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In 1986, when Surgeon General C Everett Koop challenged the nation to create a smoke free society by the turn of the century, the focus was on creating a “smoke free class of 2000”—children who would go from first grade to high school without ever smoking a cigarette.1
In 1990, when the African American community opposed the introduction of Uptown Cigarettes, a brand that RJ Reynolds Tobacco Company had designed for African Americans, the battle cry was that the tobacco company was coming after black kids. That threat galvanised the African American community.2
In the mid 1990s when David Kessler, head of the US Food and Drug Administration, began his quest for approval to regulate nicotine in cigarettes, he marshalled support by calling smoking a “pediatric disease” because smoking typically begins in late childhood or early adolescence.3 The recent FDA effort to curb teen smoking has been called “ . . .the most important public health initiative of our generation”.4
It is easy to garner public support for youth focused anti-smoking projects. No one wants kids to smoke. Polls show that smokers support programmes to keep children and teens from getting hooked on cigarettes and other tobacco products.5 Even tobacco companies have climbed on the bandwagon, spending millions in anti-smoking advertising campaigns, allegedly directed at dissuading youth.6
Yet, for an issue that has such support, the scorecard is quite dismal. In 1998, more than one third of high school seniors surveyed said they had smoked a cigarette in the previous 30 days.7 In many ways, the dreams of a “smoke free class of 2000” have gone up in smoke. What happened?
The easy answer is that the tobacco companies, for all their rhetoric, kept targeting children. A 1994 report found that 86% of teenage smokers purchased the three most advertised brands—Marlboro, Newport, and Camel—although those brands represented only 35% of total cigarette purchases.8
Another reason is that in the 1990s, Hollywood actors, musicians, and waif thin fashion models brought back a glamour to smoking that had not been seen with such intensity for decades. This is true even for African American youth, whose smoking rates have remained much lower than those of white youth,7 African American superstars are frequently seen smoking cigarettes and cigars in movies, music videos, and magazine interviews.
Tobacco control advocates point to these external influences on youth as the primary reason that the incidence of youth smoking has gone up. But there is another reason which is not talked about as much. When the tobacco control movement decided to focus on children, there was no roadmap that outlined how working with youth on tobacco prevention and cessation differed from working with adults, and which approaches and materials would be most effective in reaching young people. Many of the advocates, while well meaning, were health educators, physicians, and nurses, who had never taken courses on youth development and had little knowledge of the intricacies of working with adolescent and pre-adolescent kids. A roadmap to youth and tobacco would certainly have helped. Unfortunately, none has emerged in the past 10 years and we cannot expect to find one soon.
So, maybe it is time to stop by the side of the road and ask ourselves some hard questions:
Why were years of investment in youth smoking prevention followed by rising rates of youth smoking?
Is there a reason to take comfort in the recent downward trend of youth smoking rates7 or is it just the lull before another storm?
Is the recent increase of smokers aged 18–24 years a cohort effect of a higher smoking group growing older, or is it evidence of a new tobacco industry strategy of focusing on young adults?9
None of these are easy questions, and two articles in this issue ofTobacco Control raise even more questions. In their research, Lantz and colleagues (page 47) discovered that despite years of experimentation with various youth oriented strategies to prevent smoking among adolescents and pre-adolescents, there still remain many questions about policy and programme efficacy.
Take tobacco taxes as an example. Of course youthshould be more price sensitive because they have less money to spend than adults. In fact, there are complex econometric formulae that show how much youth smoking decreases in relation to percentage increases in the cost of cigarettes.10 Yet in California, tobacco taxes went up and adult smoking rates went down—but youth smoking did not.11
Advertising is another hot button issue. Luke and colleagues (page 16) took an in-depth look at billboard advertising and found that most of the billboards in St Louis, Missouri, were within 2000 feet (700 metres) of schools and that tobacco brands were the main advertisers. (This was pre-1999—since last April tobacco billboards have been removed under a provision of the tobacco settlement. However, significant issues related to billboard advertising remain in many other countries.)
Getting rid of billboards is a step that is consistent with efforts to decrease the rate of youth smoking. But few believe that removing the Marlboro Man and Joe Camel from billboards alone will dramatically decrease youth smoking rates. If past actions predict the future, just as tobacco companies increased their use of billboards when tobacco advertising was banned on US television and radio, it is likely that the industry will shift into other forms of media to reach youth audiences.12
Other tobacco control advocates have put their faith in strengthening youth access restrictions.13 Yet despite the Synar Amendment that requires states to enforce 18 years as the minimum age for sales of cigarettes, and threatens the loss of drug and alcohol funding if merchants do not comply and the implementation of the FDA's requirement for photo ID, the problem of underage smoking remains.
So, what are the choices? Advocates can continue to blame the rise of youth smoking on the tobacco companies and their dastardly attacks on our kids. That certainly makes us feel better, but it does not do much about youth smoking rates. Advocates can decide that the kid focus was totally wrong, throw up our hands and start paying more attention to adult smokers instead of young people. That would probably be easier than trying to fathom what kids are thinking and why kids are smoking, but it would leave us with a never ending supply of new smokers as today's children became tomorrow's adults. Or, we can set out once again on a new journey, having learned from the mistakes and successes of the past.
What will we need? First, we need a clear destination. Is our goal to stop kids from smoking or to create a smoke free community? Are we trying to stop smoking initiation by persons under 18? If so, what happens if the tobacco industry is successful in convincing college students and newcomers to the workforce to begin smoking at 18, 19 or 20?
This time we have to be sure where we are headed. There is an old saying: “If you don't know where you're going, any road will take you there.” And in tobacco control, we have travelled on too many winding roads without a clear destination in our efforts to end the epidemic of youth smoking.
Second, we need to recruit some knowledgeable guides to help us navigate the youthful terrain. There is a reason why the tobacco companies have been so anxious to form partnerships with 4-H and other youth programmes. The adults in those programmes understand young minds. Some people in tobacco control have had to learn by trial and error what many youth workers have known for a long time. To be successful, we need to form real partnerships with teachers and youth workers. (And it wouldn't hurt to have as part of our team some of those individuals who make their living marketing to kids).
Third, we have to be willing to acknowledge when we have lost our way and humble ourselves enough to ask directions. Too often, advocates have chosen to forge ahead as if we actually knew where we were going. The result has been to continue down paths that were not productive simply because we did not want to be wrong. We must be open to backtracking if necessary and taking alternate routes. If tobacco taxes are not bringing youth smoking rates down fast enough, that simply means we have to find additional ways to make it happen—particularly when industry special promotions can undermine tax rises, as happened after the November 1998 45c increase from the settlement. If advertising campaigns do not get the response we expect, then it's back to the drawing board. When working with youth, it is easy to take a wrong turn and end up travelling in circles. The trick is finding the right road again.
And finally, we must be willing to weather the storms that are inevitable without giving up. Big tobacco is terribly entrenched and will not be dislodged easily. Billions of dollars and millions of lives are at stake. As long as we continue to chip away at their customer base of potential smokers, we can expect retaliation.
Despite substantial investments, hard work, and great intentions, thousands of young people still begin smoking each day throughout the world. While it would be nice if the tobacco companies were true to their word and stopped marketing directly and indirectly to kids, we cannot rely on that possibility. If anything, recent events have made tobacco companies even more anxious to find new markets and hang on to current smokers—underage or not.
As long as the tobacco companies are marketing to our kids, the concept of giving up on the youth focus in tobacco control is not really an option. So, to quote the folk singer Willie Nelson, we are “on the road again”—but this time with a clearer destination, a knowledgeable guide or two, a willingness to ask directions, and carrying protection from the sudden storms. After all, as tobacco control advocates, we do not have much choice about whether to stay on this road or not.
None of us wants kids to smoke.