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hold, it is difficult to stop using nicotine-containing products, although a number of therapies can improve the chances of quitting. Tobacco use is also harmful to one’s health and to the health of others. Since 1964 (see Box 2-1 for a list of Surgeon General reports published from 1964 to 2006) the evidence has been building that, “smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general” (CDC 2004). More recently, the Surgeon General reported that, “secondhand smoke causes premature death and disease in children and in adults who do not smoke” (DHHS 2006). As a result, 90 percent of smokers regret having started to smoke, 70 percent want to quit and have made at least one quit attempt, and, at any given time, 40 percent are actively trying to quit or are thinking of quitting within the next six months.

SMOKING INITIATION

Given the clear and consistent evidence that smoking is addictive, quitting is difficult, and smoking is harmful to the health of everyone exposed to tobacco smoke, why do new smokers emerge each year? Because about 90 percent of adult smokers initiated smoking before the age of 18 years (DHHS 1994), addressing this question requires an understanding of why youths begin to smoke. Explanations of adolescent risk taking, including tobacco use, often point to adolescents’ underestimation of the chance that a negative outcome will occur to them (Elkind 1967; Reyna and Farley 2006; Slovic 2001), a sense of personal invulnerability to harm (Elkind 1967, 1978), a failure to appreciate the personal applicability of known risks (Arnett 2000; Romer and Jamieson 2001b), and a general immaturity that impairs judgment (Steinberg and Cauffman 1996). Theories of health behavior have incorporated this notion, theorizing that perceptions of low risk are related to engagement in health-compromising behaviors (see, for example, the Health Belief Model (Rosenstock 1974), the Theory of Planned Behavior (Ajzen 1985), Self-Regulation Theory (Kanfer 1970), and theories of decision making [e.g., (Janis and Mann 1977)]; see also Transtheoretical Model of Change (Pallonen et al. 1998; Prochaska 1994; Prochaska and DiClemente 1983; Prochaska et al. 1992). This section provides a review of the literature on adolescents’ and young adults’ tobacco-related perceptions.

Perceptions of Risks of Using Tobacco

The literature on perceptions about tobacco use among adolescents and young adults is reviewed elsewhere in this report. A number of studies have assessed the extent to which adolescents and young adults recognize and appreciate the risks of smoking. Although some studies show that smokers



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