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Other Tobacco Company Activities and Tobacco Use Among Youth

Introduction

This section summarizes those tobacco industry programs with the stated purpose of preventing smoking among youth; those programs began emerging in the 1980s. A review of industry documents made public under the terms of legal settlements shows that the focus of these programs and their timing has been in response to mounting public concern about the industry’s marketing practices and an attempt to forestall legislation or regulation that would restrict its activities (Landman et al. 2002; Mandel et al. 2006; Sebrié and Glantz 2007; Apollonio and Malone 2010). For example, a confidential presentation by the Tobacco Institute (which was dissolved in 1998 as a result of state litigation against the tobacco industry) that Landman and colleagues (2002) surmised was written around 1982–1983 indicates that the Tobacco Institute considered

“the potential positive outcomes of adopting programs of this nature [youth smoking prevention] may be … a more sophisticated understanding by government regulators of the needs/behaviors of our industry. For example, a program to discourage adolescents from smoking (an adult decision) might prevent or delay further regulation of the tobacco industry” (Tobacco Institute, n.d., Bates No. TIMN0018970/8979, p. 7).

Sussman (2002) has provided a useful chronology of the industry’s youth smoking prevention programs, which reports that these efforts have tended to focus on parental and peer influences on youth smoking, general decision making and life skills, and issues concerning youth access to tobacco, especially the notion that underage smoking is illegal. It is notable, according to Sussman, that the prevention activities and educational programs developed and supported by the industry ignore the influence of tobacco advertising and promotion on the uptake of youth smoking, the importance of parents not smoking or quitting to provide nonsmoking role models for their children, and an explanation about addiction to tobacco and the problem of serious smoking-related illnesses. In brief, the industry’s youth smoking prevention activities fall broadly into five main categories: (1) family involvement self-help booklets, (2) school-based smoking prevention programs, (3) programs to prevent youth from accessing tobacco, (4) mass media campaigns advocating that youth not smoke, and (5) community-based programs for youth. These activities rarely, if ever, include more effective messages that concentrate on the industry’s behavior (; Mandel et al. 2006) and, consistent with industry advertising themes that present smoking as a way to join the adult world, stress that smoking is an “adult choice” or “adult decision.”

Figure 5.6

Tobacco industry paradigm shift. Source: Figure A (a tobacco document reproduced as Figure 1 in Mandel et al. 2006). Note: This slide, from a 1999 Philip Morris (PM) “Key Initiative Update,” describes how it hoped to use its youth smoking (more...)

Self-Help Booklets for Families

In 1984, the Tobacco Institute formed an alliance with the National Association of State Boards of Education (NASBE) to disseminate its Helping Youth Decide booklet, which described a program emphasizing the importance of parent-child communication and responsible decision making (USDHHS 1994, pp. 237–8). Although it acknowledged that young people should not smoke, the program offered no specific advice on preventing tobacco use (Coulson 1985). In 1987, a new version of the program focused more clearly on tobacco use, although family communication and decision making were retained as key skills required to prevent tobacco use (USDHHS 1994). In 1988, NASBE withdrew its sponsorship of the Tobacco Institute’s programs after a growing conflict between the two organizations about content (Landman et al. 2002). The Tobacco Institute then created its own foundation, the Family C.O.U.R.S.E. Consortium (Communication through Open minds, Understanding, Respect and Self Esteem), which was showcased as a “not-for-profit organization comprised of educators, youth organization professionals and other interested parties” (Sparber and Blaunstein 1991, Bates No. TIMN 0188142, p. 1). No evaluation of the “Helping Youth Decide” program or Family C.O.U.R.S.E. is available to the public (USDHHS 1994).

Other parent-based booklets have been created by RJR (Right Decisions, Right Now), B&W (on its Web site for preventing smoking among youth), and Lorillard (Take 10), with the materials in those booklets similar to Helping Youth Decide (Sussman 2002). As of June 2008, Lorillard’s program for parents available through its Web site was called “Real Parents. Real Answers” (Lorillard 2010a). The company offered a brochure, digital video discs (DVDs), and podcasts for parents as well as testimonials from parents about talking to kids and resources for organizations to use with parents. Philip Morris went even further with this kind of approach by developing a televised mass media campaign to encourage parents to talk with their children about tobacco that aired between 1999 and 2006 (see “Industry-Sponsored School-Based Prevention Programs” below). From 2007, Philip Morris has relied on information provided through its Web site, including a brochure entitled Raising Kids Who Don’t Smoke (Philip Morris USA 2010).

Nearly two decades ago, DiFranza and McAfee (1992) expressed concern that by emphasizing smoking as an adult choice and excluding consideration of health consequences and addiction, brochures such as the Tobacco Institute’s Tobacco: Helping Youth Say No might have adverse consequences by portraying tobacco as a “forbidden fruit” and thereby “help youth to say ‘yes’ to tobacco.” Aside from these concerns about the possible rebound effects of the industry-preferred type of messages, a study of perceptions among youth of the brochure’s content found it was rated poorly compared with similar brochures from tobacco control sources.

Somewhat more recently, DeBon and Klesges (1996) compared the Tobacco Institute’s Tobacco: Helping Youth Say No brochure with one produced by the American Lung Association (ALA). Both brochures stressed the importance of communication, and both discussed peer pressure and responsible decision making. Unlike the Tobacco Institute brochure, however, the ALA brochure also discussed parents as role models for youth (by not smoking, or quitting) and the health consequences and other costs of smoking, and provided tips for quitting. The Tobacco Institute brochure, but not the ALA brochure, discussed smoking as an illegal act for youth. In the study by DeBon and Klesges (1996), seventh-grade students from six schools in Memphis, Tennessee, were presented with “strategy vignettes” covering all of the program components within the two brochures and were asked to rate the effectiveness of the Tobacco Institute and ALA approaches within each of seven program components. The ALA’s approach was rated as more effective by students on six of the components (peer pressure, parents as role models, the health consequences of smoking, the costs of smoking, tips for quitting, and responsible decision making), and the Tobacco Institute’s was rated as more effective on one (not smoking because it is illegal). Notably, the kind of approach adopted by the Tobacco Institute did not meet the recommended criteria established by NCI (USDHHS 1994) for effective smoking prevention or currently recommended criteria (see Chapter 6).

Industry-Sponsored School-Based Prevention Programs

During 1998, Philip Morris and B&W jointly decided to promote the LifeSkills Training (LST) program in schools throughout the United States (Mandel et al. 2006). This program had been found in National Instute of Health-funded research to prevent the uptake of smoking and also to reduce the use of alcohol and marijuana (Botvin and Griffiths 2002). The school-based curriculum focuses on social risk factors, including media influence and peer pressure, and personal risk factors such as anxiety and low self-esteem (B&W 1997). Three of the 12 LST units (Smoking: Myths and Realities; Smoking and Biofeedback; and Advertising) focus primarily on tobacco—including increasing awareness of the immediate and long-term health consequences of using tobacco and techniques employed by advertisers to influence consumer behavior (the lessons included in the program do not mention tobacco marketing specifically but refer to more general strategies).

An evaluation of the program by Interactive, Inc. (Ashland, Virginia) for the tobacco companies used a cohort design to assess change over time in knowledge, attitudes, and behavior relative to tobacco, alcohol, and other drugs within three groups of sixth-grade students: 1,985 students from a “national treatment sample” of 24 states implementing LST as a result of promotional efforts by APCO Worldwide, a public relations company headquartered in Washington, D.C., that does extensive public relations for tobacco companies (Mandel et al. 2006); 2,452 students from West Virginia, which had implemented the program on a statewide basis; and 547 students in a national control group (Interactive 2000). The study found that, compared to control students, those receiving LST showed improvements in their knowledge about the physiological effects of smoking but registered no change in their attitudes on the social acceptability of smoking and showed reductions in decision-making skills (Interactive 2000). Increases in 30-day smoking were observed in both the LST and control samples. Although it would have been possible to compare the LST and control groups to test whether LST slowed the rate of smoking uptake, this analysis was not done (Mandel et al. 2006). Interactive’s explanation was that the control group had characteristics that differed from those of the LST students, and so the comparison could not be done.

A follow-up of these cohorts in year 2 showed increases in knowledge of the physiological effects of smoking in the national sample but decreases on the same measure in the West Virginia sample (Interactive 2001). Both of these LST cohorts showed significant declines in refusal and decision-making skills and significant increases in 30-day smoking. Again, no comparison was made with the control group on these variables (Interactive 2001). Overall, the evaluation did not show positive changes from the LST program and did show some negative changes in relation to youth smoking. No report on year 3 was made public or was located in the tobacco industry documents, but despite the poor results in terms of actual reductions in youth smoking, Philip Morris and B&W continued to disseminate LST (Mandel et al. 2006).

Mandel and colleagues (2006) provide evidence that one goal of the tobacco industry in promoting LST was to encourage states to expend state Master Settlement Agreement funds for the LST program. Companies sought matching state grants to implement the program (Mandel et al. 2006), and Philip Morris publicized how many schools were involved in LST. For example, as of June 27, 2008, the Philip Morris Web site reported that between 1999 and 2007, “we provided more than $37 million to schools and school districts in 24 states for the implementation of LifeSkills Training. With our support, more than one million middle-school students have participated in this program” (Philip Morris USA 2008a).

In 2000, 2 years after its joint decision with B&W to promote the LST program in U.S. schools, Philip Morris provided schools throughout the country with covers for school books with the message “Think. Don’t Smoke” that included the company name of Philip Morris (Clegg Smith and Wakefield 2001). Some schools, however, criticized the book covers for delivering an underlying procigarette message, because the book covers were clearly identified as coming from a tobacco company. In a review of transcripts from testimony of tobacco industry witnesses in tobacco litigation cases from 1992 to 2002, Wakefield and colleagues (2006b) presented industry responses to this issue. Ellen Merlo, vice president of corporate affairs at Philip Morris, reported that even though the company had changed, it would “think long and hard, because maybe people are not yet ready for us to supply something like a book cover” (Merlo 2001).

A substantial body of research has demonstrated that antitobacco-industry attitudes reduce the likelihood of future initiation of smoking among youth and young adults (Sly et al. 2000, 2001; Farrelly et al. 2002, 2005, 2009; Hersey et al. 2003, 2005a,b; Thrasher et al. 2004, 2006; Ling et al. 2007, 2009; Davis et al. 2009). At the same time, book covers provided to students by the tobacco industry, as well as other industry-sponsored efforts with the stated purpose of preventing youth tobacco use, could create favorable impressions of the sponsoring tobacco companies among young people, their parents, or others in the community.

Industry/Community Partnerships on Tobacco Use Among Youth

The tobacco industry has also invested in other community-based programs aimed at youth, such as the national 4-H program (“Head, Heart, Hands, and Health”). 4-H is the youth education branch of the U.S. Department of Agriculture’s Cooperative Extension System and a respected organization that emphasizes “learning by doing” (Landman et al. 2002). In March 1999, the National 4-H Council announced a new partnership with Philip Morris as a result of receiving a $1.7 million grant to design and implement a youth smoking prevention initiative (Landman et al. 2002). Despite protests from the public health community and the refusal of 27 of the 50 state 4-H organizations to participate, the national 4-H organization continued its partnership that led to the “Health Rocks” program (National 4-H Council 2010). This program, which includes a Web site, emphasizes general life skills and making healthy choices. Although a longitudinal evaluation of this program in collaboration with Tufts University was discussed in a Philip Morris document in 2001 (Philip Morris USA 2001), no reports were found in the publically available tobacco industry documents on the effects of this program. Philip Morris has also sponsored two programs offered by the Boys & Girls Clubs of America, “Upward Bound” and “SMART (Skills Mastery and Resistance Training) Moves” (Boys & Girls Clubs of America 2010), that had been previously evaluated (U.S. Department of Education 1997; Harvard Family Research Project 2010).

In addition to these programs, tobacco companies have historically given funds to a wide variety of youth-serving organizations (Landman et al. 2002). This practice continued through at least 2010, with grants given by the Altria companies (Philip Morris USA, John Middleton Co., and U.S. Smokeless Tobacco). The 2010 report from Altria stated that its companies gave more than $21 million to positive youth development that year; recipients included the University of Colorado at Boulder, America’s Promise Alliance, Corporate Voices for Working Families, The Finance Project, the Forum for Youth Investment, Responsible Retailing Forum, Search Institute, Big Brothers/Big Sisters of America, Caron Foundation, and the University of Virginia (Altria 2011).

Industry-Sponsored Programs to Prevent Youth from Accessing Tobacco

The tobacco industry has aligned itself with efforts to prevent youth from purchasing tobacco since the late 1980s when laws to prevent sales to minors became popular in the United States. The industry has conducted a range of educational programs for tobacco retailers, and it has used the networks developed through its programs to affect legislation it perceived would harm tobacco sales (Landman et al. 2002).

Tobacco Industry Programs in Retailer Education

“It’s the Law,” a program introduced by the Tobacco Institute in 1990 (Tobacco Institute 1990), was an educational campaign with a primary message that it is illegal for minors to purchase tobacco (Forster and Wolfson 1998); included in the campaign were a series of decals, buttons, and educational materials for retailers. B&W launched a similar program in 1992, called “Support the Law…It Works!,” partnering with the United States Junior Chamber (Sussman 2002). The program included store signage as well as a videotape and brochure to train store personnel. In a February 1992 letter to state governors, the president of the Tobacco Institute, Samuel D. Chilcote, Jr., stated that “over one million pieces of program materials have been distributed to thousands of retail outlets across the country” (Chilcote 1992, Bates No. TI41816030/6031, p. 2). In 1992, B&W reported that more than 70,000 stores received its program material on reducing youth access (Sussman 2002).

A far less optimistic view of program implementation and effectiveness was found in a 1991 study of youth aged 13–16 years and 156 retailers in Massachusetts (DiFranza and Brown 1992). This study found that only 7 of the 156 retailers were participating in “It’s the Law.” Furthermore, six of the seven (86%) participating retailers were found to be willing to sell tobacco to minors (based on successful attempts by youth), and 88% (131 of 149) of the nonparticipating retailers were willing to make such sales (again based on the investigation). Another study compared outcomes of 480 attempted tobacco purchases by youth aged 12–17 years in 40 selected stores participating in “It’s the Law” or similar programs with data from 40 stores not participating in these programs (DiFranza et al. 1996). The study found that stores involved in “It’s the Law” were as likely to make illegal cigarette sales to these youth as were nonparticipating stores.

Philip Morris took over management of “It’s the Law” in 1994 (Landman et al. 2002) and made it part of its “Action Against Access” program in 1995. This program promised to end the distribution of samples, deny slotting fees (fees paid to retailers by tobacco companies to place a tobacco product on retail shelves) to retailers found to be selling tobacco to minors, require cigarettes to be in sight of sales clerks, encourage “reasonable” licensure laws, and require proof-of-age signage (Forster and Wolfson 1998). In 1995, another campaign, “We Card,” was launched by the tobacco-industry-created Coalition for Responsible Tobacco Retailing, Inc., and was supported by multiple tobacco companies, including B&W, U.S. Tobacco, and RJR. The campaign included age calendars, employee training videos, and purchase attempts by youth to assess compliance (Forster and Wolfson 1998). This campaign, at least in some states, was accompanied by extensive regional training meetings with retailers.

As in other studies of industry-sponsored youth access programs, the results of evaluations found limited evidence of substantial program implementation or effectiveness. One study found that retail stores selling tobacco products and displaying the tobacco industry’s “We Card” signs had average rates of sales to youth roughly equal to those of stores without signs and that the stores with the signs were significantly more likely to make illegal sales to minors than were outlets with government-sponsored signs about not selling to youth (Cowling and Robbins 2000). Tobacco industry documents show that “We Card” was undertaken for two primary purposes: to improve the tobacco industry’s image, and to undermine and co-opt retailer compliance programs run by law enforcement and state public health departments (Apollonio and Malone 2010). Apollonio and Malone reported that the tobacco industry and retailers anticipated from the program’s inception that “We Card” could be used to block stronger policies restricting youth access to tobacco. Furthermore, industry surveys in 1996 found that retailers considered the blocking of stronger policies to be an excellent use of the program (Sederholm Public Affairs 1996). However, Tobacco Institute lobbyists viewed the program as primarily political, noting in a 1997 report: “Once again, work by the WE CARD Coalition has been instrumental in state efforts to enact reasonable youth access laws” (Chilcote 1997, Bates No. 98876422/6426, p. 3)—that is, state laws preempting stronger local legislation. An audit of “Action Against Access” by former U.S. Senator Warren B. Rudman found that the program was not fully implemented and that retailers did not take it seriously (Campaign for Tobacco-Free Kids 2005). Two years after the program had been put in place, Philip Morris had penalized only 16 tobacco retailers out of the hundreds of thousands illegally selling to youth (Advocacy Institute 1998). In addition, despite Philip Morris’ promise to withhold slotting fees from retailers who had been convicted of illegal sales to minors, the company did not respond to the lists of convicted retailers furnished to them by at least four states (Forster and Wolfson 1998).

The Influences of the Tobacco Industry’s Youth Access Program on State and Local Tobacco Control Policies

By investing in retailer education programs for compliance with youth access laws, the tobacco industry further leveraged its relationships with groups of retailers, often with results that were detrimental to tobacco control. In a review of the policies and politics of youth access, for example, Forster and Wolfson (1998) found that the tobacco industry used sham citizen groups or its networks of retailers to support bills that would serve to undermine aspects of proposed laws on youth access. This finding is illustrated well by DiFranza and Godshall (1996), who reviewed bills on youth access that were introduced in 12 states by state legislators supportive of the tobacco industry. Provisions of these industry-supported bills included: (1) preemption clauses that prohibited units of local government from passing stricter laws than those passed by the state or federal government; (2) provisions restricting enforcement authority to a single state agency that was ill-equipped to carry out such enforcement (such as a department of agriculture or revenue); (3) provisions that made successful prosecution difficult or impossible (e.g., a requirement that violations of age-of-sale laws involve intent on the part of the merchant to sell tobacco products to a minor); (4) prohibition of compliance checks by individuals or organizations other than law enforcement, such as public health officials, citizen activists, or the press; and (5) prohibition of the purchase of tobacco products by minors, which would halt age-of-sale compliance operations that use youth to attempt to make purchases (DiFranza and Godshall 1996). Other studies indicate the extent to which the industry has been an active proponent of preemption laws to prohibit local government from passing stricter laws than those passed by the state (Siegel et al. 1997).

The tobacco industry has also actively supported laws to penalize youth for possessing, using, and purchasing tobacco—laws that have been criticized because they ignore the responsibilities of the industry and retailers (Wakefield and Giovino 2003). Forster and Wolfson (1998) concluded that the tobacco manufacturers’ and retailer organizations’ voluntary efforts to educate and train retailers were essentially aimed at exonerating them from any responsibility for smoking by youth and to focus blame on the minors who attempt to purchase tobacco and the clerks who sell it to them.

In a study of internal documents from tobacco companies, Landman and colleagues (2002) found that the industry used its programs on youth access to undermine tobacco control efforts. For example, a series of e-mails in 1996 between high-level Philip Morris executives revealed that Philip Morris placed ads for “Action Against Access” in locations where legislators would be sure to see them (Merlo 1996), and the company used the presence of programs such as this to argue against the need for government funding of further tobacco control efforts (Slavitt 1992). Furthermore, the tobacco industry used its network of retailers to disseminate information about proposed local ordinances on tobacco control in an effort to rally retailers to oppose them. A confidential 1992 report from the Tobacco Institute stated, “For monitoring purposes, we fund our allies in the convenience store group to regularly report on ordinance introductions and assist in campaigns to stop unreasonable measures.… Promotion of The Institute’s ‘It’s the Law’ program and other industry programs play a helpful role as well” (Malmgren 1992, Bates No. 2023959567/9579, p. 5).

Industry documents also reveal that it used its network of retailers to detect and oppose measures related to restrictions on advertising and laws requiring clean indoor air (Ohio Licensed Beverage Association 1995; Riskind and Bradshaw 1995; Hannah Report 1996; Philip Morris USA 1996; Welsh-Huggins 2001). A 1996 Tobacco Institute press release argued that the 1994 FDA proposal to end tobacco advertisements within 1,000 feet of schools, eliminate self-service tobacco displays, and require “tombstone” advertising (advertisements that consist only of black print on a white background, without pictures) for tobacco products was unnecessary because the industry’s “We Card” program was “now making a measurable difference” (Tobacco Institute 1996, Bates No. 106018947/8948, p. 2). Philip Morris also used “Action Against Access” as part of its argument that FDA’s proposal was unnecessary (Parrish 1995). Apollonio and Malone (2010) concluded that industry programs such as

“We Card … are designed to suggest that tobacco companies are part of the solution to the problem of youth tobacco use. In doing so, they also serve to reify youth tobacco use as the prevailing definition of the tobacco policy problem, distracting the public and policymakers from the fact that cigarettes remain the single most deadly consumer product ever made” (p. 1196).

Industry-Sponsored Antismoking Campaigns in the Mass Media

In 1996, Philip Morris launched a $10 million advertising campaign to promote youth smoking prevention (SCARC Action Alert 1996), a campaign that included newspaper and magazine advertisements and highlighted the company’s initiatives on restricting youth access. This campaign and others emerged at a time when the company was facing a number of legal challenges alleging corporate misconduct (Wakefield et al. 2006b).

In the late 1990s, two tobacco companies launched televised mass-media campaigns focused on the prevention of youth smoking in the United States. A Philip Morris youth smoking prevention campaign consisting of several television and magazine advertisements carrying the slogan “Think. Don’t Smoke” ran from 1998 to 2002 (Sussman 2002); according to the company, the target audience was youth aged 10–14 years (Sussman 2002). In 1999, a second Philip Morris campaign, “Talk. They’ll Listen,” made its debut on television; this campaign focused on parents talking to their children about smoking and ran until late 2006. Tobacco companies portrayed their allocations of funding as evidence that they were serious about reducing youth smoking. During testimony in the U.S. Department of Justice lawsuit in 2005, Philip Morris indicated that “our budget has fluctuated somewhat from year to year, but on average, we have spent $100 million a year over the last 6 years in the department. The expenditures from 1998 through 2004 total $657 million” (Willard 2005, p. 9). Philip Morris USA Senior Director of Communications, Peggy Roberts, indicated the company had spent “more than $1 billion on youth smoking prevention efforts” (Ascribe 2006).

Between 1999 and 2004, Lorillard’s “Tobacco Is Whacko if You’re a Teen” campaign appeared widely in youth magazines and on popular cable television, including ESPN, MTV, and Warner Bros. stations (Landman et al. 2002). Eventually, Lorillard replaced its youth campaign with advertisements targeting parents. Formerly known as “Take 10,” the Lorillard prevention campaign adopted the slogan “Parents. The Best Thing Between Kids and Cigarettes.” In 2010, the Lorillard Web site indicated it had spent more than $80 million on efforts to prevent youth smoking (Lorillard 2010b).

The monies invested in these campaigns helped to ensure widespread exposure to the industry’s efforts among youth and adults. According to Nielsen media monitoring data from 1999 to 2003, the exposure of adolescents to Philip Morris’ and Lorillard’s youth prevention ads matched those for antitobacco advertising from all state and national tobacco control programs (Wakefield et al. 2005b). However, exposure to youth prevention advertisements sponsored by tobacco companies was found to be greatest across adult audience segments and relatively lower among adolescents (Wakefield et al. 2005b). Despite these high exposure levels, the effectiveness of these campaigns in reducing youth smoking is questionable.

Studies of the efficacy of tobacco-company-sponsored advertising have most often used individual ratings of industry sponsored ads, which are compared with ratings of antitobacco ads sponsored by public health organizations or other corporate advertising in a forced-exposure setting. In these studies, youth are exposed individually or in a group setting to a series of ads and then asked to rate each ad immediately after viewing it (e.g., Henriksen and Fortmann 2002; Niederdeppe et al. 2005; Wakefield et al. 2005a; Donovan et al. 2006). Some studies have also required youth to select the ad they perceived to be the most effective or to indicate measures of smoking-related beliefs, attitudes, and intentions following exposure (e.g., Henriksen et al. 2006; Pechmann and Reibling 2006). Others have added follow-up measures of recall and cognitive processing of the ads (e.g., Terry-McElrath et al. 2005). Of the seven studies summarized in , all demonstrate that tobacco-company-sponsored youth prevention ads performed poorly in terms of increased knowledge, perceived effectiveness, and influence on intention to smoke as compared with antitobacco ads sponsored by public health organizations (the seventh study had alcohol-related ads as controls). The studies generally indicate that the ads’ low efficacy is due to their message strategy; consistent with other industry youth smoking prevention efforts, both Philip Morris and Lorillard have focused their messages on social themes, such as making a choice about smoking among peers and within the family or presenting the short-term benefits of not smoking. Ads with these kinds of messages generally perform poorly in comparison with ads that feature the serious health effects of smoking and the marketing and promotion practices of the industry (Farrelly et al. 2002, 2005; NCI 2008).

Table 5.10

Controlled-exposure studies examining televised messages in the tobacco industry’s campaign to prevent youth smoking.

Studies of ninth-graders in schools in California (Pechmann and Reibling 2006) and of Western Australia youth intercepted in shopping malls (Donovan et al. 2006) found that ads with social themes generally did not lower the intention of youth to smoke in the future, but ads focusing on the serious health consequences of smoking (Pechmann and Reibling 2006) or the disgusting aspects of smoking (Donovan et al. 2006) did so. In analyses from the NCI-funded Youth Smoking and the Media study, ads from tobacco companies were found to elicit positive emotions in youth and to be of less interest to that age group than ads sponsored by tobacco control agencies (Wakefield et al. 2005a). In addition, ads that elicited negative emotions such as those with a personal testimonial or negative visceral element were more likely to be recalled, discussed, and thought about by youth at a 1-week follow-up, but ads with these kinds of features were never developed by tobacco companies (Terry-McElrath et al. 2005).

In a study of California adolescents aged 14–17 years, exposure to industry ads engendered more favorable attitudes toward tobacco companies than seeing “truth” ads from the American Legacy Foundation or control ads about drunken driving (Henriksen et al. 2006). Sympathy with the industry was measured by agreement with statements such as “cigarette companies get too much blame for young people smoking” and “cigarette companies should have the same right to sell cigarettes as other companies have to sell their products” (Henriksen et al. 2006, p. 15). In addition, in the study of Western Australia youth described above, which included both smokers and nonsmokers, industry-sponsored ads were rated as highly believable (Donovan et al. 2006). These corporate ads served to increase the credibility of the industry’s message that, although unlikely to change attitudes about smoking per se, may increase positive attitudes toward the tobacco industry and, in turn, reduce criticism from youth advocacy groups in the community (Donovan et al. 2006).

Examining the effects of advertising by using forced-exposure designs can be useful for assessing immediate reactions to individual ads and their short-term influences on smoking-related beliefs and intentions, but available studies do not reflect the usual television-viewing environment with its contextual distractions of television programs, competing advertising, and variable viewer attention. Moreover, forced-exposure studies cannot assess the effects of cumulative exposure to campaign messages over time. By comparison, some study designs have relied on naturalistic exposure in the usual viewing environment and attempted to do so with samples of participants more representative of the population. In these studies, exposure to advertising has usually been measured by asking whether participants can recall seeing any antitobacco ads in a specified period and, if so, having them describe the ads they recall to generate a measure of confirmed recall (Biener 2002; Farrelly et al. 2002, 2009; Davis et al. 2007). Some studies, in contrast, have employed gross rating points (an advertising industry measure that involves multiplying the estimated audience reached by the frequency of the message) as a measure of exposure to advertising (Farrelly et al. 2005; Wakefield et al. 2006c).

Three types of naturalistic exposure studies have examined the effects of industry-sponsored media campaigns in the United States (). In the first type, carried out by Biener (2002), respondents were asked to assess the effectiveness of ads. The author found that adolescents aged 14–17 years rated ads that did not focus on tobacco-related illness as significantly less effective than ads from the state program that featured the serious health consequences of smoking (Biener 2002). These effects were more pronounced among youth aged 16–17 years than those aged 14–15 years.

Table 5.11

Naturalistic studies examining the effect of televised campaigns of the tobacco industry on preventing youth smoking.

The second type of study has involved comparisons of “truth” ads from the American Legacy Foundation in which nationally representative samples of U.S. adolescents aged 12–17 years have been surveyed to determine awareness of the ads, receptivity to them, and tobacco-related knowledge, attitudes, beliefs, and behavior. In the first paper from these studies, reporting a survey conducted 10 months after the launch of the national “truth” campaign, youth who recalled the “Think. Don’t Smoke” ads of Philip Morris were significantly more likely than their unexposed peers to have intentions to smoke in the future; in contrast, confirmed recall of the “truth” campaign was associated with lower intentions to smoke (Farrelly et al. 2002). In addition, youth who recalled the “Think. Don’t Smoke” campaign were less likely to agree with statements such as “cigarette companies deny that cigarettes cause cancer and other harmful diseases,” and “I would like to see cigarette companies go out of business” (Farrelly et al. 2002, p. 904). In subsequent studies using eight cross-sectional telephone surveys, exposure to additional Philip Morris advertisements reinforced these attitudes (Farrelly et al. 2009). Unlike exposure to “truth” ads, which were associated with lower perceptions of the prevalence of smoking, recall of “Think. Don’t Smoke” was unrelated to perceived smoking prevalence (Davis et al. 2007). Because the data from this second group of studies were cross-sectional, part of the explanation for the findings may be that adolescents who already held more favorable opinions about cigarette companies and expressed stronger intentions to smoke in the future were more attentive to Philip Morris ads and therefore more likely to recall them.

The third type of study featured population-based survey data linked to naturalistic data on exposure to media. Here, Wakefield and colleagues (2006c) used data from more than 100,000 students (8th-, 10th-, and 12th-grade students) who had completed the MTF school-based surveys from 1999 to 2002, where beliefs about smoking, intentions to smoke, and smoking behavior comprised the study outcomes (Wakefield et al. 2006c). This study measured exposure to advertising using gross rating points for each type of advertising campaign in the 4 months preceding the surveys in the media markets in which the schools were located. The industry-sponsored advertising included the youth prevention campaigns “Think. Don’t Smoke” and “Tobacco Is Whacko if You’re a Teen” and the Philip Morris parent-directed campaign “Talk. They’ll Listen.”

Multivariable models examined the relationship between level of exposure to advertising and attitude (beliefs), intentions to smoke, and tobacco use behavior while controlling for demographic and other personal data, region, the real price of cigarettes, an index of smoke-free air, and media utilization. The study found that greater exposure to industry-sponsored youth-directed advertising was associated with stronger intentions to smoke among 8th-grade students, but not with other outcomes for 8th-grade students or with any outcome for those in the 10th and 12th grades. Exposure to the tobacco industry’s parent-directed campaign was associated with several undesirable outcomes for 10th- and 12th-grade students, including lower perceived harm from smoking, stronger approval of smoking, stronger intentions to smoke in the future, and a higher likelihood of smoking in the past month.

Wakefield and colleagues (2006c) explained these findings as follows: as adolescents mature, they consider themselves more independent and less reliant on their parents. Thus, messages aimed at parents as authority figures may invite rejection by older adolescents. Despite the sophisticated naturalistic exposure studies available in the literature that have assessed the effectiveness of the industry’s advertising campaigns, the substantial investment of industry in these campaigns, and its insistence on the seriousness of its efforts, the tobacco companies have used very weak methods of program evaluation. For example, in court testimonies from 1992 to 2003, company witnesses focused on advertising reach as a measure of effectiveness (e.g., 90% of 10- to 14-year-olds had seen the advertisements) and on qualitative data, rather than on outcomes involving attitudes, intentions, and behaviors (Merlo 2000).

Although Philip Morris withdrew its television advertising campaign directed at parents after the study by Wakefield and colleagues (2006c) was published, it still cites its own weak evaluation data to suggest that its “Talk. They’ll Listen” campaign had beneficial effects (Philip Morris USA 2008a). Philip Morris also decreased its “Think. Don’t Smoke” campaign from 2002 following the publication of Farrelly and colleagues’ (2002) population-based study indicating that exposure to the campaign was associated with increased intentions to smoke among youth. The lack of substantive studies emerging from the tobacco industry on the actual effects of programs (dollars spent and number of youth contacted, rather than changes in smoking behavior) contrasts sharply with the very detailed evaluations used for the company’s other marketing efforts, as was revealed during litigation. Furthermore, neither Philip Morris, nor any of the other tobacco companies, has released any data on the effects of these programs on the sales of tobacco products, including the large Philip Morris/B&W funded study that demonstrated that LST was followed by increased smoking by youth (Mandel et al. 2006).

One study has examined the responses of youth to the industry’s public relations messages about its corporate responsibility. Henriksen and Fortmann (2002) conducted a controlled-exposure study of 18- to 25-year-old undergraduates in California to determine their perceptions. The authors found that youth who had viewed four ads produced by Philip Morris that contained information on the company’s charitable works had improved perceptions of that company’s corporate image as compared with a control group. The improvement in perceptions was greatest among those who were unaware that Philip Morris was a tobacco company (Henriksen and Fortmann 2002).

A review of media campaigns on prevention of smoking among youth conducted for WHO concluded that industry-sponsored campaigns do not contain message features found to be effective in reducing smoking behavior among youth (Angus et al. 2008). Further, the review noted that these campaigns tend to increase favorable industry-related attitudes among youth, which is consistent with the industry’s broader goal of improving their image and reputation of tobacco companies (Angus et al. 2008). The report concluded that these campaigns may serve to undermine the effectiveness of efforts that seek to increase anti-industry attitudes to deter youth from smoking (Farrelly et al. 2002; Thrasher et al. 2006; Ling et al. 2007, 2009) and pose a risk for youth as they age into adulthood in terms of retaining “an objective and critical perspective on tobacco” (Angus et al. 2008, p. 20).

Summary

The tobacco industry’s youth smoking prevention activities and programs have not provided evidence that they are effective at reducing youth smoking. Indeed, unpublished internal industry documents available to the public because of litigation, and published academic studies, indicate that they are ineffective or serve to promote smoking among youth. Because older adolescents rebel against the programmatic message that tobacco is for adults only, these efforts can lead to a greater likelihood of uptake among youth (Donovan et al. 2006; Henriksen et al. 2006; Wakefield et al. 2006c).

Focusing programs on issues such as parenting, decision making by youth, life skills, and reducing youth access helps to focus the responsibility for smoking on the young people themselves and on their family environment and diverts attention from the tobacco industry’s marketing efforts and the addictiveness of tobacco products. The industry’s approach also positions tobacco as “forbidden fruit,” with tobacco use being portrayed as an “adult only” practice (DiFranza and McAfee 1992), a message consistent with industry marketing messages that present smoking as a way to be “adult.” The WHO Tobacco-Free Initiative recommends that both governmental and nongovernmental organizations avoid partnering with the industry’s youth prevention programs because the programs have been proven to be ineffective and are used to persuade policymakers to opt for weaker legislation (WHO 2004).

The tobacco industry receives five benefits from its youth smoking prevention initiatives:

1. The industry uses these efforts to convey to the public, policymakers, judges, and the members of juries that it is doing something substantial about the issue of youth’s tobacco use. In this way, the programs serve to promote positive attitudes about the tobacco industry. Such positive attitudes could help to limit the industry’s legal liability and make it easier for its views to be heard on legislative issues.

2. The industry is able to use its efforts to prevent smoking by youth to argue that there is less need for public-health-funded tobacco control strategies (Mandel et al. 2006).

3. Investment in these programs provides a venue for the industry to conduct research on determinants of smoking among youth for the stated purpose of developing its prevention programs. However, this information could inform the companies’ tobacco marketing efforts to youth (Mandel et al. 2006). Tobacco industry research on youth has included Philip Morris’ “Teenage Attitudes and Behaviors Study,” which tracked the smoking behavior and motivations of approximately 20,000 11–17-year-olds annually, with a total of 180,000 teens being surveyed between 1999 and 2007 (Philip Morris USA 2008b). Although tobacco companies assert that there is a “firewall” between the research done for the department concerned with preventing smoking by youth and their cigarette marketing efforts, Philip Morris has acknowledged that it rotates employees through both departments (Tobacco on Trial 2005).