Press Youth Office 35 E. Toole Avenue Tucson, AZ 85701 • (520) 884-8663 (520) 884-8820 (fax) Tucson Police Department Full Court Press Youth Office 35 E. Toole Avenue Tucson, AZ 85701 (520) 444-1900 (520) 886-7713 (fax) University of Arizona Full Court Press Evaluation Office Arizona Cancer Center 2302 E. Speedway #202 Tucson, AZ 85719 (520) 318-7100 (520) 318-7104 (fax) Donna Grande, Director Rachel Puchi, Media Specialist Lisa Abt, Administrative Manager Bill Pfeifer, Executive Director Mary Billings, Regional Director Nancy Moyer, Director - Tobacco Con~ol Jack Nichol, Project Director Stephanie Nelson, Project Coordinator Harry Kressler, Executive Director Lynne Smith, Youth Project Manager Brigitte Jordan, Program Associate Rena Roberts, Program Associate PJ Dixon, Program Associate Julissa Jose, Program Associate Skip Woodward, Enforcement Officer Hye-ryeon Lee, Principal Investigator Rhonda Stone, Program Coordinator

Supplement 25: Tucson, Arizona: Full Court Press Coalition report Press FACT SHEET Background In the Fall of 1995, the Robert Wood Johnson Foundation awarded the Coalition for a Tobacco Free Arizona a $3.17 million grant to develop and implement a youth tobacco use reduction program in Tucson, Arizona. The staff at the RWJ Foundation named the program Full Court Press as it represents an all out effort to reduce teen tobacco use. The program is administered by the American Cancer Society through a parmership with the American Lung Association, Pima Prevention Partnership, Inc., the Tucson Police Deparlment, the University of Arizona and the youth of Tucson. Proven methods of tobacco use reduction are being applied and new innovative approaches are being developed with assistance from 15 youth interns who have been hired to help design and implement the program to their peers. Goal Tucson was the only community in the country to receive the award and is challenged with developing a prototype for achieving a 10 percent reduction in youth tobacco use inthe City of Tucson by the year 2000. The objectives are to influence and change behaviors in areas where teens are educated and where they live, work, play and spend their free time. Rationale For the past decade, adult tobacco use has been on the decline, but not for youth under the age of 18 years. In fact, youth tobacco use has been increasing. • Each day, 3000 youth under the age of 18 years begin smoking. • Eighty percent of all smokers started before they were 18 years of age. Between 1991 and 1995, past-month smoking increased 34 percent among 8~ graders. • In 1995, 21.6 percent of high school seniors smoked compared to 17.2 percent in 1991. • For the tobacco industry to preserve its market status, it must attract 2 million new smokers each year. In 1993, tobacco companies spent an estimated $6 billion--more than $16 million a day--~o advertise and promote cigarettes. • Teens who smoke are three times more likely than nonsmokers to use alcohol, eight times more likely to use marijuana and 22 times more likely to use cocaine. • Each year, more than 400,000 Americans die prematurely as a result of tobacco use. This represents one out of every five deaths in the U.S. Approach Young people are targeted by the tobacco industry to begin smoking and to start a life of addiction before they fully recognize the impact of their behavior. By providing young people with alternative programs and activities that educate them not only on the health implications of tobacco use, but the marketing and promotion of tobacco products and the politics of the industry, youth will have a better understanding of tobacco use and be able to make informed decisions. An all out effort will be made by youth to access the media, the community and their peers to inform them about the dangers of tobacco use. Working with adults throughout the community and with their peers, young people ,will be active participants in addressing the number one preventable cause of death and disease in our country. Evaluation The program will be evaluated in a number of ways. Youth tobacco use behavior will be ascertained at three points in time over the five years (i.e., baseline, midpoint and outcome). Annual surveys will also be conducted on public attitudes and opinions, public and private policies, and media exposure to both pro and anti-tobacco advertising and the overall coverage and tone of current events on the issue. For more information cal.l the Program Office on (520)321-7989 or the Youth Office on (520)884-8663.

Supplement 25: Tucson, Arizona: Full Court Press Coalition report Press TOBACCOFACTS Tobacco-related deaths total over 430,000 nationwide. (Morbidity and Mortality Weekly Report, Centers for Disease Control. (8/27193) ' Every day in the United States another 3000 children and teens become regular smokers (Institute of Medicine Report) and 1000 ~vill eventually die from this use. (Centers for Disease Control and Prevention, Office on Smoking and Health, 10/95)• 89% of all persons who smoke dally started by age 18 and 71% of those had begun smoking dally by or at age 18. (Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A report of the Surgeon General, Washington, D.C. 1994) • Nicotine has been shown to be a "gateway drug" that can lead to the use of drugs like cocaine, crack and heroin. (1991 • National Institute of Drug Abuse household survey on drug abuse) Children have easy acces~ to tobacco products. Studies throughout the nation fmd that underage children can purchase cigarettas 70%-80% of the time over the counter, and 90-100% through vending machines. (Airman, D., et al., "Reducing the Illegal Sale of Cigarettes to Minors, JAMA, 1989) The tobacco industry sells $1.26 billion in tobacco products each year to children under age 18--over one billion packs of cigarettes and 26 million canisters of chewing tobacco. (DiFranza, J., et al., "Who Profits from Tobacco Sales to Children7" Journal of the American Medical Association, 1990) • It is illegal for anyone.under the age of lg to buy tobacco products in Arizona. It is illegal to sell or give tobacco produc~s to anyone under the age of I$ in Arizona. (Arizona State Law). 202% of adults overall, 22.0% of male adults and 18.6% of female adults in Arizona'(>l $ yrs.) smoke cigarettes (CDC - S1ate Tobacco Control Highlights, 1996) and 31.0% of youth in Arizona, grades 9-12, smoke cigarettes. (AZ Dept. of Ed., 1995 YRBS) • Tobacco control legislation as of 1995 rePorts taxes in Arizona of: $.58 per pack of cigarettes and $.065 per ounce of smokeless tobacco. • Currently there are 553,00 adult smokers in Arizoz~a. (CDC-State Tobacco Control Highlights, 1996) • Years of potential life lost in Arizona amount to approximately 67 years or an average of 12 years for each death due to smoking (calculated to life expectancy). (CDC Health Impact and Costs, 1990) • The direct medical costs in Arizona related to smoking total $559,000,000. (CDC Health Impact and Costs, 1990) 74

Supplement 26: New Zealand Dental Association Smok~Free Promotion report Ms Candice Bagnall Portfolio Manager Public Health Dental Smoke-Free Programme Report for the Year 1998 3.12.98 Maggie Macgregor's letter of 14 August advising of funding approval for the proposed smoking cessation programme for the oral health team required a report b.y 20 December1998 on achievements, evaluation, and recommendations for the future of the programme. This year has now been successfully completed. Training Activities: 3x 3 hour seminars for dentists / hygienists 56 lx2 hour seminar for school dental therapists 17 lxl hour lecture 80 Development and implementation of a 'before and after' programme evaluation of therapist and dentist / hygienist programmes. Note: Because of a late venue cancellation the dentist seminar in Hamilton has had to be held over until February next year. Also only one lecture was done but the funding was taken up by greater numbers of dentists and therapists trained. Including those already trained a total of 203 dentists and hygienists have now been through the full training programme. A further152 have been given a broad overview of the content and methodology of the programme during a 1-hour lecture. Continuing education credits were given when appropriate. The programme for school dental therapists continued and to date 51 have been trained in a programme designed for the specific age groups treated by them. A total of approximately 466 oral health personnel have now received some form of smoking cessation training. Evaluation The formal 'before and after' evaluation is attached. This indicates that there have been considerable changes in the beliefs and practices about anti-smoking health education among trained oral health personnel, and that many are now involved in some way. Questionnaires completed by participants at the conclusion of courses have been very positive and observation suggests that the programme is being successful among patients (and also with dental staff, families and the general public.)

Supplement 26: New Zealand Dental Association Smoke-Free Promotion report On-going Programme: Already a number of dentists and hygienists are on the list fDr next year but the Manager of the therapists does not require any further trained at this stage. The new pamphlet for patient use on Smoking and Periodontal Disease has been delayed but should be available shortly. The obtaining of anti-smoking products directly from the wholesaler became possible but was not pursued further because of regulatory problems but mainly as it was felt counter-productive if only one supplier Was to be included. However several new products will b,e available in the near future including an oral inhaler, sub-lingual tablets and particularly the first approved non-nicotine agent. These will all add considerable effectiveness to the anti-smoking armamentarium. For next years programme a number of new activities are currently being pursued. Firstly there isthe possibility for those dentists ! hygienists already trained, to attend the same programme used for therapists which encompasses passive smoking and activities with children. This could be done in a 1-hour lecture after work or in the evening. It would be preferable for orthodontists to attend a full course this year and then the short programme when available later. There has been no training for final-year dental and hygiene students in Dunedin, as funding from educational agencies did not eventuate. However, both therapists and dental technicians are also in the future to be trained at the Dental School so that an all-encompassing course may be a possibility later on. Training Proposal 1999 : Summary: Annual Cost Dentists and hygienists Dentists and hygienists Lecture (short) 54 (3 courses) 36 (2 short courses) Preparation, printing and distribution (partnership with ASH) of an anti-smoking pamphlet for the oral health team. $? Yours sincerely John Skegg Advisor to NZDA on Smoke-Free Promotion

Supplement 27: Section of World Dentistry Against Tobacco, FDI meeting report SECTION OF WORLD DENTISTRY AGAINST TOBACCO Friday 9 October 1998, 1400-1700 Fira Palace Hotel, Rossini 1 Barcelona, Spain Meeting Report Dr'Orjan Akerberg, Section Chairman, opened the meeting with a welcome to all participants. The meeting was attended by approximately 40 individuals, an increase in attendance from the meeting in Seoul. Dr Akerberg reminded participants that every person present has unique opportunities and a professional obligation to reduce smoking and other tobacco use since use is a primary underlying cause of many oral and other diseases, adverse conditions, disability and mortality. He congratulated those present on their tobacco-control achievements to.date, thanked them for their continued interest and presence during a busy Congress program, and wished them success as they continued their work to reduce tobacco-related diseases and conditions. FDI President Dr Katsuo Tsummaki had done the section the honour of his attendance even though there were many demands on his time. He was introduced by Dr Akerberg who recognized Dr. Tsurumaki for his strong support for the World Dentistry Against Tobacco (WDAT) Section and for his leadership against tobacco use in Japan and through the FDI. Dr Tsummaki invited attention to the importance of the collaboration of international dentistry in the fight against tobacco use throughout the world. The work of the WDAT Section was noted for helping the FDI highlight the issue through its many channels of communication and in its relationships with other international organizations. Dentists throughout the world have many important tasks to fulfill in the future- with the work against tobacco use is one of them. An important role is to ensure that local societies fully understand how tobacco use undermines oral health and dental care, and know how to use scientifically sound countermeasures. Dr Tsummaki noted the destructive activities of tobacco companies, especially in developing countries. Finally, DrTsurumaki welcomed all to the section meeting and the World Dental Congress. Professor Jesper Reibel, coordinator of the EU-Working Group on Tobacco and Oral Health, reported on the background and progress of the group. The Wgrking Group was formed in 1997 upon receiving support by the EU Comission. Justification for and coordinating activities since have been a responsibility'of the Danish Dental Association since it already had been active in this subject. The objectives of the Working Group are: - To incorporate tobacco prevention in the dental curricula - To make private practitioners and dentists in the public sector aware of their role in the management and prevention of oral tobaeeo-relat&l lesions. - To train dentists in incorporating oral tobaeco-rdated lesions and the prevention of these in the examination of patients of all ages.

Supplement 27: ,Section of World Dentistry Against Tobacco, FDI meeting report One representative of the :National Dental Associations and one representative of'the • Universities of each EU country were invited to participate. (Dr Akerberg, Chairman of the WDAT Section is one of the Swedish representatives). Summaries of the lectures at the first meeting have been published in the journal "Oral Diseases". During late 1998, an inquiry is being made in all participating countries regarding the working conditions, knowledge and attitudes of dentists concerning tobacco and tobacco use. Result will be published in 1999. Dr ~Iose Bagan reported on the tobacco situation and dental response in Spain. Dr Bagan stated that far too many people smoke in Spain. The most recent data for estimating tobacco consumption in Spain were from a 1995 survey. The survey found that 47% males and 27% females ages 17 and older were smokers. The amount of tobacco consumed differed between the sexes. 57% of females smoke 10 or fewer cigarettes/day versus 35% of male. In contrast 20% of males consume more than 20 cigarettes dally versus 7% of the female population. No data was available concerning smoking among dentists in Spain. However, the 1995 survey indicates that 45% of male physicians and 59% of female physicians smoker. In Catalonia, where Barcelona is situated, data suggest that 32 percent of physicians smoke in front of their patient and 44 percent allow smoking in their reception areas. In conclusion, health care professionals in Spain smoke more than the general population and no major changes have been observed in relation to tobacco cessation counselling. Cessation advice and assistance is rarely given to patients who a still free of obvious tobacco-related conditions. Dr William Maas, Director, Division of Oral Health, Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services, was introduced. Programs in his division include the surveillance of oral diseases, assisting state and community dental public health programs, and providing expertise and guidelines for infection control practices in clinical practice. Dr. Maas spoke about a recent issue of Morbidity and Mortality Weekly Reports that described the status of oral cancer in the U.S. and which made recommendations for effective, comprehensive oral cancer prevention, detection and care. (Preventing and controlling oral cancer: recommendations from a national strategic planning conference. MMWK 1988;47, No. RR-14. Copies are available by writing to the Division of Oral Health, Mail Stop F-10, CDC, 1600 Clifton Road, N.E., Atlanta, GA 30333.) Dr Robe~ Mecklenburg, Tobacco Control Research Branch, National Cancer Institute, and WDAT Section Vice Chairman,,lectured on "Nicotine Addiction: What We Are Up Against." Recent research on brain function and nicotine's effect on the body, especially on the central nervous system, and new pharmacotherapies have helped clinicians understand that they are dealing with a chronic, progressive relapsing disease of the brain. Brief, practical tratments are available. Treatment requires reinforcement of patients' desire to quit, helping patients with coping skills and use of pharmacotherapy during the quitting process, encouraging patients who relapse to try again, and providing a low level of monitoring and reinforcement oftobacco-fi'ee behavior theraiter. The health professions once simplistically thought that a single attempt to help a patient was enough and "too bad" if relapse occurred --an approach that would be unthinkable for periodontal care and patients with high blood pressure and other life-threatening chronic conditions. Now it is realized that long-term neuronal changes caused by nicotine exposure require repeated help and the consequences of withholding help places tobacco using patients at high risk for serious oral and general diseases, and for about half of cigarette smokers, death from a smoking-related disease. Dr Seppo Wickholra, Chairman of Swedish Dentistry Against Tobacco, presented a computer tailored smoking cessation program for dental care. In his work at the Center for Tobacco

Supplement 27: Section of World Dentistry Against Tobacco, FDI meeting report Prevention at Karolinska Institute in Huddinge, Stockholm, Dr Wickholm has been involved in the development of a multimedia program. This program (called "Dr Smokefree") has a generalized structure and allows any kind of knowledge to be handled by the system. A database is connected to the multimedia program which allows both documentation and evaluation. During the first visit the patient answers several questions in the computer and diseuases the answers with his doctor or nurse. The patient is sheduled to return during the first week after quitting. Visits 3, 4 and 5 focus on relapse prevention, coping skills, and so on. In conelusiort, this is a promising new technique for minimal intervention and offers knowledge and skills for providers and patients. It is time and cost-saving, provides quality assurance, and it can be tailored to special needs. Dr Hideo Iehiki, member of the board, WDAT Section, reported on worsening tobacco use trend in Japan. However, some progress is being made, such as smoke-free airline flights. He was well informed and gave an excellent overview based on his work with the Tobacco Control Japan Medical-Dental Association. In 1997 he was elected President of the Japan Dental Association Against Tobacco. The Japan Dental Association has developed a 5 point programme; (1) help public prograrnmes for reducing smoking, (2) help reduce smoking by dentists and other health care providers, (3) promote dental clinic smoking cessation programs, (4) deelare dental conferences to be smoke-free, and (5) conduct surveys to monitor progress toward declining in Japanese dentist smoking rates. Dr. Ichiki very generaously videotaped much of the VCDAT Section meeting for future reference. He is also active in Asian-Pacific dental tobacco control activities. In recent years, the FDI has declared its Congress' and other meetings to be smoke-free. This policy is primed on the official programme. Even so, an unfortunate lack of non-smoking behaviour was noted by several delegates in the Congress center, main meeting hotel, and other areas used for the Congress. The grave concern on this phenomenon was to be brought to the attention of FDI leadership for managing in the future. Dr. Akerberg announced that the next meeting of the WDAT Section will be in Mexico City during the October 28 to November 1, 1999 Congress. Dr. Saskia Estupian-Day, Dental Advisor for the Pan American Health Organization, has agreed to be a special speaker about tobacco use in the Americas and the role of the dental profession. The programme will include information about an update of the Agency for Health Care Policy and Researeh's Clinical Practice Guideline, reports about other advances on scientifically sound tobacco intervention methods for clinicians, and reports about interesting country and regional dental tobacco control activities. Dr Akerberg then brought the meeting to a close by thanking all participants for their kind attention and several valuable contributions.

To motivate and empower people involved in the anti-tobacco movement to effectively support comprehensive global efforts aimed at reducing world tobacco use. The 11th World Conference On Tobacco OR Health will develop strong international, regional, national and community-based efforts, coalitions, strategies and tactics to make a significant and lasting impact on tobacco use throughout the world. We will ~ccomplish this by: • Sharing Information • Developing Consensus • Networking • Dialoging • Capacity Building • "Are We Winning?--Appraising Progress and Celebrating Success," "Nicotine--Present and Future" "Advocacy in Action" American Medical Association ~h0f~J'~t0rlt zxxxxxzxxxxxxxx~UrOxx~.glGIT 208 12304 RI~ERS EDGE ~ ~C ~ ~54-10~ Join :Us... UNITEDIN HEALTH PromOting AFuture Without Tobacco August 6-10, 2000,Chicago, Illinois U.S.A. ..:..!...,, ~ Join ~s " " .... to. gether t~ US :we,:uBIte : strengthen global leadership aimed at the prevention and control, of tobacco. For addltimml conference information please complete and return the z~ttached form via post or fax:

Supplement 28: llth World Conference on Tobacco OR Health-Announcement and ~ information PLACE STAMP HERE Ms. Anne Jenkins Conference Manager 11th World Conference on Tobacco OR Health c/o American Medical Association 515 North State Street Chicago, Illinois 60610 U.S.A. [] Please send me conference registration materials [] Please send me information on conference scholarships [] I am interested in submitting an abstract [] I am interested in being a presenter Please type or print legibly Trtle: [] Mr. [] Ms. [] Mrs. Name: Association, Institution or Business: Return this card to: Ms. Anne Jenkins Conference Manager llth World Conference on Tobacco OR flealth Phone: 312-464-5159 Fax: 312-464-4111 E-maih 11thWCTOH@ama-assn.org [] Ph.D. []Other Address: City and State or Region: Country: Telephone: E-mail: Fax: $1

Supplement 28: llth World Conference on Tobacco OR Health-Announcement and ~ information PLACE STAMP HERE Ms. Anne Jenkins Conference Manager 11th World Conference on Tobacco OR Health c/o American Medical Association 515 North State Street Chicago, Illinois 60610 U.S.A. [] Please send me conference registration materials [] Please send me information on conference scholarships [] I am interested in submitting an abstract [] I am interested in being a presenter Please type or print legibly Trtle: [] Mr. [] Ms. [] Mrs. Name: Association, Institution or Business: Return this card to: Ms. Anne Jenkins Conference Manager llth World Conference on Tobacco OR flealth Phone: 312-464-5159 Fax: 312-464-4111 E-maih 11thWCTOH@ama-assn.org [] Ph.D. []Other Address: City and State or Region: Country: Telephone: E-mail: Fax: $1