Over the next five years, hundreds of millions of tobacco-settlement dollars will be poured into campaigns to keep teen-agers from smoking. Public health officials had better hope the new, better-financed campaigns are more effective than those of the last five years.
Since 1992, even as the federal government turned up the rhetoric against smoking and its corporate salesmen, youth smoking has climbed sharply. Though theories abound, no one really knows why.
And because the behavior of teen-agers remains a mystery, the anti-smoking campaign about to begin on an unprecedented scale is a costly and unpredictable experiment.
"I'm not sure we really know how to reach kids effectively with health messages," says Dr. Ronald M. Davis, a Detroit physician and editor of the journal Tobacco Control. "Kids feel they're invulnerable, and that makes them hard to reach."
"The industry associates its product with an image that kids want," says John P. Pierce, a professor of cancer prevention at the University of California at San Diego who studies tobacco marketing. "How do you counter that image? We don't really know, because nobody's gotten there yet."
What is beyond dispute is the sustained, sharp increase in youth smoking, which promises big increases in lung cancer, heart disease and emphysema in a few decades. The trend is particularly striking in view of the continuing, slow decline among adults.
In 1992, 27 percent of high school seniors reported smoking in the previous 30 days; last year nearly 37 percent had smoked. Among college students, over the last four years, the smoking rate rose from 22 percent of students to almost 29 percent. Even among African-American students, whose smoking rates are far lower than white students', the recent upward trend is sharp.
A generation of young people, exposed to more education on the health consequences of smoking than any of their elders, evidently has decided to ignore them.
Nobody knows why, but there are plenty of competing explanations. For example:
Pierce, who has linked cigarette ad campaigns to smoking trends all the way back to the 1880s, makes the case that the rise in youth smoking was engineered by industry marketing mavens. He says the turnaround coincides with the 1987 appearance of the notoriously effective Joe Camel, which persuaded huge numbers of young teens to sneak their first puff. Then coupon programs offering Marlboro Gear and Camel Cash took over, converting experimenters into addicts, Pierce says.
"Every time there's been an innovative campaign in this century, there has been a huge increase in smoking among 14- to 17-year-olds," he says.
Ridiculous, replies David J. Adelman, a tobacco industry analyst at Morgan Stanley Dean Witter in New York.
"You have to pretty naive to think that kids smoke because of advertising," Adelman says. On the contrary, he argues: Youth smoking is up in the 1990s precisely because everyone from President Clinton down to elementary school teachers has been telling kids not to smoke.
"Young people like to do what's prohibited," he says. Health advocates have inadvertently spurred the smoking boom by enhancing tobacco's image as a forbidden pleasure, Adelman says.
A third view is advanced by Kenneth E. Warner, a health policy economist at the University of Michigan and veteran anti-smoking advocate. It's the price, stupid, he says.
Real prices of cigarettes have declined in the 1990s, he says, most notably after "Marlboro Friday" in April 1993, when industry giant Philip Morris cut the price of a pack by 40 cents to win market share back from cut-price generic brands.
"Prices are just a huge part of the story," Warner says. He notes that as a result of a 45-cent price increase per pack announced Tuesday by tobacco companies to cover the cost of the settlement, analysts predict a 10 percent drop in cigarette sales next year.
Tacticians of the anti-smoking movement say the rise in youth smoking is a discouraging setback. But they say it is not so much a failure of health education as a rout by massively superior forces.
By one calculation, the tobacco industry spent $19 on marketing and promotion last year for every American. In Maryland, the total spent on public anti-smoking messages and smoking cessation programs came to 36 cents per person.
"It's not even David vs. Goliath," says Lloyd D. Johnston of the Institute for Social Research at the University of Michigan, who has tracked smoking among high school students since 1975. "The money going into counter-advertising is a pittance."
That is going to change. In addition to paying $206 billion over 25 years to Maryland and 45 other states, the tobacco settlement will pay a separate $1.7 billion over the next 10 years to a foundation supporting anti-smoking programs and research.
True, industry lawyers inserted a prohibition on "attacking" or "vilifying" cigarette makers or their executives, cutting off a particularly effective approach to reaching teens.
And new money is unlikely to come close to matching industry spending, which totals nearly $6 billion a year for marketing and promotion.
But the lion's share of that money goes toward discounts and promotional payments to retailers; less than $1 billion is spent on advertising, according to the Federal Trade Commission. Almost certainly, Maryland will be spending several times the $1.8 million a year currently budgeted for programs to counter smoking.
Citing encouraging evidence from California and Massachusetts, public health advocates say well-crafted anti-smoking messages on television or in other popular media can have an effect, and now there will be sufficient funding to permit a large-scale test. But they say any effective campaign to reduce youth and adult smoking must have several other components:
Major tax increases -- such as the $1.50 increase in Maryland's 36-cents-per-pack tax being sought by the Maryland Children's Initiative -- to put the price out of reach of more young people. A price increase may not cut early, experimental smoking by young teens, but it is likely to reduce the number of experimenters who become regular, addicted smokers.
Bans on cigarette vending machines, where many kids buy cigarettes, and requirements that cigarettes not be displayed within reach at store counters, where teens often shoplift them.
Tougher enforcement of laws prohibiting cigarette sales to minors.
Continuing enforcement of bans on indoor smoking, which give adults a reason to quit and may keep some young occasional smokers from becoming addicted.
Federal legislation authorizing the Food and Drug Administration to regulate tobacco products, which would greatly strengthen the government's hand in reducing the health damage caused by smoking.
"It's true that we still have a lot of questions about what drives youth smoking," said Glenn E. Schneider, acting director of Smoke Free Maryland, the state's anti-tobacco coalition. "But we know that price increases work, and we need a comprehensive tobacco-use prevention program. The industry's very good at addicting people. We have to combat that every way we can."
Pub Date: 11/29/98