On February 11, 2014, the FDA launched “The Real Cost” education campaign, aimed at preventing at-risk youth from using tobacco and reducing the amount of teenagers who become regular smokers. In 2009, President Obama signed into law the Family Smoking Prevention and Tobacco Control Act, granting the FDA the authority to regulate tobacco. The campaign uses a series of platforms, including TV, radio, print, and the internet, and “will continue to air in more than 200 markets across the country for at least one year.”
The campaign ads include a commercial where a teenage girl is forced to remove part of the skin on her face, which she hands over to the cashier along with cash in exchange for a pack of cigarettes. A few of them feature a long-haired “nappy” man in a white t-shirt and kaki pants that bullies young people into giving him money and “puckering up.” Of course, the man is supposed to be a cigarette—referred to in the ads as “tiny bully.” Others feature faces with wrinkles and yellowing and misshapen teeth.
To those advocating for tobacco control, the question is to what extent these ads will not only capture the attention of teenagers, but also prevent them from becoming regular smokers. This year marks the 50th anniversary of the 1964 Surgeon General Report that first “link[ed] smoking and ill health, including lung cancer and heart disease.” Since then, we have learned a great deal about the negative health effects of smoking and second-hand smoke. With respect to adolescents, “each day, more than 3,200 youth under age 18 in the United States try their first cigarette and more than 700 kids under age 18 become daily smokers.” According to FDA Commissioner Margaret Hamburg, “almost nine out of every ten regular adult smokers [pick] up their first cigarette by age 18.” Through its education campaign, the FDA is aiming “to reduce the number of youth cigarette smokers by at least 300,000 within three years.”
In 2012, the U.S. Surgeon General’s report Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon Generalpublished important findings on the health effects of smoking on youth that were not limited to nicotine addiction and developing long-term diseases (such as lung cancer) at a younger age. The report explains that some of the health risks are of immediate nature—for example, smoking can impair the development of respiratory and cardiovascular systems. The report also details the extent to which advertising and promotional activities by the tobacco industry drives young people to continue smoking. Considering that almost all tobacco use begins at a young age (88% by age 18, 99% by age 26), there are serious tobacco-control efforts toward ensuring a smoke-free generation. According to the report, “evidence indicates that mass media campaigns can be one of the most effective strategies in changing social norms and preventing youth smoking.”
Studies have shown that smoking negatively impacts brain development in adolescents and affects their decision-making—the more the adolescent smokes, the lesser activity there is in his/her prefrontal cortex (the part of the brain responsible for executing decisions). The impaired development of the prefrontal cortex can lead to the inability of making “rational decisions regarding [the individual’s] well-being, and that includes the decision to stop smoking.”
The FDA campaign desperately needs to be effective. And what exactly does this mean? The U.S. Surgeon General’s 2012 report concludes that “coordinated, multicomponent interventions that combine mass media campaigns, price increases including those that result from tax increases, school-based policies and programs, and statewide or community-wide changes in smokefree policies and norms are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults.” However, just as much as the interventions need to be “multicomponent” and “coordinated,” they must also be comprehensive in their understanding of the targeted population—every complex aspect of the population needs to be taken into account—what are its sub-populations, what are the existing overlaps among them, what is each sub-population’s lifestyle and interests, what do they react to, what turns them off, etc.
From: Nichter, et al. Reading culture from tobacco advertisements in Indonesia, Tob Control 2009;18:98-107.
Anthropologists studying tobacco control efforts have highlighted the importance of understanding the cultural context of the targeted population, including lifestyle and cultural meanings of smoking, to ensure that the intervention is contextually sensitive and culturally compelling. Each sub-population requires its own analysis and intervention. In the case of women and smoking, it has been argued that tobacco-control interventions have “remained largely gender blind,” underscoring the importance of gender analysis in tobacco-control efforts, including recognizing and deconstructing the ways through which the tobacco industry has been marketing to girls and women. Much can be said about the tobacco industry’s successful efforts in fully understanding every population it has targeted—doing exactly what tobacco-control advocates (including the government) should be doing. When targeting women in Indonesia, tobacco companies have been culturally sensitive to the traditional stigma attached to a woman smoking (62% of men and 1% to 3% of women are smokers). They feature young women in advertisements, but without a cigarette or smoking and engaged in an activity or scene that the company has found is attractive to women seeking to become the “modern woman” (talking on a cell phone, in a sleeveless top, next to a convertible, or “snuggling into her boyfriend, a westerner”). It is encouraging to read that the FDA’s “[s]ubsequent campaigns will target additional discrete audiences, including multicultural youth, rural youth, and lesbian, gay, bisexual, and transgender (LGBT) youth” and that the campaign will “create space for teens to engage in peer-to-peer conversations about the issue in ways that are authentic to who they are” (emphasis added). However, the complexity of this population requires constant and continuous evaluation to ensure that the campaign is effective.
Considering the integral role that television and movies play in the lifestyle of this population and the avenues through which the FDA hopes to engage young people, the campaign appears to be counteracting the exposure that teens have to tobacco products in this space. It has been found that “youth who watched five or more hours of TV per day were six times more likely to start smoking than those youth who watched less than two hours per day.” Since the 1960s, efforts to restrict tobacco advertisement and smoking on TV and movies have consisted of a range of measures: advocacy efforts, congressional hearings, policy changes and legal actions. However, despite these efforts, we continue to see a number of movies, music videos, and shows portraying smoking.
In preparation for the campaign, the FDA has “spent more than 2 years researching and doing [their] homework and thinking about how you break through to these 10 million of the 25 million 12- to 17-year olds that are out there.” They have found that teenagers know about the health effects but they are “so far down the road that they dismiss them.” What they seem to react to is appearance, which is why the campaign ads are focusing on “skin wrinkling, gum disease, and tooth loss.” The ads have been tested and the results are promising. Director of the FDA’s Center for Tobacco Products Mitch Zeller says that the FDA is “very optimistic that over time with the right dose — and we have the funding to provide the dose — that this campaign is going to build awareness; change knowledge, attitudes, and beliefs; and ultimately, over time, alter both behavioral intent and behavior.”
We do not yet know all that the campaign has in store, but what is certain is that tobacco control efforts targeting youth and young adults must certainly take advantage of the day-to-day technology used by this section of the population and do it in very creative ways. There are already hundreds of smartphone applications to help individuals quit smoking and some that aim to deter people from smoking. In particular, an application created by the United Kingdom’s National Health Service (NHS) called “Smoking Time Machine” works to show what the user would look like in ten and twenty years if s/he smoked a pack of cigarettes a day. The application takes the photo of the user and adds “[d]eeper wrinkles around the eyes and mouth, grey palour to the skin and sagging jowls.” Similar applications can be developed that feature more drastic portrayals of the possible health effects on smokers that are as haunting as the recently launched advertisement of Terrie, a former smoker who narrates her story through a voice box while pictures of her as a teenager and later as young woman flash before the viewer.
The FDA is undoubtedly launching a very important campaign. The stakes are high. As underscored in a previous post, we have learned a great deal not only about how tobacco works and its effects on the body, but also how the tobacco industry functions. And although the tobacco industry continues to be politically and economically powerful, it is no longer the industry that it once was. The tobacco control community and its efforts continue to grow. We have gone far and will continue to go far, and President Obama has signed into law an important instrument that can become a powerful tool that further undermines the tobacco industry’s efforts to secure a future consumer base in the United States. Information is a powerful tool, and by informing our children, the FDA is getting us one step closer to creating a smoke-free generation.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.