Scientific Activities - Actividades Científicas
Honorary Committee Lecture
Tobacco: Seducing the young - II
Published in ProCOR
Bernard Lown, MD
Awarded with Nobel Prize
Seducing the young - the assault increases
An earlier article (Tobacco: Seducing the young - I) emphasized that tobacco ensnares the young leading to a life time of addiction. In the USA, approximately 2 million minors start smoking each year. The overwhelming majority, 89 percent, become hooked before they are 18 years old, of these about half initiate the habit by age 13 and one quarter are as young as 11. Early adolescence is also the peak time for introduction to smokeless tobacco (either pinches of snuff or chewing tobacco). (1) Adolescent smoking is not the result of youthful experimentation with a forbidden fruit, but the consequence of a deliberate, methodical, well thought out, psychogically malevolently brilliant, and heavily capitalized policy of social engineering by the tobacco industry. If the developing world is to wage an effective campaign on behalf of its children, the malign strategy must be fully comprehended and combated.
That tobacco companies target children is no longer in dispute. It is corroborated by thousands of hitherto secret internal company memoranda and documents. These have been exposed to wide public view through legal subpoenas during the rage of anti-tobacco litigation throughout the U.S. The latest trove of internal documents provide the strongest evidence, yet that the tobacco industry was not only targeting young smokers, it was doing it with approval of high corporate officials. The reason they focused on children has less to do with increasing profits, since the youth market accounts for about 10% of annual sales. The objective has been far more sinister, "to gain a steady flow of tobacco consumers during the long stretch of adulthood." Even for a business renowned for its lack of social conscience, the civic contempt is unmatched.
The thrust of anti-tobacco litigation has been to compel tobacco companies to stop ensnaring children. Yet despite all of the anti-tobacco efforts in recent years, smoking remains stubbornly popular among adolescents and young people. Worse still, the trend is upward. New data from the Center of Disease Control and Prevention in the USA show that teen smoking rates are soaring.(2) Following a decade of relative stability, cigarette smoking by young people has increased by 32% between the years 1991 and 1997. (3, 4) The increase appears to be related temporally to the debut of Joe Camel advertisements. For example, when Joe Camel first appeared in 1988, 700,000 teen-agers under 18 became consistent smokers. Less than a decade later, in 1996, this number had risen to 1.2 million, a 73 percent jump of first time smokers. (5) Not surprising, during this same time frame, teen-age attitudes toward smoking have grown more accepting. According to the University of Michigan's nationwide "Monitoring the Future" survey, since 1993, the proportion of eighth graders who say they disapprove of smoking a pack a day has decreased from 83 percent to 77 percent; and among 12th graders from 71 to 67per cent.
A recent study, by researchers at the Harvard School of Public Health, reports a similar trend among college students. U.S. colleges and universities enroll 12 million students, the majority of whom are aged 18-24, and represent a quarter of adults of this age group. Based on data gathered from an anonymous survey administered to approximately 15,000 students in 116 colleges in 39 states, a 28 percent increase in cigarette use was recorded between 1993 and 1997. Only 25 percent had started smoking while in college and half had tried unsuccessfully to shake the habit.(6)
Another new and disquieting trend is the enormous increase in smoking among minority communities in the USA.(7) While white students used to smoke at nearly twice the rate of blacks, that gap has strikingly narrowed. Smoking among all youths increased 33% over the past 6 years, while among black youths it has surged by 89%.(8) A similar trend is evident among young Hispanics, Native Americans and Alaska Natives.
Until recent years the low smoking rate among black youth had been regarded as a public health success story. The present growing trend may in part be related to the high use of marijuana among black minors.(9) A reversal is now being noted in the pattern of progression from cigarettes and alcohol to the use of illegal drugs. In a focus group of 1200 teen-agers around the country, about half of the black youth indicated that they began to smoke cigarettes to maintain and amplify a marijuana high. None of the white kids volunteered this as an explanation for smoking. The enhancing marijuana effect that black teenagers ascribe to cigarettes is consistent with what is already known about the working of nicotine and THC, the active ingredient in marijuana. Both spur production of dopamine that may augment pleasurable sensations. It is to be noted that from 1991 to 1995 the last year for which data is available has shown a steep increase in marijuana use by students of all ethnic groups, but blacks have now vaulted to first place. (9) (See Table)
The increase in use of marijuana and cigarettes among high school students. Percent of students who acknowledged use in the preceding 30 days. (Reported by: Office on Smoking and Health, and Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion,- USA).
* The rise is much more marked among black males from 14.1 percent to 28.2 percent.
Another disturbing development is the fact that smokeless tobacco is becoming a widespread habit among young people. More than a million boys use smokeless tobacco. By far the greatest prevalence is among white male high school students, 20.6 percent of whom report current use of smokeless tobacco. A Consumer Report noted that half of the teen-age smokeless tobacco users already have precancerous white patches in their mouths.(10) With continued tobacco use, one in 20 of these patches will become cancerous in five years. Potentially deadly lesions in the mouths of young tobacco chewers are common. Of the 141 USA major leaguer baseball players, examined in a voluntary screening program in 1998, 83 had at least one tobacco-related lesion in their mouths. Among 15 of these athletes, the lesions appreared precancerous requiring biopsy. (10) Another source of concern is the growing use of cigars, about 22 percent of students acknowledge their use and again this is most prevalent among white males.
The large increase in tobacco use among young people is ascribed to effective product advertising. Initially this was directed to adults. When the association between cancer and smoking began to be appreciated, the tobacco industry made the medical profession complicit. Advertising focused on physicians who were smoking. The message was simple, there can not be much of a health hazard if doctors smoked. A personal recollection is appropriate. During the late 1940's, while in residency training, I attended a medical congress where free packages of Camel cigarettes were handed out. Many doctors lit up. When the meeting adjourned, pollsters at the exit door inquired which brand they were smoking. The consistent response was Camels. I was dismayed thereafter to see R.J. Reynolds tobacco billboards and full-page newspaper ads with a single message, "More Doctors Smoke Camels Than Any Other Cigarette."
Advertising strategy changed after the Surgeon Generals report in 1964. The health profession no longer condoned smoking and joined the anti-tobacco crusade. Only then cigarette advertisers replaced physicians in white coats with cartoon animals in bright, preschool colors. While earlier the tobacco companies argued that smoking was safe, now with equal vigor they maintain that cartoon characters like Old Joe Camel appeal to adult smokers and encourage them to change brands. With a similar abandonment of common sense, they now aver that their advertising campaigns don't cause people to start smoking and that cartoons do not appeal to children.(11)
As the onslaught is now waged against young people in the developing world, it is important to understand the centrality of promotional marketing in hooking children into a life-long habit. Without comprehending the relationship between adolescent smoking and cigarette advertising, the tobacco addiction will not be effectively countered. Despite tobacco company claims, a number of studies have implicated advertising and promotional activities as causal agents in stimulating demands for cigarettes among adolescents.(12-14) Indeed, the three most heavily advertised brands are also the three most commonly smoked by minors. The sharp spike in smoking among black teen-agers appears to correlate with proliferation of advertising in minority communities. That youth are influenced by the content of the advertising is indicated by the finding that in general the brands Marlboro and Camel with white characters on billboards are the brands of choice of white teen-agers, while Kool and Newports with minority images are favored by African-American teen-agers as well as their parents. (9) Further noteworthy is that tobacco companies spend prodigious amounts, to promote brands popular among ages 12 to 17 in magazine advertisements with a youth readership, far more than is spent on ads in magazines read by adults. (15)
In addition to advertisements enfilading venues where children are present, including the Internet, a significant role is played by cigarette promotional items (CPI's) such as clothing, t-shirts and hats, lighters, backpacks, camping gear and electronics. A recent study of middle school and high school students suggest that CPI's are the major reason for adolescents resorting to cigarettes.(16) In this study students, grades 6-12 from five rural New Hampshire and Vermont pubic schools, were surveyed for the relationship of CPI ownership and smoking. One third of the youngsters who owned CPI's were four times as likely to smoke as students without such products. The younger the smokers the higher was the prevalence of CPI possession.
A large longitudinal study from California has recently shown that tobacco promotional activities are causally related to the onset of smoking. (17) A total of 1752 adolescents never smokers who were not susceptible to smoking when first interviewed in 1993 were reinterviewed in 1996. More than half the sample (n=979) named a favorite cigarette advertisement during the initial interview. Having such a favorite, predicted likelihood of smoking three years later, odds ratio 1.82. A far more powerful predictor was the possession or willingness to use a CPI with an odds ratio of 2.89. On the basis of these data the investigators estimate that 34 per cent of all experimentation with smoking among teen-agers in California can be ascribed to tobacco promotional activities.
Young people frequently consider smoking a necessary rite of passage. They know tobacco is addictive but think, "I can't get hurt - I'm just dabbling." They can't even imagine getting hooked. They presume that experimenting with tobacco will not lead to their becoming regular smokers. They are curious about tobacco, or rebellious, or looking for some fun or excitement, or wanting to be part of the crowd. Many of them see smoking or chewing as a "teen-age thing" and expect it to be temporary. With increasing experimentation, they derive pleasure from a positive mood effect. This leads to more frequent smoking or chewing tobacco. Eventually many find themselves addicted. (18)
While adults might read warning labels or have experienced the death of a loved one from lung cancer or emphysema, few youngsters have. Adolescents are more preoccupied with pleasure here and now, rather than being concerned with some unpredictable adverse effects many years down the road. Middle age health problems are too remote to worry about. Young people are encouraged to buy cigarettes, young people are able to buy cigarettes, but young people do not have the information and experience to recognize the dangers of tobacco. Preadolescents and adolescents everywhere are essential industry fodder. Such a market niche is an advertiser's dream and has been shamelessly and criminally exploited. They are recruited into an army to replace the estimated 3 million casualties throughout the world who will die annually of cigarette-caused diseases.
A key question is how to respond to youths' being targeted by tobacco promotional campaigns. The countermeasures hitherto undertaken have involved legislative restriction on the sales of tobacco products to minors, warning labels, counter propaganda focused on children, increases in price and some restriction in advertising.
Despite prohibitions on the sale of tobacco to minors in most states in the USA, an investigation by the Inspector General of the US Department of Health and Human Services revealed that these restrictions are seldom enforced.(20) For the entire year of 1988, only 32 violations were reported in the 44 states that had tobacco access laws at the time. (21) That same year, almost 1 billion packs of cigarettes were sold to persons under age 18 years.(22) Local "sting" operations have documented that teenagers have little difficulty in buying cigarettes where such sales are illegal.(23-25) National data confirm that 79% of eighth-graders and 92% of 10th-graders considered it to be "very easy" or "fairly easy" to get cigarettes.(26) Vending machines, free samples, and lack of enforcement combine to negate virtually all of the existing restrictive laws.
If restrictive legislation on sale to minors has proved wanting, what about campaigns to counter tobacco claims. One can learn from the experience of California that has been the leader in anti-smoking campaigns since 1988 when voters approved Proposition 99, an initiative to raise cigarette taxes, and restrict smoking at the workplace. Adult smoking dropped steadily form 26 percent to 18 percent by 1996. By contrast teen age smoking that hovered at 9 percent, began to rise and by 1993 reached 11.9 per cent. (27) It should be noted that the tobacco industry did not remain passive. Its advertising expenditures in California rose in just two years from $7.6 million to 24.6 million annually.
Another telling example derives from the experience in the state of Arizona. A 30 million dollar, tough, highly visible antismoking campaign targeted youth by appealing to them in their own language. The slogan, "Tobacco, tumor causing, teeth staining, and smelly puking habits" became ubiquitous in 1996. Slogans were emblazoned on T shirts, billboards, caps, pens, key chains, boxer shorts, and other objects across the state. (28) With many youths this campaign backfired. It appears that the more smoking is attacked by adults the more it tends to glamorize this filthy and dangerous habit for young people.
Clearly the nub of the problem is stopping the tobacco message waylaying psychologically callow minors. The investment of tobacco companies in advertising is gargantuan. In the single year of 1992, the industry spent more than $5.2 billion solely in the USA. This expenditure for advertising is only exceeded by the automobile industry. With an abundance of resources, lacking all scruple, with an important assist by governments of industrialized nations, developing countries face an unprecedented assault against their youth. Nothing in previous depredations during the long and bitter age of colonialism has imposed a greater toll of human lives.
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28. Mixed results seen in costly efforts on youth tobacco use Washington Post news service Novemebr 9, 1997.