Youth smoking

A German postcard from the first World War claims that "He is verily not a brave man, if he cannot stand tobacco."

Smoking among teenagers is an issue that affects countries worldwide. The U.S. has taken drastic measures in attempt to eliminate use of tobacco products among teenagers. 90% of smokers are estimated to have begun smoking before the age of 18 (the legal age), therefore it is necessary to reduce the number of youths who start smoking before this age in order to reduce the total number of smokers and harm done to society.

When the tobacco industry first began to target this new youth demographic, they did so in an entirely non-discreet method (for example through the use of characters that mimic cartoons). Once they began to experience resistance from the public they changed their approach by using anti-tobacco advertisements to actually raise awareness of tobacco products in youths and to increase their desire to smoke. Studies have been done to understand what factors make an advertisement more effective and more readily internalized by youths. Advertisements that follow these criteria have been shown to actually decrease the likelihood of youth smoking. In order to prevent a continued and growing pattern of youth smoking, it is necessary to recognize what social factors influence teens so that preventative measures can be determined.

While youth smoking may be viewed more or less negatively in different nations, it remains an issue regardless of how societies perceive it. Tobacco industries have tailored their messages to apply overseas and have encountered less restrictive legislation making advertising abroad highly influential to the targeted audience. This has been a concern for many nations.

History

Statistics

The National Survey on Drug Use and Health estimates that each day, over 4,000 people under the age of 18 try their first cigarette. This amounts to more than 730,000 new smokers each year. The Final Report of the National Commission on Drug-Free Schools indicate that children and adolescents consume more than one billion cigarettes every year. According to economist Kenneth Warner, Ph.D., the tobacco industry needs 5,000 new young smokers every day in order to maintain the total number of smokers. The US Department of Health and Human Services estimates that 90% of smokers begin their tobacco usage before age 20. Of these, 50% begin tobacco use by age 14 and 25% begin their use by age 12. Children are three times more sensitive to advertising as concluded in the April 1996 Journal of Marketing study. The three most heavily advertised cigarette brands are Marlboro, Newport, and Camel. The 1994 Center for Disease Control (CDC) report concluded that 86% of underage smokers prefer one of these three brands.^[1] Since the Surgeon General's Warning was released in 1964, national smoking rates have been declining. In 1965, approximately 45% of Americans smoked. As the public became more educated on the effects of smoking, the amount of smokers dropped and is currently about 20%. While smoking among adults consistently declined over time, smoking rates for high school students began to increase in the early 1990s. They did not begin to decrease until the end of the decade.^[1] One study in the Journal of the American Medical Association showed that, "Seventy-two percent of students reported experimenting with, formerly, or ever smoking cigarettes, and 32% reported smoking in the past 30 days. Students who had participated in interscholastic sports were less likely to be regular and heavy smokers than were others who had not participated. Smoking initiation rates increased rapidly after age 10 and peaked at age 13 to 14. Students who began smoking at age 12 or younger were more likely to be regular and heavy smokers than were students who began smoking at older ages."^[2] If the current smoking trends continue, 5.6 million youths alive today will die prematurely. Prevention and control measures that reduce smoking in this age group can improve the nation's short- and long-term health.^[3]

Legal action

A contributing factor in the rise of cigarette smoking among youth populations can be attributed to new tobacco advertising campaigns. R.J. Reynolds, a leading tobacco company, came out with the Joe Camel advertising campaign for Camel cigarettes, lasting from the late 1980s to the mid-1990s. On December 11, 1991 an article was published in the Journal of the American Medical Association (JAMA) about a study done on R.J. Reynold’s Joe camel campaign. The study, done with preschoolers in Georgia, showed that the character Joe Camel was almost as recognizable to children as Mickey Mouse. Another article published in that same issue of JAMA said the ad campaign had successfully increased Camel's share of the market of underage smokers from 0.5% to 32.8%.

The articles in JAMA caused controversy among the public. Shortly after publication, a San Francisco lawyer, Janet Mangini, filed a lawsuit accusing R.J. Reynolds of targeting youth with its Joe Camel campaign. The Mangini lawsuit proceeded through a number of court rulings and, in December 1997, was finally scheduled for trial. In May 1997, the U.S. Federal Trade Commission (FTC) also filed a lawsuit against R.J Reynolds and its Joe Camel ad campaign, saying the campaign violated federal law and encouraged children to smoke. The FTC fought to have the campaign discontinued.^[4] In 1997, R.J. Reynolds settled the Mangini suit. The company announced that it was dismantling its Joe Camel campaign. The company took down the Joe Camel billboards and adopted new print advertisements. The disclosure included a $10 million payment, $9 million of which went to the cities and counties that had filed lawsuit. The money went towards funding of education and awareness campaigns as well as advertisements to dissuade youth smoking.

Advertisements

Public health advocates have questioned just how appropriate industry-sponsored youth smoking prevention programs are and to what extent they work to actually promote youth smoking. There are four types of youth smoking prevention programs implemented by the tobacco industry. These consist of programs that speak directly to youths, programs that speak to parents, programs directed toward retailers, and programs that fund mainstream youth organizations. The common themes of the programs are that smoking is an "adult choice", children begin to smoke as a result of peer pressure and a lack of adequate role models and parental guidance, and an emphasis of "the law" as the reason not to smoke .

Youth programs developed in response to two main industry concerns: the threat of legislation/regulation and public scrutiny of industry marketing practices. In 1978, Joseph Califano, US secretary of Health, Education, and Welfare, accused the tobacco industry of marketing to children. As a result of this, the nonsmokers’ rights movement emerged. The Federal Trade Commission (FTC) then began to consider regulation of tobacco advertising. The youth smoking prevention program was found to serve as a means to deflect meaningful regulation of the industry’s marketing practices. The use of cartoon characters to advertise cigarettes and other child-oriented practices brought the entire tobacco industry under intense scrutiny. The tobacco industry therefore utilized youth smoking as a way to continue studying and marketing to teens while avoiding the previous danger that had been associated with teen studies.

The Tobacco Institute’s youth programs were partially motivated by the desire to displace educational programs. Public health groups had developed these programs and the tobacco industry claimed that they consisted of wrongful scare tactics in addition to presenting smoking as both repugnant and unhealthy.

Harmful effects

According to the American Journal of Public Health, youths ages 12 to 17 were less inclined to see smoking as harmful and reported an increased likelihood to smoke after they had viewed a television advertisement urging parents to speak to their children about not smoking. In 1999 Philip Morris coined the slogan "Talk. They’ll listen." This phrase was designed to encourage parents to discuss the effects of smoking with their children. The American Journal of Public Health study, though, demonstrated that commercials such as the Philip Morris one actually seemed to have an opposite effect. Researchers analyzed television ratings from 75 U.S. media markets and data from annual national surveys of 8th, 10th, and 12th graders from 1999 to 2002. 8th graders who were likely to have seen advertisements targeted at parents had an increased likelihood of believing that the dangers of smoking had been exaggerated by the advertisement and reported an increased likelihood to smoke. Similarly, older teenagers exhibited a stronger approval of smoking and had an increased chance of having smoked in the past 30 days before the school survey was conducted.^[5] In 1999, Philip Morris ran a series of full-page advertisements in news magazines, which were aimed at parents and conveyed the "forbidden fruit" message. They featured a bowl of fruit or a glass of milk with cookies and then had the questions "What else are you leaving for your kids?"^[6] and "What else is within your kids’ reach?"^[6] In 2000, Philip Morris took a different approach and distributed book covers with the phrase "Think. Don’t Smoke." These book covers were distributed to schools in California and had not been authorized previously. These covers, which were meant to make students aware of the potential dangers of smoking while at the same time enticing them to defy parental authority, failed as a result of the intervention of the California Department of Education and Justice. The California Department of Education and Justice sent out a memorandum warning schools about Philip Morris’ intent and demanding that Philip Morris recall all of its book covers.^[6]

Benefits

Anti-smoking advertisements have the capability to significantly reduce the prevalence of youth smoking. Advertisements are particularly effective when they are combined with both school and community based activities. In one study, an anti-smoking advertisement was shown before a feature film. Results from this study showed that the impact of the film’s pro-smoking imagery was significantly decreased for high school students. While anti-smoking advertisements carry no guarantees, they can be fairly effective under controlled circumstances. Many tobacco use prevention media campaigns have failed due to inadequate length and funding in addition to a variety of other factors.^[7]

General recommendations

The messages and executions of anti-smoking advertisements intended to lower adolescent smoking prevalence should be geared towards adolescents. Anti-smoking advertisements that are effective with adults will not necessarily be effective with adolescents. Different messages and means of conveying those messages should be employed. When targeting adolescents, it is useful to utilize spokespeople who are slightly more mature than the intended audience. Furthermore, the themes of second-hand smoke, the smoker as a negative role model, refusal skills, and misleading portrayal of a potentially lethal product are effective in dissuading youths from smoking.^[8]

Alternative tobacco products

Cigars

For decades cigar consumption among adolescents remained relatively constant; however, since the 1990s cigar use has surged in adolescent populations. This increase in consumption coincided with an increase in cigar marketing. The cigar industry began to take advantage of celebrity advertising. By featuring celebrities such as Madonna and Michael Jordan, cigar companies were able to successfully market to adolescents of both sexes.

A common misconception across youth populations is that casual cigar use is not a substantial health risk. Contrarily, even mild use puts the individual at an increased risk for oral, oropharyngeal, and laryngeal cancers.^[9] Similar to cigarette smoking, susceptibility to disease increases with consumption and inhalation technique. Many public health officials have become concerned that the increase in popularity of cigar smoking among adolescents, will create a greater vulnerability for nicotine dependence. They fear that cigars will be used in addition to cigarettes and will not be seen as a compounding risk factor for tobacco related diseases.

Snus

Snus use among adolescent groups has worried many leading public health officials; snus may aid youth in cessation of smoking or in harm reduction, but it can also be used in conjunction with cigarettes and thus increase risk for disease. Snus is a smokeless tobacco product that was first distributed in Sweden decades ago. The product is only now just coming to market in the United States; Camel launched their Camel Snus product in 2009.^[10] Snus is a flavored and moist tobacco contained in small teabag-like pouches sold in tin containers of about 15. The packet is placed under the upper lip for approximately 30 minutes and delivers nicotine directly into the bloodstream.

It is unclear whether the nicotine rush from snus use is great enough to satisfy a cigarette craving, but the wide use of the product in Sweden has aided many in smoking cessation. There is epidemiological evidence that shows Swedish snus has successfully emerged as healthier alternative to cigarettes.^[10] Researchers have found that Camel Snus contains levels of tobacco-specific nitrosamines that are much lower than for traditional smokeless tobacco products. Switching from cigarettes to snus can aid youth in harm reduction: substitution of a harmful product with a less harmful one. But snus use is only recommended as a replacement, and not merely a method to get around smoking bans. If used in conjunction with cigarettes, risk for tobacco-related diseases will increase drastically.

Orbs

One of the newest tobacco products currently being tested on the market is Camel’s Orbs. Orbs are dissolvable tobacco pellets with mint and cinnamon flavoring, closely resembling breath mints. They are criticized for their allure to children, imitating candy. With this new product, youth populations have been targeted in a new fashion. Kids have been the aim of advertisement campaigns in the past, such as R.J. Reynold’s Joe Camel cartoon, but never before has a tobacco product been marketed that imitates a product for children. One critic, Senator Jeff Merkley of Oregon, one of the 3 regions involved in test marketing, said regarding orbs, "They’re tobacco candy. Everything about them is designed for kids. We know from research that for people to be addicted to nicotine, you’ve got to get them before 21 when their brain is still developing."^[11] Youth populations are the target of new tobacco products so that they can become future addicted consumers, contributing to the market for years to come.

Risk Factors

Research has shown that there are some factors that are correlated with higher usage of cigarettes and other tobacco products. These risk factors include personality traits like low self-esteem and low stress tolerance, social attributes such as having family members and friends who smoke, high exposure to tobacco advertising, and being male.^[12] On average females consume less cigarettes per day and choose cigarettes with a lesser nicotine content. Other risk factors include being caucasian, multi-ethnic, American-Indian, or Alaskan Native, as these groups have higher smoking prevalences than other ethnicities. Also, adolescents who are involved in antisocial behaviors, such as fighting, stealing, and using other drugs are more likely to smoke than those who do not engage in antisocial behaviors.^[13]

It has also been found that youths who lack college plans are more likely to smoke than their peers who plan to attend four years of college. Similarly, having parents who did not attend college makes youths more likely to engage in tobacco consumption. Finally, having experienced traumatic events in childhood is associated with an increased risk of starting smoking by age 14 and with ever initiating smoking. These traumatic events can include witnessing or being a victim of abuse, having parents who are separated, or growing up with mentally ill family members.^[12]

Stages in youth smoking

There are a series of stages that young smokers go through, each of which is influenced by different factors. The stages can progress in any direction and stop or restart any number of times.

• Precontemplation - The child, while not yet considering smoking, has received messages about it. At this stage, the child is most powerfully influenced by family members that smoke, advertising, films, television, and role models.^[14]
• Contemplation - Information received from the media or from peer influence results in curiosity and the desire to try a cigarette. At this stage, friends’ behavior is added to the list of influences.^[14]
• Initiation - Most youths will try a cigarette, but the majority do not become addicted or become regular smokers. Peers tend to exert the strongest influence.^[14]
• Experimentation - This stage involves repeated smoking attempts which may result in addiction to nicotine. At this stage, youths tend to become regular smokers. Peers continue to exert the strongest influence.^[14]
• Regular smoking - Additional influences join the initial set of addiction and habituation including beliefs about the benefits of smoking, self-efficacy, self-perception, and coping. Societal factors also begin to play a role.^[14]
• Maintenance - The continuation of regular smoking involving all of the previous influences with addiction being the primary driving factor.^[14]
• Quitting - This stage only happens once the importance of influences change and the individual reaches a decision to stop smoking.^[14]

Social influences and prevention

Law

Influences on youth smoking are both national and country-wide, and tend to be determined by government legislation.^[14]

A study of the town of Needham, Massachusetts found the smoking rate among town high school students dropped by about half when the town raised the minimum purchase age from 18 to 21.^[15]

It has also been demonstrated that increasing taxation on tobacco products leads to an immediate reduction in youth smoking. Forster et al. has demonstrated that youth are approximately three times more sensitive to the price of tobacco products than adults are. A ten percent raise in the price of cigarettes reduced adult smoking by only one to two percent but reduced youth smoking by nearly five percent.^[16] Similarly, on April 1, 2009, a 61.66-cent federal cigarette tax rate was implemented. In the thirty days following implementation, the percentage of students who reported smoking fell between 9.7 percent and 13.3 percent, indicating that there were approximately between 220,000 and 287,000 fewer current youth smokers in May 2009.^[17]

In a study conducted by Jason, Ji, Birkhead, and Xaverious, it was found that in 1990 approximately 80% of stores in the Chicago area sold cigarettes to minors. Although a law against selling to minors under the age of 18 was in place, it was not viable because a police officer would need to catch the store selling to a minor for any sort of penalty to occur. In conjunction with members of the police department, the researchers implemented new licensing and enforcement laws. These laws included the following statutes: each store owner needed to obtain a license for selling cigarettes, the store owner was informed that the license would be suspended upon the second violation of selling to minors, and all cigarette vending machines would need to have a lock placed on them which could only be opened by employees. Within six months of the implementation of these laws, the percentage of stores selling tobacco products to minors dropped to 33% and within a year, no store sold to minors. This study suggests that the implementation and upholding of restrictive tobacco laws will reduce youth access to tobacco products and thus lower the prevalence of tobacco usage among youths.^[18]

The PACT (Prevent All Cigarette Trafficking) Act of 2010 also helped limit youth access to tobacco via the internet. Before the passage of the act, children as young as 11 had an approximately 90 percent success rate in purchasing cigarettes on the internet. This act uses strict identification tactics, both at the time of purchase and upon delivery of tobacco products, to deter underage youths from purchasing cigarettes.^[19]

Advertisements

Young & Rubicam conducted a research study with teens in New York City schools in 1992 and 1993. This study was meant to "understand the underlying dynamics of how youths aged 12-17 resist or succumb to social pressures, particularly as it relates to the decision not to smoke."^[20] What they found was that teens were more responsive to advertisements that depicted individuals of their own age. This meant that tobacco companies can tailor their messages to both older and younger individuals depending on the age of the actor who is conveying the message.^[20]

Advertisements can also be used for preventive purposes. California was one of the first states to initiate a mass media campaign. In the 1990s, the state used funds that were generated from an increase on cigarette taxes to fund the campaign, which featured advertisements about the devastating effects of secondhand smoke, as well as advertisements that supported youth tobacco prevention and cessation. After the campaign was launched, smoking prevalence among youths in California declined about five percent during the first four years, nearly doubling the decline rate for the other 49 states. Other states followed suit after California’s success including Massachusetts and Florida.^[21]

There is some controversy about what is the most effective element of advertisements designed to promote youth tobacco prevention and cessation. One study found that advertisements of normative messages showing that smoking will bring about social disapproval are the best to decrease young adults’ intentions of smoking in the future.^[22] Other studies have found that advertisements, which are high in sensation valued, based on their "ability to elicit sensory, affective, and arousal responses",^[23] are best for getting messages across to youths who are highly susceptible to drug use.^[24] Still, other research suggests that personal testimonies, including those of people who have dealt with addiction themselves or have had family members die from tobacco related illnesses are the most effective in deterring youths from initiating tobacco use.^[21] Researchers have attributed these discrepancies in what is the most effective method to differences in methods, as well as extraneous variables that are not being controlled for in each experiment, including the emotionality of the advertisement, the quality of production, and how the advertisement was sponsored.^[25]

Familial and social connections

There are a number of interpersonal relationships that greatly influence the likelihood that an adolescent will become a smoker. People who encounter smoking on a regular basis will be desensitized to cigarettes and will not likely see the health risks as readily. Parents are the greatest influence on their children’s behavior. Children whose parents smoke are twice as likely to become smokers themselves.^[14] Perceived parental opinion is also a major contributing factor in youth smoking. If children believe their parents disapprove of smoking they will be less likely to become smokers. In addition to parental influence, siblings also serve as contributors to youth smoking. Overall, smoking families are much more likely to raise children who will become future smokers than families that instill a negative opinion of cigarettes in their children.

Friends and social circles have a huge influence on youth smoking. It is not necessarily peer pressures that encourage or discourage smoking, but a bonding mechanism among peers. Adolescents may smoke because they want to belong to a particular group, others may lack the skills to refuse a cigarette offered by a friend or someone they want to get to know. Programs like Life Skills Training seek to give youths the skills they need to combat situations like this by promoting basic competencies such as communication proficiencies and how to effectively address anxiety.^[26] Teachers in an academic setting can also contribute to youth opinions of smoking. If a student sees that his teacher smokes, that teacher makes cigarettes seem safe and acceptable. School policy must address smoking among both students and teachers. Colleges with a non-smoking policy in place for students and faculty have been shown to have the lowest smoking prevalence among their students.^[14]

Smoking in the media

Smoking in the media is portrayed as "cool" and often shows the people who smoke as sexy and sophisticated. Tobacco companies portray smoking with images of success, pleasure, relaxation, and freedom.^[27] Since the media portrays a harmful act like smoking to be glamorous, the youth is destined to try smoking. Even with the creation of the Master Settlement Agreement (MSA), little significant change is seen in the amount that a film may reference smoking. Tobacco brand appearance in R-rated movies decreased by 55.4%, however, PG-13 movies only decreased from 15% to 11.8%.^[28] Parents must be aware of the fact that the media still incorporates smoking in movies that are said to be acceptable for children to watch. Parents need to be cautious of the movies their children are seeing and help their children understand the dangers that smoking poses to their health in case they are exposed to smoking in the media. To decrease exposure, parents should not allow their children to wear anything or place anything in their rooms like posters of celebrities smoking or other things that promote tobacco companies.^[29] By following these guidelines, children will be less likely to resort to smoking later in life.

Globalization

Youth smoking is present in every society. Each society, however, views youth smoking in a different light. While some, such as in India, view youth smoking as the norm, other societies face a problem that is very similar to the one facing the U.S. In India, pre-professionals are 250% more likely to smoke than other students due to the use of sharing of cigarettes in the professional world and the importance of cigarettes in defining caste boundaries. The tobacco industry has targeted non-English speaking countries in a fashion similar to how they target youths in America. The translations of the messages that the tobacco industry's try to convey to these youths are interpreted as ambiguous. The result of this is that the youths are either sent a "forbidden fruit" message or they focus on decision-making and not the health effects of smoking.^[20] When the tobacco industry began to experience resistance to their overseas messages, Philip Morris began to use its Action Against Access program (1990) in an attempt to prevent restrictive legislation worldwide^[20] and to show self-restraint in the industry marketing of cigarettes to children.

Future Directions in Preventive Interventions

Research has suggested some future directions that preventive interventions could take in order to be more effective in reducing the number of youths who engage in tobacco consumption. One such direction is to pass legislation banning smoking in all schools, by students and by faculty. Studies have shown that school districts who have implemented such bans have lower smoking rates among students than nearby, similar schools. In fact, schools with a zero tolerance policy for smoking can reduce smoking rates by approximately 40 percent if the ban is properly implemented and enforced.^[30] Also, it is important to make sure that programs are age-, gender-, and culturally-appropriate for the intended audience.

Another suggested direction is to implement interventions that use multi-dimensional tactics to prevent youth tobacco initiation. Programs like Life Skills Training and Project TNT use both a school-based curriculum and mass media interventions to help youth effectively develop the skills they need to avoid cigarettes and other tobacco products. They also both have multiple objectives including teaching students how to develop a positive self-concept, make independent decisions, educate students about the consequences of consuming tobacco, and allowing students to develop an understanding of the way the media can manipulate their views about tobacco. Overall, it seems that the most effective programs use a combination of psychological, social, and environmental factors to influence youth to make positive choices regarding tobacco products.^[13]

A final key aspect that future interventions should focus on are the immediate effects of tobacco consumption. It is argued that too many interventions focus on the detrimental health effects of cigarette consumption that will occur in the future rather than in the immediate future. Future effective programs may want to address the immediate consequences of tobacco consumption including the possibility of immediate addiction, changes in brain chemistry, lesser athletic ability, and elevated blood pressure.^[31]

See also

• Cigarette smoking among college students

References

Further reading

• Joe Camel advertising campaign at SourceWatch
• Action Against Access at SourceWatch

External links

• Why do teenagers smoke? Reasons and solutions