COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS Epidemiological Profile on Alcohol, Tobacco and Other Illicit Drug Use 2010 Addendum DEPARTMENT OF PUBLIC HEALTH COMMUNITY GUIDANCE CENTER Prepared by the CNMI State Epidemiological Outcomes Workgroup (SEOW) Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) CNMI Strategic Prevention Framework – State Incentive Grant (SPF-SIG)
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COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
Epidemiological Profile on Alcohol, Tobacco
and Other Illicit Drug Use 2010 Addendum
DEPARTMENT OF PUBLIC HEALTH COMMUNITY GUIDANCE CENTER
Prepared by the CNMI State Epidemiological Outcomes Workgroup (SEOW) Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) CNMI Strategic Prevention Framework – State Incentive Grant (SPF-SIG)
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
Epidemiological Profile on Alcohol, Tobacco
and Other Illicit Drug Use 2010 Addendum
DEPARTMENT OF PUBLIC HEALTH COMMUNITY GUIDANCE CENTER
Prepared by the CNMI State Epidemiological Outcomes Workgroup (SEOW) Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) CNMI Strategic Prevention Framework – State Incentive Grant (SPF-SIG)
Acknowledgements…………………………………………………………3 New Data Sources…………………………………………………………..4 Method of Work and Background Information…………………………….4 About DPH-CGC…………………………………………………………...5 Project Brabu ……………………………………………………………….6 CNMI State Epidemiological Outcomes Workgroup Charter……………...7 Acronym Key…………………………………………………………….....9 Index of Tables and Figures………………………………………………...10 Alcohol……………………………………………………………………..12 Tobacco…………………………………………………………………….20 Illicit Drug Use……………………………………………………………..25 Alcohol, Tobacco and Illicit Drugs Comparative Data…………………….30 Additional Statistics………………………………………………………..34 References………………………………………………………………….38
The Department of Public Health (DPH) would like to thank the members and partners of the Commonwealth of the Northern Mariana Islands-State Epidemiological Outcomes Workgroup (CNMI SEOW) for their dedication and assistance in identifying, collecting, and compiling data sources; selecting indicators and in updating the 2010 CNMI Epidemiological Profile Addendum on Alcohol, Tobacco and Other Illicit Drug Use. The members of the CNMI-SEOW and the technical support group include the following: Josephine T. Sablan Eulalia Villagomez Director/CNMI-SEOW Project Director Statistics Analyst Department of Public Health Criminal Justice Planning Agency Community Guidance Center David Maratita Elizabeth D. Rechebei, Ed.D. Director Researcher/Writer Department of Commerce CNMI SPF-SIG Evaluator Alcohol Beverage & Tobacco Control Division Reyna M. Saures James H. Arriola Prevention Services Manager Statistics Specialist Project Brabu Manager EPI. Chair (SEOW) Department of Public Health Department of Public Health Community Guidance Center Community Guidance Center Matilde Rosario Vivian Nogis Administrative Officer II Warrant Officer CNMI-SEOW Finance Manager Department of Finance Department of Public Health Customs Division Community Guidance Center Jesse R. Aguon Galvin Guerrero Computer Specialist II Director Project Brabu Data Manager Northern Marianas College Department of Public Health Office of Institutional Effectiveness Community Guidance Center Edward P. Diaz, Jr. Sergeant James Guerrero Epidemiologist Officer in Charge (OIC) Department of Public Health Department of Public Safety Division of Public Health Communication and Technology Section George Cruz Rita A. Sablan, Ed.D Chairperson Commissioner of Education CNMI Substance Abuse Prevention Coalition Public School System CNMI
New Data Sources Num. Data Source Year Agency Data Type
1 Youth Risk
Behavior Survey 2009
Public School System
Youth alcohol, tobacco and illicit drugs
2 Health & Vital Statistics Office
Data 2009
CNMI Department of Public Health
Mortality alcohol, tobacco and illicit drugs
3 Alcohol and Tobacco Data
Registry 2009
Department of Commerce -
ABTC
Alcohol and tobacco licenses, citations, minor sales, hearing
and suspensions
4 Birth and Death Health Registry
2009 CNMI
Department of Public Health
Births, Deaths and Fetal Death Data
5 Health & Vital Statistics Office
Data 2009
CNMI Department of Public Health
Pregnancy and alcohol and tobacco
6 CGC's Integrated Client Database
System 2009
DPH – Community
Guidance Center
Number of persons aged 12 and older meeting DSM-IV criteria for alcohol and illicit
drug abuse or dependence
7 Department of Public Safety
2008-2009
Department of Public Safety
Juvenile Criminal Offences, alcohol, traffic, criminal offenses and controlled
substances
8 Army & Air force Exchange Service
2007-2008
Office of the General Council
– Exchange Division
Tobacco, Wine, Spirits and Beer Purchases
Method of Work and Background Information
For a detailed description of the methods utilized and the background information of the CNMI which include history, demographics, population and a cultural summary, please refer to the CNMI Epidemiological Profile on Alcohol, Tobacco and other Illicit Drug Use 20081. The information contained in the 2010 Epidemiological Profile is updated information in regards to the areas of alcohol, tobacco and illicit drug use in the CNMI. Some information contained in this 2010 update may be new in these three areas or an update of previously reported data in which previous editions may be used for further referencing.
1 Commonwealth of the Northern Mariana Islands State Epidemiological Workgroup. CNMI Epidemiological Profile on Alcohol, Tobacco and other Illicit Drug Use 2008. DPH-Community Guidance Center, Navy Hill, Saipan, 2010.
The Community Guidance Center (CGC), a division under the Department of Public Health (DPH), continues to be the primary provider of mental health and substance abuse services for all individuals residing in the CNMI. The CGC incorporates all outpatient mental health services and administers all Federal health programs in the CNMI related to mental health and substance abuse, as well as all other publicly funded mental health services. All services and programs administered by the CGC are supervised by substance abuse and mental health program managers under the management of the Director of CGC, who is overseen by the Secretary of Health in turn reports all activities directly to the Governor. It is the Director of CGC who continues to facilitate the integration of mental health and substance abuse services, as well as steering policy direction. Through collaboration and establishing interdependent relationships with other system providers, the CGC is committed to providing high quality mental health and substance abuse treatment and other therapeutic services to the multi-diverse population of the CNMI, as well support services to families and friends, community outreach, prevention and education services, and referral assistance to other community resources. CGC’s vision is to ensure that every individual who has made the CNMI their home may be able to live and interact with each other in a community that is not only nurturing to its spiritual growth, psychological balance, emotional stability, and physical well-being, but at the same time fostering the development and maintenance of a cooperative and harmonious society.
In response to a submitted Strategic Prevention Framework State Incentive Grant proposal in November 2008, the Substance Abuse and mental Health Services Administration (SAMHSA) announced the five-year grant award to the Commonwealth of the Northern Mariana Islands (CNMI) Department of Public Health, Community Guidance Center in the amount of $974,674 per year for five years. This planning and implementation of this grant award will focus on four primary goals:
1.) Build Prevention Capacity and Infrastructure in the CNMI 2.) Prevent the Initiation of and Reduce Substance Abuse, Including Childhood and
Underage Drinking
3.) Reduce Substance Abuse-related Problems
4.) Evaluate All Project Activities
The Strategic Prevention Framework (SPF) is built on a community-based risk and protective factors approach to prevention and a series of guiding principles that can be utilized at the federal, state/tribal/territory, and community levels. The SPF requires states and communities to systematically access their prevention needs based on epidemiological data, build their prevention capacity, strategically plan for and implement effective community prevention programs, policies and practices, and evaluate their efforts for outcomes.
Enhanced data collection and management, capacity building, strategic planning,
implementation, and evaluation will serve as a positive effect of this grant that will only increase efforts to prevent and address substance abuse in our CNMI communities. Community Prevention Programs will be strengthened and equipped in developing, implementing, and evaluating successful, evidence based programs, practices, and services. A significant part of this grant award involves ensuring that the program(s) and decision-making and are data-driven, data reporting becomes systematic and routine, and assistance, program funding opportunities, education and awareness, and media development are just a few of the strategic components that will be offered to our community and partners to improve the quality of life and promote a drug-free CNMI!
of the Commonwealth of the Northern Mariana Islands
State Epidemiological Outcomes Workgroup (CNMI-SEOW)
Article I: Name
Section 1. The name of the entity is the “CNMI State Epidemiological Outcomes Workgroup” or “SEOW.”
Article II: Mission Statement and Purposes
Section 1. Mission: To help strengthen the quality of data available for the CNMI Substance Abuse Prevention programs and activities.
Section 2. Purpose:
A. To create and implement a systematic collection, analysis, reporting, and dissemination of accurate and comprehensive data related to substance abuse in the CNMI.
B. To generate a broader awareness, among stakeholders in the community, of the physical, mental, economic, and social impacts caused by substance abuse.
C. To strengthen information sharing among all stakeholders for the purposes of planning, implementation, monitoring, and evaluation of prevention and intervention strategies and activities.
Article III: Creation And Status Section 1. Established on July 2007, the SEW currently (SEOW) consisting of key
stakeholders/agencies and organizations officially met on February 2008. Section 2. The SEOW shall exist and comply with appropriate rules and regulations.
Article IV: Principal Office and Main Point of Contact
Section 1. The Principal Office shall be located at the CNMI’s Department of Public Health’s (DPH) Community Guidance Center (CGC).
Section 2. The main Point of Contact (POC) for the Program Director of CGC. The address
and contact information of the POC is: Community Guidance Center / Department
of Public Health / PO Box 500409 CK / Saipan, MP 96950 / Phone: 670-323-4066 or 6560 / Fax: 670-323-6580.
Article V: Functions
Section 1. A. Secure sustainable funding to support SEOW work through grants and
leveraging of resources among stakeholders. B. Recruit qualified staff and obtain professional services. C. Train staff, SEOW members, advisory council members, policy makers and
stakeholders on the purpose and operational aspects of the SEOW. D. Develop indicators on consequences, consumption and prevalence for alcohol,
tobacco and other drugs (ATOD). E. Identify sources and reliability of data for each indicator. F. Address logistical needs to conduct the routine collection, input, and analysis,
of data. G. Update and improve, as needed, the CNMI’s Epidemiological Profile based
upon data collected on the use and abuse of substances identified by the SEOW. H. Distribute the Epidemiological Profile to stakeholders to use in developing
effective prevention and intervention strategies. I. Monitor and continue to improve data collection strategies in coordination with
stakeholders on a regular basis.
Article VI: Organizational Structure
Section 1.
A. The SEOW works as a subcommittee under the advisory council. Membership shall include the Epi. Lead, the Strategic Prevention Framework – State Incentive Grant (SPF_SIG) Project Manager and stakeholders. The Epi. Lead functions under the directive of the SPF-SIG project manager. Members shall include the Department of Public Health (DPH), the Department of Public Safety (DPS), the Department of Commerce Alcoholic Beverage and Tobacco Control Division (ABTC), etc. Membership will be updated as needed, refer to appendix for list of current members.
Article XI: Meetings
Section 1. Meetings will be held monthly or as needed. And will be conducted through via the
Alcohol Table 1.1: Drinking and Driving, Age at First Use, Current Use and Binge Drinking 2003-2009 Table 1.2: Drinking and Driving 2003-2009 Figure 1.1: Drinking and Driving 2003-2009 Table 1.3: Binge Drinking 2003-2009 Figure 1.2: Binge Drinking 2003-2009 Table 1.4: Alcohol Licensing, Citation, Hearings and Suspensions 2008-2009 Figure 1.3: Alcohol Licensing, Citation, Hearings and Suspensions 2008-2009 Table 1.5: CNMI Department of Public Health - Alcohol Use During Pregnancy 2006-2009 Figure 1.4: CNMI Department of Public Health - Alcohol Use During Pregnancy 2006-2009 Table 1.6: CNMI Department of Public Health - Alcohol-Related Mortality 2006-2009 Figure 1.5: CNMI Department of Public Health - Alcohol-Related Mortality 2006-2009 Table 1.7: DSM-IV criteria for ALCOHOL 2009 Figure 1.6: DSM-IV criteria for ALCOHOL 2009 Table 1.8: Juvenile Criminal Offenses, Alcohol Involved, Calendar 2008 Table 1.9: Juvenile Traffic Offenses per Ethnic Group/Sex Calendar 2008 Table 1.10: Traffic Offense Class/Sex (DUI) 2008 Tobacco Table 2.1: Tobacco Age at First Use, Current, Daily Use, Current Use Smokeless 2003-2009 Figure 2.1: Percentage of students who smoked cigarettes on 20 or more of the past 30 days 2003-2009 Table 2.2: Tobacco Licensing, Citation, Hearings and Suspensions 2008-2009 Figure 2.2: Tobacco Licensing, Citation, Hearings and Suspensions 2008-2009 Table 2.3: CNMI Department of Public Health - Tobacco Use During Pregnancy 2006-2009 Figure 2.3: CNMI Department of Public Health - Tobacco Use During Pregnancy 2006-2009 Table 2.4: CNMI Department of Public Health – Tobacco-Related Mortality 2006-2009 Figure 2.4: CNMI Department of Public Health – Tobacco-Related Mortality 2006-2009
Illicit Drugs Table 3.1: Current Use Cocaine, Lifetime Use Cocaine, Heroin, Methamphetamines, Ecstasy 2003-2009 Table 3.2: Marijuana Age at First Use, Current Use, Lifetime Use 2003-2009 Table 3.3: Lifetime Use Illicit Drugs 2003-2009 Figure 3.1: Lifetime Use Illicit Drugs 2003-2009 Table 3.4: CNMI Department of Public Health - Illicit Drug-Related Mortality 2006-2009 Figure 3.2: CNMI Department of Public Health - Illicit Drug-Related Mortality 2006-2009 Table 3.5: DSM-IV criteria for ILLICIT DRUGS 2009 Figure 3.3: DSM-IV criteria for ILLICIT DRUGS 2009 Table 3.6: Juvenile Criminal Offenses per Ethnic Group/Sex Calendar (Controlled Substance) 2008
Alcohol, Tobacco and Illicit Drug Comparative Data Table 4.1: Age of First Use Marijuana, Alcohol and Tobacco 2003-2009 Figure 4.1: Age of First Use Marijuana, Alcohol and Tobacco 2003-2009 Table 4.2: Current Use Alcohol, Tobacco and Marijuana 2003-2009 Figure 4.2: Current Use Alcohol, Tobacco and Marijuana 2003-2009 Additional Statistics Table 5.1: CNMI Department of Public Safety - Violent Crime and Property Crime Data 2007-2008 Figure 5.1: CNMI Department of Public Safety - Violent Crime and Property Crime Data 2007-2008 Table 5.2: CNMI Department of Public Health - Births, Deaths and Fetal Death Data 2006-2009 Figure 5.2: CNMI Department of Public Health - Births, Deaths and Fetal Death Data 2006-2009 Table 5.3: Juvenile Criminal Offenses per Age/Sex Calendar 2008 Table 5.4: Army and Air Force Exchange Service Alcohol and Tobacco Sales FY 2007-2008
Alcohol abuse has both direct and indirect consequences on the people of the CNMI. Health, social, and economic consequences brought on by alcohol abuse impact the unborn as well as the youth, adults, and the elderly. Alcohol abuse is also associated with cancer, psychiatric problems, liver and cardiovascular diseases, and infant morbidity and mortality (CDC, 2008). Further the manner in which alcohol use is embodied in the CNMI population stems not only from relatable U.S. trends such as accessibility and socio-economic factors, but larger and less researched historical factors which include occupational trauma, long lasting affects of WWII and massive social factors that have impacted these small islands in such a short span of time. Among the youth, alcohol abuse could also be a factor in the use of other illicit drugs that may lead to academic problems and other risky behavior.
Table 1.1 YEAR
SEOW Construct PSS CATEGORY & YEAR 2003 2005 2007 2009
Alcohol
Drinking & Driving
Percentage of students who drove a car or other vehicle one or more times during the past 30 days when they had been drinking alcohol 19.4 14.1 15.0 13.7
Percentage of students who rode one or more times during the past 30 days in a car or other vehicle driven by someone who had been drinking alcohol. 53.8 49.0 48.1 43.3
Age at First Use
Percentage of students who had their first drink of alcohol other than a few sips before age 13 years 29.8 26.1 27.4 24.6
Current Use
Percentage of students who had at least one drink of alcohol on one or more of the past 30 days 49.0 43.6 41.1 38.8
Current Binge Drinking
Percentage of students who had five or more drinks of alcohol in a row, that is, within a couple of hours, on one or more of the past 30 days 31.0 27.0 25.5 24.0
Percentage of students who had five or more drinks of alcohol in a row, that is, within a couple of hours, on one or more of the past 30 days 31.0 27.0 25.5 24.0
Source: 2009 PSS YRBS Survey Results for the Northern Mariana Islands High School
According to the WHO’s Western Pacific Region, which covers East Asia and the Pacific including the CNMI, this area has the highest smoking rate in the world, with nearly two-thirds of men smoking. About one in three cigarettes are consumed in the Western Pacific Region alone. (WHO WPRO, 2002) Although we can see in many of the figures below that there has been a decrease in smoking trends, significantly in some instances, there is a large concern in how tobacco is being used demographically and how the larger community based numbers are not representative of the many different ways tobacco is used by population. Although the total percentages of tobacco statistics are promising, we now need to move towards more specific disaggregated data in order to take a more detailed focus on the communities more specific needs in the area of tobacco and prevention.
Tobacco usage in the CNMI is one that has many implications from various perspectives. The social and economic impacts on families, communities, and the entity as a whole are not easily measured. Furthermore, most of the research conducted on social impacts done elsewhere may be difficult to generalize to island conditions particularly in the context of unstable demographic and economic conditions. Regardless, growing concerns about tobacco and its direct and indirect impacts on health and welfare of the CNMI are reflected in various community and school anti-smoking campaigns, media ads, and efforts to enforce smoking prohibition in public facilities. As of 2009 PL 16-46 has been a triumph in the move towards better tobacco measures by banning smoking in all public locations. Although there are several areas that we are only now discovering need to be improved in regards to loop holes, the overall impact has been a great accomplishment and is strongly felt in the community.
Table 2.1 YEAR
SEOW Construct PSS CATEGORY & YEAR 2003 2005 2007 2009
Tobacco
Age at First Use
Percentage of students who smoked a whole cigarette for the first time before age 13 years 40.1 34.0 28.6 23.6
Current Use Percentage of students who smoked cigarettes on one or more of the past 30 days 48.8 35.8 31.1 26.8
Daily Use Percentage of students who smoked cigarettes on 20 or more of the past 30 days 16.8 11.1 8.2 7.5
Current Use (Smokeless Tobacco)
Percentage of students who used chewing tobacco snuff, or dip on one or more of the past 30 days 42.5 36.9 36.3 31.9
Although we have seen some promising trends in the area of alcohol and tobacco, the area of illicit drugs has a mixed review in view of the statistical trends reported. The growing problem of many new and different types of drugs being introduced and accessibility compounded with current international and social impacts of both the U.S. and near by Asian countries has brought a rising new trend in illicit drugs particularly with marijuana.
Marijuana is illegal in the CNMI and is associated with long and short term physical, mental, emotional and behavioral consequences, and is generally considered a gateway drug to stronger drugs. Methamphetamine-related crimes and abuse have figured in the news on numerous occasions in the CNMI. Drug trafficking, violent crimes, and damages to property are frequently attributed to the use or dealing in illicit drugs.
Although there has been a concerted effort by enforcement in cracking down on the trafficking and solicitation of drugs, particularly ice, this has only made clearer the increase of the growing problem.
CNMI Department of Public Health ‐ Illicit Drug‐Related Mortality
Year
2006 2007 2008 2009
Total Mortality 174 141 178 195
Illicit drug use 0 0 1 0
Source: RPMS, Health & Vital Statistics Office, Dept. of Public Health
Note: Mortality deaths are not necessarily tobacco and alcohol related.
Source: CNMI Department of Public Health, Division of Public Health.
Figure 3.2
Source: CNMI Department of Public Health, Division of Public Health.
Table 3.5
Number of persons aged 12 and older meeting DSM-IV Criteria for ILLICIT DRUG abuse or dependence Year 2009 Age Group Female Male 12-17 Year 0 2 18-20 Year 0 3 21-34 Year 1 7 35-64 Year 2 13 65 and Over 0 0 Grand Total 3 25 Source: CGC's Integrated Client Database System
Source: 2009 PSS YRBS Survey Results for the Northern Mariana Islands High School In this section we focus on table and figure 4.2 to look at the current use of alcohol, tobacco, specifically marijuana as well as other illicit substances. These items provide a good perspective over the past 7 years.
We see that with alcohol there has been a steady move downward from the alarming initial 49% reported in 2003.
Again tobacco is to be highlighted in the trends not just from the 2007-2009 reporting but over all trends since 2003.
Marijuana as mentioned before has had a slight decrease but still above the initial decline from 29.8% in 2005 when there was a great decrease from the 2003 41.2 percent. This is an area that needs more research and detailed understanding of cultural, national and global trends and its impact particularly in small island communities such as those within the CNMI.
The information on illicit drugs is also something that needs continued asserted scrutiny as we have also seen the initial decrease and increase from 2003-2007. It is good however that we have seen a slight decrease in the percentage of 2009 from the previous 2007 numbers, but the decrease is minimal and a much more detailed look into the area of these drugs has been made a priority through our departments as well as affiliated agencies.
Table 4.2 Current Use Percentage of students who…..
Category
Year
2003 2005 2007 2009
had at least one drink of alcohol on one or more of the past 30 days 49.0 43.6 41.1 38.8
smoked cigarettes on one or more of the past 30 days 48.8 35.8 31.1 26.8
used marijuana one or more times during the past 30 days 41.2 29.8 31.9 30.8
used chewing tobacco snuff, or dip on one or more of the past 30 days 42.5 36.9 36.3 31.9
used any form of cocaine, including powder, crack, or freebase one or more times during the past 30 days 3.6 2.3 2.9 2.4
Source: 2009 PSS YRBS Survey Results for the Northern Mariana Islands High School
We are very fortunate to get a total sales listing of tobacco, wine, beer and spirits from the Army & Air Force Exchange Service (AAFES). There has been a great discussion as to capturing these figures as the CNMI, who has a large portion of the population in relation to its size serving in the U.S. Military, purchases many items from AAFES of which the benefits extend to dependants of service men and women as well. In the chart below we are able to see a picture of the total sales of each item and overall figures of alcohol and tobacco sales which have been unaccounted for in our total sales for the CNMI in our data systems aside from the general public imports shared to us through the Customs division. The sales for FY 2007 to FY 2008 have decreased overall. There are several reasons that need to be further researched to determine the cause of this but for the purposes of the report the primary focus is on the total numbers as seen below and the total difference between the fiscal years. For tobacco we see a $20,583.35 decrease between FY 2007-2008. For wine we see a $1,728.58 decrease between FY 2007-2008. For beer we see a $61,361.60 decrease between FY 2007-2008. And for spirits we a $6,555.78 decrease between FY 2007-2008. So for totals between FY 2007-2008 we see a $90,229.31 decrease in sales. We are very fortunate and thankful to the AAFES Office of the General Council to have received this data as it provides for us another important component to alcohol and tobacco imports that can be researched from various perspectives. With this current information and the import data we are hoping to get illegal import data in the future to complete a more comprehensive picture of the consumption statistics of these items. In doing so we hope as we endeavor forward to create a better understanding of the community’s expenditure and intake trends in tobacco and alcohol from as many possible sources as possible for reporting and prevention in ameliorating the issues we face here in our islands.
6148110100 GUAM AND SAIPAN TROOP STORE
Departments FY 2007 FY 2008
10-Tobacco $186,177.89 $165,594.54
22-Wine $92,174.00 $90,445.42
23-Beer $949,081.92 $887,720.32
25-Spirit $77, 922.45 $71,366.67
TOTAL $1,305,356.26 $1,215,126.95 Source: Army & Air Force Exchange Service (AAFES), Office of the General Council – Exchange Division 2007-2008
References CNMI Department of Public Health. Division of Public Health, Saipan, 2010. CNMI Department of Public Safety. Saipan, 2010. CNMI Public School System. (2009). 2009 YRBS Results: Northern Mariana Islands High School Survey Trend Analysis Report. CNMI PSS. Saipan. DPH- Community Guidance Center. “CGC's Integrated Client Database System”. Saipan, 2010.
Quarter, 2009. Guam DMHSA: Guam State Epidemiological Outcomes Workgroup. CNMI Epidemiological Profile on Alcohol, Tobacco and Other Illicit Drug Use 2008. DPH-CGC: Saipan, 2008. State Epidemiological Outcomes Workgroup. CNMI Epidemiological Profile on Alcohol, Tobacco and Other Illicit Drug Use 2009 (Revised/Updated). DPH-CGC: Saipan, 2009. WHO Western Pacific Regional Office. World Health Organization Regional Office for the Western Pacific. 2010. World Health Organization. April 2010. <http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm.>