Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect

Objective

To examine whether adolescents'' exposure to youth smoking prevention ads sponsored by tobacco companies promotes intentions to smoke, curiosity about smoking, and positive attitudes toward the tobacco industry.

Design

A randomised controlled experiment compared adolescents'' responses to five smoking prevention ads sponsored by a tobacco company (Philip Morris or Lorillard), or to five smoking prevention ads sponsored by a non‐profit organisation (the American Legacy Foundation), or to five ads about preventing drunk driving.

Setting

A large public high school in California''s central valley.

Subjects

A convenience sample of 9th and 10th graders (n  =  832) ages 14–17 years.

Main outcome measures

Perceptions of ad effectiveness, intention to smoke, and attitudes toward tobacco companies measured immediately after exposure.

Results

As predicted, adolescents rated Philip Morris and Lorillard ads less favourably than the other youth smoking prevention ads. Adolescents'' intention to smoke did not differ as a function of ad exposure. However, exposure to Philip Morris and Lorillard ads engendered more favourable attitudes toward tobacco companies.

Conclusions

This study demonstrates that industry sponsored anti‐smoking ads do more to promote corporate image than to prevent youth smoking. By cultivating public opinion that is more sympathetic toward tobacco companies, the effect of such advertising is likely to be more harmful than helpful to youth.     

An ethnographic study of tobacco control in hospital settings

Background

Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm.

Objective

To study hospital workplace culture relevant to tobacco use and control as part of a mixed‐methods research project that investigated hospital‐based registered nurses'' integration of cessation interventions.

Design

The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient‐care documents on 16 adult in‐patient wards.

Results

The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients'' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence.

Conclusion

Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients'' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.     

The Tobacco Control Scale: a new scale to measure country activity

Objectives

To quantify the implementation of tobacco control policies at country level using a new Tobacco Control Scale and to report initial results using the scale.

Method

A questionnaire sent to correspondents in 30 European countries, using a scoring system designed with the help of a panel of international tobacco control experts.

Results

The 30 countries are ranked by their total score on the scale out of a maximum possible score of 100. Only four countries (Ireland, United Kingdom, Norway, Iceland) scored 70 or more, with an eight point gap (most differences in scores are small) to the fifth country, Malta, on 62. Only 13 countries scored above 50, 11 of them from the European Union (EU), and the second largest points gap occurs between Denmark on 45 and Portugal on 39, splitting the table into three groups: 70 and above, 45 to 62, 39 and below. Ireland had the highest overall score, 74 out of 100, and Luxembourg was bottom with 26 points. However even Ireland, much praised for their ban on smoking in public places, did not increase tobacco taxes in 2005, for the first time since 1995.

Conclusions

Although the Tobacco Control Scale has limitations, this is the first time such a scale has been developed and applied to so many countries. We hope it will be useful in encouraging countries to strengthen currently weak areas of their tobacco control policy.     

German tobacco industry's successful efforts to maintain scientific and political respectability to prevent regulation of secondhand smoke

Objective

To examine the tactics the tobacco industry in Germany used to avoid regulation of secondhand smoke exposure and to maintain the acceptance of public smoking.

Methods

Systematic search of tobacco industry documents available on the internet between June 2003 and August 2004.

Results

In West Germany, policymakers were, as early as the mid 1970s, well aware of the fact that secondhand smoke endangers non‐smokers. One might have assumed that Germany, an international leader in environmental protection, would have led in protecting her citizens against secondhand smoke pollution. The tobacco manufacturers in Germany, however, represented by the national manufacturing organisation “Verband” (Verband der Cigarettenindustrie), contained and neutralised the early debate about the danger of secondhand smoke. This success was achieved by carefully planned collaboration with selected scientists, health professionals and policymakers, along with a sophisticated public relations programme.

Conclusions

The strategies of the tobacco industry have been largely successful in inhibiting the regulation of secondhand smoke in Germany. Policymakers, health professionals, the media and the general public should be aware of this industry involvement and should take appropriate steps to close the gap between what is known and what is done about the health effects of secondhand smoke.     

Philip Morris's Project Sunrise: weakening tobacco control by working with it

Objective

To analyse the implications of Philip Morris USA''s (PM''s) overtures toward tobacco control and other public health organisations, 1995–2006.

Data sources

Internal PM documents made available through multi‐state US attorneys general lawsuits and other cases, and newspaper sources.

Methods

Documents were retrieved from several industry documents websites and analysed using a case study approach.

Results

PM''s Project Sunrise, initiated in 1995 and proposed to continue through 2006, was a long‐term plan to address tobacco industry delegitimisation and ensure the social acceptability of smoking and of the company itself. Project Sunrise laid out an explicit divide‐and‐conquer strategy against the tobacco control movement, proposing the establishment of relationships with PM‐identified “moderate” tobacco control individuals and organisations and the marginalisation of others. PM planned to use “carefully orchestrated efforts” to exploit existing differences of opinion within tobacco control, weakening its opponents by working with them. PM also planned to thwart tobacco industry delegitimisation by repositioning itself as “responsible”. We present evidence that these plans were implemented.

Conclusion

Sunrise exposes differences within the tobacco control movement that should be further discussed. The goal should not be consensus, but a better understanding of tensions within the movement. As the successes of the last 25 years embolden advocates to think beyond passage of the next clean indoor air policy or funding of the next cessation programme, movement philosophical differences may become more important. If tobacco control advocates are not ready to address them, Project Sunrise suggests that Philip Morris is ready to exploit them.     

Philip Morris's website and television commercials use new language to mislead the public into believing it has changed its stance on smoking and disease

Objectives

This paper analyses Philip Morris''s evolving website and the legal strategies employed in its creation and dissemination.

Methods

Internal tobacco documents were searched and examined and their substance verified and triangulated using media accounts, legal and public health research papers, and visits to Philip Morris''s website. Various drafts of website language, as well as informal discussion of the website''s creation, were located in internal Philip Morris documents. I compared website statements pertaining to Philip Morris''s stance on cigarette smoking and disease with statements made in tobacco trials.

Results

Philip Morris created and disseminated its website''s message that it agreed that smoking causes disease and is addictive in an effort to sway public opinion, while maintaining in a litigation setting its former position that it cannot be proved that smoking causes disease or is addictive.

Conclusions

Philip Morris has not changed its position on smoking and health or addiction in the one arena where it has the most to lose—in the courtroom, under oath.     

Smokers and non-smokers talk about regulatory options in tobacco control

Objective

Community members are occasionally polled about tobacco control policies, but are rarely given opportunities to elaborate on their views. We examined laypeople''s conversations to understand how 11 regulatory options were supported or opposed in interactions.

Design

Qualitative design; purposive quota sampling; data collection via focus groups.

Setting

Three locations in Sydney, Australia.

Participants

63 smokers and 75 non‐smokers, men and women, from three age groups (18–24, 35–44, 55–64 years), recruited primarily via telephone.

Measurements

Semi‐structured question route; data managed in NVivo; responses compared between groups.

Results

Laypeople rejected some regulatory proposals and certain arguments about taxation and the cost of cessation treatments. Protecting children and hypothecating tobacco excise for health education and care were highly acceptable. Plain packaging, banning retail displays and youth smoking prevention received qualified support. Bans on political donations from tobacco corporations were popular in principle but considered logistically fraught. Smokers asked for better cessation assistance and were curious about cigarette ingredients. Justice was an important evaluative principle. Support was often conditional and unresolved arguments frequent. We present both sides of these conflicts and the ways in which policies were legitimised or de‐legitimised in conversation.

Conclusions

Simple measures of agreement used in polls may obscure the complexity of community responses to tobacco policy. Support was frequently present but contested; some arguments that seem self‐evident to advocates were not so to participants. The detailed understanding of laypeople''s responses provided through qualitative methods may help frame proposals and arguments to meet concerns about justice, effectiveness and feasibility.     

Eliminating child labour in Malawi: a British American Tobacco corporate responsibility project to sidestep tobacco labour exploitation

Objectives

To examine British American Tobacco and other tobacco industry support of the Eliminating Child Labour in Tobacco Growing Foundation.

Design

Analyses of internal tobacco industry documents and ethnographic data.

Results

British American Tobacco co‐founded the Eliminating Child Labour in Tobacco Growing Foundation (ECLT) in October 2000 and launched its pilot project in Malawi. ECLT''s initial projects were budgeted at US$2.3 million over four years. Labour unions and leaf dealers, through ECLT funds, have undertook modest efforts such as building schools, planting trees, and constructing shallow wells to address the use of child labour in tobacco farming. In stark contrast, the tobacco companies receive nearly US$40 million over four years in economic benefit through the use of unpaid child labour in Malawi during the same time. BAT''s efforts to combat child labour in Malawi through ECLT was developed to support the company''s “corporate social responsibility agenda” rather than accepting responsibility for taking meaningful steps to eradicate child labour in the Malawi tobacco sector.

Conclusion

In Malawi, transnational tobacco companies are using child labour projects to enhance corporate reputations and distract public attention from how they profit from low wages and cheap tobacco.     

Tobacco industry litigation strategies to oppose tobacco control media campaigns

Objective

To document the tobacco industry''s litigation strategy to impede tobacco control media campaigns.

Methods

Data were collected from news and reports, tobacco industry documents, and interviews with health advocates and media campaign staff.

Results

RJ Reynolds and Lorillard attempted to halt California''s Media Campaign alleging that the campaign polluted jury pools and violated First Amendment rights because they were compelled to pay for anti‐industry ads. The American Legacy Foundation was accused of violating the Master Settlement Agreement''s vilification clause because its ads attacked the tobacco industry. The tobacco companies lost these legal challenges.

Conclusion

The tobacco industry has expanded its efforts to oppose tobacco control media campaigns through litigation strategies. While litigation is a part of tobacco industry business, it imposes a financial burden and impediment to media campaigns'' productivity. Tobacco control professionals need to anticipate these challenges and be prepared to defend against them.     

Decline in respiratory symptoms in service workers five months after a public smoking ban

Objective

To evaluate the effect of a total ban on smoking indoors in restaurants and other hospitality business premises in Norway, on respiratory symptoms among workers in the industry.

Methods

Phone interviews with 1525 employees in the hospitality business were conducted immediately before the enacting of the law. In a follow‐up study five months later, 906 of the workers from the baseline sample participated. Questions were asked on demographic variables, passive smoking exposure, personal smoking, attitudes towards the law, and five respiratory symptoms. Change in symptom prevalence was analysed with McNemar''s test and with analysis of variance (ANOVA) for repeated measures.

Results

The prevalence of all five symptoms declined after the ban; for morning cough from 20.6% to 16.2% (p < 0.01); for daytime cough from 23.2% to 20.9%; for phlegm cough from 15.3% to 11.8% (p < 0.05); for dyspnoea from 19.2% to 13.0% (p < 0.01); and for wheezing from 9.0% to 7.8%. ANOVA showed that the largest decline in symptom prevalence was seen among workers who themselves gave up smoking, and subjects with a positive attitude towards the law before it took effect.

Conclusion

A significant decrease in respiratory symptoms among service industry workers was found five months after the enacting of a public smoking ban.     

Working to make an image: an analysis of three Philip Morris corporate image media campaigns

Objective

To describe the nature and timing of, and population exposure to, Philip Morris USA''s three explicit corporate image television advertising campaigns and explore the motivations behind each campaign.

Methods

: Analysis of television ratings from the largest 75 media markets in the United States, which measure the reach and frequency of population exposure to advertising; copies of all televised commercials produced by Philip Morris; and tobacco industry documents, which provide insights into the specific goals of each campaign.

Findings

Household exposure to the “Working to Make a Difference: the People of Philip Morris” averaged 5.37 ads/month for 27 months from 1999–2001; the “Tobacco Settlement” campaign averaged 10.05 ads/month for three months in 2000; and “PMUSA” averaged 3.11 ads/month for the last six months in 2003. The percentage of advertising exposure that was purchased in news programming in order to reach opinion leaders increased over the three campaigns from 20%, 39% and 60%, respectively. These public relations campaigns were designed to counter negative images, increase brand recognition, and improve the financial viability of the company.

Conclusions

Only one early media campaign focused on issues other than tobacco, whereas subsequent campaigns have been specifically concerned with tobacco issues, and more targeted to opinion leaders. The size and timing of the advertising buys appeared to be strategically crafted to maximise advertising exposure for these population subgroups during critical threats to Philip Morris''s public image.     

Tobacco industry use of judicial seminars to influence rulings in products liability litigation

Objectives

This paper examines the tobacco industry''s efforts to influence litigation by sponsoring judicial seminars.

Methods

Thousands of internal tobacco documents were examined, including memos, reports, presentations, and newsletters. Connections to outside organisations were corroborated by examining tobacco industry financial records, budgets, and letters pledging funds. Facts about outside organisations were triangulated through examining their websites and publicly‐filed financial records, and verifying facts through their representatives'' statements in newspaper and law review articles.

Results

There are direct financial ties between the tobacco industry and groups that organise judicial seminars in an effort to influence jurisprudence, and judges who attend these seminars may be breaching judicial ethics either by not inquiring about the source of funding or by ignoring funding by potential litigants.

Conclusions

The tobacco industry''s attempts to clandestinely influence judges'' decisions in cases to which they are a party endangers the integrity of the judiciary.     

US news media coverage of tobacco control issues

Objective

To characterise the relative amount and type of daily newspaper, local and national TV newscast, and national news magazine coverage of tobacco control issues in the United States in 2002 and 2003.

Design

Content analysis of daily newspapers, news magazines, and TV newscasts.

Subjects

Items about tobacco in daily newspapers, local and national TV newscasts, and three national news magazines in a nationally representative sample of 56 days of news stratified by day of week and season of the year, from 2002 and 2003.

Main outcome measures

Story theme, tobacco topics, sources, story prominence, story valence (orientation), and story type.

Results

Tobacco coverage was modest over the two‐year period as estimated in our sample. Only 21 TV stories, 17 news magazine stories, and 335 daily newspaper stories were found during the two‐year sampling period. Noteworthy results for the newspaper data set include the following: (1) government topics predominated coverage; (2) government action and negative health effects topics tended not to occur together in stories; (3) tobacco stories were fairly prominently placed in newspapers; (4) opinion news items tended to favour tobacco control policies, while news and feature stories were evenly split between positive and negative stories; and (5) tobacco coverage in the southeast, which is the country''s major tobacco producing region, did not differ from the rest of the country.

Conclusion

Results suggest mixed support in news coverage for tobacco control efforts in the United States. The modest amount of news coverage of tobacco is troubling, particularly because so few news stories were found on TV, which is a more important news source for Americans than newspapers. When tobacco was covered, government themed stories, which often did not include mentions of negative health effects, were typical, suggesting that media coverage does not reinforce the reason for tobacco control efforts. However, some results were encouraging. For example, when newspapers did cover tobacco, they accorded the stories relatively high prominence, thus increasing the chance that readers would see tobacco stories when they were published.     

Community guide recommendations and state level tobacco control programmes: 1999-2004

Objective

To identify the level of effort state tobacco control programmes and partners have expended on interventions recommended by the community guide and how those efforts have changed over time between 1999 and 2004.

Design

Longitudinal study.

Setting

United States.

Participants

State tobacco control partners, including the state health department, voluntary agencies and tobacco control coalitions.

Main outcome measure

We used the Strength of Tobacco Control survey responses in 1999, 2002 and 2004 to calculate the mean proportion of state tobacco control partners working on recommended interventions and subsequently analysed changes in effort over time.

Results

The proportion of state tobacco control partners working to promote clean indoor air legislation remained at more than 70% in all three years. The proportion working to increase taxes on tobacco rose significantly between 1999 and 2002 (from 54% to 70%), and those working to reduce patient costs for tobacco cessation treatments never exceeded 31% in any year. Use of mass media targeting youths decreased significantly in all years (from 40% to 32% to 26%), and the proportion of state tobacco control partners participating in a quitline has increased steadily and significantly in all years (from 24% to 36% to 41%). The level of effort in each area varied widely between states and over time.

Conclusions

State tobacco control partners are implementing evidence based interventions, but more focus is needed on the tobacco cessation and mass media campaign components of comprehensive tobacco control programmes.     

Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries

Background

The US military is perhaps the only retailer consistently losing money on tobacco. Military stores (commissaries and exchanges) have long sold discount‐priced cigarettes, while the Department of Defense (DoD) pays directly for tobacco‐related healthcare costs of many current and former customers. Tobacco use also impairs short‐term troop readiness.

Objective

To examine the long struggle to raise commissary tobacco prices and the tobacco industry''s role in this policy effort.

Methods

Analysis of internal tobacco industry documents, searches of government and military websites and newspaper databases, and interviews with key informants identified in the documents.

Results

Efforts to raise commissary tobacco prices began in the mid‐1980s. Opposition quickly emerged. Some military officials viewed tobacco use as a “right” and low prices as a “benefit”. Others raised issues of authority, and some saw the change as threatening the stores. The tobacco industry successfully exploited complex relationships among the Congress, the DoD, commissaries, exchanges and private industry, obstructing change for over a decade. Leadership from the Secretary and Assistant Secretaries of Defense, presidential support and procedural manoeuvring finally resulted in a modest price increase in 1996, but even then, high‐level military officials were apparently threatened with retaliation from pro‐tobacco Congressmen.

Conclusions

The longstanding military tradition of cheap cigarettes persists because of the politics of the military sales system, the perception within the military of tobacco use as a right, and tobacco industry pressures. Against its own best interests, the US military still makes tobacco available to service members at prices below those in the civilian sector.The US military includes 1.4 million active duty personnel, stationed worldwide. Their smoking prevalence is higher (33.8% in 2002) than the US Department of Defense (DoD) goal of ⩽20%,¹ exceeding the civilian rate of 23.6%.² Smoking diminishes even short‐term troop health and readiness^3,4 and increases medical and training costs.^5,6 As an authoritarian, hierarchical institution, DoD should, theoretically, be able to establish and implement strong tobacco control policies. Nonetheless, DoD sells its personnel tobacco products virtually tax free. Military health personnel and some members of Congress have long sought to address this contradiction. This case study shows how for more than a decade, the tobacco industry worked to defeat policy changes by framing cheap cigarettes as a “benefit”, mobilising Congressional and military‐affiliated allies, and exploiting DoD ambivalence about tobacco.     

Levels of toxins in oral tobacco products in the UK

Objective

This study examined the constituents of smokeless tobacco products available in the UK and compared them with products available in India, Sweden, and the USA

Methods

Seven UK brands of smokeless tobacco, including a tooth cleaning powder, and four international brands of smokeless tobacco were tested for a range of toxins and known carcinogens, such as tobacco specific N‐nitrosamines (TSNA), as well as nicotine availability.

Results

Ten of the 11 brands tested had detectable levels of tobacco specific nitrosamines, which are proven carcinogens, and levels varied 130‐fold. All had detectable levels of benzo(a)pyrene, another proven carcinogen (with around 175‐fold variation) and several toxic metals (with nearly 150‐fold variation). Nicotine availability varied in the UK products from 0.1 mg/g to 63.2 mg/g. All the tobacco products tested are likely to be hazardous to users'' health, but the data indicate that it should be possible to reduce key toxins to non‐detectable levels.

Conclusions

Smokeless tobacco products should be regulated and standards set for maximum levels of toxins and carcinogens.     

Parental smoking and children's respiratory health: independent effects of prenatal and postnatal exposure

Objectives

Adverse effects have been reported of prenatal and/or postnatal passive exposure to smoking on children''s health. Uncertainties remain about the relative importance of smoking at different periods in the child''s life. We investigate this in a pooled analysis, on 53 879 children from 12 cross‐sectional studies—components of the PATY study (Pollution And The Young).

Methods

Effects were estimated, within each study, of three exposures: mother smoked during pregnancy, parental smoking in the first two years, current parental smoking. Outcomes were: wheeze, asthma, “woken by wheeze”, bronchitis, nocturnal cough, morning cough, “sensitivity to inhaled allergens” and hay fever. Logistic regressions were used, controlling for individual risk factors and study area. Heterogeneity between study‐specific results, and mean effects (allowing for heterogeneity) were estimated using meta‐analytical tools.

Results

There was strong evidence linking parental smoking to wheeze, asthma, bronchitis and nocturnal cough, with mean odds ratios all around 1.15, with independent effects of prenatal and postnatal exposures for most associations.

Conclusions

Adverse effects of both pre‐ and postnatal parental smoking on children''s respiratory health were confirmed. Asthma was most strongly associated with maternal smoking during pregnancy, but postnatal exposure showed independent associations with a range of other respiratory symptoms. All tobacco smoke exposure has serious consequences for children''s respiratory health and needs to be reduced urgently.     

Asian herbal‐tobacco cigarettes: “not medicine but less harmful”?

Objective

To describe the development and health claims of Asian herbal‐tobacco cigarettes.

Methods

Analysis of international news sources, company websites, and the transnational tobacco companies'' (TTC) documents. PubMed searches of herbs and brands.

Results

Twenty‐three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb‐only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb‐only product. Asian herbal‐tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal‐tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal‐tobacco products. In 2005, China designated two herbal‐tobacco brands as key for development.

Conclusion

Asian herbal‐tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal‐tobacco cigarette production by 2000 coincides with the Asian tobacco companies'' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.