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Alcohol Use and Job Strain

Effort-Reward Imbalance

“The concept of effort-reward imbalance (ERI) was developed by Johannes Siegrist to study lack of reciprocity (low rewards relative to high effort) and its association over a sustained period of time with the development of stress-related disorders. The ERI model also encompasses the idea of having an “over-commitment” to work, meaning that some people may be more likely to expend a large amount of effort for low reward because of an “intrinsic” or personal over-commitment to their job.

In a review of longitudinal epidemiological studies, Siegrist found that “people who experience failed reciprocity at work are twice as likely to suffer from incident cardiovascular disease, depression, or alcohol dependence compared to those who are not exposed” [29, p. 1033]. 

Finnish factory workers with effort-reward imbalance were heavier than those without effort-reward imbalance in one study [70]. Another study showed that Finnish public employees with effort-reward imbalance were more likely to have several risk factors for heart disease: overweight, smoking, heavy alcohol use, and lack of exercise [125]. Male British civil servants with effort-reward imbalance had an increased risk of developing Type 2 diabetes, although this pattern was not seen among female civil servants [126]. Finally, several studies have shown that workers with effort-reward imbalance had higher levels of cholesterol [102, 127, 128].

Long Work Hours

Overtime work was associated with unhealthy weight gain in two studies, increased alcohol use in two of three studies, and increased smoking in one of two studies, but it was not related to exercise or drug abuse [43]. One [129] of two [129, 130] Japanese studies found a relationship between work hours and adult onset (Type 2) diabetes.

Job Strain

In a preliminary analysis of data from men in the New York City Work Site BP Study, job strain was 54% more common among men with masked hypertension (at entry into the study) and more than five times more common (at the 3-year follow-up measurement period), taking into account other risk factors for high blood pressure such as age, race, weight, education, smoking, and alcohol use.

Direct Costs

According to the Institute for Health and Productivity Studies, the top physical health conditions financially affecting large U.S. employers through direct costs were chronic maintenance of angina pectoris, essential hypertension, diabetes mellitus, mechanical low back pain, acute myocardial infarction, chronic obstructive pulmonary disease, back disorders other than low back, traumatic spine and spinal cord, sinusitis, and diseases of the ear, nose, throat, or mastoid processes [4]. Six of these 10 conditions have been associated with psychosocial stressors in past studies (see chapters 6 and 7). The top mental health conditions were: bipolar disorders; depression; neurotic, personality, and non-psychotic disorders; alcoholism; anxiety disorders; acute phase schizophrenia, and psychoses. Of these conditions, anxiety disorders, depression, and alcoholism have been shown to have some roots in workplace stressors.

 

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

97. Schnall, P. L., J. E. Schwartz, P. A. Landsbergis, K. Warren, and T. G. Pickering, Relation between Job Strain, Alcohol, and Ambulatory Blood Pressure, Hypertension, 19, pp. 488-494, 1992.

11. Hasin, D. S., R. D. Goodwin, F. S. Stinson, and B. F. Grant, Epidemiology of Major Depressive Disorder: Results from the National Epidemiological Survey on Alcoholism and Related Conditions, Archives of General Psychiatry, 62:10, pp. 1097-1106, 2005.

Our page on alcohol use and its relationship to job strain is currently under construction. 

Glossary of Terms

Behavioral Risk Factors – Individual behaviors which put people at risk for the development of Cardiovascular Disease. Smokingalcohol useobesity and physical inactivity are examples.

Center for Social Epidemiology – The Center for Social Epidemiology is a private non-profit foundation established in 1988, whose purpose is to promote public awareness of the role of environmental and occupational stress in the etiology of psychological disorders and cardiovascular disease. See our About Us page for more information.

Cardiovascular Health Outcomes – Several negative effects on the Cardiovascular System have been found when Job Strain is present and chronic. These include heightened bood pressure, chronically heightened blood pressure or hypertension and heart disease

Effort-Reward Imbalance – This model of work stress was pioneered by Johannes Siegrist and defines threatening job conditions as a “mismatch between high workload (high demand) and low control over long-term rewards.” More information about the Effort-Reward Model can be found here

Emotional Labor – Defined by Muntaner et al, is a term which “describes jobs that require workers to induce or suppress feelings to sustain the outward countenance that produces the proper state of mind in others. For example, airline stewards are responsible for managing situations with customers to create a favourable experience for the customer.” More information about Emotional Labor can be found here

FORWARD Study – Firefighter Obesity Research: Workplace Assessment to Reduce Disease (FORWARD) is a 2-year project of the UCI-COEH, funded by the Center for Disease Control and Prevention/National Institute for Occupational Safety and Health (Award #: 1 R21 OH009911-01) and is supported by Research Associates of the Center for Social Epidemiology. The study will consider the unique working conditions and health behaviors of firefighters who work on a 24 hour-shift system.

Visit the FORWARD Study Website at: http://www.coeh.uci.edu/forward/

Globalization – In the Unhealthy Work website, globalization is explored in terms of its significance to the changing nature of work and its consequences on worker health. More can be found about it here.

Job Control –  According to Muntaner et al, “this refers to employees’ sense of control over their tasks and performance during the workday. Job control is also called ‘‘decision latitude,’’ which is defined as the combination of decision-making authority and the worker’s opportunity to use and develop skills on the job.”

Job Strain – Karasek’s “job strain” model states that the greatest risk to physical and mental health from stress occurs to workers facing high psychological workload demands or pressures combined with low control or decision latitude in meeting those demands. More about the job strain model can be found here, including findingsscales and other job strain models.

Low Social Support – Social support refers to the various types of support that people receive from others and is usually separated into two distinct categories: emotional and instrumental support. Emotional support is characterized by things that people do for each other that makes them feel cared for and supports feelings of esteem and worthiness. Instrumental support refers to the various types of tangible help that others may provide (i.e. financial support, child-care, etc). More on low social support can be found here.

Mental Health Outcomes – When stress becomes a prolonged or chronic experience, it can result in psychological distress. A growing body of empirical evidence in the occupational health field is making connections between the way work is organized and burnout, as well as more long-term adverse psychological health outcomes such as chronic anxiety and clinical depression.

Musculoskeletal Disorders – Musculoskeletal disorders include a wide range of inflammatory and degenerative conditions affecting the muscles, tendons, ligaments, joints, peripheral nerves, and supporting blood vessels. Body regions most commonly involved are the low back, neck, shoulder, forearm, and hand, although recently the lower extremity has received more attention. Musculoskeletal disorders (MSDs) are widespread in many countries, with substantial costs and impact on quality of life. Although not uniquely caused by work, they constitute a major proportion of all registered and/or compensable work-related diseases in many countries. More can be found about MSDs here.

Organizational Justice – Defined by Muntaner et al, organizational justice refers to whether or not decision- making procedures are consistently applied, correctable, ethical, and include input from affected parties (procedural justice). It also refers to respectful, considerate and fair treatment of people by supervisors (relational justice). More can be found about organizational justice here.

Person–Environment Fit – According to Munaner et al, the “person–environment fit” model states that, “stress develops when the work environment fails to match the motives of the person, or when the person’s abilities fail to meet the job demands. The model emphasizes the ‘‘perceived’’ fit versus the ‘‘objective’’ fit.”

Psychological Demands – Psychological demands are part of the demands in the demand–control model and part of the effort in the effort–reward imbalance model. Demands refer to the psychological stressors associated with accomplishing work, unexpected tasks and job-related personal conflict. Typical questions about psychological demands measure the pressure of output on the job: ‘‘Does your job require you to work very fast, hard, or to accomplish large amounts of work? Are you short of time?’’

Psychological Risk Factors – Individual psychological characteristics which are particularly problematic when paired with Job Strain. Depressionanxietyneuroticism (or negative affectivity) and anger  are examples.

Social Class – Extensive research has documented that Cardiovascular Disease is more common not only among people facing work stressors, but also among people of lower social class or socioeconomic position (SEP), for example, lower levels of education, income, or occupational status. One possible explanation for the social class differences in CVD is greater exposure to unhealthy working conditions among lower SEP groups. More on social class can be found here.

Threat-Avoidant Vigilance – Work that involves continuously maintaining a high level of vigilance in order to avoid disaster, such as loss of human life. This is a feature of a number of occupations at high risk for CVD, e.g., truck drivers, air traffic controllers, and sea pilots. More on threat-avoidant vigilance can be found here.

Work–Family Conflict – According to Muntaner at al, work–family conflict is a form of inter-role conflict in which the role pressures from the work and family domains are mutually incompatible in some respect, causing considerable personal and organizational problems. 

 

References:

Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

C Muntaner, J Benach, W C Hadden, D Gimeno and F G Benavides, A glossary for the social epidemiology of work organisation: Part 1, Terms from social psychologyJ. Epidemiol. Community Health 2006;60;914-916 doi:10.1136/jech.2004.032631

Foxconn workers threaten mass suicide in response to terrible working conditions

by Erin Wigger and Peter Schnall
 
Foxconn (which manufactures iPhones and iPads for Apple) has experienced a number of suicides in the last two years – 14 to date, as well as a number of  unsuccessful attempts. The company responded by raising wages 66% at it’s Shenzen plant, boosting its number of counselors, and making stress management programs available to workers there. It also built safety netting around the factory to prevent further suicide attempts and required that all employees sign a “no suicide” clause in their contract (effectively preventing further payouts to families in the event of a death by suicide). Foxconn also responded with claims that it’s number of suicides, per capita, are not much higher than China’s national average – implying the suicides are not the result of conditions at the manufacturing plant.
 
However, on January 2nd approximately 150 workers took to the roof of Foxconn’s factory in Wuhan threatening mass suicide if their demands for better pay were not met. The New York Times reports that workers involved in the protest made accused Foxconn of reneging on the salary initially offered workers agreeing to leave the Wuhan factory – paying only a third of the previously proposed salary – and cited unfair treatment at the plant as the reason for their protest. (Recall the many stories that have appeared in the press of the oppressive working conditions at Foxconn with workers reporting excessive work weeks of 72 hours or more, militaristic supervision, low wages, and company induced indebtedness that have prevented many workers from leaving it’s factories.) 
 
A protest of this nature is shocking. It is hard to condone this type of negotiation or to imagine it is anything but counter-productive in terms of entering into a legitimate dialogue between employers and employees. So what drove it into being? Is this an act of absolute desperation on the part of a collectively abused and exploited labor force, or the extremist tactics of workers trying to coerce the company into bending to their demands?
 
If this were the first step worker’s had made toward resolving their conflict that would be one thing. But this protest came about only after Foxconn rejected workers attempts at bargaining and issued an ultimatum: resign and receive compensation or stay and continue on the same pay scale as before. In response  to these conditions, approximately 45 employees resigned, but none received any compensation.
 
This underlines the fact that Chinese employees have no safety net. They do not have the avenues of recourse we, as Americans, enjoy – though these rights in the U.S. are being whittled away daily (e.g. recall the recent Wisconsin Union Bill intended to strip public workers of their collective bargaining rights). In China, Geoffrey Crathall, Director at the China Labor Bulletin, was quoted to have said “employees feel they have no other option. If there were proper channels for the resolution of grievances, they wouldn’t have needed to resort to such actions” and, after weighing the facts, it is hard to disagree. Poor working conditions and pure desperation seem to have driven these workers to the roof.
 
The protest ended eight hours later after workers were talked down by Foxconn managers and local Chinese Communist Party officials. It remains dubious as to whether or not the dispute over wages has been adequately settled or not.

http://www.upi.com/Business_News/2012/01/11/Mass-suicide-threatened-at-Chinese-Foxconn-factory/UPI-57621326312862/?spt=hs&or=bn 

What a Surprise: Apple Profit Margins Rise at the Expense of Foxconn and Pegatron Corporation

Bloomberg reports in an article today that Apple’s margins have widened at the expense of its main supplier as Foxconn Technology Group cuts prices to retain orders for the iPhone and iPad.

The profit spread at Hon Hai Precision Industry, Foxconn’s Taipei-listed flagship, has narrowed to 1.5 percent since the debut of the iPhone in June 2007 as Apple’s operating margin more than doubled over the past five years, surpassing 30 percent.
 
Apparently, Foxconn as well as Pegatron are willing to sacrifice profit margins in exchange for volume and scale.  Both companies have seen profit margins decline despite increase sales due to rising salaries and lower sale prices to Apple Corp. on Ipads and Iphones.
 
This process puts both companies under increasing pressure to get more from workers for less. So if salaries go up it becomes critical to increase worker productivity.
 
Maybe this has something to do with repetitive motion disorders, stress disorders, suicides and explosions at plants not ready for production but which are pressed into service nonethless (see my previous blog).

See http://www.bloomberg.com/news/2012-01-04/apple-profit-margins-rise-at-foxconn-s-expense.html for more information.

Unhealthy Work cited in new book by Clare Bambra

 
Work, Worklessness and the Political Economy of Health – Clare Bambra

Drawing on international research from public health, social policy, epidemiology, geography and political science, this book systematically demonstrates that work and worklessness are central to our health and wellbeing and are the underlying determinants of health inequalities. The material and psychosocial conditions in which we work have immense consequences for our physical and mental wellbeing, as well as for the distribution of population health. Recessions, job-loss, insecurity and unemployment also have important ramifications for the health and wellbeing of individuals, families and communities. Chronic illness is itself a significant cause of worklessness and low pay.

This book demonstrates that countries with a more regulated work environment and a more interventionist and supportive welfare system have better health and smaller work-related health inequalities. Specific examples of policies and interventions that can mitigate the ill-health effects of work and worklessness are examined and the book concludes by asserting the importance of politics and policy choices in the aetiology of health and health inequalities.

“I strongly recommend this volume as a way of stimulating a change of direction in the literature on the determinants of health and health inequalities” from the Foreword by Professor Vicente Navarro, The Johns Hopkins University, USA.

Clare Bambra is Professor of Public Health Policy, Wolfson Research Institute for Health and Wellbeing, Durham University, UK. 

Another explosion reported in a Chinese Manufacturer that supplies Apple

For the third time in little over a year an explosion has rocked a factory that supplies parts in the manufacturing of various Apple devices. The explosion injured 61, and sent 23 to the hospital. Fortunately, there were no fatalities. 

This particular plant (which supplies back panels needed in the manufacturing of IPads), according to Pegatron Chief Financial Officer Charles Lin, “…had not started operations yet. Part of the facility is still under pre-operation inspection and part is running trial production.” 1 
 
Chinese suppliers are under tremendous pressure from Apple to increase supply to keep up with worldwide demand for IPhones and IPads. Manufacturing the aluminum shells is, admittedly, not without risk. The shells need to be polished and the powder used in this process is potentially explosive – requiring a factory environment with adequate ventilation. Still, providing such an environment is not rocket science.
 
It is not hard to see that under pressure to increase production companies are cutting corners. In this case, a plant which has not yet “started operations” has already experienced an explosion injuring 61 people.
 
Who is responsible for this (preventable) disaster? Is it the company which rushed, recklessly, into trial production a facility not yet ready for prime-time, the Chinese government with its lax supervision of various regulations (or perhaps no regulations at all), or is it Apple computer corporation which turns a blind eye to the practices of its suppliers so that they may sell a million or so more iPhones and IPads. Apple Corporation made $7.31 billion dollars in profits in their 3rd Qtr. 2011 financial year alone.
 
Perhaps there are others who deserve mention.  Please share your take on this tragedy.
 
Peter Schnall
 

“Apple supplier Pegatron hit by China plant blast” By Clare Jim and Argin Chang, Reuters. 

Disney: American Dream or Nightmare?

By: Peter Schnall & Erin Wigger
 
The name Disney is highly evocative for many Americans. Some think of their favorite childhood movies – Bambi, Pinocchio, Snow White, Lion King, etc., others call to mind one of Disney’s 14 worldwide theme parks and resorts. Disney  has, over the last 70 years become a part of what many conceive as the American Dream.
 
Today,  when someone wins a Publisher’s Clearing House award, or the Superbowl, what do they think to scream? Many things I’m sure but, “I’m going to Disneyland” has become a catch-phrase for people who, for whatever reason, have come into enough money or fame to finally elevate themselves into the class of people who can afford to have the magical experience of a Disneyland adventure.
 
But there’s a darker side to Disney Corporation, which has a long history of labor disputes. As reported by Steve Lopez of the LA Times on October 19th, something new and unwanted has made an appearance in the perfect world called Disneyland. Disney Corp. has begun a new chapter in electronic monitoring of some of its workforce in the form of large TV screen displays in the work area. Workers at Disney’s Paradise Pier Hotel in Anaheim have labeled the large flat-screen monitors in the laundry room the “electronic whip.” This screen, displayed for all to see, visually tracks worker progress by giving “efficiency” percentages in green – for those who are at or above expected productivity – and red for those below it. Not only does this cause anxiety for workers in general, it pits them against one another in a minute-by-minute race to be on  top. Workers complain of putting off or missing toilet breaks in order to keep up.
 
If you look to the left  on our blogsite you’ll see snippets from Charlie Chaplin’s movie Modern Times. After reading Lopez’s article on the electronic monitoring of Disney Hotel Workers, Charlie’s satire of the industrial production line appears, once again, prophetic.
 
This Disney tale is one example of “lean going mean.” Though the Foxconn plants (see earlier blogs re Foxconn) are many thousands of miles away, this speeding up of the workplace has become widespread. Known to be detrimental to worker health, the ever-increasing push to produce more and faster keeps workers locked in a social and biological struggle to meet inhuman demands under inhumane working conditions. But speed ups and social isolation created by competition between workers is just the tip of the iceberg. Workers at Disney not only complain about the pace, they also complain of low wages, job insecurity, lack of respect and the injustice of having to put on a “happy face” and give, even the most slovenly of guests, a “magical experience” when they themselves are looking at dwindling wages and increased health care costs (see psychosocial stressors blog #2).

Physical Inactivity and Cardiovascular Disease

Taken from the New York State Department of Health at: http://www.health.ny.gov/diseases/chronic/cvd.htm

 

Physical Inactivity and Cardiovascular Disease

What does the term physical inactivity mean?

Physical inactivity is a term used to identify people who do not get the recommended level of regular physical activity. The American Heart Association recommends 30-60 minutes of aerobic exercise three to four times peer week to promote cardiovascular fitness. In 1996 the Report of the Surgeon General on Physical Activity and Health recommended the minimum level of physical activity required to achieve health benefits was a daily expenditure of 150 kilocalories in moderate or vigorous activities. This recommendation is consistent with guidelines established by the Centers for Disease Control and Prevention, and American College of Sports Medicine. It also is consistent with the 1996 consensus statement from the National Institutes of Health, recommending adults to accumulate at least 30 minutes of moderate activity most days of the week. Moderate activities include pleasure walking, climbing stairs, gardening, yard work, moderate-to-heavy housework, dancing and home exercise. More vigorous aerobic activities, such as brisk walking running, swimming, bicycling, roller skating and jumping rope — done three or four times a week for 30-60 minutes — are best for improving the fitness of the heart and lungs.

What are the consequences of physical inactivity for cardiovascular disease (CVD)?

Regular physical activity reduces the risk of dying prematurely from CVD. It also helps prevent the development of diabetes, helps maintain weight loss, and reduces hypertension, which are all independent risk factors for CVD. Less active, less fit persons have a 30-50 percent greater risk of developing high blood pressure. Physical inactivity is a significant risk factor for CVD itself. It ranks similarly to cigarette smoking, high blood pressure, and elevated cholesterol. One reason it has such a large affect on mortality is because of its prevalence. Twice as many adults in the United States are physically inactive than smoke cigarettes. Regular physical activity has been shown to help protect against first cardiac episode, help patients’ recovery from coronary surgeries, and will reduce the risk of recurrent cardiac events.

How large is the problem of physical inactivity in the United States?

It is estimated that approximately 35% of coronary heart disease mortality is due to physical inactivity. The significance of this relationship lies in the fact that coronary heart disease is the leading cause of death in the United States with over 700,000 deaths annually. Approximately 60% of all Americans age 18 and older report that they are physically inactive. Physical inactivity has a major economic impact. It is felt through the loss of income and productivity when disabling diseases result. It was estimated that in 1989 physical inactivity cost the nation $5.7 billion due to hospitalizations and other related health care costs.

What segments of the population are physically inactive?

Only about 22 percent of Americans report regular sustained physical activity (activity of any intensity lasting 30 minutes or more 5 times a week). Fifteen percent of Americans report vigorous activity (activity intense enough to make the heart beat fast and hard breathing for at least 20 minutes or more 3 times a week). Thus, improvements in physical activity can be gained in all segments of society. Physical inactivity is more prevalent among women, blacks and Hispanics, older adults and the less affluent. People with less than a 12th grade education are also more likely to be sedentary. In addition, people who are physically disabled, people with injures that limit movement, adolescents, adults who are overweight, women, and people with low incomes all have elevated levels of sedentary behavior.

Facts and statistics about physical inactivity in NYS:

BRFSS Reported levels of Physical Activity

Sedentary Lifestyle: no reported activity or any physical activity or pair of activities done for less than 20 minutes or less than three times per week.

Regular and Sustained: any physical activity or pair of physical activities that are done for 30 minutes or more per session, five or more times per week, regardless of intensity.

Regular and Vigorous: any physical activity or pair of activities done for at least 20 minutes, at least three times per week, that requires rhythmic contraction of large muscle groups at 50% of functional capacity.

chart of physical activitiy levels in New York interpreted below

  • 59% of the New York population reported a sedentary lifestyle
    • 58% of men
    • 60% of women
    • The nonwhite population had a 6% higher level of sedentary lifestyle
  • 20% of the population meets the criteria for regular and sustained activity levels.
    • 21% of men
    • 19% of women
    • The nonwhite population had a 4% higher level of regular and sustained physical activity
  • 14% of the population meets the criteria for regular and vigorous activity levels.
    • 13% of men
    • 15% of women
    • The nonwhite population had a 5% higher level of regular and vigorous physical activity

Smoking and Cardiovascular Disease

From: Centers For Disease Control and Prevention at http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/

Smoking harms nearly every organ of the body. Smoking causes many diseases and reduces the health of smokers in general.1

Smoking and Death

Smoking causes death.

  • The adverse health effects from cigarette smoking account for an estimated 443,000 deaths, or nearly one of every five deaths, each year in the United States.2,3
  • More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.2,4
  • Smoking causes an estimated 90% of all lung cancer deaths in men and 80% of all lung cancer deaths in women.1
  • An estimated 90% of all deaths from chronic obstructive lung disease are caused by smoking.1

Smoking and Increased Health Risks

Compared with nonsmokers, smoking is estimated to increase the risk of—

  • coronary heart disease by 2 to 4 times,1,5
  • stroke by 2 to 4 times,1,6
  • men developing lung cancer by 23 times,1
  • women developing lung cancer by 13 times,1 and
  • dying from chronic obstructive lung diseases (such as chronic bronchitis and emphysema) by 12 to 13 times.1

Smoking and Cardiovascular Disease

  • Smoking causes coronary heart disease, the leading cause of death in the United States.1
  • Cigarette smoking causes reduced circulation by narrowing the blood vessels (arteries) and puts smokers at risk of developing peripheral vascular disease (i.e., obstruction of the large arteries in the arms and legs that can cause a range of problems from pain to tissue loss or gangrene).1,7
  • Smoking causes abdominal aortic aneurysm (i.e., a swelling or weakening of the main artery of the body—the aorta—where it runs through the abdomen).1

References

  1. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [accessed 2012 Jan 10].
  2. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report 2008;57(45):1226–8 [accessed 2012 Jan 10].
  3. Centers for Disease Control and Prevention. Health, United States. Hyattsville (MD): Centers for Disease Control and Prevention, National Center for Health Statistics. [accessed 2012 Jan 10].
  4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States. JAMA: Journal of the American Medical Association 2004;291(10):1238–45 [cited 2012 Jan 10].
  5. U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989 [accessed 2012 Jan 10].
  6. Ockene IS, Miller NH. Cigarette Smoking, Cardiovascular Disease, and Stroke: A Statement for Healthcare Professionals from the American Heart Association.Exit NotificationCirculation 1997;96(9):3243–7 [accessed 2012 Jan 10].
  7. Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence.Exit Notification  (PDF–747 KB) Washington: National Academy of Sciences, Institute of Medicine, 2009 [accessed 2012 Jan 10].
  8. U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001 [accessed 2012 Jan 10].

For Further Information

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health
E-mail: tobaccoinfo@cdc.gov
Phone: 1-800-CDC-INFO

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