Tobacco use and secondhand smoke (SHS) exposure are harmful to development and have significant health risks across the life span, including asthma, respiratory infections, cardiovascular disease, and cancer.1  Most adults begin smoking during adolescence, highlighting the importance of clinical and public health interventions to prevent tobacco use and encourage youth cessation. Data from the US Centers for Disease Control and Prevention (CDC) Global Youth Tobacco Surveys (GYTS) from 61 countries reveal that a substantial number of youth report current cigarette smoking (mean prevalence: 10.7%, range: 1.7%–35%), and >50% of young smokers wish to quit.2  Globally, GYTS data indicate that youth who have never used tobacco products are susceptible to begin using them (Fig 1). In the United States, 5.8% of high schoolers currently smoke cigarettes, 58% of young smokers want to quit, and nearly half are susceptible to using cigarettes or electronic cigarettes (e-cigarettes).3  Thus, global efforts to protect youth against such vulnerabilities are critical to ensure future tobacco-free generations. In this report, we describe a partnership between CDC and the American Academy of Pediatrics (AAP) that highlights how strategic relationships can foster change.

FIGURE 1

Prevalence of susceptibility to tobacco use among never tobacco users aged 13–15 years, GYTS, 2012–2018. Percentage of never tobacco users who are susceptible to using tobacco in the future by answering (1) ”definitely yes,” “probably yes,” or “probably not” to using tobacco if one of their best friends offered it to them or (2) “definitely yes,” “probably yes,” or “probably not” to using tobacco during the next 12 months.

FIGURE 1

Prevalence of susceptibility to tobacco use among never tobacco users aged 13–15 years, GYTS, 2012–2018. Percentage of never tobacco users who are susceptible to using tobacco in the future by answering (1) ”definitely yes,” “probably yes,” or “probably not” to using tobacco if one of their best friends offered it to them or (2) “definitely yes,” “probably yes,” or “probably not” to using tobacco during the next 12 months.

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Interventions are also important to protect youth from SHS. Researchers from 21 countries indicate that half a billion youth are exposed to SHS at home.4  Youth are also exposed to thirdhand smoke (THS), which is defined as residue from smoke that accumulates on surfaces and is re-emitted into the air. Youth can be exposed to THS through inhalation, touching, or ingestion, putting them at risk for negative health effects.5  SHS and THS expose youth to nicotine and toxic pollutants, which directly impact health. Pediatric tobacco exposures are associated with asthma, bronchiolitis, respiratory infections, and increased risk of sudden unexplained infant death.1  In addition, youth exposed to SHS have lower scores on cognitive tests and experience behavioral and development issues.1  Youth with preexisting conditions or comorbidities are at higher risk for increased morbidity and mortality from tobacco.1,4,6 

In addition to preventing use of smoked tobacco products, it is critical to prevent youth use of emerging tobacco products, such as e-cigarettes and heated tobacco products. These products are changing the global landscape of youth tobacco use. Emerging products are designed to appeal to youth, with sleek designs, youth-friendly flavors, and targeted marketing strategies designed to reach young users. Youth e-cigarette use has become an epidemic in the United States, with 27.5% of high schoolers reporting current use.7  Emerging tobacco products are renormalizing tobacco use while addicting a new generation of youth to nicotine.7  Marketing of these products globally remains a cause for concern, and it is important for existing global tobacco control strategies and policies to be mobilized and enforced to ensure that the marketing, distribution, and use of e-cigarettes and other novel tobacco products are monitored closely and adequate protections are in place for preventing and reducing youth use.

Efforts are warranted to protect youth from tobacco use and exposure, as well as from tobacco advertising and marketing. The 1989 United Nations Convention on the Rights of the Child (CRC) and the World Health Organization Framework Convention on Tobacco Control provide strong blueprints for action on behalf of children. The CRC, which is a legally binding treaty with 196 country signatories, notes that children have a basic human right to breathe clean air.8  The CRC treaty contains several articles relevant to a child’s right to be protected from tobacco use and exposure, including Article 3, “in all actions concerning children… the best interests of the child shall be a primary consideration”; Article 19, “Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation”; and Article 24, “Parties recognize the right of the child to the enjoyment of the highest attainable standard of health.”8  To protect people, including youth, from tobacco, the World Health Organization Framework Convention on Tobacco Control has outlined key measures called the “MPOWER” demand reduction strategies: monitor tobacco use and prevention policies; protect people from tobacco smoke; offer help to quit tobacco use; warn about the dangers of tobacco; enforce bans on tobacco advertising, promotion, and sponsorship; and raise taxes on tobacco (For more information: https://www.who.int/fctc/en/). These strategies serve as guidelines for communities and nations working to protect youth from tobacco use and exposure, and to promote optimal health for all youth. The rights of youth to be free from tobacco could be fully realized with effective implementation and enforcement of the MPOWER evidence-based strategies.

To augment children’s voices and ensure that effective partnerships are in alignment, it is important to forge a meaningful dialogue between those generating evidence, such as CDC’s Global Tobacco Control Program, and providers serving youth and families, such as pediatricians and national medical societies. For example, from 2016 to 2020, the CDC in partnership with AAP implemented a multiyear project to use data and evidence-based interventions to encourage global efforts to protect youth from tobacco. As part of this project, CDC and AAP have partnered with national pediatric societies in 13 countries to develop and implement strategic plans to reduce youth tobacco use and exposure. These partnerships build on the Academy’s long history of global child health interventions9  and use country-level data from the CDC Global Adult Tobacco Surveys and GYTS. Using training from AAP subject-matter experts and peer leaders, these national pediatric societies have built strategic partnerships and educational programs designed to combat youth tobacco use and exposure (Table 1). The activities undertaken by national pediatric societies expand the role of health care providers in tobacco control and connect them with government and nongovernment institutions and stakeholders for mobilizing a wider circle of stakeholders who may interact with youth, their families, and community and may be in positions to protect youth from tobacco. Although it is too early to determine the long-term success of these efforts, participating societies have implemented strategies for sustainability, including forging relationships with multisectoral partners, establishing pediatrician workgroups devoted to tobacco prevention, and advocating for the prioritization of pediatric tobacco prevention in national pediatric societies’ strategic planning efforts. In addition, CDC and AAP have worked to encourage sustainability of societal efforts by engaging past participants as program faculty, developing a peer-mentorship network, and issuing sustainability grants to past participants.

TABLE 1

Overview of Tobacco Control Work Performed by National Pediatric Societies in 13 Countries, 2016–2019

CountryDescription of the Activities Undertaken by the Pediatric Society
Bangladesh Created a subcommittee to address tobacco use and vaping and promoting awareness among youth.
Created a partnership with the Bangladesh Heart Foundation and Tobacco-Free Kids to address youth tobacco use and secondhand tobacco exposure as part of building a coalition with stakeholders. 
Ethiopia Hosted a train the trainer workshop for 20 high school students to serve as peer advisors and develop a school-based tobacco awareness campaign.
Held a stakeholder meeting with representatives from the Education Bureau, Drug and Medicine Authority, and tobacco control nongovernment organizations. 
India The Public Health Foundation of India conducted a seminar on tobacco cessation with leadership from the Indian Academy of Pediatrics.
A white paper to guide future tobacco cessation strategies in partnership with the government is in development. 
Indonesia Hosted a media conference for 2018 WNTD and held a successful infographic and meme competition promoting tobacco control and reduction of SHS exposure.
Translated the CDC Treatment and Beyond module into Indonesian and identified an expert group of pediatricians to develop guidelines and tools promoting tobacco control and reduction of SHS exposure for Pediatric Society members. 
Kenya Facilitated a continuing medical education session for 75 pediatric health providers on the topic of youth tobacco control and prevention and reduction of SHS exposure.
Completed a workshop on tobacco control advocacy for 50 pediatric and mental health providers, Hosted a tobacco exposure in children webinar reaching 500+ learners.
The association also held a tobacco control workshop at the 2019 the Kenya International Scientific Lung Conference. 
Mexico Developed 3 educational videos on the dangers of tobacco use and exposure for 3 audiences: children and youth, physicians, and parents. During the society’s annual conference, the campaign materials and videos were launched. 
Nigeria Recognized WNTD 2019 with a press conference and public lecture to introduce the society’s new tobacco-free school initiative, which works to prevent tobacco use and exposure of students.
The society held a 2-day advocacy and capacity development workshop for key stakeholders in the Nigerian school system and the Pediatric Society leadership to promote the tobacco-free school initiative. 
Pakistan Pediatric Pulmonary Group of the Pakistan Pediatric Association conducted a tobacco control advocacy workshop for 25 senior pediatricians and consultants focused on tobacco-free hospitals.
A press conference was held to raise public awareness of dangers of tobacco use and exposure to SHS in children.
A seminar on tobacco-free hospitals and schools with 85 participants. 
Philippines The Philippines Pediatric Society (PPS) hosted a tobacco control advocacy workshop for 50 pediatricians from across the country, which addressed strategies for preventing youth tobacco use and decreasing secondhand and thirdhand tobacco exposure of children.
Convened a stakeholders meeting with representatives from the pediatric society, departments of health and education, World Health Organization Country Office, and multiple specialty societies.
Developed a PPS-led Pinoy Kids for Smoke-Free Philippines campaign, targeting select private and public schools. This campaign reached almost 6300 students and 100 schools with educational information about preventing youth tobacco use and reducing secondhand tobacco exposure. 
Romania Hosted an interactive workshop on tobacco use and exposure in children during the Society’s Summer Schools educational events for 70 pediatrician participants.
Hosted a second workshop with 60 attendees, which focused on targeted counseling of children and families who use tobacco, to promote cessation and reduce SHS exposure. 
Sri Lanka Conducted an advocacy workshop on tobacco control and prevention, including SHS prevention, for 30 pediatricians representing 9 provinces and facilitated 4 regional scientific conferences on tobacco use and exposure, reaching 500 physicians. 
Tanzania Conducted a training of trainers for pediatricians and pediatric health care providers on tobacco control and effects of exposure to SHS. These participants then led a workshop on tobacco control and exposure to SHS for providers.
Conducted a workshop for media focused on the long-term effects of exposure to SHS. 
Uganda The Uganda Pediatric Association facilitated a sensitization meeting for pediatricians across multiple regions followed by a 1-day stakeholders meeting to engage all local stakeholders on the current status and implementation of a national tobacco control act. 
CountryDescription of the Activities Undertaken by the Pediatric Society
Bangladesh Created a subcommittee to address tobacco use and vaping and promoting awareness among youth.
Created a partnership with the Bangladesh Heart Foundation and Tobacco-Free Kids to address youth tobacco use and secondhand tobacco exposure as part of building a coalition with stakeholders. 
Ethiopia Hosted a train the trainer workshop for 20 high school students to serve as peer advisors and develop a school-based tobacco awareness campaign.
Held a stakeholder meeting with representatives from the Education Bureau, Drug and Medicine Authority, and tobacco control nongovernment organizations. 
India The Public Health Foundation of India conducted a seminar on tobacco cessation with leadership from the Indian Academy of Pediatrics.
A white paper to guide future tobacco cessation strategies in partnership with the government is in development. 
Indonesia Hosted a media conference for 2018 WNTD and held a successful infographic and meme competition promoting tobacco control and reduction of SHS exposure.
Translated the CDC Treatment and Beyond module into Indonesian and identified an expert group of pediatricians to develop guidelines and tools promoting tobacco control and reduction of SHS exposure for Pediatric Society members. 
Kenya Facilitated a continuing medical education session for 75 pediatric health providers on the topic of youth tobacco control and prevention and reduction of SHS exposure.
Completed a workshop on tobacco control advocacy for 50 pediatric and mental health providers, Hosted a tobacco exposure in children webinar reaching 500+ learners.
The association also held a tobacco control workshop at the 2019 the Kenya International Scientific Lung Conference. 
Mexico Developed 3 educational videos on the dangers of tobacco use and exposure for 3 audiences: children and youth, physicians, and parents. During the society’s annual conference, the campaign materials and videos were launched. 
Nigeria Recognized WNTD 2019 with a press conference and public lecture to introduce the society’s new tobacco-free school initiative, which works to prevent tobacco use and exposure of students.
The society held a 2-day advocacy and capacity development workshop for key stakeholders in the Nigerian school system and the Pediatric Society leadership to promote the tobacco-free school initiative. 
Pakistan Pediatric Pulmonary Group of the Pakistan Pediatric Association conducted a tobacco control advocacy workshop for 25 senior pediatricians and consultants focused on tobacco-free hospitals.
A press conference was held to raise public awareness of dangers of tobacco use and exposure to SHS in children.
A seminar on tobacco-free hospitals and schools with 85 participants. 
Philippines The Philippines Pediatric Society (PPS) hosted a tobacco control advocacy workshop for 50 pediatricians from across the country, which addressed strategies for preventing youth tobacco use and decreasing secondhand and thirdhand tobacco exposure of children.
Convened a stakeholders meeting with representatives from the pediatric society, departments of health and education, World Health Organization Country Office, and multiple specialty societies.
Developed a PPS-led Pinoy Kids for Smoke-Free Philippines campaign, targeting select private and public schools. This campaign reached almost 6300 students and 100 schools with educational information about preventing youth tobacco use and reducing secondhand tobacco exposure. 
Romania Hosted an interactive workshop on tobacco use and exposure in children during the Society’s Summer Schools educational events for 70 pediatrician participants.
Hosted a second workshop with 60 attendees, which focused on targeted counseling of children and families who use tobacco, to promote cessation and reduce SHS exposure. 
Sri Lanka Conducted an advocacy workshop on tobacco control and prevention, including SHS prevention, for 30 pediatricians representing 9 provinces and facilitated 4 regional scientific conferences on tobacco use and exposure, reaching 500 physicians. 
Tanzania Conducted a training of trainers for pediatricians and pediatric health care providers on tobacco control and effects of exposure to SHS. These participants then led a workshop on tobacco control and exposure to SHS for providers.
Conducted a workshop for media focused on the long-term effects of exposure to SHS. 
Uganda The Uganda Pediatric Association facilitated a sensitization meeting for pediatricians across multiple regions followed by a 1-day stakeholders meeting to engage all local stakeholders on the current status and implementation of a national tobacco control act. 

Pediatricians and other pediatric health providers are critical partners for promoting well-being of youth. Each year on May 31, the public health community recognizes World No Tobacco Day (WNTD). The 2020 theme was “protecting youth from industry manipulation and preventing them from tobacco and nicotine use.” In honor of WNTD, it is important for pediatric health providers to work to prevent and eliminate youth tobacco use and exposure. Such efforts could include raising the tobacco sales age to 21 years, prohibiting flavored tobacco product sales, raising the price of tobacco products, prohibiting the marketing of tobacco products to youth, prohibiting tobacco imagery in media that is viewed by children, comprehensive smoke-free policies in public places, and provision of comprehensive tobacco cessation services to help users quit. WNTD is a critical opportunity for pediatric health providers to partner with national pediatric societies, public health organizations, and governmental health ministries to promote a tobacco-free world for youth.

We thank Mr Edward Rainey for creating the figure and Ms Kyung Ah Lee for creating the data file for the figure.

The opinions expressed by authors contributing to this report do not necessarily reflect the opinions of the US Department of Health and Human Services, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

Dr Ahluwalia participated in the described global tobacco program, conceptualized the article, and drafted the initial manuscript; Dr Wilson participated in the described global tobacco program and conceptualized the article; Ms Gorzkowski participated in the described global tobacco program; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: The global tobacco collaboration described in the final paragraph of this article is funded by a Cooperative Agreement from the US Centers for Disease Control and Prevention to the American Academy of Pediatrics (AAP); grant 5 NU38Ot000282-02-00. In addition, AAP receives funding from the Flight Attendant Medical Research Institute to support the tobacco control activities of the AAP Julius B. Richmond Center of Excellence (grant 052302_CoE).

     
  • AAP

    American Academy of Pediatrics

  •  
  • CDC

    US Centers for Disease Control and Prevention

  •  
  • CRC

    Convention on the Rights of the Child

  •  
  • e-cigarette

    electronic cigarette

  •  
  • GYTS

    Global Youth Tobacco Survey

  •  
  • SHS

    secondhand smoke

  •  
  • THS

    thirdhand smoke

  •  
  • WNTD

    World No Tobacco Day

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.