CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

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Young People and Tobacco: Preventing Addiction at Its Roots

Although prevention is the ultimate goal of tobacco control for young people, each day more than 6,000 young Americans try their first cigarette. If current smoking trends continue, 5 million of today's young people will die of tobacco-related diseases. "We hope to decrease smoking among young people by learning more about why they start smoking and by finding and promoting effective strategies to help young people avoid tobacco use," said Jeff McKenna, MS, CDC health communicator. The decision to use tobacco is nearly always made in the teen years, when young people greatly underestimate the true health risks and addictiveness of smoking.

The short-term health consequences of smoking on young people include a lower level of lung function, slower lung growth, shortness of breath, increased amounts of phlegm, and an increase in resting heart rate. As a result of the effects of smoking on the body, young people who smoke are not as physically fit—in terms of both performance and endurance—as they would be if they did not smoke. Moreover, cigarette smoking is associated with other risky behaviors: teens who smoke are three times more likely than nonsmokers to use alcohol, eight times more likely to use marijuana, and 22 times more likely to use cocaine.

The long-term health consequences of smoking among young people are reinforced by the fact that most young people who smoke daily continue to smoke throughout adulthood. In adults, cigarette smoking causes heart disease, chronic lung disease, and stroke, and early signs of these diseases can be found in adolescents who smoke. In addition, smoking increases a person's risk of lung cancer, and this risk continues to rise as long as the person smokes. On average, someone who smokes a pack or more of cigarettes a day lives 7 years less than someone who never smoked.

According to the Surgeon General's report Reducing Tobacco Use, effective educational programs for preventing tobacco use could postpone or prevent smoking in 20% to 40% of U.S. adolescents. CDC and its partners are conducting and disseminating surveillance and research and are developing educational resources and counteradvertising campaigns to aid states in establishing effective programs to help young people avoid tobacco use.

Collecting Vital Information Through School Surveys
CDC has worked with states to develop and conduct two school surveys that collect information on tobacco use among young people: the Youth Tobacco Survey (YTS) and the Youth Risk Behavior Survey (YRBS). "Data from these surveys allow us to understand who is using tobacco products and why. We use the information to make our youth tobacco prevention programs more effective," said Charles (Wick) Warren, PhD, CDC statistician. 

The YTS was first conducted in 1998 in three states—Florida, Mississippi, and Texas—that had requested help in collecting baseline data before establishing comprehensive tobacco control and prevention programs. The YRBS was introduced in 1991 to provide states with vital information on six risk behaviors: tobacco use, dietary behavior, physical activity, alcohol and other drug use, sexual behavior, and behaviors that may result in violence and unintentional injury. By the end of the 2001–2002 school year, 48 states and the District of Columbia will have conducted either the YTS, the YRBS, or both. 

The YTS is conducted in middle and high schools and consists of a core questionnaire that assesses the prevalence of tobacco use, access to tobacco products (cigarettes, cigars, smokeless tobacco, pipes, bidis, and kreteks), exposure to pro- and anti-tobacco advertising, exposure to environmental tobacco smoke, attempts and desire to quit, and exposure to tobacco education in the school curriculum. The YRBS, which is conducted in high schools, contains 12 tobacco-specific questions that are identically worded on the YTS. 

The participating states meet in Atlanta every other year to determine the content of the YTS core questionnaire. Each state can also add its own questions to collect information not included in the core questionnaire. The standardized YTS core allows states to compare their data with those of other states, with the tobacco data from the YRBS, and with data from the National Youth Tobacco Survey (NYTS). The NYTS, which is funded by the American Legacy Foundation and conducted with technical assistance from CDC, allows states to compare their data against national estimates. 

YTS and YRBS data have many tobacco prevention-related uses:

• To establish a baseline for state tobacco control and prevention programs for young people. 
• To evaluate the effectiveness of tobacco prevention and control programs and activities.
• To promote policies and funding to support comprehensive tobacco control and prevention programs. 
• To monitor trends in tobacco use among middle and high school students. 
• To monitor progress toward achieving the Healthy People 2010 objectives. 

Together, the YTS and YRBS provide states with data to support the design, establishment, and evaluation of prevention programs directed at young people as outlined in CDC's Best Practices for Comprehensive Tobacco Control Programs.

High School Students Who Reported Current Cigarette Smoking*— United States, 1991–1999

*Smoking one or more cigarettes during the previous 30 days.

Better Understanding the High Rates of Tobacco Use Among Young Adults 
CDC has recently begun research to determine the cause of high rates of smoking among young adults (aged 18–24). CDC researchers are conducting focus groups of college students and college-aged non-students in the Atlanta area and are examining data on tobacco use among young adults collected through the National Health Interview Survey and the Monitoring the Future Survey. Focus group findings to date generally support data from the surveys. Information collected thus far indicates that 

• Young adults not in college are more likely to smoke than are those in college. 
• Most college students who smoke started before college, but they are more likely to become frequent smokers in college. 
• Young adults are not interested in quitting smoking and are not motivated by health considerations. Focus group participants indicated that the only factor that would make them consider quitting was a large increase in the price of cigarettes. 
• Young adults report frequently being exposed to cigarette marketing in bars and clubs. Strategies include tobacco-themed bars (Camel bars and Marlboro bars, for example), free cigarettes, promotional gifts, and grand prize drawings for smokers only.
• In addition to marketing strategies, tobacco companies are also influencing college students by awarding scholarships to black students and by recruiting for employees on college campuses. 

According to Linda Pederson, PhD, CDC epidemiologist, the long-term goal of this project is to use the knowledge gained from the research to develop effective programs to prevent college-aged Americans from starting to smoke and to help those who have already started smoking to quit.

Counteracting the Influence of Tobacco Advertising on Young People 
Even though the 1998 Master Settlement Agreement restricted tobacco advertising, young people are still exposed to highly appealing messages and images about tobacco use that portray smoking as glamorous, social, and normal. Effective countermarketing is essential to offset the effects of these messages. To improve the effectiveness of its countermarketing efforts, in 1996 CDC convened a panel of youth marketing and research experts through the Columbia University Prevention Research Center in New York City to advise the agency on countermarketing approaches. Panelists represented a variety of companies—including Levis, Adidas, and Motown—that cater to young people. In making their recommendations, the panel drew on their own private-sector experience as well as on the results of an extensive literature review and interviews with experts in tobacco control and health promotion. 

The panel recommended that countermarketing primarily target young people aged 11–15 years, the ages during which many smokers first try tobacco. Counteradvertising for this age group should 

• Highlight a tobacco-free lifestyle as the majority lifestyle of diverse and interesting people and provide positive examples. 
• Emphasize the dangers of tobacco use in an emotional and personal way. 
• Offer young people empowerment and control, and avoid preaching. 
• Use multiple voices and strategies. 
• Offer constructive alternatives to tobacco use. 
• Portray smoking as unacceptable and undesirable for everyone. 

According to Mr. McKenna, CDC will update these recommendations regularly as new information becomes available. To encourage states to use part of their Master Settlement Agreement funds for countermarketing campaigns, CDC has become more proactive in offering states materials and technical assistance for countermarketing, said Rebecca Murphy, MPH, CDC health communicator. In this expanded role, CDC will assist states in recruiting advertising agencies and reviewing their proposals. CDC will also provide states with training and technical assistance on developing an effective counteradvertising campaign and evaluation plan. 

Reaching Young People Through the Entertainment Industry 
CDC has worked with the entertainment industry to produce materials for use in schools and communities to increase young people's awareness of the influences of the tobacco industry and to help them adopt healthy, tobacco-free lifestyles. Examples of recent products resulting from these collaborations include the following: 

• SLAM!, a 15-minute video with an accompanying facilitator's guide, tells the story of Leslie Nuchow, a young singer/songwriter who was offered a lucrative opportunity to be promoted by a new record company, WomanThing Music. However, WomanThing Music was owned by Philip Morris Tobacco Company, and the only way to get the CD that WomanThing Music was producing was to buy two packs of Virginia Slims cigarettes. Feeling a need to speak out against these exploitative marketing tactics, Leslie organized the Virginia SLAM!, a counter-concert to protest the use of music to market cigarettes. SLAM! has since become a growing movement supported by celebrity artists, including Jill Sobule, Shawn Mullins, and the Indigo Girls, and has provided thousands of young people with the information and inspiration to resist the influence of the tobacco industry. CDC produced this video for middle and high schools students to help them be more aware of the power and pervasiveness of cigarette advertising. This year, CDC is supporting SLAM's outreach into college communities to expand Leslie's message to this important market. 

• Secrets Through the Smoke is an hour-long video that documents the story of Jeffrey S. Wigand, PhD, subject of the Academy Award-nominated film The Insider. Dr. Wigand achieved national prominence in 1995 when he became the tobacco industry's highest-ranking former executive to publicly acknowledge the devastating effects of smoking on health. Dr. Wigand's conviction and courage led to his testifying in a Mississippi courtroom on the industry's knowledge of nicotine addiction and the health consequences of smoking. This testimony resulted in a landmark court decision that paved the way for the Master Settlement Agreement. In Secrets Through the Smoke, Dr. Wigand shares his experiences about the tobacco industry's manipulation of the truth. The video is intended primarily for use with middle and high school students but can also be used with community leaders and policymakers. The accompanying guides for facilitators—one for students and one for adult audiences—provide topics for critical thinking and discussion. 

• Women and Tobacco: Seven Deadly Myths is a 17-minute video aimed specifically at young women. In this video, cover model and smoking cessation advocate Christy Turlington explores common myths about smoking— such as "If I quit, I'll get fat"; "Light cigarettes are safe"; and "I won't get hooked"—to encourage women to become and stay smoke free. The video is accompanied by a facilitator's guide. 

Celebrities such as cover model/ entrepreneur Christy Turlington are influential supporters of countermarketing efforts.

In addition, CDC recently collaborated with actor Jeremy London (Party of Five cast member and director of Secrets Through the Smoke) to produce two television spots with the tagline "Tobacco: It's Killing the Ones You Love." CDC continues to provide technical support to the entertainment community to ensure that tobacco use is accurately portrayed on screen. 

CDC is also working with sports personalities to promote sports participation by young people as a healthy alternative to tobacco use. (See related article)

Promoting the Critical Role of Parents 
Recent research has documented that a strong sense of belonging to a family and being connected to parents greatly increases the likelihood that a teenager will avoid risk behaviors such as tobacco, alcohol, and drug use. However, establishing this connectedness can be a challenge. "Time-stressed parents, peer pressure, the influence of the media, and a desire for independence are common obstacles to young people maintaining close relationships with their parents," said Ralph Caraballo, PhD, MPH, CDC epidemiologist. 

Because parents are largely untapped resources in the national effort to prevent tobacco use among young people, CDC is developing a campaign kit for states called Got a Minute? Give It to Your Kid. Scheduled to be released later this year, the kit consists of radio public service announcements, print advertisements, brochures, a poster, guidelines for launching a media campaign, and a review of research that supports the importance of parental involvement. 

States can use any or all pieces of the kit to encourage parents to build and maintain strong relationships with their children and to raise parents' awareness of tobacco use as a serious issue. According to Reba Griffith, MPH, CDC health communicator, many parents see smoking as a minor risk compared with alcohol and drug use. However, in addition to the health problems that tobacco use alone can cause, it is associated with taking risks in other areas: young people who smoke are more likely than young people who don't smoke to use illicit drugs, to drink heavily, and to have unsafe sex. 

Programs to Help Young People Quit Smoking: Exploring a New Frontier 
Most young people who smoke say that they want to quit, but few are successful: three of four teenage smokers who try to quit, fail. Programs designed to help adults quit smoking have not been effective for young people, who are generally not motivated by factors such as health concerns that may be important to adults. The states see a need to provide programs to help young people stop using tobacco, but the scientific basis for such programs is lacking.

To advance research on how best to help young people give up tobacco, the Robert Wood Johnson Foundation has spearheaded the Youth Tobacco Cessation Collaborative, an effort that also involves CDC, the National Cancer Institute (NCI), the National Institute on Drug Abuse, the American Cancer Society, the American Lung Association, and others. During 1998–1999, the collaborative developed and published National Blueprint for Action: Youth and Young Adult Tobacco Use Cessation. According to Micah Milton, MPH, CDC behavioral scientist, the 10-year goal of the blueprint is to ensure that all young tobacco users in the United States have access to effective programs to help them quit. 

The first major initiative that has grown out of the blueprint is a systematic review of scientific evidence to answer the question, "What do we know about what works to help young people quit smoking?" CDC's primary funding partners in this effort are NCI and the Canadian Tobacco Research and Control Initiative. One of the major goals of the initiative is to bring researchers and practitioners together to begin translating research into effective programs. 

Although the direction that these programs will take is currently not clear, some approaches are promising. These approaches are being outlined in a toolkit for practitioners that will be published early next year. The toolkit will provide 

• Results of the systematic review of the scientific evidence on cessation programs. 
• Tools for determining local needs and local capacity for establishing programs. 
• Methods for determining which programs can most effectively meet local needs. 
• Guidelines for evaluating programs. 

A second initiative from the blueprint is now getting under way. Spearheaded by NCI with CDC participation, this research-focused effort will examine how best to measure patterns of tobacco use among teenagers and how to deter-mine which behaviors are most likely to predict successfully giving up tobacco. 

In addition, the Robert Wood Johnson Foundation recently approved an $11.2 million initiative to evaluate existing programs being used to help young people quit smoking. The purpose of this initiative is to deter-mine what works in the real world by comparing the effectiveness of existing programs. CDC and NCI are co-funding the project and providing technical assistance. 

For more information on CDC's efforts to combat tobacco use among young people, call the Office on Smoking and Health at 1/770/488-5705 and press 3, or visit the Web site at www.cdc.gov/tobacco.

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This page last reviewed August 10, 2004

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