i1 Tob Control: first published as 10.1136/tc.12.suppl_1.i1 on 1 June 2003. Downloaded from INTRODUCTION Innovative approaches to youth tobacco control: introduction and overview K E Warner, P D Jacobson, N J Kaufman ............................................................................................................................. Tobacco Control 2003;12(Suppl I):i1–i5 igarette smoking is a vicious cycle. Each WHAT WORKS year a new generation of children experi- We have some answers, though much remains Cments with smoking. In many societies, uncertain. We know that young smokers and half of them will become addicted, most destined potential smokers are especially sensitive to the to smoke for decades thereafter until either they price of cigarettes. In developed countries, a price manage to quit or death ends their struggle to do increase of 10% likely reduces youth smoking by so. The glamorous, seductive, and youthful images about 8%. Most students of tobacco control policy of cigarette advertising copy—the ruggedly hand- believe that raising prices—typically accom- some cowboy pulling on his cigarette, the sexy plished through tax increases—is the single most and impossibly lean female toying with hers— effective means of reducing youth smoking give way over time to the harsh reality of wizened quickly and substantially.2 In the instance of the faces and tar coated lungs that gasp urgently for recent decline in youth smoking in the USA, breath. Smoking kills one of every two life long tobacco industry wholesale price increases, pur- smokers. The unlucky half loses an average of 15 suant to implementation of the Master Settle- years of life compared with people who never ment Agreement between the industry and the smoke. Their children or grandchildren become states,3 served the same purpose, ultimately their replacement smokers. The cycle repeats increasing cigarette prices by approximately $0.40 itself again and again, year after year. per pack of 20. And numerous states have raised The fraction of young people who begin to their cigarette excise taxes, often substantially, in smoke is not constant year to year, however. In the the name of deficit reduction. USA, 38.8% of high school seniors had smoked As is reported by Farrelly and colleagues,4 large, within a month of being surveyed in 1976. That well designed media countermarketing cam- figure fell gradually to a low of 27.8% in 1992 and paigns appear to decrease youth smoking as well. then rose, rapidly,to 36.5% five years later in 1997. Experience with media campaigns in the two US http://tobaccocontrol.bmj.com/ A mere five years thereafter—in 2002—the states with the longest history of well funded percentage of monthly smokers had fallen to comprehensive tobacco control programmes— 26.7%, the lowest figure ever recorded in the 27 California and Massachusetts—complements year history of the survey. Among their younger new data from the national truthsm campaign, in schoolmates, the proportionate changes during the 1990s were even more dramatic: 20.8% of 10th each case showing impressive reductions in youth graders were monthly smokers in 1991, a figure smoking. Recent data from other states, including that jumped to 30.4% in 1996 and then plunged to Florida, provides encouraging evidence as well. 17.7% in 2002. Among eighth graders, the Florida’s state based truth campaign inspired the comparable figures were 14.3% in 1991, 21.0% in national campaign. 1996, and 10.7% in 2002.1 What is it that caused the proportion of high WHAT DOESN’T school seniors smoking to rise by almost a third Some interventions do not work. School health on October 2, 2021 by guest. Protected copyright. from 1992 to 1997 and then to drop below the education programmes—the traditional staple of 1992 figure a mere five years later? Why would youth tobacco control—look good in theory and the number of eighth grade smokers leap by sometimes perform well under optimal research nearly half in the five years from 1991 to 1996 and conditions.5 But in practice—in schools with then plummet by more than 40% five years there- overtaxed teachers not trained in their adminis- after? These changes are not inconsequential. A tration, with curricula leaving little room for decrease in the smoking initiation rate of 10 per- additional health education, and with tight budg- centage points can mean an eventual difference of ets that restrict curricular expansion—most of tens of thousands of lives lost—or rather not these programmes have not fared well. Often, See end of article for lost—to tobacco in a single year’s birth cohort. they change students’ attitudes toward smoking authors’ affiliations in the short run; but years down the road, ....................... Over just a few years’ birth cohorts, it would mean hundreds of thousands of lives not lost prema- programme graduates smoke at virtually identi- Correspondence to: turely to tobacco. An intervention, or a series of cal rates to students never exposed to the Kenneth E Warner, PhD, interventions, that could achieve that decline in programmes.6 Lacking an infusion of substantial Department of Health Management & Policy, smoking would thus rank as a public health new resources, with a substantial new commit- School of Public Health, triumph of the first order. It behooves us, ment from school administrations, this mom- University of Michigan, therefore, to learn why youth smoking rates have and-apple-pie intervention is not likely to signifi- 109 S Observatory Road, fluctuated so substantially over a period of a few cantly diminish the burden of smoking in new Ann Arbor, MI generations. 48109-2029, USA; years. It behooves us, as well, to learn how to [email protected] move the rates down further than has been expe- Youth access laws, designed to restrict sales to ....................... rienced to date. minors, appear to share a similar fate. In theory, www.tobaccocontrol.com i2 Tob Control: first published as 10.1136/tc.12.suppl_1.i1 on 1 June 2003. Downloaded from they can work to reduce youths’ access to cigarettes and ulti- PUP laws mately their decisions to smoke. In practice, however, lacking First on the agenda was the controversial topic of laws an extraordinary commitment to their enforcement, they have prohibiting purchase, use, and possession of tobacco by achieved little. If the laws are enforced to some degree—and minors—ironically, if aptly, identified as “PUP” laws—often compliance rates have risen substantially in recent years— accompanied by serious penalties for youth who violate them. retail outlet sales to minors do decrease. But resourceful kids As Wakefield and Giovino recount in their paper on the (and resourceful providers of cigarettes to them) find other subject,13 PUP laws have offended many tobacco control advo- sources of cigarettes, by identifying those retail outlets that cates who view them as blaming the victim and, in the proc- will sell to them, “borrowing” more frequently from their par- ess, taking the heat off the adults who provide youth with ents’ supplies, purchasing from older siblings or friends, and access to cigarettes. Further, there is limited evidence that they so on.7 Computer simulation analysis demonstrates that the are effective. In fairness, however, it must be emphasised that levels of compliance in retail outlets have to be extraordinarily evidence of any kind on this issue is sparse. high, likely well over 90%, to impact actual smoking The conference participants reached a general, if not unani- behaviour.8 One prominent experience, involving a truly com- mous, consensus that PUP laws do not appear to hold much mitted police officer in Woodbridge, Illinois, succeeded in potential to interrupt the youth tobacco use cycle and do not reducing self reported youth smoking rates by over 50%. Con- warrant significant investment of tobacco control resources. sistent with the simulation analysis prediction, however, that Among the dissenters, a few participants argued that community increased compliance with the law from 30% of effectively publicised and executed, PUP laws might deter sig- stores to over 95%.9 Although there are arguments to the nificant numbers of youths from falling into the tobacco contrary,10 the prospects for relying on youth access laws to experimentation trap.14 They noted that most states have PUP substantially reduce youth smoking in general seem dim. At laws in place, and that respect for the law demanded that they least they can serve as a rallying point for community and law be taken seriously. Even opponents of PUP laws, including the enforcement involvement in tobacco control. authors of the article, observed that attempts to overturn them likely were not worth the effort, given their public popu- larity. UNKNOWNS Any number of other interventions, many of them embodied Harm reduction products in formal policies, may or may not affect youth smoking. The In the next conference topic, Henningfield and colleagues15 data simply are not definitive at this stage. For example, we focused attention on the relevance to youth tobacco control of know that workplace smoking bans reduce adult smoking.11 the emerging issue of tobacco “harm reduction”. Primarily a But do they also send a message that filters down to change concern related to the future of adult tobacco use,16 harm young people’s behaviour? We do not know. Similarly, the best reduction addresses the possibility of getting confirmed ciga- evidence now indicates that complete (not partial) bans on all rette smokers to switch to less hazardous