Pro & Con: Do anti-smoking programs work to reduce smoking?

Even fewer people realize that beginning to smoke is almost always an adolescent decision made in response to teenagers wanting to appear cool, independent, sophisticated and glamorous — the aspirations of every teen and the very attributes promoted for decades by cigarette companies. It is no surprise that most adolescents that smoke show symptoms of nicotine addiction and want to quit smoking, but can’t, even before graduating from high school.

The real tragedy is that we know how to prevent the problem of teen nicotine addiction, but fail to act. Rigorous scientific research has shown that price increases, strict advertising restrictions and clean indoor air laws are effective in reducing smoking for everyone, but are particularly effective among young people. The research evidence also shows that counter-marketing campaigns, particularly those aimed at debunking the carefully constructed myths of the tobacco industry that make smoking appear to be the cool thing to do, are effective in reducing smoking rates and the social acceptability of smoking.

When I directed the CDC’s Office on Smoking and Health, we wanted to learn how to use marketing techniques to keep kids from starting to smoke and convened an expert panel of teen marketing experts from the private sector.

Experts from companies like Adidas, Levi-Straus, and Proctor and Gamble — companies that sell products to teens — advised us that if we wanted to be successful in competing with the tobacco industry’s multibillion-dollar effort to get people to smoke, we needed to do more than educate teens on the harm of smoking, and rather create a “brand” that would compete with the cigarette brands that appealed to young people, namely Marlboro (with its cowboy), Camel (with its Joe Camel campaign), and Newport (with its “Alive with Pleasure” campaign).

The experts recommended that the nonsmoking “brand” that might appeal most to youth was one that told the truth about smoking, i.e., that smoking really provided none of the attributes seen in the cigarette advertisements, but was in fact an expensive, dirty, smelly habit, and that the cigarette companies were simply lying to them to increase their profits.

This “brand” became known as the “Truth Campaign” and was successfully used in Florida with funds from its settlement with the tobacco industry, and was rolled out nationally by the American Legacy Foundation as an outgrowth of the 1998 Master Settlement Agreement. The Truth Campaign was unprecedented in its success. Recent analysis found that exposure to the campaign reduced the risk of starting to smoke by 20 percent, resulting in 450,000 fewer adolescent smokers, and this was done in a cost-effective manner, with every $1 spent on the counter-marketing effort resulting in a savings of $6 of future medical costs averted.

The campaign was so successful, in fact, that the Lorillard Tobacco Co. sued the Legacy Foundation to cease the campaign under the guise that the advertisements vilified them.

Smoking is perpetuated by cigarette company marketing, and smoking can be extinguished by effective counter-marketing. But the counter-marketing has to be hard-hitting, sophisticated and appealing to adolescents and young adults showing them the “truth” about smoking and also graphically depicting how devastating smoking can be to those you care about or identify with.

The tobacco industry hates the truth and hates counter-marketing campaigns that tell the truth. Why? Because it works. Given the tobacco industry has recently been found guilty in a federal district court of racketeering and perpetuating a fraud on the American people, upheld in a May federal appeals court decision, it seems to be that there is a need for more “truth” and not less.

Michael Eriksen is director of the Institute for Public Health at Georgia State and former director of the Office on Smoking and Health at the CDC.

NO: Expensive programs’ intentions good, but results are mixed.

By Michael L. Marlow

Tobacco control is a prime example of a government program with the noblest of intentions. Tobacco is unhealthy; and its impact on public health makes it easy to convince people that government should fund programs that reduce smoking. The Centers for Disease Control and Prevention is now recommending large increases in spending on anti-smoking programs — to more than double the annual spending of over $717 million.

But how effective are these programs? Not very — so why is the CDC recommending pouring millions of dollars more into programs that are unlikely to have any significant impact on public health? Early tobacco control policy efforts that largely consisted of raising taxes were quite successful in reducing smoking. The effect of more recent tobacco-control policies is much more ambiguous.

Bans on tobacco use in various places have been implemented widely. Bans have been imposed on restaurants and bars in 27 states and Washington. Four other states have imposed bans in restaurants, but exempt bars. Several more states have passed bans that take effect in the near future. Proponents argue that bans lower smoking, although evidence on this is mixed.

“Anti-tobacco” programs are the latest measure used by governments to control tobacco use. These programs fund anti-smoking ads that run in newspapers, magazines and on TV, school programs to educate children about the hazards of smoking, cessation interventions (intensive counseling services and cessation medications) and grants for researchers to demonstrate effectiveness of tobacco-control programs. These programs hire many people and are very expensive.

The CDC provides recommendations for how much money states should spend on anti-tobacco programs. According to the CDC, careful research shows that its recommendations would prevent hundreds of thousands of premature tobacco-related deaths. But the data do not back the CDC’s claims.

The CDC recommends that states should spend $15 to $20 per resident each year on anti-smoking programs. Only two states — Maine and Mississippi — have consistently met or exceeded that goal over the years 2000–2007. In contrast, three states — Michigan, Missouri and Tennessee — have spent nothing on anti-smoking programs. Georgia spent just over $2 million in 2008, barely 5 percent of what the CDC now recommends. Nationwide, states have spent a total of $5.3 billion (in inflation-adjusted 2005 dollars) over those years, an average of $18 per person. But all that money has failed to significantly reduce smoking. Nor have the states that spent more seen a more dramatic reduction in smoking than states that have spent less.

Statistical analysis that I’ve conducted shows that there is a very tenuous link between cigarette sales and state anti-tobacco spending. At best, spending large amounts of money on anti-tobacco programs seems to produce a trivial drop in cigarette sales — less than a pack a year per capita. States would be better advised to put these resources toward other public health policies that produce larger results.

What was the basis of the CDC spending recommendations? Was the agency truly trying to identify anti-smoking policies that work well and use public funds effectively, or did the CDC simply assume that, “If you spend it, they will quit smoking”? If it was the latter, then it is unfortunate for both taxpayers and public health.

The CDC is now arguing that state anti-tobacco programs are underfunded. Tobacco-control advocates — many of whom receive money through these programs — repeat the CDC under-funding claims when pleading their cases for spending increases. It will be truly unfortunate if states simply accept these claims and increase funding without investigating the programs’ effectiveness. However difficult it is to look beyond noble intentions, appraisal of a program’s effectiveness is vital — particularly in these tight fiscal times — if we truly want to improve public health effectively.

Michael L. Marlow teaches economics at Cal Poly, San Luis Obispo, Calif. His work appears in Regulation, the Cato Institute’s magazine.