The good news: The number of younger Americans who smoke has been going down since the late 1990s.

The bad news: The rates of tobacco smoking among teenagers are still higher than those of adults. On top of that, about 1 in 7 high school boys use some form of spit or other types of smokeless tobacco. Among high school girls, 2% use spit or smokeless tobacco.

Children and teens are easy targets for the tobacco industry. They're heavily influenced by TV, movies, advertising, and by what their friends do and say. They don't think much about future health consequences.

This document talks about tobacco use among children and teens and provides some tips for parents, teachers, and other adults who want to keep their kids tobacco-free.

Facts About Kids and Tobacco

Nearly all first use of tobacco takes place before high school graduation. A 2005 survey from the US Centers for Disease Control and Prevention (CDC) found that 54% of high school students had tried cigarette smoking at some point. For the most part, people who do not start using tobacco when they are teens never start using it.

Cigarette smoking causes serious health problems among children and teens, including:

• coughing 
• shortness of breath 
• production of phlegm (mucus) 
• respiratory illnesses 
• reduced physical fitness 
• poor lung growth and function 
• worse overall health 
• addiction to nicotine

The younger you are when you begin to smoke, the more likely you are to be an adult smoker. Almost 90% of adult smokers started at or before the age 19.  People who start smoking at younger ages are more likely to develop long-term nicotine addiction than people who start later in life.

Most young people who smoke regularly are already addicted to nicotine and have the same kind of addiction as adult smokers. Only 3 out of 100 high school smokers think they will be smoking in 5 years, but in reality, studies show that 60 out of 100 will still be smoking 7 to 9 years later.

Each day, more than 4,000 teens try their first cigarette and another 2,000 become regular, daily smokers. Of those, about a third will die from a smoking-related disease in the future.

Most teen smokers say that they would like to quit and have tried to do so without success. Those who try to quit smoking report withdrawal symptoms much like those reported by adults.

Research has shown that teen tobacco users are more likely to use alcohol and illegal drugs than are non-users. Cigarette smokers are also more likely to get into fights, carry weapons, attempt suicide, suffer from mental health problems such as depression, and engage in high-risk sexual behaviors.

Spit or smokeless tobacco is a less lethal, but still unsafe alternative to cigarettes. There are many terms used to describe spit tobacco that is put into the mouth, such as spit, spitless, oral tobacco products, and chewing or snuff tobacco. The use of spit or smokeless tobacco by any name can cause:

• cancers of the mouth 
• cancers of the pharynx (throat) 
• cancers of the esophagus (swallowing tube) 
• receding gums, which can progress to the point that the teeth fall out 
• pre-cancerous spots in the mouth, called leukoplakia 
• nicotine addiction

In addition, there is a possible link to heart disease and stroke. Teens who use spit or other oral tobacco are also more likely to become cigarette smokers than non-users.

Unfortunately, the new smoking bans in effect in many states may have an unintended effect on the use of spit and other smokeless tobacco. As recommended by the CDC, many schools no longer allow students, staff, parents, or visitors to smoke on school grounds, in school vehicles, or at school functions. In light of bans like this, tobacco companies are more strongly marketing their smokeless tobacco products. Several of these new spit tobacco products are being advertised as more discreet alternatives to cigarettes in places where smoking is not allowed.

Some are promoting use of spit or smokeless tobacco as a way to help quit smoking, but there is no proof that spit tobacco or oral tobacco products help smokers quit smoking. Unlike FDA-approved standard treatments with proven effectiveness, such as nicotine replacement, antidepressants, nicotine receptor blockers, and behavioral therapy, oral tobacco products have not been tested to see if they can help a person stop smoking.

Tobacco Use Among Middle School Students

The most recent numbers on tobacco use among middle school students come from a 2004 survey by the CDC. These numbers did not change much from those of the previous survey in 2002.

• About 12% of students reported using some form of tobacco -- cigarettes, spit or other oral tobacco and such as snuff, cigars, pipes, and flavored cigarettes like bidis or kreteks -- at least once in the past 30 days. 
• Cigarettes (about 8%) were the most common type of tobacco used, followed by cigars (about 5%), spit or other smokeless tobacco (about 3%), pipes (about 3%), bidis (about 2%), and kreteks (about 2%). 
• Boys (about 13%) were slightly more likely than girls (about 11%) to use some form of tobacco. Although girls were slightly more likely to smoke cigarettes, boys were more likely to use spit or other smokeless tobacco, bidis, kreteks, pipes, or cigars.

Tobacco Use Among High School Students

The most recent tobacco numbers for high school students come from the 2005 CDC survey. These numbers are about the same as they were in 2002.

• Nationwide, about 28% of high school students reported using some type of tobacco (cigarette, cigar, pipe, bidi, kretek, or spit tobacco) on at least 1 of the 30 days before the survey. 
• On average, more than 1 out of 5 students (23%) smoked cigarettes. Girls were equally as likely to smoke as boys. White students (25%) were more likely to smoke than black (11%), Hispanic/Latino (22%), or Asian (11%) students. 
• About 8% of high school students reported using spit or other smokeless tobacco at least once in the 30 days before the survey. Nearly 14% of all the boys and more than 2% of all the girls surveyed had used some form of spitsmokeless tobacco. 
• About 14% of high school students had smoked cigars in the last 30 days. Male students (19%) were more likely to smoke cigars than female students (9%). 
• Other tobacco use among high school students included pipes (about 3%), bidis (about 3%), and kreteks (about 2%).

Special Concerns Among Youths

Kreteks and Bidis

Clove and other flavored cigarettes are used mostly by younger smokers. They are nearly ideal in design as a "trainer cigarette" -- giving young people another way to experiment with tobacco and get addicted to nicotine. The false image of these products as clean, natural, and safer than regular cigarettes seems to attract some young people who may otherwise not start smoking. But they are not safer than cigarettes, and each has its own additional problems.

Clove Cigarettes (Kreteks)

Clove cigarettes, also called kreteks ("kree-teks"), are a tobacco product with the same health risks as cigarettes. They are imported mainly from Indonesia or other Southeast Asian countries. Kreteks contain 60% to 70% tobacco and 30% to 40% ground cloves, clove oil, and other additives. They deliver more nicotine, carbon monoxide, and tar than regular cigarettes. Kretek smokers have higher risks of asthma and other lung diseases than non-smokers. Regular kretek smokers have up to 20 times the risk for abnormal lung function compared with non-smokers. Unfortunately, users often have the mistaken notion that smoking clove cigarettes is a safe alternative to smoking tobacco -- this is not true.

Bidis (Flavored Cigarettes)

Flavored cigarettes, called "bidis" or "beedies," are imported mainly from India or other Southeast Asian countries. Their popularity among young people in the United States has grown in recent years. This is in part because they are sold in a variety of candy-like flavors such as chocolate, cherry, strawberry, and orange. Some people think they are safer and more natural than regular cigarettes. They also usually cost less than regular cigarettes and they give the smoker an immediate buzz.

Bidis are tobacco hand-rolled in a tendu or temburi leaf (plants native to Asia) and tied with colorful strings on the ends. Even though bidis contain less tobacco than regular cigarettes, they deliver more nicotine (the addictive chemical in tobacco) and other harmful substances such as tar and carbon monoxide. Because they are thinner than regular cigarettes, they require about 3 times as many puffs per cigarette. They are also unfiltered. Bidis appear to have all of the same health risks of regular cigarettes, if not more. Bidi smokers have much higher risks of heart attacks, chronic bronchitis, and some cancers than non-smokers.

Hookahs (Water Pipes)

Hookah is also called narghile (nar-guh-lee) smoking. It started in Asia and the Middle East and involves burning tobacco that has been mixed with flavors such as honey, molasses, or dried fruit in a water pipe and inhaling the flavored smoke through a long hose. Charcoal is usually used to heat the tobacco mixture, which is known as shisha. Hookah smoking is usually a social event which allows the smokers to spend time together and talk as they pass the pipe around. It has recently become popular among younger people in Western countries.

Hookahs are marketed as being a safe alternative to cigarettes. This claim is false. The water does not filter out many of the toxins. In fact, hookah smoke has been shown to contain concentrations of toxins, such as carbon monoxide, nicotine, "tar," and heavy metals, that are as high or higher than are seen with cigarette smoke. Several types of cancer, including lung cancer, have been linked to hookah smoking. Hookah is also linked to other unique risks not associated with cigarette smoking. For example, infectious diseases including tuberculosis (which can infect the lungs or other parts of the body), aspergillus (a fungus that can cause serious lung infections), and helicobacter (which can cause stomach ulcers) may be spread by sharing the pipe or through the way the tobacco is prepared.

What Parents Can Do

Keeping Your Kids From Starting

Concerned parents may have more power over whether their children start using tobacco than they think they do. In a recent study, teens who thought their parents would disapprove of them smoking were less than half as likely to smoke as those who thought their parents didn’t care. This held true no matter whether or not the parents were smokers themselves.

The CDC offers the following tips for parents to help them keep their kids tobacco-free:

• Remember that despite the impact of movies, music, and TV, parents can be THE GREATEST INFLUENCE in their kids' lives. 
• Talk directly to your children about the risks of tobacco use; if friends or relatives suffer with or died from tobacco-related illnesses, let your kids know. Let them know, for instance, that smoking strains the heart, damages the lungs, and can cause a lot of other problems, including cancer. Also mention what it can do to appearance: making hair and clothes stink, causing bad breath, and staining teeth and fingernails. 
• If you use tobacco, you can still make a difference. Your best move, of course, is to try to quit. Meanwhile, don't use tobacco around your children, don't offer it to them, and don't leave it where they can easily get it. 
• Start talking about tobacco use when your children are 5 or 6 years old and continue through their high school years. Many kids start using tobacco by age 11. Many are addicted by age 14. 
• Know if your kids' friends use tobacco. Talk about ways to say "no" to tobacco. 
• Talk to your kids about the false glamorization of tobacco on billboards and in other media, such as movies, TV, and magazines.

If you use tobacco yourself and don't want your children to start, know that you probably won't have any less influence on their decisions. You may even have more power, because you've been there. You can speak to your child firsthand about:

• how you got started and what you thought about it at the time 
• how hard it is to quit 
• how it has affected your health 
• what it costs you, financially and socially

Helping Your Child Quit

If your child has already started, the CDC offers these suggestions to help them kick the habit:

• Try to avoid threats and ultimatums. Find out why your child is smoking or using other forms of tobacco. Your preteen or teen may want to be accepted by a peer group, or he or she might want your attention. 
• Show your interest in a non-threatening way. Ask a few questions. Find out why your teen is using tobacco and what changes can be made in his or her life to help your child stop. 
• If you smoke, try to quit. If you did smoke and have already quit, talk to your child about your experience. Personalize the little problems around smoking and the big challenge of quitting. Teens and preteens often believe they can quit smoking whenever they want, but research shows many teens never do. Again, share these facts with them in a non-threatening way. 

• Be supportive. Both you and your teen need to prepare for the mood swings and crankiness that can come with nicotine withdrawal. Offer your teen the 5 Ds to get through the tough times: 

• Make a list with your teen or preteen of the reasons why they want to quit. Refer back to this list when your teen is tempted. 
• Finally, reward your teen when he or she quits. Plan something special for you to do together.

Helping your child quit using tobacco is one of the best parenting activities you could ever do.

Additional Resources

More Information From Your American Cancer Society

The following information may also be helpful to you and your child. These materials may be ordered from our toll-free number, 1-800-ACS-2345 (1-800-227-2345).

Guide to Quitting Smoking (also available in Spanish)

Questions About Smoking, Tobacco, and Health (also available in Spanish)

Smokeless Tobacco (also available in Spanish)

National Organizations and Web Sites*

In addition to the American Cancer Society, other sources of patient information and support include:

Centers for Disease Control and Prevention, Office on Smoking and Health
 1-800-232-4636
Internet Address: http://www.cdc.gov/tobacco/tips4youth.htm

American Lung Association
1-800-LUNG-USA (1-800-586-4872)
Internet Address: http://www.lungusa.org

National Cancer Institute
1-877-448-7848 for smoking cessation help
1-800-4-CANCER (1-800-422-6237) for cancer information
Internet Address: http://www.cancer.gov

Smokefree.gov
(Info on each state's phone-based quitting programs )
1-800-QUITNOW (1-800-784-8669 )
Internet Address: http://www.smokefree.gov

*Inclusion on this list does not imply endorsement by the American Cancer Society.

The American Cancer Society is happy to address almost any cancer-related topic. If you have any more questions, please call us at 1-800-ACS-2345 any day, 24 hours a day.

References

American Cancer Society. Cancer Prevention & Early Detection, Facts & Figures 2007. Atlanta, GA: American Cancer Society; 2007.

Campaign for Tobacco-Free Kids. The Path to Smoking Addiction Starts at Very Young Ages. 2007. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0127.pdf. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC). Got A Minute? Calling It Quits (brochure). Available at: http://www.cdc.gov/tobacco/tobacco_control_programs/campaings_events/GotAMinute_brochure/callingitquits.htm. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC). Healthy Youth. Available at: http://apps.nccd.cdc.gov/yrbss/CategoryQuestions.asp?Cat=2&desc=Tobacco%20Use. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC). Tobacco Use, Access, and Exposure to Tobacco in Media Among Middle and High School Students -- United States, 2004. MMWR. 2005; 54(12); 297-301. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5412a1.htm. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC). Preventing Tobacco Use Among Young People, A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, 1994.

Centers for Disease Control and Prevention (CDC). You(th) and Tobacco. Available at: http://www.cdc.gov/tobacco/youth/information_sheets/yuthfax1.htm. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance -- United States, 2005. Morbidity and Mortality Weekly Report. 2006; 55(SS-5). Available at: http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf. Accessed September 28, 2007.

Centers for Disease Control and Prevention (CDC) Tobacco Information and Prevention Source. Bidis and Kreteks: Fact Sheet. November 2005. Available at: http://www.cdc.gov/tobacco/factsheets/bidisandkreteks.htm. Accessed September 28, 2007.

Cogliano V, Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F. Smokeless tobacco and tobacco-related nitrosamines. Lancet Oncol 2004;5:708.

Critchley JA, Unal B. Is smokeless tobacco a risk factor for coronary heart disease? A systematic review of epidemiological studies. Eur J Cardiovasc Prev Rehabil 2004;11:101-12.

Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, Calle EE, et al. Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco. Tob Control 2007;16:22-28.

Henley SJ, Thun MJ, Connell C, Calle EE. Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States). Cancer Causes Control 2005;16:347-358.

Knishkowy B’ Amitai Y. Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics. 2005;116(1):e113-e119. Available at http://pediatrics.aappublications.org/cgi/content/full/116/1/e113. Accessed September 28, 2007.

Office of the US Surgeon General. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1994. Available at: http://www.cdc.gov/tobacco/sgr/sgr_1994/index.htm. Accessed September 28, 2007.

Robertson PB, Walsh MM, Greene JC. Oral effects of smokeless tobacco use by professional baseball players. Adv Dent Res 1997;11:307-12.

Sargent JD, Dalton M. Does Parental Disapproval of Smoking Prevent Adolescents from Becoming Established Smokers? Pediatrics. 2001;108:1256-1262.

U.S. Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services; 1986. Report No.: Publication No (PHS) 87-8398.

Revised: 10/16/2007