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.
I thank you for this editorial letter. For me it makes sense to still
expose the criminal acts of the tobacco industry. Our use of metaphors
and symbols should be contextualized on how message are to be sent. Thus
one message may be distateful to another, while to others it will not be
the case.
The article is well written and it gives me more spirit to move on and
expose the dangers of tobacco use.
thank you for this great information YOU gave me an A on my report
about smoking and banning smoking thank you so much!!!!!
PeterDubitsky
25 April, 2002
It was with great interest that I read your article regarding the
effectiveness of acupuncture on smoking cessation. I have been practing
acupuncture for eleven years and have found that acupuncture will not
alleviate anyone's desire to smoke. Not one method available will. The
smoker must have a determination and desire to quit, or they will fail to
stop smoking regardless of the type of treatment utilized.
It was with great interest that I read your article regarding the
effectiveness of acupuncture on smoking cessation. I have been practing
acupuncture for eleven years and have found that acupuncture will not
alleviate anyone's desire to smoke. Not one method available will. The
smoker must have a determination and desire to quit, or they will fail to
stop smoking regardless of the type of treatment utilized.
The proper use of acupuncture is in the treatment of the withdrawal
syndrome. I request that my patients have their last cigarette twelve
hours prior to the office visit, so that they are in withdrawal. If they
have not been compliant, we reschedule the appointment to a later date.
I use a combination of auricular and body acupuncture points, and
have found that most of my patients are able to get through the withdrawal
period and thus "quit" smoking. The difference in affect in the patient
before and after treatment is strong evidence of the effect of the
acupuncture treatment. Acupuncture is administered on the intial visit and
again two days later with a follow-up one week from the initial visit.
The behavioral aspect of the habit is not addressed with acupuncture,
and some individuals will certainly return to their habit, often as a
method of coping with some difficult or stressful life circumstance.
Very much enjoyed this article. Was hoping to learn whether
product placement tactics were used in "early" films (pre-1950), because
in viewing films from the 30's and 40's, I find it almost impossible to
find a scene without smoking.
Any thoughts appreciated.
Thanks,
James Rowland
Douglas C.Tutt
19 March, 2002
I disagree totally with Stan Glantz and his view that we abandon
youth access efforts.
As usual in every argument there is truth on both sides. He is right
in being concerned that this can be an easy way for tobacco companies to
look good and that teens will attempt to substitute other social sources.
But one of the main sources of such secondary supply is other minors
purchasing and then selling on the 'black...
I disagree totally with Stan Glantz and his view that we abandon
youth access efforts.
As usual in every argument there is truth on both sides. He is right
in being concerned that this can be an easy way for tobacco companies to
look good and that teens will attempt to substitute other social sources.
But one of the main sources of such secondary supply is other minors
purchasing and then selling on the 'blackmarket', and our experience has
been that making the primary source more difficult has led to a doubling
of the playground price - a good price deterrent.
However, he is wrong in applying his objections equally in all
jurisdictions. Would he seriously suggest that I abandon a local level
intervention that has been shown to work so well, reducing smoking among
teenagers on the Central Coast of New South Wales by a third over six
years (1)? There is no mention in the editorial of that work.
Why can't we have "smoke free workplaces and homes" (Australia has
got legislation and campaigns), "taxes" (we've got far higher taxes than
the U.S.), "media campaigns "(we've got those) and "secondhand smoke
messages" (we've got those) PLUS youth access PLUS advertising and
promotion restrictions ( the U.S. still has a long way to go there) PLUS
good anti-litter laws PLUS Quit support PLUS whatever else will work?
Perhaps his conclusion should be that youth access doesn't work IF
you haven't got a comprehensive approach to tobacco control and it is
undermined by inaction on the enforcement aspects or by inaction on the
other strategic fronts. It's certainly not sufficient by itself, but as
I've shown here - it can be a very cheap way of creating non-smokers at
one tenth the cost of Nicotine Replacement Therapy(2).
Douglas Tutt
1)Tutt D, Bauer L, Edwards C,Cook D. Reducing adolescent smoking
rates. Maintaining high retail compliance results in substantial
impovemnts. Health Promotion Journal of Australia 2000:10(1)20-24
2)Tutt D. Enforcing prohibition of tobacco sales to minors :an update.
Proceedings of 13th Winter School in the Sun, Alcohol and Drug Foundation
- Queensland, Brisbane, Australia 2000.
For those trying to quit smokeless tobacco, there are some helpful
options. Of course, making up one's MIND is the most important thing. Many
states now have Tobacco Quitlines, that give phone-based help.
Washington's is 1-877-270-STOP, and can probably direct people to other
states' lines.
To handle the very high nicotine addiction of smokeless tobacco, it often
takes combining nicotine patches and nicotine gum. The pat...
For those trying to quit smokeless tobacco, there are some helpful
options. Of course, making up one's MIND is the most important thing. Many
states now have Tobacco Quitlines, that give phone-based help.
Washington's is 1-877-270-STOP, and can probably direct people to other
states' lines.
To handle the very high nicotine addiction of smokeless tobacco, it often
takes combining nicotine patches and nicotine gum. The patch gives 24 hour
nicotine slow absorption, while the gum (2 or 4 mg, regular, mint, or
orange flavor), gives the faster nicotine replacement. These do NOT quit
FOR the tobacco addict, but HELP taper the nicotine level without as much
withdrawal, DOUBLING the chance of successfully quitting. Check out
www.nstep.org, surgeongeneral.gov/tobacco, tobaccofreekids.org,
kickbutt.org, for more. Zyban/Wellbutrin (bupropion) is a non-nicotine,
non-addictive antidepressant that doubles success quitting tobacco, and
can be used with nicotine meds. Secondline meds include clonidine and
nortriptyline.
Check with your doctor for further information. Good luck!
Chris Covert-Bowlds, MD
Maybe the fact that I am writing to you indicates that I still
haven’t learned my lesson, but I thought I would give it a try.
In 1996, I met with a young reporter from the Baltimore Sun who
wanted to do an article on the resurgence of cigar sales in the U.S. I
told him, “Alec, the real story here is that the resurgence has taken
place in spite of the cigar...
Maybe the fact that I am writing to you indicates that I still
haven’t learned my lesson, but I thought I would give it a try.
In 1996, I met with a young reporter from the Baltimore Sun who
wanted to do an article on the resurgence of cigar sales in the U.S. I
told him, “Alec, the real story here is that the resurgence has taken
place in spite of the cigar industry. Faced with an unrelenting decline
in cigar sales, the Cigar Association of America embarked on a public
relations campaign in 1981 in which it tried to improve the image of the
cigar and the cigar smoker. In spite of our efforts – which resulted in
much positive publicity – cigar sales continued to plunge and so the
campaign was discontinued in 1988. Then, when cigar sales began to
increase in 1994 – six years after the our public relations campaign was
discontinued – it caught the industry completely by surprise. That is
the real story.”
And I gave him some examples of the types of programs we funded
during the 1980s because I was proud of their creativity and what we had
accomplished with limited funds. Two years later no one was more stunned
than I when Alec Klein’s series on our so-called stealth marketing
campaign appeared in the Baltimore Sun. On one hand it made us look like
marketing geniuses. But on the other hand, its distortions are now
embodied as gospel by the anti-tobacco movement.
The misperceptions are evident in the article “How the tobacco
industry built its relationship with Hollywood”.
But first, I want to address the FTC report cited in the article.
That report indicated that total advertising and promotional expenditures
for cigars increased 32% – from $30.9 million in 1996 to $41 million in
1997. This is only .6% of the more than $5 billion spent by the cigarette
industry. According to the FTC, 40% ($16.3 million) of cigar company
advertising and promotional expenditures in 1997 were for promotional
allowances – that is, discounts and other incentives given to retailers –
and 24% ($10 million) was for magazine advertising in publications such as
Cigar Aficionado and Smoke magazines.
Point of sale advertising amounted to $5.2 million. But only
$339,000 was reportedly spent on celebrity endorsements and appearances,
and payments for product placements in movies and television.
Of course, it is much more dramatic to indicate that these latter
expenditures “more than doubled”. But how unfair not to have mentioned
how small the base was in the first place.
We are flattered by the description of our public relations campaign
as having been well thought out. The fact is, it was a shoe string
operation whose expenditures between 1981 and 1987 averaged only about
$350,000 a year. It was hardly the “massive public relations campaign”
which the article described it as being. And it pails in comparison to
the millions spent annually by others, such as the coffee and milk
industries, which also were experiencing significant sales declines during
that period.
And there is no truth in the claim that the majority of role models
were to be Hollywood personalities and that paid product placement would
be used to help with the casting. Very few companies used product
placement. In fact, it was much more common for studios to call our
members for free product much like the requests we receive to contribute
product for silent auctions to raise money for charitable events. And when
Alec said that product was placed in the movie “Independence Day”’ he was
flat out wrong.
The cigar industry does not use product placement in the
entertainment industry. Although there may be isolated instances, it is
wrong to tar an industry on the basis of activities by a few companies.
Furthermore, the article seems to blur the fact that the Cigar
Association of America and Cigar Aficionado magazine are separate
entities. And while there is no denying that the magazine helped promote
the interest in cigars, its emphasis was almost exclusively on the
premium, hand-made segment which makes up less than 6% of cigars sold
currently.
Years of fighting the cigarette industry have predisposed many in the
anti-tobacco movement to conspiracy theories. But the cigar industry is
not the cigarette industry. Unfortunately articles such as yours and Mr.
Klein’s continue to serve to blur the distinctions between these two very
different products.
There was nothing “stealthy” about our public relations campaign in
the 1980s. Our activities were those used by a number of industries. Of
course we now realize that such activities are acceptable when used by
other industries but not when they are used by a tobacco industry. We
have learned over the years that when it comes to tobacco, different
standards apply.
Alec Klein never mentioned that we discontinued our public relations
campaign in 1988, nor did he mention that during the eight years of that
campaign unit sales of large cigars declined 34% to 2.5 billion cigars.
Sales were not to reach bottom until 1993 at 2.1 billion units. (In 1964,
the peak year, nine billion were sold.)
But the fact remains that the resurgence of interest in cigars –
which has since run its course – took the cigar industry by surprise and
it happened in spite of the industry, not because of it.
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...
I thank you for this editorial letter. For me it makes sense to still expose the criminal acts of the tobacco industry. Our use of metaphors and symbols should be contextualized on how message are to be sent. Thus one message may be distateful to another, while to others it will not be the case. The article is well written and it gives me more spirit to move on and expose the dangers of tobacco use.
thank you for this great information YOU gave me an A on my report about smoking and banning smoking thank you so much!!!!!
It was with great interest that I read your article regarding the effectiveness of acupuncture on smoking cessation. I have been practing acupuncture for eleven years and have found that acupuncture will not alleviate anyone's desire to smoke. Not one method available will. The smoker must have a determination and desire to quit, or they will fail to stop smoking regardless of the type of treatment utilized.
...
Very much enjoyed this article. Was hoping to learn whether product placement tactics were used in "early" films (pre-1950), because in viewing films from the 30's and 40's, I find it almost impossible to find a scene without smoking. Any thoughts appreciated. Thanks, James Rowland
I disagree totally with Stan Glantz and his view that we abandon youth access efforts.
As usual in every argument there is truth on both sides. He is right in being concerned that this can be an easy way for tobacco companies to look good and that teens will attempt to substitute other social sources. But one of the main sources of such secondary supply is other minors purchasing and then selling on the 'black...
Is it at all possible to recieve, give me direction, on how to obtain a copy of the article which is reference one?
Thankyou in advance for your time and assistance, Julie
For those trying to quit smokeless tobacco, there are some helpful options. Of course, making up one's MIND is the most important thing. Many states now have Tobacco Quitlines, that give phone-based help. Washington's is 1-877-270-STOP, and can probably direct people to other states' lines. To handle the very high nicotine addiction of smokeless tobacco, it often takes combining nicotine patches and nicotine gum. The pat...
I have been using moist snuff for 16 years(kodiak).One can a day and have not had any health promblems or dental.
March 14, 2002
To the Editor:
Maybe the fact that I am writing to you indicates that I still haven’t learned my lesson, but I thought I would give it a try.
In 1996, I met with a young reporter from the Baltimore Sun who wanted to do an article on the resurgence of cigar sales in the U.S. I told him, “Alec, the real story here is that the resurgence has taken place in spite of the cigar...
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