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U.S. Teens in Our World

Understanding the Health of U.S. Youth in Comparison to Youth in Other Countries

Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary

CHAPTER FIVE: SMOKING AND ALCOHOL USE

In this chapter:
Smoking and Alcohol Use | What Didn't We Know | References

SMOKING AND ALCOHOL USE

Although legal for adults, tobacco and alcohol are illicit substances for adolescents in the United States. In nearly all of the HBSC countries included in the study, alcohol sales are prohibited for children under at least age 15, with the legal age ranging from 15 in Denmark to 21 in the United States; only Greece and Portugal do not restrict alcohol sales to minors.1 Laws restricting the sale and distribution of tobacco to minors vary as well, from a minimum age of 18 in several countries, including Estonia, Hungary, Lithuania, and Sweden, to no restriction at all in Israel.2

Whether legal or not, the use of alcohol and tobacco has well-documented and far-ranging health consequences in both the short and long terms. Both tobacco and alcohol use are considered top contributors to mortality and morbidity in the United States.3 Long-term risks associated with tobacco include emphysema, cancer, and cardiovascular disease, which begins as early as two years following the onset of regular smoking.2 Short-term health effects of smoking include shortness of breath on exertion, abnormal lung function, and periodontal disease. In addition, tobacco smoke is a potent trigger of asthma attacks, and maternal smoking is associated with complications of pregnancy and low birth weight.

Research shows that significant adverse effects can occur both in youth and in adults from use of alcohol, which impairs decision-making and heightens the risk of engaging in health- and life-threatening behavior. Important problematic issues include driving under the influence, fighting, unplanned sex, and binge drinking, including drinking to the point of alcohol poisoning. Long-term abusers of alcohol are at risk for serious debilitating effects during adulthood, including liver and neurological diseases, cardiac impairment, and stroke.4 Even during adolescence, abnormal physiological effects of regular alcohol use have been documented. Adolescents who have diagnosed alcohol problems are likely to have evidence of subclinical liver damage.5 In addition, adolescent females who consume alcohol on a regular basis may alter the normal timing and progression of their puberty because of interference with the production of regulatory hormone systems.6

Problem use of alcohol is also associated with unintentional injury. About one third of deaths due to unintentional injury in the United States are related to alcohol. Individuals who start drinking before the age of 21, especially those who start drinking as adolescents, are at least twice as likely to experience alcohol-related injuries as those who start drinking alcohol after age 21.7 In particular, individuals who start drinking before age 21 are more likely to report driving after drinking as well as being involved in alcohol-related motor vehicle crashes.8 A similar relationship has been found between the age of drinking onset and involvement in physical fighting.9

Most lifelong users of tobacco and alcohol begin in their adolescence.10,11 Thus, monitoring and prevention of smoking and alcohol use among youth is essential for improving the health and longevity of the population as a whole. Trajectories for tobacco and problem use of alcohol have some similarities and some differences. Adolescence is the time when individuals are most likely to start smoking, and nicotine addiction starts during adolescence among youth who smoke on a regular basis. In contrast, although drinking alcohol during adolescence is normative behavior and some adolescents certainly become addicted to alcohol, rates of alcohol dependence peak during the third and fourth decades of life (about ages 20 to 40). However, those who start drinking alcohol before the age of 15 are more likely to become dependent on alcohol than those who start drinking alcohol at age 21 or older.12 Both nicotine and alcohol addiction carry a significant delay between their onset and the full development of adverse health consequences.

An analysis performed across all HBSC countries and published in the HBSC international report analyzes family, peer, and school contextual associations with smoking and drinking. It shows that students who simply experimented with smoking are more likely to have had experiences with drinking alcohol, including being drunk, as well as disliking school and being truant from school, regardless of age or gender. Younger adolescents who smoked experimentally, including all 11-year-olds and 13-year-old boys, feel pressured by school, but this effect dissipates for 13-year-old girls and all 15-year-olds. Students who smoked experimentally report spending more time with friends after school and in the evening. Both boys and girls who ever experimented with smoking tobacco report having difficulty talking to their fathers, and girls report difficulty talking to their mothers. 13-year-olds who smoked experimentally also report feeling less happy, and 15-year-olds report feeling less healthy.

In the HBSC cross-country analysis, students at ages 13 and 15 who currently smoke frequently feel less healthy and also spend more time with friends after school and in the evenings than non-smokers. Although they were truant more often and dislike school, established smokers do not feel pressured by school. In addition, among all ages surveyed, daily smokers are more likely to have had an alcoholic drink, to drink beer more frequently and to be drunk more frequently.

Findings are similar for students who drink alcohol more frequently or who had been drunk more than twice. They are also more likely to spend time with friends after school and in the evening (13- and 15-year-olds), and are more likely to be truant from school and to dislike school (all students except 11-year-old girls). In addition, 13- and 15-year-old girls who had been drunk at least twice report feeling less healthy. There are also strong associations between being drunk at least twice and smoking.

Although the contextual analysis shows a strong relationship between use of tobacco and drinking alcohol, this relationship does not hold for all countries. For example, students in a few countries, such as Greenland, Finland, and Norway, report relatively high proportions who smoke but relatively low proportions who drink. Conversely, Greece and, to a lesser extent, Denmark, reported lower rates of tobacco use but higher proportions of students who drink.

Based on data from the HBSC Study, the following charts show how U.S. students compare to students from other countries in measures of smoking and alcohol use. These charts measure experimentation with smoking (smoking at least one time); daily smoking, which demonstrates habituation and addiction to nicotine; regular use of alcohol based on weekly drinking of beer, wine or spirits; and a history of being drunk at least twice, which connotes excessive use of alcohol episodically.

Across countries, the lowest proportions who ever experimented with tobacco are among 11-year-olds, as would be expected. In most countries, less than 20 percent of 11-year-olds had ever tried smoking (data not shown for age groups less than 15 years). However, smoking at least once increased significantly with age: 40-50 percent of 13-year-olds and 60-70 percent of 15-year-olds reported smoking at least once. Although wide variation existed across countries, students from countries with lower proportions of experimental smoking at age 11 also tend to have lower proportions of experimental smoking among 13- and 15-year-olds. Boys are more likely to smoke experimentally than girls, again varying across countries among age groups by gender. U.S. students are in the middle ranking at age 11 for experimental smoking, dropping to eighth lowest ranking at age 13 and fifth lowest at age 15.

Across all countries, daily smoking increases substantially with age: proportions of students who smoke daily increases from less than 2 percent for 11-year-olds to less than 10 percent for 13-year-olds and generally to less than 30 percent for 15-year-olds (data not shown for age groups less than 15 years.) Wide variation exists across countries. For 15-year-old females, proportions smoking daily ranges from 56 percent in Greenland to 6 percent in Lithuania.

  Graph: "Have You Ever Smoked Tobacco?"[d]   Graph: "How Often Do You Smoke Tobacco At Present?"[d]

Among 15-year-old males, 45 percent smoke on a daily basis in Greenland, compared to only 13 percent in Portugal and the U.S. U.S. students rank among the lowest four countries for daily smoking among 15-year-olds. Although a slightly lower percentage of 15-year-old girls than boys report smoking daily in the U.S., about half of participating countries report more females smoking than males.

As with smoking, the percent of students reporting beer, wine or spirit consumption on at least a weekly basis increases with age (data not shown for all age groups). 15-year-old boys in all countries are more likely to drink than girls. The U.S. is within the middle range of countries, with 15 percent of girls and 23 percent of boys drinking these beverages at least weekly. In addition, some countries vary their relative positions by adolescent age group, including the U.S., which is in the top quartile of countries for 11-year-old drinking behavior, but falls to the 40 percent mark for 13-year-olds and to almost the lowest third for 15-year-olds. The international report also shows the proportion of students who drink beer at least weekly (not included here). U.S. students are less likely than the majority of other countries to drink beer, indicating that our relatively comparable ranking for all types of alcoholic beverages is based on drinking higher levels of alcohol in forms other than beer.

  Graph: "How Often Do You Drink Beer, Wine, Or Spirits?"[d]   Graph: "Have You Ever Had So Much Alcohol That You Were Really Drunk?"[d]

The proportions reporting drunkenness on two or more occasions increase steeply across age groups but varies across countries (data not shown for all ages). For example, in the countries in which the highest percentages of adolescents report drunkenness, rates climbed from about 6 to 16 percent of 11-year-old boys, to 23 to 38 percent of 13-year-olds, to 49 to 71 percent of 15-year-old boys. In contrast, in countries reporting relatively low proportions of drunkenness among boys, proportions climb from about 1 percent of 11-year-olds to about 6 to 9 percent of 13-year-olds to about 18 to 35 percent of 15-year-olds. In nearly all countries, boys are more likely than girls to report drunkenness at all ages, and these differences increase with age. The U.S. is among the lowest third of countries for 15-year-olds, with 28 percent of girls and 34 percent of boys having been drunk at least twice.

What Didn't We Know?

While 11-year-old U.S. students experiment with smoking and alcohol in about the middle range among all countries, by age 15 our students are among the least likely to have ever experimented with smoking or to have ever had a drink of alcohol. At age 15 years, our students are among the least likely to smoke either weekly or daily - but are in the middle range for students who drink some type of alcohol at least weekly. At the same time, our students are less likely to drink beer than the students in most other countries - indicating that our students may be comparably more likely to drink other types of alcoholic beverages. Even though the total percentage of adolescents who report drinking alcohol at least once increases by age for all countries, about 80 percent of countries have higher percentages of youth who have drunk alcohol by ages 13 and 15 years than does the United States. The findings on trends in smoking and drinking by age are consistent with U.S. surveillance reports and underscore the fact that an increasing number of young people experiment with these illegal substances as they progress through adolescence.

The United States has three national data sets that provide surveillance and examine adolescent use of tobacco and alcohol.13 Each is a cross-sectional study that takes place on a regular schedule for monitoring the frequency of health behaviors in the adolescent population. The Substance Abuse and Mental Health Services Administration’s annual National Household Survey on Drug Abuse monitors the use of tobacco and alcohol among adolescents (aged 12 to 17) and adults. The University of Michigan’s annual Monitoring the Future survey (funded by NIH) also tracks the prevalence of tobacco and alcohol use, as well as the use of illicit drugs, by 8th, 10th, and 12th graders.14 The Centers for Disease Control’s Youth Risk Behavior Surveillance System monitors tobacco and alcohol use among students in grades 9 through 12 every other year.15

Comparison of findings on smoking between the HBSC study and the YRBS show similarities, especially when the overall older ages of students participating in the YRBS are considered. The 2001 Youth Risk Behavior Surveillance System (YRBS) reports that 64 percent of high school students in grades 9 - 12 had ever tried cigarettes. Higher grade levels were associated with increased risk for ever trying smoking: 71 percent of students in grade 12, 66 percent of students in grade 11, and 58 percent of students in grade 9.15

Parental disapproval helps adolescents to resist smoking.16 However, it is not clear the extent to which parents’ own smoking behavior modifies this protective effect.17 Like smoking among adolescents, adult smoking is generally more prevalent in Europe than in the U.S.: smoking rates in 1999-2001 ranged from 19 percent in Sweden to 42 percent in Hungary,18 compared to 21 percent in the U.S.19 Adolescent susceptibility to smoking has been found to be correlated with exposure to others’smoking (in the home or by friends), owning or willingness to own tobacco promotional items, having a favorite cigarette advertisement, skipping school and poor school performance, and lack of attendance in religious activities. Overall, 32 percent of non-smoking adolescents appear to be susceptibile, or amenable, to smoking. Of non-smoking adolescents, younger teens and females are more susceptible to smoking initiation.20

The 2001 National Household Survey on Drug Abuse and the 2002 Monitoring the Future report find that rates of youth smoking among 12- to 17-year-olds have declined over the past three years.21 This decline can also be measured by the number of new youth who begin smoking on a daily basis, which has decreased from 3000 per day in 1997 to 2000 per day in the year 2000.13 These three major U.S. sources of information on tobacco and alcohol use among U.S. adolescents also provide important information about disparities between racial and ethnic subgroups in the use of tobacco and alcohol. White adolescent use of tobacco generally exceeds that of either blacks or Hispanics, and past-month use of cigarettes is far more prevalent among American Indian/Alaska Native youth than among blacks, whites, or Hispanics.22 The YRBS also found that 8 percent of students had recently used smokeless tobacco and 15 percent of students had recently smoked a cigar.15 In addition, there appears to be significant geographic variation in adolescent smoking rates across the United States, similar to variation of smoking rates across countries. Alcohol use is generally found to be more prevalent among white and Hispanic youth than among blacks.

While HBSC students do not report higher associations of unhappiness or loneliness with frequent smoking, longitudinal studies do show emotional distress related to the onset of adolescent cigarette smoking. In addition, the longitudinal studies show that adolescents who smoke in the twelfth grade are more likely to experience emotional distress in young adulthood, even after controlling for family problems, rebelliousness and deviant behavior. These findings help to show that the relationship between tobacco use and emotional distress is dynamic.23 It is possible that the younger adolescents sampled in the HBSC study had not yet experienced emotional turmoil, were not sensitive to it, or HBSC measures and analysis were not specific to this issue. Because of the strong relationships among cigarette smoking, drinking alcohol, use of illicit substances and conduct disorder among older adolescents, it is expected that these students may continue to experience emotional distress through adulthood as the multiple negative consequences from smoking and alcohol evolve.

The 2001 National Household Survey on Drug Abuse and the 2001 Youth Risk Behavior Survey of high school students show use of alcohol, heavy drinking and binge drinking increases with age. Although episodic heavy drinking, or binge drinking, varied across states, students in higher grades were more likely to report this behavior (37 percent of 12th graders) than were 9th graders (24.5 percent).13 These findings demonstrate a likely extrapolation of the percentages of students reporting getting drunk as part of the HBSC study as they grow older.

Programs to prevent tobacco use and alcohol use by adolescents operate at the national, State, community, and school levels. National and State programs generally attempt to deter use through legislation and regulation. Important examples include increasing the price of tobacco and alcohol products through excise taxes, minimum age of purchase laws, and prohibiting manufacturers from marketing these products to youth. In 1998, a settlement agreement was signed between the Attorneys General of 46 states and five territories and the nation’s leading cigarette manufacturers.24 A major emphasis of the agreement is its provisions regarding the marketing of cigarettes and other tobacco products to youth and the prevention of tobacco use among youth.

By 1987, all 50 States and the District of Columbia had raised the legal age for purchasing alcohol to 21. This policy change has been shown to have been effective in reducing both youth drinking and traffic crashes,26 and lowering the legal blood alcohol concentration for youth effectively decreases the proportion of fatal single-vehicle nighttime crashes.27 Individual States and communities, as well as the Federal government, are supporting efforts both to enforce these laws as well as to educate youth about the risks associated with alcohol. One such effort is the Combating Underage Drinking program overseen by the Office of Juvenile Justice and Delinquency Prevention of the Department of Justice; this program provides funding to the States for projects aimed at prohibiting the use of alcohol by minors.28 In addition to public-sector programs, private foundations are supporting this effort as well; for example, the Robert Wood Johnson Foundation recently funded coalitions in 10 states and two territories to seek policy solutions to reduce underage drinking in their communities.29

A synthesis of the evaluations of approaches to reduction of smoking and drinking has concluded that no single strategy is successful on its own, and multiple approaches have the greatest chance of success.30 Programs designed to delay and prevent the onset of substance use, including the use of tobacco and alcohol, at the individual level are usually classroom-based. Acquiring new knowledge and skills is a normal function of school, and this setting permits consistent contact with children over the course of their development.31 Two general approaches have been used: 1) the social influence model, which addresses drug-related expectancies (knowledge, attitudes and norms) and drug-related resistance skills; and 2) a model based on enhancing personal and social competence.

Although many individual studies based on the social influence model have demonstrated success, especially in the short term, more recent studies have shown that their effectiveness may have been overstated, especially over the long-term. Most recently, the Hutchinson Smoking Prevention Project, which is considered an extremely well-designed and - conducted study of the social influences approach to smoking prevention, found no evidence that this approach is effective in the long term deterrence of adolescent tobacco use, as measured among twelfth graders.32

The model based on enhancing personal and social competence includes elements of the social influences approach but also emphasizes information and skills designed to promote personal self-management and competence in social skills. Effective programs based on this model, such as Life Skills Training, specifically target tobacco, alcohol and marijuana use.33 Multiple evaluation studies demonstrate that it cuts use of tobacco, alcohol and marijuana by 50 to 75 percent. In addition, long-term evaluation has shown that this program reduces pack-a-day smoking by 25 percent.

Another example of a program that uses this model is the Midwestern Prevention Project, a comprehensive, community-based, multi-faceted program for adolescent drug abuse prevention.34 It focuses on students in middle schools and follows them through high school. The overall program is a coordinated system that includes a school program, a parent education and organization program, community organization and training, and local policies directed toward tobacco, alcohol and other drugs. The program helps adolescents to recognize the social pressures to use substances and provides training skills on avoiding both high-risk situations and substance use. Parent education, community organization and training, a mass media campaign, and local policy changes aimed at limiting minors’ access to substances all bolster and support the student-centered curriculum. Evaluation of this program found reductions of up to 40 percent in daily smoking. By age 18, a 5 percent reduction in daily cigarette and a 7 percent reduction in monthly drunkenness remained, and by age 23, young adulthood, a 2 percent reduction in cigarette smoking persisted.

Promotion of youth development is a national movement that encourages programs to be based on a developmental framework that supports young people’s acquisition of personal and social skills. Acquisition of personal and social skills help youth to mature into healthy, economically self-sufficient, and happy adults who practice good citizenship and to thrive during adolescence. Both the Life Skills Training Program and the Midwest Prevention Project are examples of programs that promote youth development. This strategy, as evaluation results continue to grow across multiple programs, is poised to become the cornerstone of youth programming.33

Multiple approaches are necessary to control tobacco and alcohol use; no single step appears effective by itself.31 Community-based interventions directed at preventing tobacco and alcohol use by youth have had variable success. Policy-level interventions aimed at restricting substance use by youth, such as clean air laws, price increases through taxation, counter-advertising, and enforcement of existing laws restricting minors’ purchase of tobacco and alcohol products, need to be combined for maximum effectiveness.

REFERENCES

* Note: If you used a link in the text to reach these footnotes, please use the "Back" button on your browser to return to the text you were reading.

  1. Settertobulte W, Jensen B, Hurrelmann K. Drinking Among Young Europeans. Copenhagen: World Health Organization Office for Europe, 2001.
  2. Centers for Disease Control and Prevention. National Tobacco Information Online System (NATIONS).
  3. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-2212.
  4. U.S. Department of Health and Human Services. Public Health Service. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. Ninth Special Report to the U.S. Congress on Alcohol and Health, NIH Publication No. 97-4017, 1997.
  5. Clark DB, Lynch KG, Donovan JE, Block GD. Health problems in adolescents with alcohol use disorders: Self-report, liver injury, and physical examination findings and correlates. Alcoholism: Clinical and Experimental Research 2001;25(9):1350-9.
  6. Dees WL, Srivastava VK, Hiney JK. Alcohol and female puberty; the role of intraovarian systems. Alcohol Research and Health 2001;25(4):271-5.
  7. Hingson RW, Heeren T, Jamanka A, Howland J. Age of drinking onset and unintentional injury involvement after drinking. JAMA 2000;284:1527-1533.
  8. Hingson R, Heeren T, Levenson S, Jamanka A, Voas R. Age of drinking onset, driving after drinking, and involvement in alcohol related motor vehicle crashes. Accid Anal Prev 2002;34:85-92.
  9. Hingson R, Heeren T, Zakocs R. Age of drinking onset and involvement in physical fights after drinking. Pediatrics 2001;108:872-877.
  10. Khuder SA, Dayal HH, Mutgi AB. Age at smoking onset and its effect on smoking cessation. Addict Behav 1999;24(5):673-7.
  11. White HR, Pandina RJ, Chen PH. Developmental trajectories of cigarette use from early adolescence into young adulthood. Drug Alcohol Depend 2002;65(2):167-178.
  12. Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM-IV alcohol dependence. Alcohol Health Res World 1997; 22:144-148.
  13. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse. Highlights, 2001. (Available at http://www.samhsa.gov/oas/nhsda/2k1nhsda/vol1/highlights.htm.)
  14. Bachman JG, Johnston LD, O'Malley PM. Monitoring the Future: Questionnaire responses from the nation's high school seniors, 2000. Ann Arbor, MI: Institute for Social Research, 2001.
  15. Youth Risk Behavior Surveillance - United States, 2001. MMWR June 21, 2002;51(SS04);1-64.
  16. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? Pediatrics 2001;108(6):1256-62.
  17. Anderson MR, Leroux BG, Marek PM, Peterson AV, Kealey KA, Bricker J, Sarason IG. Mothers' attitudes and concerns about their children smoking: Do they influence kids? Prev Med 2002;34(2):198-206.
  18. World Health Organization Regional Office for Europe. Smoking prevalence in adults.
  19. National Center for Health Statistics. Health United States, 2002 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2002.
  20. Kaufman N, Castrucci BC, Mowery PD, Gerlach KK, Emont S, Orleans CT. Predictors of change on the smoking uptake continuum among adolescents. Arch Pediatr Adolesc Med 2002;156:581-587.
  21. LD Johnston, PM O'Malley, JG Bachman. Teen smoking declines sharply in 2002, more than offsetting large increases in the early 1990s. Ann Arbor, MI: University of Michigan News and Information Services, December 16, 2002. (Available at www.monitoringthefuture.org; last accessed January 28, 2003.)
  22. Substance Abuse and Mental Health Services Administration. Summary of Findings from the 2000 National Household Survey on Drug Abuse. Rockville, MD: Office of Applied Studies, NHSDA Series H-13, DHHS Publication No. (SMA) 01-3549, 2001.
  23. Orlando M, Ellickson PL, Jinnett K. The temporal relationship between emotional distress and cigarette smoking during adolescence and young adulthood. J Consult Clin Psychol 2001;69(6):959-70.
  24. National Association of Attorneys General. Master Settlement Agreement. 1998.
  25. Campaign for Tobacco-Free Kids. Show Us the Money: a mid-year update on the states allocation of the tobacco settlement dollars. Campaign for Tobacco-Free Kids, July 2002.
  26. Wagenaar AC, Perry CL. Community strategies for the reduction of youth drinking: Theory and application. J Res Adolesc 1994;319-345. (Communities Mobilizing for Change in Alcohol Project)
  27. Hingson R, Heeren T, Winter M. Lower legal blood alcohol limits for young drivers. Publ Health Rep 1994;109(6):738-744.
  28. Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice. Enforcing the Underage Drinking Laws Program: A Compendium of Resources. Washington, DC: U.S. Department of Justice, March 2001.
  29. The Robert Wood Johnson Foundation. Call for Proposals: Reducing Underage Drinking Through Community and State Coalitions. Princeton, New Jersey: The Robert Wood Johnson Foundation, 1996.
  30. Committee on Health and Behavior, Research, Practice and Policy, Board on Neuroscience and Behavioral Health, Institute of Medicine. Health and Behavior. The Interplay of Biological, Behavioral and Societal Influences. Washington, DC: National Academy Press, 2001.
  31. Botvin GJ. Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors 2000;25(6):887-897.
  32. Peterson AV, Kealey KA, Mann SL, Marek, PM, Sarason IG. Hutchison smoking prevention project: Long-term randomized trial in school-based tobacco use prevention - results on smoking. J Natl Ca Inst 2000;92:1979-1991.
  33. National Research Council and Institute for Medicine. Community Programs to Promote Youth Development. Committee on Community-Level Programs for Youth. J Eccles and JA Gootman, eds. Board on Children, Youth and Families, Division of Behavioral and Social Sciences and Education. Washington DC: National Academy Press, 2002.
  34. Pentz MA, Mihalic SF, Grotpeter JK. Blueprints for Violence Prevention, Book One: The Midwestern Prevention Project. Boulder, CO: Center for the Study and Prevention of Violence, 1998.

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Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary

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