Foreword and Preface

Foreword

This Surgeon General's report on smoking and health is the twenty-third in a series that was begun in 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 all 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 considerable 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% 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 community wide basis—has proven successful in preventing the onset and development of tobacco use among young people.

Preface

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 Tobacco 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 well known, 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 promotion, 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 will: schools, communities, legislatures, and public opinion all testify to the growing support for encouraging young people to avoid tobacco use.

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.