Indigenous to the New World, tobacco was introduced to Europe by Christopher Columbus following his eventful journey of 1492. The demand for tobacco spread rapidly, aided by such personages as Queen Elizabeth, Sir Walter Raleigh, and the Frenchman Jean Nicot. Yet, the popularity of tobacco did not long remain unchallenged. James I in his “Counterblaste to Tobacco” in 1604 referred to use of tobacco as “a custome lothesome to the eye, hateful to the nose, harmfull to the braine,dangerous to the lungs, and in the black stinking fume thereof neerest resembling the horrible stigian smoke of the pit that is bottomless.”Since then, use of this native weed has become pervasive. Phillip Morris,the seventh largest United States corporation, with more than $50 billion in sales in 1992, posted the largest profit of any United States company at $4. 9 billion. Currently, 45 million adult smokers (25% of the population) cost the nation $100 billion a year in health-care expenditures and lost productivity. Smokers have a 40% probability of premature death, and tobacco is related in some way to one in five deaths in this nation.The effects of tobacco smoking on children is both direct and indirect. Numerous studies have documented the adverse effects of maternal cigarette smoking on fetal development. Associations with increased incidences of stillbirths,prematurity, and low birthweight long have been demonstrated. Exposed neonates weigh an average 200 g less than babies of nonsmoking mothers. More recently, evidence suggests that intrauterine exposure adversely affects neuro-behavioral development and even fetal lung development.The effects of tobacco on the growing child continue after birth. The American Heart Association considers passive tobacco exposure to be a serious pediatric health problem, and the Environmental Protection Agency has classified environmental tobacco smoke (ETS) as a class A carcinogen. Early exposure to passive smoke increases the risk of sudden infant death syndrome three times over baseline. Numerous investigators have noted a causal relationship between ETS and the incidence of otitis media, middle ear effusion, upper respiratory infections, bronchitis, and pneumonia. Exposure to ETS not only increases the incidence and severity of asthmatic exacerbations, but it doubles the likelihood of developing asthma.Adolescent smokers suffer from the same physiologic effects and risks as their adult counterparts, although the risks seem to be lost in the distant future. The more immediate problem is addiction. The 1988 Surgeon General’s report concluded, “Cigarettes and other forms of tobacco are addicting … and … nicotine is the drug that causes addiction.” As early as 1963, a secret tobacco company report stated, “We are, then, in the business of selling nicotine, an addictive drug.” This includes the psychoactive effects of nicotine, physical dependence and tolerance,compulsive use, and the reinforcing effect of the drug. Most teenage smokers regret ever starting, and 75% to 90% of those who try to quit smoking are unsuccessful. It is no easier for teen smokers to quit than adults.Although the prevalence of cigarette smoking has continued to decline among adults, there has been a recent rise in the number of underage smokers. More than 1 million teens begin smoking every year. This has not escaped the notice of tobacco companies. In 1996, the prevalence of teen-age smoking was reported to be nearly 35%, and almost 50% were frequent smokers. Of adult smokers, more than 80% began their habit before the age of 21.Evidence of the effectiveness of smoking cessation programs among adolescents is not as strong as that for adults, but studies have shown that programs can increase the percentage of smokers who quit. The simple act of encouragement to quit by a physician has been cited by smokers as an important motivator. Close follow-up is critical. Certain characteristics make success more likely, including relevance, risk, rewards, and repetition. The patient must be informed of the risks related to smoking, but because the risks often are far in the future, reasons for quitting must be made relevant for the present. This is especially true for teenagers, who find the future to be an abstract concept compared with their concrete concept of the universe. The multiple short-term and long-term rewards of smoking cessation should be emphasized. In addition, there is a strong dose-response relationship between the amount of counseling and the long-term success rate. Pharmacotherapy, specifically one of the various nicotine preparations,significantly increases the rate of smoking cessation. Anticipatory guidance on what to expect after quitting also appears to be important. This includes discussion of probable physiologic withdrawal symptoms such as weight gain,irritability, dysphoria, and difficulty concentrating. Finally, lack of peer support may be a critical problem. The clinician will need to continue to encourage the cessation of smoking at every opportunity.Then there’s smokeless tobacco (including chewing tobacco and snuff), the use of which is on the rise among adolescents and which is a contributor to oral cancer. Tobacco is clearly a pediatric problem; rates of use have increased among youth, and habits begin in childhood. If one does not start smoking as a teenager, it is unlikely that he or she ever will become a smoker. Once again, prevention is key!