This Program Announcement expires on June 30, 2004, unless reissued.


Release Date:  June 11, 2001

PA NUMBER:  PA-01-109

National Institute of Nursing Research (NINR)
National Cancer Institute (NCI)
National Institute of Child Health and Human Development (NICHD)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
National Institute of Neurological Disorders and Stroke (NINDS)



This Program Announcement (PA) solicits applications for investigator-
initiated research related to the prevention and management of cachexia to 
improve the quality of life for these patients.  Cachexia is a condition of 
severe malnutrition characterized by anorexia, weight loss and muscle wasting 
that occurs as a consequence of chronic conditions such as cystic fibrosis, 
cerebral palsy, cancer, AIDS, congestive heart failure, failure to thrive in 
older populations, end-stage organ failure, neurological degenerative 
diseases, chronic obstructive lung disease, chronic liver disease, and chronic 
renal disease. Cachexia has repeatedly been associated with adverse clinical 
outcomes, and increased morbidity and mortality. Research findings are 
reported in the literature which address individual symptoms and speculated 
causes of cachexia but data are not available to provide a scientific base for 
a multidisciplinary approach to prevent cachexia and manage the associated 
symptoms to improve the quality of life for patients suffering from cachexia. 
The goal of this PA is threefold:  1) to stimulate basic and clinical research 
in cachexia; 2) to examine cachexia in relation to several related symptoms to 
improve quality of life; and 3) to examine cachexia symptoms in two or more 
chronic conditions. 


The Public Health Service (PHS) is committed to achieving the health promotion 
and disease prevention objectives of "Healthy People 2010," a PHS led national 
activity for setting priority areas.  This Program Announcement (PA), 
Cachexia: Research into Biobehavioral Management and Quality of Life, is 
related to one or more of the priority areas.   Potential applicants may 
obtain a copy of "Healthy People 2010" at


Applications may be submitted by domestic and foreign, for-profit and non-
profit organizations, public and private, such as universities, colleges, 
hospitals, laboratories, units of State and local governments, and eligible 
agencies of the Federal government.  Racial/ethnic minority individuals, 
women, and persons with disabilities are encouraged to apply as principal 


This PA will use the National Institutes of Health (NIH) Research Project 
Grant (R01) award mechanism.  Responsibility for the planning, direction, and 
execution of the proposed project will be solely that of the applicant.  The 
total project period for an application submitted in response to this PA may 
not exceed 5 years.

Specific application instructions have been modified to reflect "MODULAR 
GRANT" and "JUST-IN-TIME" streamlining efforts being examined by the NIH. 
Complete and detailed instructions and information on Modular Grant 
applications can be found at



Cachexia is a condition of severe malnutrition and negative nitrogen balance 
characterized by anorexia, weight loss and muscle wasting.  The physiological, 
metabolic, and behavioral changes in cachexia are associated with patient 
complaints of weakness, fatigue, gastrointestinal distress, sleep/wake 
disturbances, pain, listlessness, shortness of breath, lethargy, depression, 
malaise and the fear of being a burden on family and friends. Although 
cachexia has been classically associated with chronic infections and malignant 
conditions, it has also been identified in patients after extensive traumatic 
injury and sepsis, and in aging persons with failure to thrive syndrome.    

Muscle cachexia, mainly reflecting degradation of myofibrillar proteins, is an 
important clinical feature in cachectic patients.  A redistribution of the 
body’s protein content occurs, with preferential depletion of skeletal muscle 
and an increase in the synthesis of proteins involved in the response to 
tissue injury.  Muscle cachexia is associated with increased gene expression 
and activity of the calcium/calpain and ubiquitin/proteasome-proteolytic 
pathways.  Calcium/calpain-regulated release of myofilaments from the 
sarcomere is an early, and perhaps rate-limiting, component of the catabolic 
response in muscle. Understanding the mechanisms regulating muscle protein 
breakdown is important for the development of therapeutic strategies aimed at 
preventing and managing muscle cachexia. The catabolic response in skeletal 
muscle may result in muscle wasting and weakness that has important clinical 
implications such as difficulty with ambulation, impaired rehabilitation and 
increased risk for pulmonary complications.  

The cachexia-anorexia syndrome involves metabolic pathology and is associated 
with hypertriacylglycerolemia, lipolysis, and acceleration of protein 
turnover.  These changes result in the loss of fat mass and body protein.  
Increased resting energy expenditure in weight-losing cachectic patients can 
occur despite the reduced dietary intake, indicating systemic dysregulation of 
host metabolism.  Cachexia, regardless of the underlying diagnosis, can rarely 
be explained by the actual energy and substrate demands or by the diagnosis 
itself.  Cachexia involves immune changes, and cytokines have been identified 
in the development and/or progression of the cachexia-anorexia syndrome.  For 
example, interleukin-1, interleukin-6 (and its subfamily such as ciliary 
neurotrophic factor and leukemia inhibitory factor), interferon-gamma, tumor 
necrosis factor-alpha, and brain derived neurotrophic factor have been 
associated in various cachectic conditions.  Cytokines are proposed to 
participate in the development and progression of cachexia.  Data show that 
cytokines may be involved in cachexia processes by being produced and by 
acting locally in specific brain regions.  Brain synthesis of cytokines has 
been demonstrated in peripheral models of cancer, in peripheral inflammation, 
and during peripheral cytokine administration.  Since the data reveal a 
multifactorial syndrome in cachexia, understanding the interactions between 
peripheral and brain mechanisms may be pivotal to characterizing the 
underlying integrative pathophysiology in this disorder and in designing 
effective prevention and management strategies. 

Immunological pathology has been linked to cachexia in different diseases such 
as cancer and chronic heart failure.  Data show that the development of 
chronic heart failure includes phenotypic changes in numerous homeostasis 
systems so that in late chronic heart failure, extra-cardiac manifestations 
occur, in particular immunological abnormalities.  Increased levels of the 
proinflammatory cytokine tumor necrosis factor (TNF) are found in the 
circulation and in the myocardium of patients with chronic heart failure in 
higher numbers than in controls. Numerous therapies for chronic heart failure 
directed against TNF are reported in the literature and represent an approach 
to heart failure management.  Basic and clinical research studies are needed 
to measure the effectiveness of these therapies in ameriorating the multiple 
symptoms affecting patients with cachexia. 

Cachexia can be a hallmark condition of Acquired Immune Deficiency Syndrome 
(AIDS).  Limited success has been reported with the use of several anabolic 
agents to retard or prevent progressive muscle wasting in persons with AIDS.  
One recent published finding reported that insulin administration improved 
metabolic profiles (lowering triglycerides, liver enzymes, and glycohemoglobin 
concentrations and normalizing the 24 hour urine) to the point of patients 
being in a positive energy balance.  No adverse effects, including 
hypoglycemic episodes, were reported and a marked rise in CD4 counts and an 
improvement in the thyroid hormone profile were noted. The possibility that 
insulin administration may improve cachexia in AIDS and in other chronic 
conditions may warrant further evaluation. 

Trials of conventional nutritional supplements in patients with cancer 
cachexia have failed to show appreciable benefit in terms of weight gain or 
quality of life. The difficulties in introducing sound and effective 
nutritional support or metabolic manipulation to reverse cachexia are outlined 
in the literature. A variety of pharmacological and dietary agents have been 
studied in an attempt to normalize lipid and protein metabolic changes with 
only limited success.  For example, preliminary clinical studies have shown 
that eicosapentanoic acid stabilizes body weight and protein and fat reserves 
in cachectic patients with pancreatic carcinoma.   Recent studies have 
demonstrated the ability of anabolic and anticatabolic agents to mitigate the 
loss of skeletal muscle and to improve clinical outcomes of cachectic patients 
in selected circumstances.  Preclinical initiatives target the cytokine 
regulation of protein metabolism.  Further, a recent study reported that an 
energy-enriched formula was more effective in improving the nutritional status 
of cachectic children with cancer during the intensive phases of treatment 
than the standard formula. Combinations of nutritional, pharmacological, and 
alternative/complementary medicine therapies to normalize the metabolic milieu 
may have the potential to reverse cachexia and improve the associated symptoms 
that affect quality of life.  However, metabolic manipulations in cachexia 
could have positive or negative clinical effects, which need to be 
distinguished through basic and clinical research and appropriate clinical 

In order to improve quality of life during cachexia, numerous educational 
interventions are available for patients and families to treat and manage 
physical and emotional symptoms associated with cachexia.   However, they have 
not been scientifically validated.  There are published research results to 
document interventions to ameliorate the inflammation and deterioration of 
oral mucous membranes as a side effect of cancer therapy and interventions to 
assist patients in modulating shortness of breath.  However, data-based 
research publications are lacking to describe how patients should manage 
cachexia-anorexia syndrome to improve their quality of life. Clinical research 
studies are needed to combine behavioral strategies with nutritional 
interventions in order to impact the anorexia-cachexia syndrome.  Clinical 
research studies are warranted to test effective approaches to manage 
unintentional weight loss as a side effect of cancer treatment and AIDS 
progression.  Research studies are needed to validate ways for cachectic 
patients and their families to increase their ability to intervene 
appropriately for pain, psychosocial needs, bereavement, depression, and 
issues for end of life. Research is needed to document how interventions can 
improve these diverse symptoms.  Also, reversing cachexia may not always be 
possible, for example in patients at the end stages of life. In these 
conditions, research is needed to test ways to manage multiple associated 
sequalae of cachexia.  


This PA solicits applications that investigate ways to prevent and manage 
cachexia in order to improve the quality of life of patients with this 
condition.  The purpose of the PA is: 1) to stimulate basic and clinical 
research in cachexia; 2) to examine cachexia in relation to several related 
symptoms or other sequalae to improve quality of life (e.g., decrease in pain 
and weakness, fatigue and dyspnea; investigate ways to prevent muscle wasting 
and evaluate the validity of its effectiveness on patients’ sleep/wake cycles 
and complaints of shortness of breath); and 3) to examine cachexia symptoms in 
two or more chronic conditions (e.g., test effective strategies to manage 
anorexia in patients diagnosed with AIDS and cancer).  Multidisciplinary 
research teams composed of basic and clinical researchers are encouraged to 
address the goals of this PA.  For example, basic researchers could emphasize 
the interactions among multiple underlying pathophysiological mechanisms of 
cachexia while clinical researchers define the specific impact of loss of 
independence or how patients can improve upon skeletal muscle function 
recovery. In addition, both basic and clinical research could test multiple 
combination therapy interventions that include nutritional, immunological, 
pharmacological, and alternative/complementary medicine components. These 
combination therapies could be evaluated for their effects on clusters of 
symptoms occurring with cachexia such as subjective complaints by patients 
that affect quality of life that include sleep/wake disturbances, malaise, 
pain, listlessness, shortness of breath, fatigue and depression. Attention 
could also be directed to differences in therapeutic interventions based on 
age, gender, and underlying disease.    

Listed below are examples of areas of basic and clinical research that would 
be responsive to this program announcement.  They are not listed in any 
priority order and are not intended to be inclusive or restrictive.  These 
examples are only illustrative examples, and applicants are encouraged to 
propose other topics consistent with the goals of this program.  

o  Determine which symptoms of cachexia are amenable to metabolic or 
biochemical interventions and which symptoms require behavioral interventions 
in order to improve quality of life;

o  Identify and test nutritional, pharmacological, and 
psychoneuroimmunological interventions to prevent or treat the anticipated 
onset of anorexia with cachexia; 

o  Test biobehavioral interventions to promote quality of life in cachectic 
patients who have different underlying conditions/diseases;

o  Compare and contrast traditional treatments alone or in tandem with 
alternative/complementary therapies to arrest cachexia in two or more 
different underlying conditions/diseases; 

o  Identify biological, immunological, chemical, genetic or behavioral markers 
to be used as an index of successful outcome measures in cachexia or the 
treatment and management of cachexia;

o  Explore regimens (e.g., physical activity and nutrient supplementation) to 
improve dyspnea, impaired mobility, pain, anorexia and fatigue associated with 

o  Explore the role of the neuroendocrine system in the development of 
cachexia; and

o  Examine the contribution of cachexia to the progression of 
neurodegenerative disease.

It is the policy of the NIH that women and members of minority groups and 
their sub-populations must be included in all NIH-supported biomedical and 
behavioral research projects involving human subjects, unless a clear and 
compelling rationale and justification are provided indicating that inclusion 
is inappropriate with respect to the health of the subjects or the purpose of 
the research.  This policy results from the NIH Revitalization Act of 1993 
(Section 492B of Public Law 103-43). 

All investigators proposing research involving human subjects should read the 
UPDATED "NIH Guidelines for Inclusion of Women and Minorities as Subjects in 
Clinical Research," published in the NIH Guide for Grants and Contracts on 
August 2, 2000 
a complete copy of the updated Guidelines are available at  The 
revisions relate to NIH defined Phase III clinical trials and require: a) all 
applications or proposals and/or protocols to provide a description of plans 
to conduct analyses, as appropriate, to address differences by sex/gender 
and/or racial/ethnic groups, including subgroups if applicable; and b) all 
investigators to report accrual, and to conduct and report analyses, as 
appropriate, by sex/gender and/or racial/ethnic group differences.


It is the policy of NIH that children (i.e., individuals under the age of 21) 
must be included in all human subjects research, conducted or supported by the 
NIH, unless there are scientific and ethical reasons not to include them.  
This policy applies to all initial (Type 1) applications submitted for receipt 
dates after October 1, 1998.

All investigators proposing research involving human subjects should read the 
"NIH Policy and Guidelines on the Inclusion of Children as Participants in 
Research Involving Human Subjects" that was published in the NIH Guide for 
Grants and Contracts, March 6, 1998, and is available at the following URL 

Investigators also may obtain copies of these policies from the program staff 
listed under INQUIRIES.  Program staff may also provide additional relevant 
information concerning the policy.


All applications and proposals for NIH funding must be self-contained within 
specified page limitations.  Unless otherwise specified in an NIH 
solicitation, Internet addresses (URLs) should not be used to provide 
information necessary to the review because reviewers are under no obligation 
to view the Internet sites.  Reviewers are cautioned that their anonymity may 
be compromised when they directly access an Internet site.


Applications are to be submitted on the grant application form PHS 398 (rev. 
4/98) and will be accepted at the standard application deadlines as indicated 
in the application kit.  Application kits are available at most institutional 
offices of sponsored research and may be obtained from the Division of 
Extramural Outreach and Information Resources, National Institutes of Health, 
6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/710-0267, email:

Applicants planning to submit an investigator-initiated new (type 1), 
competing continuation (type 2), competing supplement, or any amended/revised 
version of the preceding grant application types requesting $500,000 or more 
in direct costs for any year are advised that he or she must contact the 
Institute or Center (IC) program staff before submitting the application, 
i.e., as plans for the study are being developed.  Furthermore, the 
application must obtain agreement from the IC staff that the IC will accept 
the application for consideration for award.  Finally, the applicant must 
identify, in a cover letter sent with the application, the staff member and 
Institute or Center who agreed to accept assignment of the application.  

This policy requires an applicant to obtain agreement for acceptance of both 
any such application and any such subsequent amendment.  Refer to the NIH 
Guide for Grants and Contracts, March 20, 1998 at

The modular grant concept establishes specific modules in which direct costs 
may be requested as well as a maximum level for requested budgets. Only 
limited budgetary information is required under this approach.  The 
just-in-time concept allows applicants to submit certain information only when 
there is a possibility for an award. It is anticipated that these changes will 
reduce the administrative burden for the applicants, reviewers and Institute 
staff.  The research grant application form PHS 398 (rev. 4/98) is to be used 
in applying for these grants, with the modifications noted below.



Modular Grant applications will request direct costs in $25,000 modules, up to 
a total direct cost request of $250,000 per year. (Applications that request 
more than $250,000 direct costs in any year must follow the traditional PHS 
398 application instructions.)  The total direct costs must be requested in 
accordance with the program guidelines and the modifications made to the 
standard PHS 398 application instructions described below:

PHS 398

o FACE PAGE: Items 7a and 7b should be completed, indicating Direct Costs (in 
$25,000 increments up to a maximum of $250,000) and Total Costs [Modular Total 
Direct plus Facilities and Administrative  (F&A) costs] for the initial budget 
period Items 8a and 8b should be completed indicating the Direct and Total 
Costs for the entire proposed period of support.

of the PHS 398. It is not required and will not be accepted with the 

categorical budget table on Form Page 5 of the PHS 398. It is not required and 
will not be accepted with the application.

o NARRATIVE BUDGET JUSTIFICATION - Prepare a Modular Grant Budget Narrative 
page. (See for sample 
pages.) At the top of the page, enter the total direct costs requested for 
each year.  This is not a Form page.

o Under Personnel, list all project personnel, including their names, percent 
of effort, and roles on the project. No individual salary information should 
be provided. However, the applicant should use the NIH appropriation language 
salary cap and the NIH policy for graduate student compensation in developing 
the budget request.

For Consortium/Contractual costs, provide an estimate of total costs (direct 
plus facilities and administrative) for each year, each rounded to the nearest 
$1,000. List the individuals/organizations with whom consortium or contractual 
arrangements have been made, the percent effort of all personnel, and the role 
on the project. Indicate whether the collaborating institution is foreign or 
domestic. The total cost for a consortium/contractual arrangement is included 
in the overall requested modular direct cost amount.  Include the Letter of 
Intent to establish a consortium.

Provide an additional narrative budget justification for any variation in the 
number of modules requested.

o BIOGRAPHICAL SKETCH - The Biographical Sketch provides information used by  
reviewers in the assessment of each individual's qualifications for a specific 
role in the proposed project, as well as to evaluate the overall 
qualifications of the research team. A biographical sketch is required for all 
key personnel, following the instructions below. No more than three pages may 
be used for each person. A sample biographical sketch may be viewed at:

- Complete the educational block at the top of the form page;
- List position(s) and any honors;
- Provide information, including overall goals and responsibilities, on 
research projects ongoing or completed during the last three years.
- List selected peer-reviewed publications, with full citations;

o CHECKLIST - This page should be completed and submitted with the 
application. If the F&A rate agreement has been established, indicate the type 
of agreement and the date. All appropriate exclusions must be applied  in the 
calculation of the F&A costs for the initial budget period and all future 
budget years.

o The applicant should provide the name and phone number of the individual to 
contact concerning fiscal and administrative issues if additional information 
is necessary following the initial review. 

The title and number of the program announcement must be typed on line 2 of 
the face page of the application form and the YES box must be marked.

Submit a signed, typewritten original of the application, including the 
Checklist, and five signed photocopies in one package to:

BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)


Applications will be assigned on the basis of established PHS referral 
guidelines.  Applications will be evaluated for scientific and technical merit 
by an appropriate scientific review group convened in accordance with the 
standard NIH peer review procedures.  As part of the initial merit review, all 
applications will receive a written critique and undergo a process in which 
only those applications deemed to have the highest scientific merit, generally 
the top half of applications under review, will be discussed, assigned a 
priority score, and receive a second level review by the appropriate national 
advisory council or board.

Review Criteria

The goals of NIH-supported research are to advance our understanding of 
biological systems, improve the control of disease, and enhance health.  In 
the written comments reviewers will be asked to discuss the following aspects 
of the application in order to judge the likelihood that the proposed research 
will have a substantial impact on the pursuit of these goals.  Each of these 
criteria will be addressed and considered in assigning the overall score, 
weighting them as appropriate for each application.  Note that the application 
does not need to be strong in all categories to be judged likely to have major 
scientific impact and thus deserve a high priority score.  For example, an 
investigator may propose to carry out important work that by its nature is not 
innovative but is essential to move a field forward.

(1) Significance:  Does this study address an important problem?  If the aims 
of the application are achieved, how will scientific knowledge be advanced?  
What will be the effect of these studies on the concepts or methods that drive 
this field?

(2) Approach:  Are the conceptual framework, design, methods, and analyses 
adequately developed, well-integrated, and appropriate to the aims of the 
project?  Does the applicant acknowledge potential problem areas and consider 
alternative tactics?

(3) Innovation:  Does the project employ novel concepts, approaches or method? 
Are the aims original and innovative?  Does the project challenge existing 
paradigms or develop new methodologies or technologies?

(4) Investigator:  Is the investigator appropriately trained and well suited 
to carry out this work?  Is the work proposed appropriate to the experience 
level of the principal investigator and other researchers (if any)?

(5) Environment:  Does the scientific environment in which the work will be 
done contribute to the probability of success?  Do the proposed experiments 
take advantage of unique features of the scientific environment or employ 
useful collaborative arrangements?  Is there evidence of institutional 

In addition to the above criteria, in accordance with NIH policy, all 
applications will also be reviewed with respect to the following:

o  The adequacy of plans to include both genders, minorities and their 
subgroups, and children as appropriate for the scientific goals of the 
research.  Plans for the recruitment and retention of subjects will also be 

o  The reasonableness of the proposed budget and duration in relation to the 
proposed research

o  The adequacy of the proposed protection for humans, animals or the 
environment, to the extent they may be adversely affected by the project  
proposed in the application.

Additional scientific/technical merit criteria specific to the objectives of 
the PA and the mechanism used must be included if they are to be used in the 


Applications will compete for available funds with all other recommended 
applications. The following will be considered in making funding decisions:  
Quality of the proposed project as determined by peer review, availability of 
funds, and program priority.


Inquiries are encouraged.  The opportunity to clarify any issues or questions 
from potential applicants is welcome.

Direct inquiries regarding programmatic issues to:

Dr. Hilary Sigmon
Office of Extramural Programs
National Institute of Nursing Research
Building 45, Room Number 3AN12, MSC 6300
Bethesda, MD  20892-6300
Telephone:  (301) 594-5970
FAX:  (301) 480-8260

Dr. Claudette Varricchio
Program Director
Division of Cancer Prevention
National Cancer Institute
6130 Executive Blvd.  EPN 300
Bethesda, MD, 20892
Telephone: (301) 496-8541
FAX: (301) 496-8667

Dr. Louis A. Quatrano
National Center for Medical Rehabilitation Research
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 2A03, MSC 7510
Bethesda, MD 20892-7510
Telephone:  (301) 402-4221
FAX:  (301) 402-0832

Dr. Frank A. Hamilton
Chief, Digestive Disease Program Branch
Division of Digestive Diseases and Nutrition
National Institute of Diabetes and Digestive and Kidney Diseases
6707 Democracy Blvd. Room 669
Bethesda, Maryland 20892-5450
Telephone: (301) 594-8877
FAX: (301) 480-8300

Dr. Jill E. Heemskerk
Program Director
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Neuroscience Center, Room 2204
6001 Executive Boulevard 
Bethesda, MD 20892-9525 (for courier service, use: Rockville, MD  20852)
Telephone: (301) 496-5680
FAX: (301) 480-1080

Direct inquiries regarding fiscal matters to:

Ms. Tara Mowrey
Office of Grants and Contract Management
National Institute of Nursing Research
Building 45, Room Number 3AN12, MSC 6300
Bethesda, MD  20892-6300
Telephone:  (301) 594-5979
FAX:  (301) 480-8260

Ms. Eileen Natoli
Grants Administration Branch
National Cancer Institute
6120 Executive Boulevard, Room 243, MSC 7150
Rockville, MD  20892-7150
Telephone: (301) 496-8791
FAX: (301) 402-0275

Ms. Carolyn Kofa
Grants Management Branch
National Institute of Diabetes and Digestive and Kidney Diseases
Bethesda, MD  20892
Telephone: (301) 594-7687
FAX: (301) 480-3504

Mr. Christopher Myers
Grants Management Branch
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 8A17H, MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 435-6996
FAX: (301) 402-0915

Ms. Kimberly Pendleton
Grants Management Branch
National Institute of Neurological Disorders and Stroke
6001 Executive Blvd., NSC Room 3260
Bethesda, Maryland  20892 (USPS)
Rockville, MD  20852  (Courier and FedEx)
Tel:  301-496-7480
Fax:  301-402-0219


This program is described in the Catalog of Federal Domestic Assistance No. 
93.361 (NINR), 93.393 (NCI),93.929, 93.848 (NIDDK), and 93.853 (NINDS). Awards 
are made under authorization of sections 301 and 405 of the Public Health 
Service Act as amended (42 USC 241 and 284) and administered under NIH grants 
policies and Federal Regulations 42 CFR 52 and 45 CFR Parts 74 and 92.  This 
program is not subject to the intergovernmental review requirements of 
Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a 
smoke-free workplace and promote the non-use of all tobacco products.  In 
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking 
in certain facilities (or in some cases, any portion of a facility) in which 
regular or routine education, library, day care, health care or early 
childhood development services are provided to children.  This is consistent 
with the PHS mission to protect and advance the physical and mental health of 
the American people.

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