USDHHS, 2000)—but smoking during pregnancy has been linked to adverse pregnancy outcomes (DiFranza and Lew, 1995; Hebel et al., 1988; LeClere and Wilson, 1997; Li et al., 1993; Shu et al., 1995; USDHHS, 2000; Ventura et al., 1997; Walsh, 1994). Nonsmoking people are not immune to tobacco’s health hazards, inasmuch as exposure to second-hand smoke has serious health consequences for adults and children (USDHHS, 1986, 2000; U.S. Environmental Protection Agency [USEPA], 1992).

Although cigarette-smoking among adults leveled off in the 1990s, tobacco use among adolescents increased in that period (USDHHS, 2000). That cigarette-smoking among younger people has increased is particularly alarming for several reasons. Evidence shows not only that tobacco is addictive (USDHHS, 2000) and that only a relatively small percentage of smokers can stop smoking permanently each year (Centers for Disease Control and Prevention [CDC], 1993, 1996b; USDHHS, 2000), but also that nicotine addiction develops in most smokers during adolescence (Institute of Medicine [IOM], 1994; USDHHS, 1988a, 1994, 2000). Curbing or eradicating tobacco use might remain a daunting task. Prevention is the primary objective, but many benefits are associated with smoking cessation, and such efforts should not be ignored.

Measuring the Public Health Burden of Cigarette-Smoking

There is widespread agreement in the public health and medical communities that cigarette-smoking is the biggest external (nongenetic) contributor to death in the United States. Tobacco-related diseases account for more than 400,000 deaths among adults in the United States each year (CDC, 1993; NCHS, 1998b; USDHHS, 2000). Deaths attributable to tobacco use have been found to exceed deaths from acquired immunodeficiency syndrome (AIDS), traffic accidents, alcohol use, suicide, homicide, fire, and use of illegal drugs combined (IOM, 1994). One World Health Organization report showed that the burden of disease and death attributable to tobacco in developed countries was substantially higher than that attributable to any other risk factor, including alcohol use, unsafe sex, hypertension, and physical inactivity (Murray and Lopez, 1996).

Because there is a long delay between the onset of persistent smoking and the full development of its adverse health consequences, current tobacco-attributable mortality and morbidity are consequences of smoking that began decades ago. If current U.S. tobacco use patterns persist, it is



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