National Academies Press: OpenBook

Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths (1994)

Chapter: 4 TOBACCO ADVERTISING AND PROMOTION

« Previous: (GRAPHIC AND CONTENTS FOR CHAPTER 4)
Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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INTRODUCTION: MAINTAINING THE MARKET

Every day, children and youths in the United States are exposed to a wide array of persuasive, carefully crafted commercial messages encouraging the use of tobacco products. In 1991 the tobacco industry spent $4.6 billion—more than $12.6 million a day, $8,750 a minute—on advertising and promoting* cigarette consumption, and over $100 million on advertising and promoting smokeless tobacco products.1 During the past 15 years, the tobacco industry has nearly quadrupled** its marketing expenditures, at a time when tobacco consumption has been declining. Each day, approximately 3,500 Americans quit smoking and an additional 1,200 tobacco customers and former customers die of smoking-related illness; therefore, maintaining current levels of tobacco use and revenues requires that approximately 5,000 new smokers be recruited every day (about 2 million a year).2 Children and youths constitute the most likely source of new smokers. The 1991 National Household Surveys on Drug Abuse data reveal that the large majority (89%) of persons ages 30-39 who ever smoked daily tried their first cigarette by age 18, and 62% by age 16; over three quarters (77%) were smoking daily before age 20. At least 3 million

*As used in this report, "advertising" refers to expenditures for advertisements in newspapers and magazines and on billboards and transit systems; "promotions" refers to all other expenditures to promote tobacco consumption, especially point-of-sale displays, distribution of samples and specialty items, sponsorship of public entertainment, direct mail, coupons, and retail value-added products.

**All figures have been converted from nominal to real dollars with a base of 1991, the year for which the most recent data are available from the Federal Trade Commission.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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American teenagers smoke regularly and 3 million people who regularly use smokeless tobacco are under age 21.4

Three trends have caused a growing number of public health professionals to call attention to the role of marketing (advertising and other promotional approaches) in making tobacco use attractive to children and youths and in encouraging them to use cigarettes and smokeless tobacco. First, boys and girls are beginning to use tobacco at ever younger ages. The average age at which boys and girls initiate smoking has declined over the past 4 decades by 2.4 years overall for whites, 1.3 years overall for African Americans, and 5.4 and 4.6 years for white girls and African-American girls, respectively.5 The trend for girls to begin smoking at an earlier age began between 1955 and 1966,6 and the likelihood of becoming a daily smoker at an earlier age increased sharply in the early to mid-1970s both for boys and girls.7 During the same period, a second alarming trend in tobacco use has been noted: more and more, youths began using smokeless tobacco products. Half of the nation's 6 million smokeless tobacco users are under the age of 21, and several national surveys show an increase in prevalence, especially among boys.8 A third trend, which has occurred over the past 10 years, entails a slowing down of the rate at which smoking prevalence by youths had been decreasing. Between 1977 and 1981, daily smoking among high school seniors dropped a total of about 9% (from 29% to 20%), an average of 2.25 percentage points per year. Yet during the following 11 years, 1981 to 1992 (during which time the tobacco industry more than doubled its advertising and promotion expenditures) smoking by high school seniors fell by only a total of about 3% (to 17.2%), or only 0.26 percentage points per year. Among college students, from 1980 to 1992, the decrease in daily smoking was about the same as for high school seniors, except that for 1989-1992 there was a slight upward trend in prevalence of cigarette use.9 Notably, during this same period (19811991), the per capita cigarette consumption fell 28% among adults.10

What factors have contributed to stable smoking rates and to increased rates of smokeless tobacco use among children and youths, but have proven to be less effective in sustaining tobacco use by adults? Public health advocates suggest that youths have a heightened sensitivity to image advertising and promotion themes at a time in their lives when they are struggling to define their own identities. Adolescence is characterized by three major types of developmental challenges: (a) physical maturation, (b) cultural pressures to begin the transition to adult roles and emotional independence from parents, and (c) establishment of a coherent self-concept and values.11 Cigarette advertisements are often evocative and play off these challenges in addition to being positioned to appeal to specific groups defined by social class and ethnic identity. Early adolescence (ages 11-14) in particular may be a time of increased susceptibility to the appeal of image advertising and promotions. The possible effects of marketing techniques on youths are considered below, following a brief review of shifting trends in the appropriation of tobacco marketing dollars.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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SHIFTING TRENDS IN TOBACCO MARKETING

Tobacco advertising and promotions are clearly on the rise in the United States. In 1991, expenditures ($4.65 billion) on advertising and promotion of tobacco products were almost four times the amount ($1.22 billion) invested in 1980 (figure 4-1). From 1990 to 1991 alone, expenditures increased 13%.12 The current annual expenditures amount to $18 for every man, woman, and child in the United States. Promotional activities take many forms and are the fastest growing mode of product marketing; they have been found to be effective in leading consumers to act once exposed to advertising.13

The tobacco industry's distribution of marketing expenditures over the past 2 decades represents a major shift in marketing trends; overall, the ratio of promotional expenditures to advertising expenditures has reversed. Whereas in

image

FIGURE 4-1  Source: Federal Trade Commission. Report to Congress for 1991:
Pursuant to the Federal Cigarette Labeling and Advertising Act.
Washington, D.C.: Federal Trade Commission, 1994.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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1970 advertisements represented 82%* of total spending on tobacco marketing,  they were down to 67% in 1980, 21%  in 1990, and 17% in 1991. Although advertising expenditures per se have decreased, overall spending on marketing (advertising plus promotional activities) has increased. Of the $4.6 billion spent annually on tobacco marketing, about $700 million is spent on advertising. The remaining $4 billion is spent on a variety of promotional activities designed to: (a) place cigarettes and chewing tobacco in the hands of prospective users, (b) position cigarettes and chewing tobacco in prominent locations in shops and other points of sale where they will be psychologically appealing and physically available to customers, and (c) create good will for the tobacco industry among the public, community leaders, and politicians.

Promoting Tobacco Use to Consumers

The goal of marketing is to increase the appeal and acceptability of a product as well as to make the product available to the potential consumer. Tobacco marketing strategies (a) establish attitudinal predispositions that lead nonusers to experiment with tobacco products and interpret their experience as positive and rewarding, (b) foster the perception that consumption of tobacco products in general and in particular contexts (places, times) is normative, (c) minimize concern about the potential risks associated with tobacco use, propagating the perception that there are ''safe" smoking options, and (d) reassure smokers and users of smokeless tobacco that possible risks are worth the benefits received from tobacco use. Marketing strategies promote both brand-specific and aggregate tobacco use. The impression that tobacco use is desirable and normative is conveyed through image advertising and promotions that make tobacco products highly visible in public spaces—if not by their presence, then by proxy in the forms of brand trademarks, insignia, logos, and items associated with preestablished brand images (for example, adventure scenarios). The major forms of marketing are highlighted below.

1. Retail value-added promotions and specialty items. Dramatically on the rise are retail value-added promotions such as multiple packs (buy one, get one free), cents-off coupons, and a free key chain or lighter blister-packed to a cigarette pack. Value-added promotions and coupons constituted the largest marketing expenditure (40% of total marketing expenditures) by the tobacco industry in 1991. Promotional items have special appeal to youths. Since youths have less disposable income and are more price-sensitive than adults, promotions such as discount buy-one-get-one-free schemes may be especially attractive to them. Coupons are easily accessible to youths through direct-mail promotions. (See figure 4-2 for expenditure data for this section.)

*The 1970 figure includes radio and television advertising. Broadcast advertising was banned after January 1. 1971.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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image

FIGURE 4-2  Note: "All Others" = Coupons and retail value-added items, direct mail, and audio-visuals.
Source: Federal Trade Commission. Report to Congress for 1991 Pursuant to the Federal
Cigarette Labeling and Advertising Act.
Washington, D.C.: Federal Trade Commission, 1994.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Attractive specialty items—such as T-shirts, caps, calendars, and sporting goods—are distributed by the tobacco industry through the mail and at promotional events. These items, which sport a logo or brand name, become walking advertisements capable of penetrating areas of a child's world that might be offlimits to other forms of advertising. The ubiquity of such speciality items conveys the impression that tobacco use is the norm. Spending for specialty items accounted for 4% of expenditures in 1991. A 1992 Gallup survey found that half of all adolescent smokers and one-quarter of adolescent nonsmokers owned at least one promotional item from a tobacco company.14 Similar data were reported in a survey of almost 8,000 ninth graders in Erie County, New York: 65% of regular smokers, 48% of occasional smokers, and 28% of nonsmokers reported owning clothing with a cigarette brand logo.15 Although most youths seem to find logo clothing appealing, some high school students in focus groups (conducted under the auspices of the Committee) found them "tacky" and would not consider wearing them. Notably, however, these same teens save Marlboro Miles and Camel Cash coupons in order to acquire other types of goods. In a 1993 survey of 1,047 respondents ages 12-17, ownership of an average of 3.2 tobacco promotional items was reported by 10.6% of the sample. While 68.2% of current smokers reported participating in promotional campaigns, 28.4% of nonsmoking teens were also active participants. These promotional items carry no warning labels and provide free advertising.16

"My brother gets the Camel Cash. He's got stacks and stacks of them to get hats or whatever. "
—adolescent in focus group

2. Promotional allowances constitute the second largest tobacco marketing expenditure—25% of all marketing-related expenditures. Through this form of promotion, tobacco companies pay retailers for shelf space, engage in cooperative advertising with retailers, and offer trade promotions to wholesalers, etc. Retailers are rewarded for stocking a wide variety of brands, even brands with low market demand. For example, a convenience store owner who sells 2,000 packs per week may be motivated to stock over 180 different brand packings (some having only 0.1% market share) in order to be eligible to receive incentive payments, which might be as high as $8,000 per year for a moderate-size retailer.17

As a result of trade incentives, cigarettes and other tobacco products are displayed prominently where adults as well as youths of all ages can see them. Self-service displays are an important source of tobacco products for minors.18 Cigarettes are commonly displayed near checkout counters, and flavored chewing tobacco has been reported to be displayed near candy racks in convenience shops. A survey in California of stores near high schools found chewing tobacco next to candy and snacks in 42% of the stores.19 In addition to catching the eye of a potential buyer who may not consciously be in the market for a tobacco

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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product, the positioning of tobacco with other commodities conveys subtle associational meanings. For example, when placed near liquor, as they often are, cigarettes come to be associated with adult status as well as with products promoted to shift one's consciousness away from the stress, strains, anxieties, and boredom of routine existence, as a means of providing some temporary release and relief.

3. Point-of-sale advertising showcases particular brands of cigarettes in shops to stimulate impulse purchases. Since the 1971 ban on broadcast advertising, tobacco companies have made marketing through distribution a major function of their sales forces, which numbered more than 9,000 industry wide in the early 1980s.20 This marketing technique places the tobacco products in convenient, visible racks, usually self-service, and in point-of-purchase displays. Point-of-sale promotions tend to involve the retailer, as well as the consumer, in a brand product. Support of brands through point-of-sale advertising helps to bolster the legitimacy of a brand in the eyes of retailers who make stocking decisions.21 Point-of-sale materials are coordinated with national advertising campaigns to tie retailers in with the image-building for the product. In this sense, point-of-sale advertising both influences product distribution and directly induces consumption.22 Point-of-sale advertising in retail establishments has been increasing and in 1991 represented 7.4% of advertising and promotional expenditures.

4. Magazine and newspaper advertising accounted for about 7% of marketing expenditures in 1991, when expenditures on newspaper ads reached an all-time low of 1.0%, a large drop since the 1980 high of 24.5%. Magazine ads were down to 6% of marketing dollars in 1991, from 21.4% in 1980. Nevertheless, expenditures on tobacco advertising in the print media do continue to be substantial and the decreases are not occurring at the same rate across all market segments; for example, while the number of ads per magazine issue has declined in men's and women's magazines, it has remained relatively stable in those magazines having substantial African-American and youth readerships.23 In addition, advertisements are often combined with interactive promotional items that appeal to children and youths. For example, many magazine advertisements feature giveaway, non-cigarette utility items (calendars, lighters, T-shirts, and "action products") associated with "cash coupon" catalogue offers. Magazines often inform potential customers to be on the lookout for additional information about these offers at point-of-sale locations.

"They advertise a lot.  Every magazine I have—there's an ad for Camels, Marlboros, Newports."
—high school girl in focus group

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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5. The tobacco industry was the number one spender for outdoor advertising in 1989;24 of the approximately 3 million billboards in the United States, 30% were allocated to tobacco and alcohol products.25 Advertising through the use of outdoor billboards and transit system signs accounted for 9.6% of all tobacco marketing expenditures in 1991. The industry has saturated African-American neighborhoods with cigarette billboards. Studies reveal that the intensity of cigarette billboard advertising is 2.6 times greater in African-American than in white neighborhoods in Columbia, South Carolina,26 and 3.8 times greater in Baltimore.27 Despite supposed industry standards to the contrary, billboards advertising tobacco products can be found next to homes, schools, churches, parks, playgrounds, health centers, stadiums, shopping centers, and along rural and city streets. More permanent than magazine advertising, and seen over and over again by youths, billboard ads expose children repeatedly to pro-tobacco messages and give the erroneous impression that smoking is pervasive and normative.

6. Sponsorship of sporting events and public entertainment associates tobacco with (a) all-American cultural events, such as music concerts and art exhibits, where fundamental social values are celebrated, and (b) high-risk sporting events, such as rodeos and car racing, where risks are socially approved and taken by individuals who brave the odds. The tobacco industry sponsors opera and ballet performances, and concerts of rock, rap, country and western, blues, jazz, and classical music, making tobacco products highly visible to diverse populations and strengthening the association between cigarettes, artistic expression, entertainment, glamour, and individuality.

Expenditures on the promotion of sports and sporting events are growing. The 1994 surgeon general's report has called special attention to sponsorship of sporting events associated with a company's brand name and/or logo, noting that this constitutes one of the most effective means of covert advertising. Even during events that are not sponsored by the tobacco industry, tobacco products are permanently displayed: tobacco billboards are the dominant form of advertisement in many major professional stadiums. Youths attend such sporting events, and watch them on television; many seek to emulate sports superstars, such as baseball players, who visibly chew and spit tobacco during these sports events, thereby actually demonstrating the use of the products on the billboards. Each 3-second exposure of a billboard in a ballpark has a marketing impact similar to a 10-second TV commercial.28A widely cited example of just how much product exposure is realized through covert advertising during sporting events is the 1989 Marlboro Grand Prix: when the event was televised, the Marlboro logo could be seen for 46 of the 94 total minutes of this sport event's broadcast time.29 In the 1987 NASCAR Stock Race Circuit the Winston logo appeared for a total of 6 hours and 22 minutes—nonpaid covert advertising on the air valued at $7.5 million.30 In 1992, 354 motorsports broadcasts were quantitatively measured for estimates of product exposure value. The programs had a

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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total viewing audience of 915 million, 7% of whom were children and teens, and an overall tobacco product exposure value of $68 million ($41 million for Winston, $12 million for Marlboro, $7 million for Skoal, $4 million for Camel, and $4 million for others).31 Studies have found that youths accurately associate sporting events with tobacco brands.32

7. Distribution of free samples of cigarettes in public places, for "adults only," was at its highest percentage (about 7%) of total marketing dollars in the early 1970s, and has stayed about 2% since the late 1980s. Monitoring of who is given free samples has been poor, and tobacco companies who contract-out sample distribution have taken no responsibility for cited violations in which minors have been given samples.

8. Expenditures for direct-mail promotions are on the rise; $65 million was spent in 1991, an increase of 22% over 1990. All five major cigarette companies actively compile mailing lists of customers, largely from coupons, which ask for name, address, usual brand, etc; from promotion redemptions; from the return of "smoker surveys" in magazines; and from the return of more general consumer information questionnaires. The forms sometimes ask detailed questions about brand use and about demographic characteristics.  Brown & Williamson, Lorrilard, and American Brands use their lists occasionally to send out coupons. R. J. Reynolds Tobacco Company (RJR), Philip Morris Tobacco Company, and United States Tobacco Company (UST) have made more substantial use of their mailing lists. UST sends its listees a slick quarterly magazine, Heartland, which puts Skoal and Copenhagen in a pleasant context and contains various offers. RJR and Philip Morris mount regular mailings promoting a variety of brands, depending on the characteristics of the persons on the lists. RJR promotes Camel and discount brands, and sometimes sends out coupons good for any top-of-the-line RJR cigarette product. Philip Morris has distinct mail programs for Marlboro, Virginia Slims, Merit, and Benson & Hedges. Individuals on the Camel lists have received at least six mailings in the past year apart from any coupon redemptions.

These direct-mail efforts are large undertakings. Philip Morris, in a letter to its retailers dated July 20, 1993, indicated that it had 26 million people on its mailing lists. While a large number of teenagers may be included on these mailing lists, the tobacco companies has no mechanism for purging minors from their lists. Slade and colleagues conducted a nationally representative, random-digit dial survey of 1,047 respondents aged 12 to 17 to assess participation in promotional activities.33 They found that 7.6% of the sample had received mail from a tobacco company. Extrapolating this figure to the entire 12- to 17-year-old population, they estimate that 1.6 million teens are on tobacco industry mailing lists.

Direct mail may be a form of promotion that tobacco companies will pursue

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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more aggressively if restrictions on conventional advertising are adopted. The expenditure data show a continuing trend toward advertising and promotional practices that are not required to carry health warnings.

Inhibiting Opposition to Tobacco Use

The tobacco industry's spending on advertising inhibits dissemination of anti-tobacco messages. Billboard companies allegedly have expressed reluctance to rent space for antismoking ads because they are well paid to saturate African-American neighborhoods with smoking ads and believe that they cannot afford to lose tobacco conglomerate accounts. Magazines that receive sizable revenues for advertising tobacco are less likely to run articles that discuss the negative aspects of tobacco use than magazines not dependent on tobacco industry revenue.34 When articles are run that could potentially shed a negative light on tobacco use, they are toned down through editing.35 This practice, termed "latent censorship," gives the public a distorted view of the dangers of smoking. For example, during the first 7 years after cigarette ads were banned on television (in 1971), the only two magazines (Reader's Digest and The New Yorker) that carried accurate articles on the link between tobacco and disease refused to accept cigarette ads.36 A study of tobacco advertising in 99 magazines between 1959 through 1969 and 1973 through 1986 noted and confirmed a tendency toward latent censorship in women's magazines regarding the health effects of smoking as a result of their large amount of advertising income: "Magazines that did not carry advertisements for cigarettes were more than 40% more likely to cover the hazards of smoking than were magazines that carried cigarette advertisements. . . . women's magazines that did not carry cigarette advertisements were 2.3 times more likely to cover the risks of smoking."

Magazines for African Americans have earned revenues from tobacco ads since at least 1950. A study of patterns of tobacco advertising in magazines from 1950 to 1965 found that African Americans were at first subject to less, then to more, advertising than whites.37 The greatest concentration of tobacco company advertising is in African-American publications such as Jet, Essence, and Ebony, but many small, local publications and other media serving the African-American community have found it extremely difficult to find other means of financial support, and might not survive without tobacco advertisements.

A similar effect of "latent censorship" results when revenue for advertising comes from one of the numerous companies that belong to tobacco industry conglomerates (for example, Nabisco, General Foods, Kraft). In 1988, after the ad agency Saatchi and Saatchi prepared ads touting the no-smoking policy of its client Northwest Airlines, RJR/Nabisco cancelled an $80 million annual contract with that agency for advertising food products.38 A study of advertising executives found that they do fear economic reprisals from tobacco conglomerates should they print articles unfavorable to the tobacco industry.39

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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THE TOBACCO MARKET AND MARKET SEGMENTATION

Tobacco has been aggressively marketed to the American public through a number of different channels and interactive modalities in order to foster demand for particular brands of tobacco products, create a more permissive environment in which to engage in tobacco use, and establish tobacco use as a norm of acceptable social behavior if not a "habit" to be emulated. Ever sensitive to social and cultural differences, the tobacco industry has gone to great pains to position tobacco products through market segmentation. Tobacco products are marketed to appeal to specific market niches; to existing smokers as well as potential smokers.

Tobacco: A Mature and a Growth Market

The tobacco industry claims that its primary, if not sole, purposes for advertising and promoting tobacco products are to (a) provide information to tobacco consumers regarding product choice, (b) capture brand share from competitors, and (c) maintain product loyalty in a mature market. Identifying a market as "mature" bears close examination for what the term both reveals and conceals. Some, but not all, products are categorized by marketing experts as constituting either a "mature" or "growth" market. In mature markets, awareness of a product is nearly universal and demand is relatively stable. Most of the market segment is already using the product, rises in product use are not dramatic, and expansion results from getting consumers to use a product more often or in new ways. In growth markets, new market segments are identified, new users are a source of significant market expansion, and rises in product use are significant.40

The cigarette market simultaneously displays characteristics of being both a mature and a growth market. The industry calls attention to the fact that cigarette sales have been fairly consistent over the last decade; however, it is clear that per capita consumption has decreased, and that the tobacco industry loses 2 million smokers a year—those who quit and those who die (about 44 million and 9 million, respectively, since 1964).41 Consequently, market expansion must be occurring to maintain total tobacco sales at a consistent level. Adults are not a likely population for that market expansion because few new smokers are adults. Furthermore, for three decades the trend among adults has been to quit smoking. In fact, most new smokers are youths: 77% of daily smokers are daily smokers by age 20.

Market Segmentation to Reach Youths

Considerable research on the part of the tobacco industry has resulted in the positioning of specific brands in different market segments. This entails vigilant

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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monitoring of changing responses to brand images and consumption patterns among specific populations in a competitive market. Particular market niches are targeted for intensive advertising activities. Capturing a share of the starters market, which is predominantly under age 20, is important to tobacco companies because of the amount of brand loyalty and switching within brand families. Several studies have been specially commissioned by the tobacco industry to study the youth market,42 although the tobacco industry has claimed that it does not target underage youth in its advertising campaigns. Youths constitute not only a market segment in their own right but also a subgroup of market segments defined in relation to gender, socioeconomic status, ethnicity, etc. Research suggests that, regardless of intent, marketing pitches aimed at young adults ages 20-25 are also appealing to youths of the same class, gender, and ethnic group. For example, the tobacco industry heavily advertises in magazines that appeal to youthful readerships, for example Spin, Rolling Stone, Cycle World, Mademoiselle, Glamour, and New Woman.43 A consideration of the impact of advertising on children and youths therefore demands an understanding of those subpopulations targeted by the industry as market growth segments: women, the less educated, and ethnic groups. A method for identifying which market segments are specially targeted by the tobacco industry would entail trend surveillance of two elements of tobacco advertising and promotion: (1) where the ads are being placed and therefore who is likely to see the ads, and (2) to whom the context and message of the ads appeal.

An example of research that has considered the power of image messages in reinforcing tobacco use is a study by Pierce and colleagues that found an association between trends in female smoking initiation and the sales of leading cigarette brands targeted to women through image advertisements from 1944 through the mid-1980s. Age-specific rates of smoking initiation for boys and girls ages 10-20 were constructed from National Health Interview Survey data. The analysis revealed gender-specific relationships with the tobacco advertising campaigns that targeted women and were launched in 1967. Specifically, in girls under 18, smoking initiation increased abruptly around 1967 and peaked around 1973, at about the same time that sales of such brands as Virginia Slims peaked. The increase was especially marked among girls who never attended college (1.7-fold higher). The trend did not apply to women 18-20 years old, nor to men. The investigators concluded that "tobacco advertising has a temporal and specific relationship to smoking uptake in girls younger than the legal age to purchase cigarettes."44

THE APPEAL OF TOBACCO ADS TO CHILDREN AND YOUTHS

The recent success of the Old Joe Camel campaign, introduced in 1987, has rekindled a longstanding debate on what role advertising plays in

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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predisposing youths to use tobacco, and to use specific brands of tobacco products. Choices to smoke are often spontaneous and based on psychological and social processes of identification, individuation, and differentiation. The effect of advertising is complex, and measuring the relative magnitude of any one type of influence on human behavior in isolation from other influences is difficult. Nevertheless, research data suggest that adolescents are more responsive than adults to advertisements. Surveys conducted between 1976 and 1990 among seventh to twelfth graders suggest an association between an explosive growth in the use of Camel cigarettes and the Old Joe Camel campaign. A study of this age group in 1990 found that 32.8% of children who smoked reported smoking Camel cigarettes.45 While there is some debate about the underage market for Camel cigarettes before the campaign, that market was very small.46 Furthermore, the study found that the market share for Camels decreased abruptly with age. Camel was the brand choice of 24.5% and 21.7% of boys and girls, respectively, ages 12-17, but of only 12.7% and 5.0% of youths ages 18-24. Thus, it would seem that, whether or not youths are a targeted market segment, advertisements present images that appeal to children and youths and are seen and remembered by them. Concern has been expressed that while smoking advertisements may not have had an immediate effect on smoking uptake, they may increase susceptibility to smoking, which over time translates into behavior.47

"Camel's cartoons are for the younger kids. Joe Camel's a cool person—a model."
—adolescent in a focus group

Psychosocial Mechanisms Through Which Advertising Influences the Behavior of Children and Youths

Advertising may influence consumer behavior in two broad ways—either cognitively or affectively. A cognitive influence convinces an individual that there are benefits to be derived from purchasing (or consuming) a particular product. These benefits may be related to (a) a specific need or desire that an individual maintains, or (b) an ideal image that the individual would like to adopt and convey to others. An affective response to a product is fostered by psychological conditioning: an advertisement sets up a positive evocative response.48 The affective appeal of an advertisement is often unconscious and automatic, apparent when individuals identify a particular advertisement as their "favorite."49 Both advertising pitches are used to encourage potential consumers to smoke or chew tobacco as well as to buy a particular brand of cigarettes.

Psychologists have described specific mechanisms by which advertising makes tobacco use appear attractive to smokers and potential smokers. Ajzen and Fishbein's theory of reasoned action postulates, in brief, that intentions to perform a particular act are predicted both by a person's attitude toward the act

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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and by normative beliefs about it, concordant with ''what others think."50 Ajzen and Fishbein argue that personal attitudinal factors are probably more important in decisions that adults make concerning smoking, whereas social normative factors are more important in the decisions of children. Other psychologists have suggested that children understand the intent of image advertising at a young age.51 According to the theory of reasoned action, advertising can function either as a direct normative influence by shaping a child's image of what it means to be a smoker or as an indirect normative influence by increasing peer pressure associated with the emulation of role models provided by cigarette advertising. In his exhaustive 1976 review of the literature, Fishbein noted: "there can be little question that cigarette ads attempt to create a positive image of the 'smoker."' He concluded that "our review suggests that cigarette advertising does affect cigarette consumption."52

Bandura's social cognitive theory emphasizes the central role played by modeling influences in shaping human thinking, values, and patterns of behavior.53 Through modeling, one learns behavior and develops preferences as well as a sense of what is normative. The process of social modeling exerts its effects in several different ways.

One way in which the power of modeling is substantially increased is by showing that the modeled behavior produces desired benefits. In image advertising, smoking is portrayed as an expression of independence, individualism, and social sophistication. It engages the consumer in a fantasy and invites the consumer to participate in a promise "that the product can do something for you that you cannot do for yourself."54 A self-image that the target audience already desires is reinforced.55 For example, smoking is associated with a strong masculine self-conception. It is depicted as relieving stress, and as winning the admiration of wholesome, fun-loving peers. The models in cigarette ads appear healthy and happy, in stark contrast to the negative health consequences of smoking. Adolescents who evaluate positively the attributes of models used in cigarette advertising strongly overestimate the prevalence of smokers and give less thought to long-term consequences of risky behavior.56 Associating the names and logos of tobacco products with sporting and musical events serves as yet another vehicle for framing tobacco use around images.

Another way in which social modeling exerts itself is through belief of personal efficacy. According to social cognitive theory, behavior is regulated, in large part, by belief of personal efficacy to exercise control over events and the consequences expected to flow from one's behavior. After people develop a dependence on smoking, their beliefs about personal efficacy affect every phase of their efforts to quit the habit. Such beliefs influence whether they even try to quit smoking, whether they can enlist the motivation and perseverance needed to succeed should they choose to do so, and whether they are vulnerable to relapse after they have given up the smoking habit.57

Adolescence is marked by cognitive developmental stages that in turn affect

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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one's concept of self. Early adolescence has been characterized as a period of heightened self-awareness as well as preoccupation with one's self-image. Elkind and Bowen described the notion of the imaginary audience, wherein young adolescents feel that they are always on a stage with imaginary others monitoring and evaluating their appearance and activity.58 Indeed, studies have shown that adolescents whose actual self-concepts are consistent with their perceptions of "stereotypic" smokers (derived from advertisements) are more likely to smoke.59 Among nonsmokers, teens who admire the attributes depicted by smokers in ads are also more likely to intend to smoke in the future.60 In order to acquire selected attributes of model smokers, adolescents may be motivated to use tobacco, even when they view smoking as negative.61

Social psychologists have found that the tendency to choose behaviors that are consistent with self-concept is stronger when one's self-concept is threatened.62 Smoking experimentation commonly occurs at transition points in adolescence when there is a threat to a teen's emerging self-concept: "Teenagers are typically less secure in their identities than most groups in the population, and their age-appropriate task is in part to experiment with different adult identities. They are more subject to social pressure and more attuned to advertising than most groups in the population."63 For example, Imperial Tobacco Limited's Project Sting tested "overtly masculine imagery, targeted at young males." Young males were seen as "going through a stage where they are seeking to express their independence and individuality under constant pressure of being accepted by their peers.... very young starter smokers choose Export A because it provides them with an instant badge of masculinity, appeals to their rebellious nature, and establishes their position amongst their peers."64 Advertisers recommended that ads be designed for the company's Player's brand that showed someone ''free to choose friends, music, clothes, own activities, to be alone if he wishes"; who can manage alone and "be close to nature" with "nobody to interfere, no boss/parents; someone self reliant enough to experience solitude without loneliness."65 The theme of independence is appealing to those teens that exhibit a proclivity toward "destructive deviance" (low self-esteem, reactant nonconformity) and "constructive deviance" (high self-esteem, autonomy, independence).66 Most research on tobacco use among teen subgroups has found the highest levels of tobacco use among "dirts" (problem prone) and "skaters" (skateboarders)67 but one study found that 28% of "hot shots" (academic and social leaders) currently smoked (and 62% of "dirts" currently smoked).68 What these data suggest is that a wide range of youths are attracted to tobacco advertisements that play up the theme of independence.

Themes and Images

Considerable psychographic research underlies tobacco ad designs.69 Image advertising tends to appeal to youths.70 Notably, each of the three brands

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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(Marlboro, Newport, Camel) most popular among youths maximizes a considerable amount of image-based advertising.71 Even children ages 6-10 are able to identify the images and slogans associated with popular brands of cigarettes.72 The symbols of the most popular cigarettes among youths, a cowboy and a camel cartoon character, are more likely to appeal to children than to adults.73 In addition to the theme of independence noted above, five other themes are pervasive in tobacco ads: that tobacco use is a rite of passage to adulthood, that successful people use tobacco, that tobacco use is relaxing in social situations, that tobacco use is normative, and that tobacco use is safe.

1. "Tobacco use is a rite of passage to adulthood." Advertising associates smoking with a passage from childhood to adulthood through sets of images and messages. Smoking is portrayed as a marker of social status (adulthood) and of pleasure appreciated by popular young adults whom teens wish to emulate. Market research has found that teens are more attracted to young adult models in advertisements than to other teens.74 "Adult themes"—adventure, rugged individualism, independence, sophistication, glamour, and sex—appeal to youths, a fact well established by research of the youth market.75 Indeed, the popularity of the Marlboro cowboy dispels the myth that in order to appeal to young people as potential smokers, the ad must show young people.76

2. "Successful, popular people use tobacco." Advertisements effectively associate smoking with sophistication in social and sexual relations. Tobacco image advertisements are appealing to those who are young and impressionable, who would like to acquire the attributes of the models in the ads. The brands most successful with teenagers commonly employ evocative images in their advertising, whether in the form of models or cartoon characters that depict success, sophistication, and self-reliance.77 Quality of life is an attribute often depicted in smoking ads. Tobacco industry support of cultural events further conveys the impression that smoking is socially acceptable to successful people who patronize the arts and have a high quality of life.

3. "Tobacco use is relaxing in social situations." Advertisements position cigarettes and other forms of tobacco as products facilitating peer acceptance. Associating cigarettes with a sense of carefree belonging is reassuring to adolescents at a time of identity construction when social relations are extremely important and teens often feel awkward in social situations. In addition to gaining social approval, ads depict cigarettes as a means of initiating social exchanges and sharing in a relaxed social environment.78

4. "Tobacco use is the norm." By associating tobacco use with commonplace activities, events, social spaces, or mind-sets, advertising reassures users that smoking and chewing are normal, pervasive, and socially acceptable. Advertising links tobacco consumption to routine social activities and transition points in the daily work-play cycle. For example, cigarettes are depicted as going with a coffee break, an after-work drink, and time off. The sheer volume

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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of tobacco advertising contributes to the false impression that smoking is normative in a wide variety of contexts.79

5. "Tobacco use is safe and healthful. " Tobacco-related imagery saturates the public world, leading many potential consumers to believe that its use must be less dangerous than health messages make it out to be. In ads, tobacco use is associated with healthy, outdoor activities, leaving the impression that tobacco use is not only safe but the choice of healthy, vigorous people. Healthiness has been a manifest theme in cigarette ads for at least 60 years. Images of healthy smokers offer reassurance to would-be quitters. Such imagery undermines the effects of public health programs to inform the public of the hazards of tobacco use and to discourage youths from initiating smoking.

Cigarette advertising has persistently used images and language to reassure smokers and would-be smokers that one can engage in "healthy smoking." Cigarettes have been described over the years as being "mild," " light," "fresh,'' "smooth," "clean," "pure," "soft," and "natural." The history of cigarette advertising is punctuated by a steady stream of "news" announcements about scientific discoveries and modern materials reducing the hazards and increasing the pleasures of smoking. The public has been exposed to "miracle tip filters," descriptions of "20,000 filter traps," and filters made of activated charcoal, "selectrate," "millicel," "cellulose acetate," or "micronite," described as "effective," "complete," "superior," etc.80 The inferred, perhaps implied, benefit of such filtration systems is reduction if not elimination of cancer-causing agents and other established health risks. Whereas filtered cigarettes constituted 58% of the market in 1963, they accounted for 96% of the market in 1991, having risen steadily since the first surgeon general's report.81 Currently, low-smoke cigarettes are being introduced into the market. Philip Morris Superslim ads call attention to 70% less smoke from the lit end of their product, a message likely to be interpreted by many smokers in terms of lower health risks. The association between low smoke and health is conjoined to an association between thinness and health and beauty ideals. An ad for Carlton is provocative in establishing its purported health benefits by juxtaposing ten packs of this lower-tar/nicotine cigarette to one pack of Marlboro and Camel with the line: "10 packs of Carlton has less than 1 pack of these brands."

Analysis of the forms and styles of cigarette ads over the years reveals the industry's responsiveness to consumer health concerns tied to public health messages. The means of projecting healthiness has changed in response to regulatory efforts as well as insights from psychology-based consumer research. The most dramatic change occurred in the late 1950s and early 1960s. Until then, most health claims were made in direct verbal assertions, such as "more doctors recommend" . .. "not a cough in a carload" . .. "Scientific studies prove . . ." In the late 1950s, motivation researchers informed the industry that such ads drew attention to health problems, cautioning that a more oblique approach to the

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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health issue would be beneficial. The new strategy replaced verbal statements with visual images in which healthiness was communicated through people and settings that were the very "pictures of health."82

A recent trend has been to appropriate the rhetoric of smoking cessation programs.  For its low-tar brand Merit, Philip Morris launched an advertising campaign that features such rhetoric in slogans like "you can do it," subtly conveying the message that switching to low-tar cigarettes is a major health accomplishment associated with personal agency. In reality, once addicted, most smokers adjust their smoking habits to maintain their consumption of nicotine at an optimal psychophysiological level irrespective of the brand of cigarette smoked (see chapter 2).83

Ads playing up one's ability to down-switch to the lower-tar/nicotine brands gloss over the difficulties in giving up smoking once one is addicted to nicotine. Data from the Monitoring the Future Study reveal that the proportion of high school seniors who perceive "great risk" of physical harm from pack-a-day smoking has risen less than 6% since 1980 (to 69.5% in 1993).84 Several studies have found that teenagers who smoke underestimate their chances of becoming addicted to nicotine and overestimate their ability to quit smoking at will.85 Low-tar/nicotine cigarettes appeal to a growing segment of the youth market. Advertising and promotional activities that tend to convey a message that healthy smoking is feasible undermine smoking prevention messages aimed at youth.

The five themes described above appear not only in tobacco ads, but also in other ads and media images that foster tobacco use. For example, there are no restrictions on how smoking may be portrayed in ads for non-tobacco products in youth magazines. A study by the Health Education Authority in the United Kingdom found that in youth fashion and style magazines, many non-advertisement-driven scenes depict a glamorous model smoking.86 Rolling Stone and other popular magazines for youths have featured interviews with stars of the popular teen television program, Beverly Hills 90210, who are all pictured with cigarettes dangling from their mouths. Recently, several major print advertisers whose products have nothing to do with tobacco have featured models who smoke; for example, Guess Jeans ran an ad in the October 1992 issue of Esquire showing their newest model in a sexy pose, holding a cigarette with a dangling ash. Pictures of popular people smoking who are not associated with a particular brand may be more likely to attract the attention of teens, than ads pitching name brands.87 They are an indirect endorsement of smoking. The media have associated smoking with glamour, style, sophistication, sex appeal, street credibility, rebellion, independence, etc. Research is needed on the extent to which indirect promotion of tobacco use contributes to its appeal and may be countered by educational programs that teach youth to critically assess the enticement of commercial and noncommercial appeals.88

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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CRITICAL ASSESSMENT OF STUDIES ON ADVERTISING RECALL, ADVERTISING EXPENDITURES, AND TOBACCO CONSUMPTION

The surgeon general's report released in March of 1994, Preventing Tobacco Use Among Young People, thoroughly reviews the research literature on the impact of tobacco advertising and promotional activities on tobacco consumption by youths, and provides an historical account of cigarette advertising that highlights changes and continuity in cigarette advertising and promotional activities of tobacco and its likely impact on youths. The surgeon general's report summarizes the review in five conclusions:

1. Young people continue to be a strategically important market for the tobacco industry.

2. Young people are currently exposed to cigarette messages through print media (including outdoor billboards) and through promotional activities, such as sponsorship of sporting events and public entertainment, point-of-sale displays, and distribution of specialty items.

3. Cigarette advertising uses images rather than information to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, healthfulness, adventure-seeking, and youth activities—themes correlated with psychosocial factors that appeal to young people.

4. Cigarette advertisements capitalize on the disparity between an ideal and actual self-image and imply that smoking may close the gap.

5. Cigarette advertising appears to affect young people's perceptions of the pervasiveness, image, and function of smoking. Since misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette advertising appears to increase young people's risk of smoking.89 Readers who are interested in the details of the studies leading to those conclusions should refer to the surgeon general's report. The Committee does not repeat that review here, but instead focuses on methodological approaches to advertising research.

Studies of Advertising Recall

Several studies have shown a positive correlation between adolescents' ability to recall a particular advertisement, logo, or brand insignia and smoking intent, initiation, or level of smoking.90 The key variable in such studies is exposure to cigarette ads. The concept of exposure has been applied in myriad ways, from environmental exposure to attention, physical exposure to psychological engagement.91 Advertisement recall studies have consistently found that young people who maintain an interest in smoking retain more information from

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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cigarette ads. In some cases this correlation has been used to imply that there is a causal link between consumption and exposure to advertising, as well as between recognition of ads and smoking behavior. This leap in the interpretation of the data is questionable. What can be said is that experimentation with cigarettes does affect the extent to which individuals recognize information presented in cigarette advertisements and that this may influence smoking-related behavior over time in a variety of ways.92 For example, attentiveness to ads may reinforce smoking behavior by providing the smoker "evidence" of the values and benefits of smoking, such as reassurance that popular people use tobacco. What is not known at present is whether youths already interested in smoking become more attentive to advertisements or whether advertisements lead youths to become more interested in smoking. This is analogous to the issue of whether "peer pressure" leads youths to smoke or whether youths interested in smoking gravitate to peer groups (friends) who smoke. Studies of advertising recall, assessed independently of other data on smoking behavior, are insufficient to determine the direction of influence.

Econometric Studies of the Relationship Between Advertising and Consumption

Econometric studies of the relationship between advertising and tobacco use are prominent in debates between public health advocates and the tobacco industry. Econometric studies provide insights into the effects of general advertising trends, but are too imprecise to support firm conclusions about advertising's impact on the behavior of specific populations over time. It is unrealistic to expect that studies correlating trends in tobacco consumption with aggregate expenditures on advertising can provide meaningful insight about the influence of advertising on tobacco use by children and youths. The results, therefore, from numerous econometric studies do not provide a consistent picture regarding the impact of tobacco advertising on consumption. The mixed conclusions drawn from these studies should not be interpreted as evidence that advertising has little or no influence on tobacco use. Econometric methods are better suited to assessing the impact of governmental policies intended to restrict tobacco advertising or significantly increase the price of tobacco products, but even these studies are incapable of providing definitive information about how different population groups (for example, youths and ethnic groups) are likely to respond to advertising restrictions.

Studies of the Effects of Advertising Bans

Several studies have concluded that advertising bans have significantly reduced smoking prevalence in the population as a whole. In 1993 the Chief Economic Advisor of the Department of Health of the Government of Great

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Britain reviewed the existing data and noted that advertising tends to increase consumption of tobacco products and that bans on tobacco advertising tend to decrease tobacco use beyond what would have occurred in the absence of such a ban. Focusing on the four countries with the most complete data—Norway, Finland, Canada, and New Zealand—the British report found that in all four countries, bans or restrictions on advertising resulted in an overall decrease in consumption.

The strongest evidence to date on the effect that legal restrictions of promotional activities have on tobacco consumption is drawn from a study of trends in 33 countries between 1970 to 1986, commissioned by the government of New Zealand. The 33 countries studied (24 free-market economies and 9 centrally planned East European economies) provide over 400 calendar years of observation of different tobacco prices, personal incomes, and advertising restrictions, including tobacco advertising bans. The methodology of this study was rigorous and examined adult tobacco consumption, accounting for income and tobacco price effects as well as health education effects. The overall finding of this study was that: ". . . the greater a government's degree of control over tobacco promotion, the greater the annual average fall in tobacco consumption and in the rate of decrease of smoking among young people."93 Highlights of the report include the following (also see tables 4-1 and 4-2):

· "Total advertising bans for health reasons are, on average, accompanied by falls in tobacco consumption four times faster than in partial ban countries."

· "In countries where tobacco has been promoted virtually unrestricted in all media, consumption has markedly increased (+1.7% per year)."

· "In countries where advertising has been totally banned or severely restricted, the percentage of young people who smoke has decreased more rapidly than in countries where tobacco promotion has been less restricted."

· "When the results of this study of promotion/consumption trends in 33 countries between 1970 and 1986 are put alongside the evidence from econometric studies . . . it seems more likely than not that, other factors remaining unchanged, the elimination of tobacco promotion causes a reduction in tobacco consumption and smoking prevalence to a level below what it would have been otherwise."94

The report also concluded that comprehensive policies to reduce tobacco consumption are more effective than any single measure, for example:

· "Tobacco consumption increases when tobacco promotion is permitted and real price is allowed to fall; consumption declines markedly when promotion is totally banned and prices [are] raised."95

The three features deemed essential for an effective government policy to reduce the health consequences of tobacco use were (1) programs to educate the public

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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TABLE 4-1  Annual average rates of change in the percentage of adults smoking according to tobacco advertising restriction in force, 20 advanced economy countries, 1970-1986

 

Surveyed

     

Annual % change

Country (year of ban)

Age group

Years
Begin    End

% Smokers
Begin

End

Per country

Per group

Enforced tobacco advertising ban

         

Iceland (1972)

18-69

1985-1986

40.0

36.2

-9.5

Group

Finland (1978)a

15-64

1978-1986

25.8

25.5

-0.1

average

Norway (1975)

16-74

1973-1986

41.5

34.5

-1.1

-3.6

Portugal (1983)

na

1983-1984

na

23.5

na

 

Tobacco promotion in few media

         

Belgium

15+

1980-1987

41.5

32.0

-3.3

Group

France

15+

1976-1983

44

39.0

-1.6

average

Italy (enforced ban)

14+

1980-1983

34.9

31.1

-3.6

-2.5

New Zealand

15+

1976-1986

35.0

30.0

-1.4

 

Singaporeb

15+

1977-1984

23.0

19.0

-2.5

 

Swedenb

16+

1976-1985

38.5

29.6

-2.6

 

Tobacco promotion in most media

         

Australiab

16+

1972-1983

38.0

33.5

-1.1

 

Austria

15+

1972-1981

28.0

27.0

-0.4

 

Belgium

15+

1970-1979

20.2

21.3

-0.6

 

Canada

15+

1970-1986

45.0

32.0

-1.8

 

Denmark

15+

1970-1979

57.9

48.9

-1.7

 

France

15+

1970-1976

53.1

46.7

-2.0

 

Ireland

15+

1973-1982

43.0

35.0

-2.1

 

Netherlands

15+

1970-1986

58.5

38.0

-2.2

 

Switzerland

15+

1972-1981

34.6

37.5

+0.9

 

United Kingdom

16+

1972-1986

46.0

33.0

-2.0

 

United States

17+

1970-1986

36.6

26.5

-1.7

 

West Germany

15+

1970-1984

41.7

36.0

-1.0

 

Tobacco promotion in all media

         

Greece

15+

1985

na

21.5

na

 

Japan

20+

1970-1986

46.6

37.6

-1.2

 

Spain

15+

1970-1987

na

40.5

na

 

aAverage of two surveys.

         

bMale and female percentage averaged.

         

Sources: The following were cited by the Toxic Substances Board. Health or Tobacco: An End to Tobacco Advertising and Promotion. Wellington, New Zealand: Department of Health, 1989; Rothwell, K. and R. Masironi. Cigarette Smoking in Developed Countries Outside Europe. WHO, 1987; Rothwell, K., R. Masironi, and D. O'Byrne. Smoking in Europe. WHO, 1987.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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TABLE 4-2  Annual average rates of change in the percentage of young people who smoke daily according to tobacco advertising restrictions in force, 18 advanced economy countries, 1970-1986

 

Surveyed

     

Annual % change

 

Country

Age
group

Years


Begin   End

% Smokers


Begin        End

Survey

Per
country

Per
group

Tobacco promotion banned for health reasons

         

Iceland

12-16

1974-1986

23

9

-5.1

   

Iceland

17-18

1974-1986

34

29

-1.3

-3.0

 

Iceland

19-20

1974-1986

41

29

-2.5

   

Italy

15-18

1972

51

na

na

 

Group

Finland

16

1973-1985

35.5

26.5

2.6

 

average

Finland

18

1973-1985

47

29

-3.2

 

-2.7

Norway

16-24

1974-1986

41

28.5

-2.5

-2.5

 

Portugal

20-24

1983

46

na

 

na

 
 

15-24

na

87

45

 

na

 

Tobacco promotion in few media

         

Belgium

17

1975-1981

44.5

28.5

-6.0

-3.0

 

Belgium

18-24

1982-1984

44

44

0

   

France

14-16

1976-1984

29

25.5

-1.5

-1.95

 

France

18-24

1976-1983

66

55

-2.4

 

Group

Italy

15-24

1987

 

32.5

 

na

average

New Zealand

15-19

1976-1987

30

27.5

-0.8

-0.08

-2.7

Singapore

15-19

1984

na

4.8

na

na

 

Sweden

16

1974-1984

38

19

-5.0

-5.15

 

Sweden

16-24

1977-1986

41

21.5

-5.3

   

Tobacco promotion in most media

         

Australia

16-19

1974-1986

33.8

29.6

-1.0

   

Austria

14-29

1972-1981

30.0

35.0

+1.8

   

Canada

15-19

1972-1983

31.7

20.3

-3.3

 

Group

Denmark

17-19

1974-1980

38.1

33.0

-2.2

 

average

FR Germany

14-19

1976-1984

40.5

27.5

-4.0

 

-1.9

Ireland

18

1970-1980

39

36

-0.8

-2.4

 
 

16-24

1973-1982

48

31

-3.9

   

Netherlands

15-19

1970-1986

56

22

-3.8

   

Switzerland

15-24

1981

 

36.5

na

   

United States

17-18

1968-1979

24.5

22.5

-0.7

   

United Kingdom

16-19

1972-1986

41

30

-1.9

   

Tobacco promotion in all media

       

Group

Japan

20-29

1970-1986

45

43.3

-0.2

 

average

Spain

15-24

1981-1987

53.5

55

+0.5

 

+0.1

NOTE: In all countries the rate given represents both sexes. In most countries female and male rates were averaged.

Sources: The following were cited by the Toxic Substances Board. Health or Tobacco: An End to Tobacco Advertising and Promotion. Wellington, New Zealand: Department of Health, 1989, Appendix 5; International Digest of Health Legislation. WHO; Aoki, M., S. Hisamichi, and S. Tominaga, eds. Smoking and Health, 1987. Elsevier Science Publishers. BV, 1988; Smoking in Europe. WHO, 1987; Smoking in Developed Countries Outside Europe. WHO, 1987.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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about the dangers of tobacco use, (2) an increase in tobacco prices, and (3) a total  ban on tobacco promotion.96

Currently, 18 countries have total bans on tobacco advertisements. Advertisement bans have been instituted as part of more comprehensive tobacco control efforts in Canada and New Zealand. In these countrires, ad bans have been complemented by aggressive antismoking activities and tax increases on tobacco. The rate of decline in Canada after implementation of an advertising ban was double that reported prior to the ban, and in New Zealand an ad ban was associated with an 11.3% decrease in smoking during a 6-month period. An assessment of the independent effect of each antismoking measure would be difficult, perhaps impossible, but the effect of the combination is clear.97

An important reason for calling attention to comprehensive approaches to reduce tobacco use is that single-factor approaches might have paradoxical effects on tobacco consumption. For example, restrictions of advertising that are accompanied by a reduction in counter-advertising efforts may thwart prevention efforts. In 1971, in the United States, the tobacco industry voluntarily removed from radio and television all cigarette advertising. Following this act, per capita cigarette consumption, which had been declining since the 1964 surgeon general's report, leveled off and then increased. This unexpected trend may be related to the fact that as the cigarette ads were removed from the airwaves, so too were the cigarette counter-ads in the form of public service announcements (PSAs). The PSAs, developed by the Public Health Service in the late 1960s, were designed to increase the public's knowledge about the dangers of smoking, and were pretested accordingly. These public service antismoking messages, which had appeared from July 1967 to January 1971 along with cigarette ads as a result of the FCC's Fairness Doctrine, apparently had been far more effective in reducing smoking than the pro-smoking ads in increasing it.98 For this reason it was in the tobacco industry's best interest to remove ads from radio and television, and to shift marketing dollars to promotionals and giveaways.

RATIONALE FOR RESTRICTIONS

Over the decades, tobacco advertising and promotional efforts that reach children and youths have not diminished unless social or legal pressure was brought to bear on the tobacco industry or the advertising media. Criticism of the tobacco industry was widespread and strong in 1963, a year in which the average teenager viewed 100 cigarette commercials a month, and the average child viewed 70 due to airing of ads during programs commonly watched by youths. In 1965, in response, the tobacco industry adopted a voluntary code of conduct.99 The voluntary code notwithstanding, a later analysis, in 1968, by the FTC revealed that the average teenager was exposed to 60 full-length cigarette commercials a month. 100

The tobacco industry's self-regulatory code covered four areas of behavior:

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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advertising appealing to the young, advertising containing health representations, the provision of samples, and the distribution of promotional items to the young.101 Notably, guidelines for following the code are lacking. For example, a specific stipulation of the voluntary code is that models used in ads should not appear to be younger than 25 years of age. Interpretation of what a model of 25 looks like is open to question. One study of cigarette ads found that 17% of models in cigarette ads were perceived (by persons 13 years old and older) to be younger than 25 years, that certain brands tend to employ younger-looking models, and that these models appeal to a broad audience. 102 In the wake of criticism, both from antismoking activists and from the advertising profession itself, that the Joe Camel campaign is especially appealing to those under 25, Philip Morris and R. J. Reynolds have responded by creating national advertising campaigns built around their commitment to "educate children" about smoking. The campaign is framed around smoking as an adult behavior and therefore the need for children to wait until they are of legal age before making decisions about smoking. A booklet entitled Tobacco: Helping Youth Say No has been widely distributed to governors, school boards, community groups, and parents who request it. The booklet makes no reference to the health and addictive effects of tobacco use. The educational impact of the campaign on youths has not been evaluated.

Another code stipulation states, "Cigarette advertising shall not depict as a smoker any person participating in, or obviously having just participated in, physical activity requiring stamina or athletic conditioning beyond that of normal recreation.103 Nevertheless, ads routinely use imagery associated with athletics and physical activity, thereby linking smoking and vitality; Marlboro's Adventure Team of whitewater rafters, dirt bikers, and other adventure enthusiasts is a case in point. As currently framed, advertising and promotion of so-called "light" or "low-tar" cigarettes fail to convey accurate information regarding the hazards of smoking, and instead tend to foster the illusion of a "healthful" smoking alternative. Whether or not these product innovations reduce harm from smoking, they do address the marketing objective of reducing consumer concern; they are tools in a public relations approach to minimizing a major public health problem.104 Furthermore, under self-regulation, many health issues are not presented to the public, issues such as the addictiveness of tobacco; risk of cancer, heart disease, and stroke; effects on nonsmokers; and risk from tobacco smoke constituents such as benzene and arsenic.

Public health groups contend that the industry's voluntary code is often inadequate in content and is inadequately enforced. They have therefore pressed for Congress to restrict tobacco promotion and advertising, arguing that the advertising and promotion of tobacco products on the scale and in the manner described in this chapter tend to increase the overall prevalence of tobacco consumption as well as increase the initiation of smoking by youths. In response, the tobacco industry argues that, among smokers, advertising and promotion affect market share, not the level of consumption. Moreover, the industry denies

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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that advertising and promotion causally affect the decisions of young people to begin smoking.

Many of the participants in this ongoing debate seem to assume that a definitive finding of causality is a necessary predicate for legislative action restricting tobacco promotion and advertising. In the Committee's view, however, requiring definitive proof of causality on issues of this nature would unjustifiably stymie sensible public health regulation. Indeed, the history of public health successes, from vaccination to cholera prevention and injury control, suggest that detailed causal understanding is apt to follow an intervention, rather than be a precondition for it. If youth smoking fell after advertising and promotion were eliminated, this would corroborate a hypothesis for which there is already ample, suggestive evidence—that such advertising and promotion is an important factor in the initiation of tobacco use by youths. This seems to be the lesson from the experiences reviewed in the New Zealand report.

The inability to conduct case control studies in an environment free of tobacco marketing makes it impossible to discern the independent causal effect of advertising and promotion on tobacco consumption. It is difficult to disentangle the actual impact of marketing expenditures from the other social and cultural factors that affect tobacco use. Moreover, the influence of any of these environmental variables is mediated by, and interacts with, so many other variables affecting perceptions of and attitudes toward tobacco use that any statistical association between levels of promotional expenditures and levels of tobacco use is difficult to interpret. This is not to say that the relationship is not a causal one, only that any causal effect is inevitably obscured by layers of other factors, and that it is virtually impossible to quantify the causal effect in any definitive way. Indeed, when one takes into account the inherent difficulty of discerning a causal influence, the substantial convergent evidence that advertising and promotion increases tobacco use by youths is impressive and, in the Committee's view, provides a strong basis for legal regulation.

Having said this, the Committee does not think that the argument for restricting the advertising and promotion of tobacco products must rest on a definitive or unequivocal finding that such activities causally influence levels of consumption. It is enough that the advertising and promotional activities described above in this chapter have the natural tendency to encourage initiation and maintenance of smoking by children and adolescents. There can be no doubt that the tobacco companies aim to portray smoking in a favorable light and to communicate messages that link use of tobacco products to positive feelings, images, and experiences. Even if the primary objective of those marketing expenditures is to preserve or expand market share among existing smokers, youngsters are routinely exposed to messages that encourage them to smoke.

Tobacco advertising is characterized by images and themes that are especially appealing to adolescents, and some are appealing to children. In addition, a large proportion of promotional expenditures associate use of tobacco with

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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activities and products that are attractive to children and youths. The sheer amount of expenditures for advertising and promotion assures that young people will be exposed to these messages on a massive scale. It is clear that society's efforts to discourage young people from smoking are obstructed—and perhaps fatally undermined—by the industry's efforts to portray their dangerous products in a positive light.105

In sum, portraying a deadly addiction as a healthful and sensual experience tugs against the nation's efforts to promote a tobacco-free norm and to discourage tobacco use by children and youths. This warrants legislation restricting the features of advertising and promotion that make tobacco use attractive to youths. The question is not, ''Are advertising and promotion the causes of youth initiation?" but rather, "Does the preponderance of evidence suggest that features of advertising and promotion tend to encourage youths to smoke?" The answer is yes and this is a sufficient basis for action, even in the absence of a precise and definitive causal chain.

RECOMMENDATIONS

Policy Recommendations

The images typically associated with advertising and promotion convey the message that tobacco use is a desirable, socially approved, safe and healthful, and widely practiced behavior among young adults, whom children and youths want to emulate. As a result, tobacco advertising and promotion undoubtedly contribute to the multiple and convergent psychosocial influences that lead children and youths to begin using these products and to become addicted to them.

As already noted, the Committee believes that American society, through all organized social institutions, should take aggressive measures to discourage the use of tobacco products by children and youths. The message should be unequivocal—tobacco use is unhealthy and socially disapproved. In the context of this emergent social norm, the contradictory messages now conveyed by the tobacco industry can no longer be tolerated. The Committee therefore recommends a step-by-step plan to eliminate these commercial messages from the various media of mass communication. Realizing that implementation of this recommendation will require careful planning and a period of transition, the Committee proposes a sequential process for phasing in the necessary restrictions.

First, Congress should repeal the federal law preempting state regulation of tobacco promotion and advertising that occurs entirely within the states' borders. This should be accomplished by the end of 1995. The repeal will have the effect of stimulating local interest in tobacco regulation and community participation in reviewing tobacco data and in drafting legislation aimed

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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at promotion, distribution, and use of tobacco products. Concordant with federal guidelines, a wide range of national experiments will take place, providing data on the effect of various programs.

State and local regulation of cigarette advertising to a large extent has been foreclosed by federal law, which expressly prohibits states and localities from imposing "any requirement or prohibition based on smoking and health . . . with respect to the advertising and promotion of any cigarettes" that meet federal labeling requirements.106 To the extent that state and local regulation of tobacco advertising or promotion aims to promote public health objectives, it is curtailed by this sweeping federal preemption. It can be argued, however, that state and local governments retain the authority to ban advertising likely to reach a large audience of children because such action aims mainly to minimize violations of laws against youth access and is, therefore, not "based on smoking and health." Relying on this argument, transportation systems in the cities of Boston, Denver, Portland, New York, Seattle, and San Francisco, and in the state of Utah, have eliminated tobacco advertising on their vehicles.107 Whether those actions are lawful remains unclear.

The communication and tobacco industries have legitimate interests in avoiding diverse and often incompatible state-by-state regulation of advertising and promotional activities occurring in national media. However, state and local governments should be free to circumscribe advertising and promotion that occur exclusively within the geographic boundaries of a single state in order to protect and promote the health and welfare of its citizens, subject only to the command of the first amendment. Therefore, Congress should modify the preemption provision so that the states have clear authority to restrict or ban advertising and promotion at the point of sale, on public transportation systems and vehicles, on billboards, in public arenas or sports facilities, or other locations located entirely within a state's boundaries.

Second, after state regulatory authority has been clarified and restored, states and localities should severely restrict the advertising and promotion of tobacco products on billboards and other outdoor media, on vehicles, in facilities of public transportation, in public arenas and sports facilities, and at the point of sale. States and localities should either ban tobacco advertising and promotion altogether or should restrict such messages to a "tombstone" format. Tombstone advertising would limit commercial messages to information about the product and would forbid the use of images and pictures. This approach is designed to eliminate all the images that imply that tobacco use is beneficial and make it attractive, and that encourage young people to use tobacco products. The most common concept of tombstone advertising would allow only text in an advertisement. A broader concept of tombstone advertising would permit the use of slogans, scenes, or colors in tobacco advertisements or on tobacco packaging. Specific decisions regarding the type of information that would be permitted should be made by a regulatory authority.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Third, Congress should enact comprehensive legislation establishing a timetable for gradual implementation of a plan for restricting tobacco advertising and promotion in interstate commerce. Essential components of this plan, which should be enacted by the end of 1996 and should become fully effective by the year 2000, include:

(a) restricting to a tombstone format the advertising of tobacco products in print media, including magazines and newspapers, or in other visual media, including videotape, videodisc, video arcade game, or film;

(b) banning the commercial use of the registered brand name of a tobacco product, trademark, or logo, or other recognizable symbol for such a product in any movie, music video, television show, play, video arcade game. or other form of entertainment, or on any other product; and

(c) banning the use of the registered brand name of a tobacco product, a trademark or logo, or other recognizable symbol for such a product, in any public place, or in any medium of mass communication for the purpose of publicizing, revealing, or documenting sponsorship of, or contribution to, any athletic, artistic, or other public event.

These proposals represent essential components of the regulatory plan. By recommending these steps, the Committee does not mean to exclude other restrictions or to disapprove more restrictive steps, such as banning advertising altogether. The Committee has endorsed the tombstone format because this approach is necessary to eliminate those features of advertising that tend to encourage tobacco use by children and youths. No less restrictive approach would accomplish the legislative objective. The Committee is confident that state and federal legislation implementing these recommendations will substantially further the nation's compelling interest in preventing tobacco use by children and youths and that such legislation would survive constitutional challenges brought by the affected media or by the tobacco industry.108

Research Recommendations

The Committee recommends:
Research should be conducted that attends to ethnic, gender, and social class differences; that is sensitive to youths' responses to advertising and promotional messages; and that assesses the success as well as the failure of advertising campaigns. The research question to date has primarily been, "What does advertising do to people?" Research should now ask, "What do people do with advertising (and counter-advertising)?"109

As a result of the types of research methods used and the research questions asked, much of the literature on tobacco use and advertising attributes little agency to the public in general and to youths in particular; the public is consid-

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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ered to be rather passive and easily manipulated. While there is some truth to this view, it hardly expresses a complete picture of this complex, interactive phenomenon. Required are longitudinal and ethnographic accounts of tobacco use that are responsive to local context, studies that are notably absent in the smoking literature. In need of consideration are the ways in which:

(a) advertising provides resources (images) for teen subgroup identity construction and social statement,

(b) advertising is responsive to existing and emergent social uses of smoking among various subgroups,

(c) tobacco use takes on meaning in response to anti-tobacco-use messages (generated by the tobacco industry as well as by public health advocates), that is, messages that are moralistic or focus attention on adult status, and

(d) imagery of tobacco use is appropriated and transformed by teens themselves.

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1. Federal Trade Commission. Report to Congress for 1991: Pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: Federal Trade Commission, 1994; Federal Trade Commission. Report to Congress: Pursuant to the Comprehensive Smokeless Tobacco Health Education Act of 1986. Washington, DC: Federal Trade Commission, 1993. 19, 26.

2. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People. A Report of the Surgeon General, 1994. S/N 017-001-004901 -0. Washington, DC: U.S. Government Printing Office, 1994. 175.

3. Ibid., 65.

4. Ibid., 58, 230.

5. Centers for Disease Control. "Differences in the Age of Smoking Initiation Between Blacks and Whites—United States." Morbidity and Mortality Weekly Report 40:44 (1991): 754-757.

6. Centers for Disease Control and Prevention. Preventing Tobacco Use. 74.

7. Johnston, Lloyd D., Patrick M. O'Malley, and Jerald G. Bachman. Smoking, Drinking, and Illicit Drug Use Among American Secondary Students, College Students, and Young Adults, 19751991, Volume 1. NIH Pub. No. 93-3480. Rockville, MD: National Institute on Drug Abuse, 1992. 125.

8. Centers for Disease Control and Prevention. Preventing Tobacco Use. 230.

9. Johnston, Lloyd D., Patrick M. O'Malley, and Jerald G. Bachman. National Survey Results on Drug Use from The Monitoring the Future Study, 1975-1992, Volume 11. NIH Pub. No. 93-3598 Rockville, MD: National Institute on Drug Abuse, 1993. 14, 163-165.

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12. All spending amounts are from the Federal Trade Commission report, 1994.

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Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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16. Slade, John. "Teenagers Participate in Tobacco Promotions."  9th World Conference on Tobacco and Health. Paris. October 10-14, 1994. (Abstract.)

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36. Smith, R. C. "The Magazines' Smoking Habit." Columbia Journalism Review (Jan/Feb 1978): 29-31. In Roemer, Ruth. Legislative Action to Combat the World Tobacco Epidemic. 2nd ed. Geneva, Switzerland: World Health Organization, 1982. 28.

37. Pollay, Richard W., Jung S. Lee, and David Carter-Whitney. "Separate But Not Equal: Racial Segmentation in Cigarette Advertising." Journal of Advertising 21:1 (1992): 45-57.

38. Warner et al., 1992.

39. Bishofsky, Steven. "Magazines Uneasy about Accepting Anti-Smoking Ads." University of Washington: Office of News and Information, 1993. (Thesis.)

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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40. Ward, S. Testimony in Tobacco Issues (Part 2). In Hearings Before the Committee on Energy and Commerce. House of Representatives. Serial No. 101-126. 1989. 302-308.

41. Centers for Disease Control. "Cigarette Smoking among Adults—United States, 1991." Morbidity and Mortality Weekly Report 42:12 (1993): 230-233; Tye, Joe B., Kenneth E. Warner, and Stanton A. Glantz. "Tobacco Advertising and Consumption: Evidence of a Causal Relationship." Journal of Public Health Policy (Winter 1987): 492-508.

42. Pollay, Richard W., and Anne M. Lavack. "The Targeting of Youths by Cigarette Marketers: Archival Evidence on Trial." In McAlister, Leigh, and Michael L. Rothschild. eds. Advances in Consumer Research 20. Provo, UT: Association for Consumer Research, 1993. 266-271.

43. Basil, Michael D., Caroline Schooler, David G. Altman, Michael Slater, Cheryl L. Albright, and Nathan Maccoby. "How Cigarettes Are Advertised in Magazines: Special Messages for Special Markets." Health Communication 3:2 (1991): 75-91; Warner, Kenneth E. Selling Smoke: Cigarette Advertising and Public Health.  Washington, DC: American Public Health Association, 1986; Krupka, L. R., and A. M. Vener. "Gender Differences in Drug (Prescription, Non-Prescription, Alcohol and Tobacco) Advertising: Trends and Implications."  The Journal of Drug Issues 22:2 (1992): 339-360; and Hutchings. "A Review of the Nature and Extent of Cigarette Advertising in the United States." In Proceedings of the National Conference on Smoking and Health: Developing a Blueprint for Action. New York: American Cancer Society, 1981. 249-262.

44. Pierce, John P., Lora Lee, and Elizabeth Gilpin. "Smoking Initiation by Adolescent Girls. 1944 Through 1988." Journal of the American Medical Association 271:8 (23 Feb. 1994): 608-611.

45. DiFranza, Joseph R., John W. Richards, Paul M. Paulman, Nancy Wolf-Gillespie, Christopher Fletcher, Robert Jaffe, David Murray. "RJR Nabisco's Cartoon Camel Promotes Cigarettes to Children." Journal of the American Medical Association 266:22 (1991): 3149-3153.

46. Dubow, Joel. "Was Joe Camel Framed?" Food and Beverage Marketing (July 1993): 28ff.

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48. Reed, O. Lee, and D. Whitman. "A Constitutional and Policy-Related Evaluation of Prohibiting the Use of Certain Nonverbal Techniques in Legal Advertising." Brigham Young University Law Review 2 (1988): 265-338.

49. Batra, Rajeev, and M. L. Ray. "How Advertising Works at Contact." In Alwitt, Linda, and A. Mitchell, eds. Psychological Processes and Advertising Effects. Hillsdale, NJ: L. Erlbaum Assoc., 1985; and Zajonc, R. B. "Feeling and Thinking: Preferences Need No Inferences." American Psychologist 35:2 (1980): 151-175.

50. Fishbein, Martin, and Icek Ajzen. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: Addison Wesley, 1975.

51. Donohue, Thomas R., Lucy L. Henke, and William A. Donohue. "Do Kids Know What TV Commercials Intend?" Journal of Advertising Research 20:5 (Oct. 1980): 51-57.

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53. Bandura, Albert. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall, 1986; Bandura, Albert. "Social Cognitive Theory of Mass Communication." In Bryant, Jennings, and D. Zillmann, eds. Media Effects: Advances in Theory and Research. Hillsdale, NJ: Lawrence Erlbaum, 1994. 61-92.

54. Comerford et al., 8.

55. Goldman, R. Reading Ads Socially. London: Rouledge, 1992: Wernick, Andrew. Promotional Culture: Advertising, Ideology, and Symbolic Expression. London: Sage Publications, 1991.

56. Wong-McCarthy, William J., and Ellen R. Gritz. "Preventing Regular Teenage Cigarette Smoking." Pediatric Annals 11:8 (1982): 683-689; Chassin, Laurie, Clark C. Presson, Steven J. Sherman, Eric Corty, and Richard W. Olshavsky. "Predicting the Onset of Cigarette Smoking in Adolescents: A Longitudinal Study." Journal of Applied Social Psychology 14:3 (1984): 224-243.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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57. DiClemente, C. Carlo, Scott K. Fairhurst, and Nancy A. Piotrowski. "The Role of Self-Efficacy in the Addictive Behaviors." In Maddux, James, ed. Self-Efficacy, Adaptation, and Adjustment: Theory, Research, and Application. New York: Plenum, 1994. (In press.)

58. Elkind, David, and R. Bowen. "Imaginary Audience Behavior in Children and Adolescents." Developmental Psychology 15:1 (1979): 38-44.

59. Chassin, Laurie, Clark C. Presson, Steven J. Sherman, Eric Corty, and Richard W. Olshavsky. "Self-Images and Cigarette Smoking in Adolescence." Personality and Social Psychology Bulletin 7:4 (Dec. 1981): 670-676; Grube, Joel W., Ivan L. Weir, Shelly Getzlaf, and Milton Rokeach. "Own Value System, Value Images, and Cigarette Smoking." Personality and Social Psychology Bulletin 10:2 (1984): 306-313.

60. Chassin, Laurie, C. C. Presson, and S. J. Sherman. "Social Psychological Contributions to the Understanding and Prevention of Adolescent Cigarette Smoking." Personality and Social Psychology Bulletin 16:1 (1990): 133-151; McCarthy, W. J., and E. R. Gritz. "Teenagers, Cigarette Smoking and Reactions to Selected Cigarette Ads." Los Angeles, CA: Western Psychological Association Meeting, April 16, 1984; and Grube et al.

61. Chassin et al., 1981.

62. Greenberg, Jeff, and Tom Pyszczynski. "Compensatory Self-Inflation: A Response to the Threat to Self-Regard of Public Failure." Journal of Personality and Social Psychology 49:1 (1985): 273-280.

63. Schudson, Michael. "Symbols and Smokers: Advertising. Health Messages, and Public Policy." In Rabin, Robert L., and Stephen D. Sugarman. Smoking Policy: Law, Politics, and Culture. New York: Oxford University Press, 1993. 216.

64. Pollay and Lavack, 268-269.

65. Ibid.

66. Chassin, Laurie, Clark C. Presson, and Steven J. Sherman. "'Constructive' vs. 'Destructive' Deviance in Adolescent Health-Related Behaviors." Journal of Youth and Adolescence 18:3 (1989): 245-262.

67. Jessor, Richard, and Shirley L. Jessor. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York: Academic Press, 1977; Moshbach. Peter, and H. Leventhal. "Peer Group Identification and Smoking: Implications for Intervention." Journal of Abnormal Psychology 97:2 (1988): 238-245; Sussman, Steve, Clyde W. Dent, Alan W. Stacy, Catherine Burciaga, Anne Raynor, Gencie E. Turner, Ventura Charlin, Sande Craig, William B. Hansen, Dee Burton. and Brian R. Flay. "Peer-Group Association and Adolescent Tobacco Use." Journal of Abnormal Psychology 99:4 (1990): 349-352.

68. Moshbach and Leventhal.

69. Pollay, 1990.

70. Basil et al.

71. Blum, Alan, and Matt Myers. "Tobacco Marketing and Promotion." In Houston. Thomas P., ed. Tobacco Use: An American Crisis (1993): 63-71.

72. Aitken, P. P., D. S. Leathar, F. J. O'Hagan, and S. I. Squair. "Children's Awareness of Cigarette Advertisements and Brand Imagery." British Journal of Addiction 82 (1987): 615-622.

73. Glantz, Stanton A. "Removing the Incentive to Sell Kids Tobacco. A Proposal." Journal of the American Medical Association 269:6 (1993): 793-794.

74. Pollay and Lavack.

75. Ibid.; and Altman, David G., Michael D. Slater, Cheryl L. Albright, and Nathan Maccoby. "How an Unhealthy Product Is Sold: Cigarette Advertising in Magazines, 1960-1985." Journal of Communication 37:4 (1987): 95-106.

76. Burnett, L. Communications of an Advertising Man. Chicago: Burnett, 1961.

77. Pollay and Lavack, 1993.

78. Pollay, 1990. 24.

79. Wong-McCarthy and Gritz; and Gritz, E. R. "Cigarette Smoking by Adolescent Females: Implications for Health Care and Behavior." Women and Health 9:2/3 (1984): 103-115.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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80. Pollay. 1990. 9.

81. Federal Trade Commission, 1994. 12.

82. Pollay, 1990. 9, 27.

83. Centers for Disease Control. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General, 1988. USDHHS Pub No. (CDC) 88-8406. Washington, DC: U.S. Department of Health and Human Services, 1988.

84. Johnston, Lloyd D., Jerald G. Bachman, and Patrick M. O'Malley. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. (27 January 1994.)

85. Allen, Karen, Abigail Moss, Gary A. Giovino, Donald R. Shopland, and John P. Pierce. "Teenage Tobacco Use: Data Estimates From the Teenage Attitudes and Practices Survey, United States, 1989." Advance Data 224 (1 Feb. 1993): 1-20.

86. Amos, Amanda. "Youth and Style Magazines: Hooked on Smoking?" Health Visitor 66:3 (1993): 91-93.

87. Ibid.

88. McKenna, Jeffrey W., and K. N. Williams. "Crafting  Effective Tobacco Counter-advertisements: Lessons from a Failed Campaign Directed at Teenagers." Public Health Reports 108:S  (1993): 85-89.

89. Centers for Disease Control and Prevention. Preventing Tobacco Use, 195.

90. Aitken et al., 1987; Goldstein, Adam O., Paul M. Fischer, John W. Richards, and Deborah Creten. "Relationship Between High School Student Smoking Recognition of Cigarette Advertisements." Journal of Pediatrics 110:3 (1987): 488-491; Pierce et al., 1994; and Pierce, John P., Elizabeth Gilpin, David M. Burns, Elizabeth Whalen, Bradley Rosbrook, Donald Shopland, and Michael Johnson. "Does Tobacco Advertising Target Young People to Start Smoking?" Journal of the American Medical Association 266:22 (1991): 3154-3158.

91. For a review of exposure as an ambiguous construct, see: Klitzner, Michael, Paul J. Greunewald, and Elizabeth Bamberger. "Cigarette Advertising and Adolescent Experimentation with Smoking." British Journal of Addiction 86 (1991): 287-298.

92. Aitken, P. P., D. R. Eadie. G. B. Hastings, and A. J. Haywood. "Predisposing Effects of Cigarette Advertising on Children's Intentions to Smoke When Older." British Journal of Addiction 86 (1991): 383-390.

93. New Zealand Toxic Substances Board. Health or Tobacco: An End to Tobacco Advertising and Promotion. Wellington, New Zealand: Department of Health, 1989. xxix.

94. Ibid., xxiii, xxiv, 76.

95. Ibid., 76.

96. Ibid., 103.

97. Action on Smoking and Health. Tobacco Advertising: The Case for a Ban. London: ASH, 1991. Cited in Amos, Amanda. "Cigarette Advertising and Marketing Strategies." Tobacco Control 1 (1992): 3-4.

98. Warner, K. "Clearing the Airwaves: The Cigarette Ban Revisited."  Policy Analysis 5:4 (1979): 435-450.

99. Pollay, Richard W. "The Major Minor Issue: Children, Cigarettes and Advertising Self-Regulation in the Sixties." In Thorson, Esther, ed. Proceedings of the American Academy of Advertising. Columbia: University of Missouri, 1993. 2-11.

100. Federal Trade Commission. Report to Congress: Pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: Federal Trade Commission, 1968.

101. U.S. Congress. Hearings on HR2248 Before the Committee on Interstate and Foreign Commerce. House of Representatives, 89th Congress, 1st Session. Serial No. 89-1 1. Washington, DC: U.S. Government Printing Office, 1965.

102. Mazis, Michael B., Debra J. Ringold, Elgin S. Perry, and Daniel W. Denman. "Perceived Age and Attractiveness of Models in Cigarette Advertisments." Journal of Marketing 56:1 (Jan. 1992): 22-37.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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103. Tobacco Industry. "Cigarette Advertising Code." 5.

104. Comerford and Slade.

105. Pollay, 1990. 33-35.

106. 15 U.S.C. Par. 1334, cited in Shiffrin, Steven H. "Alcohol and Cigarette Advertising: A Legal Primer." Adolescent Medicine 4:3 (1993): 627.

107. Ibid.

108. See, for example, Gostin, Lawrence 0. and Allan M. Bandt. "Criteria for Evaluating a Ban on the Advertisement of Cigarettes." Journal of the American Medical Association 269 (17 February 1993): 904-909.

109. Chapman, S. "The Limitations of Econometric Analysis in Cigarette Advertising Study." British Journal of Addiction (1989): 1267-1274.

Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Suggested Citation:"4 TOBACCO ADVERTISING AND PROMOTION." Institute of Medicine. 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington, DC: The National Academies Press. doi: 10.17226/4757.
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Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths Get This Book
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Tobacco use kills more people than any other addiction and we know that addiction starts in childhood and youth.

We all agree that youths should not smoke, but how can this be accomplished? What prevention messages will they find compelling? What effect does tobacco advertising—more than $10 million worth every day—have on youths? Can we responsibly and effectively restrict their access to tobacco products?

These questions and more are addressed in Growing Up Tobacco Free, prepared by the Institute of Medicine to help everyone understand the troubling issues surrounding youths and tobacco use.

Growing Up Tobacco Free provides a readable explanation of nicotine's effects and the process of addiction, and documents the search for an effective approach to preventing the use of cigarettes, chewing and spitting tobacco, and snuff by children and youths. It covers the results of recent initiatives to limit young people's access to tobacco and discusses approaches to controls or bans on tobacco sales, price sensitivity among adolescents, and arguments for and against taxation as a prevention strategy for tobacco use. The controversial area of tobacco advertising is thoroughly examined.

With clear guidelines for public action, everyone can benefit by reading and acting on the messages in this comprehensive and compelling book.

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