health problem in the face of strong counterpressures from industry and from those in the population who smoke.
Currently, about 25 percent of adults (CDC, 1996c) and 16 percent of adolescents (CDC, 1996a) smoke regularly. Because more than 80 percent of current smokers began as preteens or teenagers (CDC, 1994a), increasing efforts are being made to reduce youth access to tobacco by enforcing restrictions on the sale of tobacco products to minors. State education agencies also require public schools to teach the hazards of tobacco use, even in states that grow and process tobacco. Encouraging current tobacco users to quit is also a priority. Largely in response to the ill effects of environmental tobacco smoke, restrictions on public indoor smoking are increasingly widespread. California and Massachusetts have both increased excise taxes on cigarettes to encourage reduced consumption and to fund a variety of activities (e.g., media campaigns, school-based programs) aimed at reducing levels of tobacco use.
Healthy People 2000 (USDHHS, 1991) includes several objectives that target preventing and reducing tobacco use. More recently, both the U.S. Preventive Services Task Force (1996) and the Smoking Cessation Guideline Panel (1996), which was assembled by the Agency for Health Care Policy and Research (AHCPR), have issued recommendations that health care practitioners routinely provide cessation counseling to tobacco users and counseling to children and adolescents aimed at preventing initiation. In addition, the current draft of HEDIS 3.0 (NCQA, 1996) proposes that health plans report on the percentage of adult smokers who received advice to quit.
Tobacco use and its health effects can be measured in several ways. Morbidity and mortality from tobacco-related diseases can be measured, but these conditions often occur decades after smoking begins, so they are not immediately sensitive to changes in tobacco use. Data on the association between tobacco use and these diseases, however, make it possible to predict future levels of morbidity and mortality that would result from reduced tobacco use. Therefore, the intermediate measure of tobacco use can serve as a proxy for those health outcomes. Such measures include the numbers of people who currently use tobacco, who quit, and who start using tobacco.
It is also possible to measure efforts being made to reduce tobacco use through prevention and cessation. In addition, efforts to increase tobacco use through marketing and blocking tobacco control policies can be assessed. The current competition