Preventing
Tobacco Use

Among Young People

A Report of the
Surgeon General

Executive Summary

U.S.DEPARTMENTOFHEAITHANDHUMANSERVKES
Public Health Service
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health

Federal Recycling Program
   o ?
??
Printed on Recycled Paper


Suggested Citation

U.S. Department of Health and Human Services. Prezmting Tobacco Use Among Young People:
A Report of the Surge& General. Atlanta, Georgia: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease Control and Prevention, National Ce&er
for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

Use of trade names is for identification only and does not constitute endorsement by the Public
Health Service or the U.S. Department of Health and Human Services.


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WASHINGTON. D.C. 20201

The Honorable Thomas S. Foley
Speaker of the House of Representatives
Washington, D.C. 20515

Dear Mr. Speaker:

It is my pleasure to transmit to the Congress the Surgeon
General's report on the health consequences of smoking
entitled Preventins Tobacco Use Amons Youns Peoole. This
report is mandated by section 8(a) of the Public Health
Cigarette Smoking Act of 1969 (Public Law 91-222) and includes
the health effects of smokeless tobacco products as mandated
by section 8(a) of the Comprehensive Smokeless Tobacco Health
Education Act of 1986 (Public Law 99-252).  The report was
prepared by the Centers for Disease Control and Prevention's
Office on Smoking and Health.

This report focuses on the vulnerable adolescent ages of 10
through 18 when most users start smoking, chewing, or dipping
and become addicted to tobacco.  It examines the health
effects of early smoking and smokeless tobacco use, the
reasons that young men and women begin using tobacco, the
extent to which they use it, and efforts to prevent tobacco
use by young people.

Smoking kills 434,000 Americans each year.  Adolescent smoking
and smokeless tobacco use are the first steps in this totally
preventable public health tragedy.  The facts are simple: one
out of three adolescents in the United States is using tobacco
by age 18, adolescent users become adult users, and few people
begin to use tobacco after age 18.  Preventing young people
from starting to use tobacco is the key to reducing the death
and disease caused'by tobacco use.  This report documents that
intervention programs targeting the broad social environment
of adolescents are both effective and warranted.

A great opportunity lies before us to prevent millions of
premature deaths and improve the quality of lives.   This
report points out the overwhelming need in public health for
efforts directed toward stopping young people before they
start using tobacco.

Enclosure


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WASHINGTON. O.C. 20201

The Honorable Albert Gore, Jr.
President of the Senate
Washington, D.C. 20510

Dear Mr.  President:

It is my pleasure to transmit to the Congress the Surgeon
General's report on the health consequences of smoking
entitled Preventins Tobacco Use Amons Young People.   This
report is mandated by section 8(a) of the Public Health
Cigarette Smoking Act of 1969 (Public Law 91-222) and includes
the health effects of smokeless tobacco products as mandated
by section 8(a) of the Comprehensive Smokeless Tobacco' Health
Education Act of 1986 (Public Law 99-252).  The report was
prepared by the Centers for Disease Control and Prevention's
Office on Smoking and Health.

This report focuses on the vulnerable adolescent ages of 10
through 18 when most users start smoking, chewing, or dipping
and become addicted to tobacco.   It examines the health
effects of early smoking and smokeless tobacco use, the
reasons that young men and women begin using tobacco, the
extent to which they use it, and efforts to prevent tobacco
use by young people.

Smoking kills 434,000 Americans each year.  Adolescent smoking
and smokeless tobacco use are the first steps in this totally
preventable public health tragedy.  The facts are simple: one
out of three adolescents in the United States is using tobacco
by age 18,  adolescent users become adult users, and few people
begin to use tobacco after age 18.  Preventing young people
from starting to use tobacco is the key to reducing the death
and disease caused by tobacco use.  This report documents that
intervention programs targeting the broad social environment
of adolescents are both effective and warranted.

A great opportunity lies before us to prevent millions of
premature deaths and improve the quality of lives. This
report points out the overwhelming need in public health for
efforts directed toward stopping young people before they
start using tobacco.

Donna E. Shalala

Enclosure


Foreword

This Surgeon General's report on smoking and health is the twenty-third in a
series that was begunin 1964 and mandated by federal law in 1969. This report is the
first in this series to focus on young people. It underscores the seriousness of tobacco
use, its relationship to other adolescent problem behaviors, and the responsibility of alI
                                       ..
citizens to protect the health of our children.

Since 1964, substantial changes have occurred in scientific knowledge of the
health consequences of smoking and smokeless tobacco use. Much more is also known
about programs and policies that encourage nonsmoking behavior among adults and
protect nonsmokers from exposure to environmental tobacco smoke. Although con-
siderable gains have been made against smoking among U.S. adults, this progress has
not been realized with young people. Onset rates of cigarette smoking among our
youth have not declined over the past decade, and 28 percent of the nation's high school
seniors are currently cigarette smokers;

The onset of tobacco use occurs primarily in early adolescence, a developmental
stage that is several decades removed from the death and disability that are associated
with smoking and smokeless tobacco use in adulthood. Currently, very few people
begin to use tobacco as adults; almost all first use has occurred by the time people
graduate from high school. The earlier young people begin using tobacco, the more
heavily they are likely to use it as adults, and the longer potential time they have to be
users. Both the duration and the amount of tobacco use are related to eventual chronic
health problems. The processes of nicotine addiction further ensure that many of
today's adolescent smokers will regularly use tobacco when they are adults.

Preventing smoking and smokeless tobacco use among young people is critical to
ending the epidemic of tobacco use in the United States. This report examines the past
few decades' extensive scientific literature on the factors that influence the onset of use
among young people and on strategies to prevent this onset. To better understand
adolescent tobacco use, this report draws not only on medical and epidemiologic
research but also on behavioral and social investigations. The resulting examination of
the advertising and promotional activities of the tobacco industry, as well as the review
of research on the effects of these activities on young people, marks an important
contribution to our understanding of the epidemic of tobacco use in the United States
and elsewhere. In particular, this research on the social environment of young people
identifies key risk factors that encourage tobacco use. The careful targeting of these risk
factors-on a communitywide basis-has proven successful in preventing the onset
and development of tobacco use among; young people.

Philip R. Lee, M.D.
Assistant Secretary for Health
Public Health Service

David Satcher, M.D., Ph.D.
Director
Centers for Disease Control
and Prevention


Preface

   fvom the Surgeon General,
U.S. Department of Health and Human Services

The public health movement against tobacco use will be successful when young
people no longer want to smoke. We are not there yet. Despite 30 years of decline in
overall smoking prevalence, despite widespread dissemination of information about
smoking, despite a continuing decline in the social acceptability of smoking, substantial
numbers of young men and women begin to smoke and become addicted. These
current and future smokers are new recruits in the continuing epidemic of disease,
disability, and death attributable to tobacco use. When young people no longer want to
smoke, the epidemic itself will die.

  This report of the Surgeon General, Preventing Tobucco Use Among Young People,
delineates the problem in no uncertain terms. The direct effects of tobacco use on the
health of young people have been greatly underestimated. The long-term effects are, of
course, well established. The addictive nature of tobacco use is also wellknown, but it
is perhaps less appreciated that early addiction is the chief mechanism for renewing the
pool of smokers. Most people who are going to smoke are hooked by the time they are
20 years old.

Young people face enormous pressures to smoke. The tobacco industry devotes
an annual budget of nearly $4 billion to advertising and promoting cigarettes. As this
report so well describes, there has been a continuing shift from advertising to promo-
tion, largely because of banning cigarette ads from broadcast media. The effect of the
ban is dubious, however, since the use of promotional materials, the sponsoring of
sports events, and the use of logos in nontraditional venues may actually be more
effective in reaching target audiences. Clearly, young people are being indoctrinated
with tobacco promotion at a susceptible time in their lives.

A misguided debate has arisen about whether tobacco promotion "causes" young
people to smoke-misguided because single-source causation is probably too simple
an explanation for any social phenomenon. The more important issue is what effect
tobacco promotion might have. Current research suggests that pervasive tobacco
promotion has two major effects: it creates the perception that more people smoke than
actually do, and it provides a conduit,between actual self-image and ideal self-image-
in other words, smoking is made to look cool. Whether causal or not, these effects foster
the uptake of smoking, initiating for many a dismal and relentless chain of events.

On the brighter side, a large portion of this report is devoted to countervailing
influences. We have the justification: there is a substantial scientific basis for primary
prevention of cigarette smoking and smokeless tobacco use. A number of successful
prevention programs, based on the psychological and behavioral factors that create
susceptibility to smoking, are available. We have the means: the report defines a
coordinated, effective, nonsmoking public health program for young people. And we
have the wilh schools, communities, legislatures, and public opinion all testify to the
growing support for encouraging young people to avoid tobacco use.

. . .
212


The task is by no means easy. This report underscores the commitment all of us
must have to the health of young people in the United States. Substantial work will be
required to translate the justification, the means, and the will into a world in which
young people no longer want to smoke. I, for one, relish the task.

M. Joycelyn Elders, M.D.
Surgeon General

iv


Preventing Tobacco Use Among Young People

Acknowledgments

This report was prepared by the Department of Health
and Human Services under the general direction of the
Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health.

David Satcher, M.D., Ph.D., Director, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Jeffrey P. Koplan, M.D., M.P.H., Director, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Richard B. Rothenberg, M.D., M.P.H., Associate Director
for Science, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Michael I'. Eriksen, Sc.D., Director, Office on Smoking
and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

The editors of the report were

Dee,Burton, Ph.D., Associate Director for Media Research,
University of Illinois at Chicago Prevention Research
Center, School of Public Health, Chicago, lllinois.
Frank J. Chaloupka IV, Ph.D., Assistant Professor,
Department of Economics, The University of Illinois at
Chicago, Chicago, Illinois.

K. Michael Cummings, Ph.D., M.P.H., Director, Smoking
Control Program, Roswell Park Cancer Institute, New
York State Department of Health, Buffalo, New York.

Joseph R. DiFranza, M.D., Director of Research, Fitchburg
Family Practice Residency Program, Fitchburg,
Massachusetts.

Roselyn Payne Epps, M.D., M.P.H., Expert, National Cancer
Institute, National Institutes of Health, Bethesda, Maryland.

Jean L. Forster, Ph.D., M.P.H., Associate Professor,
Division of Epidemiology, School of Public Health,
University of Minnesota, Minneapolis, Minnesota.
Gary A. Giovino, Ph.D., Chief, Epidemiology Branch,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,

Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor,

       ,                   A
Division of Epidemiology, School of Public Health,

Gayle Lloyd, M.A., Managing Editor, Office on Smoking
Universitv of Minnesota, Minneapolis, Minnesota.

and Health, National Center for Chronic Disease

Georgia.
Elbert D. Glover, Ph.D., Director, Tobacco Research Center,
University School of Medicine/Robert C. Byrd Health
Mar-v Babb Randolph Cancer Center, West Virginia

Sciences Center, Morgantown, West Virginia.

Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Frederick L. Hull, Ph.D., Technical Editor, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Jack E. Henningfield, Ph.D., Chief, Clinical Pharmacology
Branch, Addiction Research Center, National Institute on
Drug Abuse, National Institutes of Health, Baltimore,
Maryland.
Lloyd Johnston, Ph.D., Program Director, Institute of
Social Research, University of Michigan, Ann Arbor,
Michigan.

Contributing authors were

David R. Arday, M.D., M.P.H., Preventive Medicine
Specialist, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Dennis V. Ary, Ph.D., Research Scientist, Oregon Research
Institute, and President, Oregon Center for Applied
Science, Eugene, Oregon.

Michael Booth, Ph.D., Lecturer, Department of Public
Health, University of Sydney, Sydney, Australia.

Laura Kann, Ph.D., Chief, Surveillance Research Section,
Division of Adolescent and School Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

R. Monina Klevens,D.D.S., M.P.H.,Epidemiologist,Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Edward Lichtenstein, Ph.D., Research Scientist, Oregon
Research Institute, Eugene, Oregon.


Marc Manley, M.D., M.P.H., Chief, Public Health
Applications Research Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Maryland.

Robert K. Merritt, M.A., Behavioral Scientist, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

David E. Nelson, M.D., M.P.H., Medical Epidemiologist,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Donald Nutbeam, Ph.D., Professor, Department of Public
Health, University of Sydney, Sydney, Australia.

Mario Orlandi, Ph.D., M.P.H., Chief, Division of Health
Promotion Research, American Health Foundation, New
York, New York.

Cheryl L. Perry, Ph.D., Professor, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

Richard W. Pollay, Ph.D., Professor of Marketing and
Curator, History of Advertising Archives, Faculty of
Commerce, University of British Columbia, Vancouver,
British Columbia.

Edward T. Popper, D.B.A., Professor of Business
Administration and Marketing, Dean, School of Business
and Professional Studies, Aurora University, Aurora,
Illinois.

Jonathan M. Samet, M.D., Professor of Medicine,
University of New Mexico, School of Medicine,
Albuquerque, New Mexico.

Herbert H. Severson, Ph.D., Research Scientist, Oregon
Research Institute, Eugene, Oregon.

Dana M. Shelton, M.P.H., Epidemiologist, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Charles W. Warren, Ph.D., Sociologist, Division of
Adolescent and School Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

John K. Worden, Ph.D., Research Professor, Department
of Family Practice and Office of Health Promotion
Research, University of Vermont, Burlington, Vermont.

Surgeon General's Report

Reviaoers were

David G. Altman, Ph.D., Senior Research Scientist,
Stanford Center for Research in Disease Prevention,
Stanford University, Palo Alto, California.

Karl E. Bauman, Ph.D., Professor, Department of Health
Behavior and Health Education, School of Public Health,
University of North Carolina, Chapel Hill, North Carolina.
Richard F. Beltramini, Ph.D., Associate Professor,
Department of Marketing, Arizona State University,
Tempe, Arizona.

Glen Bennett, M.P;H., Coordinator, Smoking Education
Program, National Heart, Lung and Blood Institute,
National Institutes of Health, Bethesda, Maryland.

Neal Benowitz, M.D., Professor of Medicine, University
of California at San Francisco, San Francisco, California.

Gilbert J. Botvin, Ph.D., Professor and Director, Institute
for Prevention Research, Cornell University Medical
College, New York, New York.
Robert G. Brubaker, Ph.D., Professor, Department of
Psychology, Eastern Kentucky University, Richmond,
Kentucky.

David M. Bums, M.D., Professor of Medicine, University
of California, San Diego School of Medicine, San Diego,
California.

Laurie Chassin, Ph.D., Professor, Arizona State University,
Department of Psychology, Tempe, Arizona.

Arden G. Christen, D.D.S., Professor of Oral Biology,
Department of Oral Biology, Indiana University School
of Dentistry, Indianapolis, Indiana.
Robert J. Collins, D.M.D., M.P.H., Chief Dental Officer,
Public Health Service, Indian Health Service, Rockville,
Maryland.

Gregory Connolly,  D.M.D., M.P.H., Director,
Massachusetts Tobacco Control Program, Massachusetts
Department of Public Health, Boston, Massachusetts.

K. Michael C ummings, Ph.D., M.P.H., Director, Smoking
Control Program, Roswell Park Cancer Institute, New
York State Department of Health, Buffalo, New York.
Dorynne J. Czechowicz, M.D., Associate Director for
Medical and Professional Affairs, Division of Clinical
Research, National Institute on Drug Abuse, National
Institutes of Health, Rockville, Maryland.

Michael M. Daube, Public Service Commission, Perth,
Australia.

vi


Preventing Tobacco Use Among Young People

Ronald M. Davis, M.D., Chief Medical Officer, Michigan
Department of Public Health, Lansing, Michigan.

John Elder, Ph.D , M.P.H., Professor of Health Promotion,
Graduate School of Public Health, San Diego State
University, San Diego, California.

Paul Fischer, M.D., Editor, Journal of Family Practice,
Augusta, Georgia.

Michael C. Fiore, M.D., M.P.H., Director, Center for
Tobacco Research and Intervention, University of
Wisconsin Medical School, Madison, Wisconsin.

Brian R. Flay, D. Phil., Professor and Director, Prevention
Research Center, School of Public Health, University of
Illinois, Chicago, Illinois.

Erica Frank, M.D., M.P.H., Assistant Professor,
Department of Community Preventive Medicine/
Department of Medicine, Emory University School of
Medicine, Atlanta, Georgia.

Betsy Gelb, Ph.D., Director, Institute for Health Care
Marketing, and Professor of Marketing, University of
Houston, Houston, Texas.

Samuel S. Gidding, M.D., Associate Professor of Pediatrics,
Northwestern University Medical School, Division of
Cardiology, Children's Memorial Hospital, Chicago,
IlhOiS.

Thomas Glynn, Ph.D., Acting Associate Director, Cancer
Control Science Program, National Cancer Institute,
National Institutes of Health, Bethesda, Maryland.

Ellen R. Gritz, Ph.D., Professor and Chair, Department of
Behavioral Science, The University of Texas M.D.
Anderson Cancer Center, Houston, Texas.

Sandra W. Headen, Ph.D., Assistant Professor of Research,
Department of Health Behavior and Health Education,
School of Public Health, Chapel Hill, North Carolina.

Richard B. Heyman, M.D., Committee on Substance
Abuse, American Academy of Pediatrics, and Suburban
Pediatric Associates, Inc., Cincinnati, Ohio.

David Hill, Ph.D., Director, Anti-Cancer Council of
Victoria, Victoria, Australia.

Thomas Houston, M.D., Director, Department of
Preventive Medicine and Public Health, American
Medical Association, Chicago, Illinois.
John Hughes, M.D., Professor, Human Behavioral
Pharmacology Laboratory, Departments of Psychiatry,
Psychology, and Family Practice, University of Vermont,
Burlington, Vermont.

vii

Saundra MacD. Hunter, Ph.D., Research Professor, Tulane
University Medical Center, Department of Applied Health
Sciences, School of Public Health and Tropical Medicine,
New Orleans, Louisiana.

Dushanka V. Kle' mman, D.D.S., Deputy Director, National
Institute of Dental Research, National Institutes of Health,
Bethesda, Maryland.

Norman A. Krasnegor, Ph.D., Chief, Human Learning
and Behavior Branch, National Institute of Child Health
and Human Development, National Institutes of Health,
Bethesda, Maryland.

Edward Lichtenstein, Ph.D., Research Scientist, Oregon
Research Institute, Eugene, Oregon.

Douglas S. Lloyd, M.D.,M.P.H., Associate Administrator
for Public Health Practice, Health Resources and Services
Administration, Department of Health and Human
Services, Rockville, Maryland.

Russell V. Luepker, M.D., M.S., Professor and Head,
Division of Epidemiology, School of Public Health,
University of Minnesota, Minneapolis, Minnesota.

William R. Lynn, Public Health Advisor, Cancer Control
Science Program, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland.

Willard Manning, Ph.D., Professor, Institute for Health
Services Research, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.
Stephen E. Marcus, Ph.D., Senior Epidemiologist, National
Institute of Dental Research, National Institutes of Health,
Bethesda, Maryland.

J. Michael McGinnis, M.D., Deputy Assistant Secretary
for Health, Office of Disease Prevention and Health
Promotion, Department of Health and Human Services,
Washington, D.C.

Ann D. McNeil, Ph.D., Manager, Smoking Program,
Health Education Authority, London, England.

David Murray, Ph.D., Professor, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.
Thomas, Novotny, M.D., M.P.H., Centers for Disease
Control and Prevention Liaison Officer and Assistant
Dean for Public Health Practice, School of Public Health,
University of California, Berkeley South, Berkeley,
California.

Patrick O'Malley, Ph.D., Research Scientist, Institute for
Social Research, Survey Research Center, University of
Michigan, Ann Arbor, Michigan.


Guy S. Parcel, Ph.D., Professor and Director, Center for
Health Promotion and Research Development, University
of Texas Health Science Center, Houston, Texas.

Joseph Patterson, Director of Government Relations and
Special Projects, American Cancer Society, Atlanta, Georgia.
Terry F. Pechacek, Ph.D., Associate Professor, School of
Medicine and Biomedical Sciences, State University of
New York, Buffalo, New York.

Michael Pertschuk, J.D., Co-Director, The Advocacy
Institute, Washington, D.C.

John P. Pierce, Ph.D., Associate Professor and Head,
Cancer Prevention and Control, University of California,
San Diego, California.

John M. Pinney, Chief Executive Officer, Corporate Health
Policies Group, Bethesda, Maryland.

Patrick Remington, M.D., State Medical Officer and
Epidemiologist, Chronic Disease and Health Promotion
Section, Wisconsin Department of Health and Social
Services, Madison, Wisconsin.

John W. Richards, Jr., M.D., Associate Editor, journal of
Family Practice, Augusta, Georgia.
Julius Richmond, M.D., John D. McArthur Professor of
Health Policy Emeritus, Harvard Medical School, Boston,
Massachusetts.

Nancy A. Rigotti, M.D., Assistant Professor of Medicine
and Preventive Medicine, Harvard Medical School and
Associate Director, Quit Smoking Service, Massachusetts
General Hospital, Boston, Massachusetts.

Jonathan M. Samet, M.D., Professor of Medicine,
University of New Mexico, School of Medicine,
Albuquerque, New Mexico.

Thomas C. Schelling, Ph.D., Distinguished Professor of
Economics and Public Affairs, Department of Economics/
School of Public Affairs, University of Maryland, College
Park, Maryland.
Russell Sciandra, M.A., Project Manager, American Stop
Smoking Intervention Study for Cancer Prevention, New
York State Department of Health, Albany, New York.

Donald R. Shopland, Coordinator, Smoking and Tobacco
Control Program, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland.

Vivian L. Smith, M.S.W., Acting Director, Center for
Substance Abuse Prevention, Substance Abuse and
Mental Health Services Administration, Rockville,
Maryland.

Jesse Steinfeld, M.D., Surgeon General, U.S. Public Health
Service, 1969-1973, San Diego, California.

*..
21111

Surgeon General's Report

Steve Sussman, Ph.D., Associate Professor, Institute for
Health Promotion and Disease Prevention Research,
University of Southern California, Alhambra, California.
ha B. Tager, M.D., Professor of Epidemiology, University
of California, Berkeley, School of Public Health, Berkeley,
California.

Larry Wallack, Dr. P.H., Professor, School of Public
Health, University of California at Berkeley, Berkeley,
California.

Kenneth E. Warner, Ph.D., Professor and Chair,
Department of Public Health Policy and Administration,
School of Public Health, University of Michigan, Ann
Arbor, Michigan.

Jeffrey Wasserman, Ph.D., Associate Director, Health
Policy Research, SysteMetrics, Santa Barbara, California.
Scott T. Weiss, M.D., Associate Professor of Medicine,
Harvard School of Public Health, and Channing
Laboratory, Harvard Medical School, and Brigham and
Women's Hospital, Boston, Massachusetts.
Judith Wilkenfeld, J.D., Assistant Director, Division of
Advertising Practices, Federal Trade Commission,
Washington, D.C.

Deborah M. Winn, Ph.D., Chief, Analytical Studies and
Decision Systems Branch, Epidemiology and Oral Disease
Prevention Program, National Institute of Dental
Research, National Institutes of Health, Bethesda,
Maryland.

Ernst L. Wynder, M.D., President, American Health
Foundation, New York, New York.

Other contributors were

Deborah Anker, M.A., Graphic Artist, Circle Solutions,
Inc., McLean, Virginia.

Victoria Agee, M.L.S., Agee Indexing Services,
Albuquerque, New Mexico.

Kelly L. Byrne, Word Processing Specialist, Circle
Solutions, Inc., McLean, Virginia.
Michele Chang, Special Assistant to the Director, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Jeffrey H. Chrismon, Computer Programmer, The Orkand
Corporation, Atlanta, Georgia.
Anita Cowan, M.L.S., Director, Information Systems and
Services Group, Circle Solutions, Inc., McLean, Virginia.


Preventing Tobacco Use Among Young People

Karen M. Deasy, Assistant Director (Liaison), Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Washington, D.C.

Susan R. Derrick, Editorial Assistant, Office on Smoking
and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Alice A. DeViemo, M.L.S., Manager,Technical Information
Center, Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Atlanta, Georgia.
Elizabeth D. E&l, M.S.L.S., Information Specialist, Circle
Solutions, Inc., McLean Virginia.
Joseph Gfroerer, Statistician, Division of Epidemiology
and Prevention Research, National Institute on Drug
Abuse, National Institutes of Health, Rockville, Maryland.

Donna Gloria, secretary, HCR Consulting Group, Atlanta,
Georgia.

Lakshmi M. Grama, M.L.S., Database Advisor, Circle
Solutions, Inc., McLean, Virginia.

Janet C. Greenblatt, Statistician, Office of Applied Studies,
Substance Abuse and Mental Health Services
Administration, Washington, D.C.

William A. Harris, Computer Specialist, Division of
Adolescent and School Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Lillian Hatch, M.S.L.S., Information Specialist, Circle
Solutions, Inc., McLean, Virginia.

Corinne G. Husten, M.D., M.P.H., Medical Officer, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Gwendolyn A. Ingraham, Writer-Editor, National Center
for Injury Prevention and Control, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Jeffrey C. Johnson, Computer Specialist, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

Doreen Johnson-Kloehn, M.A., Scientist, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.
Steven C. Joseph, M.D., Dean, School of Public Health,
University of Minnesota, Minneapolis, Minnesota.

Sarah Knowlton, J.D., Attorney-Advisor, Office of the
General Counsel, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Kelli Komro, M.S. W., M.P.H., Doctoral Student, Division
of Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

Sushi1 Kriplani, M.A., Consultant, Minneapolis,
Minnesota.

Mark J. Leech, M.A., Information Specialist, Circle
Solutions, Inc., McLean, Virginia.
Peggy Lytton, Editor, Circle Solutions, Inc., McLean,
Virginia.

Karen McCloud, Editorial Assistant, HCR Consulting
Group;Atlanta, Georgia.
Bonnie L. Manning, Executive Secretary, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.
William L. Marx, Technical Information Specialist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Daniel F. McLaughlin, Editor, Circle Solutions, Inc.,
McLean, Virginia.

Jennifer A. Michaels, M.L.S., Technical Information
Specialist, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Nancy A. Miltenberger, M.A., Editor, Circle Solutions,
Inc., McLean, Virginia.

Kimberly J. Miner, Ph.D., Postdoctoral Fellow, Division
of Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.
Paul D. Mowrey, M.S., Research Scientist, Battelle
Memorial Institute, Atlanta, Georgia.

Suong Nguyen, Student, School of Public Health, San
Diego University, San Diego, California.
Gwen J. Nunnally, Secretary, Office on Smoking and
Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

Cathie M. O'Donnell, Project Director, Circle Solutions,
Inc., McLean, Virginia.

ix


Surgeon Gmertll's Report

J.P. Peddicord, M.S., Computer Scientist, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Richard Ray, Director of Computer Services, Circle
Solutions, Inc., McLean, Virginia.

John Robey, Word Processing Specialist, Circle Solutions,
Inc., McLean, Virginia.

Kathleen L. Schroeder, D.D.S., Associate Professor of
Oral Pathology, West Virginia University School of
Medicine, Morgantown, West Virginia.

Maggie Shelby, Secretary, HCR Consulting Group,
Atlanta, Georgia.

Michael B. Siegel, M.D., M.P.H., Epidemiologist, Office
on Smoking and Health, National Center for Chronic
Disease ,Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Renee E. Sieving, M.S.N., Doctoral Student, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

Michael J. Staufacker, M.P.H., Doctoral Student, Division
of Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.

Scott L. Tomar, D.M.D., Dr.P.H., Epidemiologist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Traci L. Toomey, M.P.H., Doctoral Student, Division of
Epidemiology, School of Public Health, University of
Minnesota, Minneapolis, Minnesota.-

Laura Williams, Student, Northeast Ohio University
College of Medicine, Rootstown, Ohio.

Rebecca B. Wolf, M.A., Program Analyst, Office of
Program Planning and Evaluation, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Bao-Ping Zhu, Ph.D., Research Scientist, Battelle Memorial
Institute, Atlanta, Georgia.


Chapter 1

Introduction, Summary, and Chapter Conclusions

Introduction 5

Development of the Report  5
Major Conclusions 5

Summary 6

Introduction 6

Health Consequences of Tobacco Use Among Young People  6
The Epidemiology of Tobacco Use Among Young People  7
Efforts to Prevent the Onset of Tobacco Use  8
Summary 8

Chapter Conclusions 9

Chapter 2. The Health Consequences of Tobacco Use by Young People  9
Chapter 3. Epidemiology of Tobacco Use Among Young People in the United States  9
Chapter 4. Psychosocial Risk Factors for Initiating Tobacco Use  9
Chapter 5. Tobacco Advertising and Promotional Activities  20
Chapter 6. Efforts to Prevent Tobacco Use Among Young People  20

References 2 1


Preventing Tobacco Use Among Young People

Introduction

  Previous Surgeon General's reports on tobacco use
and health have largely focused on the epidemiologic,
clinical, biologic, and pharmacologic aspects of adult use
of tobacco products. This report on Preventing Tobacco
Use Among Young People provides a more detailed look at
adolescence, the time of life when most tobacco users
begin, develop, and establish their behavior. Because
regular use soon results in addiction to nicotine, this
behavior may persist through adulthood, significantly
increasing, through the extended years of use, the risk of
long-term, severe health consequences.
  Despite three decades of explicit health warnings,
large numbers of young people continue to take up
tobacco; currently, over three million adolescents smoke
cigarettes, and over one million adolescent males cur-
rently use smokeless tobacco. Clearly, effective interven-
tions are needed to prevent more young people from
trying tobacco. To achieve significant long-term reduc-
tions in tobacco use and tobacco-related deaths `in the
United States, we must examine the nature and scope of
adolescent tobacco use, consider the social, psychologi-
cal, and marketing factors that influence young people in
their decision to use tobacco products, and evaluate cur-
rent efforts to prevent young people from becoming
users. This report addresses the crucial problems of
adolescent tobacco use.

Development of the Report

  This report of the Surgeon General was prepared
by the Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Public Health
Service, U.S. Department of Health and Human Services,
as part of the departments responsibility, under Public
Law 91-222 and Public Law 99-252, to report current
information on the health effects of cigarette smoking
and smokeless tobacco use to the United States Congress.
This report is the first to focus on the problem of tobacco
use among young people. Given the continuing onset of
use in adolescence and the growing evidence of health
consequences associated with early use, the report was
seen as both needed and timely.

The current report has been produced through the
efforts of experts in the medical, pharmacologic,
epidemiologic, developmental, economic, behavioral,
legal, and public health aspects of smoking and smoke-
less tobacco use among young people. Initial manu-
scripts for the report were prepared by 28 scientists who

Major Conclusions

1.

2.

3.

Nearly all first use of tobacco occurs before high
school graduation; this finding suggests that if ado-
lescents can be kept tobacco-free, most will never
start using tobacco.

Most adolescent smokers are addicted to nicotine
and report that they want to quit but are unable to do
so; they experience relapse rates and withdrawal
symptoms similar to those reported by adults.
Tobacco is often the first drug used by those young
people who use alcohol, marijuana, and other drugs.

were selected for their expertise in specific content areas.
This material was consolidated into chapters, each of
which underwent peer review. The entire document was
reviewed by a number of experts in the field, as well as by
institutes and agencies within the U.S. Public Health
Service. The final draft of the report was reviewed by
the Assistant Secretary for Health and by the Secretary,
Department of Health and Human Services.

  Several concerns guided the development of this
report. The first, which is addressed in Chapter 2, is
whether tobacco use is associated with health conse-
quences during the period of adolescence (broadly de-
fined as ages 10 through 18, although research cited in
this report varies somewhat in the ages considered ado-
lescent). The long-term health consequences--that is,
those that emerge in adulthood-have been the subject
of extensive review and are widely acknowledged in the
scientific and public literature. The chapter thus focuses
on the serious health consequences, as well as the in-
creased risk factors for subsequent health consequences,
that are evident early in life among young smokers and
smokeless tobacco users. Chapter 3 examines the
epidemiologic patterns of tobacco use among the young.
National data on trends in adolescent use are analyzed to
determine the extent of the current problem, as well as to
note changes in patterns of initiation and use. The factors
that influence adolescents in their decision to use tobacco
are examined in Chapter 4, tihich considers psychosocial
risk factors, and Chapter 5, which examines the influence
of tobacco advertising and promotion. The final concern,
the focus of Chapter 6, was to assess what has been
done-from the individual level to the legislative level-
to prevent tobacco use among young people.

Introduction 5


Surgeon General's Report

Adolescents with lower levels of school achieve-     perceptions of the pervasiveness, image, and func-
ment, with fewer skills to resist pervasive influences     tion of smoking.

to use tobacco, with friends who use tobacco, and
with lower self-images are more likely than their
peers to use tobacco.
Cigarette advertising appears to increase young
people's risk of smoking by affecting their

6.  Communitywide efforts that include tobacco tax in-
creases, enforcement of minors' access laws, youth-
oriented mass media campaigns, and school-based
tobacco-use prevention pr&&ms are successful in
reducing adolescent use of tobacco.

Introduction

  The health effects of cigarette smoking have been
the subject of intensive investigation since the 1950s. Ciga-
rette smoking is still considered the chief preventable
cause of premature disease and death in the United
States. As was documented extensively in previous Sur-
geon General's reports, cigarette smoking has been caus-
ally linked to lung cancer and other fatal malignancies,
atherosclerosis and coronary heart disease, chronic ob-
structive pulmonary disease,, and other conditions that
constitute a wide array of serious health consequences
(USDHHS 1989). More recent studies have concluded
that passive (or involuntary) smoking can cause disease,
including lung cancer, in healthy nonsmokers. In 1986,
an advisory committee appointed by the Surgeon Gen-
eral released a special report on the health consequences
of smokeless tobacco, concluding that smokeless tobacco
use can cause cancer and can lead to nicotine addiction
(USDHI-IS 1986). In the 1988 report, nicotine was desig-
nated a highly addictive substance, comparable in its
physiological and psychological properties to other ad-
dictive substances of abuse WSDHHS 1988).

   Considerable evidence indicates that the health
problems associated with smoking are a function of the
duration (years) and the intensity (amount) of use. The
younger one begins to smoke, the more likely one is to be
a current smoker as an adult. Earlier onset of cigarette
smoking and smokeless tobacco use provides more life-
years to use tobacco and thereby increases the potential
duration of use and the risk of a range of more serious
health consequences.  Earlier onset is also associated
with heavier use; those who begin to use tobacco as
younger adolescents are among the heaviest users in
adolescence and adulthood. Heavier users are more
likely to experience tobacco-related health problems and
are the least likely to quit smoking cigarettes or using
smokeless tobacco. Preventing tobacco use among young
people is therefore likely to affect both duration and

intensity of total use of tobacco, potentiaUy reducing
long-term health consequences significantly.

Health Consequences of Tobacco Use
Among Young People

  Active smoking by young people is associated
with significant health problems during childhood
and adolescence and with increased risk factors for
health problems in adulthood. Cigarette smoking
during adolescence appears to reduce the rate of lung
growth and the level of maximum lung function that
can be achieved. Young smokers are likely to be less
physically fit than young nonsmokers; fitness levels
are inversely related to the duration and the intensity
of smoking. Adolescent smokers report that they are
significant1.y more likely than their nonsmoking peers
to experience shortness of breath, coughing spells,
phlegm production, wheezing, and overall dimin-
ished physical health. Cigarette smoking during child-
hood and adolescence poses a clear risk for respiratory
symptoms and problems during adolescence; these
health problems are risk factors for other chronic con-
ditions in adulthood, including chronic obstructive
pulmonary disease.

  Cardiovascular disease is the leading cause of
deathamong adults in the United States. Atheroscle-
rosis, however, may begh in childhood and become
clinically significant by young adulthood. Cigarette
smoking has been shown to be a primary risk factor
for coronary heart disease, arteriosclerotic peripheral
vascular disease, and stroke. Smoking by children
and adolescents is associated with an increased risk of
early atherosclerotic lesions and increased risk factors
for cardiovascular diseases. These risk factors include
increased levels of low-density lipoprotein cholesterol,
increased very-low-density lipoprotein cholesterol,
increased triglycerides, and reduced levels of

6 Infroducfion


Preventing Tobacco Use Among Young People

high-density lipoprotein cholesterol. If sustained into
adulthood, these patterns significantly increase the risk
for early development of cardiovascular disease.

   Smokeless tobacco use is associated with health
consequences that range from halitosis to severe health
problems such as various forms of oral cancer. Use of
smokeless tobacco by young people is associated with
early indicators of adult health consequences, including
periodontal degeneration, soft tissue lesions, and general
systemic alterations. Previous reports have documented
that smokeless tobacco use is as addictive for young
people as it is for adults. Another concern is that smoke-
less tobacco users are more likely than nonusers to be-
come cigarette smokers.

  Among addictive behaviors such as the use of alco-
hol and other drugs, cigarette smoking is most likely to
become established during adolescence. Young people
who begin to smoke at an earlier age are more likely than
later starters to develop long-term nicotine addiction.
Most young people who smoke regularly are already
addicted to nicotine, and they experience this addiction
in a manner and severity similar to what adult smokers
experience. Most adolescent smokers report that they
would like to quit smoking and that they have made
numerous, usually unsuccessful attempts to quit. Many
adolescents say that they intend to quit in the future and
yet prove unable to do so. Those who try to quit smoking
report withdrawal symptoms similar to those reported
by adults. Adolescents are difficult to recruit for formal
cessation programs, and when enrolled, are difficult to
retain in the programs. Success rates in adolescent cessa-
tion programs tend to be quite low, both in absolute
terms and relative to control conditions.

  Tobacco use is associated with a range of problem
behaviors during adolescence. Smokeless tobacco or
cigarettes are generally the first drug used by young
people in a sequence that can include tobacco, alcohol,
marijuana, and hard drugs. This pattern does not imply
that tobacco use causes other drug use, but rather that
other drug use rarely occurs before the use of tobacco.
Still, there are a number of biological, behavioral, and
social mechanisms by which the use of one drug may
facilitate the use of other drugs, and adolescent tobacco
users are substantially more likely to use alcohol and
illegal drugs than are nonusers. Cigarette smokers are
also more likely to get into fights, carry weapons, attempt
suicide, and engage in high-risk sexual behaviors. These
problem behaviors can be considered a syndrome, since
involvement in one behavior increases the risk for in-
volvement in others. Delaying or preventing the use of
tobacco may have implications for delaying or prevent-
ing these other behaviors as well.

The Epidemiology of Tobacco Use Among
Young People

  Overall, about one-third of high-school-aged ado-
lescents in the United States smoke or use smokeless
tobacco. Smoking prevalence among U.S. adolescents
declined sharply in the 197Os, but this decline slowed
significantly in the 198Os, particularly among white males.
Although female adolescents during the 1980s were more
likely than male adolescents to smoke, female and male
adolescents are now equally likely to smoke. Male ado-
lescents are substantially more likely than females to use
smokeless tobacco products; about 20 percent of high
school males report current use, whereas only about 1
percent of females do. White adolescents are more likely
to smoke and to use smokeless tobacco than are black
and Hispanic adolescents.

  So&demographic, environmentai, behavioral, and
personal factors can encourage the onset of tobacco use
among adolescents. Young people from families with
lower socioeconomic status, including those adolescents
living in single-parent homes, are at increased risk of
initiating smoking. Among environmental factors, peer
influence seems to be particularly potent in the early
stages of tobacco use; the first tries of cigarettes and
smokeless tobacco occur most often with peers, and the
peer group may subsequently provide expectations, re-
inforcement, and cues for experimentation. Parental
tobacco use does not appear to be as compelling a risk
factor as peer use; on the other hand, parents may exert a
positive influence by disapproving of smoking, being
involved in children's free time, discussing health mat-
ters with children, and encouraging children's academic
achievement and school involvement.

  How adolescents perceive their social environment
may be a stronger influence on behavior than the actual
environment. For example, adolescents consistently over-
estimate the number of young people and adults who
smoke. Those with the highest overestimates are more
likely to become smokers than are those with more accu-
rate perceptions. Similarly, those who perceive that ciga-
rettes are easily accessible and generally available are
more likely to begin smoking than are those who per-
ceive more difficulty in obtaining cigarettes.

  Behavioral factors figure heavily during adoles-
cence, a period of multiple transitions to physical matu-
ration, to a coherent sense of self, and to emotional
independence. Adolescents are thus particularly vulner-
able to a range of hazardous. behaviors and activities,
including tobacco use, that may seem to assist in these
transitions. Young people who report that smoking serves
positive functions or is potentially useful are at increased
risk for smoking. These functions are associated with

Introduction 7


Surgeon General's Report

bonding with peers, being independent and mature, and
having a positive social image. Since reports from
adolescents who begin to smoke indicate that they have
lower self-esteem and lower self-images than their non-
smoking peers, smoking can become a self-enhancement
mechanism. Similarly, not having the confidence to be
able to resist peer offers of tobacco seems to be an impor-
tant risk factor for initiation. Intentions to use tobacco
and actual experimentation also strongly predict subse-
quenxgular use.
   e positive functions that many young people
attribute to smoking are the same functions advanced in
most cigarette advertising. Young people are a strategi-
cally important market for the tobacco industry. Since
most smokers try their first cigarette before age 18, young
people are the chief source of new consumers for the
tobacco industry, which each year must replace the many
`consumers who quit smoking and the many who die
from smoking-related diseases. Despite restrictions on
tobacco marketing, children and adolescents continue to
be exposed to cigarette advertising and promotional ac-
tivities, and young people report considerable familiar-
ity with many cigarette advertisements. In the past, this
exposure was accomplished by radio and television pro-
grams sponsored by the cigarette industry. Barred since
1971 from using broadcast media, the tobacco industry
increasingly relies on promotional activities, including
sponsorship of sports events and public entertainment,
outdoor billboards, point-of-purchase displays, and the
distribution of specialty items that appeal to the young.
Cigarette advertisements in the print media persist; these
messages have become increasingly less informational,
replacing words with images to portray the attractive-
ness and function of smoking. Cigarette advertising fre-
quently uses human models or human-like cartoon
characters to display images of youthful activities, inde-
pendence, healthfulness, and adventure-seeking. In pre-
senting attractive images of smokers, cigarette
advertisements appear to stimulate some adolescents
who have relatively low self-images to adopt smoking as
a way to improve their own self-image. Cigarette adver-
tising also appears to affect adolescents' perceptions of
the pervasiveness of smoking, images of smokers, and
the function of smoking. Since these perceptions are
psychosocial risk factors for the initiation of smoking,
cigarette advertising appears to increase young people's
risk of `smoking.

Efforts to Prevent the Onset of Tobacco Use

  Most of the U.S. public strongly favors policies that
might prevent tobacco use among young people. These
policies include mandated tobacco education in schools,
a complete ban on smoking by anyone on school grounds,

further restrictions on tobacco advertising and promo-
tional activities, stronger prohibitions on the sale of to-
bacco products to minors, and increases in earmarked
taxes on tobacco products. Interventions to prevent ini-
tiation among young people--even actions that involve
restrictions on adult smoking or increased taxes-have
received strong support among smoking and nonsmok-
ing adults.

  Numerous research studies over the past 15 years
suggest that organized interventions can help prevent
the onset of smoking and smokeless tobacco use. School-
based smoking-prevention programs, based on a model
of identifying social influences on smoking and provid-
ing skills to resist those influences, have demonstrated
consistent and significant reductions in adolescent smok-
ing prevalence; these program effects have lasted one to
three years. Programs to prevent smokeless tobacco use
have used a similar model to achieve modest reductions
in initiation of use. The effectiveness of these school-
based programs appears to be enhanced and sustained,
at least until high school graduation, by adding coordi-
nated communitywide programs that involve parents,
youth-oriented mass media and counteradvertising, com-
munity organizations, or other elements of adolescents'
social environments.

  A crucial element of prevention is access: adoles-
cents should not be able to purchase tobacco products in
their communities. Active enforcement of age-at-sale
policies by public officials and community members ap-
pears necessary to prevent minors' access to tobacco.
Communities that have adopted tighter restrictions have
achieved reductions in purchases by minors. At the state
and national levels, price increases have significantly
reduced cigarette smoking; the young have been at least
as responsive as adults to these price changes. Maintain-
ing higher real prices of cigarettes provides a barrier to
adolescent tobacco use but depends on further tax in-
creases to offset the effects of inflation. The results of this
review thus suggest that a coordinated, multicomponent
campaign involving policy changes, taxation, mass me-
dia, and behavioral education can effectively reduce the
onset of tobacco use among adolescents.

summary

  Smoking and smokeless tobacco use are almost
always initiated and established in adolescence. Besides
its long-term effects on adults, tobacco use produces
specific health problems for adolescents. Since nicotine
addiction also occurs during adolescence, adolescent to-
bacco users are likely to become adult tobacco users.
Smoking and smokeless tobacco use are associated with
other problem behaviors and occur early in the sequence
of these behaviors. The outcomes of adolescent smoking

8 Introduction


Preventing Tobacco Use Among Young People

and,smokeless tobacco use continue to be of great public   relevant, and tobacco use may begin. This process most
health importance, since one out of three U.S. adoles-   affects adolescents who, compared with their peers, have
cents uses tobacco by age 18. The social environment of   lower self-esteem and self-images, are less involved with
adolescents, including the functions, meanings, and im-   school and academic achievement, have fewer skills to
ages of smoking that are conveyed through cigarette   resist the offers of peers, and come from homes with
advertising, sets the stage for adolescents to begin using   lower socioeconomic status. Tobacco-use prevention
tobacco. As tobacco products are available and as peers   programs that target the larger social environment of
begin to try them, these factors become personalized and    adolescents are both efficacious and warranted.

Chapter Conclusions

  Following are the specific conclusions for each chap
ter of this report:

Chapter 2. The Health Consequences of
Tobacco Use by Young People
1. Cigarette smoking during childhood and adoles-
cence produces significant health problems among
young people, including cough and phlegm pro-
duction, an increased number and severity of respi-
ratory illnesses, decreased physical fitness, an
unfavorable lipid profile, and potential retardation
in the rate of lung growth and the level of maximum
lung function.

2.  Among addictive behaviors, cigarette smoking is the
one most likely to become established during ado-
lescence. People who begin to smoke at an early age
are more likely to develop severe levels of nicotine
addiction than those who start at a later age.

3.  Tobacco use is associated with alcohol and illicit
drug use and is generally the first drug used by
young people who enter a sequence of drug use that
can include tobacco, alcohol, marijuana, and harder
drugs.

4.  Smokeless tobacco use by adolescents is associated
with early indicators of periodontal degeneration
  and with lesions in the oral soft tissue. Adolescent
smokeless tobacco users are more likely than nonus-
ers to become cigarette smokers.

Chapter 3. Epidemiology of Tobacco Use
Among Young People in the United States

1.  Tobacco use primarily begins in early adolescence,
typically by age 16; almost all first use occurs before
the time of high school graduation.
2. Smoking prevalence among adolescents declined
sharply in the 197Os, but the decline slowed

3.

4.

5.

significantly in the 1980s. At least 3.1 million adoles-
cents and 25 percent of 17- and 18-year-olds are
current smokers.

Although current smoking prevalence among fe-
male adolescents began exceeding that among males
by the mid- to late-197Os, both sexes are now equally
likely to smoke. Males are significantly more likely
than females to use smokeless tobacco. Nationally,
white adolescents are more likely to use all forms of
tobacco than are blacks and Hispanics. The decline
in the prevalence of cigarette smoking among black
adolescents is noteworthy.

Many adolescent smokers are addicted to cigarettes;
these young smokers report withdrawal symptoms
similar to those reported by adults.

Tobacco use in adolescence is associated with a range
of health-compromising behaviors, including being
involved in fights, carrying weapons, engaging in
higher-risk sexual behavior, and using alcohol and
other drugs.

Chapter 4. Psychosocial Risk Factors for
Initiating Tobacco Use

1.

2.

3.

The initiation and development of tobacco use among
children and adolescents progresses in five stages:
from forming attitudes and beliefs about tobacco, to
trying, experimenting with, and regularly using to-
bacco, to being addicted. Thi's process generally
takes about three years.

Sociodemographic factors associated with the onset
of tobacco use include being an adolescent from a
family with low socioeconomic status.

Environmental risk factors for tobacco use include
accessibility and availability of tobacco products,
perceptions by adolescents that tobacco use is

Introductiorr 9


normative, peers' and siblings' use and approval of
tobacco use, and lack of parental support and in-
volvement as adolescents face the challenges of
growing up.

Behavioral risk factors for tobacco use include low
levels of academic achievement and school involve-
ment, lack of skills required to resist influences to use
tobacco, and experimentation with any tobacco prod-
uct.

Personal risk factors for tobacco use include a lower
self-image and lower self-esteem than peers, the be-
lief that tobacco use is functional, and lack of self-
efficacy in the ability to refuse offers to use tobacco.
For smokeless tobacco use, insufficient knowledge
of the health consequences is also a factor.

Chapter 5. Tobacco Advertising and
Promotional Activities

1.  Young people continue to be a strategically impor-
tant market for the tobacco industry.

2.  Young people are currently exposed to cigarette
messages through print media (including outdoor
billboards) and through promotional activities, such
as sponsorship of sporting events and public enter-
tainment, point-of-sale displays, and distribution
of specialty items.

3.  Cigarette advertising uses images rather than infor-
mation to portray the attractiveness and function of
smoking. Human models and cartoon characters in
cigarette advertising convey independence, health-
fulness, adventure-seeking, and youthful activities-
themes correlated with psychosocial factors that
appeal to young people.

4.  Cigarette advertisements capitalize on the disparity
between an ideal and actual self-image and imply
that smoking may close the gap.

5.  Cigarette advertising appears to affect young people's
perceptions of the pervasiveness, image, and func-
tion of smoking. Since misperceptions in these areas
constitute psychosocial risk factors for the initiation
of smoking, cigarette advertising appears to increase
young people's risk of smoking.

Chapter 6. Efforts to Prevent Tobacco Use
Among Young People

1.

Most of the American public strongly favor policies
that might prevent tobacco use among young people.
These policies include tobacco education in the
schools, restrictions on tobacco advertising and pro-
motions, a complete ban on smoking by anyone on
school grounds, prohibition of the sale of tobacco
products to minors, and earmarked tax increases on
tobacco products.

2.

School-based smoking-prevention programs that
identify social influences to smoke and teach skills to
resist those influences have demonstrated consistent
and significant reductions in adolescent smoking
prevalence, and program effects have lasted one to
three years. Programs to prevent smokeless tobacco
use that are based on the same model have also
demonstrated modest reductions in the initiation of
smokeless tobacco use.

3.

The effectiveness of school-based smoking-preven-
tion programs appears to be enhanced and sustained
by comprehensive school health education and by
communitywide programs that involve parents, mass
media, community organizations, or other elements
of an adolescent's social environment.

4.

Smoking-cessation programs tend to have low suc-
cess rates. Recruiting and retaining adolescents in
formal cessation programs are difficult.

5.

Illegal sales of tobacco products are common. Active
enforcement of age-at-sale policies by public officials
and community members appears necessary to pre-
vent minors' access to tobacco.

6.

Econometric and other studies indicate that increases
in the real price of cigarettes significantly reduce
cigarette smoking; young people are at least as re-
sponsive as adults to such price changes. Maintain-
ing higher real prices of cigarettes depends on further
tax increases to offset the effects of inflation.

Surgeon General's Report

10 Introduction


Preventing Tobacco Use Among Young People

References

US DEPARTMENT OF HEALTH AND HUMAN SERVICES.
The health consequences of using smokeless tobacco. A report of the
advisory committee to the Surgeon General. US Department of
Health and Human Services, Public Health Services, National
Institutes of Health. NIH Publication No. 86-2874,1986.

US DEPARTMENT OF HEALTH AND HUMAN SERVICES.
Reducing the health consequences of smoking: .25 years of progress.
A report of the Surgeon General. US Department of Health and
Human Services, Public Health Service, Centers for Disease
Control, Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health. DHHS Publication

US DEPARTMENT OF HEALTH AND HUMAN SERVICES.
The health consequences ofsmoking: nicotine addiction. A report of
the Surgeon General, 1988. US Department of Health and Hu-
man Services, Public Health Service, Centers for Disease Con-
trol, Center for Health Promotion and Education, Office on
Smoking and Health. DHHS Publication No. (CDC) 88-8406,
1988.

No. (CDC) 89-8411,1989.

lntroduclion 11


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Mail to: Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9328