Chapter Conclusions

Following are the specific conclusions for each chapter of this report:

Chapter 2. The Health Consequences of Tobacco Use by Young People

1. Cigarette smoking during childhood and adolescence produces significant health problems among young people, including cough and phlegm production, an increased number and severity of respiratory 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 adolescence. 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 nonusers 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 1970s, but the decline slowed significantly in the 1980s. At least 3.1 million adolescents and 25% of 17- and 18-year-olds are current smokers.
3. Although current smoking prevalence among female adolescents began exceeding that among males by the mid- to late-1970s, 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.
4. Many adolescent smokers are addicted to cigarettes; these young smokers report withdrawal symptoms similar to those reported by adults.
5. 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. 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 tobacco, to being addicted. This process generally takes about three years.
2. Sociodemographic factors associated with the onset of tobacco use include being an adolescent from a family with low socioeconomic status.
3. Environmental risk factors for tobacco use include accessibility and availability of tobacco products, perceptions by adolescents that tobacco use is normative, peers' and siblings' use and approval of tobacco use, and lack of parental support and involvement as adolescents face the challenges of growing up.
4. Behavioral risk factors for tobacco use include low levels of academic achievement and school involvement, lack of skills required to resist influences to use tobacco, and experimentation with any tobacco product.
5. Personal risk factors for tobacco use include a lower self-image and lower self-esteem than peers, the belief 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 important 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 entertainment, point-of-sale displays, and distribution of specialty items.
3. Cigarette advertising uses images rather than information to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, healthfulness, 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 function 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 promotions, 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-prevention 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 success 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 prevent 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 responsive as adults to such price changes. Maintaining higher real prices of cigarettes depends on further tax increases to offset the effects of inflation.