Although the epidemic of disease and death from
smoking is played out in adulthood, it begins in childhood. Every
day another 3000 young people become regular smokers. A person
who has not started smoking as a teenager is unlikely ever to
become a smoker. The tobacco industry has argued that the
decision to smoke and to continue smoking is a free choice made
by an adult, but nicotine addiction is really a condition that
takes hold in young people.
Ask a smoker when he or she began to smoke, and chances are you will hear the tale of a child. The image of children sneaking away to experiment with tobacco is a familiar one, and people often consider smoking a rite of passage. But many young people progress steadily from experimentation to regular use, with addiction taking hold within a few years, making the image more disconcerting. Between one third and one half of adolescents who try smoking even just a few cigarettes soon become regular smokers.
Young people's addiction to nicotine is not limited to smoking. Many children also use smokeless tobacco, such as snuff and chewing tobacco. Of the 6 million people in this country who use smokeless tobacco, as many as 1 in 4 is under the age of 19 years. An understanding of the forces that encourage tobacco use by children and adolescents, including industry marketing and easy access, is an essential ingredient in the development of a public policy to reduce the morbidity and mortality associated with smoking.
Young people are the tobacco industry's primary source of new customers in this country, replacing adults who have either quit smoking or died. As the prevalence of smoking among adults in the United States has steadily declined, the prevalence among adolescents has remained unchanged or even increased slightly.
In 1991, 28 percent of high-school seniors had smoked within the previous 30 days, and by 1993 the proportion had increased to 30 percent. Smoking prevalence among college freshmen rose from 9 percent in 1985 to 13 percent in 1994.
An internal document of a Canadian tobacco company, an affiliate of a tobacco company in the United States, underscores the importance of the youth market to the tobacco industry: "If the last ten years have taught us anything, it is that the industry is dominated by the companies who respond most effectively to needs of the younger smokers.
What is perhaps most striking is that 7 of 10 young people who smoke report that they regret ever having started. Three of four young smokers have tried to quit at least once and failed. The sense of regret and helplessness among teenagers was documented in focus group studies of young smokers sponsored by one tobacco company more than a decade ago. A report on one of those studies noted: "However intriguing smoking was at 11, 12, or 13, by the age of 16 or 17 many regretted their use of cigarettes for health reasons and because they feel unable to stop smoking when they want to. Over half claim they want to quit. However, they cannot quit any easier than adults can."
A subsequent report on youth smoking for the company stated: "The desire to quit seems to come earlier now than before, even prior to the end of high school. In fact, it often seems to take hold as soon as the recent starter admits to himself that he is hooked on smoking. However the desire to quit, and actually carrying it out, are two quite different things, as the would-be quitter soon learns."
Young people are aware of the dangers associated with smoking and nicotine addiction, but they do not believe that these dangers apply to them. Until they are in the grip of nicotine addiction, they greatly underestimate its power over them.
Nicotine meets the key criteria for addiction or dependence used by major medical organizations. The marketplace for tobacco products is sustained by this addiction. The 1988 Surgeon General's report concluded, "Cigarettes and other forms of tobacco are addicting . . . [and] nicotine is the drug in tobacco that causes addiction."
The Surgeon General's conclusion drew on criteria for addiction or dependence used by U.S. and international medical organizations, including the following: "Compulsive use (despite a desire, or repeated attempts, to quit), psychoactive effects produced by the action of the substance on the brain, and behavior motivated by the "reinforcing" effects of the psychoactive substance."
For policy makers, the key fact is that young people are becoming addicted. Statements in internal documents by industry researchers and executives show their understanding that nicotine is addictive. The general counsel of one large American tobacco company said, more than three decades ago, "We are, then, in the business of selling nicotine, an addictive drug."
As recently as last year, a former chief executive officer of another large American tobacco company told the Wall Street journal, "Of course it's addictive. That's why you smoke. . . ." According to a chemist formerly employed by a manufacturer of smokeless tobacco, "There used to be a saying at [the company] that 'There's a hook in every can . . . and that hook is nicotine.'"
The epidemic of addiction to nicotine among young people has enormous consequences for public health. Each year in the United States, more than 400,000 smokers die of smoking-related illnesses. Smoking kills more people than AIDS, car accidents, alcohol, homicides, illegal drugs, suicides, and fires combined. Diseases associated with smoking include heart disease, lung cancer, chronic bronchitis, and emphysema. Smokeless tobacco is linked to oral cancers and can cause tooth abrasion, gum recession, and leukoplakia.
We cannot adequately address this enormous health problem without recognizing the important influences on a young person's decision to smoke. One such influence is the tobacco industry's advertising and promotion. Despite a long-standing ban on broadcast tobacco advertisements, in 1992 alone the cigarette industry spent more than $5.2 billion on advertising. Only the automobile industry spends more on advertising in the United States.
Tobacco is advertised in the print media; on billboards; in the stores that sell it; through direct mail; on an array of consumer items such as hats, T-shirts, jackets, and lighters; and at concerts and sporting events. Half of all adolescent smokers and one quarter of adolescent nonsmokers own at least one promotional item from a tobacco company, according to a 1992 Gallup survey. Tobacco companies also sponsor athletic, musical, sporting, and other events in an effort to link their products with images of physical prowess, glamour, excitement, and fun.
Studies show that tobacco advertising and promotion are especially effective with young people. For example, a recent study by the Centers for Disease Control and Prevention found that 86 percent of underage smokers who purchase their own cigarettes buy one of the three most heavily advertised brands: Marlboro, Camel, or Newport. Adults are far more likely to purchase brands that do not rely on imagery in their packaging or advertising, which account for 39 percent of cigarette sales. Another study found that an advertising campaign intended for women was associated with a substantial increase in the number of girls who started smoking. Advertising experts describe the cigarette package as a "badge" product that adolescents use to project a desired self-image to their peers.
Moreover, the sheer magnitude of cigarette advertising creates the impression among young people that smoking is much more widespread and socially acceptable than it is. Young smokers consistently overestimate the percentage of people who smoke.
One cigarette company's marketing campaign, called the Young Adult Smokers, or YAS, program, illustrates how marketing strategies can influence young smokers. The program was designed to appeal to people between the ages of 18 and 24 years and, more narrowly, to the 18-to-20-year-old audience. One element of the YAS campaign, known as FUBYAS, for First Usual Brand Young Adult Smokers, was based on the company's research in the 1980s, which showed that the brand that smokers use when they begin to smoke regularly is the brand they stay with for years. In the course of the YAS program, a division manager of the company in Sarasota, Florida, issued a memorandum January 10, 1990, asking sales representatives and others to identify stores in their areas that "are heavily frequented by young adult shoppers. These stores can be in close proximity to colleges [and] high schools. . . ." The memorandum was intended to make sure that the stores would be stocked with youth-oriented consumer items featuring the name of the company's cigarettes and associated images.
The Wall Street journal revealed the contents of this letter and quoted company officials as saying it was a mistake that had been corrected. Three months later, however, a division manager in Oklahoma sent a memorandum to sales representatives about "Retail Young Adult Smoker Retailer Account [s]." The memorandum stated, "The criteria for you to utilize in identifying these accounts are as follows: (1) . . . calls located across from, adjacent to [or] in the general vicinity of the High Schools. . . ."
In 1988 the company launched a campaign featuring Joe Camel, a cartoon character who gave dating advice called "smooth moves" and was joined by other hip camels at the "watering hole." The campaign created an icon that was recognizable even to young children. One study found that children as young as three to six years old recognized Camel and know that he is associated with cigarettes. The study found that children are as familiar with Joe Camel as they are with Ronald McDonald.
The YAS campaign had a clear effect on young smokers. Previously, Camel was not generally regarded as a brand with youth appeal. In a 1978-1980 survey, only 2 percent of 18- and 19-year-olds named Camel as their brand. No data are available on the brand's appeal to younger smokers. But a year into the campaign, studies show that Camel's share of the 12-to-18-year old market was 8 percent, and within a few years it was 13 percent. During the same period, Camel's share of the adult market barely moved from 4 percent.
Another example of marketing practices that attract young people comes from the largest producer of smokeless tobacco in America, which in the 1970s redesigned its products and re-focused its advertising and promotion to appeal to young people, especially young men. Company documents indicate that lower- nicotine "starter" brands were created to attract new users who could not tolerate the higher-nicotine products. One document shows that the company expected its customers to "graduate" from low-nicotine products to those containing the highest levels of nicotine. The company also developed a cherry-flavored product, which a former sales representative told the Wall Street journal "is for somebody who likes the taste of candy, if you know what I'm saying."
The idea behind this product-development and marketing strategy was captured in a statement made in 1968 by a vice-president of the company: "We must sell the use of tobacco in the mouth and appeal to young people....... We hope to start a fad .1132 The strategy was extremely successful in recruiting young users of smokeless tobacco. The use of snuff by 18-to-19-year old boys increased by 1500 percent from 1970 to 1991.
Young people who choose to smoke cigarettes or use smokeless tobacco have easy access to these products. They are among the most widely available consumer products in the United States, sold in virtually every gas station, convenience store, drug store, and grocery store. Although every state in the country prohibits the sale of cigarettes to customers who are underage (under 18 years in most states, under 19 in a few, and under 21 in one state), study after study demonstrates that these, laws are widely ignored. A 1990 survey by the National Cancer Institute found that 8 of 10 ninth graders said it would be easy for them to buy their own cigarettes. By some estimates, at least as many as 255 million packs are sold to minors each year.
Young smokers are likely to buy their cigarettes from vending machines, where they can make their purchases quickly, often unnoticed by adults. The 1994 Surgeon General's Report examined nine studies on vending machine sales and found that underage persons were able to buy cigarettes 82 to 100 percent of the time. But easy access is not restricted to vending machines. Self-service displays also allow buyers to help themselves to packs of cigarettes or cans of smokeless tobacco, making it easier for underage persons to buy tobacco products.
What are the options for developing a policy to respond to this serious epidemic in young people? A year and a half ago, the Food and Drug Administration (FDA) raised the question whether nicotine-containing tobacco products are subject to regulation by the FDA under the Federal Food, Drug, and Cosmetic Act. That statute defines a drug, in part, as an article "intended to affect the structure or any function of the body." During the past year, the FDA has been investigating this question, but already certain policy considerations are clear.
With some 40 million smokers in this country addicted to nicotine, a ban on tobacco is not feasible. Abrupt removal of these products from the market could lead to serious adverse effects on those addicted to nicotine and possibly result in a black market as well. A more reasonable approach is to focus on the problem of smoking where it begins - in young people. A comprehensive and effective policy is needed to prevent future generations of young people from becoming addicted to nicotine in tobacco. Such an approach should have three objectives: to reduce access to tobacco products by children and teenagers; to convince young people that nicotine is addictive and that tobacco products pose serious health hazards for them, not just for other people; and to reduce the powerful imagery in tobacco advertising and promotion that encourages young people to begin using tobacco products.
These types of actions have been advocated by many public health experts and organizations, including, most recently, the Institute of Medicine. Moreover, a recent poll sponsored by the Robert Wood Johnson Foundation showed widespread public support for measures to reduce smoking by young people. When it comes to health, we Americans are impatient. We venerate the deliberate, cautious scientific method but yearn for instant cures. We grow restless waiting years or even months for answers to medical problems, but the solution to this epidemic lies in the next generation. By altering the smoking habits of young people, we could radically reduce the incidence of smoking-related death and disease, and the next generation would see nicotine addiction go the way of smallpox and poliomyelitis.
DAVID A. KESSLER, M.D.
Food and Drug Administration
Rockville, MD 20857
This text, with references,
was published in the New England Journal of Medicine, July 20th,
1995.
