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Cancer Trends Progress Report – 2011/2012 Update

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In the Report
Summary Tables
Smoking Initiation
> Youth Smoking
Adult Smoking
Quitting Smoking
Clinicians’ Advice to Quit Smoking
Medicaid Coverage of Tobacco Dependence Treatments
Fruit and Vegetable Consumption
Red Meat Consumption
Fat Consumption
Alcohol Consumption
Physical Activity
Sun Protection
Secondhand Smoke
Tobacco Company Marketing Expenditures
Early Detection
Life After Cancer
End of Life

Youth Smoking
Prevention: Behavioral Factors

Cigarette smoking by high school students rose early and through the mid 1990s, but this rate has fallen more steeply since the end of the 1990s. The most recent data point in 2009 is consistent with a falling trend. Smokeless tobacco use by high school students fell from the 1990s to 2003 but did not change significantly from 2003 to 2009.

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Youth Tobacco Use and Cancer

From 1997 to 2010, the number of youth under 18 who became daily cigarette smokers (defined as smoking every day for at least 30 days) each day declined from 3,000 to about 1,000, according to the National Survey on Drug Use and Health.

Other forms of tobacco commonly used by young people include smokeless tobacco (chewing tobacco and snuff, also known as spit tobacco) and cigars. Both of these can also cause cancer.

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Percentage of high school students who were current cigarette, cigar, or smokeless tobacco users: Students (Grades 9–12) who reported having used cigarettes, cigars, or smokeless tobacco in the 30 days before the survey.

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Period – 1991–2009

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Cigarettes: After a non-significant rise from 1991 to 1997, current cigarette smoking among youth has fallen. From 1997 to 2009, youth smoking showed a statistically significant long-term downward trend. The trends between 1999 and 2009 were similar by sex and by race/ethnicity.

Smokeless tobacco: Current smokeless tobacco use fell from 1991 to 2003, followed by a non-significant rise from 2003 to 2009.

Smokeless tobacco use among females was low, with a non-significant increase from 1999 to 2003; smokeless tobacco use among females has remained stable since 2003, while male trends were similar to the overall trends.

Trends among non-Hispanic whites indicated a non-significant rise for use of smokeless tobacco between 1995 and 1999, while trends among non-Hispanic blacks indicated a statistically significant rise, and trends among Hispanics indicated stability over this same time period.

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Most Recent Estimates

Among high school students in 2009:

  • 19.5 percent were current cigarette smokers (19.1 percent for female, 19.8 percent for male)
  • 8.9 percent were current users of smokeless tobacco
  • 14 percent were current cigar smokers (including little cigars)
  • 26 percent were current users of "any tobacco" product

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Healthy People 2020 Targets

Decrease the proportion of high school students who currently:

  • Smoke cigarettes to 16 percent
  • Use smokeless tobacco to 6.9 percent
  • Smoke cigars to 8 percent
  • Use any tobacco product to 21 percent

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Groups at High Risk for Tobacco Use

In 2009, cigarette use was higher among non-Hispanic white (22.5 percent) and Hispanic students (18.0 percent) than non-Hispanic black students (9.5 percent). Male students’ use of cigarettes was about the same as female students’ use (19.8 percent for males and 19.1 percent for females). Cigarette use was higher among 12th graders (25.2 percent), 11th graders (22.3 percent), and 10th graders (18.3 percent) than 9th-grade students (13.5 percent). Overall, 7.3 percent of high school students had smoked on 20 or more of the preceding 30 days, and frequent use was more common among white students than black and Hispanic students. Among current smokers, 7.8 percent of students smoked more than 10 cigarettes per day on the days that they smoked, with this rate being higher for male students than female students.

High school males are far more likely than females to use smokeless tobacco (15 percent males, 2.2 percent females). Non-Hispanic whites reported a greater use of smokeless tobacco products (11.9 percent) than either non-Hispanic blacks (3.3 percent) or Hispanics (5.1 percent).

Current cigar use was higher among male students (18.6 percent) than among female students (8.8 percent) and was slightly higher among non-Hispanic white (14.9 percent) students than among Hispanic (12.7 percent) and non-Hispanic black students (12.8 percent).

Typically, as high school grade increases, use of each of the three types of tobacco products (cigarettes, smokeless, and cigars) increases.

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Key Issues

In 2006, in her Final Opinion in the U.S. Department of Justice lawsuit against the cigarette industry, Federal District Judge Gladys Kessler determined that despite their denials, cigarette companies market to young people, and that their “marketing activities are intended to bring new, young, and hopefully long-lived smokers into the market in order to replace those who die (largely from tobacco-caused illnesses) or quit.” She further noted that cigarette companies “intensively researched and tracked young people’s attitudes, preferences, and habits...knew youth were highly susceptible to marketing and advertising appeals, would underestimate the health risks and effects of smoking, would overestimate their ability to stop smoking, and were price sensitive,” and that the companies “used their knowledge of young people to create highly sophisticated and appealing marketing campaigns targeted to lure them into starting smoking and later becoming nicotine addicts.”

Cigarettes are one of the most heavily marketed products in the United States. Between 1940 and 2005, U.S. cigarette manufacturers spent about $250 billion (in 2006 dollars) on cigarette advertising and promotion. In 2008, the last year for which data is available, advertising expenditures totaled about $10 billion. Much tobacco advertising targets the psychological needs of adolescents, such as popularity, peer acceptance, and positive self-image, and creates the perception that smoking will satisfy these needs. Even brief exposure to tobacco advertising influences adolescents’ attitudes and perceptions about smoking and smokers and adolescents’ intentions to smoke. Strong and consistent evidence from longitudinal studies indicates that exposure to cigarette advertising influences adolescents to initiate smoking and to move toward regular smoking. Studies of tobacco advertising bans in various countries show that comprehensive bans reduce tobacco consumption. In addition, studies show that mass media campaigns designed to discourage tobacco use can change youth attitudes about tobacco use and curb youth smoking initiation. Children and adolescents are heavily exposed to entertainment media, averaging 7.5 hours of media use per day. Depictions of smoking are pervasive in movies but are currently less common in television and music videos. The total weight of evidence from research indicates a causal relationship between exposure to movie smoking depictions and youth smoking initiation.

The Food and Drug Administration (FDA) was granted regulatory authority over tobacco by Congress through the Family Smoking Prevention and Tobacco Control Act, which was signed into law by the president on June 22, 2009. The new law gives the FDA authority to regulate tobacco product manufacturing, marketing, and sale, including marketing and sale to youth. In September 2009, FDA banned fruit and candy-flavored cigarettes, widely viewed as appealing to youth. In March 2010, the FDA re-issued a rule that prohibits sale of cigarettes and smokeless tobacco to youth younger than age 18 and imposes certain marketing, labeling, and advertising requirements. On March 31, 2010, President Obama signed the Prevent All Cigarette Trafficking Act, intended to reduce the availability of low-cost cigarettes sold over the Internet or by mail order and stop sales of such products to youth. Later in 2010, the FDA published a plan to enforce restrictions on advertising of menthol and other cigarettes to youth in minority communities. In March 2011, after a year-long review of the public health consequences of menthol in cigarettes, the FDA’s Center for Tobacco Products (CTP) Tobacco Product Scientific Advisory Committee (TPSAC) concluded, “The evidence is sufficient to conclude that it is more likely than not that the availability of menthol cigarettes increases the likelihood of experimentation and regular smoking beyond the anticipated prevalence if such cigarettes were not available, in the general population and particularly in African Americans. The evidence is sufficient to conclude that it is more likely than not there is a causal relationship between the availability of menthol cigarettes and regular smoking among youth.

As restrictions on smoking and cigarette sales increase, some tobacco companies are developing cigarette alternatives. One such example is the development of dissolvable tobacco products, nicotine-containing products that dissolve in the mouth such as lozenges, strips, and sticks. There is not much data about the national use of these products because they have been test-marketed in only a few U.S. locations. In addition, not much is known about the health risks of dissolvable tobacco use. However, many clinicians have expressed concern that dissolvable tobacco products, which often resemble candy, may have particular appeal for youth and that use of these products by adolescents may lead to nicotine addiction and possible overdose. The FDA’s CTP-TPSAC met several times between July 2011 and March 2012 to discuss what is known and what additional information is needed to provide a basis for regulation of such products.

The overall declining long-term trend in cigarette use by youth is encouraging. However, reaching the Healthy People 2020 (HP2020) goal will require increased prevention efforts, including increasing taxes on cigarettes, sustained anti-tobacco media campaigns, expanded smoke-free indoor air laws, and community mobilization combined with other interventions to decrease youth’s access to cigarettes. The Surgeon General’s report Preventing Tobacco Use Among Youth and Young Adults outlines evidence that mass media campaigns, community and school-based programs, and statewide tobacco control programs can effectively reduce the prevalence of youth smoking. Increases in cigarette prices can also reduce both the initiation and prevalence of youth smoking.

In addition to preventing smoking initiation, efforts need to target smoking cessation among youth. Many adolescents who smoke would like to quit, and HP2020 Objective TU-7 focuses on increasing tobacco use cessation attempts among adolescent smokers. The 2008 Public Health Service Guidelines note that smoking cessation counseling has been shown to be effective in the treatment of adolescent smokers, and recommends that adolescent smokers be provided with counseling interventions to aid them in quitting smoking (Strength of Evidence = B).

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Additional Information on Youth Smoking

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Back: Smoking Initiation

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