• The United States should support international tobacco control efforts and should refrain from implementing policies that would increase the future health toll from tobacco use abroad.

REFERENCES AND NOTES

1. Lynch, B.S., and R.J. Bonnie, Eds., Institute of Medicine. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, D.C.: National Academy Press, 1994.

2. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, D.C.: Department of Health and Human Services, 1994.

3 Data on youth tobacco use from the University of Michigan's "Monitoring the Future" study (http://www.isr.umich.edu/src/mtf/) (percent respondents):

 

1991

1992

1993

1994

1995

1996

Any daily use of cigarettes

 

8th grade

7.2

7.0

8.3

8.8

9.3

10.4

10th grade

12.6

12.3

14.2

14.6

16.3

18.3

12th grade

18.5

17.2

19.0

19.4

21.6

22.2

More than 1/2 pack per day

 

8th grade

3.1

2.9

3.5

3.6

3.4

4.3

10th grade

6.5

6.0

7.0

7.6

8.3

9.4

12th grade

10.7

10.0

10.9

11.2

12.4

13.0

Smokeless tobacco

 

8th grade

1.6

1.8

1.5

1.9

1.2

1.5

10th grade

3.3

3.0

3.3

3.0

2.7

2.2

12th grade

 

4.3

3.3

3.9

3.6

3.3

30-day prevalence of cigarette use

 

12th grade

28.3

27.8

29.9

31.2

33.5

34.0

 

Lifetime

Last 30 days

 

1991

1992

1993

1994

1995

1996

1991

1992

1993

1994

1995

1996

Cigarettes, any use

 

8th grade

44.0

45.2

45.3

46.1

46.4

49.2

14.3

15.5

16.7

18.6

19.1

21.0

10th grade

55.1

53.5

56.3

56.9

57.6

61.2

20.8

21.5

24.7

25.4

27.9

34.0

12th grade

63.1

61.8

61.9

62.0

64.2

63.5

28.3

27.8

29.9

31.2

33.5

34.0

Smokeless tobacco

 

8th grade

22.2

20.7

18.7

19.9

20.0

20.4

6.9

7.0

6.6

7.7

7.1

7.1

10th grade

28.2

26.6

28.1

29.2

27.6

27.4

10.0

9.6

10.4

10.5

9.7

8.6

12th grade

 

32.4

31.0

30.7

30.9

29.8

 

11.4

10.7

11.1

12.2

9.8

4. Doll, R., R. Peto, K. Wheatley, R. Gray, and I. Sutherland. Mortality in Relation to Smoking: 40 Years' Observations on Male British Doctors. British Medical Journal 309:901-911, 1994.

5. Stellman, S.D., and L. Garfinkel. Proportions of Cancer Deaths Attributable to Cigarette Smoking in Women. Women's Health 15:19-28, 1989; Shopland, D.R. Tobacco Use and Its Contribution to Early Cancer Mortality with a Special Emphasis on Cigarette Smoking . Environmental Health Perspectives 103(Suppl. 8):131-142, 1995.



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The United States should support international tobacco control efforts and should refrain from implementing policies that would increase the future health toll from tobacco use abroad. REFERENCES AND NOTES 1. Lynch, B.S., and R.J. Bonnie, Eds., Institute of Medicine. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, D.C.: National Academy Press, 1994. 2. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, D.C.: Department of Health and Human Services, 1994. 3 Data on youth tobacco use from the University of Michigan's "Monitoring the Future" study (http://www.isr.umich.edu/src/mtf/) (percent respondents):   1991 1992 1993 1994 1995 1996 Any daily use of cigarettes   8th grade 7.2 7.0 8.3 8.8 9.3 10.4 10th grade 12.6 12.3 14.2 14.6 16.3 18.3 12th grade 18.5 17.2 19.0 19.4 21.6 22.2 More than 1/2 pack per day   8th grade 3.1 2.9 3.5 3.6 3.4 4.3 10th grade 6.5 6.0 7.0 7.6 8.3 9.4 12th grade 10.7 10.0 10.9 11.2 12.4 13.0 Smokeless tobacco   8th grade 1.6 1.8 1.5 1.9 1.2 1.5 10th grade 3.3 3.0 3.3 3.0 2.7 2.2 12th grade   4.3 3.3 3.9 3.6 3.3 30-day prevalence of cigarette use   12th grade 28.3 27.8 29.9 31.2 33.5 34.0   Lifetime Last 30 days   1991 1992 1993 1994 1995 1996 1991 1992 1993 1994 1995 1996 Cigarettes, any use   8th grade 44.0 45.2 45.3 46.1 46.4 49.2 14.3 15.5 16.7 18.6 19.1 21.0 10th grade 55.1 53.5 56.3 56.9 57.6 61.2 20.8 21.5 24.7 25.4 27.9 34.0 12th grade 63.1 61.8 61.9 62.0 64.2 63.5 28.3 27.8 29.9 31.2 33.5 34.0 Smokeless tobacco   8th grade 22.2 20.7 18.7 19.9 20.0 20.4 6.9 7.0 6.6 7.7 7.1 7.1 10th grade 28.2 26.6 28.1 29.2 27.6 27.4 10.0 9.6 10.4 10.5 9.7 8.6 12th grade   32.4 31.0 30.7 30.9 29.8   11.4 10.7 11.1 12.2 9.8 4. Doll, R., R. Peto, K. Wheatley, R. Gray, and I. Sutherland. Mortality in Relation to Smoking: 40 Years' Observations on Male British Doctors. British Medical Journal 309:901-911, 1994. 5. Stellman, S.D., and L. Garfinkel. Proportions of Cancer Deaths Attributable to Cigarette Smoking in Women. Women's Health 15:19-28, 1989; Shopland, D.R. Tobacco Use and Its Contribution to Early Cancer Mortality with a Special Emphasis on Cigarette Smoking . Environmental Health Perspectives 103(Suppl. 8):131-142, 1995.

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6. Lightwood, J.M., and S.A. Glantz. Short-Term Economic and Health Benefits of Smoking Cessation: Myocardial Infarction and Stroke. Circulation 96:1089-1096, 1997. 7. Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990. Atlanta: Centers for Disease Control and Prevention, 1990. 8. Murray, C.J.L., and A.D. Lopez, The Global Burden of Disease and Global Health Statistics, 1 and 2. Global Burden of Disease series. Cambridge, Mass.: Harvard University Press, 1996. 9. As this report went to press, Senate bills addressing broad tobacco-related issues and introduced since announcement of the June 20, 1997, settlement included: S. 1060 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01060:], the Worldwide Tobacco Disclosure Act of 1997, introduced by Senator Lautenberg; S. 1238 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01238:], the Tobacco Use by Minors Deterrence Act of 1997, introduced by Senator Smith; the House companion measures are H.R. 2017 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02017:] and 2034 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02034:], introduced by Rep. Bishop; S. 1310 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01310:], the Long-Term Economic Assistance for Farmers (LEAF) Act, introduced by Senator Ford; S. 1313 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01313:], the Tobacco Transition Act, introduced by Senator Lugar; S 1343 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01343:], the Public Health and Education (PHAER) Act, introduced by Senator Lautenberg, with House companion measure H.R. 2764, introduced by Rep. Hansen; S. 1411 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01411:], which disallows a federal income tax deduction for payments from any settlement and channels funds to research, introduced by Senator Mack (this is separate from other measures introduced, and passed, to repeal a tax provision of the Balanced Budget Act of 1997); S. 1414 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01414:] and S. 1415 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01415:], the Universal Tobacco Settlement Act, introduced by Senator McCain; S. 1471 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01471:], the Treatment of Tobacco Settlement Payments to States as Medicaid Overpayments Prohibition, introduced by Senator Graham, with House companion measure H.R. 2938 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02938:], introduced by Rep. Bilirakis; S. 1491 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01491:] and S. 1492 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01492:], the Healthy and Smoke Free Children Act, introduced by Senator Kennedy; and S. 1530 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:s.01530:], the Placing Restraints on Tobacco's Endangerment of Children and Teens (PROTECT) Act, introduced by Senator Hatch. House bills in addition to the companion measures noted above included: H.R. 2519 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02519:], the Tobacco-Free Youth Act, introduced by Rep. DeGette; H.R. 2594 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02594:], the Control Youth Access to Tobacco Act, introduced by Rep. Fox; H.R. 3027 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.03027:] to increase the tobacco excise tax, introduced by Rep. DeLauro; H.R. 2897 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02897:] to tax tobacco sales through vending machines, introduced by Rep. John Lewis; H.R. 2740 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02740:] limiting attorneys' fees related to the settlement, introduced by Rep. McInnis; and

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H.Con.Res. 184 [http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.con.res.00184:], a resolution expressing the sense of the Congress that motion pictures should discourage youth smoking, introduced by Rep. Luther. The board thanks staff of the American Cancer Society and Senate Labor Committee for help preparing this list of pending legislation. 10. Warner, K. University of Michigan. Effects of Price on Consumption of Tobacco Products. Presentation at the National Cancer Policy Board Tobacco Control Workshop, July 15, 1997, Washington, D.C. 11. Denmark, Finland, Iceland, Ireland, New Zealand, Norway, Sweden, and the United Kingdom would all have higher prices even with a $2 increase in the United States. A $2 excise tax increment would produce prices comparable to those in Australia, Hong Kong, and Singapore. 12. Novotny, T.E., and M.B. Siegel. California's Tobacco Control Saga. Health Affairs 15 (Spring):58-72 1996; Barinaga, M. UC Objects to Research Restrictions. Science 273:178, 1996. 13. Lynch and Bonnie, op cit. For more recent figures, see the University of California's Tobacco-Related Diseases Research Program at http://www.ucop.edu/srphome/trdrp/homeback.html. 14. U.S. Public Health Service, Healthy People 2000. National Health Promotion and Disease Prevention Objectives. Washington, D.C.: U.S. Department of Health and Human Services (Pub. No. [PHS] 91-50212), 1990. 15. National Cancer Institute Expert Panel. The Impact of Cigarette Excise Taxes on Smoking Among Children and Adults, Summary Report of a National Cancer Institute Expert Panel, Cancer Control Science Program, Division of Cancer Prevention and Control, Bethesda, Md., 1993. 16. Warner, K., op cit.; also Meier, K.J., and M. J. Licari. The Effect of Cigarette Taxes on Cigarette Consumption, 1955 through 1994. American Journal of Public Health 87:1126-1130, 1997; F.J. Chaloupka. The Effects of Prices and Tobacco Control Policies on the Demand for Tobacco Products. Robert Wood Johnson Foundation Conference, New Partnerships and Paradigms for Tobacco Prevention Research, Sundance, Utah, May 1997, pp. 213-228; Grossman, M., and F. J. Chaloupka. Cigarette Taxes: The Straw to Break the Camel's Back? Public Health Reports 112:290-297, 1997; and Chaloupka, F.J. Testimony before the Senate Judiciary Committee, Subcommittee on Antitrust, Business Rights, and Competition, U.S. Senate, October 29, 1997. 17. Harris, J.E. Economic Analysis of the Proposed Tobacco Settlement. Tab 16 in An Analysis and Review of the Proposed Tobacco Settlement. Atlanta: American Cancer Society, 1997. 18. Impact of the Proposed Resolution on the U.S. Cigarette Industry. A report prepared for the Conrad Senatorial Task Force, October 8, 1997. 19. Federal Trade Commission. Evaluation of the Tobacco Industry Analysis Submitted to Congress on October 8, 1997. Washington, D.C.: Federal Trade Commission, November 10, 1997. 20. American Medical Association. Analysis, Report, and Recommendations of the American Medical Association Task Force on the Proposed Tobacco Settlement. Chicago: American Medical Association, 1997. 21. The goal would be payments sufficient to make the brands most attractive to youths less profitable than others. This could be achieved by payments based on youth consumption of specific brands—for example a total penalty estimated to reduce youth consumption to target levels, with payments apportioned among manufacturers according to market share of underage users. The assessments would have to be revised periodically to adjust for brand shifting. A similar effect could be achieved via a tax, although unusual in having manufacturer-specific tax rates. Reassessments could be continued until the goals for reduced youth consumption were achieved. 22. Data were presented by Dileep Bal (California data) and Carolyn Celebucki (Massachusetts data) the National Cancer Policy Board Tobacco Control Workshop, July 15, 1997, Washington, D.C. [see http://www2.nas.edu/cancerbd/218a.html]. 23. Lynch and Bonnie, op. cit. 24. U.S. Public Health Service, Healthy People 2000, op cit.

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25. Durch, J.S., L.A. Bailey, and M.A. Stoto, Eds., Institute of Medicine. Improving Health in the Community: A Role for Performance Monitoring. Washington, D.C.: National Academy Press, 1997. 26. The measure could change without actual behavior change initiation if self-reporting habits change (perhaps due to knowledge that results would be used to raise prices), if the duration covered by the question is not optimal, or if those surveyed subtly change how they interpret the questions. 27. Shopland, D.R. Smoking and Tobacco Control Program, National Cancer Institute, Unpublished data. Preliminary estimate from the 1995-1996 Current Population Survey, October 1997. 28. Agency for Health Care Policy and Research. Smoking Cessation: Clinical Practice Guideline (Number 18). Washington, D.C.: U.S. Department of Health and Human Services (Pub. No. [AHCPR] 960692), 1996. 29. Lightwood and Glantz, op cit. 30. Witsuba, I.I., S. Lam, C. Behrens, et al. Molecular Damage in the Bronchial Epithelium of Current and Former Smokers. Journal of the National Cancer Institute 89:1366-1373, 1997. 31. Robert Wood Johnson Foundation. Call for Proposals: Addressing Tobacco in Managed Care. Princeton, N.J.: Robert Wood Johnson Foundation, 1997. 32. Pinney, J.M. Review of the Current Status of Smoking Cessation in the USA: Assumptions and Realities. Tobacco Control 4:S10-S14, 1995. 33. For details, see the Request for Applications Prevention and Cessation of Tobacco Use by Children and Youth in the U.S. at http://www.nih.gov/grants/guide/rfa-files/RFA-CA-98-002.html. 34. Warner, K., J. Slade, and D. Sweanor. The Emerging Market for Long-Term Nicotine Maintenance. Journal of the American Medical Association 278:1087-1092, 1997. 35. Wall Street Journal, October 1, 1997, p. B 12. 36. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 46:867871, 1997. 37. Orleans, C.T. Review of the Current Status of Smoking Cessation in the USA: Progress and Opportunities. Tobacco Control 4:S3-S9, 1995. 38. National Heart, Lung, and Blood Institute. National High Blood Pressure Education Program: 20 Years of Achievement. Bethesda, Md.: National Institutes of Health, 1992. 39. A query of NIH's Computer Retrieval of Information on Scientific Projects database for 1994, 1995, and 1996 was performed on the terms "tobacco" or "nicotine." The search produced the following counts of extramural awards (grants, contracts, and cooperative agreements):   1994 1995 1996 National Institute on Drug Abuse 62 54 82 National Cancer Institute 62 62 70 National Center for Research Resources 17 13 14 National Heart, Lung, and Blood Institute 20 8 7 National Institute on Alcohol Abuse and Alcoholism 4 15 12 National Institute on Neurological Disorders and Stroke 9 5 6 Other NIH institutes and centers 27 42 11 Total 201 199 202 40. Cancer Control Review Group. A New Agenda for Cancer Control Research. Bethesda, Md.: Board of Scientific Advisors, National Cancer Institute, August 7, 1997. 41. This point is amplified by Stanton Glantz in an editorial to be published in a future issue of Tobacco Control, "After ASSIST, What Next? Science." Courtesy of the author. 42. Society for Research on Nicotine and Tobacco. The Importance of Research in the Development of National Tobacco Control Efforts. Rockville, Md.: Society for Research on Nicotine and Tobacco, 1997. 43. The findings described below are discussed in several places in Lynch and Bonnie, op cit., especially in Chapters 2 and 9.

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44. Hurt, R.D., D.P.L. Sachs, E. D. Glover, et al. A Comparison of Sustained-Release Bupropion and Placebo for Smoking Cessation. New England Journal of Medicine 17:1195-1202, 1997. 45. Henningfield, J.E. Nicotine Medications for Smoking Cessation. New England Journal of Medicine 333:1196-1203, 1995; Benowitz, N.L. Treating Tobacco Addiction—Nicotine or No Nicotine? New England Journal of Medicine 337:1230-1231, 1997; and Warner, K., J. Slade, and D. Sweanor. The Emerging Market for Long-Term Nicotine Maintenance. Journal of the American Medical Association 278:1087-1092. 1997. 46. Roundtable on Social and Economic Aspects of Reduction of Tobacco Smoking by Use of Alternative Nicotine Delivery Systems. Conclusions and Recommendations. UN Focal Point on Tobacco or Health, Palais des Nations, Geneva, September 1997. Recommendation 6. 47. Jha, P., The World Bank, Washington, D.C. International Implications of the Proposed U.S. Legal Settlement on Tobacco Manufacture, Production, and Marketing. Presentation at the National Cancer Policy Board Tobacco Control Workshop, July 15, 1997, Washington, D.C. 48. Peto, R. Global Tobacco Mortality: Monitoring the Growing Epidemic. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 24, 1997. 49. Mackay, J. Lessons from the Conference. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 28, 1997. 50. The World Bank. Investing in Health, World Development Report. New York: Oxford University Press, 1993. 51. Koplan, J. Discussion: Developing Countries. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 25, 1997. 52. Country case studies prepared for the board by Kathleen McCormally provide a snapshot of tobacco control efforts in Australia, Brazil, Canada, China, Norway, Poland, South Africa, and Thailand. These countries were selected to represent different stages of economic development and different levels of tobacco control, as well as for geographical balance; see http://www2.nas.edu/cancerbd/22da.html. 53. Laugeson, M., and Meads, C. Tobacco Advertising Restrictions, Price, Income, and Tobacco Consumption in OECD Countries 1960-86. British Journal of Addiction 86:1343-1354, 1990. 54. Prabhat, J. International Implications of the Proposed U.S. Legal Settlement on Tobacco Manufacture, Production, and Marketing. Presentation at the National Cancer Policy Board Tobacco Control Workshop, July 15, 1997, Washington, D.C. 55. Roemer, R. Legislative Action to Combat the World Tobacco Epidemic, 2nd edition. Geneva: World Health Organization, 1993. 56. Yach, D. Settlement in the U.S.A: Benchmark for All or Global Sell Out? Presentation at the Fourth International Conference on Preventive Cardiology, July 2, 1997. 57. Levin, M. Targeting Foreign Smokers. Los Angeles Times, November 17, 1994. Pp. A 1, A5. 58. Koplan, J. Discussion: Developing Countries. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 25, 1997. 59. Jha, P. Economic Development and Tobacco Use: The Role of Governments and Developmental Agencies in Global Tobacco Control. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 25, 1997. 60. Collishaw, N., World Health Organization, personal communication. Tobacco or Health Program, September 15, 1997. 61. World Health Organization. Investing in Health Research and Development. Report of the Ad Hoc Committee on Health Research Relating to Future Intervention Options (Document TDR/Gen/96.1). Geneva: World Health Organization, 1996. 62. Yach, D., World Health Organization, personal communication, September 8, 1997. 63. Collishaw, N., personal communication, op. cit. 64. The World Bank. Health, Nutrition and Population: Sector Strategy Program. Washington, D.C.: The World Bank, 1997. 65. Jha, P., The World Bank, Washington, D.C., personal communication, October 1997. 66. Collishaw, N. An International Framework Convention for Tobacco Control. Presentation at the Tenth World Conference on Tobacco or Health, Beijing, China, August 28, 1997.

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67. Ibid. 68. Rules, Sanctions, and Enforcement Under Section 301 of the Trade Act of 1974, as Amended, available at: http://www.snado.com/intartl.htm. 69. Ibid. 70. Thailand—Restrictions on Importation of and Internal Taxes on Cigarettes. Report of the GATT Panel Adopted on November 7, 1990 (DS10/R-37S/200). World Trade Organization. This report can be downloaded in WordPerfect Version 5 format from the World Trade Organization home page at: http://www.wto.org/wto/dispute/panel.htm. 71. Ibid, Section 73. 72. Ibid, Section 81. 73. Ibid, pp. 711-712. 74. Ibid. 75. Frankel, G. Thailand Resists U.S. Brand Assault; Stiff Laws Inspire Other Asians to Curb Smoking. The Washington Post, November 18, 1996. P. Al. 76. Kluger, R. Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Vintage Books, 1997, pp. 710-711. 77. Ibid. 78. Public Law 105-119, Section 618, states that "None of the funds provided by this Act shall be available to promote the sale or export of tobacco or tobacco products, or to seek the reduction or removal by any foreign country of restrictions on the marketing of tobacco or tobacco products, except for restrictions which are not applied equally to all tobacco or tobacco products of the same type." For the full text, see http://thomas.loc.gov/cgi-bin/bdquery/z?d105:h.r.02267. This provision is associated with the efforts of Rep. Lloyd Doggett, and is often referred to as the "Doggett Amendment." 79. Pierce, J. Progress and Problems in International Public Health Efforts to Reduce Tobacco Usage. Annual Review of Public Health 12:383-400, 1991; Roemer, R. Legislative Action to Combat the World Tobacco Epidemic, 2nd edition. Geneva: World Health Organization, 1993. 80. Advisory Committee on Tobacco Policy and Public Health. Final Report. Washington, D.C.: Science and Public Policy Institute, 1997. 81. Ibid. 82. Ibid. 83. Institute of Medicine. America's Vital Interest in Global Health. Washington, D.C.: National Academy Press, 1997. 84. Shopland, D.R., H.J. Eyre, and T.F. Pechacek. Smoking-Attributable Cancer Mortality in 1991: Is Lung Cancer Now the Leading Cause of Death Among Smokers in the United States? Journal of the National Cancer Institute 83:1142-1148, 1991. CDC data on cancer mortality are available on-line at http://www.cdc.gov/nccdphp/osh/mortali.htm. 85 Murray, C.J.L., and A.D. Lopez. Alternative Projections of Mortality and Disability by Cause 1990-2020: Global Burden of Disease Study. Lancet 349:1498-1504, 1997; Murray, C.J.L and Lopez. The Global Burden of Disease and Global Health Statistics, 1 and 2. Global Burden of Disease Series. Cambridge, Mass.: Harvard University Press, 1996.