"The increase in smoking rates in the 1990s was dramatic and frightening, and part of the reason why our agency was created," said Danny McGoldrick, director of research at the Washington, D.C.-based Campaign for Tobacco-Free Kids, a tobacco prevention advocacy organization. "It's a common misperception that there were a lot of anti-tobacco efforts going on back then, but there weren't."

Thanks in part to the $206 billion master tobacco settlement and the work of organizations like Tobacco-Free Kids, times are changing. Building on the experience of tobacco-tax funded prevention programs in California, Massachusetts and Arizona, states such as Florida and Mississippi have used settlement money to enact comprehensive anti-tobacco campaigns that are garnering attention and results. With the stakes as high as they are, time is of the essence. More than 3,000 adolescents become regular smokers every day. One-third of them will go on to die of a tobacco-related cause.³

Grabbing Their Attention
When Florida began its progressive tobacco prevention program in March 1998, bystanders scratched their heads in wonder. "It was an upside-down idea," remembered Lynnette Kennison, NP, clinical coordinator of the Nicotine Dependence Center at the Mayo Clinic in Jacksonville, FL. "It was difficult for adults to grasp at first."

The theory: Drop the preachy adults. Instead, let kids-nonsmokers and smokers alike-develop an anti-tobacco message that they think would get their friends' attention.

The result? The "truth" campaign, a model that was so successful that the American Legacy Foundation borrowed the title for its national anti-tobacco campaign. Declaring itself "the voice of a generation united against tobacco," Florida's truth campaign funneled teen risk and rebellion to work against the deceptiveness and manipulation of the tobacco establishment. In one truth commercial, two teens drive to a tobacco company looking for the Marlboro Man, only to be told by the security guard that he's dead. In another, teen-agers call people who profit from tobacco and question their motives for being in that business.

Less than 2 years after Florida's truth campaign was initiated, smoking among middle school students dropped 40 percent. Smoking among high school students decreased 18 percent. Overall, 50,000 fewer adolescents were smoking in Florida within 24 months of launching the truth campaign.⁴

Of the campaign's appeal, Kennison said, "Kids don't like to be used, and they don't like to be manipulated for money by adults. Personally, I love the commercials that we're seeing."

Similar in-your-face ads are appearing all over the country. Arizona, recently lauded for its 21 percent drop in smoking rates, has been running ads since 1996 that label tobacco as a "tumor-causing, teeth-staining, smelly, puking habit." To get its point across, the Arizona Department of Health Services Tobacco Education and Prevention Program uses an equation sure to get the attention of its young target audience: humor, graphically intense images and "grossness." One spot begins with a girl brushing her teeth ? only to have her toothpaste turn to wiggling maggots, her skin rot, and her hair fall out. Others, which feature a urinating dog and a girl drinking spit, are equally revolting-and effective.

Anti-tobacco campaigns in a handful of other states are also producing results. A 25-cent-per-pack cigarette tax passed by California voters in 1988 helped fund a prevention program that has diminished cigarette use by more than 50 percent. A similar tax enacted in Massachusetts in 1992 also funded a prevention program and resulted in a 30 percent drop in cigarette use. And Oregon used its tobacco tax revenue to develop a prevention program in 1997, modeled after those in California and Massachusetts, that has led to a 21% drop in tobacco use since its inception.⁴

"What we're finding is that states that have funded comprehensive tobacco prevention programs are making an impact," said McGoldrick. "Unfortunately, most states haven't."

Reading Between the Lines
Meanwhile, tobacco companies aren't sitting idly by. The most recent report from the Federal Trade Commission shows the industry shelling out $8.24 billion in advertising in 1999. That's a 22.3 percent increase from the previous year.⁵

"After the tobacco companies said they would quit marketing to kids, their marketing expenses went up dramatically," noted McGoldrick. Even "anti-smoking" advertisements put out by tobacco companies, some claim, are nothing more than brand promotion ads in disguise.

One such Phillip Morris ad aimed at teens cautions: "Think. Don't Smoke." Casual readers might not bat an eye at the simple slogan, but anti-tobacco advocates warn it's a sophisticated way of saying just the opposite. First, research has shown the word "don't" doesn't work with teen-agers. When teens are told not to do something, especially when they are not given a reason why, their natural impulse is to do it anyway. Second, the ad's representation of a nonsmoking teen isn't exactly the look that risk-taking adolescents are going for these days.

"They show these well-scrubbed 13- and 14-year-olds with an earring in their ear to suggest on the surface that they're 'hip,'" noted McGoldrick. "But it subtly reinforces the message that smoking is something that bad boys and cool kids do, not these nice, young kids shown in the ads."

A similar promotion distributed by Lorillard Tobacco Co. declared, "Tobacco is whacko if you're a teen," which opponents say positions tobacco as an adult habit. For teens yearning to look older than they are, the ad provides incentive to take up smoking, they say.

"These ads play to youth aspirations, which the tobacco companies are so good at," McGoldrick said. "Saying 'don't smoke' instead of 'smoking is a cool habit that bad kids do' is really just saying the same thing in a way that's much more publicly acceptable. If you ask me, it's pretty insidious."

Choosing to Smoke
That's why anti-smoking advocates stress the importance of beginning tobacco prevention messages at a young age. The American Academy of Pediatrics recommends that smoking prevention messages begin with children as young as 5, with an emphasis on resisting the influence of advertising and peer pressure.

According to the Campaign for Tobacco-Free Kids, little data exists on smoking rates for kids younger than 12. But the peak years for first-time cigarette use appear to be around the ages of 11 or 12, or sixth and seventh grades.

"If we can get to them with tobacco prevention message before they reach that age, they may not start," said Jonnie Hamilton, NP, chairwoman of the Tobacco Prevention & Control Task Force for the National Association of Pediatric Nurse Practitioners. "A lot of it also depends on their environment. Parents need to reinforce anti-smoking messages by not smoking themselves."

Kennison agreed. "Kids are influenced by other adults, and their parents particularly. If parents smoke, not only is it a role model for smoking, but it makes it easier for kids to get cigarettes. They get them at home."

Some adults prefer it that way. A nurse practitioner in the Pediatric Allergy and Respiratory Division at Boston Medical Center, Lois Doerr noted that it's not uncommon for employees in local hospitals and health centers, including hers, to allow their children to smoke at home. "These are staff workers from the inner-city who are just so addicted to smoking. They're raising children, and usually in their early teens their children will start, too," she said. "And the mothers' attitudes are, 'Well, I'd rather have them smoking in front of me than sneaking around doing it behind my back.'"

Conquering Myths and Addiction
Consequently, if youth from smoking households are ever going to quit, tobacco education also needs to be aimed at adults. Too often, however, providers overlook the issue when dealing with patients. "Believe it or not, a lot of people still aren't being asked their smoking status by health care professionals," said McGoldrick. "But simply asking patients their smoking status and advising them to quit has an impact on people, especially when it comes from people who are held in such high regard as nurse practitioners, nurses and other health care professionals. It's amazing, but the literature shows that brief counseling of smokers increases their ability to quit."

Providers must also remember that smoking is physically addictive. When teens smoke, adults sometimes have a tendency to write the practice off as a bad behavior rather than a physical and psychological addiction. The reality is that what may have begun as experimentation usually results in addiction. According to the Campaign for Tobacco-Free Kids, almost three of every four teen smokers have tried to quit but failed. Fewer than one in seven high school smokers could quit for 30 days. And while only 3 percnet of teen-age daily smokers think they'll be smoking in 5 years, more than 60 percent are still smoking daily 7 to 9 years later.⁶

The use of pharmaceuticals for teen smoking cessation is controversial, and current clinical studies are evaluating their efficacy with the population. According to Kennison, there are multiple concerns with prescribing for teens. Many medications are not tested or approved for adolescent use, which leaves issues like safety and effectiveness in question. Also, there are obstacles for using nicotine replacement products in school settings, and teens have different psychosocial and behavioral patterns of tobacco use that may reduce the effectiveness of medications that require compliance.

Finally, "teens have expressed a lack of interest in taking pharmaceuticals," said Kennison. "If a pharmaceutical is prescribed, the nurse practitioner should be assured of the teen's tobacco dependence and commitment to quit."

While Kennison is hopeful that the rest of the country will see a decrease in teen smoking like the one in Florida, she's cautious about presuming too much. Before anything groundbreaking happens, she's convinced that more providers, more teachers, more parents and more role models will need to take up the anti-tobacco cause and carry it to new lengths.

If more people would step back and look at the reality of the situation, she said, maybe more would be inclined to act.

"Cigarettes are the only legal product that, when used as directed, is lethal. Other products may have some consequences that aren't always good, but with cigarettes there are very few people who don't get hooked. And if people continue to use cigarettes, half of them are going to die or suffer significant health issues related to them.

"It's a public health disaster," Kennison declared. "And it's time to do something about it."

References

1. National Center for Tobacco-Free Kids. March 20, 2001. Smoking and kids. Fact sheet available at the Campaign for Tobacco-Free Kids Web site: http://tobaccofreekids.org/research/factsheets/pdf/0001.pdf.

2. American Academy of Pediatrics. April 2001. Tobacco's toll: Implications for the pediatrician. Policy statement available at the American Academy of Pediatrics Web site: www.aap.org/policy/re0041.html.

3. National Association of Pediatric Nurse Practitioners. Jan. 26, 2000. NAPNAP position statement: Prevention of tobacco use in the pediatric population. Available at the National Association of Pediatric Nurse Practitioners Web site: www.napnap.org/tobacco.html.

4. National Center for Tobacco-Free Kids. Nov. 21, 2000. Comprehensive statewide tobacco prevention programs effectively reduce tobacco use. Fact sheet available at the Campaign for Tobacco-Free Kids Web site: http://tobaccofreekids.org/research/factsheets/pdf/0045.pdf.

5. Federal Trade Commission. News release announcing Federal Trade Commission Cigarette Report for 1999. March 13, 2001. Available at the Federal Trade Commission Web site: http://www.ftc.gov/opa/2001/03/cigarette.htm.

6. National Center for Tobacco-Free Kids. Nov. 13, 2000. The path to smoking addiction starts at very young ages. Fact sheet available at the Campaign for Tobacco-Free Kids Web site: http://tobaccofreekids.org/research/factsheets/pdf/0127.pdf.

Jolynn Tumolo is the associate editor. Reach her at jtumolo@merion.com.