Tobacco Use

Goal

Reduce illness, disability, and death related to tobacco use and exposure to secondhand smoke.

Overview

Scientific knowledge about the health effects of tobacco use has increased greatly since the first Surgeon General’s report on tobacco was released in 1964.[1], [2] Cigarette smoking causes heart disease, several kinds of cancer (lung, larynx, esophagus, pharynx, mouth, and bladder), and chronic lung disease. Cigarette smoking also contributes to cancer of the pancreas, kidney, and cervix. Smoking during pregnancy causes spontaneous abortions, low birth weight, and sudden infant death syndrome.[3]

Other forms of tobacco are not safe alternatives to smoking cigarettes. Use of spit tobacco causes a number of serious oral health problems, including cancer of the mouth and gum, periodontitis, and tooth loss.1, [4] Cigar use causes cancer of the larynx, mouth, esophagus, and lung.[5] In recent years, reports have shown an increase in the popularity of bidis.[6] Bidis are small brown cigarettes, often flavored, consisting of tobacco hand-rolled in tendu or temburni leaf and secured with a string at one end. Research shows that bidis are a significant health hazard to users, increasing the risk of coronary heart disease and cancer of the mouth, pharynx and larynx, lung, esophagus, stomach, and liver.[7]

Issues and Trends

Tobacco use is responsible for more than 430,000 deaths per year among adults in the United States, representing more than 5 million years of potential life lost.[8] If current tobacco use patterns persist in the United States, an estimated 5 million persons under age 18 years will die prematurely from a smoking-related disease.[9] Direct medical costs related to smoking total at least $50 billion per year;[10] direct medical costs related to smoking during pregnancy are approximately $1.4 billion per year.[11]

Evidence is accumulating that shows maternal tobacco use is associated with mental retardation and birth defects such as oral clefts. Exposure to secondhand smoke also has serious health effects.[12], [13], [14] Researchers have identified more than 4,000 chemicals in tobacco smoke; of these, at least 43 cause cancer in humans and animals.13 Each year, because of exposure to secondhand smoke, an estimated 3,000 nonsmokers die of lung cancer, and 150,000 to 300,000 infants and children under age 18 months experience lower respiratory tract infections.13, 14 Asthma and other respiratory conditions often are triggered or worsened by tobacco smoke. (See Focus Area 8. Environmental Health; Focus Area 16. Maternal, Infant, and Child Health; and Focus Area 24. Respiratory Diseases.)

Studies also have found that secondhand smoke exposure causes heart disease among adults.[15], [16] Data reported from a study of the U.S. population aged 4 years and older indicated that among nontobacco users, 88 percent had detectable levels of serum cotinine, a biological marker for exposure to secondhand smoke.[17] Both home and workplace environments have contributed to the widespread exposure to secondhand smoke. Data from a 1996 study indicated that 22 percent of U.S. children and adolescents under age 18 years (approximately 15 million children and adolescents) were exposed to secondhand smoke in their homes.[18]

Smoking among adults declined steadily from the mid-1960s through the 1980s. However, smoking among adults appears to have leveled off in the 1990s. The rate of smoking among adults in 1997 was 25 percent.[19]

Tobacco use and addiction usually begin in adolescence. Furthermore, tobacco use may increase the probability that an adolescent will use other drugs. (See Focus Area 26. Substance Abuse.) Among adults in the United States who have ever smoked daily, 82 percent tried their first cigarette before age 18 years, and 53 percent became daily smokers before age 18 years.[20] Preventing tobacco use among youth has emerged as a major focus of tobacco control efforts.

Tobacco use among adolescents increased in the 1990s after decreasing in the 1970s and 1980s. Data from the 1999 Monitoring the Future Study indicated that past-month smoking among 8th, 10th, and 12th graders was 18, 26, and 35 percent, respectively. These rates represent increases of 20 to 33 percent since 1991.[21] Data from the Youth Risk Behavior Survey revealed that past-month smoking among 9th to 12th graders rose from 28 percent in 1991 to 36 percent in 1997.[22] Past-month spit tobacco use among 9th to 12th graders was 9 percent in 1997 (2 percent among females and 16 percent among males).22 In 1997, past-month cigar use among 9th to 12th graders was 22 percent (11 percent of females and 31 percent of males).22

Youth are put at increased risk of initiating tobacco use by sociodemographic, environmental, and personal factors. Sociodemographic risk factors include coming from a family with low socioeconomic status. Environmental risk factors include accessibility and availability of tobacco products, cigarette advertising and promotion practices, the price of tobacco products, perceptions that tobacco use is normal, peers’ and siblings’ use and approval, and lack of parental involvement. Personal risk factors include low self-image and low self-esteem, the belief that tobacco use provides a benefit, and the lack of ability to refuse offers to use tobacco.20

Overwhelming evidence indicates that nicotine found in tobacco is addictive and that addiction occurs in most smokers during adolescence.20, [23] Among students who were high school seniors during 1976–86, 44 percent of daily smokers believed that in 5 years they would not be smoking. Followup studies, however, indicated that 5 to 6 years later 73 percent of these persons remained daily smokers.20 In 1995, 68 percent of current smokers wanted to quit smoking completely, and 46 percent of the current daily smokers had stopped smoking for at least 1 day during the preceding 12 months.19 Less than 3 percent of current smokers stopped smoking permanently.[24]

Disparities

Men are more likely to smoke than women (26 percent compared to 22 percent).19 Disparities in tobacco use exist among certain racial and ethnic populations.American Indians or Alaska Natives (35 percent) are more likely to smoke than other racial and ethnic groups, with considerable variations in percentages by Tribe.[25] Hispanics (18 percent) and Asians or Pacific Islanders (13 percent) are less likely to smoke than other groups. Regional and local data, however, reveal much higher smoking levels among specific population groups of Hispanics and Asians or Pacific Islanders.25 Smoking levels among Vietnamese and Korean Asian Americans are higher than previously reported, according to a 1997 multilingual survey.[26]

Studies have found higher levels of cigarette use among gay men and lesbians than among heterosexuals.[27], [28], [29], [30] Gay men and lesbians with higher education levels are less likely to use cigarettes as frequently as those with lower levels of education.28

Persons with 9 to 11 years of education (38 percent) have significantly higher levels of smoking than individuals with 8 years or less of education or 12 years or more. Individuals with 16 or more years of education have the lowest smoking rates (11 percent). Individuals who are poor are significantly more likely to smoke than individuals of middle or high income (34 percent compared to 21 percent).19

Data reveal high levels of tobacco use among college students. In 1995, 29 percent of college students smoked in the previous month (28 percent of females and 30 percent of males). Five percent of college students used spit tobacco in the previous month (0.3 percent of females and 12 percent of males).[31]

Among adolescents, smoking rates differ between whites and African Americans.21, 22 By the late 1980s, smoking rates among white teens were more than triple those of African American teens. In recent years, smoking has started to increase among African American male teens, but African American female teens continue to have lower smoking rates. In 1997, 40 percent of white high school females were smokers, compared to 17 percent of African American high school females.22

Spit tobacco use among adolescents also differs significantly by students’ gender, race, and ethnicity. In 1997, 15.8 percent of male high school students currently used spit tobacco, compared to only 1.5 percent of female high school students. Current spit tobacco use was 12.2 percent for non-Hispanic whites, 2.2 percent for non-Hispanic African Americans, and 5.1 percent for Hispanics.22

Opportunities

Efforts to reduce tobacco use in the United States have shifted from focusing primarily on smoking cessation for individuals to more population-based interventions. Such interventions emphasize prevention of initiation, reduction of exposure to environmental tobacco smoke, and policy changes in health care systems to promote smoking cessation.20, [32], [33], [34], [35], [36], [37] Federal, State, and local government agencies and numerous health organizations have joined together to develop and implement population-based approaches.

Community research studies and evidence from California, Florida, Massachusetts, and Oregon have shown that comprehensive programs can be effective in reducing average cigarette consumption per person. Both California and Massachusetts increased cigarette excise taxes and designated a portion of the revenues for comprehensive tobacco control programs. Data from these States indicate that (1) increasing excise taxes on cigarettes is one of the most cost-effective short-term strategies to reduce tobacco consumption among adults and to prevent initiation among youth and (2) the ability to sustain lower consumption increases when the tax increase is combined with an antismoking campaign.[38] In addition, recent data from Florida indicate that past-month smoking decreased significantly among public middle school students (19 percent to 15 percent) and high school students (27 percent to 25 percent) from 1998 to 1999 following implementation of a comprehensive program to prevent and reduce tobacco use among youth in that State.[39]

As education programs for school-aged youth are developed and proven effective in preventing initiation and in cessation, these programs should be included in quality health education curricula at the grade level. Education should aim to prevent initiation among youth, provide knowledge about effective cessation methods, and increase understanding of the health effects of tobacco use. (See Focus Area 7. Educational and Community-Based Programs.)

The goals of comprehensive tobacco prevention and reduction efforts include preventing people from starting to use tobacco, helping people quit using tobacco, reducing exposure to secondhand smoke, and identifying and eliminating disparities in tobacco use among population groups. To address these goals, community programs, media interventions, policy and regulatory activities, and surveillance and evaluation programs are being implemented. Specifically, the following elements are used to build capacity to implement and support tobacco use prevention and control interventions: a focus on change in social norms and environments that support tobacco use, policy and regulatory strategies, community participation, establishment of public and private partnerships, strategic use of media, development of local programs, coordination of statewide and local activities, linkage of school-based activities to community activities, and use of data collection and evaluation techniques to monitor program impact.

The importance of these various strategic elements has been demonstrated in a number of States, such as Arizona, California, Florida, Massachusetts, and Oregon.[40] In these and other States, tobacco control programs are supported through funding from the Federal Government, private foundations, State tobacco taxes, State lawsuit settlements, and other sources. These programs address issues such as reducing exposure to secondhand smoke, restricting minors’ access to tobacco, treating nicotine addiction, limiting the impact of tobacco advertising, increasing the price of tobacco products, and directly regulating the product (for example, requiring product ingredient reporting). Tobacco control programs and materials should be culturally and linguistically appropriate.

Interim Progress Toward Year 2000 Objectives

Of the 26 tobacco-related objectives, 3 have been met: reducing the rate of lung cancer deaths, reducing the rate of oral cancer deaths, and increasing the number of States that have tobacco control plans.

Sixteen additional objectives are showing progress. These include reducing cigarette smoking among adults, which declined in the early part of the 1990s and then leveled off, and reducing children’s exposure to secondhand smoke, which also declined. Some objectives, though showing progress, are far from their targets. For example, although 13 States have laws limiting smoking in public places and worksites, few ban smoking or limit it to separately ventilated areas in private workplaces or restaurants. As of December 31, 1998, only one State had met the objective for private worksites, and three had met it for restaurants. All 50 States and the District of Columbia have laws prohibiting the sale of tobacco to minors. However, the objective on enforcement of minors’ access laws to achieve illegal buy rates of no more than 20 percent is far from being met: in fiscal year 1998, only 12 States had met this target. Although Healthy People 2000 data indicate that smoking among adolescents is declining somewhat, other surveys indicate that smoking among youth increased through 1997 and remained unchanged or declined somewhat in 1998 and 1999. Two additional objectives that include the use of and perception of harm from using drugs, alcohol, and cigarettes by high school seniors show mixed progress; for cigarettes there is slight progress.

Three objectives (perception of social disapproval of cigarette smoking among adolescents, States with preemptive clean indoor air laws, and smoking cessation during pregnancy) are moving away from the targets.

Data beyond baseline were not available for two objectives (tobacco product advertising and promotion to youth, and health plans offering treatment for nicotine addiction).

Note: Unless otherwise noted, data are from the Centers for Disease Control and
Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Tobacco Use

Goal: Reduce illness, disability, and death related to tobacco use and exposure to secondhand smoke.

Number	Objective Short Title
Tobacco Use in Population Groups
27-1	Adult tobacco use
27-2	Adolescent tobacco use
27-3	Initiation of tobacco use
27-4	Age at first tobacco use
Cessation and Treatment
27-5	Smoking cessation by adults
27-6	Smoking cessation during pregnancy
27-7	Smoking cessation by adolescents
27-8	Insurance coverage of cessation treatment
Exposure to Secondhand Smoke
27-9	Exposure to tobacco smoke at home among children
27-10	Exposure to environmental tobacco smoke
27-11	Smoke-free and tobacco-free schools
27-12	Worksite smoking policies
27-13	Smoke-free indoor air laws
Social and Environmental Changes
27-14	Enforcement of illegal tobacco sales to minors laws
27-15	Retail license suspension for sales to minors
27-16	Tobacco advertising and promotion targeting adolescents and young adults
27-17	Adolescent disapproval of smoking
27-18	Tobacco control programs
27-19	Preemptive tobacco control laws
27-20	Tobacco product regulation
27-21	Tobacco tax

Healthy People 2010 Objectives

Tobacco Use in Population Groups

27-1.		Reduce tobacco use by adults.

Target and baseline:

Objective	Reduction in Tobacco Use by Adults Aged 18 Years and Older	1998 Baseline*	2010 Target
		Percent
27-1a.	Cigarette smoking	24	12
27-1b.	Spit tobacco	2.6	0.4
27-1c.	Cigars	2.5	1.2
27-1d.	Other products	Developmental

*Age adjusted to the year 2000 standard population.

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

Adults Aged 18 Years and Older, 1998 (unless noted)	27-1a. Cigarette Smoking	27-1b. Spit Tobacco	27-1c. Cigars
	Percent
TOTAL	24	2.6	2.5
Race and ethnicity
American Indian or Alaska Native	35	DSU	DSU
Asian or Pacific Islander	13	DSU	DSU
Asian	13	DSU	DSU
Native Hawaiian and other Pacific Islander	17	DSU	DSU
Black or African American	25	1.1	1.9
White	25	2.9	2.6
Hispanic or Latino	19	0.5	1.3
Not Hispanic or Latino	25	2.8	2.6
Black or African American	25	1.1	1.9
White	25	3.2	2.8
Gender
Female	22	0.3	0.2
Male	26	4.9	4.9
Family income level
Poor	34	3.0	2.2
Near poor	31	3.0	2.7
Middle/high income	21	2.6	2.6
Education level (aged 25 years and older)
Less than high school	34	4.1	2.4
Less than 9 years	27	3.8	2.5
9 to 11 years	38	3.9	2.3
High school graduate	29	2.6	2.4
At least some college	17	1.7	2.7
13 to 15 years	24	2.2	2.7
16 years or more	11	1.2	2.6
Disability status
Persons with disabilities	33 (1997)	DNA	DNA
Persons without disabilities	23 (1997)	DNA	DNA
Sexual orientation	DNC	DNC	DNC
Select populations
Age groups(not age adjusted)
18 to 24 years	28(1997)	3.5(1997)	2.2(1997)
25 to 44 years	27(1997)	3.2(1997)	2.8(1997)
45 to 64 years	25(1997)	1.7(1997)	3.0(1997)
65 years and older	11(1997)	1.8(1997)	0.9(1997)