Chapter 1

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 currently use smokeless tobacco. Clearly, effective interventions are needed to prevent more young people from trying tobacco. To achieve significant long-term reductions 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, psychological, and marketing factors that influence young people in their decision to use tobacco products, and evaluate current 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 department's 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 smokeless tobacco use among young people. Initial manuscripts for the report were prepared by 28 scientists who 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 consequences during the period of adolescence (broadly defined as ages 10 through 18, although research cited in this report varies somewhat in the ages considered adolescent). 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 increased 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, which 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.

Major Conclusions

1. Nearly all first use of tobacco occurs before high school graduation; this finding suggests that if adolescents can be kept tobacco-free, most will never start using tobacco.
2. 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.
3. Tobacco is often the first drug used by those young people who use alcohol, marijuana, and other drugs.
4. Adolescents with lower levels of school achievement, with fewer skills to resist pervasive influences to use tobacco, with friends who use tobacco, and with lower self-images are more likely than their peers to use tobacco.
5. Cigarette advertising appears to increase young people's risk of smoking by affecting their perceptions of the pervasiveness, image, and function of smoking.
6. Communitywide efforts that include tobacco tax increases, enforcement of minors' access laws, youth-oriented mass media campaigns, and school-based tobacco-use prevention programs are successful in reducing adolescent use of tobacco.