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Surgeon General's report focuses on young people

'Nearly all tobacco use begins during youth and young adulthood'

March 13, 2012

By Craig Palmer, ADA News staff

Regina Benjamin, M.D.

Washington—Industry marketing of smokeless tobacco products “could have contributed to the stagnant levels of risk perception” among young people, the U.S. Surgeon General said in a report on Preventing Tobacco Use Among Youth and Young Adults.

The 2012 Surgeon General’s report is the second to focus solely on young people since these reports began in 1964 with the landmark report by Luther Perry’s, M.D., on smoking and health and the first since 2009 enactment of the ADA-supported Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration new authority to regulate tobacco products.

“Nearly all tobacco use begins during youth and young adulthood,” Surgeon General Regina Benjamin, M.D., said in a preface. Peer influences, imagery and messages that portray tobacco as a desirable activity “help attract youth to tobacco use and reinforce the perception that smoking and various forms of tobacco use are a social norm - a particularly strong message during adolescence and young adulthood.”

The Association hailed the new report as helpful in the fight against youth tobacco use. The ADA is concerned about recent attempts to market smokeless tobacco products as somehow safer or less harmful than cigarettes and has filed comments with the FDA on the scientific framework for evaluating “modified risk” claims. Visit for information on the Association's tobacco control policy.

SG tobacco report’s major conclusions

Preventing Tobacco Use Among Youth and Young Adults, an evidence-based report of the Surgeon General (see related report), has five major conclusions:

• Cigarette smoking by youth and young adults has immediate adverse health consequences, including addiction, and accelerates the development of chronic diseases across the full life course.

• Prevention efforts must focus on both adolescents and young adults because among adults who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age (88 percent) with 99 percent of first use by 26 years of age.

• Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults.

• After years of steady progress, declines in the use of tobacco by youth and young adults have slowed for cigarette smoking and stalled for smokeless tobacco use.

• Coordinated, multicomponent interventions that combine mass media campaigns, price increases including those that result from tax increases, school-based policies and programs and statewide or community-wide changes in smoke-free policies and norms are effective in reducing the initiation, prevalence and intensity of smoking among youth and young adults.

This report of the Surgeon General was prepared by the Centers for Disease Control and Prevention (CDC) Office on Smoking and Health.

The Surgeon General’s report examines the health effects, industry marketing and youth perception of risk associated with these products and concludes, “Although there is some discussion in the medical literature on whether the harmful consequences of using smokeless tobacco are as severe as those from smoking, the literature confirms both short- and long-term negative consequences for using smokeless tobacco. The majority of these studies have focused on health outcomes occurring in adulthood.”

Use of smokeless tobacco products, including snuff and chewing tobacco, has been linked to localized oral health consequences at the site of tobacco placement and systemic effects, the report said. Smokeless tobacco contains at least 28 carcinogens, according to the International Agency for Research on Cancer, and there is strong evidence to show that users have an increased risk of developing leukoplakia, a precancerous lesion on oral soft tissue, as well as oral cancers.

“Other undesirable oral health outcomes that have been linked to smokeless tobacco use include gingival recession, periodontal disease and tooth decay. Less serious outcomes include staining of teeth and halitosis,” the report said with reference to research reported in the medical literature since 1994 publication of the first Surgeon General’s report on youth tobacco use.

“The systemic effects of using smokeless tobacco include nicotine addiction and dependence and acute cardiovascular effects like an elevated heart rate and high blood pressure. Use of smokeless tobacco may also be related to long-term cardiovascular effects and mortality, although the evidence on such associations is mixed.”

A National Institute on Drug Abuse survey administered by the University of Michigan’s Institute for Social Research and cited by the Surgeon General, Monitoring the Future, has monitored perceptions of risk concerning smokeless tobacco since 1986. Overall, in 2010, 41.2 percent of 12th grade students believed there is great risk of harm associated with the regular use of smokeless tobacco.

“Since 1986, there was a gradual but substantial increase in the proportion of 12th grade students believing that there is a great risk in using smokeless tobacco regularly, but the increasing trend stalled after 1999, with the percentage holding this perception essentially the same in 1999 and 2010,” said the SG’s report.

“The smokeless tobacco industry has participated in the debate about reducing harm by switching from cigarettes to smokeless [products], and subtle marketing of its products that may suggest they are safer than cigarettes could have contributed to the stagnant levels of risk perception.”

Initiation of smokeless tobacco use appears to occur somewhat later in adolescence than does cigarette smoking, the report said. The prevalence of smokeless tobacco use is highest among males, whites and older youth and lowest among females and blacks. Moist snuff is the most popular type of smokeless tobacco among youth, and discount brands like Grizzly have become popular among young people in recent years.

The report examines the epidemiology, health effects and causes of tobacco use among youth ages 12 through 17 and young adults ages 18 through 25 and the social, environmental, advertising and marketing influences that encourage youth and young adults to initiate and sustain tobacco use. The report is concerned with active smoking or use of smokeless tobacco products but does not consider young people’s exposure to secondhand smoke.

Although cigarette smoking is the most common form of tobacco use in the United States, the report also focuses on other forms such as smokeless chew and snuff products and smoking a product other than a cigarette, such as a pipe, cigar or bidi, the latter tobacco wrapped in tendu leaves. Emerging forms of tobacco such as bidis, kreteks and hookahs have been shown in some local and state surveys to be popular with youth.

“Measures of the use of other emerging tobacco products like snus and dissolvables were not available on surveys that had been implemented before production of this chapter was complete, so these products are not addressed here,” the report said in a chapter on the epidemiology of tobacco use among young people in the United States and worldwide.

“We know what works to prevent tobacco use among young people,” said Dr. Benjamin. “The science contained in this and other Surgeon General’s reports provides us with the information we need to prevent the needless suffering of premature disease caused by tobacco use, as well as save millions of lives.”