I. Statement of the Problem
Alcohol and tobacco use are two of the most common risk factors for preventable diseases, injuries, and premature death. Alcohol use by youth is also associated with motor vehicle injuries, suicide, and homicide, all of which are major causes of adolescent mortality. Although it is illegal to sell alcoholic beverages to youths under 21 and, in most states, to sell tobacco products to teenagers under 18, the alcohol and tobacco industries actively target young people with advertising and promotions. Through youth-oriented campaigns, the alcohol and tobacco industries create an environment in which the consumption of these dangerous products is acceptable and, within some teenage peer groups, even expected. Many health promotion efforts to reduce health risks emphasize individual behavior change and ignore the critical role of environmental and social factors. Although the use of tobacco and alcohol is legal for adults, the aggressive marketing and promotion tactics of both the alcohol and tobacco industries heavily target the youth market. Both industries use similar strategies to appeal to youth and increase market share. The public health community must respond with a concerned, coordinated effort against the tactics used to appeal to youth through tobacco and alcohol advertising and promotion. This response is consistent with long-standing efforts by the American Public Health Association in support of restrictions on advertising, promotion, and consumption of alcohol and tobacco products. The purpose of this paper is to outline alcohol and tobacco industry marketing practices directed at youth and to provide policy recommendations to restrict these targeting efforts.
A. Public Health Impact
Tobacco use results in approximately 434,000 deaths and costs society $52 billion in the United States annually.1 Over 100,000 Americans die each year from alcohol-related causes with an annual economic cost of over $90 billion.2 Early use of either product can result in long-term addiction, health problems, and premature death.
While the majority of health problems associated with teenage tobacco use arise later in life, alcohol-related trauma is the leading cause of death for minors. Over two-thirds of high school seniors are current drinkers, with 33% reporting binge drinking–the consumption of five or more drinks at a sitting–within the past two weeks.3 Approximately 454,000 seniors report binge drinking at least once a week.3 Among college freshmen, the percent of recent binge drinkers rises to 57.4% of the men and 35.5% of the women.4 It is estimated that four and one-half million young people are dependent or problem drinkers.2
Alcohol-related trauma–including child abuse, auto crashes, violence, and drownings –is the leading cause of death among those aged 1 to 19.5 Of the 22,000 drinking driving fatalities in 1990, roughly 3,400 were aged 16 to 20 and another 3,200 deaths were aged 20 to 24.6 Alcohol also can lead to academic and employment problems, high-risk behaviors including unplanned sexual activity, and interpersonal difficulties.
Most tobacco users develop the habit as adolescents. Eighty to 90% of smokers start before the age of 20.7 Of the 434,000 US tobacco-related deaths in 1988, one-half occurred in people who began smoking by age 13 and one-quarter in people who began smoking by age 11. Smokeless tobacco users start earlier. One study8 found that 88% of users began by age 14. In the native American population, usage rates as high as 50% have been reported9 among adolescents, and use among pre-school-age children has been reported.10 From 1970 to 1985 there was an eightfold increase in the use of moist snuff among 17- to 19-year-olds. According to a commentary in AJPH, this increase in sales, while smoking and chewing tobacco rates declined, “did not occur by accident, but rather as the result of a carefully crafted marketing strategy by tobacco companies.”11
Reports by the Inspector General, DHHS12 and the Surgeon General13 led to passage of the Comprehensive Smokeless Tobacco Health Education Act of 1986. This Act failed to incorporate important recommendations about addiction warning labels and exempted billboard advertisements from regulation. Specific funds for implementing provisions of the Act were never appropriated. Since passage of the Act, smokeless tobacco sales have increased,14 prompting the Surgeon General to undertake a follow-up study of youth use of smokeless tobacco in 1992.
Smokeless tobacco products are displayed at grocery check-out counters along with chewing gum and cough drops. There is even a shredded chewing gum called Big League Chew that, according to AJPH, “prepares very young mouths for the future chewing of tobacco.”11 In 1989, 29% of high school seniors were current smokers, with 18% of all seniors smoking daily. The number of high school seniors who are current and daily smokers has not significantly decreased since 1984. About one-quarter of the high school seniors smoked their first cigarette by grade 6 and one-half by grade 8.3 In 1988, Americans under the age of 18 spent $1.26 billion for a billion packs of cigarettes and 26 million containers of smokeless tobacco.15 The earlier smoking is initiated and the longer it is continued, the greater the probability of addiction and tobacco-related disease. The addictive properties of tobacco make it as difficult for young people to quit as it is for adults.16
B. Advertising and Promotion
Alcohol and tobacco are two of the most heavily promoted product categories in America. Annual advertising and promotion costs are estimated at $3.6 billion for the tobacco industry17 and $2.0 billion for the alcohol industry.18 These costs are tax deductible. Although the tobacco and alcoholic beverage industries deny that they promote to young people, research documents that cigarette and alcohol advertising and promotional campaigns are especially appealing and attractive to teenagers and children.19-21 Tobacco and alcohol companies claim to present smoking and drinking as adult behaviors in their “prevention” programs. However, these campaigns are often unclear. Despite a 1981 Federal Trade Commission Report criticizing one such tobacco prevention campaign because it did not qualify as discouragement to smoking, prevention themes of the industry have remained the same.22 Both the tobacco and alcohol industries rely heavily on images in print, broadcast, and point-of-purchase campaigns that link their products with success, social acceptance, sexuality, friendship, youth, attractiveness, and physical vigor. Such images often have a significant impact on impressionable teens who are grappling with these issues.23
In 1988, RJR Nabisco launched its Old Joe Camel campaign for Camel cigarettes, featuring a cartoon camel modeled after James Bond and Don Johnson of “Miami Vice.” Since the campaign began, Camel’s share of the children’s cigarette market increased from 0.5% to 32.8%.24 The December 11, 1991, Journal of the American Medical Association documented that Joe Camel cartoons more successfully reach children than adults. In one study, 93.6% of high school students identified Joe Camel with Camel cigarettes as compared to 57.7% of adults.24 In another study, 91.3% of 6-year-olds could identify Joe Camel, approximately the same as the number who recognized Mickey Mouse.25 In March 1992, the Surgeon General joined the American Medical Association in asking the RJReynolds Tobacco Company to stop using the Joe Camel cartoon character in all its advertising and promotional efforts because of its appeal to youth.26 Self-generated “industry codes” for advertising, addressing such matters as the age of models in advertisements and the use of cartoons, are largely ignored by the alcohol and tobacco industries.
Both the Surgeon General and the Congressionally appointed National Commission for Drug-Free Schools determined that voluntary advertising codes limiting youth-oriented images are not being followed. The Commission asserted that alcohol and tobacco industries often target those under the legal drinking and smoking ages with highly attractive and persuasive advertising and promotional techniques.27 Consequently, many young people do not perceive alcohol and tobacco as having risks, in contrast to perceptions of marijuana and cocaine.3 According to a 1990 Weekly Reader National Survey on Drugs and Drinking, slightly over 45% of students in grades 4 to 6 identified cigarettes and alcohol as drugs whereas about 90% of the students identified marijuana and cocaine as drugs. Only 27% of the students identified wine coolers as a drug.
Countless times before reaching age 21, the average American child will see alcohol attractively presented on television advertisements, in magazine and billboard ads, and in point-of-purchase displays where alcohol is sold. Studies show that the more children are exposed to beer advertising the more likely they are to expect to drink as adults. Additionally, surveys have consistently demonstrated that young people see and are influenced by beer commercials.28,29 In a poll conducted for the industry-funded Century Council, 73% of respondents felt that alcohol advertising was a major contributor to underage drinking.30 A November 1991 report by the Inspector General of the Department of Health and Human Services concluded that numerous governmental loopholes allow the alcohol industry to target their advertising and promotion to youth. These loopholes include fragmentation of federal jurisdiction among several agencies, a lack of specific regulations prohibiting youth-oriented advertisements, limited enforcement authority given the Bureau of Alcohol, Tobacco and Firearms, and difficulties with state regulation.31
The report also concluded that alcohol industry standards do not effectively restrict advertisements that appeal to youth, because the standards are often vague, narrow, and inconsistent and because most industry organizations fail to address marketing and promotional activities. Tobacco producers incorporate images and messages into their campaigns that speak to the concerns of adolescents. Campaigns like the “Marlboro Man” appeal to young men and women who want to appear strong and independent. “Slim” cigarettes target young women concerned with weight and body image. Tobacco producers advertise heavily in magazines that appeal to young people, including Mademoiselle, Spin, and Rolling Stone.19,21 Industry documents released during a court trial in Canada and supporting testimony revealed that tobacco companies actively and purposefully incorporated youth-targeting into their advertising research and plans.15 Tobacco and alcohol products are advertised extensively on billboards; it is not uncommon to see billboards for tobacco and alcohol products adjacent to schools, churches, parks, transit stands, and playgrounds. Billboards saturate low-income neighborhoods; a 1987 study in St. Louis found twice as many billboards in Black neighborhoods as White ones. Almost 60% of the billboards in Black communities advertised tobacco or alcohol.32
Another increasingly common promotional strategy is the provision of utilitarian objects with sales of packages of cigarettes. These include: sunglasses, t-shirts, fleece shorts, stereo headphones, tapes and compact discs, towels, caps, and many other items with a strong youth appeal. These promotions are given away with the purchase of cigarettes. These objects are often directly tied to the brand image being promoted, are very popular, and are easily recognized by youth. Utilitarian objects offered with smokeless tobacco products are required to carry a Surgeon General’s warning but those objects related to cigarettes are exempt.33 Tobacco companies have also turned to direct mail efforts and coupons to build mailing lists of consumers. While the mail-back coupons ask for the sender to certify that he or she is at least 21, there is no attempt on behalf of the companies to confirm ages.
Sponsorships are frequently used by alcohol and tobacco companies to target young people. Both industries extensively promote their products through sponsorship of events that have particular appeal to youth including sporting events and concert tours. In 1988, US brewers spent $175 million on sponsorships, 10% of all money spent on corporate sponsorships.34 Alcohol producers sponsor local and national sporting events, athletes and teams, musicians and other entertainment, spring break activities, educational programs, and scholarships. Anheuser-Busch helps finance all 26 major league baseball teams, 20 of the 28 NFL teams, more than 300 college teams, and about 1,000 other sporting events.35 In 1984, Miller sponsored 600 college market rock concerts and 3,000 concerts for the youth market in general.36 Beer commercials are heavily concentrated on sports programs, one of the most popular entertainment forms for young people. On average, sports programs contain approximately 8 beer commercials per event; over 73% of young people have watched a sporting event in the last month.28 Due in large part to the television advertising ban, tobacco companies sponsor many sporting events and buy billboard space in stadiums, providing television coverage during events for companies and specific products. Winston, Marlboro, and Camel cigarettes sponsor auto race events across the country.37 Virginia Slims, a cigarette brand targeted at women, sponsors a women’s tennis tour, and RJReynolds supports the soccer World Cup series. Tobacco companies sponsor major league baseball, ski weekends, and horse and auto racing.38 In addition, chewing tobacco companies are expanding sponsorship of motorsports events, rodeos, and personal appearances by former athletes.
D. Product Development
Alcohol and tobacco companies actively develop new products aimed directly at younger markets. Such products have a taste or appearance that makes them desirable for young people. In the 1980s, alcohol producers introduced wine coolers, sweet alcoholic beverages packaged like popular soft drinks, with success. According to the DHHS Inspector General, junior and senior high school students drink 35% of all wine coolers sold in the United States or an estimated 31.2 million gallons each year.39 The success of wine coolers prompted the liquor and beer industries to introduce mixed drink coolers and fruit-flavored malt beverage coolers. These products, because of their lower alcohol content, are advertised on television, allowing for greater recognition of the company name and product line. The introduction of new and diverse smokeless tobacco products in different flavors likens the product to chewing gum. The tobacco industry does not challenge the use of its brand names on candy cigarettes presumably because they provide children with positive associations to smoking and no information about adverse health consequences. Other products, such as Camel Wides and the Salem Box, are essentially repackaging of old brands in order to make them “hip” cigarettes and extend them to reach into the children’s market.40 Girls begin smoking at an earlier age than their male counterparts and are the targets of cigarettes developed to be the “slimmest of slims,” promising both sophistication and weight control in their packaging and design.
Easy access to alcohol and tobacco products greatly influences their use, especially among underage youth. New outlets for both product groups have appeared over recent years. Although laws vary from state to state, alcohol has become more easily and widely available nationwide.41 Alcohol is now available at gas station mini-marts and supermarkets and provides easy access to underage drinkers. Many states now permit the sale of liquor-by-the-drink and have removed limits on the number of outlet licenses available. Similarly, tobacco products are easily available at gas stations, the only major store category to increase its cigarette sales.40 A recent report by Doctors & Lawyers for Drug-Free Youth found that 59% of underage drinkers and 74% of underage heavy drinkers buy their own alcohol.42 A similar study by the DHHS Inspector General reports that students as young as 12 and 13 buy their own alcohol.43 Students purchase alcohol by using fake identifications and frequent establishments known to sell to youth. Forty-four states permit youth under 21 to sell alcohol. A recent attempt to teach responsible beverage service to underage clerks in one California county was a failure, in part because those clerks were not comfortable with refusing sales to their peers.44
Ordinances prohibiting sale of cigarettes to persons under 18 are common but are rarely enforced.19 A report by the Office of the Inspector General, an agency created to promote efficiency and effectiveness in programs of the US Department of Health and Human Services, assesses the effectiveness of state laws prohibiting the sale of cigarettes to minors. It summarizes studies showing that generally minors are able to purchase cigarettes illegally about 80% of the time.45 In response to the poor enforcement of minors’ access laws, the US Department of Health and Human Services recommended model legislation to the states to control sales of tobacco products to minors.46 The ready availability of cigarettes in unsupervised vending machines makes their purchase by children an easy task. At least three states (Hawaii, Idaho, and Utah) prohibit cigarette vending machines accessible to minors. Increasingly, local ordinances prohibit or impose restrictions on sales of cigarettes from vending machines.47
II. Purpose and Objectives
The purpose of this position paper is to provide the basis for APHA to take a leadership role in efforts to reform alcohol and tobacco advertising and promotional efforts that target youth. The current national debate between the interests of alcohol and tobacco industries in maintaining and/or expanding their markets and the health and the well-being of the nation has attracted the attention of numerous and diverse groups. APHA has been instrumental in providing a much needed and vital public health perspective to these important policy debates through its advocacy efforts, conferences, journal publications, resolutions, and prior position statements on various aspects of alcohol and tobacco marketing, consumption, and promotion. These position statements include: Advertising and Promotion of Tobacco Products (8605), Alcohol Advertising on Radio and Television (8512), Alcohol and Cigarette Excise Tax Positions (8613, 8604), Health Risks and Advertising of Smokeless Tobacco Products (8507), Alcohol Warning Labels (8812), and a Smoke-free Society by the Year 2000 (8318).48
III. Action Desired and Methods To Be Used
By adopting this position paper, APHA will continue to work with numerous health, safety, and consumer organizations in calling for reforms in alcohol and tobacco marketing practices toward youth. APHA will call for marketing reform to eliminate advertising practices targeted at youth. APHA will inform other relevant national organizations of its position to restrict these practices, provide appropriate testimony at federal and state legislative hearings, and send letters of support to relevant legislators and legislative committees. APHA will inform its membership of the need to reform alcohol and tobacco industries’ marketing practices that are directed at youth.
The American Public Health Association,
- Adopts as the goal of the Association a federal ban on all forms of tobacco advertising including marketing, promotions, and sponsorships targeted at children and increase excise taxes and restriction on children’s access as the major strategies to prevent tobacco use by children.
- Supports legislation that would require rotating health messages in all print and broadcast alcohol advertising.
- Calls for legislation to license tobacco vendors, ban cigarette vending machines, and require alcohol and tobacco sellers to be over 21.
- Supports legislative and other regulatory efforts to restrict cigarette advertising on television, including industry sponsored events and strategic billboard placement.
- Urges Congress to enact legislation to ban sponsorship of sports and cultural events by tobacco and alcohol companies.
- Urges Congress and state legislatures to increase federal and state taxes on cigarettes and alcohol and urges the appropriate use of these funds to help those who find smoking cessation difficult; to replace industry sponsorship of sports and cultural events, and for counter-advertising.
- Urges Congress to enact legislation to require strong warning labels on all tobacco products, including loose tobacco and cigars.
- Urges the Federal Trade Commission to require the Surgeon General’s warnings on all utilitarian objects that promote tobacco products.
- Urges DHHS and others to study marketing techniques to examine product awareness and penetration among various age groups.
- Calls on the alcohol and tobacco industries to cease their marketing and promotional practices targeted at youth.
- Urges Congress to eliminate the tax deductibility of expenses for promoting and advertising of alcohol and tobacco products.
- Supports community, school, and college health promotion efforts designed to counter the marketing and promotional practices targeted at youth by alcohol and tobacco industries.
- Joins coalitions committed to reforming alcohol and tobacco marketing that targets youth, including those concerned with increased excise taxes, billboard placements, labeling, availability, advertising, and promotions.
- Calls upon health care professionals and agencies to refrain from placing in their waiting rooms magazines that allow alcohol and tobacco advertising.
IV. Implementation Suggestions
Costs associated with the desired actions are limited to communication efforts in support of advertising reform and tax initiatives. Expenses include testimony, letters of support, and mailgrams as necessary as issues come before Congress (estimated cost $750). Should constitutional issues regarding free speech or other objections be raised, as they have been in the past, APHA could be called upon to enter a court case as an amicus curiae, at an estimated expense of $350.
- US Department of Health and Human Services. Reducing the Health Consequences of Smoking–25 Years of Progress. A Report of the Surgeon General. Washington, DC: DHHS; 1989. DHHS Publication No. (CDC) 89-8411.
- US Department of Health and Human Services. Seventh Special Report of the US Congress on Alcohol and Health. Rockville, MD: Alcohol, Drug Abuse, and Mental Health Administration; 1990.
- Johnston LD, O’Malley P, Bachman JG. 1989 National High School Senior Drug Abuse Survey: Monitoring the Future. Rockville, MD: National Institute on Drug Abuse; 1990.
- US Department of Health and Human Services. Youth and Alcohol–A National Survey. Drinking Habits, Access, Attitudes and Knowledge. Washington, DC: DHHS; 1991.
- National Highway Traffic Safety Administration. Alcohol Involvement in United States Traffic Accidents. Washington, DC: NHTSA, National Center for Statistics and Analysis; annual publication.
- US Department of Transportation. Fatal Alcohol Reporting System–A Review of Information on Fatal Traffic Crashes in the United States. Washington, DC: National Highway Traffic Safety Administration; 1990.
- Kandel DB, Logan JA. Patterns of drug use from adolescence to young adulthood, I: periods of risk for initiation, continued use, and discontinuation. Am J Public Health. 1984;74:660-666.
- Schlife C. Smokeless tobacco use in rural Alaska. MMWR. March 20, 1987; 36:140-143.
- Wolfe MD and Carlos JP. Oral health effects of smokeless tobacco use in Navajo Indian adolescents. Comm Dent Oral Epid. 1987;15:230-235.
- Bruerd B. Smokeless tobacco use among Native American school children. Pub Health Reports. March-April 1992; 115(2):196-201.
- Connolly G, Orleans CT, Blum A. Snuffing tobacco out of sport: a commentary. Am J Public Health. 1992;82(3).
- US Department of Health and Human Services. Youth Use of Smokeless Tobacco - More Than a Pinch of Trouble. Washington, DC: Office of Inspector General; 1986.
- US Department of Health and Human Services. The Health Consequences of Smokeless Tobacco Use. Washington, DC: National Cancer Institute; 1988.
- Maxwell J. Maxwell Consumer Report. Richmond, VA: The Smokeless Tobacco Industry; 1991.
- Mintz M. Marketing tobacco to children. Nation. May 6, 1991;594.
- Johnston LD, O’Malley PH, and Bachman JG. National Trends in Drug Use and Related Factors Among American High School Students and Young Adults, 1975-1986. Washington, DC: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute for Drug Abuse; 1987. DHHS, Publication No. (ADM) 87-1535.
- Federal Trade Commission. January 27, 1992.
- Federal Trade Commission, 1983.
- Warner K. Selling Smoke: Cigarette Advertising and Public Health. Washington, DC: American Public Health Association; 1986.
- Atkin C, Block M. Content and Effect of Alcoholic Beverage Advertising. Lansing: Michigan State University. Prepared for the Bureau of Alcohol, Tobacco, and Firearms, Federal Trade Commission, Department of Transportation, and National Institute of Alcohol Abuse and Alcoholism.
- Jacobson M, Hacker G, Atkins R. The Booze Merchants: The Inebriating of America. Washington, DC: Center for Science in the Public Interest, 1983.
- US Department of Health and Human Services. Youth and Drugs–Society’s Mixed Messages. Washington, DC: DHHS; 1990. OSAP Prevention Monograph 6.
- Postman N, Nystrom C, Strate L, et al. Myths, Men, and Beer–An Analysis of Beer Commercials on Broadcast Television, 1987. Falls Church, VA: AAA Foundation for Traffic Safety; 1988.
- DiFranza JD, Richards JW Jr, Paulman PM, MD, et al. RJR Nabisco’s cartoon Camel promotes Camel cigarettes to children. JAMA. 1991;266(22):3149.
- Fischer PM, Schwartz MP, Richards JW Jr, et al. Brand logo recognition by children aged 3 to 6 years–Mickey Mouse and Old Joe Camel. JAMA. 1991;226(22):3145.
- Lipman J. Surgeon General says it’s high time Joe Camel quit. Wall Street Journal. March 10, 1992;B1.
- National Commission on Drug-Free Schools. Toward a Drug-Free Generation: A Nation’s Responsibility. Final report. 1990.
- Wallack L, Cassady D, Grube J. TV Beer Commercials and Children: Exposure, Attention, Beliefs, and Expectations About Drinking as an Adult. Washington, DC: AAA Foundation for Traffic Safety; 1990.
- Atkin CK. Mass Communication Effects on Drinking and Driving. Surgeon General’s Workshop on Drinking and Driving: Background Papers. Rockville, MD: US DHHS; 1989.
- Wirthlin Group. A National Benchmark Survey of Public Attitude Toward Beverage Alcohol. Sept. 1990;13.
- Department of Health and Human Services. Youth and Alcohol – Controlling Alcohol Advertising that Appeals to Youth. Washington, DC: Office of the Inspector General; 1991.
- Scenic America: Alcohol and Tobacco Advertising on Billboards.
- P.L. 98-474: Comprehensive Smoking Education Act of 1984 and P.L. 99-252: Comprehensive Smokeless Tobacco Health Education Act of 1986.
- Center for Science in the Public Interest. Alcohol Advertising Facts. Washing-ton, DC: CSPI; February 1989.
- Center for Science in the Public Interest. Alcohol Advertising Facts. Washing-ton, DC: CSPI; March 1989.
- College beer marketing under fire. Market Watch. July/August 1985.
- Gerbner G. Stories that hurt: tobacco, alcohol, and other drugs in the mass media. In: Resnick H. Youth and Drugs: Society’s Mixed Messages. Rockville, MD: Office for Substance Abuse Prevention.
- DeParle J. Warning: sports stars may be hazardous to your health: Washington Monthly. September 1989.
- Department of Health and Human Services, Office of the Inspector General. Youth and Alcohol: A National Survey: Do they Know what They’re Drinking? Washington, DC: DHHS; June 1991.
- John Slade, MD, personal communication.
- Cowen R, Mosler J. Public health implications of beverage marketing alcohol as an ordinary consumer product. Contemporary Drug Problems. Winter 1985.
- Radecki T. Sales of Alcohol to Underage Youth in 17 Midwest and Eastern States. Report Conducted by Doctors and Lawyers for a Drug-Free Youth. September 1991.
- Department of Health and Human Services: Office of the Inspector General. Youth and Alcohol: Laws and Enforcement: Is the 21-Year Old Drinking Age a Myth? Washington, DC: DHHS; September 1991.
- University of California, San Diego Extension. Evaluating community prevention strategies, alcohol and other drugs. Proceedings of a conference held in San Diego, CA; January 11-13, 1990.
- Office of Inspector General. Youth Access to Cigarettes. May 1990.
- US Department of Health and Human Services. Model Sale of Tobacco Products to Minors Control Act. A model Law for Adoption by States or Localities to Prevent the Sale of Tobacco Products to Minors; 1990.
- Lando HA, Forster JL, Hourigan M. The movement to restrict cigarette vending machines in Minnesota: the fight against pre-emption. In: Durston B, Jamrozik K. Tobacco & Health 1990. The Global War. Proceedings of the Seventh World Conference on Tobacco and Health, Perth, Western Australia; 1990, no. 741-746.
- American Public Health Association Resolutions/Position Papers: 8318, 8604, 8812, 8613, 8512, 8507, 8605. APHA Public Policy Statements, 1948–present, cumulative. Washington, DC: APHA, current volume.
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