Introduction of smoking
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.