Prevention by Restricting Sales of Tobacco Products to Minors

One฀ major฀ methodological฀ problem฀ is฀ that฀ retailers’฀ attitudes฀ to฀ selling฀ cigarettes฀ to฀ minors฀cannot฀be฀revealed฀even฀by฀undercover฀checks.฀Retailers฀recognise฀undercover฀pur- chasers฀because฀they฀behave฀unusually฀and฀tend฀to฀be฀are฀slightly฀older.฀In฀cases฀of฀doubt,฀ they฀claim฀to฀sell฀cigarettes฀only฀to฀children฀who฀are฀known฀to฀them;฀alternatively,฀they฀argue฀ that฀children฀ask฀grown-ups฀to฀buy฀the฀cigarettes฀for฀them฀ [88] .฀The฀campaigns฀conducted฀to฀ date฀reduce฀smoking฀behaviour฀among฀children฀by฀restricting฀youth฀access฀to฀cigarettes. A฀fall฀in฀the฀sales฀of฀tobacco฀products฀to฀minors฀must฀necessarily฀also฀be฀relected฀in฀a฀ fall฀in฀sales฀igures.฀Trends฀such฀as฀these฀have฀been฀demonstrated฀in฀some฀communities.฀ The฀study฀conducted฀in฀Woodridge฀conirms฀this฀trend฀when฀the฀policy฀is฀applied฀consis- tently.฀Also,฀according฀to฀data฀from฀Massachusetts,฀it฀is฀clear฀that฀a฀high฀inhibitory฀thresh- old฀has฀to฀be฀established฀in฀order฀to฀achieve฀a฀measurable฀reduction฀in฀tobacco฀consumption฀ among฀children.฀The฀density฀of฀the฀retail฀network฀is฀also฀an฀important฀factor฀in฀these฀con- siderations.฀In฀the฀USA,฀despite฀the฀enactment฀of฀the฀Synar฀Amendment฀by฀Congress฀in฀ 1992,฀not฀all฀individual฀states฀90฀so฀far฀have฀yet฀passed฀appropriate฀legislation฀prohib- iting฀the฀sale฀of฀tobacco฀products฀to฀minors฀ [89] .฀Similar฀problems฀exist฀in฀the฀developing฀ countries฀because,฀over฀and฀beyond฀the฀differently฀structured฀social฀situations,฀it฀is฀essen- tial฀to฀protect฀children฀from฀the฀sale฀of฀tobacco฀products. If฀the฀youth฀initiation฀rate฀could฀be฀reduced฀or฀completely฀eliminated,฀smoker฀numbers฀ would฀be฀clearly฀reduced฀after฀20–40฀years฀ [90] .฀According฀to฀one฀simulation฀model,฀if฀ initiation฀among฀18-year-olds฀had฀been฀reduced฀by฀50฀starting฀in฀1993,฀the฀smoking฀rate฀ would฀ have฀ fallen฀ from฀ 19฀ 48.1฀ million฀ smokers฀ to฀ 16.4฀ 44.1฀ million฀ smokers฀ 10฀years฀later฀in฀2003฀Fig.฀ 12.6 ,฀and฀this฀would฀have฀been฀only฀3.7฀million฀smokers฀fewer฀ Fig. 12.4 ฀฀฀Anti-smoking฀ poster:฀“That’s฀real฀strength”฀ DHM฀1995-668 than฀without฀any฀policy฀to฀reduce฀initiation.฀Effective฀reductions฀in฀smoking฀prevalence฀ would฀only฀have฀become฀apparent฀20–30฀years฀later฀ [90] .฀In฀order฀to฀halve฀the฀number฀of฀ smokers฀in฀the฀general฀population฀within฀30฀years,฀initiation฀would฀have฀to฀be฀eliminated฀ completely,฀causing฀the฀smoking฀rate฀to฀fall฀from฀19฀48.1฀million฀smokers฀in฀1993฀to฀ about฀9฀25.9฀million฀smokers฀in฀2023฀Fig.฀ 12.6 ฀ [90] .

12.10 Role of the Mass Media in Sales of Tobacco Products to Adolescents

The฀ mass฀ media฀ TV,฀ newspapers,฀ radio,฀ posters฀ have฀ been฀ recruited฀ increasingly฀ to฀ deliver฀preventive฀health฀warnings฀Fig.฀ 12.7 ,฀particularly฀since฀they฀can฀be฀used฀to฀reach฀ a฀high฀proportion฀of฀the฀population฀ [91] .฀Children฀and฀adolescents฀in฀the฀USA฀spend฀twice฀ as฀much฀time฀on฀watching฀TV฀as฀on฀their฀school฀education฀ [92] ,฀with฀the฀result฀that฀by฀the฀ age฀of฀18฀an฀adolescent฀has฀spent฀more฀time฀exposed฀to฀the฀media฀TV฀than฀on฀any฀other฀ Fig. 12.5 ฀฀฀Anti- smoking฀poster:฀ “Cancer฀is฀not฀a฀ disease฀of฀old฀ age”฀and฀ “Cancer฀can฀ strike฀anyone”฀ Chiron-Behring฀ 8A.6.99 activity฀apart฀from฀sleeping฀ [93] .฀The฀TV฀is฀therefore฀be฀a฀useful฀means฀of฀inluencing฀ children฀and฀adolescents฀with฀regard฀to฀acceptable฀social฀behaviour,฀cultural฀norms,฀issues฀ of฀daily฀living฀and฀health-related฀matters฀ [94] .฀In฀fact,฀several฀mass฀media฀campaigns฀have฀ been฀run฀in฀the฀past฀in฀attempts฀to฀inluence฀smoking฀behaviour฀among฀young฀people฀ [95] .฀ Speciic฀programmes฀have฀been฀used฀for฀some฀schools฀ [34,฀79,฀96,฀97] .฀Information฀pro- grammes฀prepared฀speciically฀for฀the฀mass฀media฀have฀been฀very฀much฀less฀common฀ [98,฀99] ,฀although฀such฀campaigns฀can฀actually฀lead฀to฀a฀transient฀reduction฀in฀smoking฀ prevalence฀see฀also฀Fig.฀ 12.7 ฀ [98] . An฀analysis฀recently฀published฀by฀the฀Cochrane฀Group฀ [100] ฀warns฀that฀the฀results฀of฀ different฀campaigns฀cannot฀be฀evaluated฀from฀a฀single฀viewpoint฀because฀the฀baseline฀situ- ation฀in฀one฀study฀is฀not฀necessarily฀comparable฀with฀that฀in฀another฀study฀or฀campaign.฀ Generalisation฀of฀the฀information฀obtained฀is฀complicated฀by฀a฀wide฀range฀of฀individual฀ factors฀arising฀out฀of฀the฀characteristics฀of฀a฀community฀and฀the฀location฀of฀the฀particular฀ school฀ [101] .฀ Similarly,฀ according฀ to฀ a฀ meta-analysis฀ of฀ other฀ school-based฀ prevention฀ programmes฀only฀16฀21฀out฀of฀131฀studies฀analysed฀their฀data฀on฀a฀statistically฀sound฀ basis฀ [102] ,฀the฀common฀failing฀being฀that฀changes฀in฀the฀control฀group฀were฀not฀consis- tently฀included฀in฀the฀analysis.฀Furthermore,฀the฀level฀of฀impartiality฀of฀the฀media฀agencies฀ or฀periodicals฀was฀not฀always฀clearly฀deined. According฀to฀one฀analysis฀from฀the฀USA฀of฀the฀impact฀of฀magazine฀articles฀on฀health฀ education฀topics฀over฀the฀period฀from฀1950฀to฀1983,฀it฀is฀clear฀that฀print฀media฀may฀in฀fact฀ inluence฀ the฀ initiation฀ rate฀ in฀ the฀ general฀ population฀ [25] .฀ The฀ number฀ of฀ educational฀ articles฀on฀the฀harmful฀effects฀of฀smoking฀correlated฀with฀smoking฀cessation฀in฀adults฀but฀ not฀with฀smoking฀initiation฀in฀adolescents฀because฀this฀latter฀group฀was฀not฀the฀target฀read- ership฀for฀these฀magazines,฀and฀greater฀emphasis฀on฀this฀aspect฀needs฀to฀be฀made฀in฀future฀ [25] .฀Without฀doubt,฀broad-based฀PR฀campaigns฀of฀this฀type฀are฀appropriate฀instruments฀ for฀educational฀purposes฀in฀those฀countries฀with฀a฀high฀smoking฀prevalence,฀e.g.฀Southern฀ and฀Southeastern฀Europe. According฀to฀the฀analysis฀published฀by฀the฀Cochrane฀Group฀ [100] ฀on฀the฀inluence฀of฀ mass฀media฀interventions฀on฀smoking฀behaviour฀among฀young฀people,฀six฀mass฀media฀cam- paigns฀were฀suitable฀for฀preventing฀smoking฀initiation฀in฀this฀target฀population,฀and฀two฀of฀ these฀six฀media฀interventions฀also฀caused฀a฀reduction฀in฀smoking฀prevalence฀among฀adoles- cents฀ [103–105] .฀Overall,฀eficacy฀has฀been฀assessed฀as฀only฀moderately฀positive฀to฀date. Fig. 12.6 ฀฀฀Effect฀of฀initiation฀ policies฀on฀the฀number฀of฀ smokers฀in฀the฀United฀States฀ within฀50฀years.฀a฀Status฀ quo;฀b฀50฀reduction;฀฀ c฀100฀reduction;฀d฀ 100฀reduction฀plus฀25฀ delayed฀initiation฀ [90] 60 50 40 30 20 10 1993 2003 2013 2023 2033 2043 Smokers [Millions] a b c d