Tobacco Documents Online

Surgeon General's Report J.P. Peddicord, M.S.,'Computer Scientist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard Ray, Director of Computer Services, Circle Solutions, Inc., McLean, Virginia. John Robey, Word Processing Specialist, Circle-Solutions, Inc., McLean, Virginia. Kathleen L. Schroeder, D.D.S., Associate Professor of Oral Pathology, West Virginia University School of Medicine, Morgantown, West Virginia. Maggie Shelby, Secretary, HCR Consulting Group, Atlanta, Georgia. Michael B. Siegel, M.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Renee E. Sieving, M.S.N., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Michael J. Staufacker, M.P.H., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Scott L. Tomar, D.M.D., Dr.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Traci L. Toomey, M.P.H., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Laura Williams, Student, Northeast Ohio University College of Medicine, Rootstown, Ohio. Rebecca B. Wolf, M.A., Program Analyst, Office of Program Planning and Evaluation, Centers for Disease Control and Prevention, Atlanta, Georgia. Bao-Ping Zhu, Ph.D., Research Scientist, Battelle Memorial Institute, Atlanta, Georgia. x TIMN 0138856

THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. 0 L 20201 The Honorable Thomas S. Foley Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: It is my pleasure to transmit to the Congress the Surgeon General's report on the health consequences of smoking entitled Preventing Tobacco Use Among Young People. This report is mandated by section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products as mandated by section 8(a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention's Office on Smoking and Health. This report focuses on the vulnerable adolescent ages of 10 - through 18 when most users start smoking, chewing, or dipping, and become addicted to tobacco. It examines the health effects of early smoking and smokeless tobacco use, the reasons that young men and women begin using tobacco, the extent to which they use it, and efforts to prevent tobacco use by young people. Smoking kills 434,000 Americans each year. Adolescent smoking and smokeless tobacco use are the first steps in this totally preventable public health tragedy. The facts are simple: one out of three adolescents in the United States is using tobacco by age 18, adolescent users become adult users, and few people begin to use tobacco after age 18. Preventing young people from starting to use tobacco is the key to reducing the death and disease caused by tobacco use. This report documents that intervention programs targeting the broad social environment of adolescents are both effective and warranted. A great:,-opportunity lies before us to prevent millions of premature deaths and improve the quality of lives. This report points out the overwhelming need in public health for efforts directed toward stopping young people before they start using tobacco. Enclosure TIMN 0138846

Preface from the Surgeon General, U.S. Department of Health and Human Services 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 promo- tion, 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. Ort 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. itt TIMN 0138849

Sur'gcun General'> ReEorP Table 1. Continued Reference Location/year Study population Stanhope and Prior 1975 New•Zealand, 1972 Maori and European high school students aged 13-15 years Bewley and Bland 1976 England, 1971 5,355 schoolchildren aged 10-12 years Bland et al. 1978 England, 1974 5,835 schoolchildren; first-year level in secondary school Weiss et a1.1980 Massachusetts, 1975 650 children aged 5-9 years, population sample Kujala 1981 Finland, 1976 1,075 male military recruits, mean age = 20 years . Charlton 1984 England, 1982 15,709 students aged 8-19 years Adams et al.1984 .='-`;. England,1975-1979 405 secondary schoolchildren 141 Rim eIs 2985 ela and Rim Finland 1983 4,279 16- and 17-year-olds p p • , in a national sample Oechsli, Seltzer, California, 1977-1979 1,445 children in a cohort van den Berg.1987 study "Smoking at least one cigarette weekly. Percentages combine data reported separately in authois'`table V for urban and rural children. "RR = Relative risk for children smoking ? one cigarette weekly vessus children who had never smoked, adjusted for parental smoking. xSmoking at least one cigarette weekly. 20 Health Consequences TIMN 0138873

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 con- siderable 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 percent of the natiori 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 communitywide basis-has proven successful in preventing the onset and development of tobacco use among young people. Philip R. Lee, M.D. David Satcher, M.D., Ph.D. Assistant Secretary for Health Director Public Health Service Centers for Disease Control and Prevention i TIMN 0138848

Preveatiny Tobacco Use Anwng Young People Symptoms Prevalence (%a) by smoking status Never smoker Smoker' Phlegm _ 3 months/yr 2.4 • 26.5x Breathlessness 2.4 20.5= Wheezing (apart from colds) 7.3 31.3t Colds go to chest 4.9 31.3t General findings: Increased cough and phlegm in smokers of > i cig/week versus never smokers. Dose-response evident. Prevalence of cough and phlegm dropped among smokers who quit smoking between 1965 and 1966. Never smoker Smokert Daily cough ? 3 months 4 10 Daily phlegm ? 3 months 3 9 Dyspnea when hurrying 16 30 Chest cold for 1 week 22 30 Wheezing or asthma 12 13 Number of cigarettes smoked per day 0 < 1 1-10 11-20 > 20 Cough 2.0 5.8 18.1 27.8 64.7 Phlegm 3.3 5.8 19.4 31.9 58.8 Shortness of breath _ 5.3 13.5 13.5 36.1 58.8 Never smoker Smoker' Morning cough Boys 5.4 18.2 Girls 5.9 19.8 Cough 3 months Boys 3.8 15.4 Girls 3.5 12.1 Never smoker Ex-smoker Present smoker Cough (day ortfi M in winter) Boys Girls 5.2 6.5 7.1 10.5 13.9 16.0 Nonsmoker Ex-smoker Smoker Number of cigarettes smoked per day Cough >_ 3 months/yrt S 1-9 10-14 _ 15 Boys' 2.9 4.5 9.2 16.2 29.0 Girls 4.4 6.0 12.0 23.1 35.9 tAt least one cigarette daily for the past year. t p < 0.01. , ' 'Smoking at least one cigarette weekly. Percentages combine data reported separately in authors'•Table 4 for urban and rural children. 9For white children only. Health Consequences 19 TIMN 0138872

Surgeon General's Report Table 1. Published studies of the effects of smoking on respiratory symptoms among young people, various countries, 1965-1983 Reference* Location/year Study population Peters and Ferris 1967 Massachusetts, 1965 124 Harvard College seniors Holland and Elliott 1968 England, 1965-1966 9,786 13- and 14-year-olds in 1965; 9,433 in 1966 Addington et al. 1970 Oklahoma9 557 high school students, (grades 9-12) aged 13-19 years Seeley, Zuskin, Bouhuys 1971 ConnecticutS 195 male and 170 female high - school students aged 15-19 years ; Bewley, Halil, Snaith 1973 England, 1971 8,682 schoolchildren aged 10 and 11 years Colley, Douglas, Reid 1973 United Kingdom, 1966 3,899 persons aged 20 years sampled from 1946 birth cohort study Rush 1974 New York, 1968 12,595 high school students aged 13-18 years *Listed chronologically by publication date. . °Year not provided. 18 Health Consequences TIMN 0138871

Prerviiting Tohaceo Use Among YvunY Pevple Symptoms Prevalence (%) by smoking status Gerierrzl rinudine: Cough grade, phlegm grade, and loose cough sign significantly associated with smoking. Never smoker Smoker** RR" Morning cough Boys 8.3 16.3 5.9 Girls 8.5 28.6 6.8 Cough 3 months Boys 7.2 13.4 2.4 Girls 6.0 10.7 2.6 Never smoker Smokeru RR49 Morning cough Boys 3.1 19.2 5.9 Girls 1.8 13.5 6.8 Cough day or night Boys 20.4 46.5 2.4 Girls 18.5 47.3 2.6 Breathlessness Boys 11.8 34.9 2.9 Girls 16.5 39.2 2.3 General findings: Persistent wheezing reported for 13.8% of ever smokers and 9.7% of never smokers; difference not significant. Nonsmoker'' Ex-smokerll Smoker*** Cough all day 1 2 8 Phlegm all day 1 1 7 Wheezing 5 13 22 Frequent cough 0 Number of cigarettes smoked per day 1-6 > 6 Boys Age 11-13 23 32 42 Age->14 9 16 29 Girls Age 11-13 19 34 49 Age>-14 9 18 32 General findings: Increased risk of cough, dyspnea, and phlegm. Never smoker Low-tar smokerm Medium-tar smoker$# Morning phlegm 2.7 7.6 11.4 Morning cough 6.3 20.7 20.5 Phlegm day or night 5.2 13.8 13.2 Cough day or night 19.1 43.9 40.6 General findings: Starting smoking associated with bronchitis and pneumonia. '°RR = Relative risk for children smoking at least one cigarette weekly versus children who hatd never smoked. "Nonsmoker =:Vever smoking and smoking not more than one cigarette daily for 5 one year. 9lEx-smoker = Smoking one month or more before date of the interview. •*5moker = Smoking ? 1 g of tobacco daily; one cigarette was estimated to contain Ig of tobacco. '-Smoking daily, cigarettes < 10mg of tar. tuSmoking daily, cigarettes 10-18mg of tar. Health Consequences 21 TIMN 0138874

Surgeon General's Report Table 3. Published studies of the effects of smoking on respiratory morbidity among young people, various countries, 1963-1987 Reference* Location/year Study population Haynes, Krstulovic, Bell 1966 New Jersey' 191 male prep school students aged 14-19 years Parnell, Anderson, Kinnis 1966 Canada, 1963-1964 175 senior student nurses Finklea et al. 1971 South Carolina, 1968-1969 1,900 college students Pollard et a1.1975 Florida, 1971-1972 1,100 U.S. Navy recruits, most aged 18-22 years , Kark and Lebiush 1981 Israe1,1979 Female military recruits, mean age = 18.5 years Kark, Lebiush, Rannon 1982 Israel, 1978 Male military recruits, mean age = 18.5 years Blake, Abell, Stanley 1988 . Georgia, 1982 1,230 Army recruits, ~ ~ most aged < 22 years Charlton and Blair 1989 England, 1987 2,885 schoolchildren aged. 12 and 13 years Schwartz and Zeger 1990 Californiat 100 student nurses *Listed chronologically by publication date. tYear not provided; 26 Health Consequences TIMN 0138879

Surgeon Genera!'s Report normative, peers' and siblings' use and approval of tobacco use, and lack of parental- support and in- volvement as adolescents face the challenges of growing up. 4. Behavioral risk factors for tobacco use include low levels of academic achievement and school involve- ment, lack of skills required to resist influences to use tobacco, and experimentation with any tobacco prod- uct. 5. Personal risk factors for tobacco use include a lower self-image and lower self-esteem than peers, the be- lief 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 impor- tant 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 enter- tainment, point-of-sale displays, and distribution of specialty items. 3. Cigarette advertising uses images rather than infor- mation to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, health- fulness, 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 dose the gap. 5. Cigaretteadvertisingappearstoaffectyoungpeople's perceptions of the pervasiveness, image, and func- tion of smoking. Sinco 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 pro- motions, 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-preven- tion 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 suc- cess rates. Recruiting and retaining adolescents in formal cessation programs are difficult. 5. IIlegal sales of tobacco products are common. Active enforcement of age-at-sale policies by public officials and community members appears necessary to pre- vent 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 re- sponsive as adults to such price changes. Maintain- ing higher real prices of cigarettes depends on further tax increases to offset the effects of inflation. 10 Introduction TIMN 0138864