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I I I I I I I I I I I I I I I I July 9, 1993 / Vol. 42 / No. 26 501 I t h t A mported . er. o seodat.d with . N.w4y Deeerib.d Toxipenic VTbrio cho/en. 0 139 Strain - CNiiom/a. 11163 504 Smotlnq C.ss.tbn puring Previous Y..r Anqnq Aduks - Unit.d Stat.s 507 AvsilabUity of Compnhenslve Adol..c.nt Hoaklf Swvkas - Unit.d Suts+s, 1990 NAtAMR 51• SdmonNla Sorvtype Tenns.w in rowden.d Milk Ptoducts snd Infant Formuta -Ganads and Unked States t " S/7 .ed°n 'n"r'n" in MOR9IDITYAND MORTALITY WEEKLY REPORT su :.`s` Emerging Infectious Diseases Imported Cholera Associated with a Newly Described Toxigenic Vibrio cholerae 0139 Strain - California, 1993 Epidemics of choiera-iike illness caused by a previously unrecognized organism occurred recently in southern Asia (1 ). This report documents the first case of cholera imported into the United States that was caused by this organism, the newly de- scribed toxigenic Vibrio cholerae 0139 strain. On February 5, 1993, a 48-year-old female resident of Los Angeles County sought care at a local outpatient health-care facility for acute onset of watery diarrhea and back pain. A few hours before seeking medical care, she had retumed to the United States from a 6-week visit with relatives in Hyderabad, India. Her diarrheal illness began in India on February 4 and increased in severity while she traveled to the United States. She reported a maximum of 10 watery stools per day but no vomiting, visible blood or mucous in her stools, or documented fever. The patient was prescribed trimethoprim-sulfamethoxazole without rehydration treatment and recovered uneventfully. Duration of illness was approximately 4 days. No secon- dary illness occurred amqng family members. When the patient sought medical care, the physician suspected cholera, and a cul- ti of a stool specimen obtained from the patient at that time yielded colonies `iuspected of being VV cholerde. This was confirmed by the Los Angeles County Public Health Laboratory. The isolate was identified as VV cholerse non-01. The isolate pro- duced cholera toxin by Y 1 adrenal cell assay and latex agglutination in the Califomia State Public Health Laboratory. Testing at CDC identified the isolate as toxigenic V cholerae serogroup 0139, resistant to trimethoprim-sulfamethoxazole. Before this illness, the patient had been In good health. In Hyderabad, she stayed with relatives and did not travel outside the city. Although the source of her infection was not confirmed, on January 30, the patient had eaten fried shrimp and prawns purchased from a local market and prepared by relatives. She also recalled drinking a haH glass of unbottled water in Hyderabad on February 3. , ` Reporred by~ M Tormey, MPH, L Mascola, MD, L Kilman, Los Angeles County Dept of Health Svcs, Los Angeles; P Nagami, MD, Southern California Permanente Medical Group, Los Ange- les; E DeBess, DVM, S Abbot4 GW Rutherford, lll, MD, State Epidemiologist, Califorrtia Dept of U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service

m.r mmi.rm r.r gm " =am M m ..m mm m M+rn ~~ 604 MMWR July 9, 1993 Vol. 42 / No.26 MMWR 506 Progress In Chronlc Disease Prevention Smoking Cessation During Previous Year Among Adults - United States, 1990 and 1991 Although most smokers in the United States report that they want to stop using cigarettes (1), 48 milllon persons aged 218 years continue to smoke (2). Current infor- mation about factors predictive of smoking or cessation Is required to develop and assess measures effective In reducing smoking prevalence. To characterize the pat- terns of attempting to quit smoking and smoking cessation among U.S. adults during 1990 and 1991, CDC's N4tlonal Health Interview Survey-Health Promotion and Dis- ease Prevention (NHIS-HPDP) supplement collected self-reported information on cigarette smoking from a representative sample of the U.S. civilian, noninstitutional- ized population aged 218 years. This report summarizes findings from this survey. The overall response rate for the 1991 NHIS-HPDP was 87.8%. Participants (n-43,732) were asked: "Have you smoked at least 100 cigarettes In your entire life?" Those who responded "yes" (I.e., ever smokers) were asked: "Around this time last year, were you smoking cigarettes every day, some days, or not at all?" They were then asked: "Do you smoke cigarettes now?" TFiose who responded "yes' were esked: "Do you now smoke cigarettes every day or some days?"; those who re- sponded "no" were asked: "Do you now smoke cigarettes not at all or some days?" The time period from the reference time 1 year earlier (about which the ever smoker reporied the frequency of smoking) to the date of Interview was considered the study period. Current every-day smokers were persons who stated that they smoked now end that they smoked every day. Those who stated that they did not smoke at all at the time of the survey were considered former smokers. Some-day smokers were those who smoked on some days. These definitions differ slightly from traditional defini- tions used by CDC's National Center for Health Statistics because they Incorporate the concepts of every-day and some-day smoking. Current every-day smokers who stated that they quit for at least 1 day during the past year, some-day smokers, and form/ smokers were all considered to hsve been abstinent from smoking for at least 1 dif- during the study period. Those former smokers who quit smoking cigarettes for at least 1 month at the time of the survey In 1991 were considered to have maintained abstinence. For this analysis, three raciaVethnlc categories were used: white, non-Hispanic; black, non-Hlspanic; and Hispanic. Other raciaUethnic groups were not included be- cause numbers were too small for meaningful analysis. Data were adjusted for nonresponse and weighted to provide national estimates. Investigators used the Soft- ware for Survey Data Analysis (SUDAAN) to calculate 95% confidence Intervals (CIs) and adjusted odds ratios (3). Among U.S. adults who had smoked at least 100 cigarettes during their lifetimes as of 1991, an estimated 40.5 million smoked cigarettes every day at the beginning of the study period. Approximately 17.0 million (42.1%) of these did not smoke cigarettes for at least 1 day during the subsequent 12 months. Hispanics (62.1% (95Y. CI-46.4Y.- 57.8Y.1) end blacks (48.79L 195% CI-45.2Y.-52.2%I) were more likely then whites (40.3% 1959L CI-39.0Y.-41.6Y.1) to quit smoking cigarettes for at least 1 day. Abstinence Smoking Cessation - Continued for at least 1 day, by age, was highest among persons aged 18-24 years (56.7Y.196% CI-52.9Y.-60.5Y.1) and, by educetlon, was lowest among those with <12 years of edu- jtion (36.5% 195% CI-34.1%-38.9Y.1)• These relations were also evident after atlstlcal adjustment was made for other sociodemographic variables (Table 1). Among persons who reported that they did not smoke cigarettes for at least 1 day during the previous year, 13.8% (2.3 million) were abstinent for 1 month or more al the end of the study period. Hispanics 416.3% 195% CI-10.39L-22.2Y.1) and whiles (14.0% 195% CI-12.6Y.-15.49'.1) were more likely than blacks (7,9Y. 195% CI-5.1Y.-10.1Y.11 to remain abstinent; this difference remained after statistical adlustments were made for sex, age, education, and poverty status (Table 1). P,ersons aged 265 years (19.49'.195Y. CI-14.6Y.-24.2Y.1) and college graduates (18.8% 195% CI-14.9Y.-22,7%I) were the most likely to maintain abstinence. Persons at or above the poverty level• (14.8y. (95Y. CI-13.4Y.-16.3Y.1) were more likely to maintain abstinence than those below the pov- erty level (7.5% (95Y. CI-4.7Y.-10.3Ye1). Of all persons who were daily smokers at the beginning of the study period, 5.7% quit smoking and maintained abstinence for at least 1 month. Among persons who were daily smokers at the beginning of the study period, college graduates and per- sons at or above the poverty level were more likely than those with fewer years of formal education and persons below the poverty level, respectively, to abstain from I cigarette smoking for 1 month or more. Reported by: Office on Smoking and Health, National Center for Chronic Disease Preventlon and Health Promotlon; Div of Health Interview Staristics, National Canrer for Health Slatlstlcs, CDC. Editorial Nota: The findings from this survey indicate that, in 1990 and 1991, approxi- mately 42% of daily smokers abstained from smoking cigarettes (or at least 1 day but that approximately 86% of these persons subsequently resumed smoking. The high relapse rate is likely because of the addictive nature of nicotine (4 ). However, because relapse occurs later In the process of maintenance, the overall rele of cessation will be .' lower than suggested by this report. From 1974 through 1991, an estimated 45.8- 63.6 milllon persons aged 218 years smoked; of these, approximately 1.2 millson per- ~Jns beceme former smokers each year (CDC, unpublished date), suggesting that Lpproximetely 2.6% of U.S. smokers quit smoking permanently each year. Education level and age are both Imporianl predictors for cessation attempts end maintaining abstinence. The findings in this report are consistent with previous stud- les noting that Increasing level of education correlates directly with smoking cessation prevalence and Inversely with prevalence of smoking (2). In addition, although per- sons aged 285 years were less likely to abstain for 1 day, those who did abstain were the most likely to be successful In maintaining abstinence during the study period. Thls finding may suggest that older persons may be more motivated than younger persons to overcome nicotine addiction 15). In 1991, among the three racial/ethnic groups studied, the maintenance rate of eb stinence from smoking was higher for Hispanics and whites than for blacks. Potential explanations for the high relapse rate among blacks include the use of cigarettes with higher tar and nicotine yields (4). a higher prevalence of nicotine dependency emong 'Poverty statistics sre based on definitions developed by the Social Security AdmInletratlon that Include a set of Income thresholds that vary by family size and composition. 6T~66E9~~~

EWs ~ "'MMrr EN mono M ,ft smil, 506 MMWR July 9, 1993 Vol. 421 No. 26 MMWR Smoking Cessatton - Continued Smoking Cessation -Conttnuad persons who smoke (6). and comparatively limited access to preventive health serv- ices (4,7). Smoking-cessatlon programs are important for all recial/ethnic groups. Programs have been developed for AalaNPeclflc Islenders, American Indians/Aleskt-- Natives IT. Stratton, California Department of Health Services, personal communic., tion, 1993), and Hispanics (8). The elevated prevalence of cigarette smoking among (2) and the higher smoking-attrlbutabla death rate for (9) blacks indicate the need for TABLE 1. Adjusted odds ratios (AORa)e for three measures of abstinence from cigarette smoking during the previous year, by sex, race/ethnicity,t age group, level of educatlon,$ and poverty statusl-Unltsd States, National Health Interview Survey, 1991•e bstinence for aintenance Malntenancert among all persons who were daily smokers 21 day amono abstalners 1 year earlier Category AOR (95% C111t) AOR (96% CI) AOR (95Y.Cq Sex Male 1.0 Referent 1.0 " Referent 1.0 Referent Female 1.0 10.9-1.2) 1.1 (0.9-1.31 1.0 (0.9-1.3) Race/Ethnlclty White, non•Hlspanic 1.0 Referent 1.0 Referent 1.0 Referent Black, non-Hispanic 1.6 (1.3-1.6) 0.6 (0.4-0.9) 0.e (0.6-1.21 Hispanic 1.7 (1.3-2.1) 1.3 10.9-2.1) 1.7 (1.1-2.7) Age group (yrs) 18-24 1.0 Referent 1.0 Referent 1.0 Referent 26-44 0.6 (0.6-0.6) 0.9 (0.8-1.3) 0.7 (0.6-0.9) 46-E4 0.4 (0.3-0.6) 0.9 (0.6-1.4) 0.e (0.4-0_e1 266 0.6 (0.4-0.8) 1.5 11.0-2.4 ) 0.9 (0.e-1.4) Education (yre) <12 1.0 Referent 1.0 Referent 1.0 Releren 12 1.3 (1.1-1.6) 1.0 (0.7-1.4) 1.2 (0.9-1.1 13-15 1.e (1.3-1.8) 1.1 (0.8-1.5) 1.4 11.0-1.9 21e 1.8 (1.3-2.0) 1.6 11.0-2.2) 1.9 (1.3-2.71 Poverty status At/above poverty level 1.0 Referent 1.0 Referent 1.0 Referent Below poverty level 1.0 (0.8-1.11 0.6 (0.3-0.8) 0.6 (0.4-0.8) Unknown 0.7 (0.0-0.9) 0.9 (0.6-1.4) 0.8 (0.5-1.1) 'The odds rallos presented for each soclodemoyraphlc variable are adjusted for the other four sociodemographlc varlables In the table. tExcludes 288 respondents of other or unknown race; race/ethnlclty and education were both unknown for tour respondents. tExcludes 24 respondents of unknown education status. 1Poverty statlstics are based on dennltlons developed by the Social Security Administration that Include a set of Income thresholds that vary by family site and composition. ••SampIa site-9416. trAbstinence from smoking cigarettes for at least 1 month preceding the Intervlew. Excludes 92 respondents who abstained from cigarettes for <1 month or for whom duration of abstinence was unknown. ttConlldence Interval. . o996s2gtog specific efforts to reduce the adverse Impact of tobacco use among blacks. CDC and the National Medical Association are Initlating a targeted mass media campaign In luly 1993 called 'Legends' that contrasts the deaths of black civil-rights lesders to Neventable smoking-related deaths. in addition, a tol(-tree telephone number (18001 132-1311) is available to request a smoking-cessation guide, Pathways to Freedom. This guide addresses Important topics including nicotine addiction, possible miscon- ceptions about the safety of smoking menthol cigaretles, stress-reduction techniques. preparing for quitting, relapse-prevention techniques, and the cultural meaning of smoking (6). References J 1. Thomas RM, Larsen MD. Smoking prevalence, beliefs, and activities by qender and other demographic Indicators. Princeton, New Jersey: The Gallup Orpanitatlon, Inc, 1993. 2. CDC. Cigarette smoking among adults-United States, 1991. MMWR 1993;42:230-3. 3. Shah By. Software for Survey Data Analysis ISUDAANI version 6.30 ISoftware documenta- tionl. Research Triangle Park. North Carolina: Research Triangle Instltuts, 1989. 4. Public Health Service. The health consequences of smoking: nicotine addlction. flockvllle, Maryland: US Department of Health and Human Services, Public Health Service. 1988; DHHS publication no. (CDCI88-8406. 6. Hatziendreu U. Pierce JP, Lelkopoulou M. at al. Quitting smoking In the United States In 1986. J Natl Cancer Inst 1990;82:1402-8. 8. Royce JM, Hymowitt N. Corbett K. Hartwell TO, Orlandi MA, for the COMMIT Research Group Smoking cessation factors among African Americans and whites. Am J Public Heaht 1993;e3:220-E. 7. Hymowltt N, Sexton M. Ockene J. Grandlts G. for the MRFIT Research Group. Basellne Iactorr, associated with smoking ceasation and relapse. Prev Mad 1991;20:690-601. 8. Marln G. Merin By, Perez-Stable EJ. Sabogal F. Otero-Sabogal R. Changes In Informatlon u a function of a culturally appropriate smoking cessation community Interventlon for Hlspanlcs Am J Community Psychol 1990;18:847-64. 9. CDC. Smoking-attilbutabte mortality and years of potential llfe lost-United Sules, 1988 MMWR 1991;40:82-3,69-71. Current Trends Availability of Comprehensive Adolescent Health Services - United States, 1990 The national health objectives for the year 2000 target the reduction of behaviors that piece adolescents at risk for human immunodeficiency virus IHIV) infection anrl' other sexually transmitted diseases, unintended pregnancies, and other health prob lems (1). Although clinlcal preventive services are an Importent component of heelth-promotion and dlsease-prevention programs required to achieve these objec tlves (2), adolescents and young adults are less likely to have access to health carr, than younger and older persons (2,11). To characterize comprehensive health-servia programs for adolescents (i.e., persons aged 13-19 years) and whether such pro grams provide targeted services to adolescents at risk for HIV Infection or infecto.t with HIV, the Center for Health Promotion and Disease Prevention at the University w North Carolina at Chapel Hill conducted a national survey of such programs in 199 t This report summarizes the results of this survey. fContinued on page 6Lt'