Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Reframing the Tobacco Prevention Issue: A Social & Behavioral Science Argument to Switch the Focus from Youth to Society – Sani Karam

Protecting our children from cigarette smoking should always be a priority of public health. However, many interventions to address this problem have been too centered on youth, omitting critical factors that affect adolescents’ decision to smoke. The factors range from environmental, such as the tobacco industry’s manipulation through advertising, to the social atmosphere of children. Unfortunately, most youth tobacco programs have identified the problem as solely within the context of their lives. One particular initiative that stands out in this regard is preventing access to tobacco by youth through imposing age restrictions.

The Synar Amendment to the 1992 Alcohol, Drug Abuse and Mental Health Administration Reorganization Act, incorporated youth access restrictions into federal tobacco control policy, and therefore required states to prevent the sale of tobacco to minors (below the age of 18) (1). Youth access laws gained widespread acceptance: all 50 states and 1139 local governments had passed youth access laws by August 2001. Furthermore, the US Centers for Disease Control and Prevention and the Institute of Medicine advocate youth access restrictions as an integral piece of tobacco control policy (1).

Towards the end of the 1980’s, increasing awareness that tobacco products were easily within reach of children encouraged support for youth access laws (2). The 1994 surgeon general’s report Preventing Tobacco Use Among Young People paved the way for future implementation of such restrictions, stating: “when young people no longer want to smoke the epidemic itself will die” (3). Implicit in this statement is a fundamental belief behind youth access restrictions: preventing children from smoking would inevitably decrease smoking among adults (4).

Children were identified as a practical intervention target for two reasons. First, children are more marketable politically due to the belief that, relative to adults, they are less rational and therefore the government should intervene to prevent irrational decisions regarding smoking. However, the same logic does not apply to adults, whose rational decisions concerning smoking do not warrant the government’s intrusion of their individual rights (4). Second, children are significantly more responsive to tobacco prevention measures: the price elasticity of demand of children is 2 to 3 times that for adults. The predominant belief was that targeting children would have a greater reduction in smoking than with adults (4).

The reality of access restrictions
Given the base of knowledge at the time, youth access laws were understandably appealing. However, over a decade’s worth of information has been accumulated regarding youth access interventions, illuminating their efficacy, or lack thereof. Access programs undeniably have the potential to reduce illegal sales of tobacco products to children; on the other hand, insufficient data has been gathered to demonstrate that these interventions result in lowered tobacco consumption (2). Based on data from 9 studies, there was no statistically significant difference in the prevalence of youth smoking between communities with access restrictions and control communities (1).

Social sources
The underlying idea of restricting minors from purchasing cigarettes is that children heavily rely on retailers as their source of tobacco products. According to this logic, youth access restrictions should substantially reduce smoking among children. However, the program’s logic is flawed in the fact that restricting who can purchase cigarettes is merely another hurdle for youth. After all, kids are more resourceful than that!
In reality, youth obtain half of their cigarettes from commercial sources (1). Alternative sources of cigarettes include friends, siblings and even theft. Therefore, depending on cigarettes’ availability in stores, teens will shift to social sources of tobacco (5). Youth access restrictions failed to incorporate children’s versatile nature and study the social environment of children, with regards to the availability of communal sources.

Maturity appeal
Restricting youth from access to commercial sources of cigarettes reinforces their adult appeal to teens. Proponents of access laws did not consider the teenage experience: the constant desire to be welcomed into adulthood; to feel mature among their peers; to rebel against measures that restrict their freedom and individuality. Teenagers will react rebelliously to access restrictions just as they do to punishment. Access restrictions negatively impact teens by amplifying their resentment of not having the freedom to make their own decision. Furthermore, as will be discussed later with advertising, the tobacco industry has taken advantage of this idea, implying that the only reason not to smoke is age (7).

One of the greatest alleged benefits of smoking among youth is the social connection with peers, predominantly as a form of rebellion (6). Erik Erikson’s stages of psychosocial development explain an underlying factor of this relationship, which policymakers behind youth access restrictions clearly did not take into account. Erikson’s concept states that adolescents must resolve the crisis between identity and role confusion, commonly through peer groups (8). Therefore, for the first time in their life, teenagers are aware and self-conscious of their appearance to their classmates. As a result, teenagers increasingly reach out to fellow peers for identity, in a cry of their devotion.

Perceived prevalence and accessibility
Children’s perception of an overestimated prevalence of smoking among youth is largely influenced by the tobacco industry (9). In addition, access restrictions are one component of the general anti-tobacco messages that say: “‘resist your peers, don’t smoke.’ The message should be ‘be like your friends, be a nonsmoker.’”8 Rather than feed children’s frustrations with limited freedoms, the message should positively enforce their desire for independence. They should be provided with an accurate representation of the average teen’s lifestyle. The truth is that most teen smokers are actually ‘experimenters’, and have consumed less than 100 cigarettes throughout their lifetime, making it extremely difficult to limit such erratic smoking behavior (6). If youth were provided with truthful information and the freedom to make their own decisions, then rational adult decision-making would be promoted and childhood rebelliousness discouraged.

Youth access laws’ reasoning implies that smoking among children would decrease if they felt that cigarettes are no longer easy to access (10). Social sources aside, even though access laws reduced the number of illegal sales to minors, it had no effect on children’s perceived access to cigarettes (11). There are two explanations behind this phenomenon. First, tests of compliance used to measure illegal sales are significantly overestimated for a number of reasons; for example, teens may overstate their skill at buying cigarettes or the youth that really purchase cigarettes differ from teens used for compliance tests in terms of their dress, attitude and so on (11). Second, successful attempts at sting operations send the wrong message to youths that cigarettes are still easily accessible (9). As a result, compliance tests exposed the cracks and loopholes of access restrictions to children.

Tobacco industry’s manipulation
As described above, the tobacco industry has influenced the effectiveness of youth access restrictions. Tobacco companies have been well-ahead of policymakers in targeting youth, since for many years they had been marketing tobacco products in order to “present the cigarette as one of the few initiations into the adult world” (9). As a result, children had misconceived notions about smoking and its prevalence. In effect, tobacco companies’ advertising had set children up to rebel against access restrictions, which prevented them from gaining a ‘tool of maturity’.

Tobacco companies also exposed one of youth access restrictions’ fundamental drawbacks. By focusing solely on youth, the intervention only addressed one aspect of society and did not incorporate young adults, who have become the recent targets of tobacco’s adapted strategy, through aggressive advertising in nightclubs and bars (12). Young adults comprise an even more troubling age bracket than teens for a number of reasons: more young adults smoke than teens; young adults are more likely to be in the phase between social smoking and addiction; and young adults tend to be siblings of teens, who act as role models and possible social sources (13). Therefore, the tobacco companies’ marketing strategies have successfully rendered the youth access restrictions ineffective and are exploiting a new market of young adults that access laws have failed to address.

An alternative solution: the ‘truth’ campaign
The Florida ‘truth’ campaign initiated a provocative and comprehensive initiative to deal with youth smoking, the tobacco companies and not just the purchase of cigarettes (12). As opposed to access laws restricting teens’ independence, the truth campaign seeks to empower adolescents, engaging them in the initiative to spread awareness concerning the tobacco industry’s manipulation through advertising (14). The efficacy of this form of education was demonstrated by Florida teens having reported similar belief about the health effects of tobacco when compared with the nation, but worse beliefs with regards to tobacco companies (15). Therefore, teens were more willing to change their consumption patterns in response to a growing resentment of the industry’s manipulation rather than the established harms of cigarette smoke. A likely explanation is that children are more likely to discount future health risks, reducing their importance in teens’ attitudes towards smoking.

A major component of the truth campaign’s success came from addressing two of the problems of youth access restrictions mentioned above. First, similar to how access restrictions pushed teenagers to rebel by smoking, as predicted by Erikson’s behavioral theory, the truth campaign effectively galvanized their support against the tobacco industry through awareness of its exploitation of teens. Second, contrary to access restrictions, antismoking advertising resulted in children’s more accurate, as opposed to overestimated, perception of smoking prevalence (16).

Present obstacles to a smoke-free society
“It is clear that in the face of increased enforcement of youth access laws, tobacco remains an alluring and addictive substance of great appeal to youth” (9). As the inefficiency of youth access interventions is contrasted with the success of the truth campaign, the next logical step would be to discard youth access restrictions, which are vulnerable to tobacco companies’ manipulation and have yet to demonstrate efficacy, towards comprehensive interventions. These would include youth prevention strategies with demonstrated efficacy, sustained advocacy of adult cessation and further elimination of smoking in public (17).

The sad reality is that time and resources continue to be wasted in access restrictions despite the emergence of such findings. The key factors preventing the switch in focus of tobacco prevention from youth to society are the tobacco industry, the media and the lack of community mobilization. The tobacco industries’ hand stretches far beyond the boundaries that have been publicized by anti-tobacco advertising. Even after measures to reduce tobacco companies’ influence through advertising, our society remains to be continuously bombarded with incentives to smoke, such as free merchandise and subliminal messages. The latter is tied into a mutual relationship with the media to maintain tolerance of cigarette smoking as part of our society, even after losing acceptance. In addition, movies continue to romanticize cigarette smoking, offering an adult appeal for youth, a trendy statement for young adults and even a form of stress alleviation.

In order to tackle these underlying obstacles to change, we need to invest more in educational interventions, such as the truth campaign, to spread awareness. Once the tobacco industries’ manipulation is exposed to increasing numbers, support will amplify pushing more communities to mobilize. At the community level, parents should take responsibility for their children during the developmental years, preparing them to make their own decisions when faced with the temptations from tobacco companies.

The general “message should not be ‘we don’t want kids to smoke’; it should be ‘we want a smoke free society’” (9). Overall tobacco use should be reduced throughout society, including and not constrained to children. If we can achieve this, then we will no longer think of protecting our children from smoking, rather they will defend and shape our future society from tobacco’s influence.

1. Fictenberg, C., Glantz, S.Youth Access Interventions Do Not Affect Youth Smoking. Pediatrics. 2002;109;1088-1092
2. Lantz P., Jacobson P. et al. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco Control. 2000;9;47-63
3. Bayer, R., Kiesgi V. Is child-centered tobacco prevention a trap? American Journal of Public Health. March 2003,Vol 93,No.3
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5. Dent C., Biglan A. Relation between access to tobacco and adolescent smoking. Tobacco Control. 2004;13;334-338
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8.Gazzaniga, M. Psychological Science. NY: W. W. Norton & Company, 2007.
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10. Stead L., Lancaster T. A systematic review of interventions for preventing tobacco sales to minors. Tobacco Control. 2000;9;169-176
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13. Ling P., Glantz S. Using Tobacco-Industry Marketing Research to Design More Effective Tobacco-Control Campaigns. Journal of American Medical Association. June 12, 2002—Vol 287, No. 22
14. Altman D., Feighery E. Future Directions for Youth Empowerment: Commentary onApplication of Youth Empowerment Theory to Tobacco Control. Health Education & Behavior. Vol. 31(5):641-647
15. Niederdeppe J., Farrelly M., Haviland M. Confirming ‘truth’: More evidence of successful tobacco countermarketing campaign in Florida. American Journal of Public Health. February 2004,Vol 94,No.2
16. Siegel, M., Biener, L. The Impact of an Antismoking Media Campaign on Progression to Established Smoking: Results of a Longitudinal Youth Study. American Journal of Public Health. March 2000, Vol. 90, No.3
17. Siegel, M., Biener, L. Evaluating the Impact of Statewide Anti-Tobacco Campaigns: The Massachusetts and California Tobacco Control Programs. Journal of Social Issues, Vol. 53, No. 1, 1997, pp. 147–168

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