Stop Selling Tobacco to Children!

John P. Fulton, PhD is Assistant Division Director, Division of Preventive Health Services, Rhode Island Department of Health, and Clinical Assistant Professor of Community Health, Brown University School of Medicine.

The Tobacco Industry Wants You!

The tobacco industry uses its vast advertising resources to recruit replacements for the 1900 Rhode Islanders who die each year because of tobacco use. It is clear to all except the most staunch supporters of the industry that its recruitment efforts yield the greatest results among children. After all, tobacco use statistics have consistently demonstrated that initiation of tobacco use is almost exclusively limited to minors in our society. Regular cigarette smoking may begin for some children as early as elementary school. By the seventh grade, about 6% of Rhode Island children have smoked at least five packs of cigarettes. By the twelfth grade, about 26% have done so.

Although much smoking among children is "experimental," addiction steadily follows for many. Nicotine is one of the most addictive substances known to medicine, and the inhalation of cigarette smoke is the most efficient means of delivering nicotine to the body. Some authorities have suggested that smoking as few as ten cigarettes may result in measurable addictive effects.

Addicting Children

Statistics from Rhode Island's 1993 Adolescent Substance Abuse Survey¹ clearly demonstrate the inexorable course of addiction among children, from experimenting with cigarettes through regular use. In the seventh grade, only about 4% of school children have smoked as many as 100 cigarettes and continue to smoke. This percentage increases to 8% in the eighth grade, 12% in the ninth grade, 14% in the tenth grade, 17% in the eleventh grade, and 19% in the 12th grade.

As physicians well know, once a person is addicted to nicotine, sustained cessation of tobacco use is extremely difficult. For example, it takes an average of seven years to quit smoking after the smoker has clearly decided to quit. A recent study demonstrated that of many possible determinants of sustained smoking cessation, two of the strongest were being older and having tried to quit smoking a number of times.² In short, neither nicorette nor "the patch" nor any other cessation support has proven to be a magic bullet. This is why the best solution to nicotine addiction is to avoid using the substance entirely.

More Bad News

That's not the only bad news. Recent statistics have demonstrated that the recruitment and addiction of children as cigarette smokers may be increasing in Rhode Island and the U.S. as a whole.³ Declines in smoking among children achieved largely through anti-tobacco use education in the 1970s and 1980s began to slow around 1990 and now appear to be reversing.

This should be no surprise. In the late 1980s the tobacco industry intensified cigarette advertising, using techniques which were especially effective with children. "Joe Camel," seen ubiquitously throughout the U.S. on billboards and buses, in magazines and corner stores, became as recognized among children as popular cartoon characters on T.V. "Marlboro gear" and other promotions of neat clothes and accessories began appearing on children's backs and in their pockets despite protestations by tobacco industry spokesmen that these items were "for adults only." What better way to get a teen's attention?

An Old but Good Idea

Years before "Joe Camel," Rhode Island law prohibited the sale of tobacco to children under 16, and the law was amended a few years ago to prohibit sales to 16 and 17 year olds as well. Similar state laws have been on the books throughout the country for decades. All have been totally ineffective, however, because enforcement, left to the discretion of local police departments, has languished in competition with higher priorities.

The U.S. Congress has recently attempted to remedy this problem by threatening the loss of Substance Abuse Prevention Block Grant funds to states which don't effectively enforce the prohibition of tobacco sales to minors. The "Synar amendment," as this combination of legislation and regulation has come to be known, specifies three conditions for the receipt of full block grant funding: a prohibition of tobacco sales to minors, proof of regular enforcement, and proof that ever-increasing proportions of tobacco vendors comply with the law.

What a wake up call! Acting to comply with the Synar amendment, Rhode Island quickly discovered how easy it was for children to buy cigarettes (the tobacco product most popular among children). In 1994 and 1995 tests of tobacco vendor compliance, about half the vendors approached by underage teens offered to sell them cigarettes. Worse still, underage teens were able to use cigarette vending machines unchallenged almost 9 out of 10 times.

In response, the State has taken two actions.

First, as the result of legislation passed in the 1995 Rhode Island General Assembly, all tobacco vending machines in Rhode Island will have to be positioned in the direct line of sight of a responsible person, and will be locked with an electronic device to prevent the sale of tobacco to unauthorized persons. This law takes effect January 1, 1996.

Second, the Rhode Island Department of Health, in collaboration with the Substance Abuse Prevention Task Force Association and other community members, has begun working with local Substance Abuse Prevention Task Forces to assure effective enforcement of the law prohibiting tobacco sales to minors.

Business as Usual

The latter effort would have been helped significantly by a bill introduced in the last session of the Rhode Island State Legislature. The bill would have revised the law prohibiting tobacco sales to minors and facilitated its enforcement. The tobacco industry and its allies were able to defeat the bill by arguing that it would be burdensome to Rhode Island business!

Actually, we should thank tobacco industry representatives in Rhode Island for clarifying the profits-versus-children's-health issue so forthrightly. Illegal tobacco sales to children is no penny-ante game in Rhode Island. A recent study published in the American Journal of Public Health estimates that illegal tobacco sales to children in our State gross $1.9 million annually.⁴

The fight in the legislature has not ended. The Coalition on Smoking OR Health, whose members include the American Cancer Society, the American Lung Association, and the American Heart Association, will continue to urge the passage of legislation which effectively restricts youth access to tobacco. The tobacco industry and its economic allies will just as assuredly resist all such attempts, despite claims that they have no interest in recruiting children as tobacco users.

Let's Not Forget Taxes

Another strategy which effectively restricts youth access to tobacco is to raise its cost, and the easiest way to do that is to raise tobacco taxes, either nationally or locally. The elasticity of cigarette sales in relation to price is about -0.5; a 1.0% increase in price causes a 0.5% decrease in sales. This figure is generally accepted by the tobacco industry and tobacco control advocates, alike, and explains why the tobacco industry resists increases in tobacco taxation as vigorously as it does.

Recent figures from California demonstrate an even stronger effect.⁵ Between 1989 (when Proposition 99 raised the California state tax on cigarettes $0.25/pack) and 1992, the elasticity of cigarette sales in relation to the state cigarette tax alone (not total price) was about -0.3; a 1.0% increase in tax caused a 0.3% decrease in per capita cigarette sales. This effect was about six times stronger than the effect of the anti-smoking media campaign purchased by Proposition 99's cigatette tax dollars!

Rhode Island is no slouch in this arena. Our state has one of the highest cigarette taxes in the nation. Even so, much more could be accomplished with this strategy, as recent statistics on tobacco use among children indicate. Furthermore, as the effect of inflation on the impact of previous tax increases is inexorable, so too must be the tax increases.

The Role of Physicians

Physicians are central to the fight against children's addiction. The American Medical Association (AMA) has taken a strong stand in fighting the devious strategies of the tobacco industry.

In July, 1995, AMA leadership ended a tough editorial with these words: "In summary, the evidence is unequivocal -- the US public has been duped by the tobacco industry. No right-thinking individual can ignore the evidence. We should all be outraged, and we should force the removal of this scourge from our nation and by doing so set an example for the world. We recognize the serious consequences of this ambition, but the health of our nation is more important than the profits of any single industry. On behalf of the physicians of this country and the people they serve, the AMA pledges its best efforts to the eradication of tobacco-related disease. We solicit the support of the public and our government in this endeavor. It is a worthy cause."⁶

The editorial, which accompanied a four-article, in-depth analysis of "approximately 4000 pages of memoranda, reports, and letters, covering a 30-year period, from the Brown and Williamson Tobacco Corporation," listed 14 recommendations for tobacco control adopted by the AMA leadership (Table 1). Among them were two recommendations concerning the restriction of youth access to tobacco (recommendations 7 and 10).

Table 1. The AMA position on tobacco, July 19, 1995.

"The AMA maintains an unequivocal stance against tobacco. The AMA reminds physicians, the public, and politicians that the damning evidence against tobacco makes opposition to its use a pressing, nonpartisan public health isue. If the industry uses political weapons, so shall we. The AMA will not relent in its opposition to tobacco use.

To accomplish this goal, the AMA recommends and will pursue the following steps:

1. Further efforts should be made to educate physicians, the public, and policymakers about the consequences of tobacco use, the predatory nature of the tobacco industry, and ways individuals can break their addiction to tobacco.

2. Medical schools and research institutions, as well as individual researchers, should refuse any funding from the tobacco industry and its subsidiaries to avoid giving them an appearance of credibility. The B&W [Brown and Williamson] documents affirm our belief that such tobacco industry entities as the Council for Tobacco Research, the Smokeless Tobacco Research Council, and the Center for Indoor Air Research are used by the tobacco industry to convince the public that there still is a controversy about whether tobacco has ill effects, to buy respectability, and to silence universities and researchers. We concur with the recommendation of a subcommittee of the National Cancer Advisory Board that federal funding be withdrawn from cancer research organizations that accept tobacco industry support.

3. Politicians should not accept money from the tobacco industry but should direct their efforts to protection of the nonsmoking majority. Those who do accept money should be identified publicly.

4. The federal Occupational Safety and Health Administration should move forward with its proposal to require smoke-free workplaces nationwide.

5. Local communities should continue to control smoking in public.

6. State legislatures should assume responsibility for ensuring smoke-free areas. Any preemptive tobacco laws should be repealed by public demand.

7. Purchase of tobacco products should be strictly limited to adults, with severe penalties for those who transgress. Underage use of tobacco should carry consequences for the user. All tobacco advertising should be eliminated, and a vigorous counteradvertising campaign should be instituted.

8. The Justice Department should enforce the ban against indirect tobacco advertising such as televised sports events.

9. Tobacco itself should be considered a drug delivery vehicle and placed under the oversight of the Food and Drug Administration, with appropriate regulation as for other life-threatening drugs.

10. State and federal excise taxes on tobacco products should be increased, both to help defray costs of tobacco-induced diseases and to deter young people from becoming addicted.

11. The federal government should prevent the export of tobacco to other countries.

12. The continued contribution to knowledge of the control of tobacco by the National Cancer Institute should be strongly supported.

13. Physicians and the public should support legal action against the tobacco industry to recover billions of dollars in excess medical costs from tobacco-related diseases borne by Medicare, Medicaid, and the Department of Veterans Affairs.

14. All avenues of individual and collective redress should be pursued through the judicial system."

Source: Todd JS, Rennie D, McAfee RE. (Editorial) The Brown and Willimason documents. Where do we go from here? JAMA 1995;274(3):256-258.

In Rhode Island, some physicians have joined the Coalition on Smoking OR Health, Rhode Island Project ASSIST, and their local Substance Abuse Prevention Task Forces to educate the public and its leaders about the need to restrict youth access to tobacco. (Please call Ms. Betty Harvey, Rhode Island Department of Health, 277-3293, for more information on any of these groups.)

All physicians should make a point of speaking to every school age pediatric patient and every adult patient who uses tobacco about the health consequences of tobacco. Research has shown that such messages from health providers, if given consistently and relentlessly, are an important motivation for avoiding tobacco or giving it up, once hooked.

Tobacco use is now recognized as the primary cause of preventable chronic disease in the U.S. Prohibiting the sale of tobacco to children is the single best way to reduce tobacco use and hence, preventable disease. We need every physician in the front lines to defeat this scourge. Even as the tobacco industry is untiring in its efforts to recruit replacement tobacco users, we must be determined to keep tobacco away from children. Together, we can do it.

References

1. Hesser JE, Cavallo A, Buechner J. The 1993 Rhode Island Adolescent Substance Abuse Survey. Report of statewide results. Providence, RI: RI Dept Health, March, 1994.

2. Bjornson W, Rand C, Connett JE, et al. Gender differences in smoking cessation after 3 years in the Lung Health Study. Am J Public Health 1995;85(2):223-230.

3. Johnston LD, O'Malley PM, Bachman JG. National survey results on drug use from the Monitoring the Future Study, 1975-1994. Rockville, MD: National Institute on Drug Abuse, 1995.

4. Cummings KM, Pechacek T, Shopland D. The illegal sale of cigarettes to US minors: estimates by state. Am J Public Health 1994;84(2):300-302.

5. Hu T, Sung H, Keeler TE. Reducing cigarette consumption in California: tobacco taxes vs an anti-smoking media campaign. Am J Public Health 1995;85(9):1218-1222.

6. Todd JS, Rennie D, McAfee RE. (Editorial) The Brown and Willimason documents. Where do we go from here? JAMA 1995;274(3):256-258.

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