Preventing Tobacco Use Among

Youth and Young Adults

A Report of the Surgeon General

Executive Summary

2012

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Office of the Surgeon General

Rockville, MD
Suggested Citation

U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and 

Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention 

and Health Promotion, Office on Smoking and Health, 2012.

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Go to http://www.cdc.gov/tobacco

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Use of trade names is for identification only and does not constitute endorsement by the

U.S. Department of Health and Human Services. Any recommendations expressed by 

non-governmental individuals or organizations do not necessarily represent the views or opinions 

of the U.S. Department of Health and Human Services.
Message from Kathleen Sebelius

Secretary of Health and Human Services

Tobacco is the leading cause of preventable and premature death, killing an estimated 443,000 

Americans each year. Cigarette smoking costs the nation $96 billion in direct medical costs and $97 

billion in lost productivity annually. In addition to the billions in medical costs and lost productivity, 

tobacco is enacting a heavy toll on young people. 

Each day in the United States, over 3,800 young people under 18 years of age smoke their first 

cigarette, and over 1,000 youth under age 18 become daily cigarette smokers. The vast majority of 

Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood. 

Despite the well-known health risks, youth and adult smoking rates that had been dropping for many 

years have stalled. When this Administration took office, we decided that if these numbers were not 

changing, we had to do something. We accelerated our efforts to fight tobacco by helping Americans 

stop smoking and protecting young people from starting to smoke.

The first step was the historic Family Smoking Prevention and Tobacco Control Act which gives 

the U.S. Food and Drug Administration the authority to regulate tobacco products to prevent use by 

minors and reduce the impact on public health. The law includes many vital provisions, including a 

ban on cigarettes with certain characterizing flavorings such as candy and fruit, restrictions on the sale 

of single cigarettes and the prohibition of marketing practices aimed at children. The Family Smoking 

Prevention and Tobacco Control Act also provides for graphic warning labels that make the danger of 

smoking abundantly clear.

Second, as part of the Recovery Act, the Department of Health and Human Services (HHS) 

invested $225 million to support tobacco prevention and control efforts in states. These investments 

were made in communities that have used evidence-based tobacco interventions and will eventually 

become models for the rest of the country. 

The third step was the Affordable Care Act, which provides a new opportunity to transform how 

our nation addresses tobacco use through the Prevention and Public Health Fund. The law expands 

access to recommended treatment programs, such as tobacco use cessation, often at no additional cost. 

For the first time, Medicare and Medicaid will cover tobacco use cessation for all beneficiaries. The 

health care law also provides support for state 1-800 quitlines and implementation of innovative social 

media initiatives including text messaging and smart phone applications. 

We are using the many tools at our disposal, from regulatory power to state and local investments, to end the tobacco epidemic. In November 2010, HHS announced the Department’s first ever 

comprehensive tobacco control strategic action plan, titled Ending the Tobacco Epidemic, which will 

help us bring all of these strategies together to achieve our goals. An important component of our HHS 

plan focuses on preventing the initiation of tobacco use among young people, through hard-hitting 

mass media campaigns that will discourage our country’s youth from starting to use tobacco products 

and motivate current tobacco users to quit. This key strategic action, combined with others in the plan, 

signify HHS’s commitment to provide a clear roadmap for the future of tobacco prevention and control.

We have come a long way since the days of smoking on airplanes and in college classrooms, 

but we have a long way to go. We have the responsibility to act and do something to prevent our youth 

from smoking. The prosperity and health of our nation depend on it.

Message from Howard Koh

Assistant Secretary for Health

Tobacco use imposes enormous public health and financial costs on this nation—costs that are 

completely avoidable. Until we end tobacco use, more young people will become addicted, more people 

will become sick, and more families will be devastated by the loss of loved ones. 

The simple fact is that we cannot end the tobacco epidemic without focusing our efforts on young 

people. Nearly 100% of adults who smoke every day started smoking when they were 26 or younger, 

so prevention is the key. The tobacco industry spends almost $10 billion a year to market its products, 

half of all movies for children under 13 contain scenes of tobacco use, half of our states continue to 

allow smoking in public places, and images and messages normalize tobacco use in magazines, on the 

Internet, and at retail stores frequented by youth. With a quarter of all high school seniors and a third 

of all young adults smoking, and with progress in reducing prevalence slowing dramatically, the time 

for action is now.

This Surgeon General’s Report is an important addition to our base of knowledge on the prevalence, causes, effects, and implications of tobacco use by young people. It elucidates in powerful detail 

the factors that lead youth and young adults to initiate tobacco use, and the devastating health and 

economic impact of that decision on our nation as well as on individuals, their families, and their communities. This report also identifies proven, effective strategies that hold the potential of dramatically 

reducing tobacco use.

The Department’s overall tobacco control strategy is to strengthen and fully implement these 

proven, effective strategies as part of a comprehensive approach that combines educational, clinical, 

regulatory, economic, and social initiatives. In November 2010, the Department released Ending the 

Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and 

Human Services which provides a framework for coordinating this approach. The plan sets forth specific actions which HHS can implement to build on recent legislative milestones, respond to the changing market for tobacco products, and promote robust tobacco control programs at the federal, state, 

and community levels.

From 1997 to 2004 youth smoking fell rapidly. Since that time smoking among high school 

seniors has continued to fall, but slowly from 24.4% in 2003 to 18.7% in 2010 (daily smoking among 

youth has fallen from 16.8% in 1999 to 7.3% in 2009). Since 2003 prevalence among adults has fallen 

from 21.6 to 19.3% in 2010 The current problem is not that the evidence-based tools that drove the 

progress from 1997 to 2004 stopped working; it is that they have not been applied with sufficient effort 

or nationwide. That these tools still work is reflected in the fact that many states have seen significant 

reductions since 2005. Between 2005 and 2010 twenty states had declines of 20% or more.

Even with decades of progress and recent tobacco control initiatives, however, we must do more. 

We have ample evidence that comprehensive, multi-component interventions are effective at reducing tobacco use. But knowledge is not enough. We must also have commitment—the commitment to 

sustain comprehensive programs, to give our young people another perspective on tobacco, to create 

an environment that makes it harder for youth to smoke, to make cessation services accessible and 

affordable. It is within our grasp to make the next generation tobacco-free if we have the will to do so.

i

Foreword

Preventing smoking and smokeless tobacco use among young people is critical to ending the epidemic of tobacco use. Since the first Surgeon General’s report on youth in 1994, the basis for concern 

about smoking during adolescence and young adulthood has expanded beyond the immediate health 

consequences for the young smoker to a deeper understanding of the implications for health across the 

life span from early use of tobacco. Cigarette smoking remains the leading cause of preventable death 

in the United States, accounting for approximately 443,000 deaths, or about 1 of every 5 deaths, in the 

United States each year.

Since 1994, there have been many legal and scientific developments that have curtailed somewhat the tobacco companies’ ability to market to young people. The 1998 Master Settlement Agreement eliminated most cigarette billboard and transit advertising, print advertising directed to underage 

youth, and limited brand sponsorship. In addition, the Master Settlement Agreement resulted in the 

release of internal tobacco industry documents that have been analyzed by scientists. Furthermore, 

during this time, the prices of cigarettes and smokeless tobacco products also increased. These significant developments, among others, resulted in a sharp decrease in tobacco use among adults and youth. 

However, this progress has stalled in recent years.

More than 80% of adult smokers begin smoking by 18 years of age with 99% of first use by 26 years 

of age. In addition, adolescent smokeless tobacco users are more likely than nonusers to become adult 

cigarette smokers. Adolescents and young adults are uniquely susceptible to social and environmental 

influences to use tobacco, and tobacco companies spend billions of dollars on cigarette and smokeless tobacco marketing. The findings in this report provide evidence that coordinated, high-impact 

interventions including mass media campaigns, price increases, and community-level changes protecting people from secondhand smoke and norms are effective in reducing the initiation and prevalence 

of smoking among youth. However, many of these comprehensive tobacco control programs remain 

underfunded. Now more than ever, it is imperative that we continue investing in tobacco prevention 

and control. An increase in spending on sustained comprehensive tobacco control programs will result 

in reductions in youth and adult smoking rates and, ultimately, in health care costs. 

Reducing tobacco use is a winnable battle. We have the science and, with additional effort and 

support for evidence-based, cost-effective strategies that we can implement now, we will improve on 

our nation’s health and our children’s future.

Thomas R. Frieden, M.D., M.P.H.

Director

Centers for Disease Control and Prevention

and

Administrator

Agency for Toxic Substances and Disease Registry

iii

Preface

from the Surgeon General,

U.S. Department of Health and Human Services

Nearly all tobacco use begins during youth and young adulthood. These young individuals progress from smoking occasionally to smoking every day. Each day across the United States over 3,800 

youth under 18 years of age start smoking. Although much progress has been made to reduce the 

prevalence of smoking since the first Surgeon General’s report in 1964, today nearly one in four high 

school seniors and one in three young adults under age 26 smoke.

Of every three young smokers, only one will quit, and one of those remaining smokers will die 

from tobacco-related causes. Most of these young people never considered the long-term health consequences associated with tobacco use when they started smoking; and nicotine, a highly addictive drug, 

causes many to continue smoking well into adulthood, often with deadly consequences.

This Surgeon General’s report examines in detail the epidemiology, health effects, and causes 

of tobacco use among youth ages 12 through 17 and young adults ages 18 through 25. For the first 

time tobacco data on young adults as a discrete population has been explored. This is because nearly 

all tobacco use begins in youth and young adulthood, and because young adults are a prime target for 

tobacco advertising and marketing activities. This report also highlights the efficacy of strategies to 

prevent young people from using tobacco.

After years of steady decrease following the Tobacco Master Settlement Agreement of 1998, 

declines in youth tobacco use have slowed for cigarette smoking and stalled for use of smokeless 

tobacco. The latest research shows that concurrent use of multiple tobacco products is common among 

young people, and suggest that smokeless tobacco use is increasing among White males.

An important element of this Surgeon General’s report is the review of the health consequences of tobacco use by young people. Cigarette smoking by youth and young adults is proven to 

cause serious and potentially deadly health effects immediately and into adulthood. One of the most 

significant health effects is addiction to nicotine that keeps young people smoking longer, causing 

increased physical damage. Early abdominal aortic atherosclerosis has been found in young smokers 

which affects the flow of blood to vital organs such as the lungs. This leads to reduced lung growth that 

can increase the risk of chronic obstructive pulmonary disease later in life, and reduced lung function.

This report examines the social, environmental, advertising, and marketing influences that 

encourage youth and young adults to initiate and sustain tobacco use. Tobacco products are among 

the most heavily marketed consumer goods in the U.S. Much of the nearly $10 billion spent on marketing cigarettes each year goes to programs that reduce prices and make cigarettes more affordable; 

smokeless tobacco products are similarly promoted. Peer influences; imagery and messages that portray tobacco use as a desirable activity; and environmental cues, including those in both traditional and 

emerging media platforms, all encourage young people to use tobacco. These influences help attract 

youth to tobacco use and reinforce the perception that smoking and various forms of tobacco use are a 

social norm—a particularly strong message during adolescence and young adulthood.

Many initiatives have been put into place to help counter the influences that encourage young 

people to begin tobacco use. The Tobacco Master Settlement Agreement in 1998 curtailed much of the 

advertising that was particularly appealing to young people. With the passage of the 2009 legislation 

giving the U.S. Food and Drug Administration the authority to regulate tobacco products and tobacco 

advertising, we now have another important means of helping decrease the appeal of tobacco use to this 

population. Coordinated, multi-component interventions that include mass media campaigns, comprehensive community programs, comprehensive statewide tobacco control programs, price increases, 

and school-based policies have also proven effective in preventing onset and use of tobacco use among 

youth and young adults.
iv

We know what works to prevent tobacco use among young people. The science contained in this and other Surgeon General’s reports provides us with the information we need to prevent the needless suffering of premature disease 

caused by tobacco use, as well as save millions of lives. By strengthening and continuing to build upon effective policies 

and programs, we can help make our next generation tobacco free.

Regina Benjamin, M.D., M.B.A.

Surgeon General
Preventing Tobacco Use Among Youth and Young Adults

Executive Summary 1

The Tobacco Epidemic Continues Because Youth and 

Young Adults Begin to Use—and Become Addicted 

to—Cigarettes and Smokeless Tobacco Products

Tobacco use is a pediatric epidemic, around the 

world as well as in the United States. Although progress 

has been made since the first Surgeon General’s report in 

1964, too many of our youth still use tobacco. Among U.S. 

high school seniors, one out of four is a regular cigarette 

smoker (Youth Risk Behavior Survey [YRBS] 2009, Chapter 3). Because few high school smokers are able to break 

free from the powerful addicting effects of nicotine, about 

80% will smoke into adulthood. Among those who persist 

in smoking, one-half will die about 13 years earlier than 

his or her nonsmoking peers (Fagerström 2002; Doll et 

al. 2004).

In addition to cigarette smoking, use of other forms 

of tobacco by youth and young adults is epidemic. Nearly 

one in five White adolescent males (12–17 years old) uses 

smokeless tobacco (YRBS 2009, Chapter 3), and 1 in 10 

young adults (18–25 years old) smokes cigars (National 

Survey on Drug Use and Health [NSDUH] 2010, Chapter 3). The concurrent use of multiple tobacco products 

is common, too, with over 50% of White and Hispanic 

male tobacco users reporting that they use more than one 

tobacco product (YRBS 2009, see Chapter 3). The numbers are staggering. They translate into over a million 

new tobacco users a year in the United States alone. But 

there are proven methods to prevent this epidemic from 

claiming yet another generation, if our nation has the will 

to implement those methods in every state and community.

Nearly all tobacco use begins in childhood and 

adolescence. In all, 88% of adult cigarette smokers who 

smoke daily, report that they started smoking by the age of 

18 (NSDUH 2010, Chapter 3). This is a time in life of great 

vulnerability to social influences, and the pervasive presence of tobacco product marketing—including everything 

from sleek ads in magazines to youth-generated posts on 

social networking sites, to images of smoking in the movies—conveys messages that make tobacco use attractive 

to youth and young adults. 

The first comprehensive Surgeon General’s report 

on youth, Preventing Tobacco Use Among Young People, 

was published in 1994 (U.S. Department of Health and 

Human Services [USDHHS] 1994). That report concluded that if young people can remain free of tobacco 

until age 18, most will never start to smoke. The report 

documented the addiction process for young people and 

how the symptoms of addiction in youth are similar to 

those in adults. Use of tobacco was also presented as a 

gateway drug among young people, because its use generally precedes and increases the risk of illicit drug use. 

Cigarette advertising and promotional activities were seen 

as a potent way to increase the risk of cigarette smoking 

among young people, while community-wide efforts were 

shown to have been successful in reducing tobacco use 

among youth. All of these conclusions remain important, 

relevant, and accurate, as documented in the current 

report, but there has been considerable research since 

1994 that greatly expands our knowledge about tobacco 

use among youth, its prevention, and the dynamics of cessation among young people. Thus, there is a compelling 

need for the current report.

Since 1994, multiple legal and scientific developments have altered the tobacco control environment and 

consequently have affected smoking among youth. All 

states and the U.S. Department of Justice brought lawsuits against the cigarette companies, with the result that 

internal documents of the tobacco industry have been 

made public, analyzed, and introduced into the science of 

tobacco control. Also, the Master Settlement Agreement 

with the tobacco companies in 1998 resulted in the elimination of billboard and transit advertising, eliminated 

print advertising that directly targeted underage youth, 

and limited the use of brand advertising (National Association of Attorneys General [NAAG] 1998). This settlement 

also created the American Legacy Foundation, which was 

charged with implementing a nationwide antismoking 

campaign targeting youth. In 2009, the U.S. Congress 

passed a law that gave the U.S. Food and Drug Administration (FDA) authority to regulate tobacco products in 

order to promote the public’s health (Family Smoking 

Prevention and Tobacco Control Act [2009]). Thus, the 

tobacco companies have, in the U.S., been somewhat curtailed in their ability to market to young people, have had 

to reimburse the state governments (through agreements 

made with certain states, the Master Settlement Agreement) for a portion of tobacco-related health care costs. 

These actions have, in part, resulted in a sharp decrease in 

tobacco use among adults and among youth, the latter of 

which is documented in this current report.
Surgeon General’s Report

2 Executive Summary

In addition, substantial new research has added 

to our knowledge and understanding of tobacco use 

and control as it relates to youth since the 1994 Surgeon General’s report, including updates and new data 

in Healthy People 2000, 2010, subsequent Surgeon 

General’s reports, in NCI Monographs, in Institute of 

Medicine reports, and in the Cochrane Collaboration 

reviews in addition to hundreds of peer-reviewed publications, book chapters, and policy reports. Thus, although 

this report is a follow-up to the 1994 report, other 

important reviews have been undertaken in the past 17 

years and have served to fill the gap during an especially 

active and important time in research on tobacco control 

among youth.

Evidence Summary

This report reviews updated evidence on the: 1) 

health consequences of tobacco use in youth and young 

adults, 2) epidemiology of cigarette and smokeless tobacco 

use among youth and young adults, 3) etiological factors 

associated with the onset and progression of tobacco use, 

4) tobacco industry influences on the use of tobacco by 

youth, and 5) effective efforts to prevent or reduce tobacco 

use among youth.

With 99% of all first use of tobacco occurring by age 

26 (NSDUH 2010, Chapter 3), if youth and young adults 

remain tobacco-free, very few people will begin to smoke 

or use smokeless products. Unfortunately, early use of 

tobacco has substantial health risks that begin almost 

immediately in adolescence and young adulthood, including impairment to the respiratory and cardiovascular 

systems. Many of the long-term diseases associated with 

smoking, such as lung cancer, are more likely among 

those who begin to smoke earlier in life (Doll and Peto 

1978; Peto 1986; USDHHS 2004). Tobacco use is addictive 

for young people and, therefore, cessation is problematic 

and challenging, even for young users, and early quitting 

is very difficult (Chassin et al. 2000; Mayhew et al. 2000; 

Riggs et al. 2007). Adolescent and young adult smokers 

become adult smokers, with the associated and welldocumented chronic diseases associated with adult smoking (White et al. 2002). And while young people might 

believe that smoking is associated with weight loss, the 

data do not support any reduction in weight among adolescent smokers (Klesges et al. 1998; Cachelin et al. 2003, 

Cooper et al. 2003; Bean et al. 2008). 

One in four high school seniors (YRBS 2009, Chapter 3), and one in three young adults (NSDUH 2010, Chapter 3), are current smokers. While reductions in tobacco 

use have been realized, particularly since the Master 

Settlement Agreement in 1998, the data indicate that 

these reductions have stalled. Importantly, smokeless 

tobacco use is increasing among young White males and 

cigar smoking is increasing among Black females. In fact, 

over half of White and Hispanic high school males who 

use tobacco use more than one tobacco product, and just 

under half of Hispanic females who use tobacco use more 

than one tobacco product, too (YRBS 2009, Chapter 3).

Adolescence and emerging adulthood are stages of 

life with increased vulnerability to tobacco use. These are 

times of remarkable growth—physically, mentally, and 

socially—that are not always synchronous and are complicated because the brain has not yet fully developed (Steinberg 2007). Peer influence is paramount during these life 

stages, and young people with greater numbers of peers 

who smoke are more likely to begin to smoke themselves 

(Landrine et al. 1994; Hu et al. 1995; Killen et al. 1997; 

Urberg et al. 1997; Flay et al. 1998; Robinson et al. 2006). 

Those who have fewer pro-social bonds to conventional 

institutions, such as school or places of worship, are also 

more likely to use tobacco (Choi et al. 2002; Evans-Whipp 

et al. 2004; van den Bree et al. 2004; Metzger et al. 2011). 

This is evidenced by the compelling associations between 

low academic achievement and smoking onset and use 

among adolescents (Dewey 1999; Sutherland and Shepherd 2001; Diego et al. 2003; Scal et al. 2003; Cox et al. 

2007; Forrester et al. 2007; Tucker et al. 2008). Even exposure to smoking by actors in movies increases the likelihood that a young person will begin to smoke (Sargent et 

al. 2001, 2005; Hanewinkel and Sargent 2007; Thrasher et 

al. 2008). 

Tobacco companies have capitalized on the vulnerability of this age group to more effectively promote their 

products. Marketing efforts of the tobacco companies 

have caused young people to smoke, as demonstrated by 

extensive cross-sectional and longitudinal research outlined in this report (Armstrong et al. 1990; Aitken et al. 

1991; Evans et al. 1995; Schooler et al. 1996; Gilpin et 

al. 1997, 2007; Pierce et al. 2010). Further, information 

explicitly revealed in tobacco industry documents makes 

clear the industry’s interest in and efforts to entice young 

people to use their products (Perry 1999; United States 

v. Philip Morris, 449 F. Supp. 2d 1 [2006]). With young 

smokers being more price-sensitive than older smokers, 
Preventing Tobacco Use Among Youth and Young Adults

Executive Summary 3

tobacco companies have increasingly focused attention 

on strategies that reduce the price of tobacco products 

(Chaloupka et al. 2002; Slater et al. 2007). The tobacco 

companies’ own smoking prevention campaigns have not 

demonstrated any reduction in adolescent smoking or 

any evidence of effectiveness (Interactive Inc. 2000, 2001; 

Mandel et al. 2006).

Effective programs and policies are available and 

have demonstrated success in reducing youth smoking, though adequate dissemination and sustainability 

of these successful approaches is currently lacking in 

nearly all states. Nonetheless, sufficient evidence exists 

to clearly indicate that coordinated, multi-component 

interventions that combine mass media campaigns, price 

increases, school-based policies and programs, community-wide changes, and statewide programs as effective 

in reducing the initiation, prevalence, and intensity of 

smoking among youth and young adults.

This report has drawn from the evidence reviewed 

and has five major conclusions.

Major Conclusions of This Report

1. Cigarette smoking by youth and young adults has 

immediate adverse health consequences, including 

addiction, and accelerates the development of chronic 

diseases across the full life course.

2. Prevention efforts must focus on both adolescents 

and young adults because among adults who become 

daily smokers, nearly all first use of cigarettes occurs 

by 18 years of age (88%), with 99% of first use by 26 

years of age.

3. Advertising and promotional activities by tobacco 

companies have been shown to cause the onset and 

continuation of smoking among adolescents and 

young adults.

4. After years of steady progress, declines in the use of 

tobacco by youth and young adults have slowed for 

cigarette smoking and stalled for smokeless tobacco 

use.

5. Coordinated, multicomponent interventions that 

combine mass media campaigns, price increases 

including those that result from tax increases, 

school-based policies and programs, and statewide or 

community-wide changes in smokefree policies and 

norms are effective in reducing the initiation, prevalence, and intensity of smoking among youth and 

young adults.

Chapter Summaries and Conclusions

Chapter 2: The Health 

Consequences of Tobacco Use 

Among Young People

While the 1994 Surgeon General’s report clearly 

identified that smoking had immediate and long-term 

health consequences for young people, further evidence 

presented in the current report has strengthened these 

conclusions. Research now documents strong causal associations between active cigarette smoking in young people 

and addiction to nicotine, reduced lung function, reduced 

lung growth, asthma, and early abdominal aortic atherosclerosis. These associations have met the criteria for 

causality first introduced in the 1964 Surgeon General’s 

report: consistency, strength, specificity, temporality, and 

biological plausibility of the scientific evidence. These are 

serious social, physical, and mental health problems that 

manifest during adolescence and young adulthood and 

are the precursors to other long-term chronic diseases. 

Smoking is the chief preventable cause of premature 

death in this country, and the early stages of the diseases 

associated with adult smoking are already evident among 

young smokers (Doll and Peto 1978; Peto 1986; USDHHS 

2004). For example, young adult smokers under age 30 

exhibit signs of and are being diagnosed with early disease 

of the abdominal aorta, a serious indicator of heart disease (McGill et al. 2000; McMahan et al. 2005, 2006). This 

chapter also includes a comprehensive review of the associations between smoking and body weight and weight 
Surgeon General’s Report

4 Executive Summary

control methods, given the country’s current concern 

with childhood obesity. While there is ample evidence 

that young people believe that cigarette smoking will help 

them control their body weight, there is no evidence that 

young smokers weigh less or lose weight because of their 

smoking (Cachelin et al. 2003; Cooper et al. 2003; Klesges 

et al. 1998; Bean et al. 2008).

Conclusions

1. The evidence is sufficient to conclude that there is a 

causal relationship between smoking and addiction to 

nicotine, beginning in adolescence and young adulthood.

2. The evidence is suggestive but not sufficient to conclude that smoking contributes to future use of marijuana and other illicit drugs.

3. The evidence is suggestive but not sufficient to conclude that smoking by adolescents and young adults 

is not associated with significant weight loss, contrary 

to young people’s beliefs.

4. The evidence is sufficient to conclude that there is a 

causal relationship between active smoking and both 

reduced lung function and impaired lung growth during childhood and adolescence. 

5. The evidence is sufficient to conclude that there is 

a causal relationship between active smoking and 

wheezing severe enough to be diagnosed as asthma in 

susceptible child and adolescent populations.

6. The evidence is sufficient to conclude that there is a 

causal relationship between smoking in adolescence 

and young adulthood and early abdominal aortic atherosclerosis in young adults.

7. The evidence is suggestive but not sufficient to conclude that there is a causal relationship between 

smoking in adolescence and young adulthood and 

coronary artery atherosclerosis in adulthood. 

Chapter 3: The Epidemiology of 

Tobacco Use Among Young People 

in the United States and Worldwide

The major national data sets that assess youth and 

young adult smoking were analyzed to provide updated 

data for this report. Cigarette smoking is shown, again, 

to primarily begin in adolescence, and very few adults 

begin to smoke after age 26 (1%) (NSDUH 2010, Chapter 

3). Since the 1994 Surgeon General’s report, tobacco use 

among adolescents and young adults has substantially 

decreased, especially since 1998. However, there has been 

a leveling off in the past few years, particularly since 2007, 

and in some groups there are increases in the prevalence 

of tobacco use, such as smokeless tobacco use among 

White males. Some groups of young people continue to 

smoke more than others, notably American Indians and 

Alaska Natives, but also Whites and Hispanics. With the 

introduction of new tobacco products and promotion 

of smokeless tobacco products, use of multiple tobacco 

products is common. Among tobacco users, more than 

one-half of White and Hispanic high school males and 

almost one-half of Hispanic high school females use more 

than one product.

Conclusions

1. Among adults who become daily smokers, nearly all 

first use of cigarettes occurs by 18 years of age (88%), 

with 99% of first use by 26 years of age.

2. Almost one in four high school seniors is a current 

(in the past 30 days) cigarette smoker, compared 

with one in three young adults and one in five adults. 

About 1 in 10 high school senior males is a current 

smokeless tobacco user, and about 1 in 5 high school 

senior males is a current cigar smoker.

3. Among adolescents and young adults, cigarette smoking declined from the late 1990s, particularly after the 

Master Settlement Agreement in 1998. This decline 

has slowed in recent years, however. 

4. Significant disparities in tobacco use remain among 

young people nationwide. The prevalence of cigarette 

smoking is highest among American Indians and 

Alaska Natives, followed by Whites and Hispanics, and 

then Asians and Blacks. The prevalence of cigarette 

smoking is also highest among lower socioeconomic 

status youth.

5. Use of smokeless tobacco and cigars declined in the 

late 1990s, but the declines appear to have stalled 

in the last 5 years. The latest data show the use of 

smokeless tobacco is increasing among White high 

school males, and cigar smoking may be increasing 

among Black high school females.

6. Concurrent use of multiple tobacco products is prevalent among youth. Among those who use tobacco, 
Preventing Tobacco Use Among Youth and Young Adults

Executive Summary 5

nearly one-third of high school females and more 

than one-half of high school males report using more 

than one tobacco product in the last 30 days. 

7. Rates of tobacco use remain low among girls relative 

to boys in many developing countries, however, the 

gender gap between adolescent females and males is 

narrow in many countries around the globe.

Chapter 4: Social, Environmental, 

Cognitive, and Genetic Influences 

on the Use of Tobacco Among Youth 

Adolescents and young adults are uniquely vulnerable to influences to use tobacco (Steinberg 2007). As 

young people move toward adulthood, they increasingly 

rely on their social contexts and peer groups in adopting 

or changing behavior. In particular, this chapter documents the potent influence of peer groups, and whether 

peers in their environment use tobacco and perceive of 

tobacco use as normative or acceptable. Young people are 

more likely to use tobacco if their peers use tobacco or are 

anti-social (Landrine et al. 1994; Hu et al. 1995; Headen et 

al. 1991; Killen et al. 1997; Urberg et al. 1997; Flay et al. 

1998; Robinson et al. 2006). Those with higher academic 

achievement are less likely to use tobacco (Dewey 1999; 

Sutherland and Shepherd 2001; Diego et al. 2003; Scal et 

al. 2003; Cox et al. 2007; Forrester et al. 2007; Tucker et al. 

2008). Because of the particular vulnerability of this age 

group to peer group influences, external messages that 

target the peer group can be especially potent. 

Conclusions

1. Given their developmental stage, adolescents and 

young adults are uniquely susceptible to social and 

environmental influences to use tobacco. 

2. Socioeconomic factors and educational attainment 

influence the development of youth smoking behavior. The adolescents most likely to begin to use 

tobacco and progress to regular use are those who 

have lower academic achievement.

3. The evidence is sufficient to conclude that there is a 

causal relationship between peer group social influences and the initiation and maintenance of smoking 

behaviors during adolescence. 

4. Affective processes play an important role in youth 

smoking behavior, with a strong association between 

youth smoking and negative affect. 

5. The evidence is suggestive that tobacco use is a heritable trait, more so for regular use than for onset. The 

expression of genetic risk for smoking among young 

people may be moderated by small-group and larger 

social-environmental factors.

Chapter 5: The Tobacco Industry’s 

Influences on the Use of Tobacco 

Among Youth

The tobacco companies spent nearly $10 billion 

in 2008 on advertising and promotional efforts (Federal 

Trade Commission [FTC] 2011a,b). While there have been 

restrictions on marketing to young people as a result of the 

Master Settlement Agreement, there have not been corresponding reductions in marketing expenses—these have 

increased since 1998 (FTC 2011a,b). Most tobacco industry marketing efforts involve promotional activities that 

reduce the price of cigarettes, strategies that should be 

effective with price-sensitive adolescents (FTC 2011a,b). 

Since the 1994 Surgeon General’s report, considerable 

evidence has accumulated that supports a causal association between marketing efforts of tobacco companies 

and the initiation and progression of tobacco use among 

young people. This evidence includes data from crosssectional studies on exposure to advertising and use of 

tobacco; longitudinal studies with non-susceptible, neverusers of tobacco and subsequent initiation; examination 

of industry marketing efforts and use of specific brands; 

and evidence from tobacco industry documents on their 

marketing practices (Armstrong et al. 1990; Aitken et al. 

1991; Evans et al. 1995; Schooler et al. 1996; Gilpin et al. 

1997; Perry 1999; Chaloupka et al. 2002; United States v. 

Philip Morris, 449 F. Supp. 2d 1 [2006]; Gilpin et al. 2007; 

Slater et al. 2007; Pierce et al. 2010). This body of evidence 

consistently and coherently points to the intentional marketing of tobacco products to youth as being a cause of 

young people’s tobacco use. The tobacco companies have 

launched anti-smoking efforts themselves, but while these 

efforts have had a positive impact on public perceptions 

of the tobacco industry among youth and young adults, 

they have not demonstrated success in impacting young 

people’s tobacco use (Interactive Inc. 2000, 2001; Mandel et al. 2006). Importantly, new avenues for restrictions 
Surgeon General’s Report

6 Executive Summary

on tobacco companies are now available and can be considered, such as changes in packaging, labeling, product 

design, and restricting smoking in movies.

Conclusions

1. In 2008, tobacco companies spent $9.94 billion on the 

marketing of cigarettes and $547 million on the marketing of smokeless tobacco. Spending on cigarette 

marketing is 48% higher than in 1998, the year of 

the Master Settlement Agreement. Expenditures for 

marketing smokeless tobacco are 277% higher than 

in 1998.

2. Tobacco company expenditures have become increasingly concentrated on marketing efforts that reduce 

the prices of targeted tobacco products. Such expenditures accounted for approximately 84% of cigarette 

marketing and more than 77% of the marketing of 

smokeless tobacco products in 2008.

3. The evidence is sufficient to conclude that there is a 

causal relationship between advertising and promotional efforts of the tobacco companies and the initiation and progression of tobacco use among young 

people. 

4. The evidence is suggestive but not sufficient to conclude that tobacco companies have changed the packaging and design of their products in ways that have 

increased these products’ appeal to adolescents and 

young adults. 

5. The tobacco companies’ activities and programs for 

the prevention of youth smoking have not demonstrated an impact on the initiation or prevalence of 

smoking among young people.

6. The evidence is sufficient to conclude that there is 

a causal relationship between depictions of smoking 

in the movies and the initiation of smoking among 

young people.

Chapter 6: Efforts to Prevent and 

Reduce Tobacco Use Among Young 

People

There is a large, robust, and consistent evidence base 

that documents known effective strategies in reducing the 

initiation, prevalence, and intensity of smoking among 

youth and young adults. Since the release in 1994 of the 

first Surgeon General’s report on preventing tobacco use 

among young people, the emphasis on environmental 

and policy approaches to tobacco control has increased, 

including increasing the unit price of tobacco products 

and implementing smoking bans through policies, regulations, and laws, as well as other coordinated efforts that 

establish smokefree social norms (USDHHS 2000; Task 

Force on Community Preventive Services [TFCPS] 2005; 

NIH [National Institutes of Health] State-of-the-Science 

Panel 2006; Bonnie et al. 2007; Centers for Disease Control and Prevention [CDC] 2007; National Cancer Institute [NCI] 2008). Evidence indicates that mass media 

campaigns can be one of the most effective strategies in 

changing social norms and preventing youth smoking. 

Influential and successful campaigns contain a number 

of essential elements including optimized themes, appropriate emotional tone, appealing format, clear messages, 

intensity, and adequate repetition (Pechmann 2001; Siegel 

2002; Farrelly et al. 2003; Wakefield et al. 2003a,b; Schar 

et al. 2006; Richardson et al. 2007; Angus et al. 2008; 

NCI 2008). There also is strong evidence that media ads 

designed for adults also decrease the prevalence of smoking among youth. 

In addition to mass media campaigns, a number 

of high-impact legislative and regulatory strategies have 

been proven to reduce tobacco use (USDHHS 2000; 

TFCPS 2005; NIH 2006; CDC 2007a,b). Federal, state, and 

local taxes that raise prices on tobacco products improve 

public health by reducing initiation, prevalence, and 

intensity of smoking among young people. The evidence 

shows that increasing tobacco prices is effective at lowering smoking prevalence as well as consumption levels of 

tobacco products, especially by youth and young adults, 

and other price-sensitive populations (Chaloupka and 

Warner 2000; USDHHS 2000b; Zaza et al. 2005). Evidence 

reviewed indicates that the strength of clean indoor air 

laws was inversely related to the prevalence of smoking 

among youth and increased the probability of smoking 

cessation among young adults (Tauras 2004; IARC 2009). 

FDA has continued a progression of legislative and regulatory initiatives that have reduced youth access to tobacco 

products and has implemented bans on a variety of other 

promotional activities traditionally used by the tobacco 

industry that are especially appealing to youth and young 

adults. Evidence cited in this chapter from a broad range 

of studies has concluded that bans on cigarette advertising, especially if the bans are comprehensive rather than 

partial, reduce youth smoking (Saffer and Chaloupka 

2000; Lancaster and Lancaster 2003; Iwasaki et al. 2006; 

NCI 2008). 

Numerous studies over many years have consistently concluded that comprehensive state tobacco con-
Preventing Tobacco Use Among Youth and Young Adults

Executive Summary 7

trol programs that include a range of coordinated and 

complementary strategies have been effective at not only 

reducing tobacco use by youth and young adults, but also 

have resulted in overall reductions in smoking prevalence 

and concomitant decreases in state spending on tobaccorelated health care (USDHHS 2000; Sly et al. 2001; Rigotti 

et al. 2002; Soldz et al. 2002; Niederdeppe et al. 2004; Pierce 

et al. 2005; Bonnie et al. 2007; Lightwood et al. 2008; NCI 

2008; Lightwood and Glantz 2011). Evidence on schoolbased programs points to short-term results for programs 

based on the social influences model using interactive 

delivery methods and teaching refusal skills, with some 

school-based prevention programs also demonstrating 

longer-term outcomes. As is the case with other strategies 

to prevent and reduce youth tobacco use, school-based 

programs produce larger and more sustained effects when 

they are implemented in combination with other initiatives such as mass media campaigns, family programs, 

and state and community programs. Further, the evidence 

indicates that sustained programs combining mass media 

campaigns; price increases on tobacco products, including 

those that result from tax increases; regulatory initiatives 

such as those that ban advertising to youth, restrictions 

on youth access to tobacco, and establishment of smokefree public and workplace environments; and statewide, 

community-wide, and school-based programs and policies 

are effective in reducing the initiation, prevalence, and 

intensity of smoking among youth and young adults.

Conclusions

1. The evidence is sufficient to conclude that mass 

media campaigns, comprehensive community programs, and comprehensive statewide tobacco control 

programs can prevent the initiation of tobacco use 

and reduce its prevalence among youth.

2. The evidence is sufficient to conclude that increases 

in cigarette prices reduce the initiation, prevalence, 

and intensity of smoking among youth and young 

adults.

3. The evidence is sufficient to conclude that schoolbased programs with evidence of effectiveness, 

containing specific components, can produce at 

least short-term effects and reduce the prevalence of 

tobacco use among school-aged youth.

Chapter 7: A Vision for Ending the 

Tobacco Epidemic

Public health programs and policies have been in 

effect since the 19th century to dissuade young people 

from using tobacco. The first Surgeon General’s report in 

1964 provided irrefutable evidence of the harmful consequences of smoking and yet, 15 years later, as noted in the 

1979 Surgeon General’s report, rates of smoking among 

young people had not changed. By 1994, when the first 

Surgeon General’s report focused on youth was released, 

smoking rates among young people were increasing, 

despite 30 years of evidence that cigarette smoking had 

become the leading cause of death in the United States. 

Since that landmark 1994 report, a large body of research, 

litigation by individual states and the federal government, 

the Master Settlement Agreement, and authority granted 

to the FDA have substantially changed the tobacco control 

policy environment, and tobacco advertising and promotional activities have been somewhat curtailed. The rates 

of tobacco use among youth and young adults began to 

decrease from the late 1990s to the mid-2000s. Thus, 

progress in reducing tobacco use has been achieved, but 

there still remain significant challenges ahead. Nearly 

one-fourth of our high school seniors are current smokers, and the decreasing rates of tobacco use have leveled 

off, and in some subgroups have increased since 2007. The 

efforts of the early 21st century need to be reinvigorated, 

and additional strategies considered, to end the tobacco 

epidemic. Providing and sustaining sufficient funding for 

comprehensive community programs, statewide tobacco 

control programs, school-based policies and programs, 

and mass media campaigns must be a priority. Taxing 

tobacco products is especially effective in reducing their 

use among young people. Greater consideration of further 

restrictions on advertising and promotional activities as 

well as efforts to decrease depictions of smoking in the 

movies is warranted, given the gravity of the epidemic and 

the need to protect young people now and in the future. 
Surgeon General’s Report

8 Executive Summary

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