Lete to the Editor veys: an experimental study. Am J Public Health. 1989;79:638-639. 3. Sallis JF, Fortmann SP, Solomon DS, Farquhar JW. Increasing returns of physician surveys.AmJPubiicHealth. 1984;74:1043. Letter to the Editor. 4. Linsky AS. Stimulating responses to mailed questionnaires: a review. Public Opin Q. 1975;39:82-101. 5. Spry VM, Hovell MF, Sallis JG, Hofstetter CR, Elder JP, Molgaard CA. Recruiting survey respondents to mailed surveys: Controlled trials of incentives and prompts. Am JEpidemiol 1989;130:166-172.
Habits and Attitudes of Public Health Students Medical students are under constant scrutiny. Index Medicus lists more than a hundred articles per year concerning their knowledge, beliefs, and conduct. By contrast, public health students have remained relatively free from inquiry. We discovered fewer than a dozen studies in the past 2 decades focusing on public health students. We decided to investigate the habits and attitudes of students at the Harvard School of Public Health (HSPH). In May of 1990 an anonymous twopage questionnaire was sent to all students at HSPH. Questions, taken verbatim from various national polls were asked concerning (1) individual healthrelated behavior and (2) views on public health issues. Students also rated the quality of their educational experience and indicated whether, if they had it to do over, they would again seek public health training. The response rate was 64%. Reflecting school enrollment, 27% of the respondents were physicians, and about 33% were foreign nationals. It might be argued that, because of their interest and training, the conduct of public health students represents an upper limit to what might be expected from health education interventions. Fortunately, these students seem to have incorporated much public health wisdom into their life-styles. Of US students, 89% claimed to wear their seatbelt all the time and 97% said they did not smoke. This level of cigarette consumption is below the very low rates found among US medical students. On the other hand, US public health students tended to drink more often than the average citizen although less often than medical students. US public health students at Harvard are politically "liberal" regarding public health issues. They overwhelmingly supported legal abortions (96%), seatbelt laws 464 American Joumal of Public Health
(87%), national health insurance (76%), and handgun bans (75%); they opposed the death penalty. Compared with the US students, those from abroad were more likely to smoke and less likely to wear a seatbelt. They were more likely to favor national health insurance and handgun restrictions. Overall, however, US and foreign HSPH students were found to be more similar to each other than to the general or college-educated US population. In terms of their health attitudes and behavior, there was little to distinguish physician from nonphysician HSPH students except that physician students were (a) somewhat more likely to oppose national health insurance and (b) somewhat less likely to believe that abortion should be legal under all circumstances. If they had it to do over, 92% of the students would again seek public health training. The findings indicate that public health students have clear common interests although are a disparate group. Widespread agreement exists among them on many health-related policy issues, and compared even with American medical students, their personal behavior seems very healthy. Few appear to regret their decision to seek a public health education. L David Hemenway, PhD Sar J. Solnck M D1ogla S. Wei4 MS Christan M. Kowck MD, MH The authors are with the Harvard School of Public Health. Requests for reprints should be sent to David Hemenway, PhD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Readability of Health Warnings on Alcohol and Tobacco Products The United States government requires specific health warnings on alcohol and tobacco products, some of which include complex sentences and unusual terms like "carbon monoxide." Because adolescents and other individuals with limited reading skills often have problems with alcohol and tobacco, the readability of the warnings may be crucial to their effectiveness in preventing these problems. Although the federal government started requiring some warnings more than 20 years ago, it appears that no one has ever determined the reading ability needed to understand them. Hence, we
decided to evaluate the readability of government-required warnings on alcohol, cigarette, and smokeless tobacco containers.
We assessed the readability of the warnings with three standard tests called the Flesch,l Gunning's Fog,2 and Dale/ Chall3 methods. These methods focus on length of sentences, average number of syllables per word, and the unfamiliarity of the words. Higher scores on the Flesch indicate that material is easier to read; lower scores on the Gunning and Dale/ Chall indicate that material is easier to read. All three methods produced similar results, indicating that the single alcohol warning and each of the four cigarette warnings require a reading level typical of college students or college graduates. Flesch formula scores ranged from 8.4 to 47.6; Gunning formula scores from 13.9 to 31.6; and Dale/Chall formula scores from 10.0 to 12.2. These findings are unfortunate for the many Americans with lower reading ability. The three smokeless tobacco warnings require more appropriate reading levels typical of middle school or high school students. For them Flesch scores ranged from 52.9 to 86.7; Gunning scores from 2.8 to 12.0; and Dale/Chall scores from 7.3 to 8.5. The results persuade us that the federal government should consider (a) modifying existing alcohol and cigarette warnings to make them more readable and (b) using readability analyses in developing new warnings. O John Malouff, PhD, JD
Nicoa Schulte, PhD The authors are with Nova College in Fort Lauderdale, Fla. Requests for reprints should be sent to John Malouff, PhD, JD, Nova College, 3301 College Avenue, Fort Lauderdale, FL
33314.
References 1. Flesch R. How to Write Plain Engrsh. New York, NY: Harper & Row Publishers, Inc.; 1979. 2. Gunning R. The TechnwofClear Wring. New York, NY: McGraw-Hill International Book Co. 3. Dale E, Chall J. A formula for predicting readability. Educ Res BulL 1948;27:11-20, 37-54.
Lead Exposure in Sandblasting With respect to the discussion of exposure to lead in sandblasting and the possibility that this exposure may have March 1992, Vol. 82, No. 3
to the Editor
contributed to the excess risk of endstage renal disease reported by Steenland et al.' I would like to add the following information to that from Schirmer.2 According to a recent report by the Environmental Protection Agency on mining wastes, waste material from lead mines is sold as material for sandblasting.3 This material, finely ground slag and other wastes, can contain lead in concentrations of parts per hundred. Thus it is possible that sandblasters could have exposures to lead that exceed those ofworkers in identified lead industries, particularly under conditions where "environmental" protections are taken, such as draping and enclosing the site, measures that may reduce releases of lead but tend to increase worker exposure. Given the federal government's passivity on this subject, state and local public health officials may wish to take steps to prevent the use of this dangerous material. It is not enough to realize that construction and demolition operations may result in lead exposure and release; if lead-containing materials are used in the process, this exposure may occur even at sites where no lead paint is present. O
Elen K. Silbereld, PhD Requests for reprints should be sent to Ellen K Silbergeld, PhD, University of Maryland at Baltimore, The University Program in Toxicology, Howard Hall, Room 544, 660 West Redwood Street, Baltimore, MD 21201.
References 1. Steenland K, Thun MJ, Ferguson CW, Port FK. Occupational and other exposures associatedwith male end-stage renal disease: a case/control study. Am J Public Health.
1990;80:153-157. 2. Schirmer J. Lead risks overlooked in sandblasters?AmJPubftcHealth. 1990;80:1275. Letter to the Editor. 3. US Environmental Protection Agency. Report to Congress on Mining Wastes. Washington, DC: Office of Solid Waste and Emergency Response; 1990:10-33.
Improving the American Diet In their article published in the December 1990 issue of this Journal, Patterson et al.' call for a national campaign to make the public aware of the connection between food intake-particularly that of fruits and vegetables-and health outcome. Few could argue with the priority of such a recommendation if we are to benefit from the scientifically based US Dietary Guidelines, which call for the consumption of fi[ve or more servings of fruits
March 1992, Vol. 82, No. 3
and vegetables per day. Indeed, the provision of micronutrients, fiber, and other chemopreventive substances, known to be related to health promotion and disease prevention, have been identified in reports issued by the surgeon general's office,2 the National Research Council's Food and Nutrition Board,3 and the US Department of Health and Human Services.4 Clearly, vegetables represent important sources of vitamins A and C, potassium, thiamine, trace minerals, and sufficient fiber to achieve the National Cancer Institute's recommendation of 20 to 35 g per day (as demonstrated by the 17 g reported in the analysis). Yet where will sufficient amounts of fruits and vegetables come from and how will they be paid for? As the authors point out, only 9% of the population surveyed consume the recommended amounts of fruits and vegetables, with only a quarter consuming three or more servings of vegetables and less than a third consuming two or more servings of fruit. To make matters worse, many of these servings are fried, and most others are dinner salads. The real goal of current dietary recommendations applies to the intake ofgarden vegetables, yet less than 50% of the population consumed even one serving per day. Part ofthe problem stems from a lack of leadership in launching a national public education campaign, as has been successfully conducted by other specific food industries (e.g., for beef, pork, oils, snacks, cereals, desserts). Conspicuously absent are any advertisements for garden vegetables and fruits, though ads do appear on behalf of avocados, prunes, raisins, and bananas. In addition, given the high rate of spoilage and short shelf-life of fresh produce, much of it ends up in food banks where, fortunately, the most needy are in fact the beneficiaries (e.g., shelters for the homeless, soup kitchens); it would be interesting to leam how these garden items are consumed, whether it be out of sheer hunger, price (free), special recipes for preparation, no or little choice, and so forth. In any case, there seems to be some discrepancy between the priority placed on consuming fruits and vegetables and the priority for developing a national campaign to promote their consumption. The reality may be, however, that altematives must be sought for the provision of micronutrients and fiber in the American diet. Since 1939, the Food and Drug Administration (FDA) has made special provisions for foods for special dietary purposes (through the Food, Drug,
and Cosmetics Act). At long last, the FDA has begun to take steps toward developing guidelines for the use of this category on the basis of studies done by the Life Science Office of FASEB. As nutrition scientists continue to identify specific chemical components of fruits and vegetables, such as fiber, micronutrients, oxygen radical scavengers, and other antioxidants that play an important role in the prevention and treatment of disease, we will have a greater knowledge foundation on which to base decisions for enriching, fortifying, and supplementing popular foods and beverages. These strategies are already popular in Japan and Europe. As Patterson et al.1 emphasize, nearly every survey of the American diet has confirmed the findings of this report (i.e., nutrient deficiency due to lack of fruits and vegetables). Thus, there exists an enormous potential to garner significant savings from our nation's current annual medical bill of $650 billion by developing successful strategies for getting the nutrients found in garden vegetables and fruits into the American diet so as to prevent and to treat diet-related disorders (e.g., cardiovascular disease, hypertension, stroke, cancer, diabetes, gastrointestinal disease, obesity). We could reasonably expect a savings of $150 billion in addition to one third ofthe years of lost life (YLL) reported by the Centers for Disease Control.5 The public health community must act on the recommendations put forth by these authors by working with the government, industry, and academia to implement a national campaign on the use ofthe US Dietary Guidelines. Perhaps it is even time for another White House Conference to get things moving on this critical public health issue. [] George L. Blackbun, MD, PhD Requests for reprints should be sent to George L. Blackburn, MD, PhD, New England Deaconess Hospital, 194 Pilgrim Road, Boston, MA 02215.
References 1. Patterson BH, Block G, Rosenberger WF, Pee D, Kahls LL. Fruits and vegetables in the American diet: data from the NHANES II survey. Am J Public Health.
1990;80:1443-1449. 2. US Department of Health and Human Services. The Surgeon General's Report on Nutnition and Health. Washington, DC: US Government Printing Office; 1988. DHHS (PHS) publication 88-520210. 3. Committee on Diet and Health, Food and Nutrition Board, Commiission on Life Sciences, National Research Council. Diet and
American Journal of Public Health 465
Habits and Attitudes of Public Health Students Medical students are under constant scrutiny. Index Medicus lists more than a hundred articles per year concerning their knowledge, beliefs, and conduct. By contrast, public health students have remained relatively free from inquiry. We discovered fewer than a dozen studies in the past 2 decades focusing on public health students. We decided to investigate the habits and attitudes of students at the Harvard School of Public Health (HSPH). In May of 1990 an anonymous twopage questionnaire was sent to all students at HSPH. Questions, taken verbatim from various national polls were asked concerning (1) individual healthrelated behavior and (2) views on public health issues. Students also rated the quality of their educational experience and indicated whether, if they had it to do over, they would again seek public health training. The response rate was 64%. Reflecting school enrollment, 27% of the respondents were physicians, and about 33% were foreign nationals. It might be argued that, because of their interest and training, the conduct of public health students represents an upper limit to what might be expected from health education interventions. Fortunately, these students seem to have incorporated much public health wisdom into their life-styles. Of US students, 89% claimed to wear their seatbelt all the time and 97% said they did not smoke. This level of cigarette consumption is below the very low rates found among US medical students. On the other hand, US public health students tended to drink more often than the average citizen although less often than medical students. US public health students at Harvard are politically "liberal" regarding public health issues. They overwhelmingly supported legal abortions (96%), seatbelt laws 464 American Joumal of Public Health
(87%), national health insurance (76%), and handgun bans (75%); they opposed the death penalty. Compared with the US students, those from abroad were more likely to smoke and less likely to wear a seatbelt. They were more likely to favor national health insurance and handgun restrictions. Overall, however, US and foreign HSPH students were found to be more similar to each other than to the general or college-educated US population. In terms of their health attitudes and behavior, there was little to distinguish physician from nonphysician HSPH students except that physician students were (a) somewhat more likely to oppose national health insurance and (b) somewhat less likely to believe that abortion should be legal under all circumstances. If they had it to do over, 92% of the students would again seek public health training. The findings indicate that public health students have clear common interests although are a disparate group. Widespread agreement exists among them on many health-related policy issues, and compared even with American medical students, their personal behavior seems very healthy. Few appear to regret their decision to seek a public health education. L David Hemenway, PhD Sar J. Solnck M D1ogla S. Wei4 MS Christan M. Kowck MD, MH The authors are with the Harvard School of Public Health. Requests for reprints should be sent to David Hemenway, PhD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Readability of Health Warnings on Alcohol and Tobacco Products The United States government requires specific health warnings on alcohol and tobacco products, some of which include complex sentences and unusual terms like "carbon monoxide." Because adolescents and other individuals with limited reading skills often have problems with alcohol and tobacco, the readability of the warnings may be crucial to their effectiveness in preventing these problems. Although the federal government started requiring some warnings more than 20 years ago, it appears that no one has ever determined the reading ability needed to understand them. Hence, we
decided to evaluate the readability of government-required warnings on alcohol, cigarette, and smokeless tobacco containers.
We assessed the readability of the warnings with three standard tests called the Flesch,l Gunning's Fog,2 and Dale/ Chall3 methods. These methods focus on length of sentences, average number of syllables per word, and the unfamiliarity of the words. Higher scores on the Flesch indicate that material is easier to read; lower scores on the Gunning and Dale/ Chall indicate that material is easier to read. All three methods produced similar results, indicating that the single alcohol warning and each of the four cigarette warnings require a reading level typical of college students or college graduates. Flesch formula scores ranged from 8.4 to 47.6; Gunning formula scores from 13.9 to 31.6; and Dale/Chall formula scores from 10.0 to 12.2. These findings are unfortunate for the many Americans with lower reading ability. The three smokeless tobacco warnings require more appropriate reading levels typical of middle school or high school students. For them Flesch scores ranged from 52.9 to 86.7; Gunning scores from 2.8 to 12.0; and Dale/Chall scores from 7.3 to 8.5. The results persuade us that the federal government should consider (a) modifying existing alcohol and cigarette warnings to make them more readable and (b) using readability analyses in developing new warnings. O John Malouff, PhD, JD
Nicoa Schulte, PhD The authors are with Nova College in Fort Lauderdale, Fla. Requests for reprints should be sent to John Malouff, PhD, JD, Nova College, 3301 College Avenue, Fort Lauderdale, FL
33314.
References 1. Flesch R. How to Write Plain Engrsh. New York, NY: Harper & Row Publishers, Inc.; 1979. 2. Gunning R. The TechnwofClear Wring. New York, NY: McGraw-Hill International Book Co. 3. Dale E, Chall J. A formula for predicting readability. Educ Res BulL 1948;27:11-20, 37-54.
Lead Exposure in Sandblasting With respect to the discussion of exposure to lead in sandblasting and the possibility that this exposure may have March 1992, Vol. 82, No. 3
to the Editor
contributed to the excess risk of endstage renal disease reported by Steenland et al.' I would like to add the following information to that from Schirmer.2 According to a recent report by the Environmental Protection Agency on mining wastes, waste material from lead mines is sold as material for sandblasting.3 This material, finely ground slag and other wastes, can contain lead in concentrations of parts per hundred. Thus it is possible that sandblasters could have exposures to lead that exceed those ofworkers in identified lead industries, particularly under conditions where "environmental" protections are taken, such as draping and enclosing the site, measures that may reduce releases of lead but tend to increase worker exposure. Given the federal government's passivity on this subject, state and local public health officials may wish to take steps to prevent the use of this dangerous material. It is not enough to realize that construction and demolition operations may result in lead exposure and release; if lead-containing materials are used in the process, this exposure may occur even at sites where no lead paint is present. O
Elen K. Silbereld, PhD Requests for reprints should be sent to Ellen K Silbergeld, PhD, University of Maryland at Baltimore, The University Program in Toxicology, Howard Hall, Room 544, 660 West Redwood Street, Baltimore, MD 21201.
References 1. Steenland K, Thun MJ, Ferguson CW, Port FK. Occupational and other exposures associatedwith male end-stage renal disease: a case/control study. Am J Public Health.
1990;80:153-157. 2. Schirmer J. Lead risks overlooked in sandblasters?AmJPubftcHealth. 1990;80:1275. Letter to the Editor. 3. US Environmental Protection Agency. Report to Congress on Mining Wastes. Washington, DC: Office of Solid Waste and Emergency Response; 1990:10-33.
Improving the American Diet In their article published in the December 1990 issue of this Journal, Patterson et al.' call for a national campaign to make the public aware of the connection between food intake-particularly that of fruits and vegetables-and health outcome. Few could argue with the priority of such a recommendation if we are to benefit from the scientifically based US Dietary Guidelines, which call for the consumption of fi[ve or more servings of fruits
March 1992, Vol. 82, No. 3
and vegetables per day. Indeed, the provision of micronutrients, fiber, and other chemopreventive substances, known to be related to health promotion and disease prevention, have been identified in reports issued by the surgeon general's office,2 the National Research Council's Food and Nutrition Board,3 and the US Department of Health and Human Services.4 Clearly, vegetables represent important sources of vitamins A and C, potassium, thiamine, trace minerals, and sufficient fiber to achieve the National Cancer Institute's recommendation of 20 to 35 g per day (as demonstrated by the 17 g reported in the analysis). Yet where will sufficient amounts of fruits and vegetables come from and how will they be paid for? As the authors point out, only 9% of the population surveyed consume the recommended amounts of fruits and vegetables, with only a quarter consuming three or more servings of vegetables and less than a third consuming two or more servings of fruit. To make matters worse, many of these servings are fried, and most others are dinner salads. The real goal of current dietary recommendations applies to the intake ofgarden vegetables, yet less than 50% of the population consumed even one serving per day. Part ofthe problem stems from a lack of leadership in launching a national public education campaign, as has been successfully conducted by other specific food industries (e.g., for beef, pork, oils, snacks, cereals, desserts). Conspicuously absent are any advertisements for garden vegetables and fruits, though ads do appear on behalf of avocados, prunes, raisins, and bananas. In addition, given the high rate of spoilage and short shelf-life of fresh produce, much of it ends up in food banks where, fortunately, the most needy are in fact the beneficiaries (e.g., shelters for the homeless, soup kitchens); it would be interesting to leam how these garden items are consumed, whether it be out of sheer hunger, price (free), special recipes for preparation, no or little choice, and so forth. In any case, there seems to be some discrepancy between the priority placed on consuming fruits and vegetables and the priority for developing a national campaign to promote their consumption. The reality may be, however, that altematives must be sought for the provision of micronutrients and fiber in the American diet. Since 1939, the Food and Drug Administration (FDA) has made special provisions for foods for special dietary purposes (through the Food, Drug,
and Cosmetics Act). At long last, the FDA has begun to take steps toward developing guidelines for the use of this category on the basis of studies done by the Life Science Office of FASEB. As nutrition scientists continue to identify specific chemical components of fruits and vegetables, such as fiber, micronutrients, oxygen radical scavengers, and other antioxidants that play an important role in the prevention and treatment of disease, we will have a greater knowledge foundation on which to base decisions for enriching, fortifying, and supplementing popular foods and beverages. These strategies are already popular in Japan and Europe. As Patterson et al.1 emphasize, nearly every survey of the American diet has confirmed the findings of this report (i.e., nutrient deficiency due to lack of fruits and vegetables). Thus, there exists an enormous potential to garner significant savings from our nation's current annual medical bill of $650 billion by developing successful strategies for getting the nutrients found in garden vegetables and fruits into the American diet so as to prevent and to treat diet-related disorders (e.g., cardiovascular disease, hypertension, stroke, cancer, diabetes, gastrointestinal disease, obesity). We could reasonably expect a savings of $150 billion in addition to one third ofthe years of lost life (YLL) reported by the Centers for Disease Control.5 The public health community must act on the recommendations put forth by these authors by working with the government, industry, and academia to implement a national campaign on the use ofthe US Dietary Guidelines. Perhaps it is even time for another White House Conference to get things moving on this critical public health issue. [] George L. Blackbun, MD, PhD Requests for reprints should be sent to George L. Blackburn, MD, PhD, New England Deaconess Hospital, 194 Pilgrim Road, Boston, MA 02215.
References 1. Patterson BH, Block G, Rosenberger WF, Pee D, Kahls LL. Fruits and vegetables in the American diet: data from the NHANES II survey. Am J Public Health.
1990;80:1443-1449. 2. US Department of Health and Human Services. The Surgeon General's Report on Nutnition and Health. Washington, DC: US Government Printing Office; 1988. DHHS (PHS) publication 88-520210. 3. Committee on Diet and Health, Food and Nutrition Board, Commiission on Life Sciences, National Research Council. Diet and
American Journal of Public Health 465
