PURPOSE OF THE STUDY

In 1996, the US Food and Drug Administration issued regulations designed to reduce the illegal sale of tobacco products to young people and to reduce the appeal of tobacco use by restricting the manner in which the tobacco industry markets its products.1 In his State of the Union address on 4 February 1997, President Clinton affirmed his administration’s resolve to ban the advertising and marketing of cigarettes to young people.2 These dramatic actions reflect the wide citizen concern about tobacco use in teenagers and the perceived actions of the tobacco industry to promote its products to children.3 4

Federal recognition and response are appropriate given the current situation. Teenage smoking rates in the United States have been rising over the past four years after a decade of relative stability; smoking rates for high school students rose from 27.5% in 1991 to 34.8 % in 1995.5

Given the high level of awareness about the dangers of tobacco, why are teenagers smoking in ever greater numbers? Many cite tobacco advertising as a major contributor to this increase.3 4The amount being spent by this industry in the United States has more than doubled in a 10-year period, rising to 4–6 billion dollars in recent years.6 As a result, young people see tobacco advertising messages everywhere: on billboards, in stores, in magazines, on clothing, and at community events.7These ubiquitous images and messages serve as symbolic social influences by conveying to young people that tobacco use is desirable, socially acceptable, safe, healthy, and prevalent in society.8

In an earlier study, we found a significant association between seventh graders’ (aged 12–13) perceived exposure to tobacco advertising and promotions and their experimentation with smoking. This raised the question of whether there might be a relationship between interest and desire for tobacco marketing materials and young people’s susceptibility to smoke—that is, would we find that children who are more receptive to tobacco marketing materials also are more susceptible to smoking?

The goal of the current study is to assess the effect of the tobacco industry’s marketing practices on young adolescents by examining the relationship between young people’s receptivity to tobacco marketing strategies and their susceptibility to smoke, while controlling for particular demographics and the social influences of peers and parents who smoke. In this section, we present the framework for the study by reviewing the marketing strategies used to promote cigarettes, teenagers’ receptivity to these strategies, and its relationship to their smoking susceptibility.

MARKETING OF CIGARETTES

Marketing is used to influence consumer behaviour by signalling how a product meets a perceived need. Advertising, such as tobacco advertisements on billboards and in stores, is designed to influence consumer knowledge, attitudes, and beliefs about a product. Promotions, such as teeshirts and lighters emblazoned with brand logos, are intended to stimulate consumer action toward the use of the product. A mix of these marketing types is intended to move consumers through a sequential decision-making process that ultimately leads to selection and regular use of the product.9

The decision to use a particular product generally includes the following steps: (a) awareness of, interest in, and shifting attitudes toward a product; (b) desire and intentions to use the product; (c) experimentation with the product; and finally, (d) regular use.10 It is interesting to note that there are similarities between the process articulated in the marketing literature and the stages of smoking initiation by young people that have been identified in several tobacco prevention research studies: (a) a preparatory stage in which attitudes and beliefs about the benefits and desirability of smoking are consolidated; (b) first attempts at smoking to conform with perceived norms; (c) irregular, experimental use; and finally, (d) addiction.11 12

Tobacco companies use a sophisticated blend of advertising and promotions to effectively communicate the symbolic social value of tobacco use. Symbolic social influences that are behavioural depictors in mass media have been found to play an important role in shaping adolescent tobacco use.13 14 Effective advertising is imbedded with product symbolism intended to stimulate particular behaviours. Clothing and other promotional items are intended to serve as a clear link between “me” and the role “I” wish to play.15 The tobacco industry’s advertising and promotional products are replete with messages and images that reflect the qualities teenagers value, such as popularity, independence, sexiness, and “coolness”. The marketing approaches imply that these qualities can be achieved by using their tobacco products.

The tobacco companies’ multibillion dollar efforts seem to guide children through a psychological process of product attachment, the outcome of which may increase their susceptibility to smoking. Their advertisements may shift young people’s attitudes and beliefs to view smoking as a means to acquire the above valued qualities. Their promotions may entice them to try on the image of a smoker, which also may resonate with their desired self-image. Their trading stamps, such as Marlboro Miles and Camel Cash, may reflect the companies’ intent to stimulate repeat purchases to build allegiance to their products. This is not a surprising goal because brand loyalty has been found to be established with the first cigarette.16

TEENAGERS’ RECEPTIVITY TO TOBACCO INDUSTRY MARKETING

An understanding of consumers is a critical element in the development of marketing strategies. In the past several years, internal tobacco industry documents confirm that manufacturers conducted extensive research on teenage behaviour and attitudes, and used this information to design tobacco marketing that appeals to young people’s psychosocial needs and the stages of initiation of smoking.17

To determine if the tobacco industry’s marketing efforts are reaching teenagers, we have developed a receptivity scale. This scale approximates the stages in decision-making processes involved with product use that were discussed above. Our first level, “See”, reflects awareness of tobacco advertising in various venues such as billboards and magazines. Our second level, “Want”, captures aroused interest in and desire for tobacco products, which is reflected in the acquisition of catalogues, mailings, and trading stamps, such as Marlboro Miles or Camel Cash. Our third level, “Own”, reflects the teenager’s identification with the product by trying on the smoker identity via the use of promotional items. Therefore, an assessment of receptivity provides a good indicator of the impact of the tobacco industry’s marketing strategies on young people.

SUSCEPTIBILITY TO START SMOKING

In this study, we examine the association between teenagers’ receptivity to tobacco marketing as described above, and their susceptibility to start smoking. As mentioned earlier, we believe that teenagers do not move in one step from non-smoking to smoking, but rather, proceed through various stages of smoking initiation. Young people are considered more susceptible to smoke if there is an absence of a clear resolve not to smoke in the future; this increases their vulnerability to personal, social, and environmental factors that may prompt experimentation with smoking.18 Two longitudinal studies have concluded that susceptibility is a significant predictor of smoking initiation in adolescents.19 20 Other studies of susceptibility have found associations between levels of susceptibility and liking of advertisements21; awareness of and involvement with tobacco promotional items22 23; and receptivity to tobacco advertising.24

If we are to succeed in reversing the upward trend in teenage smoking, we need to understand the effect of the tobacco industry’s ubiquitous marketing practices on young people to help us understand how a teenager moves from being a non-smoker to a smoker. This study seeks to add to this understanding by looking at the association between teenagers’ receptivity to marketing and their smoking susceptibility.

Results

Table 1 shows the three levels of receptivity to tobacco marketing strategies that were used to stratify survey respondents and the distribution of the respondents into these categories. Almost a third of the sample were in See, 46% were in the Want, and 24% were in the Own category. Only three children (0.5% of the sample) indicated that they had never seen any tobacco advertisements or promotions or frequented places likely to display such items. We excluded these children from the subsequent analyses and results.

In table 2, the reported bivariate analyses reveal that boys (χ² = 8.30, p<0.05), and blacks and Hispanics (χ² = 30.29, p<0.001) were more likely to report higher levels of receptivity to marketing. In addition, those with more real-world social influences to smoke (having parents or friends who smoked, or both) also reported greater receptivity (χ² = 73.38, p<0.001). Among those who reported having neither smoking parents nor friends, more than half (52.5%) were in See, the lowest receptivity level. In contrast, among those who had parents and friends who smoked, only 13% were in See.

We classified 495 children into three susceptibility levels; the remaining children were either regular smokers (n = 65) or had missing data (n = 11). We observed a significant relationship between susceptibility and receptivity (χ² = 44.84, p<0.001). Those with lower levels of receptivity to tobacco marketing were at the lower levels of smoking susceptibility. Of those seventh-graders who had no experience and a clear resolve not to smoke, 44.7% were in the See group. This contrasts sharply with those children who had experience with and lack of resolve not to smoke, of whom 11.4% were in the See group. The reverse occurs at the higher levels of receptivity where those less susceptible are the least likely to want or own promotional material, and the most susceptible are more likely to want or own such items.

In the proportional odds model, we observed that all the covariates, except some of the ethnicity dummy variables, were statistically significant. Beyond the significant role gender and ethnicity as well as parental and peer smoking played in predicting a teen’s susceptibility, receptivity to tobacco marketing materials also increases the odds that one will smoke. As a group, the regressors predict susceptibility and we observed that the χ² of all the covariates is 130.28 (df=9, p<0.0001). The test for equality of slopes for these variables proved to be non-significant (χ² = 10.93, df = 9, p<0.28).

Table 3 presents the change in odds for being in the higher susceptibility levels. Considering our set of predictors, girls were less likely than boys to have experience with smoking or lack a clear resolve not to smoke, or both. The odds that a Hispanic child had experience or lack a resolve not to smoke, or both, were two and a half times greater than the odds for a white child. Having parents who smoked increased the odds by a factor of 1.12 and having friends who smoked increased the odds by 2.98. The combination of having parents and friends who smoke increased the odds that a child was more susceptible to 5.23. Being in the Want or Own receptivity level increased the odds of being susceptible at similar rates (approximately 2.30 times greater). The odds act in a multiplicative manner such that a Hispanic child whose parents and friends smoked had odds of being in higher susceptibility levels that were 13.23 times greater than if the child was white and had neither parents nor friends who smoked. If that same child owned tobacco promotional material, then the odds that he or she was susceptible would be 31.09 times greater than the odds for a child without these characteristics.

Using the estimated parameter coefficients and intercepts, we calculated fitted probabilities that given children would be in the different susceptibility groups (figure 1). Here, we see that it is highly probable (p = 0.78) that a white boy, whose parents or friends did not smoke, and is in the See category, is in the lowest susceptibility category (no smoking experience and has a clear resolve not to smoke). On the other hand, a Hispanic boy, whose parents and friends smoke, and is in the Own category, has a high probability (p = 0.71) of being in the highest susceptibility category (having experience and lacking a clear resolve to smoke in the future.

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Probability of being in susceptibility level 1, 2, or 3, based on predictors in proportional odds model.

It should be noted that we also performed these analyses with current smokers included as a fourth level to the susceptibility index. The results resemble those encountered in the level 3 susceptibility index, with similar significant bivariate relationships and significant variables in the proportional odds model.

Discussion

This study examines the relationship between receptivity to tobacco marketing materials and susceptibility to start smoking as reported by 571 seventh-graders. The results show that virtually all young people in the study were aware of tobacco advertising, in that more than 99% of them reported seeing tobacco advertising and promotions in a variety of venues. Remarkably, about 70% of the seventh-graders in this study population indicated a level of receptivity to tobacco marketing materials that is greater than the simple awareness of advertising and promotions. Most of these young people said that they received tobacco company mailings, saved Camel Cash or Marlboro Miles, wanted to own promotional items, or actually owned them.

Not surprising is the finding that the odds of being susceptible to smoking are greatly increased when a parent or friends smoke. This is consistent with other research findings, which have found that these social influences are important contributors to a teenager’s decision to smoke.30 What is very disturbing, however, is that the odds of being susceptible more than doubled for those in the Want and Own categories even when controlling for gender, ethnicity, and knowing others who smoke. Interestingly, mere desire (Want) for tobacco promotional items increased the odds of being susceptible to smoking almost as much as actually owning them.

Equally disturbing are the findings on ethnicity. A Hispanic boy with family and friends who smoke and a high level of receptivity to tobacco marketing was 25% more likely than his white counterpart to be highly susceptible to smoking. We believe this finding warrants further study.

These findings indicate that the marketing campaigns designed by tobacco companies are extremely effective in capturing teenagers’ attention and increasing desire for their promotional items. The findings also suggest that the tobacco industry is successfully using promotions to stimulate movement toward regular use of their products by providing young people with paraphernalia that allows them to take on the identity of a smoker.

A vast majority (almost 90%) of the adolescents who have experimented with smoking and lack a firm commitment not to smoke in the future also report much higher levels of receptivity to tobacco marketing in the forms of working toward the acquisition of promotionals by saving Camel Cash or Marlboro Miles, and ownership of these items. These findings demonstrate that the most susceptible teenagers are most receptive to using promotional items that may help them achieve the “smoker” identity. This is consistent with marketing theories mentioned previously which explain that promotions allow a consumer to “try on” an identity and are intended to move consumers closer to using a product.

Those who report being the least receptive to these materials (30%) are also less likely to be susceptible toward tobacco use. However, more than 50% of those with no experience and a clear resolve not to smoke, either want or own tobacco promotional items; this illustrates the obvious appeal of these materials. We suspect that this might be the first step in moving some of these young people along the continuum of decision making toward the use of their products. Only a longitudinal study would allow us to find this out.

There are several limitations to this study. This sample is drawn from two school districts in northern California and is more ethnically diverse than the American population, so it may not be generalisable to the general population. Another potential limitation is that these are self-reported data of exposure to marketing strategies, as well as experience in smoking and intent to smoke. Response bias is possible; however, prevalence rates observed here are similar to those reported in other research.31 Most importantly, these are cross-sectional data; therefore, a causal relationship between advertising and smoking behaviour cannot be determined. Although these data show that a relationship exists between receptivity and susceptibility, it is possible that susceptibility to smoke precedes interest in and receptivity to tobacco advertising. A well-controlled longitudinal study would identify which variable causes the other.

The findings of this study indicate that although parents and peers play a significant role in whether a teenager begins to smoke, tobacco marketing materials may also have a strong influence. Previously confidential tobacco company records reveal that these companies studied teenagers and used this information to design marketing strategies to move them from non-smoking to smoking status. The results of this study confirm that the massive marketing efforts of the tobacco industry are in fact working: their advertising is noticed, and their promotional items are desired and owned by significant numbers of teenagers. Moreover, teenagers who are more receptive to the sophisticated marketing practices of the tobacco industry are more likely to report experimentation, intent to smoke, or regular use. These findings add to the growing body of research demonstrating the influence of tobacco marketing practices on youngsters’ susceptibility to start smoking.

The results of the study provide a new framework on how to talk with young people about how the marketing strategies of the tobacco industry are designed to move them from non-smoking to smoking status. Of particular benefit is a discussion of the use of promotional items that may bring a consumer closer to the use of a product. In addition, the findings of this and other studies cited here provide compelling support for regulating and overseeing the manner in which tobacco products are marketed, to protect young people from the highly effective strategies of the tobacco industry to reach them.