Advertising and Promotion of Tobacco Encourage Smoking Among Youth: Study


(The report below is from The International Tobacco-Control Network and was prepared by Ronald M. Davis, M.D. in 1998. Dr. David was the director of the Center for Health Promotion and Disease Prevention of the Henry Ford Health System in the United States.)

CONTENTS

1. Background and author’s qualifications
2. How tobacco advertising and promotion affect tobacco consumption
3. Evidence that advertising and promotion affect overall tobacco consumption
4. Countries with tobacco advertising bans have lower consumption (or slower increases in consumption) than those without bans
5. Tobacco advertising and promotion have material effects on children and adolescents
A. Tobacco advertising and promotion reach children and adolescents
B. Tobacco advertising and promotion increase tobacco use by children and adolescents

# Cross-sectional studies
# Longitudinal studies
# Relationship between cigarette advertising and brand preference among youth
# Other evidence
# Billboards represent a particularly effective and intrusive medium for advertising in general, and for promotion of cigarettes in particular (especially to children)

1. Billboards are a favorite medium for tobacco advertising
2. Billboards are intrusive and cannot be avoided
3. Billboards are in people’s neighborhoods and are constantly exposing youth and adults to unsolicited messages
4. Billboards in urban, inner-city environments are more likely to carry tobacco and alcohol advertisements, often targeted to racial and ethnic minorities

# Conclusions

1. Conclusions of the 1994 Surgeon General’s report
2. Conclusions of the Food and Drug Administration
3. My own conclusions

# References
# Appendix. Author’s biographical sketch

I. Background and author’s qualifications

I have been asked by the City of Chicago Law Department to provide an expert opinion on issues related to the effects of tobacco advertising and promotion on youth, and the importance of legislation that would restrict the placement of tobacco billboards within the city. I have also been asked to describe my qualifications to render these opinions, and my involvement as an expert witness in other tobacco-related litigation.

A biographical sketch is attached as an Appendix to this report. It summarizes my professional career. A longer and more detailed curriculum vitae has also been made available. In brief, I am a physician with board certification in preventive medicine, and an epidemiologist trained at the U.S. Centers for Disease Control and Prevention (CDC). My current position is Director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health System, a large managed care organization in Southeast Michigan serving approximately 850,000 residents of the state. I was Chief Medical Officer for the Michigan Department of Public Health from 1991 to 1995, and Director of the CDC’s Office on Smoking and Health from 1987 to 1991. I currently serve as chair of the American Medical Association’s Council on Scientific Affairs, and I am editor of Tobacco Control, an international journal published quarterly by the British Medical Association.

In this report, per the request from the City of Chicago Law Department, I will focus primarily on the epidemiologic evidence related to the effects of tobacco advertising and promotion on youth. I will not review in any detail the evidence on the psychosocial effects of advertising and promotion (e.g., how the imagery and messages in tobacco advertising appeal to the developmental needs of youth). Nor will I review the many industry documents that have come to light in recent months and years that bear upon this issue.

I will base my opinions on my background as a physician, as an epidemiologist, as one who has conducted substantial research on tobacco advertising and promotion for at least a dozen years, and as one who has worked extensively in the field of tobacco and health during the past two decades. The research I have performed is documented in the journal articles I have published, which are listed in my curriculum vitae.

Two roles in particular have put me in a position where I have been exposed to a breadth of information on this subject. One of these was my tenure as director of the CDC’s Office on Smoking and Health, which is the lead federal office relating to tobacco and health. The Office produces the annual Surgeon General’s reports on smoking and health, which use a rigorous peer-review process in summarizing the scientific literature in the field, and maintains the world’s largest bibliographic database containing technical material on the subject.

The other important role is my service, since 1992, as editor of Tobacco Control, which is the only journal in the world devoted to this subject. Serving as editor has ensured my awareness of the pertinent research being conducted in the field.

I have served as an expert witness in several other tobacco-related lawsuits, including the State Attorney General lawsuits filed in Mississippi, Texas, and Washington State, and the Broin and Engle class actions filed in Florida.

An important role for an epidemiologist — and a physician specializing in preventive medicine — is to identify the antecedents or determinants of disease. Eliminating or reducing those antecedents will then reduce the incidence or prevalence of disease. In this case, we know that smoking is a major antecedent in the causation of numerous diseases, including cancer, heart disease, emphysema, and stroke. We can extend this process further by assessing the antecedents or determinants of behavioral risk factors for disease, such as smoking. As indicated by the evidence reviewed in this report, exposure to tobacco advertising and promotion is an antecedent in the initiation of smoking among youth.

II. How tobacco advertising and promotion affect tobacco consumption

The 1989 Surgeon General’s report “The Health Consequences of Smoking: 25 Years of Progress”1 reviewed the mechanisms by which tobacco advertising and promotion may affect tobacco consumption. Four direct mechanisms by which advertising and promotion may increase tobacco consumption were discussed:

1. Advertising and promotion could encourage children or young adults to experiment with tobacco products and initiate regular use;
2. Advertising and promotion could increase tobacco users’ daily consumption of tobacco products by serving as a cue to tobacco use.
3. Advertising and promotion could reduce current tobacco users’ motivation to quit.
4. Advertising and promotion could encourage former smokers to resume smoking.

The Surgeon General’s report also discussed several indirect mechanisms by which advertising and promotion might increase tobacco consumption. One of these is that “the ubiquity and familiarity of tobacco advertising and promotion may contribute to an environment in which tobacco use is perceived by users to be socially acceptable, or at least less socially objectionable and less hazardous than it is in fact.”

The report reviewed the evidence bearing on these effects. Although it concluded that no single study would be likely to provide a definitive answer to the question of whether advertising and promotion increase the level of tobacco consumption, the report noted that “The most comprehensive review of both the direct and indirect mechanisms concluded that the collective empirical, experiential, and logical evidence makes it more likely than not that advertising and promotion activities do stimulate cigarette consumption.”

Substantial research on the effects of cigarette advertising and promotion has been conducted and published since the release of that report in 1989. As a result, the Surgeon General and the U.S. Department of Health and Human Services have extended and strengthened their conclusions about the effects of advertising and promotion on smoking behavior, particularly in regards to children and adolescents. These stronger and more recent conclusions were published in the Surgeon General’s 1994 report on smoking and youth (see Section VI (A) below)2 and by the U.S. Food and Drug Administration in documents related to its rule-making on tobacco sales and marketing.3,4

My own conclusions are similar to those of the Surgeon General, the Department of Health and Human Services, and the Food and Drug Administration. Tobacco advertising and promotion do indeed stimulate cigarette consumption, especially among youth.

III. Evidence that advertising and promotion affect overall tobacco consumption

Several time-series studies have assessed the relationship between tobacco consumption and tobacco advertising expenditures. Simply put, time-series analysis is the study of observations taken in a series of instances over time. It often uses statistical techniques such as multiple regression, a method for distinguishing among competing and simultaneous influences on the end result (tobacco consumption, in this case). It has been used to assess the relationship between tobacco advertising expenditures and tobacco consumption over time, taking into account (”controlling for”) other potential influences on consumption such as price and income.

The Economics and Operational Research Division of the British Department of Health (in the “Smee Report”) analyzed the results of 19 time-series studies of cigarette advertising, including seven in the U.S., seven in the United Kingdom, two in New Zealand, and one each in Australia and West Germany.5 They found that 13 studies showed positive results (i.e., that higher advertising expenditures are associated with higher tobacco consumption), one showed negative results, and five showed both positive and negative results. The main findings of their review were as follows:

“Year-to-year variations in advertising expenditure within countries: there are many studies of this type, both for the UK and for other countries, particularly the US. Details of the analysis vary from one study to another, but the basic approach is to model the demand for tobacco products by relating annual changes in consumption to corresponding changes in advertising expenditure and in other variables such as price and income. Some studies have found that advertising has a statistically significant effect on consumption; others, including our own study, have not. There are several possible reasons for failure to find a statistically significant effect of advertising, including data imperfections and the inherent difficulty of identifying the separate effect of advertising when this is only one of many potential influences on smoking behaviour. Taken together, however, the studies point to a more decisive result. Because the studies differ in specification and data, a range of results is always to be expected. If, however, advertising genuinely has no effect on consumption, it would also be expected that the number of studies reporting positive and negative results would be much the same; in other words, some studies would show that advertising increases consumption, but others that advertising reduces consumption. In practice this symmetry is not observed; the great majority of results point in the same direction — towards a positive impact. The balance of evidence thus supports the conclusion that advertising does have a positive effect on consumption.”

Andrews and Franke6 conducted a meta-analysis of 48 time-series studies of tobacco advertising and sales, which covered the period from 1933 to 1990. Twenty-five of the studies were based on U.S. data and another 13 used data from the U.K. The weighted mean advertising elasticity was positive and significantly different from zero, meaning that higher advertising expenditures were associated with higher levels of cigarette consumption. These findings are especially impressive given a basic limitation of such studies — they assess the effects of the annual fluctuations in advertising expenditures, which “presumably relate to the least productive slice of expenditure, on the reasonable assumption that advertising is subject to diminishing returns.”5 One would expect a much greater impact from a total ban on advertising, or from a ban on a particular method or medium of advertising (e.g., billboards) — “which cuts away the most effective core of advertising”5 — than from marginal changes in total advertising expenditures from year to year.

In a 1989 review of 14 time-series studies, the New Zealand Toxic Substances Board found that 11 of the studies showed that tobacco advertising significantly affected national cigarette sales.7 The Board concluded that

“Advertising is directly related to the number of cigarettes smoked; increased advertising means more cigarettes smoked, and less advertising means fewer smoked…. The effect of advertising on cigarette consumption can be substantial…. [E]ven a 10 percent rise in advertising will tend to increase consumption by 0.7 percent, that is by 37 million cigarettes [in New Zealand] in a year…. Changes in cigarette consumption of this magnitude will produce significant changes in death rates. This can be deduced from the high numbers exposed to the risk, the intensity and duration of that exposure, and the high relative risks for smokers of a number of common and serious diseases.”7

IV. Countries with tobacco advertising bans have lower consumption (or slower increases in consumption) than those without bans

The New Zealand Toxic Substances Board commissioned a study on the relationship between tobacco advertising and tobacco consumption between 1970 and 1986 in 33 countries with varying levels of controls on advertising. The study, published in the 1989 report7 referred to above, classified countries into four main categories: those allowing tobacco advertising in all media, in most media, or in a few media, and those not allowing tobacco advertising in any media. Countries prohibiting all tobacco advertising were further subdivided into countries not allowing tobacco advertising for “health reasons” and those not allowing tobacco advertising for “political reasons” (i.e., centrally planned Eastern European economies that did not, during the study period, permit advertising of consumables, including tobacco).

The New Zealand study found a clear pattern between rate of change in tobacco consumption and the restrictiveness of controls on advertising. In countries allowing tobacco advertising in all media, per capita tobacco consumption increased annually by 1.7% on average. Consumption decreased on average by 0.4% annually in countries with partial bans on advertising, and by a similar amount in countries that had banned advertising of any kind for political reasons. Consumption fell annually by 1.6% on average in countries that had banned all tobacco advertising for health reasons. Furthermore, the study found that the percentage of young people who smoke had decreased more rapidly in countries where advertising had been totally banned or severely restricted, than in countries where tobacco promotion had been less restricted.

A later study, published in the British Journal of Addiction,8 used a pooled cross-sectional time-series analysis to examine the relationship among tobacco advertising restrictions, price, income, and tobacco consumption in 22 OECD countries from 1960 to 1986. (See Section V. B. below for a definition of “cross-sectional.”) The investigators found that tobacco advertising restrictions after 1973 were increasingly associated with lower tobacco consumption.

The “Smee Report”5 (mentioned above) reviewed trends in smoking in four countries that banned tobacco advertising: Norway, Finland, Canada, and New Zealand. It reached the following conclusion:

“Though there are qualifications (for example, the bans in Canada and New Zealand are relatively recent and so may not yet have had their full impact), the current evidence available on these four countries indicates a significant effect. In each case the banning of advertising was followed by a fall in smoking on a scale which cannot reasonably be attributed to other factors.”

Based on this evidence, the Food and Drug Administration (FDA) came to the following conclusion in promulgating its rules on tobacco sales and marketing:

“FDA finds that the international experience provides empirical evidence that restrictions on tobacco advertising, when given appropriate scope and when fully implemented, will reduce cigarette and smokeless tobacco use among children and adolescents under the age of 18.”9

These findings from country-level data, described above in Sections III and IV, have been confirmed by studies on the effects of cigarette advertising at a “micro” level — i.e., involving individuals — as described below.

V. Tobacco advertising and promotion have material effects on children and adolescents

A. Tobacco advertising and promotion reach children and adolescents

In considering the effects of tobacco advertising on children and adolescents, the first issue to address is whether advertising and promotion reach children and adolescents. Although the tobacco and advertising industries deny that advertising is targeted to children — denials that are contradicted by internal industry documents that have surfaced in recent years — the key question is whether minors are exposed to advertising. Substantial evidence indicates clearly that they are indeed so exposed.

An example of a study confirming the exposure of children to tobacco advertising was published in the Journal of the American Medical Association (JAMA). Investigators showed that 91% of six-year-old children from five different states correctly matched a picture of “Joe Camel” with a picture of a cigarette, similar to the percentage who recognized the logo of the Disney Channel (a silhouette of Mickey Mouse).10

Confirmatory evidence came from two studies funded by R.J. Reynolds Tobacco Company (RJR). One of these studies found that 72% of six-year-olds and 52% of children aged 3-6 years could identify Joe Camel.11 The other study, conducted for RJR by Roper Starch, surveyed more than 1,000 children aged 10-17. Of these children, 86% recognized Joe Camel, in both aided and unaided recall, 95% of whom knew that he sold cigarettes.12

Further evidence derives from studies measuring children’s recognition of cigarette brands, models, logos, and slogans in cigarette advertisements in which identifying information has been obscured. Another study published in JAMA found that students in grades 9-12 in five different states were much more likely than adults to recognize Joe Camel as a character whom they had seen before, and to identify the products being advertised and the brand name of the product.13 In a study of 11- to 14-year-olds in Australia, Chapman and Fitzgerald found that children who reported smoking in the last four weeks were almost two times more likely to correctly identify the edited advertisements and to complete the slogans than were children who reported not having smoked during that period.14 Similar findings have been reported from Georgia,15 Massachusetts,16 and North Carolina17 (USA); the United Kingdom; 18-20 and Hong Kong.21

Additional evidence that tobacco promotions reach children and adolescents comes from studies showing that many youth obtain and use merchandise from “cigarette continuity programs” (e.g., Camel Cash, Marlboro Miles).22-25 Much of this merchandise bears cigarette brand names, such that children become, in essence, walking billboards by wearing Camel T-shirts, Marlboro caps, and so on. These programs are advertised heavily on billboards, as demonstrated by a photograph I took of a billboard for Marlboro Gear (in front of a Toys “R” Us store and a Chuck E Cheese’s Pizza establishment), which was reproduced with an editorial I wrote on the subject.13c

Exposure of children and adolescents to cigarette advertising and promotion is not surprising given the ubiquity of, and heavy expenditures for, these marketing activities. In recent years, cigarette companies have spent more than $5 billion per year ($160 per second) to advertise and promote cigarettes.27 Children and adolescents are exposed to most of the media used for tobacco advertising (especially billboards — see Section VI below).

The Institute of Medicine, in an expert committee report entitled “Growing Up Tobacco Free,” reviewed the evidence on the extent of tobacco advertising and its effects on youth.28 With respect to youth exposure to tobacco advertising and promotion, it concluded:

“Tobacco advertising is characterized by images and themes that are especially appealing to adolescents, and some are appealing to children. In addition, a large proportion of promotional expenditures associate use of tobacco with activities and products that are attractive to children and youths. The sheer amount of expenditures for advertising and promotion assures that young people will be exposed to these messages on a massive scale. It is clear that society’s efforts to discourage young people from smoking are obstructed — and perhaps fatally undermined — by the industry’s efforts to portray their dangerous products in a positive light.”

B. Tobacco advertising and promotion increase tobacco use by children and adolescents

1. Cross-sectional studies

Many cross-sectional studies have found that smoking status and smoking initiation among youth are correlated with awareness, recognition, and approval of tobacco advertisements and promotions; exposure to tobacco advertisements and promotions; “receptivity” to tobacco advertising and promotion; receipt or ownership of tobacco promotional items; and a feeling that cigarette ads make them want to smoke a cigarette.13, 25, 29-38

Cross-sectional studies evaluate correlations at a single point in time. Although the correlations between smoking behavior and cigarette advertising in these studies are compelling when considering the total body of evidence — which includes many different study designs, study populations, and investigators — the cross-sectional nature of these studies does not allow a definitive conclusion about the direction of causality. For example, if a cross-sectional study shows that teenage smokers are more likely than nonsmokers to “like” cigarette ads, two explanations (with opposite directions of causality between the associated variables) are possible: a) teens who like cigarette ads are more likely to become smokers over time than teens who don’t like the ads; or b) teens who become smokers are more likely to develop a liking of the ads than teens who don’t become smokers. Longitudinal studies, which assess correlations at two or more points in time, can determine the temporal relationship between two associated variables, and hence the causal relationship between the two. Two longitudinal studies of youth smoking in relation to tobacco advertising are described below.

2. Longitudinal studies

Two important longitudinal studies followed up on earlier cross-sectional investigations. In a cross-sectional survey of 6000 primary school children (10-12 years old) in New South Wales, Australia, the children were asked whether cigarettes should be advertised. Logistic regression was used to determine the relative importance of several factors, including approval of cigarette advertising, in relation to the children’s smoking status. Approval of advertising was the second most important predictor of smoking status, after friends’ smoking behavior but ahead of siblings’ smoking behavior, amount of money available to spend weekly, sex, age, and parents’ smoking status.29

The investigators then assessed changes in smoking behavior over 12 months among these 6000 children in a longitudinal study design.39 This design allowed the investigators to assess the strength of the association between several personal and social variables and the process of adopting or quitting smoking. Four study groups were defined: a) children who became smokers (adopters); b) those who remained nonsmokers; c) those who became nonsmokers (quitters); and d) those who remained smokers. As noted by the authors, “Children who approved of cigarette advertising were twice as likely to become smokers as children who disapproved, with the smoking behaviour of those who were ambivalent about advertising falling between that of the other two groups.” The smoking adoption rate per 100 children was 27.0 for those approving of cigarette advertising, 12.1 for those not approving, and 19.3 for those who said they “don’t know,” a difference which was highly statistically significant (p < 0.001). Similarly, children who disapproved of cigarette advertising were significantly more likely to quit smoking than those who approved of it.39

Pierce and colleagues have also used both cross-sectional and longitudinal study designs to establish the relationship between cigarette advertising and smoking initiation among youth. They have defined constructs for “susceptibility to smoking” and “receptivity to tobacco marketing.” With regard to the former, adolescents with no smoking experience are asked two questions to probe the likelihood of future smoking: “Do you think you will try a cigarette soon?” and “If one of your best friends were to offer you a cigarette, would you smoke?” Any answer other than “no” or “definitely not” to both questions results in classifying an adolescent as susceptible to smoking.34

In an earlier cross-sectional study, Evans et al. defined an “Index of Receptivity to Tobacco Marketing.”34 The index was based on the total score from five items: a) whether the adolescent felt that a tobacco advertisement contained at least one of nine messages (e.g., smoking is enjoyable, it helps people relax, it helps people stay thin); b) whether the adolescent could name a cigarette brand in response to either of two questions — “What is the name of the cigarette brand of your favorite cigarette advertisement?” and “Of all the cigarette advertisements you have seen, which do you think attracts your attention the most?”; c) whether the adolescent could name a cigarette brand in response to the question “If you wanted to buy a pack of cigarettes tomorrow, what brand do you think that you would buy?”; d) whether the adolescent said “yes” to the question “Have you ever bought or received for free any product which promotes a tobacco brand or was distributed by a tobacco company?”; and e) whether the adolescent said “yes” to the question “Do you think that you would ever use a tobacco industry promotional item such as a T-shirt?”

Using data from 3,536 adolescent never-smokers from the 1993 California Tobacco Survey in a cross-sectional, logistic regression analysis, Evans et al. found that receptivity to tobacco marketing was independently associated with susceptibility to smoking, after adjustment for sociodemographic variables (including age, sex, and race/ethnicity) and perceived school performance. Adolescents who scored 4 or more on the Index of Receptivity to Tobacco Marketing were 3.91 times more likely to be susceptible to smoking than those who scored 0. Even adolescents who scored 2 on the Index were twice as likely to be susceptible.34

Pierce et al.40 extended these findings in a longitudinal study design. A total of 1,752 of the adolescents who were not susceptible to smoking when first interviewed in 1993 were re-interviewed in 1996. In a measure of receptivity to tobacco marketing similar to that used by Evans et al,34 Pierce et al. defined receptivity as minimal if the respondent did not name a brand when asked to identify the brand advertised the most on billboards or in magazines recently seen. If respondents also had a favorite advertisement, they would be considered to have moderate receptivity. Respondents who said that they had bought or received a promotional item from a tobacco company, or that they would ever use a promotional item, were classified as highly receptive to advertising. Pierce and colleagues then investigated the progression toward smoking of the non-susceptible never-smokers.

In a logistic regression analysis of predictors of which adolescents progressed toward smoking, Pierce et al. found that

“The baseline receptivity (in 1993) to tobacco industry promotional activities was strongly related to which adolescents progressed toward smoking. Among those who were assessed as having a minimal level of receptivity, 37.7% progressed toward smoking. Compared with this group, those who had a favorite advertisement but who were not willing to use a promotional item (the moderate level) were 82% more likely to progress toward smoking, which is a statistically significant increase compared with those at the minimal level. Those with a high level of receptivity (at least willing to use a promotional item) were almost 3 times more likely to progress toward smoking, which was highly statistically significant.”40

The authors estimated that 34% of all smoking experimentation in California between 1993 and 1996 can be attributed to tobacco promotional activities, translating to experimentation by 700,000 adolescents nationally.40

In summary, the evidence from these two longitudinal studies39, 40 extends the findings from many cross-sectional studies, and confirms that awareness and approval of tobacco advertising and promotion, and “receptivity” to tobacco marketing, are causal factors in smoking initiation among youth.

3. Relationship between cigarette advertising and brand preference among youth

Another line of evidence indicating the effect of tobacco advertising and promotion on youth is the relationship between cigarette advertising and brand preference among youth. In a study of students in two junior high schools in the Chicago area, seventh- and eighth-grade children who smoked were asked to view a series of cigarette advertisements and to rate how much they “liked” each ad. The investigators found that the students’ cigarette buying preferences closely paralleled the perceived appeal of the cigarette advertisements.41

Particularly compelling evidence is the huge increase in teenage use of Camel cigarettes coinciding with R.J. Reynolds’ youth-oriented “Joe Camel” advertising campaign.13, 42 – 44 Furthermore, studies have shown that youth find Joe Camel to be appealing.13, 41 Similarly, tobacco advertising campaigns targeting women beginning in the late 1960s (i.e., Virginia Slims) were associated with a major increase in smoking initiation among adolescent girls.45 In general, the brand choices of adolescent smokers reflect the brands with the largest advertising budgets.43, 44 Especially noteworthy is the finding by Pollay and colleagues that the relationship between brand choices and brand advertising is about three times stronger among teenagers than among adults.46 Based on this area of research, the FDA came to the following conclusion:

“… these studies are evidence that, when considered together, form a coherent pattern that establishes the role that advertising plays in young people’s smoking behavior.”47

4. Other evidence

King et al. showed that cigarette brands popular among adolescent smokers are more likely than “adult brands” to be advertised in magazines with high youth readerships.48 This suggests that exposure to advertising affects smoking behavior and cigarette brand preference among youth.

The evidence summarized in this section (V. B), taken as a whole, makes a persuasive case that tobacco advertising and promotion increase tobacco use among children and adolescents.

VI. Billboards represent a particularly effective and intrusive medium for advertising in general, and for promotion of cigarettes in particular (especially to children)

There are a number of reasons why tobacco billboards warrant special concern with respect to their impact on youth:

1. billboards are a favorite medium for tobacco advertising;
2. billboards are intrusive and cannot be avoided;
3. billboards are in people’s neighborhoods and are constantly exposing youth and adults to unsolicited messages; and
4. billboards in urban, inner-city environments are more likely to carry tobacco and alcohol advertisements, often targeted to racial and ethnic minorities.

A. Billboards are a favorite medium for tobacco advertising.

There are two ways in which we can look at expenditures for tobacco advertising on billboards. The first is the proportion of total tobacco marketing expenditures devoted to billboards. This gives us a measure of how important billboards are in tobacco company marketing efforts. The second is the proportion of total advertising in various media devoted to tobacco. This gives us a measure of the extent to which tobacco advertising dominates those media.

According to data submitted by tobacco companies to the Federal Trade Commission, the companies have used outdoor media heavily through the years in comparison to other print media. In 1996, the last year for which data are available, cigarette companies spent $292 million on advertising in outdoor media in the United States (5.7% of total cigarette advertising and promotional expenditures for that year), compared to $253 million (4.9%) for advertising at the point of sale, $243 million (4.8%) in magazines, $28.9 million (0.6%) in transit media, and $14.1 million in newspapers (0.3%).27 In other words, billboards continue to be a preferred medium for print advertising of cigarettes.

If we consider total advertising expenditures for different media, we see that tobacco advertising has dominated outdoor media to a far greater extent than it has other print media. My own research showed that in 1985, cigarette advertising expenditures accounted for more than one-fifth (22.3%) of all advertising in outdoor media ($210.8 million out of a total of $945 million), compared to 7.1% for magazines ($367.1 million out of a total of $5.155 billion) and 0.8% for newspapers ($199.8 million out of a total of $25.17 billion). In 1984, the figures were 21.1%, 8.4%, and 1.0%, respectively. In 1985, cigarettes were the most heavily advertised product or service in outdoor media, the second most heavily advertised in magazines (after passenger cars), and the third most heavily advertised in newspapers (after passenger cars and airlines). Of the seven companies with the largest advertising expenditures in outdoor media in 1985, six were cigarette companies. Also in that year, tobacco advertising expenditures for “eight-sheet” (5 by 11 feet) billboards were $7.8 million — about half the total expenditures for that medium ($15.6 million).49

A subsequent analysis for the year 1988 showed that cigarettes remained the most heavily advertised product or service in outdoor media, compared to a ranking of second in magazines (after passenger cars) and sixth in newspapers. In 1988, cigarette advertising expenditures accounted for 16.9%, 5.7%, and 0.4% of total advertising expenditures in outdoor media, magazines, and newspapers, respectively.50 As these figures show, billboards remained a favorite medium for cigarette advertising, even though the tobacco industry was gradually shifting its marketing dollars from traditional forms of print advertising into promotional activities such as distribution of free samples and coupons, sponsorship of sporting and entertainment events, value-added offers (e.g., buy one, get one “free”).49, 50

B. Billboards are intrusive and cannot be avoided.

In Packer Corp v State of Utah,51 the U.S. Supreme Court upheld legislation in the state of Utah that prohibited all tobacco advertising in outdoor media and at the point of sale, against a challenge based on the 14th Amendment Equal Protection Clause. In its opinion, the Court approvingly cited a passage from the Utah Supreme Court’s decision upholding that law,51 (page 110) which speaks to the intrusiveness of billboards:

“Billboards, street car signs, and placards and such are in a class by themselves…. Advertisements of this sort are constantly before the eyes of observers on the streets and in street cars to be seen without the exercise of choice or volition on their part…. Other forms of advertising are ordinarily seen as a matter of choice on the part of the observer. The young people as well as the adults have the message of the billboard thrust upon them by all the arts and devices that skill can produce. In the case of newspapers and magazines, there must be some seeking by the one who is to see and read the advertisement. The radio can be turned off, but not so the billboard or street car placard. These distinctions clearly place this kind of advertisement in a position to be classified so that regulations or prohibitions may be imposed upon all within the class.”

The billboard industry’s own marketing material emphasizes the intrusive nature of the medium:

“Outdoor: … You can’t zap it. You can’t ignore it…. It asks little time, but leaves a long impression…. Outdoor is right up there. Day and night. Lurking. Waiting for another ambush.”52

Materials from the outdoor advertising industry in Chicago make similar, albeit less colorful, claims. The Eller Media Company notes that its “bulletins” assure “dominance in selected area(s),” and are “positioned on highly visible traffic locations such as expressways, primary arteries, and major intersections.” “Rotary bulletins” provide “full market coverage … to ensure total saturation of the market.” The company’s “Wallscape” sign on the sides of buildings “towers above the streets, creating a spectacular landmark … [and provides] dominance in key market (sic).” Eller’s 30-sheet posters “are located on primary and secondary streets where traffic volumes are high, … [provide] complete and instantaneous coverage of the market, … deliver exposures to both residents as well as commuter traffic, … [create] rapid consumer top-of-mind awareness, … [and provide] continuous presence, up to 18 hours every day.” “In Chicago,” Eller notes, “it takes a combination of 164 poster panels to achieve a daily circulation (number of impressions) equal to fifty percent of Chicago’s population. Showings can be specialized to reach various ‘niches’ within the overall market.”

Noticeably absent from Eller’s materials is any mention of avoiding youth exposure to advertising for age-restricted products such as tobacco and alcohol. On the contrary, the materials note that “Outdoor advertising displays are giant, dramatic and visible … their presence in the market ensures nearly everyone will be exposed to them … [they] generate massive awareness of an advertising message…. Outdoor reaches a highly mobile audience … where people live, work and socialize.” (Emphasis added.)

C. Billboards are in people’s neighborhoods and are constantly exposing youth and adults to unsolicited messages.

As Judge Hargrove noted in Penn Advertising of Baltimore Inc v Mayor of Baltimore,53

“A billboard is a constant fixture in a neighborhood. It looms over children every day while they walk to school, and every time they play in their neighborhood, thus forming an inescapable part of their daily life.”

“Eight-sheet” (5 by 11 feet) billboards are particularly effective in encroaching on people in their neighborhood, because they are smaller than the typical highway billboards, are low to the ground, and are close to the street (and thus, to sidewalks, cars, and school buses). As noted above, in 1985 tobacco advertising expenditures for eight-sheet billboards were $7.8 million — about half the total expenditures for that medium ($15.6 million).49

Voluntary codes by the billboard industry have been ineffective in preventing youth exposure to tobacco billboards (e.g., the code of the Outdoor Advertising Agencies of America, which recommends that its member companies not advertise tobacco and alcohol within 500 feet of schools and other areas where underage youth congregate).54 Evidence presented to the Lansing, Michigan city council, which recently banned tobacco billboards in that city, showed a substantial overlap between tobacco billboards and school bus routes. A similar problem has been reported from the United Kingdom, where many tobacco billboards are found near schools, in violation of a voluntary agreement on cigarette advertising between the government and cigarette manufacturers.55

In the Roper Starch study conducted for R.J. Reynolds Tobacco Company (mentioned above),12 children (10-17 years old) who said they knew Joe Camel were asked “Please tell me the ways that you might have seen or heard about this character.” The largest proportion (51%) said the information came from a billboard advertisement, followed by an advertisement in a magazine (45%), an advertisement in a store (32%), or from a T-shirt (22%). On the other hand, for other cartoon characters in advertisements — e.g., the Energizer Bunny, Ronald McDonald, and the Keebler Elves — recognition based on billboard exposure was between 6% and 13%.12

Further evidence that tobacco billboards are reaching (and probably influencing) youth comes from a survey conducted for the trade publication Advertising Age. It showed that 46% of children 8-13 years old said they most often saw cigarette advertising on billboards. Moreover, 34% of those 14-18 years of age cited billboards as the predominant advertising medium for tobacco products.56

D. Billboards in urban, inner-city environments are more likely to carry tobacco and alcohol advertisements, often targeted to racial and ethnic minorities.

A number of studies have shown that billboards in urban, inner-city environments are more likely to carry tobacco and alcohol advertisements, often targeted to racial and ethnic minorities. A survey in Baltimore, before that city banned tobacco and alcohol billboards, showed that of 2,015 billboards in the city, 75% were located in predominantly poor, African American neighborhoods; 75% of those billboards carried tobacco or alcohol ads, compared to 20% in white neighborhoods.57

The Detroit Planning Commission conducted a study of the 4,144 billboards in the city in 1989. It found that advertisements for tobacco and alcohol products accounted for 55% to 58% of all billboards in lower income Detroit, compared to 34% to 43% in higher income areas. The two billboards found to be the tallest and largest both advertised tobacco.58

A Chicago Lung Association survey found 27% more billboards in predominantly African American wards in Chicago than in white wards.59 In Washington, D.C., few alcohol and tobacco billboards were found in ward 3, which is predominantly white; however, 78% of billboards advertised alcohol or tobacco in wards 7 and 8, which are heavily African American.60 A similar pattern of targeting ethnic and poor neighborhoods was found in St. Louis, Atlanta, and San Francisco.61

Based on the evidence cited elsewhere in this report, it is reasonable to assume that the higher density of tobacco billboards in poor, ethnic neighborhoods is responsible for smoking by large numbers of young people in racial and ethnic populations in urban areas. This is a matter of great concern given the recent report that smoking prevalence increased substantially from 1991 to 1997 among African American high school students (from 12.6% to 22.7%) and among Hispanic students (from 25.3% to 34.0%).62

VII. Conclusions

A. Conclusions of the 1994 Surgeon General’s report

Based on much of the evidence cited above, the 1994 Surgeon General’s report “Preventing Tobacco Use Among Young People”2 reached the following conclusions about tobacco advertising and promotion:

1. Young people continue to be a strategically important market for the tobacco industry.
2. Young people are currently exposed to cigarette messages through print media (including outdoor billboards) and through promotional activities….
3. Cigarette advertising uses images rather than information to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, healthfulness, adventure-seeking, and youthful activities — themes correlated with psychosocial factors that appeal to young people.
4. Cigarette advertisements capitalize on the disparity between an ideal and actual self-image and imply that smoking may close the gap.
5. Cigarette advertising appears to affect young people’s perceptions of the pervasiveness, image, and function of smoking. Since misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette advertising appears to increase young people’s risk of smoking.”

B. Conclusions of the Food and Drug Administration

The Food and Drug Administration, having reviewed the same body of evidence discussed in this report, has come to the following conclusion:

“FDA recognizes that advertising may not be the most important factor in a child’s decision to smoke; however, the studies cited by the agency establish that it is a substantial, contributing, and therefore material, factor…. The proper question is not, ‘Is advertising the most important cause of youth initiation?’ but rather, ‘does FDA have a solid body of evidence establishing that advertising encourages young people’s tobacco use such that FDA could rationally restrict that advertising?’ The answer to this question is ‘yes.’” (emphasis in original)63

C. My own conclusions

My own conclusions are similar to those of the 1994 Surgeon General’s report and the Food and Drug Administration. The evidence reviewed in this report clearly indicates that tobacco advertising and promotion increase aggregate tobacco consumption, in part through a material effect on smoking by youth. The several lines of evidence that lead to these conclusions include:

o Time-series studies from several countries showing a relationship between tobacco consumption and tobacco advertising expenditures at the national level;
o Studies showing that countries with tobacco advertising bans have lower tobacco consumption (or slower increases in consumption) than those without bans;
o Studies showing that tobacco advertising and promotion reach children and adolescents;
o Numerous cross-sectional studies showing that smoking status and smoking initiation are correlated with awareness, recognition, and approval of tobacco advertisements and promotions; exposure to tobacco advertisements and promotions; “receptivity” to tobacco advertising and promotion; receipt or ownership of tobacco promotional items; and a feeling that cigarette ads make them want to smoke a cigarette;
o Two longitudinal studies showing that approval of cigarette advertising and “receptivity” to tobacco marketing predict the likelihood of taking up smoking or moving through the process of smoking initiation; and
o Studies showing relationships between cigarette brand preference among youth and the following variables: a) cigarette advertising expenditures for certain brands, b) the use of youth-oriented imagery in certain advertising (e.g., Joe Camel), and c) the degree to which teenagers “like” different ads.

Billboards are a special source of concern because: 1) they are a favorite medium for tobacco advertising; 2) they are intrusive and cannot be avoided; 3) they are in people’s neighborhoods and are constantly exposing youth and adults to unsolicited messages; and 4) billboards in urban, inner-city environments are more likely to carry tobacco and alcohol advertisements, often targeted to racial and ethnic minorities.

Because legislation prohibits the sale of tobacco to minors, because tobacco advertising and promotion encourage minors to buy and use tobacco products, and because tobacco billboards are a prime medium through which advertising and promotion accomplish these effects, I believe that implementation of legislation banning or limiting tobacco billboards in the City of Chicago will have a direct and material benefit on the welfare of the city and its children and adolescents.

VIII. References

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32. Aitken PP, Eadie DR. Reinforcing effects of cigarette advertising on under-age smoking. British J Addiction 1990;85:399-412.
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Appendix — Biographical Sketch for Ronald M. Davis, M.D.

Ronald M. Davis, M.D., became the director of the Center for Health Promotion and Disease Prevention of the Henry Ford Health System in September 1995. He was appointed Associate Medical Director of Health Alliance Plan of Michigan in September 1996. From 1991 to 1995, he served as Chief Medical Officer in the Michigan Department of Public Health. From 1987 to April 1991, Dr. Davis served as the director of the U.S. Centers for Disease Control’s Office on Smoking and Health. He completed the Epidemic Intelligence Service program and the preventive medicine residency program at CDC; received his M.D. and Master of Arts degree in Public Policy Studies from the University of Chicago; and a Bachelor of Science degree from the University of Michigan. Dr. Davis was elected as the first resident physician member of the American Medical Association’s Board of Trustees, and served in that capacity from 1984 through 1987. He was elected to the AMA Council on Scientific Affairs in June 1993, and became chair of the Council in June 1997.

Dr. Davis has published widely in peer-reviewed journals, and has received many award and honors, including the Surgeon General’s Medallion and the American Public Health Association’s Jay S. Drotman Memorial Award. He is a member of the World Health Organization’s Technical Advisory Group on Tobacco or Health; and is the editor of Tobacco Control: An International Journal, which was launched by the British Medical Association in March 1992.(PinoyPress)

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