In their editorial “It is time to abandon youth access tobacco
programmes,” Ling, Landman and Glantz1 base their argument on an in press
meta-analysis of youth access interventions by Fichtenberg and Glantz.2
These authors conclude that there is no proof that youth access
interventions work to reduce youth smoking rates. Sadly, this analysis
includes ten methodological flaws, each o...
In their editorial “It is time to abandon youth access tobacco
programmes,” Ling, Landman and Glantz1 base their argument on an in press
meta-analysis of youth access interventions by Fichtenberg and Glantz.2
These authors conclude that there is no proof that youth access
interventions work to reduce youth smoking rates. Sadly, this analysis
includes ten methodological flaws, each one of which individually renders
the conclusions scientifically invalid.2 One of the invalid figures from
the Fichtenberg analysis has been reprinted in Tobacco Control.1
1. Three of the eight studies included in the meta-analysis did not
involve any actual enforcement of the law, and the authors of a fourth
study concluded that enforcement was inadequate due to a political
backlash from merchants.3-7 The inclusion of at least three of these
studies is scientifically unjustifiable as it has been established for
over a decade that merchant education programmes alone are ineffective at
attaining the levels of merchant compliance that can be expected to reduce
youth access to tobacco.8,9 Three out of the five studies included in the
analysis of the effects of youth access restrictions on past 30-day
smoking did not involve enforcement. The authors inappropriately list the
Baggot study as including enforcement and fines when in actuality, the
inspection method was so flawed that no merchant was ever caught and none
were prosecuted.4
2. In the Baggot study, merchant compliance is reported as 100%.4 None of
the stores sold to youths aged 13 or under during enforcement checks, yet
100% of smokers among the community youths surveyed reported that they
regularly bought tobacco from stores and only rare subjects reported ever
having been turned down. The study’s authors correctly concluded that the
compliance inspections were an invalid measure of youth access. Yet
Fichtenberg and Glantz included this invalid data in the analyses of a
threshold effect and it is also included in the figure printed in Tobacco
Control.2
3. It was improper to include a study from England where the legal age is
16 as the majority of secondary school students would be of legal age to
purchase and no impact on youths ages 14-15 would be expected.4
4. It was improper to include the study from Australia. In addition to
the fact that the study involved no enforcement, 46% of the students in
the intervention group actually lived outside the intervention area!10
5. The meta-analysis improperly combined studies of different designs
including cohort, cross-sectional, controlled interventions and non-
controlled interventions.
6. Combining these studies is also inappropriate because the ages of the
youths, and the methods used to test compliance, differed dramatically
from study to study. For example, a compliance rate of 82% for a 14 year
old is equivalent to a compliance rate of 62% for a 17 year old.11 A
compliance rate of 42% for behind the counter sales is equivalent to a
compliance rate of 58% for self-service sales.12 Differences in the
techniques used to measure compliance render all of the computations and
conclusions in this paper invalid.
7. The authors’ basic premise is that the percentage change in merchant
compliance should correlate with the percentage change in the prevalence
of youth smoking. The use of this measure represents a straw man. In my
review of 176 articles concerning youth access, I cannot recall anybody in
this field ever suggesting that the change in percentage of merchant
compliance is an appropriate measure of youth access. To the contrary,
there is wide agreement among experts in this field that absolute levels
of merchant compliance above 90% as measured through realistic compliance
checks using youths close to the legal limit will be necessary to effect a
change in the prevalence of youth smoking.13
8. In the figure presented in the Tobacco Control editorial, intervention
communities are being inappropriately compared to control communities from
other continents and legal systems. If the authors wanted to compare
smoking rates and youth access interventions across communities, a random
sample should be used, uniform measures should be employed and other
confounding factors such as socio-economic status and the cost of tobacco
should be controlled for. When this type of analysis has been performed
on a community and state level of analysis, reductions in youth smoking
have been observed.14,15
9. It has been known for centuries that the prevalence of smoking
increases during adolescence. This factor must be controlled for in
cohort studies by the inclusion of a matched control group. During the
period when most of these studies were conducted there was a secular trend
of dramatically rising teen smoking rates observed in English speaking
countries. Since merchant compliance would also be expected to increase
over time in these intervention studies, it would be expected that a
positive association between the intervention and smoking prevalence would
be seen in both cohort and cross-sectional studies if enforcement were
completely ineffective. The meta-analysis does not appropriately
incorporate control communities for each intervention community. Only 3
control communities are included for 15 intervention communities across 7
studies.
10. In the same analysis, the few control communities are inappropriately
included as additional “data points” in the mix. Baseline data rather
than outcome data were used for one intervention community. These
procedures indicate that the intention of this analysis was not to
determine the impact of the interventions as the authors state.
The Fichtenberg and Glantz article is strongly reminiscent of the
‘scientific’ papers secretly commissioned by the now defunct Tobacco
Institute. It is sad that the scientific literature continues to be
poisoned for political ends. The Tobacco Control editorial which was
based on this travesty of science also excludes and misinterprets data
which contradict the authors’ long held biases.16
Joseph R DiFranza MD
Professor of Family and Community Medicine
Department of Family Medicine and Community Health
University of Massachusetts Medical School
55 Lake Avenue
Worcester, MA 01655
References
1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access
tobacco programmes. Tobacco Control. 2002;11:3-6.
2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect
youth smoking. Pediatrics (In press).
3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between
tobacco access and use among adolescents: A four community study. Soc.
Sci. Med. 1999;48;759-775.
4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young
people to obtain cigarettes and do test sales by trading standards have
any effect? A survey of two schools in Gateshead. Child: Care, Health and
Development. 1998;24:2007-216.
5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can
non-prosecutory enforcement of public health legislation reduce smoking
among high school students? Aust N Z J Public Health. 1998;22:332-335.
6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The
effect of enforcing tobacco sales laws on youth's access to tobacco and
smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51.
7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth
access laws at the community level. Tobacco Control. 1999;8:152-155.
8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal
sale of cigarettes to minors. JAMA. 1989;261:80-83.
9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of
an educational program to reduce dales of cigarettes to minors. American
Journal of Public Health. 1991;81:891-893.
10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can
non-prosecutory enforcement of public health legislation reduce smoking
among high school students? Aust N Z J Public Health. 1998;22:332-335.
11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to
illegal tobacco sales to young people in Ontario. Tobacco Control
1999;8:301-305.
12. Teall AM, Graham MC. Youth access to tobacco in two communities.
Journal of Nursing Scholarship. 2001;33:175-178.
13. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement
of minimum purchase age laws for tobacco. J Public Health Management
Practice. 2000.6:107-114.
14. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws
on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342.
15. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early
impact of the Synar Amendment on youth smoking. Working paper: Department
of Economics, University of Illinois at Chicago; 1998.
16. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public
Health. 1996;86:221-4.
Firstly, congratulations to Hastings & MacFadyen on highlighting
the issues inherent in attempting to ‘negatively emote’ people into doing
what we’d like them to do. I use the term ‘negatively emote’ to take into
account the following journal article by Biener & Taylor [T C
11(1):75] - their point being that fear is not the only emotion involved.
There are admittedly many attempts at ‘pushing’ people through the...
Firstly, congratulations to Hastings & MacFadyen on highlighting
the issues inherent in attempting to ‘negatively emote’ people into doing
what we’d like them to do. I use the term ‘negatively emote’ to take into
account the following journal article by Biener & Taylor [T C
11(1):75] - their point being that fear is not the only emotion involved.
There are admittedly many attempts at ‘pushing’ people through the Stages
of Change (Prochaska & DiClemente) by means of perceptual triggers
generating feelings of loss; sadness; guilt etc. This at first glance
seems a viable approach – after all it works with some and we’re doing it
for their own good! However, in my experience, life changes tend to be
permanent most often when people experience acceptable emotional states
during their progression through the stages.
If a person enters the contemplation stage in high negative arousal
(e.g. fear) there are two possible avenues of ‘escape’. The first avenue
is to move on to the next stage - Planning (and then hopefully to
Action). This happens more easily with ‘self-actuated’ individuals who
have enough knowledge to know what to do and then enough confidence to
implement that knowledge. What defines ‘self-actuated’ people is that fear
or other negative emotions only remain transiently to be replaced by a
resolve to avoid negative consequences by focusing on a set of positive
outcomes with the associated positive emotions that they trigger. With
this group ‘scare tactics’ may have a high chance of long-term success.
The first avenue is also often taken by less self-actuated individuals who
are pushed into moving on by their anxiety, fear or even panic. Yet their
negative emotions are not dissipated in the same way as in the latter
group. Smoking cessation advisers and health promotion message designers
should aim to reduce negative emotions in the latter group of people, not
enhance them.
The second avenue is the one taken by those who feel unable to move
on and involves one of two strategies – fight against the truth or
personal relevance of the emotive tactic or withdraw by pushing the
emotive information to the far reaches of their mind (often having a
cigarette alongside the process in order to reduce the stress of it all!).
This of course is the pathway to the precontemplation stage
There are serious consequences relevant to the less self-actuated in
either avenue. Those who move to stopping do so in an anxious state thus
making the experience of not smoking a difficult one. Further, if they
experience a lapse (highly probable) they fall back to a contemplation
state that was originally anxious and now is doubly so – this often
precludes another attempt at taking action. And those who avoided the
issue by withdrawing attention or downplaying it? They have had a life
strategy re-affirmed with perhaps underlying feelings of inadequacy. Thus,
emotive tactics can in the end reinforce, in those groups, a perception
that making significant life changes is beyond their reach. The relevance
of this to current government targeting of certain populations of smokers
is significant to say the least.
Even the language of smoking cessation kicks the less self-actuated
when they are already down. The logic and associated emotions are clear:
1. Smoking always has a value in a smoker’s life (stress relief;
pleasure; social acceptance etc). Emotionally a cigarette is often
referred to as ‘my one and only – friend – standby – vice etc’
2. The exhortations: quit it; cut it out; give it up; etc carry the
message ‘remove this valuable thing from your life’. Emotionally, such
messages push the listener into a state of deprivation with its associated
response – ‘how can I live without my – friend – standby – vice?’
3. When any human gets to feeling deprived enough, intelligence switches
off and ‘fight or flight’ switches on. This is the moment the less self-
actuated withdraw or the action takers lapse and smoke unthinkingly – but
oh the relief from that deprived state!
4. Of course, once out of that state, the rational mind re-appears with
the concomitant regret; guilt; anger; frustration – some will be back in
contemplation in an emotionally aroused state ready to fall into making
the journey again. This is the classic vicious circle.
Biener & Taylor’s conclusion that people haven’t tired of
repeated emotive messages because they report that the messages don’t
exaggerate the dangers of smoking seems lacking in logic. I can assert
that a TV ad does not exaggerate Mr Dunky’s claim to kitchen cleaning
power. But I can do without seeing it now because the product brought me
out in a rash. Just being true doesn’t make an assertion motivating or
useful!
So what is the solution to giving health messages such that we avoid
the vicious circle outlined above. It seems clear that to avoid relapse
one would have to ensure that a smoker felt comfortable in actuating each
step of their journey. Ideally, for that to happen, smokers must either
choose each step or be given advice they are comfortable in going along
with. This would be a learning experience with the person acquiring self-
actualisation skills. Other approaches can lead to people becoming
reliant on external forces to fuel movement or to keep their life stable.
An external force focus in smoking cessation can lead to the often heard –
‘I can’t stop, can’t you give me something’; ‘how can I survive without
the stop smoking group’; ‘how will I cope when my NRT ends’ etc. Even the
focus on the power of nicotine as an addictive substance undermines self-
actualisation – ‘how can I do anything, they say nicotine’s as addictive
as heroin’; ‘I’ve always smoked, it’s got me well and truly hooked’ etc
As a smoking cessation adviser and a communications trainer I see my
role as one of facilitating people in choosing to do for themselves that
which will enhance their lives in important ways. As part of this I make
it clear that the manner in which a smoker thinks about things will either
help or hinder. To illustrate this point I use an analogy: imagine you buy
a new TV set for £200. Would you sit in front of it thinking ‘I’ve lost
£200 and it’s not coming back!’ or would you accept that you chose it,
it’s new, it takes learning to live with it. Of course, both points of
view are a true reflection. But the former way of thinking guarantees a
miserable experience watching TV. The latter way of thinking seems more
appropriate if the decision to spend your money was based on some good
reasoning about what you wanted in your life. After relating this analogy,
if someone becomes pessimistic at any stage, I say – ‘you’re in minus £200
mode! Remind yourself why you’re choosing to do this.’
Negatively emoting messages can point out what is life depriving
about smoking (or any health promotion issue) – that’s OK. But the aim is
to have the smoker act, and this is where the less self-actuated need
different messages that leave them in emotionally comfortable states
conducive to moving to the next stage of change. The focus needs to be on
the design of such messages for a wide audience. For example, with
smokers I refrain from setting a ‘quit day’ – but suggest a ‘freedom day’.
The former provokes emotional deprivation, the latter, a self-actuated
choice to do something of personal benefit.
Fichtenberg and Glantz have responded separately to the technical
issues that DiFranza raised about their paper.
Both Tutt and DiFranza are missing the larger point of our editorial.
Unlike public health forces, the tobacco industry has unlimited resources
to push their agenda. We made the point that in a real world of limited
public health resources, those resources are better concentrated where
they have been...
Fichtenberg and Glantz have responded separately to the technical
issues that DiFranza raised about their paper.
Both Tutt and DiFranza are missing the larger point of our editorial.
Unlike public health forces, the tobacco industry has unlimited resources
to push their agenda. We made the point that in a real world of limited
public health resources, those resources are better concentrated where
they have been shown to be most effective. Youth access is clearly not
that area. Tobacco industry documents show that the industry has run
rings around public health forces when it comes to youth access,
successfully co-opting it to the point that it now serves the industry's
purposes.
Notwithstanding evidence on the impact of advertising in sport, the
powers that be in F1 have little interest in seeing tobacco sponsorship
curtailed anytime in the near future.
Bernie Ecclestone, the man most responsible for F1's recent dramatic
growth is on record as saying a ban on tobacco advertising isn't needed as
it would have a negligible impact on the smoking habits of its millions of
viewers.
Notwithstanding evidence on the impact of advertising in sport, the
powers that be in F1 have little interest in seeing tobacco sponsorship
curtailed anytime in the near future.
Bernie Ecclestone, the man most responsible for F1's recent dramatic
growth is on record as saying a ban on tobacco advertising isn't needed as
it would have a negligible impact on the smoking habits of its millions of
viewers.
'If tobacco was killing people it was doing so a long time ago. There
has been no evidence, ever, that people who watch [F1] smoke. No one has
ever proved that to me. Kids smoke because they think it's the right thing
to do. It's more likely they do so because their parents or the people who
surround them smoke. All the tobacco commercial says is, "If you are
smoking, smoke our brand". It doesn't say "Smoke!"'
(http://www.observer.co.uk/osm/story/0,6903,708327,00.html )
Since DiFranza's criticism of the editorial by Ling et al.(1)
concentrates mostly on criticism of the paper by Fichtenberg and Glantz,
published in Pediatrics,(2) we are writing to respond to these criticisms
separately. We recognize that this is unusual, since the standard
procedure would have been for DiFranza to write Pediatrics after the paper
was published there. DiFranza, however, chose to write Tobacco Control
(b...
Since DiFranza's criticism of the editorial by Ling et al.(1)
concentrates mostly on criticism of the paper by Fichtenberg and Glantz,
published in Pediatrics,(2) we are writing to respond to these criticisms
separately. We recognize that this is unusual, since the standard
procedure would have been for DiFranza to write Pediatrics after the paper
was published there. DiFranza, however, chose to write Tobacco Control
(based on a preprint we provided him as a courtesy), so we are responding
here.
The premise of youth access programs is that if merchant compliance
reaches a high enough level, it will reduce youth access to cigarettes
and, therefore, youth smoking. The goal of the first part of our analysis
was to see if, based on the available literature, there was a relationship
between merchant compliance and youth smoking. Whether or not the laws
were being enforced at the time and if so, in what manner, is irrelevant
to this analysis. If youth access programs work because high merchant
compliance leads to lower smoking, there should be an association between
high merchant compliance rates and low youth smoking rates, regardless of
what led to those rates of compliance. If an intervention designed to
increase merchant compliance was successful, we should see high compliance
rates and low smoking. If the intervention was not successful, because
they did not include enforcement as DiFranza suggests, there we should see
low compliance and low smoking. (Whether there is prosecution of
merchants or not (3) is irrelevant to testing whether making it difficult
for teens to purchase cigarettes affects teen smoking prevalence.) Both of
these cases would contribute to our test of the hypothesis that increased
merchant compliance was associated with reduced smoking. The data to not
exhibit such an association (Figure 1a of Fichtenberg and Glantz(2)).
All youth access program measure merchant compliance through
undercover sales attempts by underage youth as was done in the Bagott(4)
study. If merchant compliance measured in this was is not an accurate
reflection of youth access, then none of the studies of youth access that
base their effectiveness on merchant compliance are valid. The goal of
our analysis was not to determine if compliance is a good measure of youth
access but rather to relate the most commonly used metric for measuring
the effectiveness of youth access programs, namely merchant compliance,
and to youth smoking rates.
DiFranza says that we should not include studies from England because
the legal age to purchase cigarettes is 16. We see no reason why youths
aged 14-15 would not be affected by laws limiting purchase of cigarettes
to those 16 and older.
DiFranza objects to including data from Australia, because 46% of the
students lived outside the enforcement area.(10) As discussed above,
whether or not active enforcement was involved is irrelevant to our
analysis of the association between merchant compliance with youth access
laws and youth smoking prevalence. All that is important is that
compliance and smoking was assessed in the same community. In this case
the authors point out that for the follow-up survey, 46% of students in
the intervention community – which was defined based on school location –
did not live in the intervention area. They conclude that this would be a
problem if these children bought cigarettes closer to home rather than to
school. Since there was no residence information from the baseline survey
it was not possible to limit the analysis to student living in the
intervention area. Nevertheless, we chose to include the study in our
analysis despite this limitation. It is important to note that the
results of this study were consistent with the others.
There is no problem with combining studies of different design in a
quantitative meta-analysis as long as all studies are measuring the same
endpoint. (11,12) As was reported in the methods section of our paper,
the quantitative meta-analysis only included controlled studies.
DiFranza objects to combining studies because the ages of the youths, and
the methods used to test compliance, differed. (14) While we agree that
factors such as age and gender of the youths may impact measured merchant
compliance, we did not expect this variability to mask the effect of youth
access programs, if they actually affected youth smoking rates. The small
number, 5, of controlled studies of youth access programs which reported
youth smoking made it impossible to stratify according to the age of the
youths used in the compliance checks.
DiFranza objected to our evaluation of the change in youth smoking
prevalence as a function of change in merchant compliance on the grounds
that it is necessary to obtain compliance rates above 90% to have an
effect on youth smoking prevalence. (15) In addition to the fact that the
data shows no empirical evidence to support the hypothesis of such a
threshold (Figure 1A in Fichtenberg and Glantz (2), reproduced as Figure 1
in Ling, et. al(1)), our basic premise is that if youth access programs
actually reduced youth smoking, higher compliance rates would be
associated with lower youth smoking rates. We examined this hypothesis in
three ways. First we compared compliance and smoking rates in all
communities for which both variables were measured at the same time.
Since this is an ecological analysis which does not take into account
trends over time, we then examined the relationship between changes in
compliance and changes in smoking in case what mattered was whether there
was a reduction in sales to youth rather than the absolute level of
compliance at one time (Figure 1B in Fichtenberg and Glantz (2)) The data
presented in Figure 1A demonstrate that there is no threshold of
effectiveness at 90% compliance. Smoking rates for communities with
compliance above 90% vary between 19.4%and 32.5%, with a mean of 25.9%.
In communities with compliance rates below 90%, smoking rates vary between
15.6% and 37.7% with a mean of 25.7%. There is no evidence of a threshold
of effectiveness.
DiFranza suggested that we control for a wide variety of
socioeconomic and demographic factors. Because "When this type of analysis
has been performed on a community and state level of analysis, reductions
in youth smoking have been observed. (16,17)" Given the small number of
studies available, it was not possible to explore the effects of potential
confounders such as other tobacco control policies, price of cigarettes,
socio-economic status. Nonetheless, in our discussion we report the
results of population based studies, including but not limited to, those
referred to by DiFranza. Chaloupka and Pacula (17) in the study cited by
DiFranza do indeed find that statewide enactment and enforcement of youth
access laws associated with reduced youth smoking. However in another
analysis (18), the same authors found that this effect was restricted to
black teens. The study by Siegel et al. (16) does indeed find that the
presence of youth access laws was associated with decreased smoking
initiation rates, however they conclude that this decrease was not
mediated by decreased access because youths reported no decreased in
perceived access.
In the first part of our analysis (Figure 1A), we compared compliance
and smoking in all communities for which there was information. Since we
were not trying to assess the effects of interventions but rather to see
if there is a relationship between compliance and smoking, we did not make
a distinction between control and intervention communities, or between
baseline and follow-up data. As DiFranza points out, this type of analysis
does not take into account temporal trends or other potential confounders.
In order to take these into account we performed a quantitative meta-
analysis using only controlled studies (n=5). This analysis yielded a
pooled effect of a 1.5% decrease in youth prevalence (95%CI: 6% decrease
to 3% increase).
Tutt cited a paper by his group (20) that was not included in our
meta-analysis because it was not listed in Medline or cited in any of the
other papers we located. Adding his results to those we report, however,
does not affect the conclusions of our analysis. The correlation between
merchant compliance and 30 day teen smoking prevalence including these
data is .042 (P=.799) compared with .116 (P=.486) reported in Figure 1A of
our paper. (2) Likewise the correlation between change in merchant
compliance and change in youth smoking is -.163 (P=.504) compared with
.294 (P=.237) without it. Thus, including Tutt, et. al's data actually
strengthens the conclusions in our paper.
It is time for enthusiasts for youth access interventions to
recognize that while these interventions may have seemed like a good idea,
they do not achieve their primary goal of reducing youth smoking. All
that happens is that youth obtain their cigarettes from other sources.(21)
Caroline Fichtenberg, MS, Department of Edidemiology, Johns Hopkins
School of Public Health, Baltimore, MD
Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education,
University of California, San Francisco
References:
1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access
tobacco programmes. Tobacco Control 2002;11:3-6.
2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect
youth smoking. Pediatrics (In press).
3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between
tobacco access and use among adolescents: A four community study. Soc.
Sci. Med. 1999;48;759-775.
4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young people
to obtain cigarettes and do test sales by trading standards have any
effect? A survey of two schools in Gateshead. Child: Care, Health and
Development 1998;24:2007-216.
5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can
non-prosecutory enforcement of public health legislation reduce smoking
among high school students? Aust N Z J Public Health 1998;22:332-335.
6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The
effect of enforcing tobacco sales laws on youth's access to tobacco and
smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51.
7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access
laws at the community level. Tobacco Control 1999;8:152-155.
8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal
sale of cigarettes to minors. JAMA 1989;261:80-83.
9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an
educational program to reduce dales of cigarettes to minors. American
Journal of Public Health 1991;81:891-893.
10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can
non-prosecutory enforcement of public health legislation reduce smoking
among high school students? Aust N Z J Public Health 1998;22:332-335.
11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to
illegal tobacco sales to young people in Ontario. Tobacco Control
1999;8:301-305.
12. Pettiti D. Meta-Analysis, Decision Analysis, and Cost Effectiveness
Analysis. 2nd ed. New York, NY: Oxford University Press; 2000.
13. Stroup DF, Berlin JA, Morton SC. Meta-analysis of observational
studies in epidemiology. JAMA 2000;283:2008-2012.
14. Teall AM, Graham MC. Youth access to tobacco in two communities.
Journal of Nursing Scholarship 2001;33:175-178.
15. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement
of minimum purchase age laws for tobacco. J Public Health Management
Practice 2000.6:107-114.
16. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws
on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342.
17. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early
impact of the Synar Amendment on youth smoking. Working paper: Department
of Economics, University of Illinois at Chicago; 1998.
18. Chaloupka F, Pacula R. Sex and race differences in young people’s
responsiveness to price and tobacco control policies. Tobacco Control
1999;8:373-77.
19. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public
Health. 1996;86:221-4.
20. Tutt D, Bauer L, Edwards C, Cook D. Reducing adolescent smoking
rates: Maintaining high retail compliance results in substantial
improvements. Health Promotion Journal of Australia 2000;10:20-24.
21. Jones SE, Sharp DJ, Husten CG, et al. Cigarette acquisition and proof
of age among U.S. high school students who smoke. Tobacco Control
2002;11:20–5.
We have found a small error in the Methods section of our paper, “Exposure of hospitality workers to environmental tobacco smoke”, recently published in Tobacco Control (2002; 11:125-9). The reference in the third paragraph, under the chemical analysis subheading should have referred to a 1/X2 (X-squared) weighting, not a 1/÷2 (chi-squared) weighting, as published. X was the concentration of cotinine in saliva samples.
Our ap...
We have found a small error in the Methods section of our paper, “Exposure of hospitality workers to environmental tobacco smoke”, recently published in Tobacco Control (2002; 11:125-9). The reference in the third paragraph, under the chemical analysis subheading should have referred to a 1/X2 (X-squared) weighting, not a 1/÷2 (chi-squared) weighting, as published. X was the concentration of cotinine in saliva samples.
Our apologies for any confusion this has caused.
Upon reading the paper by Biener (Tobacco Control, June 2002), I
couldn't help but be struck by the similarity between the reported effects
of the Philip Morris anti-smoking campaign and the fictional campaign in
Christopher Buckley's (1994) satirical novel "Thank You for Smoking."
In the fictional version, Nick Naylor, chief spokesperson for the
Academy of Tobacco Studies (a.k.a. the tobacco industry), announces...
Upon reading the paper by Biener (Tobacco Control, June 2002), I
couldn't help but be struck by the similarity between the reported effects
of the Philip Morris anti-smoking campaign and the fictional campaign in
Christopher Buckley's (1994) satirical novel "Thank You for Smoking."
In the fictional version, Nick Naylor, chief spokesperson for the
Academy of Tobacco Studies (a.k.a. the tobacco industry), announces a $5
million industry-funded campaign designed to keep underage kids from
smoking. The advertising creatives, despite being a little concerned at
being asked to produce "an ineffective message that will have no impact on
the people it is targeted at," come up with a new campaign titled
"Everything Your Parents Told You About Smoking Is Right." The great
strength of the campaign in Naylor's view is that "It is dull." In the
agency's words "Kids are going to look at this and go, 'Puuke'."
In the factual version, Philip Morris spends a large amount of money
developing and running a campaign titled "Think, Don't Smoke," which
"featured an off camera adult asking teenagers…whether or not they smoked.
The teens interviewed were all non-smokers who answered the interviewer by
saying that they didn't need to smoke to be cool" (Biener, p.44). Not
surprisingly, the study found that the Philip Morris ads are rated by the
target audience (underage kids) as less effective than any of the other
anti-smoking ads they recalled seeing.
You may wonder why it is that a company like Philip Morris, with many
years of advertising experience, could develop such a spectacularly
ineffective ad campaign. This is the same Philip Morris who won first
place among Ad Age's Top 100 Ad Icons for the Marlboro Man: "The most
powerful - and in some quarters, most hated - brand image of the century,
the Marlboro Man stands worldwide as the ultimate American cowboy and
masculine trademark, helping establish Marlboro as the best-selling
cigarette in the world" (Ad Age, 2001).
You may wonder, indeed, unless you've read Buckley's book.
References:
Biener L. Anti-tobacco advertisements by Massachusetts and Philip Morris:
what teenagers think. Tobacco Control 2002;11(2):44-47.
Advertising Age. The Advertising Century, 2001,
http://www.adage.com/century
Buckley, C. Thank You for Smoking, New York: Random House, 1994.
Bernie Ecclestone's strategy of continuing Formula 1's relationship
with tobacco sponsors at seemingly any cost
is raising the ire of motor racing purists.
As European bans on sponsorship become increasingly likely,
Ecclestone plans to move races from traditional circuits to countries that
have no foreseeable plans to ban tobacco sponsorship.
Rumour has it that among the courses to be axed from the F1...
Bernie Ecclestone's strategy of continuing Formula 1's relationship
with tobacco sponsors at seemingly any cost
is raising the ire of motor racing purists.
As European bans on sponsorship become increasingly likely,
Ecclestone plans to move races from traditional circuits to countries that
have no foreseeable plans to ban tobacco sponsorship.
Rumour has it that among the courses to be axed from the F1 schedule
is the venerable Spa-Francorchamps in Belgium. Wriitng in the Guardian (26
August, 2002), Richard Williams assesses the history of the track and the
reasons for its apparent imminent loss of F1 status.
"Incredibly" he says, "Spa is said to be high on Bernie Ecclestone's
hit-list of circuits that may lose their formula one race in order to
accomodate newcomers to the calendar."
That Spa's loss has less to do with it's inherent quailites than
tobacco sponsorship appears obvious, "Should the worst happen, the
immediate beneficiary is likely to be China, the UAE, Bahrain or Turkey.
Ecclestone's desire to spread formula one to new markets - and preferably
markets with no immediate plans to ban tobacco advertising- admits to no
sentiment or even to a sense of history."
Dear Mr Meyers,
Thank you for your article about the name change of Philip Morris. It is
appropriate that PM should wish to become invisible. In fact, they are
simply backward, so I shall reverse their new name to airtla, meaning
Aberrant Industry in Regular Touch with Legal Attorneys. I hope they
shall hence forward remain named with this backward sign of wrong doing.
Branding, after all, is one of their specialties...
Dear Mr Meyers,
Thank you for your article about the name change of Philip Morris. It is
appropriate that PM should wish to become invisible. In fact, they are
simply backward, so I shall reverse their new name to airtla, meaning
Aberrant Industry in Regular Touch with Legal Attorneys. I hope they
shall hence forward remain named with this backward sign of wrong doing.
Branding, after all, is one of their specialties that we too should
appreciate.
Stephen Hamann
Tobacco Control Policy Research Network
Bangkok, Thailand
Efforts at requiring fire safe cigarettes have been underway for
years, lead by the late Representative Moakley of Massachusetts. Tobacco
industry opposition has always stopped progress. Now that Senator Helms
has retired, Philip Morris has publicly voiced its intent not to oppose
such efforts, and the tobacco industry's public image is lower than ever,
it is time to try again.
Efforts at requiring fire safe cigarettes have been underway for
years, lead by the late Representative Moakley of Massachusetts. Tobacco
industry opposition has always stopped progress. Now that Senator Helms
has retired, Philip Morris has publicly voiced its intent not to oppose
such efforts, and the tobacco industry's public image is lower than ever,
it is time to try again.
New York has passed a fire safe cigarette law, only to have it
attacked and possibly weakened after the fact. On a parallel track, let's
sue the tobacco companies, to force action. Is there anyone pursuing a
class action, or individual lawsuits, against Philip Morris, for over 20
years of 1000 U.S. deaths a year, since PM has known how to make an
acceptable fire safe cigarette in 1982?
May 8, 2002 To the editor,
In their editorial “It is time to abandon youth access tobacco programmes,” Ling, Landman and Glantz1 base their argument on an in press meta-analysis of youth access interventions by Fichtenberg and Glantz.2 These authors conclude that there is no proof that youth access interventions work to reduce youth smoking rates. Sadly, this analysis includes ten methodological flaws, each o...
Firstly, congratulations to Hastings & MacFadyen on highlighting the issues inherent in attempting to ‘negatively emote’ people into doing what we’d like them to do. I use the term ‘negatively emote’ to take into account the following journal article by Biener & Taylor [T C 11(1):75] - their point being that fear is not the only emotion involved. There are admittedly many attempts at ‘pushing’ people through the...
Fichtenberg and Glantz have responded separately to the technical issues that DiFranza raised about their paper.
Both Tutt and DiFranza are missing the larger point of our editorial. Unlike public health forces, the tobacco industry has unlimited resources to push their agenda. We made the point that in a real world of limited public health resources, those resources are better concentrated where they have been...
Notwithstanding evidence on the impact of advertising in sport, the powers that be in F1 have little interest in seeing tobacco sponsorship curtailed anytime in the near future.
Bernie Ecclestone, the man most responsible for F1's recent dramatic growth is on record as saying a ban on tobacco advertising isn't needed as it would have a negligible impact on the smoking habits of its millions of viewers.
...
Since DiFranza's criticism of the editorial by Ling et al.(1) concentrates mostly on criticism of the paper by Fichtenberg and Glantz, published in Pediatrics,(2) we are writing to respond to these criticisms separately. We recognize that this is unusual, since the standard procedure would have been for DiFranza to write Pediatrics after the paper was published there. DiFranza, however, chose to write Tobacco Control (b...
Upon reading the paper by Biener (Tobacco Control, June 2002), I couldn't help but be struck by the similarity between the reported effects of the Philip Morris anti-smoking campaign and the fictional campaign in Christopher Buckley's (1994) satirical novel "Thank You for Smoking."
In the fictional version, Nick Naylor, chief spokesperson for the Academy of Tobacco Studies (a.k.a. the tobacco industry), announces...
Bernie Ecclestone's strategy of continuing Formula 1's relationship with tobacco sponsors at seemingly any cost is raising the ire of motor racing purists.
As European bans on sponsorship become increasingly likely, Ecclestone plans to move races from traditional circuits to countries that have no foreseeable plans to ban tobacco sponsorship.
Rumour has it that among the courses to be axed from the F1...
Dear Mr Meyers, Thank you for your article about the name change of Philip Morris. It is appropriate that PM should wish to become invisible. In fact, they are simply backward, so I shall reverse their new name to airtla, meaning Aberrant Industry in Regular Touch with Legal Attorneys. I hope they shall hence forward remain named with this backward sign of wrong doing. Branding, after all, is one of their specialties...
Efforts at requiring fire safe cigarettes have been underway for years, lead by the late Representative Moakley of Massachusetts. Tobacco industry opposition has always stopped progress. Now that Senator Helms has retired, Philip Morris has publicly voiced its intent not to oppose such efforts, and the tobacco industry's public image is lower than ever, it is time to try again.
New York has passed a fire safe...
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