State Tobacco Counteradvertising and Adolescents

The study by Emery et al¹ in this issue of ARCHIVES provides new insights about state-sponsored antitobacco media advertising (counteradvertising). In a carefully designed and comprehensive study, they generally found strong associations between population level exposure to state-sponsored tobacco counteradvertising and adolescent beliefs about smoking and current smoking status. These associations were found despite what were, in most instances, low levels of exposure to state-sponsored counteradvertising and much higher levels of exposure to tobacco industry–sponsored “antitobacco” ads that, not surprisingly, have been found to be ineffective.² This study adds to a large body of literature on the critical role that counteradvertising plays in tobacco prevention,^{3 - 5} supporting the findings of many others, including the United States Community Preventive Services Task Force, that mass media counteradvertising campaigns are effective in preventing tobacco use initiation.³

The Emery et al study has several major strengths, and some weaknesses, that must be noted. The authors obtained estimates of exposure to specific types of counteradvertising, and adolescent data on tobacco-related beliefs and behaviors, from the same geographic areas by using 2 large, independent, and long-running data sources (Monitoring the Future and Nielsen). This helped overcome a major problem in mass media research—quantitatively estimating the level of exposure to specific antitobacco ads without relying solely on message recall from survey respondents.

Use of Nielsen data provided exposure information on relevant tobacco and pharmaceutical industry advertisements, which could potentially reduce counteradvertising effectiveness. Because counteradvertising does not occur in a vacuum, it is especially important to obtain such contextual information. The authors studied multiple areas throughout the United States, which strengthens their findings and makes them generalizable. Finally, they controlled for many potentially confounding factors in their models that may affect adolescent beliefs, intentions, or behaviors.

Because these are cross-sectional data and information on exposure and outcomes were collected over the same time period, it is not possible to assess cause and effect. That is, it cannot be definitely concluded that higher exposure to counteradvertising caused stronger adolescent antitobacco beliefs or lower smoking prevalence. Prior research has shown that funding and support for tobacco prevention and control efforts tend to be greater in areas where there are strong preexisting antitobacco beliefs and social norms against tobacco use.⁶ It could be that adolescents living in areas with higher counteradvertising exposure already had stronger antitobacco beliefs and lower smoking prevalence. But even if counteradvertising functioned solely to maintain antitobacco beliefs and behavior in these areas, it would still be serving an important maintenance role in preventing tobacco use. It was unfortunate that the authors could not examine the association between exposure to the American Legacy Foundation’s Truth advertisements (eg, “body bags”), or more fully explore the association between much higher levels of exposure to state counteradvertising and adolescent tobacco beliefs and behavior.

There has been a substantial, and unprecedented, national decline in adolescent smoking since the late 1990s.⁷ Since 1975, the Monitoring the Future project has been continuously tracking cigarette smoking using nationally representative samples of high school seniors in the United States; the 2003 estimate of 24.4% was the lowest ever recorded, and represented a relative decline of 33% since 1997.⁷

State and national tobacco counteradvertising has played an important role in this decline in youth smoking. Counteradvertisting has been shown to be successful in preventing smoking initiation among youth, especially when audiences receive adequate exposure, if the exposure occurs over a long time period, and if counteradvertising is used in combination with other antitobacco activities, such as increasing the price of tobacco products, strong clean indoor air policies, and other community interventions.^{3 - 4 ,8} Perhaps the best known recent effect of counteradvertising occurred in Florida, where an extensive youth tobacco prevention program with a strong emphasis on paid television and other media advertisements contributed to substantial declines in smoking prevalence among middle school and high school students over a 2-year period.⁸

Unfortunately, because of state financial crises, about half the states have cut their tobacco prevention and control programs over the past few years.⁹ Between fiscal year 2002 and 2004 alone, there was an overall decline of 28% in state spending on such programs.¹⁰ Because counteradvertising is expensive, it is often a major target for spending reduction or elimination. State antitobacco program cuts exceeded 75% in some states, essentially gutting programs in flagship states such as Florida, Massachusetts, and Minnesota and ending their state-sponsored tobacco counteradvertising. Such cutbacks have already had detrimental effects, as evidenced by an increase in intentions to smoke among adolescents in Minnesota shortly after that state ended its counteradvertising efforts.¹¹

Much of the state and national funding for tobacco counteradvertising comes from 1 of 2 sources: the 1998 Master Settlement Agreement (MSA) (or some other legal settlement with the tobacco industry), or state tobacco excise taxes.⁵ On the national level, cigarette companies made their final payments in 2003 to fund the American Legacy Foundation’s nationwide counteradvertising campaign. At the state level, the MSA was intended to provide a stable funding source for states over 25 years to help address the single largest health problem in the country. Because of states’ promises to use this money for health and tobacco prevention programs, the federal government waived its claim to a portion of the MSA funds.¹⁰

Despite promises from state leaders to spend a significant portion of MSA funds on antitobacco efforts,¹⁰ only an estimated 3% of state MSA funds are now used for such purposes,¹² and few states earmark tobacco excise tax revenue to support state tobacco control programs. Master Settlement Agreement funds and increased tobacco excise tax revenues have been used by many states to fill short-term budget deficits.¹³

Some examples of MSA spending are far removed from tobacco control or health purposes at all, such as financial support for tobacco farmers, debt service on flood control projects, and industrial bonds¹² ; 5 states and the District of Columbia use none of their settlement money for tobacco control.¹⁰ This diversion of MSA and other state legal settlement money has been called “moral treason” by Michael Moore, the Mississippi attorney general who filed the first state tobacco lawsuit in 1994.¹⁴

Despite tremendous strides in reducing youth tobacco use, and substantial research demonstrating that counteradvertising and other components of comprehensive programs are effective in reducing prevalence, as well as being cost-effective,¹⁵ it is obvious that tobacco prevention activities are not institutionalized and that state program expenditures in this area are viewed by many as discretionary. One wonders whether cutbacks of 75% or more would be tolerated, for example, in childhood immunization programs.

Given the challenges described, what can pediatricians and other child health care providers do? Pediatricians and their professional organizations, including the American Academy of Pediatrics, have a lengthy history of tobacco prevention activities, recognizing early on that tobacco use is a pediatric disease.¹⁶ Given the magnitude of the tobacco problem, and the fact that most regular smokers begin by age 18 years,⁵ preventing tobacco use among children and adolescents is one of the most important pediatric successes imaginable.

Pediatricians should continue to routinely counsel patients and their parents or guardians about tobacco use. However, individual patient or parental counseling, by itself, will not be as effective in preventing tobacco use without the use of more comprehensive population approaches.⁵ After all, the tobacco industry spends nearly $12.5 billion per year, or about $34 million per day, in their advertising and promotional efforts.¹⁷

Counteradvertising and other components of comprehensive state programs can act synergistically with individual provider counseling to help prevent tobacco use.⁵ Pediatricians and other health care providers, either individually or collectively through professional or other organizations, need to actively support sustaining state comprehensive tobacco control and prevention activities that include counteradvertising. Failing to do so could mean losing the hard-won gains achieved in tobacco prevention over the past several years, and unfortunately, that would be deadly for many people.

Correspondence: Dr Nelson, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mailstop K50, Atlanta, GA 30341 (den2@cdc.gov).