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 Superintendent of Documents Publications Order Form Order Processing Code 7279 To fax your orders: 202\512-2250 m Yes, please send me copy(ies) of Preventing Tobacco Use Among Young People, S/N 017-001-00491-0, at $19 each. The total cost of my order is $ . (International customers please add 25%.) Prices include regular domestic postage and handling and are subject to change. 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