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This provocative book is a critique of the anti-tobacco campaign in the USA in the 1990s. At the beginning of the decade, Males writes, the industry was in retreat. After several years of dealing with C Everett Koop, the most effective surgeon general in history, the industry was faced with the prospect of a smoke free society by the year 2000. In 1990, according to Males, smoking rates among adults and young people were declining. But by decade's end, available data showed that adult prevalence had not changed much since 1990. Prevalence in adolescents, at least as measured by school surveys, was higher in 1997 than in 1992. Further, in 1998 the industry had negotiated a settlement that was, quoting Stan Glantz, “one of the biggest con jobs in the history of the world” (page 2). Worse yet, Males' laments, the drives to decrease the social acceptability of smoking and provide increasingly more smoke-free indoor environments that highlighted the Koop era were replaced by efforts to reduce the initiation of smoking by young people.
Males writes that the industry's role in the turnaround of its fortunes was “merely opportunistic,” and instead blames two forces for the unfavourable developments of the 1990s. He first chides the Clinton administration for backing off strategies to raise taxes on tobacco products and promote smoke-free policies in favour of “poll-driven, pop-culture irrelevancies aimed at boosting their popular standing by blaming children and their supposed vulnerability to industry flimflam” (page 3). He also suggests that health lobbies that focus on reducing adolescent tobacco use perpetuate the youth only focus because they obtain funding from the settlement. Males argues that the second key factor contributing to the poor showing for tobacco control efforts in the 1990s was the presence of a high risk group of adolescents whose parents had abused heroin, cocaine, and alcohol. He reasons that these young people were choosing “lighter use of softer drugs such as beer, marijuana, and tobacco in reaction against the debilitation of the adults around them” (page 4).
I found this book to contain several insightful observations. Most in the tobacco control movement would agree with Males that the youth only focus is too limited, that President Clinton's cigar smoking set a poor example, and that politicians who kept saying that “kids shouldn't smoke because smoking is for adults” likely provided young people with incentive to smoke and adult smokers with reasons to continue. Such messages were probably equal in worth to millions of dollars of tobacco advertising. Males also does a fine job of outlining the points of victory attained by the industry. Additionally, his concerns about policies that blame and punish teenagers are noteworthy. Finally, Males' call for parents to set a better example by not smoking and his suggestion that the quality of the parent–child relationship plays a role are right on target.
However, this book misinterprets several key phenomena. It is overly simplistic in its description of trends from the Monitoring the Future surveys. Males' reliance on data from the National Household Survey on Drug Abuse ignores the methodological concerns raised about the lack of respondent privacy afforded by the interview method. Males' argument that marketing does not contribute to teen smoking is fraught with error. For example, he describes how increased marketing expenditures during the 1970s and 1980s were associated with decreased smoking rates among high school seniors. Males ignores the likely influence of other forces on smoking prevalence, such as concurrent increases in the real price of cigarettes. He also ignores the possibility that some of the additional advertising expenditures were not youth focused. The Camel campaign, with novel advertising and promotional strategies, was clearly youth focused and was associated with a sharp increase in smoking among young white males—the real target of Joe's attention.
The suggestion that the Clinton administration's actions on teenage smoking was a major cause for prevalence increasing is ludicrous. First, the surgeon general's report, Preventing tobacco use among young people, was released in February 1994. The major story on tobacco for that day was not the release of the report, but that many McDonald's restaurants were going smoke-free. Second, the proposed Food and Drug Administration (FDA) rule was not formally announced until August 1995. The rise in smoking among eighth, 10th, and 12th grade students began well before these events. I find it naive to think that the industry was minimally involved in the rise in teen smoking in the 1990s.
Males' discussion of minors' access restrictions are also off target. For example, he includes a brief description of the FDA regulations in a section entitled, “Criminalizing teen smoking,” when the FDA provisions penalise only the vendors. He frequently states that Montana has a reasonable approach to minors' access legislation and the lowest prevalence of tobacco use in the nation, when Youth Risk Behavior Survey data indicate that Montana does not have the lowest rate of cigarette smoking and has nearly the highest rate of smokeless tobacco use. Males' implies that Rigotti's data show an increase in smoking in the group that received the minors' access intervention, when the changes were not statistically significant. Additionally, he ignores the findings of Forster and others on the affects of minors' access on smoking prevalence. It is simply wrong to imply that minors' access legislation is iatrogenic, when studies to date are essentially equivocal.
Lastly, I found Males' discussions of harm reduction strategies for illicit drugs to be only weakly relevant, and his suggestion that smoking rates went up in the 1990s because of the presence of a group of high risk children of parents with drug problems to be, at most, a hypothesis in need of investigation. Monitoring the Future data do not support the emergence of a high risk group in the 1990s.
Despite the many analytic errors, Males closes the book with some important recommendations (for example, renewed emphasis on denormalising smoking and protecting people from environmental tobacco smoke). All in all, this book is probably worth a look, but please make it a very careful one.