they evolved into monitoring a wide variety of communicable diseases for detection and control purposes. Selected chronic illnesses became the target of surveillance programs beginning in the 1970s. Later, a host of surveillance techniques were used to monitor environmental exposures such as hazardous occupations, personal injuries, and health-related individual behaviors. Tobacco use was first studied in a federal survey in 1955 (Haenszel et al, 1956). In 1996, the Council of State and Territorial Epidemiologists added the state-specific prevalence of cigarette smoking to the list of conditions designated as notifiable by states to the CDC (CDC, 1996).

Among the attributes that are used to evaluate surveillance systems are simplicity, flexibility, acceptability, sensitivity, representativeness, and timeliness (Klaucke et al., 1988). The simplicity of a given surveillance system is influenced both by its structure and ease of operation. A given surveillance system will ideally be as simple as possible and still meet all of its objectives. A flexible system can economically adapt to changing information needs or operating conditions. Acceptability refers to the willingness of organizations and individuals to adopt and/or participate in the surveillance system. In this instance, acceptability will be influenced by whether the system is mandated. Sensitivity refers to the ability of a system to detect diseases and conditions, health states, or various health behaviors or attitudes of interest. A representative surveillance system will accurately describe the distribution of a health event by person, place, and time. A timely system minimizes the delay between occurrence of an event and the initiation and completion of the process of monitoring and reporting of findings.

Another important attribute of surveillance systems is whether the detection targets are collected actively or passively. Passive surveillance generally involved the collection of spontaneously reported health events from interested health professionals or others. The current system of reporting adverse drug events to the Food and Drug Administration generally falls into this category. On the other hand, active surveillance involves expending the resources to marshal all available data collection modes to assure as complete an ascertainment as possible of the health and behavioral events of interest. Active surveillance would seem to be essential for helping to assess the impact of PREPs in population context.

This chapter reviews existing surveillance systems and activities for monitoring tobacco product exposure and their health consequences, with emphasis on the introduction and use of PREPs and the issue of harm reduction in the United States. Then proposals to enhance existing surveillance programs are offered. While surveillance data provide only one part of the information needed for scientific and regulatory judgments, it is a critical component that complements clinical, basic, and other data



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