be addressed. Most of these new smokers are youth and adolescents who, in part because of their developmental stage, do not clearly understand the full range of risks and consequences of smoking or who discount these long-term health risks because of a belief that they do not apply to them personally.
These distortions of judgment include a failure of youth and adolescents to appreciate the risk and grip of addiction when they begin smoking. Tolerance and dependence to nicotine can occur early on after initiation (Bottorff et al. 2004; DHHS 1994; DiFranza et al. 2000; IOM 1994), and the early initiation of smoking is related to the number of years that a person will smoke and the quantity of cigarettes smoked per day in childhood. Less is known about initiation and subsequent intensity after adolescence (Escobedo et al. 1993; Taioli and Wynder 1991). Unfortunately, many youths view themselves as invulnerable to addiction and its associated harm. They are also sensitive to the social factors and norms that promote smoking, such as the influences exerted by peers, family members, and the exposure to smoking in the media. These influences tend to override the information about the risks of smoking. Therefore, to substantially reduce the rate of smoking initiation, it will be necessary to do a better job of counteracting the perceived benefits of smoking and to develop new tools that make the personal risks of starting to smoke more salient.
All new smokers are not young, however. Some initiate smoking during their college years, which helps to explain why some new smokers have characteristics that differ from those of usual smokers: they tend to have higher levels of education and income than other smokers. It is also noteworthy that some new smokers smoke at lower levels, and some never reach a level of dependence. It will be important for tobacco control experts to pay close attention to these emerging trends and to design appropriate interventions to respond to them.
On the other side of the ledger are smokers who have a more difficult time quitting. “Hardcore” smokers with a long career of smoking and individuals with psychiatric comorbidities or special circumstances, including incarceration and homelessness, have not been the primary targets of traditional cessation treatments or research studies. Achieving success in substantially reducing tobacco use will require taking stock of the progress made with current tobacco prevention and control strategies, identifying where they fall short in responding to emerging smoking trends, and identifying the characteristics and behaviors of subpopulations of smokers. Success will also require the rigorous implementation of known, effective strategies and pushing the envelope to develop new and innovative approaches that can build on the existing tools and strategies used to help people quit smoking.