1994 Surgeon General's Report—Preventing
Tobacco Use Among Young People
Chapter 1: Summary
Disclaimer
Introduction
The health effects of cigarette smoking have been the subject of intensive
investigation since the l950s. Cigarette smoking is still considered the
chief preventable cause of premature disease and death in the United States.
As was documented extensively in previous Surgeon General's reports, cigarette
smoking has been causally linked to lung cancer and other fatal malignancies,
atherosclerosis and coronary heart disease, chronic obstructive 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 General
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 (USDHHS 1986). In the 1988 report, nicotine was designated a highly
addictive substance, comparable in its physiological and psychological properties
to other addictive substances of abuse (USDHHS 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, potentially 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 significantly
more likely than their nonsmoking peers to experience shortness of breath,
coughing spells, phlegm production, wheezing, and overall diminished physical
health. Cigarette smoking during childhood and adolescence poses a clear
risk for respiratory symptoms and problems during adolescence; these health
problems are risk factors for other chronic conditions in adulthood, including
chronic obstructive pulmonary disease.
Cardiovascular disease is the leading cause of death among adults in
the United States. Atherosclerosis, however, may begin 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
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 smokeless tobacco users are more likely
than nonusers to become cigarette smokers.
Among addictive behaviors such as the use of alcohol 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 cessation 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 involvement in
others. Delaying or preventing the use of tobacco may have implications
for delaying or preventing these other behaviors as well.
The Epidemiology of Tobacco Use Among Young People
Overall, about one-third of high-school-aged adolescents in the United
States smoke or use smokeless tobacco. Smoking prevalence among U.S. adolescents
declined sharply in the 1970s, but this decline slowed significantly in
the 1980s, 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 adolescents are substantially
more likely than females to use smokeless tobacco products; about 20%
of high school males report current use, whereas only about 1% of
females do. White adolescents are more likely to smoke and to use smokeless
tobacco than are black and Hispanic adolescents.
Sociodemographic, environmental, 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, reinforcement, 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 matters
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
overestimate 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 accurate perceptions. Similarly, those who perceive that cigarettes
are easily accessible and generally available are more likely to begin smoking
than are those who perceive more difficulty in obtaining cigarettes.
Behavioral factors figure heavily during adolescence, a period of multiple
transitions to physical maturation, to a coherent sense of self, and to
emotional independence. Adolescents are thus particularly vulnerable 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 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 nonsmoking 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 important risk factor for
initiation. Intentions to use tobacco and actual experimentation also strongly
predict subsequent regular use.
The positive functions that many young people attribute to smoking are
the same functions advanced in most cigarette advertising. Young people
are a strategically 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 activities,
and young people report considerable familiarity with many cigarette advertisements.
In the past, this exposure was accomplished by radio and television programs
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 attractiveness and function of smoking.
Cigarette advertising frequently uses human models or human-like cartoon
characters to display images of youthful activities, independence, healthfulness,
and adventure-seeking. In presenting 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 advertising 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 promotional activities, stronger
prohibitions on the sale of tobacco products to minors, and increases in
earmarked taxes on tobacco products. Interventions to prevent initiation
among young people—even actions that involve restrictions on adult smoking
or increased taxes—have received strong support among smoking and nonsmoking
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 providing skills to resist those influences,
have demonstrated consistent and significant reductions in adolescent smoking
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 coordinated communitywide programs that involve parents,
youth-oriented mass media and counteradvertising, community organizations,
or other elements of adolescents' social environments.
A crucial element of prevention is access: adolescents should not be
able to purchase tobacco products in their communities. Active enforcement
of age-at-sale policies by public officials and community members appears
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. Maintaining higher real prices of cigarettes provides
a barrier to adolescent tobacco use but depends on further tax increases
to offset the effects of inflation. The results of this review thus suggest
that a coordinated, multicomponent campaign involving policy changes, taxation,
mass media, 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 tobacco 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 and smokeless tobacco use continue to
be of great public health importance, since one out of three U.S. adolescents
uses tobacco by age 18. The social environment of adolescents, including
the functions, meanings, and images of smoking that are conveyed through
cigarette advertising, sets the stage for adolescents to begin using tobacco.
As tobacco products are available and as peers begin to try them, these
factors become personalized and relevant, and tobacco use may begin. This
process most affects adolescents who, compared with their peers, have lower
self-esteem and self-images, are less involved with school and academic
achievement, have fewer skills to resist the offers of peers, and come from
homes with lower socioeconomic status. Tobacco-use prevention programs that
target the larger social environment of adolescents are both efficacious
and warranted.
Disclaimer: Data and findings provided on this page reflect the content of
this particular Surgeon General's Report. More recent information may exist
elsewhere on the Smoking & Tobacco Use Web site (for example, in fact sheets,
frequently asked questions, or other materials that are reviewed on a regular
basis and updated accordingly).
Page last updated February 24, 1994