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SALLY FAITH DORFMAN (director of Public Health and Education for the Medical Society for the State of New York): My preliminary question is for Dr Eriksen. You mentioned that increased funding will be made available to the state health department. The Medical Society has worked very closely with the state for years; I hate to think the money will go only to managed care. There are many physicians who are not exclusively involved with managed care. Managed care is very problematic these days. If everything is getting funded through managed care, that may leave out a lot of avenues for constructive actions, although we do recognise managed care as an important entity.

I should like to express my concerns over some of the advertisements that were presented. I recognise that I am totally out of touch with the generation that you are aiming to reach. I recognise that sexuality is a major issue for teenagers and pre-teenagers, but to pander to their greatest insecurities seems to me to be doing a terrible disservice to young women. To be calling a young woman who is a smoker a “garbage face”, and to imply that she is not going to get a date, or her boyfriend is not going to kiss her, only increases her already shaky self-esteem. We know that the girls who are smoking are probably the ones with the low self-esteem in the first place. Does this just make everything worse for that kid whose mother probably also smokes? Is she going to think of herself and her family as “trash”? What are we doing to these kids? What are we telling them? What other messages are we sending them? Are we saying that the most important thing in life is to have a boyfriend when you are 10, 11, 12, 13, 14, or 15? We have enormous problems in this country with teenage pregnancies and epidemics of sexually transmitted diseases. Let’s not forget that as we deal with the tobacco pandemic.

MICHAEL ERIKSEN: In terms of my comments about money for the state health departments going to managed care, I didn’t mean to imply that the money was flowing to managed care organisations, but that there was a potential for a partnership there. We have provided very little money to The HMO Group who contributed to the projects in Colorado and Washington. We would like to see more collaboration, but clearly it is not an exclusive relationship in any way.

In terms of the second issue—how children are being portrayed in these advertisements—my comment would be that we have to be careful to avoid any type of victim blaming. The tobacco industry has exploited the children; they created the demand for their products and now we are trying to counter that. You raised some important points of which we have been aware; at the same time, we have to talk in terms of the audience. What teenagers attend to is not cancer; unfortunately, it is social factors. We need to conduct counter-advertising in a way in which we do not victimise the children or contribute to already low self-esteem, such as by using positive modelling.

SANDRA SANDELL: I agree with Dr Eriksen and certainly you have made some very valid points. We did, quite frankly, wrestle with this issue. We brought a lot of resources from various community partners to the table on this coalition. The consensus was that the overriding issue was to get the message out, and to produce some television spots that the kids were really going to watch. Unfortunately, children cannot relate to being 20 or 25, or the fact that smoking is going to create some serious health consequences as they get older. Having said that, and having said that we did wrestle with this, we did reach the conclusion that we had to produce spots which the kids could really identify with.

MICHAEL ERIKSEN: I should like to add that we have to strike the balance between de-glamorising tobacco use without stigmatising the kids, and providing alternatives such as the soccer team. We have just started a collaboration with Boyz II Men, the music group, who are putting the message out. We recently produced posters where Boyz II Men are promoting the non-smoking message.

We have also just started a commercial with Christy Turlington, one of the supermodels, whose father died of lung cancer. The idea is to get positive role models to speak out, as opposed to diminishing those who are already addicted.

JOE ADAMS (Doctors Health, Inc., Maryland): On the “Smoking Stinks” campaign, were there members of the committee who were interested in working on advocacy at the local or state level? Also, now that the funds are used up, do you think that the programme will lead to any kind of continuing activity in the advocacy area, to institutionalise some of the things that you were doing?

JENNY DESVAUX OAKES: Yes, we do plan to have some more active advocacy efforts in the next phase of our programme. We also plan to implement evaluation of the programme.

GLEN MORGAN (Family medicine educator, Pennsylvania): Dr Eriksen, you gave a couple of figures in terms of increases in federal funding. What are those figures again?

MICHAEL ERIKSEN: The President released his budget on Monday, and the funding on state-based tobacco control increased government-wide. Presently, the Department of Health and Human Services (HHS) gives states $34 million in fiscal year 1999 (which will start in October 1998); then it will increase from$34 million to $51 million. So there will be a 50% increase in that period. Our budget will have the large increase because we will be managing the resources that will go to assist the states. CDC will be administering the entire nationwide program starting in October. Our budget for states will have increased from$12 million this year up to $51 million in October, if Congress approves the President’s budget. The bottom line is that we have more resources already in the President’s budget. Beyond that, in terms of discussion and national legislation, there is talk about hundreds of millions of dollars being available for tobacco control. The campaigns that have been done on shoestrings, can be done on a much more aggressive and larger scale. This will require the type of collaboration, coordination, and creativity presented today. BILL LEAD (Mount Sinai, New York): What about the “losers” who do smoke and identify with the adolescent counter-culture? What are we going to do with the kids who would not be eligible for the soccer team? What are you going to do with the kids who do not identify with your advertisements? Taxation and the question of how much it costs to smoke is an important issue as well. The media campaign is very exciting, but it seems to focus on upper-middle-class kids who identify with being attractive. What are we going to do with the kids who are not in that category? MICHAEL ERIKSEN: We do know that kids who smoke, as a rule, are those who have the lowest self-esteem, are not doing well in school, and come from the worst family situations. That does not describe every kid who smokes, but this is disproportionately the case. Once kids start smoking, we do not have anything to offer them in terms of cessation. There is a huge void in cessation research here. We had a meeting in September 1997 in Atlanta, Georgia, where we pulled together the cessation research experts to try to address this very critical issue. Your organisations can play a role in determining the best practices around cessation in teenagers. We have to be careful again not to stigmatise or victimise children who get drawn into a habit which we allowed to seduce them. The reality is that with the way that tobacco has been marketed, made available, and regulated in this country, it is no surprise that kids who need something seek tobacco to fulfill that need. To change that, it will take time and energy and the type of involvement that we finally have in this country. TRISH SEGHERS: I should like to add that what we want to keep in mind is that the ultimate goal is to try to get these kids to not use tobacco. One way to do that is to change the norm in the community to where it is not acceptable to use tobacco. That is what we are trying to do with these advertisements—to change the societal norm. SANDRA SANDELL: To some extent, we face the same challenges with adults as we do with teenagers in that smoking is becoming increasingly a habit of the less educated and the less affluent. We have not really solved the problem of how we get messages out to that group; nor have we solved the problem of helping them find alternative ways of dealing with stress. Tobacco seems to be one of the ways in which they deal with a lot of the environmental stressors in their lives. MICHAEL ERIKSEN: We really have to do a better job of providing positive alternatives so kids do not turn to what is obviously there for them. TED MARCY (University of Vermont): Media interventions are ripe for the development of evidenced-based guidelines, in the same way as individual cessation treatment. Rather than producing more campaigns, it may be more important to spend some time reviewing the data to determine where further research needs to be focused. Media interventions need to be evidence-based and more carefully done. MICHAEL ERIKSEN: I agree. In fact I was hoping to use this as a segue to the data that was presented from Colorado and Washington. It did not show much of an impact on the programme in terms of quit attempts in teenagers. Why is that? Is it a sample size issue? I am sure it did not decrease attempts to quit, but it certainly did not appear to increase it. The Vermont data which we frequently use show that media campaigns coordinated with school-based activities can have a sustained effect. The effect of media is questionable if it is not integrated into a comprehensive programme in the community and the schools. Media has a lot of potential and we need to use it in the same way that the tobacco industry uses it. There is no ambiguity about who Joe Camel is or who the Marlboro man is. Whether it is on billboards, in magazines and stores, it all reinforces, and is very consistent with, an image. We have not done that with tobacco control and it needs to be coordinated, but it is going to take a large-scale effort. Obviously, with a couple of thousand dollars, you cannot change the lifetime of imagery which kids have been exposed to. BOB FAY (Pharmacy Council on Tobacco Dependence): I thought all the advertisements were very well done. I should like to offer a suggestion to the people on the committee here. Community pharmacies are very interested in an anti-smoking programme. If you have any posters or pamphlets that you would like to give out, it would be beneficial if you could stop at one of your community pharmacies and offer these things. We really like to distribute them. In the United States there are about 30 000 pharmacies that are no longer selling cigarettes. We should like to recognise those pharmacies as the first step in making smoking a public health pharmacy issue. If anyone needs any information, they can get in touch with their state pharmacy association. MICHAEL ERIKSEN: That is fantastic, thank you. We applaud your efforts. The only thing that is more offensive than cigarettes being sold in pharmacies is smokeless tobacco being sold next to candy, literally on the same shelf. ALBERT SCHILLING (Rhode Island Hospital, Rhode Island): Minnesota has a long and strong history of managed care organisations, and certainly its surgeon general is outstanding. This is not a criticism, but in examining the goals of the partners as you described, tobacco control is not one of them. An effective approach may be to get the message across to the insurance companies that they should offer reduced premiums for non-smokers or penalty premiums for smokers. The easiest and the most cost-effective preventive medicine is tobacco control. That message has not been received by the powers that be and they have not put necessary resources into it. Perhaps a nationally recognised individual could compose a letter to insurance agencies and managed care organisations outlining the benefits of smoking cessation. MICHAEL ERIKSEN: What I hear is a gentleman calling for some type of action out of this meeting, for some type of communication that will go to managed care organisations. Perhaps the conference leaders could consider this in terms of your conference outcomes. This is not a governance body here, but certainly the attendees could draft something that might help in terms of prioritisation. RICHARD WINDSOR: Dr Eriksen, could you comment on the very substantial decline of smoking among black youth? Is it a consequence of delayed initiation, with a substantial decline followed by an increasing rate when they reach 18, 19, and 20? MICHAEL ERIKSEN: A fascinating phenomenon that has occurred over the past two decades in this country is the difference between smoking among white and black teenagers. Where 20 years ago they were equally likely to smoke, today black teenagers are two to three times less likely to smoke than their white counterparts. This is particularly prominent among black adolescent females. Forty per cent of white high-school girls smoke; 10 per cent of black high-school girls smoke. That is a four-fold difference. It is not due to later initiation. What we are finding is that the difference holds true all the way to 30 year olds among black females. For the first time in history, black females are smoking less than white females. We have spent a lot of time documenting, studying, and doing qualitative research. There is clearly a non-public health intervention that has occurred that has resulted in this change which we need to preserve and understand. RICHARD WINDSOR: Can you explore reasons why? I do not have a good sense of why this is happening. MICHAEL ERIKSEN: We cannot explain its evolution, but we can characterise it. White and black females view tobacco diametrically differently. White girls see it as an asset and benefit, which makes them appear older, more glamorous, and more sophisticated. Black teenage girls tend to view tobacco as a liability, as an impediment that will interfere with their progress and success in their lives. They basically see it as a hassle which they do not need. Is there any generalisability here? We are struggling with that. We think it may be much more intricately involved within the context in which white and black girls grow up in society. It is a fascinating issue and one that I encourage all of you to be attentive to. A surgeon general’s report will be published that documents this in much greater detail.1 MARY BETH GAINES (Kaiser Permanente, Vermont): As I drive down the highway and see huge billboards showing glamorous white females smoking, I know that there is some type of targeted marketing effort occurring. Speaking of targeted marketing efforts, one of the things that has been suggested to make our media campaigns more effective is follow up in the schools. There is a kind of follow up that the tobacco industry uses in their marketing that we have not addressed. That is “give-aways.” Kids love the give-aways, they love the backpacks, the jackets, the socks, and whatever else. Has there been any consideration in using give-aways as a means of marketing anti-smoking to teenagers? MICHAEL ERIKSEN: Absolutely—the whole issue of promotions, caps, teeshirts, and items that kids can use to establish an identity to parallel what the tobacco company has done is a very fruitful area. It is clear, there is data showing that it is not just advertising. The merchandising is key and we need to counter that. There is a lot of potential there. We will be part of any advertising campaign, but it will not be just advertising; it will also include marketing. TIM MCAFEE (Group Health, Puget Sound, Washington): There is evidence that counter-advertising campaigns, especially in conjunction with school-based campaigns, can have a significant effect. I think the issue is really a volume issue. I am pleased that you are receiving$51 million instead of $12 million, but if this is to counteract$6 billion, we just do not have a chance. Managed care organisations do not have the political will or budgets in this area to contribute substantively into the ocean of what is needed. What can we do to ensure that, if there are larger sources of funds available, the money gets dedicated to this type of community activity?

MICHAEL ERIKSEN: The settlement, as well as the national legislation calling for \$500 million to be used for a national media campaign, would really be a significant counter-attack. Coupled with the FDA [United States Food and Drug Administration] rules when they take effect, this would make a huge difference. The issue of what funding comes from the national legislation, if anything, is going to depend upon the insistence that actions focus on public health.

SUE SHWARTZ (Maine Medical Assessment Foundation, Maine): I have had the privilege of being involved in programmes in two states which have passed tobacco tax initiatives—Oregon, and now Maine. When the states are forming their budgets and priorities, there is tension between prevention and cessation. The community folks want to put a lot of money into prevention. My feeling is that cessation is prevention. If you stop adults from smoking, their children are less likely to smoke. Was there a product of the meeting on cessation in teenagers, and a subsequent research agenda?

MICHAEL ERIKSEN: The meeting included not only experts in cessation in teenagers, but also a number of possible funders with the National Cancer Institute (NCI), the Robert Wood Johnson Foundation, and Centers for Disease Control and Prevention (CDC) to look at how we could move the research agenda forward on cessation in this age group. The proceedings of that meeting are in progress.2