Time to up the ante in the war on smoking. - Term paper / research paper writing service

In the past few years, it has become disturbingly clear that the remarkable progress made in recent decades in reducing tobacco use has stalled, if not stopped. In 1964, when the surgeon general first raised warnings about the health hazards of cigarettes, 40.4 percent of adults smoked. By 1990, only about 26 percent did. Unfortunately, there it has leveled off. In addition, the use of smokeless tobacco, especially snuff and chewing tobacco, has become a serious problem. But the biggest reason progress in reducing tobacco use is in jeopardy is that young people are smoking about as much as they did a decade and a half ago. Indeed, the number of young tobacco users may be on the rise.

According to the University of Michigan's Monitoring the Future Project, 29.9 percent of high school seniors smoked regularly (in the last 30 days) in 1993, about the same as in 1980 (30.5 percent). The number of daily smokers was 21.3 percent in 1980 and 19 percent in 1993. Although small increases and decreases have occurred in these rates over the years, a 1.8 percent increase in daily smoking between 1992 and 1993 is statistically significant and therefore of concern. Among eighth-graders, 16.7 percent were regular smokers and 8.3 percent smoked daily in 1993. Overall, more than 3 million children and youths now smoke in the United States, consuming a conservatively estimated 516 million packs of cigarettes annually. A bright spot in this otherwise dim picture has been a dramatic decline in daily smoking among African-American youths, from 16 percent in 1980 to 4.4 percent in 1993. Experts are uncertain about the reasons for this decline.

The use of smokeless tobacco, which was seldom used by adolescents before 1970, has tripled since then. According to the Michigan study, 10.7 percent of high school seniors were using snuff and chewing tobacco in 1993, 3.3 percent of them daily. Among 18- to 24-year-old men, the daily rate was 8.2 percent in 1991. Young people consume more than 26 million containers of smokeless tobacco each year.

It is obvious that the forces propelling the consistent decline in adult smoking have not worked as effectively among the young. Statistics on youths are troubling in that they prefigure a continuing heavy societal burden from tobacco use, especially since surveys indicate that most smokers (about 89 percent) begin between the ages of 11 and 18 and that nicotine addiction begins during the first few years of tobacco use. More than 400,000 people die prematurely each year from diseases attributable to tobacco use--more than from AIDS, alcohol, car accidents, murders, suicides, drugs, and fires combined. In addition, the Office of Technology Assessment estimated the social costs of smoking--additional health care costs, for instance--at $68 billion a year in 1990. Thus, the nation has a compelling interest in reducing the social burden of tobacco use.

Yet another concern is that just as progress in reducing tobacco use has stalled, aggressive marketing by the tobacco companies has continued to increase. Industry spending on tobacco products hit $4.6 billion in 1991, up 13 percent from 1990. Advertisements inevitably are seen by the young at a susceptible time in their lives. The ubiquitous display of messages promoting tobacco use clearly fosters an environment in which experimentation by youths is expected, if not implicitly encouraged.

To make a substantial and enduring reduction in the prevalence of tobacco use among America's children and youths, aggressive measures are needed. Indeed, public health officials fear that consumption of tobacco will rise unless decisive steps are taken to prevent it. It is time for a national commitment to implement a youth-oriented strategy for preventing nicotine addiction. Such an effort must include greater enforcement of existing federal, state, and local regulations and enactment of strict new ones.

Skewed choices

If adequately informed, adults are assumed to be capable of making rational and voluntary choices that involve weighing the risks and benefits of a particular behavior in light of their own preferences and values. On the question of tobacco use, the critical issue is whether children and adolescents are capable of doing the same. No one argues that preteens have the necessary abilities to make rational choices about tobacco use. Unfortunately, though, a significant number of adult smokers begin using tobacco before becoming teenagers. Data from the 1990 Youth Risk Behavior Survey indicate that 56 percent of youths have tried smoking and 9 percent have become regular smokers by age 13.

Some researchers have suggested that adequately informed adolescents (over age 13) exhibit cognitive decisionmaking skills similar to those used by young adults (through age 25). Others have claimed that adolescents are well-informed about some specific health risks of tobacco use. But even if these controversial assertions are accurate, they do not show that adolescents can make sound choices about tobacco use. It is also necessary to take into account other faulty beliefs held by adolescents regarding the consequences of tobacco use as well as youthful tendencies to evaluate and weigh risks and benefits within a shortened time frame. Evidence indicates that adolescent decisions to engage in risky behavior, including tobacco use, reflect a distinctive focus on short-term benefits and a tendency to discount long-term risks and to believe that those risks can be controlled by personal choice.

When children and youths begin to use tobacco, they tend to do so for transient reasons closely linked to specific stages in their development--for example, to assert independence and achieve perceived adult status or to establish bonds with peers who use tobacco. Compared with nonsmokers and youths who do not intend to smoke, smokers and likely smokers also tend to exaggerate the social benefit (by overestimating the prevalence and popularity of smoking among peers and adults) and to underestimate the risks (by underestimating the prevalence of negative attitudes toward smoking held by their peers).

Evidence also shows that adolescents who have begun to smoke tend to discount long-term health risks, even though they seem to be aware of the link between tobacco use and various diseases. For example, in 1989, only half of high school seniors who smoked (compared with three-fourths of nonsmokers) reported believing that smoking a pack or more per day is a serious health risk. In addition, although young smokers understand that a lifetime of smoking is dangerous, they also tend to believe that smoking for a few years will not be harmful. Indeed, they do not expect to become lifetime smokers. What they fail to appreciate, of course, is the grip of nicotine addiction.

The University of Michigan's Monitoring the Future Project demonstrates adolescents' failure to envision the long-term consequences of decisions to smoke. High school seniors were asked: "Do you think you will be smoking cigarettes five years from now?" Among the occasional smokers (less than one cigarette per day) who replied, 85 percent predicted that they probably or definitely would not be smoking in five years, as did 32 percent of those who smoked one pack per day. However, at the five-year follow-up, of those who had smoked one pack per day as seniors, only 13 percent had quit and 70 percent still smoked one pack or more per day. Of those who smoked occasionally as seniors, only 58 percent had quit, but 37 percent had actually increased their cigarette consumption.

If a youth decides to begin smoking at the age of 12 or 13, the deficit in his or her ability to appreciate the long-term risks of doing so is even more pronounced, and more disturbing, than it is at 16 or 17. Indeed, it is clear that nicotine addiction is most powerful and enduring for youths who begin smoking at the youngest ages. Unfortunately, the age of onset of tobacco use has decreased significantly over the past 20 years, especially for girls.

Many youths already regret their decision to start smoking and report difficulty quitting even during adolescence. The 1989 Teenage Attitudes and Practices Survey data show that 74 percent of 12- to 18-year-old smokers reported that they had seriously thought about quitting, 64 percent had tried, and 49 percent had tried to quit in the previous six months. Among high school seniors in the years 1985 to 1989, 43 percent of those who had smoked at all in the past 30 days reported a desire to stop smoking. Of this group, and of the sub-group who smoked daily, 28 percent and 39 percent, respectively, stated that they had tried unsuccessfully to stop. In the 1991 Youth Risk and Behavior Survey of more than 12,000 adolescents in grades 9 to 12, a majority of self-reported smokers (54 percent of boys and 62 percent of girls) reported that they had tried to quit smoking in the previous six months.

In sum, when children and adolescents begin to use tobacco, they put their health at risk without a sound understanding of the long-term consequences. They simply do not appreciate the personal relevance of the long-term statistical risks of multiple diseases, and they suffer from a profound inability to understand the power of nicotine. These risk-perception deficiencies as well as tendencies to exaggerate the social benefits of using tobacco justify concerted action to prevent children and youths from starting to use tobacco.

Priorities for action

A youth-oriented, tobacco-control strategy must, above all, include measures to make tobacco products less accessible to young people and to bolster the social factors that discourage consumption while mitigating those that encourage it. Strong legislative and regulatory action will be required.

In its new report, the Institute of Medicine's Committee on Preventing Nicotine Addiction in Children and Youths urged Congress to take three steps immediately.

Substantially increase the federal excise tax on tobacco products. Data indicate that young people are more price-sensitive than adults and that pricing has a strong and immediate impact on reducing sales of tobacco products. Increasing the federal cigarette tax by $2 a pack from the current average of 56 cents a pack for federal, state, and local taxes--thus making it comparable to the tax levels in other major industrialized countries--would make cigarettes far less affordable and would likely result in a reduction in the number of new smokers. It would also create a barrier to sustained use, which is so important in establishing an addiction to nicotine. Proportional tax increases should also be enacted for smokeless tobacco products.

Repeal the federal law that precludes state and local governments from regulating tobacco promotion and advertising within their jurisdictions. The tobacco industry was the number one spender on outdoor advertising in 1989. Of the about 3 million billboards in the United States, 30 percent were allocated to tobacco and alcohol products. Point-of-sale advertising in retail stores has been increasing and represented 7.4 percent of the tobacco industry's advertising and promotional expenditures in 1991. Many state and local governments have signaled a willingness to experiment with stronger measures to restrict these pervasive pro-tobacco messages. They should be given the power to take actions such as regulating advertising at the point of sale and banning tobacco advertising on billboards and on public transportation vehicles.

Help state and local governments and other interested organizations to pursue youth-centered tobacco-control initiatives. Many local governments have already established innovative programs to prevent illegal tobacco sales to minors. These include partial bans on vending machines, increased enforcement (including sting operations), merchant education, posting of warning signs, and increased penalties. In Woodbridge, Illinois, the use of retailer licensing, regular police stings, and fines reduced illegal sales to minors from 70 percent of retail stores to less than 5 percent over a period of a year and a half. A survey of seventh- and eighth-graders before and after the program was set up found that experimentation and regular tobacco use had decreased by more than 50 percent. Other communities around the country have adopted this approach. However, the experience of other communities indicates that use of educational programs alone is not enough to sustain reductions in illegal retail sales to youths. For instance, in four suburban communities in Solano County, California, a comprehensive merchant and community education program failed to put a major dent in illegal sales. Only after stepped-up enforcement--involving the use of underage police cadets empowered to issue citations--did illegal sales decrease substantially.

Community action at the state and local levels is also increasing because of the National Cancer Institute's 17-state demonstration program--the American Stop Smoking Intervention Study (ASSIST). Because smoking-cessation programs among adults were not working and larger-scale community programs were necessary, ASSIST has focused on convincing the media to do stories that serve to promote tobacco-control policies and thereby prevent tobacco use and encourage cessation. The Centers for Disease Control and Prevention (CDC) has initiated similar programs in non-ASSIST states. In addition, the Robert Wood Johnson Foundation is collaborating with the American Medical Association to mount the SmokeLess States program, a four-year, $10-million program to support 18 statewide antitobacco coalitions.

In spite of the importance of these programs, their future is not secure. ASSIST was set up as a demonstration program only, and the CDC funding is very low. We should not allow these efforts to wither. The federal government should broaden them with technical assistance, grants, and cooperative agreements.

Long-term strategy needed

These immediate actions will have a stronger impact if they are viewed as first steps in a long-term strategy for preventing nicotine dependence in children and youths. Such a strategy should have four key components.

Congress should establish a regulatory program for tobacco products with a long-term public health objective of dramatically reducing the prevalence of nicotine addiction. Tobacco products have been consistently exempted from coverage under consumer safety, food, and drug legislation, and as a result have been largely unregulated--in stark contrast to other products that have far less disastrous long-term health implications. Congress should give an agency, such as the Food and Drug Administration (FDA), the necessary authority to regulate tobacco products for the dual purposes of discouraging consumption and reducing the morbidity and mortality associated with their use. Such authority should encompass the packaging and the ingredients of all tobacco products, including the possibility of prescribing ceilings on yields of tar and nicotine.

Some federal regulatory initiatives can be undertaken without congressional action. FDA is considering using its existing authority to regulate tobacco products and labeling. The Federal Trade Commission could take a more active role in assuring that advertising and promotion of tobacco complies with existing statutory requirements. The Environmental Protection Agency has stepped forward in recent years to review the effects of environmental tobacco smoke, and the Occupational Safety and Health Administration is considering regulations restricting smoking in the workplace. The Department of Transportation has banned smoking on domestic airline flights. An active, multipronged federal regulatory effort can set the stage for analogous actions at state and local levels.

Congress and state legislatures should eliminate all features of advertising and promotion of tobacco products that tend to encourage initiation of tobacco use among young people. Children and youths believe that adults and even their peers smoke and use tobacco products far more than they actually do. Ubiquitous messages that associate tobacco use with images of youthfulness, athletic prowess, and sexuality reinforce a social norm that encourages tobacco use. The pro-tobacco messages in advertising and promotion are particularly difficult to combat among children and youths. Thus, advertising and promotion of tobacco products should be severely curtailed.

Governments and voluntary organizations at all levels should increase initiatives aimed at sustaining and reinforcing the continued evolution of a tobacco-free norm in American society. Only a few decades ago, smoking was the social norm; now, it is approaching a status of deviance. The continued evolution of a tobacco-free norm is a potentially powerful component of a long-term strategy for reducing the prevalence of tobacco use among children and youths. It also protects children's health by reducing their exposure to environmental tobacco smoke. Governments and private organizations should step up the implementation of smoke-free policies in schools, workplaces, fast-food restaurants, and other places where children and youths spend their time. In addition, mass-media campaigns, including paid antitobacco advertisements, should be intensified to offset the inimical effects of pro-tobacco messages, especially those that appeal to children and youths.

Agencies and foundations that sponsor tobacco-related research should implement a youth-centered research agenda including studies of the efficacy of policy interventions. Such efforts must recognize cultural differences among members of the major ethnic groups and attempt to develop culturally appropriate strategies. Understanding the reasons for the remarkable decline in smoking prevalence among African-American youths should be a top priority. In addition, a better understanding of the molecular and cellular correlates of nicotine addiction as well as the factors that mediate the adverse health effects of tobacco use could provide helpful clues to guide future efforts. Efforts should also be made to improve smoking-cessation treatments for the 49 million Americans who still smoke.

The committee's recommendations, if implemented, would also tend to reduce tobacco use by adults and might be criticized for unduly restricting the rights of sellers and buyers of a legal product. However, sound and well-justified youth-oriented interventions should not be weakened simply because they make tobacco use more costly or inconvenient for adults. The ultimate goal of a youth-centered prevention strategy is to reduce the overall prevalence of tobacco use in society. Indeed, the relationship between such a strategy and a broader tobacco-control policy is a reciprocal one. On the one hand, reducing the onset of tobacco use by children and youths is an essential element of a successful long-term strategy to reduce tobacco use. On the other hand, successful initiatives in society as a whole--including widespread adoption of tobacco-free policies that establish a climate unfavorable to smoking--play an important role in preventing tobacco use by children and youths. In both respects, a successful youth-centered prevention policy is the most expeditious way to reduce tobacco-related disease.