Tobacco* use is the single most preventable cause of death and disease in the United States. People begin using tobacco in early adolescence; almost all first use occurs before age 18. An estimated 45 million American adults currently smoke cigarettes. Annually, cigarette smoking causes approximately 438,000 deaths. For every person who dies from tobacco use, another 20 suffer with at least one serious tobacco-related illness. Half of all long-term smokers die prematurely from smoking-related causes. In 2004, this addiction costs the nation more than $96 billion per year in direct medical expenses as well as more than $97 billion annually in lost productivity. Furthermore, exposure to secondhand smoke causes premature death and disease in nonsmokers. In 2005, the Society of Actuaries estimated that the effects of exposure to secondhand smoke cost the United States $10 billion per year.