Despite decades of efforts to keep the tobacco industry away from children, tobacco companies are successfully promoting their products to nine out of 10 middle and high school students in the U.S., according to the study by researchers at the Centers for Disease Control.
What’s more, the dramatic decline in tobacco use among California high school students appears to have flattened out, a troubling development both because of the health effects and because tobacco use is strongly associated with failing to graduate from high school on time, according to recent research.
Twenty-nine percent of students who used tobacco failed to complete high school on time, compared to a dropout rate of 21 percent for teens who used alcohol and 25 percent for teens who used drugs, according to a study published in the Journal of Psychiatric Research.
“It’s not that tobacco causes students to do poorly in school or to leave school, but that smoking is a marker of being on a negative education trajectory,” said Joshua Breslau, lead author of the study, which he conducted while at University of California, Davis. Previous research has linked poor academic performance with smoking, said Breslau, who is now a medical anthropologist at the Rand Corporation, a research group based in Santa Monica.
“Smoking could be taken more seriously by schools,” Breslau said. “It’s a marker not necessarily of a disciplinary issue, but that a student may need help academically with grades.”
Most California school districts address tobacco use through a health curriculum.
Meanwhile, the CDC study found that students continue to be saturated with pro-tobacco messages at convenience stores, in magazines and on the Internet.
Television commercials for cigarettes are long gone, banned by federal law. Still, the study found that middle and high school students face pervasive tobacco marketing through “power wall” displays of cigarette packs in convenience stores, cigarette ads in magazines such as Sports Illustrated, Rolling Stone and ESPN, and a vast number of images of cigarette smoking, tobacco chewing, cigar puffing and hookah-pipe inhaling on YouTube and elsewhere online.
“The tobacco industry has really gone underground,” said Pamela Ling, associate professor of medicine at the University of California, San Francisco. “If you don’t shop at 7-11 and you aren’t online going around on YouTube, you don’t see it.”
But teenagers do see it, the study found. Some 91 percent of middle school students reported seeing pro-tobacco marketing in a store, a magazine or online, as did 93 percent of high school students. Store advertising was most often reported, with 83 percent of middle school students and 87 percent of high school students saying they saw tobacco ads there. Data were gathered from the 2011 National Youth Tobacco Survey conducted by the Centers for Disease Control.
Research has established a “causal relationship” between tobacco advertising and the likelihood a teen would start smoking, according to a 2012 report from U.S. Surgeon General Regina Benjamin. Benjamin also presented a chilling equation: Of every three young smokers, one will quit and, of the remaining two, one will die from tobacco-related causes. Smoking causes multiple types of malignancies, including cancer of the lung, throat, mouth and stomach, and tobacco use remains the No. 1 cause of preventable death in the U.S.
The CDC study on teens and tobacco advertising comes amid concerns from many in the public health community that California’s dramatic success in the fight against tobacco may be in jeopardy. As the first in the nation to launch a campaign to change the social norms around smoking in 1989, the state has been a model for what works in policy and media campaigns, and the results have been impressive. The teen smoking rate is 13.8 percent, the second-lowest rate in the nation, behind Utah’s teen smoking rate of 5.9 percent.
Teen smoking rates stall
But California’s anti-tobacco efforts are now woefully underfunded, according to the Tobacco Education and Research Oversight Committee, a state advisory committee charged with overseeing the use of Proposition 99 tobacco tax revenues for tobacco control. And after years of dazzling reductions, the decline in teen smoking in California appears to have hit a plateau.
Data from three California cities that participated in the CDC’s 2011 Youth Risk Behavior Survey – Los Angeles, San Diego and San Francisco – show a stunning drop in teen smoking from 1997 to 2011. In Los Angeles, for example, 27 percent of teens smoked in 1997 and 9 percent of teens smoked in 2011. But the rates of teen smoking were unchanged in the three cities between 2009 and 2011; the CDC termed the differences in rates between those years statistically insignificant.
In the meantime, tobacco industry spending on marketing in California increased by more than 30 percent between 1998 and 2008 to reach $656 million, according to the California Tobacco Control Program, part of the state Department of Public Health. In theory, the increase in tobacco marketing should not have affected middle and high school students, because the landmark 1998 federal Master Settlement Agreement prohibited the industry from targeting youth, directly or indirectly, in advertising, marketing or promotion.
But that agreement has only made the industry more creative in how it markets to youth, said Robert Jackler, a professor of medicine at Stanford University who leads the research group Stanford Research into the Impact of Tobacco Advertising.
“Virtually all tobacco advertising is aimed at young people, and the reason is because almost nobody starts smoking beyond age 21 or 22,” Jackler said.
To reach students, tobacco companies have concentrated advertising and discounts in small stores, particularly those near schools, he said. “It’s an absolute carnival of tobacco products behind the check-out,” Jackler said.
At the same time, state funding for anti-smoking media campaigns, education and research has shrunk and policy changes have been tough to pass in California, noted Danny McGoldrick, vice president for research at the Washington-based advocacy group Campaign for Tobacco-Free Kids. Proposition 29, which would have mandated a $1-a-pack cigarette tax hike, was defeated in June 2012, a significant blow to tobacco control efforts, he said. Research has established that raising the price of cigarettes is one of the most effective ways to stop teenagers from smoking, yet efforts to do that in California have failed.
“California used to be a leader in the tobacco tax, but it’s now ranked 33rd in the country,” McGoldrick said. The state tax on a pack of cigarettes is 87 cents, compared to a national average state tax of $1.46, and the price of a pack is $5.44, according to data from the Campaign for Tobacco-Free Kids. New York has the highest state tax on a pack of cigarettes – $4.35 – and the cost of a pack is $10.
Higher tobacco tax proposed
“The single most effective thing California could do is to increase the tobacco tax,” McGoldrick said. A proposal to raise the tobacco tax in California by $2 per pack of cigarettes passed the Senate committee on health as well as the committee on governance and finance on Wednesday and is heading to appropriations. Senator Kevin de León, D-Los Angeles, who introduced the bill, SB 768, said the $1.5 billion raised from the tobacco tax each year would help pay for state spending on tobacco-related medical care, education and law enforcement.
Another key element in tobacco control is to reverse the idea that smoking is a hip, sophisticated and rebellious activity. But that effort has become more difficult, in part because smoking by actors is on the rise in movies, according to a 2012 UCSF study. Research has found that 44% of adolescents who start smoking do so because of smoking images they have seen in the movies, according to Legacy, a Washington-based nonprofit established as part of the Master Settlement Agreement to educate the public.
Evidence of the continued allure of smoking for middle and high school students appeared in the CDC study, which found that more than 20 percent of those who have never smoked reported being “open” to trying smoking in the next year, said Shanta R. Dube, a CDC researcher and the lead author of the new study, “Pro-Tobacco Influences and Susceptibility to Smoking Cigarettes Among Middle and High School Students – United States 2011,” published in the Journal of Adolescent Health.
Even more troubling is that the percentage of students “open” to smoking has stayed the same, year after year, since 2000, Dube noted. And advertising plays a role in keeping that allure going.
“Middle school students who reported seeing tobacco ads in all three venues – stores, magazines and on the Internet – were two to three times more likely to say there were open to smoking in the next year than students who reported seeing no advertisements,” Dube said.
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