Interventions to prevent tobacco use by children and adolescents have become an integral component of tobacco control policy. However, three articles in the March 2003 issue of the American Journal of Public Health (2003;93:412–416; 416–418;418–420) raise an interesting question: “Do programs that reduce adolescent smoking prevalence merely delay onset of smoking, or do they have a lasting impact on smoking prevalence among adults?”
The answer to this question is somewhat hazy due to limitations in available data. However, it appears that some of the reduction in smoking does persist over time. But if policies do not also address adult smoking, the full benefit of youth-focused programs becomes attenuated over time.
“Educating young people and helping them to make rational decisions in regard to smoking is sound and appropriate public health policy,” writes the author of the first of the three articles, Sherry Glied, PhD, of the Mailman School of Public Health, Columbia University, NY. However, she notes, “Reducing smoking among teens is a necessary condition for a program aimed at young people to have an effect on adult smoking rates. But it may not be a sufficient condition.”
Using data from the National Longitudinal Survey of Youth (NLSY), Glied found that the impact of increased tobacco tax rates encountered during youth diminishes during adulthood. However, “the studies examined only the effects of tobacco taxation; they did not assess the effects of other forms of tobacco control.”
In the second article, Stephen D. Sugarman, JD, School of Law, University of California, Berkeley, notes that while the impact of tobacco taxes is greatest on teens, adults are also influenced. He suggests it is unwise “…to make tobacco taxes almost the entire focus of tobacco control… As nonsmokers become an increasing majority of the voting public, the ease with which they can push more of the regular costs of government onto smokers is worrying as a matter of fairness.”
The third article describes differences in age of smoking initiation among White and African-American women. Among the former, the prevalence of smoking decreases slightly after age 20. In the latter, smoking prevalence continues to increase until the early 40s. Author Joyce Moon-Howard, DrPH, also of the Mailman School of Public Health, Columbia University, warns that a “…one size fits all approach… that targets only youths may miss a significant at-risk population.”
According to Tom Glynn, PhD, the American Cancer Society's (ACS) national director of science and trends, these three articles taken together point to an essential truth discovered in more than 25 years of research—that no single approach, target audience, or treatment will reduce tobacco use substantially. The only effective, data-based method for reducing use is a comprehensive one, as demonstrated by the successful experiments in California and Massachusetts where reduction in the rates of tobacco use has been more than double that of most other US states over the past decade.
Glynn says both of these states have employed a comprehensive approach to tobacco control, including:
• Increasing tobacco taxes.
• Using a portion of those revenues to sup-port a broad and sustained tobacco counter-advertising campaign.
• Passing enforceable clean indoor-air regulations.
• Restricting youth access to tobacco.
• Distributing tobacco-dependence treatment guidelines to health care providers.
• Introducing tobacco-use prevention programs in schools.
The research indicates, Glynn stressed, that control efforts should be broad-based in the audience they target too. “Youth, for example, may be more sensitive than adults to tax increases and to the more than nine billion dollars on US advertising the tobacco industry spends each year,” said Glynn, “but as long as there are adult role models who smoke—both in the everyday lives of adolescents as well in the movies, magazines, and TV—the success of our efforts to reduce youth tobacco use will be constrained.”
In addition, Glynn said, as noted in the Moon-Howard article, we can no longer assume that our two primary audiences for tobacco control efforts are merely youth and adults.
Glynn is quick to point out that such efforts need not be conducted only through government efforts nor should they be wholly dependent on taxes for their success. Physicians and other health care providers, for example, can use the US Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence in all encounters with patients who smoke (JAMA 2000;283:3244–3254). Managed care organizations and insurers can guarantee the availability of low-cost cessation programs. Schools, restaurants, hospitals, and other public facilities can enforce clean air regulations. Merchants can regularly comply with laws requiring identification for youth who wish to purchase tobacco products.
“If the primary message that tobacco use is not a normative behavior (fewer than one-fourth of adults in the United States are now smokers) and comprehensive tobacco controls efforts are aimed at our population across the lifespan,” said Glynn, “these efforts will be rewarded sooner through reduced disease.”