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.     

The Philip Morris External Research Program: results from the first round of projects

Background

Philip Morris (PM) launched the Philip Morris External Research Program (PMERP) in 2000, two years after the company agreed to the dissolution of two industry‐wide, external research programmes: the Council for Tobacco Research (CTR) and the Center for Indoor Air Research (CIAR). Our previous analysis of PMERP''s Request for Applications noted that PMERP''s structure, while ostensibly concerned with new product development, was remarkably similar to that of CIAR. We also found the majority of designated peer‐reviewers had previous ties to the tobacco industry and the research solicitation seemed to invite mitigating evidence concerning cigarettes and constituent risks. We concluded that a prime reason for PMERP''s existence was to garner scientific credibility for PM.

Objective

To examine the grants awarded in the first round of PMERP and subsequent peer‐reviewed publications.

Methods

Searches of industry documents available on the internet using PMERP and its variations as initial keywords; searches on Medline for publications from PMERP grantees.

Results

Of 153 applications, 61 proposals were funded, 36 of which generated 78 scientific publications. Of these, 65% deal specifically with the tobacco plant or constituents. Over half the researchers listed as PMERP participants had previously received or applied for tobacco funding. One internal document indicated PMERP''s objectives included gaining “credibility” and “goodwill”, and finding “young scientists”. In addition, PM has launched its own and more extensive internal product design research programme.

Conclusion

PMERP appears to exist less as a conduit for critical scientific inquiry than to fit into a corporate strategy intended to burnish PM''s public image.     

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.     

"Accommodating" smoke-free policies: tobacco industry's Courtesy of Choice programme in Latin America

Objective

To understand the implementation and effects of the Courtesy of Choice programme designed to “accommodate” smokers as an alternative to smoke‐free polices developed by Philip Morris International (PMI) and supported by RJ Reynolds (RJR) and British American Tobacco (BAT) since the mid‐1990s in Latin America.

Methods

Analysis of internal tobacco industry documents, BAT “social reports”, news reports and tobacco control legislation.

Results

Since the mid‐1990s, PMI, BAT and RJR promoted Accommodation Programs to maintain the social acceptability of smoking. As in other parts of the world, multinational tobacco companies partnered with third party allies from the hospitality industry in Latin America. The campaign was extended from the hospitality industry (bars, restaurants and hotels) to other venues such as workplaces and airport lounges. A local public relations agency, as well as a network of engineers and other experts in ventilation systems, was hired to promote the tobacco industry''s programme. The most important outcome of these campaigns in several countries was the prevention of meaningful smoke‐free policies, both in public places and in workplaces.

Conclusions

Courtesy of Choice remains an effective public relations campaign to undermine smoke‐free policies in Latin America. The tobacco companies'' accommodation campaign undermines the implementation of measures to protect people from second‐hand smoke called for by the World Health Organization Framework Convention on Tobacco Control, perpetuating the exposure to tobacco smoke in indoor enclosed environments.Latin Americans are highly exposed to second‐hand tobacco smoke (SHS) both in public places and in workplaces.^1,2 In 2001, the Pan American Health Organization launched its “Smoke Free Americas” initiative³ to “raise awareness of the harm caused by secondhand tobacco smoke, and support efforts to achieve more smoke‐free environments in the Americas.” There is longstanding strong public concern over the effects of SHS in Latin America. In 1997, research conducted for Philip Morris International (PMI) showed that about 80% of respondents in four Latin American countries agreed that “Other people''s tobacco smoke poses a long term health risk to nonsmokers.”⁴ These results reflect a stronger consensus that SHS is hazardous than Philip Morris (PM) found in the US in 1989—62% of non‐smokers and 32% of smokers—as the movement for smoke‐free workplaces and public places was beginning to accelerate them.⁵ A 2001 survey conducted for the World Health Organization (WHO) in the main urban areas of Argentina showed strong public support (94%; 96% non‐smokers and 89% smokers) for the creation of smoke‐free places to avoid SHS.⁶ Public opinion polls conducted in 2006 in Argentina⁷ and Uruguay⁸ reported that 92% of respondents agreed that “SHS is dangerous for nonsmokers'' health”, showing an increase in public concern about SHS by 12% since 1997.The main barrier to progress in implementing smoke‐free policies in Latin America has been the efforts by two transnational tobacco companies, PMI and British American Tobacco (BAT), which control almost the entire cigarette market in the region through their subsidiaries (PMI 40%, BAT 60%). Similar to the voluntary self‐regulating advertising codes, which the tobacco companies use to fight restrictions on tobacco advertising,^9,10 the tobacco industry has orchestrated public relations campaigns in Latin America since the mid‐1990s to avoid legislated smoke‐free policies.^11,12 As in the US, beginning in the late 1980s,¹¹ this effort mobilised the hospitality industry to block meaningful tobacco control legislation to preserve the social acceptability of smoking and to protect industry profits. These programmes, known as Accommodation in the US and Courtesy of Choice in most parts of the rest of the world,^11,13,14,15 encourage the voluntary creation of smoking and non‐smoking sections in the hospitality industry as an alternative to legislation requiring 100% smoke‐free environments. Also, as in the US, the tobacco industry sought to present ventilation as the “solution” to SHS.¹⁶As of April 2007, 12 Latin American countries (Bolivia, Brazil, Chile, Ecuador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, Uruguay and Venezuela) had ratified the WHO Framework Convention on Tobacco Control (FCTC). The FCTC, the first international public health treaty, calls for the implementation of “effective legislative, executive, administrative or other measures … at the appropriate governmental level to protect all persons from exposure to tobacco smoke” (Article 4.1) “in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.” (Article 8).¹⁷ Given the fact that the only truly effective protection from SHS is the creation of 100% smoke‐free environments,¹⁸ in 2003, Venezuela approved a state law (in Monagas¹⁹) and between 2005 and 2006, Argentina passed and regulated two provincial laws (in Santa Fe and Tucumán) to establish 100% smoke‐free public places and workplaces. In March 2006, Uruguay became the first 100% smoke‐free country in the Americas. In response to this movement, one can expect the tobacco industry to accelerate its Accommodation efforts as a way of undermining such effective smoke‐free policies to implement FCTC.     

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.     

Tobacco sales in pharmacies: time to quit

Objective

To assess the pharmacy profession''s perceptions of tobacco sales in US pharmacies and explore whether a policy prohibiting sales of tobacco in pharmacies would alter adult consumer shopping behaviour.

Subjects and design

In California, surveys were administered to 1168 licensed pharmacists and 1518 pharmacy students, and telephone interviews were conducted with 988 adult consumers.

Results

Most (58.1%) licensed pharmacists were strongly against sales of tobacco in pharmacies, 23.6% were against it, 16.7% were neutral, 1.2% were in favour of it, and 0.4% were strongly in favour of it. Pharmacists who were current tobacco users were more likely to be in favour of tobacco sales in pharmacies than were pharmacists who were current non‐users (p < 0.005). Similar statistics were observed for pharmacy students. Most consumers (72.3%) disagreed with the statement, “I am in favour of tobacco products being sold in drugstores”; 82.6% stated that if the drugstore where they most commonly shopped were to stop selling tobacco products, they would shop there just as often, 14.2% would shop there more often, and 3.2% would shop there less often.

Conclusion

Little professional or public support exists for tobacco sales in pharmacies.     

22 years on: the impact and relevance of the UK No Smoking Day

Objectives

To evaluate the impact and relevance of the national awareness day “No Smoking Day” 22 years after it was launched.

Design

Triangulation of data from a variety of sources. Retrospective surveys conducted one week and three months after No Smoking Day, media coverage, website activity, and volume of calls to national smokers'' helplines.

Main outcome measures

Self reports of awareness and smoking behaviour changes one week and three months after No Smoking Day. Volume of media coverage, visits to No Smoking Day website, and volumes of calls to smokers'' helplines.

Results

Follow up at one week indicates awareness of No Smoking Day is lower in 2004 than in 1986 but still high at 70% for all smokers. The decline in participation from 18% of aware smokers in 1994 to 7% in 2001 has been reversed and in 2005 19% quit or reduced their smoking on No Smoking Day. Three months after No Smoking Day awareness was 78% in 2004, lower than in previous studies but still high and equivalent to 9 965 000 smokers when applied to the population estimate of UK smokers. Likewise participation has decreased but at 14% in 2004 is equivalent to an estimated 1 840 000 (1 in 7 of UK smokers) claiming to quit or reduce their consumption on the Day. Among those who participated, 11% were still not smoking more than three months after the Day, equivalent to an estimated 85 000 smokers (0.7% of UK smokers). Media volume has increased even though campaign spend has remained relatively constant and calls to national smokers'' helplines on No Smoking Day are typically four times those received on an average day.

Conclusions

These data suggest that after 22 years No Smoking Day continues to be successful in reaching smokers. With a budget insufficient to pay for advertising, this public awareness campaign supported by local activities appears to be effective in helping smokers to stop.     

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.     

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.     

Impact of smoking images in magazines on the smoking attitudes and intentions of youth: an experimental investigation

Objective

To determine the effect of magazine incidental smoking imagery on youths'' smoking intentions.

Methods

A magazine was developed incorporating photographs of smokers (Smoking Magazine). A second version of the magazine (Non‐smoking Magazine) included these photographs with the tobacco paraphernalia digitally erased. Equal numbers of smokers and non‐smokers aged 14–17 years (n = 357) were randomly assigned to look through one version of the magazine and then asked a series of questions.

Results

Smokers made more unprompted mention of smoking imagery than non‐smokers after viewing Smoking Magazine (52% vs 34%; p<0.05). Smokers viewing Smoking Magazine were more likely to report an urge to smoke (54% vs 40%; p<0.05). Female non‐smokers who viewed Smoking Magazine were more likely than those who viewed Non‐smoking Magazine to state a future intention to smoke (13% vs 0%; p<0.05). Female smokers were more attracted to the male models appearing in Smoking Magazine than Non‐smoking Magazine (49% vs 24%; p<0.05) and the opposite was true for female non‐smokers (28% vs 52%; p<0.05). Female smokers were also marginally more likely to desire looking like the female models in Smoking Magazine (64% vs 46%; p = 0.06) but no difference was observed in the non‐smoking females (46% vs 46%). Male smokers and non‐smokers did not differ in their responses by magazine type.

Conclusions

Incidental positive smoking imagery in magazines can generate the same sorts of consumer effects attributed to advertising in general, including tobacco advertising. Sex specific results of our study may be explained by the choice of smoking images used.With a view to reducing tobacco related harm, a number of countries around the world have implemented comprehensive advertising and sponsorship bans of tobacco in accordance with the World Health Organization''s Framework Convention on Tobacco Control (FCTC). Even with comprehensive tobacco control legislation, loopholes remain that can be exploited by the tobacco industry to circumvent comprehensive advertising restrictions. For example, product placements in movies and television programmes popular with adolescents are a noted tactic of the tobacco industry.¹ Furthermore, incidental depictions of tobacco in popular media, although not necessarily instigated by the tobacco industry, can serve to counter restrictions on advertising. Smoking depictions within youth oriented advertisements for non‐tobacco products are common, being used as a device by advertisers to focus on the lifestyle and image of the user, rather than on the intrinsic value or merits of the product itself.² Incidental images of smoking are also common in editorial and feature components of youth oriented entertainment media, including movies, television, magazines and the internet. Although social determinants such as having parents, older siblings and peers who smoke are the best predictors of smoking initiation in youth,³ portrayals of smoking in popular media appear to contribute by presenting socially attractive images and inflating the perception of smoking prevalence.^2,4,5Studies consistently suggest that incidental smoking is depicted far more commonly than is normal within the actual population, and that the majority of depictions are associated with popular and desirable role models with positive attributes such as fame, attractiveness, sexiness, sophistication and glamour.^6,7,8 For instance an analysis of popular Hollywood movies in the late 1990s suggested that one in two heroes smoke, including 80% of leading male characters.⁸ In the early 1990s an audit of Australian youth oriented magazines suggested that photographs featuring smoking were “infrequent” (one depiction per 147 pages). An increase of 12% in smoking depictions was noted between 1990 and 1993 in the period after the introduction of the complete tobacco advertising ban but, as this increase was non‐significant, natural variation could not be discounted.⁹ However, a similar audit of magazines conducted a decade later suggested that far from being infrequent, depictions of smoking were commonplace: 96% of a sample of youth oriented magazines included at least one depiction of incidental smoking (average 3.5 per magazine; one per 50.3 pages), with 97% of these depictions being favourable.¹⁰ Although the methodologies differed between the two studies, it appears that the tobacco advertising ban in Australia was followed by an increase rather than decrease in prevalence of smoking portrayals in magazines.There is clear evidence that exposure to positive portrayals of smoking in movies and on television increases adolescents'' positive attitudes towards smoking, the likelihood of smoking initiation, and imitation of modelled smoking actions.^11,12 However, research investigating the impact of incidental portrayals of tobacco use in magazines is sparse. Amos and colleagues¹³ assessed adolescents'' perceptions of photographs of models using tobacco products and compared these to adolescents'' perceptions of identical photographs but with the tobacco paraphernalia digitally removed. They found that the presence of a cigarette affected how the model in a photograph was perceived: when tobacco products were present, models were associated with “drug taking,” “wildness” and being “depressed,” and to a lesser extent being “vain,” “tarty” and “posers.” Without the smoking paraphernalia the same models were perceived as being more “healthy,” “rich,” “nice,” “fashionable,” “slim” and “attractive.” Although traits such as “druggy,” “wild” and “tarty” may appear to be negative associations, smokers sampled in the study were found to be more drawn to such traits than non‐smokers, and were found to rate themselves less negatively in terms of these traits than non‐smokers. The authors concluded that although young smokers and non‐smokers associated the same attributes to the smoking models, smokers identified more strongly with these attributes than did non‐smokers, and hence the smoking imagery served to positively reinforce the self identity of young smokers. In a later complementary study,¹⁴ Amos and her colleagues conducted focus groups with young smokers and found that smoking imagery in magazines helped reinforce positive perceptions of smoking as attractive, sociable and reassuring thereby reinforcing young smokers'' own identities. Furthermore the lack of obvious vested interests in incidental smoking portrayals meant that such were potentially more powerful than tobacco advertising imagery.The present study aims to extend the studies of Amos and colleagues by using a randomised controlled trial to assess the impact of smoking images in magazines on smoking and non‐smoking youth, and particularly their intentions for future smoking. We hypothesised that positive smoking imagery in a youth oriented magazine would:

• lessen young smokers'' future intentions to quit;
• increase non‐smokers'' future intentions to take up smoking;
• increase young people''s perceptions of the prevalence of smoking;
• increase young smokers'' urge to smoke while reading the magazine; and
• increase young smokers'' positive perceptions of the depicted models but decrease young non‐smokers'' positive perceptions of the depicted models.

     

Finding the Kool Mixx: how Brown & Williamson used music marketing to sell cigarettes

Objective

To describe the history of Kool''s music‐themed promotions and analyse the role that music played in the promotion of the brand.

Methods

Analysis of previously secret tobacco industry documents, legal documents, and promotional materials.

Results

Brown & Williamson started Kool sponsorship of musical events in 1975 with Kool Jazz concerts. Music was considered to be an effective marketing tool because: (1) music helped consumers make emotional connections with the brand; (2) music concerts were effective for targeted marketing; (3) music tied together an integrated marketing campaign; and (4) music had potential to appeal widely to a young audience. Brown & Williamson''s first music campaigns successfully targeted young African‐American male audiences. Subsequent campaigns were less effective, exploring different types of music to achieve a broader young adult appeal.

Conclusions

This case study suggests Brown & Williamson used music most successfully for targeted marketing, but they failed to develop a wider audience using music because their attempts lacked consistency with the Kool brand''s established identity. The 2004 “Kool Mixx” campaign both returned to Brown & Williamson''s historic practice targeting young African‐American males, and also exploited a musical genre with much more potential to bring Kool more universal appeal, as hip‐hop music is increasingly popular among diverse audiences. Tobacco control efforts led by African‐American community activists to oppose these marketing strategies should continue; expanding these coalitions to include the hip‐hop community may further increase their effectiveness.     

Smoking too few cigarettes to be at risk? Smokers' perceptions of risk and risk denial,a French survey

Background

Past studies on smokers'' risk perception have produced mixed results. We endorsed a new approach to assess smokers'' perceptions of risk by asking them to estimate threshold values for the cancer risk associated with daily consumption of tobacco and number of smoking years. We expected that many smokers would endorse a “risk denial” attitude, with threshold estimates higher than their own smoking consumption and duration.

Methodology

A French national telephone survey (n = 3820; 979 current smokers) included several questions about smoking behaviours and related beliefs.

Results

Among current smokers, 44% considered that smoking can cause cancer only for a daily consumption higher than their own consumption, and an additional 20% considered that the cancer risk becomes high only for a smoking duration higher than their own. Most smokers also agreed with other “risk denial” statements (“smoking is not more dangerous than air pollution,” “some people smoke their whole life but never get sick”). Those who considered they smoked too few cigarettes to be at risk were less likely to report personal fear of smoking related cancer.

Conclusion

Risk denial is quite widespread among smokers and does not simply reflect a lack of information about health risks related to tobacco. Fully informing smokers about their risks may necessitate changing the way they process information to produce beliefs and limiting their capacity to generate self exempting beliefs.     

Non-smokers seeking help for smokers: a preliminary study

Objectives

To examine the phenomenon of non‐smokers spontaneously taking action to seek help for smokers; to provide profiles of non‐smoking helpers by language and ethnic groups.

Setting

A large, statewide tobacco quitline (California Smokers'' Helpline) in operation since 1992 in California, providing free cessation services in English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese.

Subjects

Callers between August 1992 and September 2005 who identified themselves as either white, black, Hispanic, American Indian, or Asian (n  =  349 110). A subset of these were “proxies”: callers seeking help for someone else. For more detailed analysis, n  =  2143 non‐smoking proxies calling from October 2004 through September 2005.

Main outcome measures

Proportions of proxies among all callers in each of seven language/ethnic groups; demographics of proxies; and proxies'' relationships to smokers on whose behalf they called.

Results

Over 22 000 non‐smoking proxies called. Proportions differed dramatically across language/ethnic groups, from mean (±95% confidence interval) 2.7 (0.3)% among English‐speaking American Indians through 9.3 (0.3)% among English‐speaking Hispanics to 35.3 (0.7)% among Asian‐speaking Asians. Beyond the differences in proportion, however, remarkable similarities emerged across all groups. Proxies were primarily women (79.2 (1.7)%), living in the same household as the smokers (65.0 (2.1)%), and having either explicit or implicit understandings with the smokers that calling on their behalf was acceptable (90.0 (1.3)%).

Conclusions

The willingness of non‐smokers to seek help for smokers holds promise for tobacco cessation and may help address ethnic and language disparities. Non‐smoking women in smokers'' households may be the first group to target.     

Youth smoking prevention and tobacco industry revenue

Objectives

Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue.

Main outcome measures

This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes.

Results

In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives.

Conclusions

Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.     

Observed smoking in cars: a method and differences by socioeconomic area

Objectives

To establish a reproducible method to estimate he point prevalence of smoking and second‐hand smoke (SHS) exposure in cars, and to compare this prevalence between two areas of contrasting socioeconomic status.

Method

A method involving two teams of observers was developed and evaluated. It involved observing 16 055 cars in Wellington, New Zealand. Two of the observation sites represented a high and a low area of deprivation (based on a neighbourhood deprivation index) and three were in the central city.

Results

A 4.1% point prevalence of smoking in cars was observed (95% confidence interval (CI) 3.8% to 4.4%). There was a higher prevalence of smoking in cars in the high deprivation area relative to the other sites, and particularly compared to the low deprivation area (rate ratio relative to the latter 3.2, 95% CI 2.6 to 4.0). Of cars with smoking, 23.7% had other occupants being exposed to SHS. Cars with smoking and other occupants were significantly more likely to have a window open (especially if the smoker was not the driver). The observation method developed was practical, and inter‐observer agreement was high (κ value for the “smoking seen in car” category 0.95).

Conclusions

Observational studies can be an effective way of investigating smoking in cars. The data from this survey suggest that smoking in cars occurs at a higher rate in relatively deprived populations and hence may contribute to health inequalities. Fortunately, there are a number of policy options for reducing SHS exposure in cars including mass media campaigns and laws for smoke‐free cars.     

"Creative Solutions": selling cigarettes in a smoke-free world

Objective: To analyse the development and execution of the "Creative Solutions" Benson & Hedges advertising campaign to understand its social, political, and commercial implications. Methods: Searches of the Philip Morris documents and Legacy Tobacco Documents websites for relevant materials; Lexis/Nexis searches of major news and business publications; and denotative and connotative analyses of the advertising imagery. Results: Philip Morris developed the Creative Solutions campaign in an effort to directly confront the successes of the tobacco control movement in establishing new laws and norms that promoted clean indoor air. The campaign''s imagery attempted to help smokers and potential smokers overcome the physical and social downsides of smoking cigarettes by managing risk and resolving internal conflict. The slogans suggested a variety of ways for smokers to respond to restrictions on their habit. The campaign also featured information about the Accommodation Program, Philip Morris''s attempt to organise opposition to clean indoor air laws. Conclusion: The campaign was a commercial failure, with little impact on sales of the brand. Philip Morris got some exposure for the Accommodation Program and its anti-regulatory position. The lack of commercial response to the ads suggests that they were unable to successfully resolve the contradictions that smokers were increasingly experiencing and confirms the power of changing social norms to counter tobacco industry tactics.     

Healthcare provider smoking cessation advice among US worker groups

Objective

Among workers in dusty occupations, tobacco use is particularly detrimental to health because of the potential synergistic effects of occupational exposures (for example, asbestos) in causing disease. This study explored the prevalence of smoking and the reported smoking cessation discussion with a primary healthcare provider (HCP) among a representative sample of currently employed US worker groups.

Methods

Pooled data from the 1997–2003 National Health Interview Survey (NHIS) were used to estimate occupation specific smoking rates (n = 135 412). The 2000 NHIS Cancer Control Module was used to determine (among employed smokers with HCP visits) the prevalence of being advised to quit smoking by occupation (n = 3454).

Results

The average annual prevalence of current smoking was 25% in all workers. In 2000, 84% of smokers reported visiting an HCP during the past 12 months; 53% reported being advised by their physician to quit smoking (range 42%–66% among 30 occupations). However, an estimated 10.5 million smokers were not advised to quit smoking by their HCP. Workers with potentially increased occupational exposure to dusty work environments (including asbestos, silica, particulates, etc), at high risk for occupational lung disease and with high smoking prevalence, had relatively low reported discussions with an HCP about smoking cessation, including farm workers (30% overall smoking prevalence; 42% told to quit), construction and extractive trades (39%; 46%), and machine operators/tenderers (34%; 44%).

Conclusion

The relatively low reported prevalence of HCP initiated smoking cessation discussion, particularly among currently employed workers with potentially synergistic occupational exposures and high current smoking prevalence, needs to be addressed through educational campaigns targeting physicians and other HCPs.     

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.     

Sidestream cigarette smoke toxicity increases with aging and exposure duration

Objectives

To determine the effects of aging on the toxicity of sidestream tobacco smoke, the complex chemical mixture that enters the air from the lit end of burning cigarettes and constitutes the vast bulk of secondhand smoke.

Design

Statistical analysis of data from controlled experimental exposures of Sprague Dawley rats to fresh and aged (for more than 30 minutes) sidestream smoke for up to 90 days followed by histological sectioning of the respiratory epithelium. The data were obtained from a series of experiments conducted at Philip Morris'' formerly secret INBIFO (Institut für Biologische Forschung) laboratory in Germany.

Results

Using total particulate material as the measure of smoke exposure, aging sidestream cigarette smoke for at least 30 minutes increases its toxicity fourfold for 21 day exposures and doubles the toxicity for 90 day exposures, relative to fresh sidestream smoke.

Conclusions

These results help explain the relatively large biological effects of secondhand smoke compared to equivalent mass doses of mainstream smoke.     

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.