Like many heavy smokers, Steven "Bubba" Ash* wanted to quit. "It's messing up my whole life," he told me. In addition to draining his finances, his pack-a-day habit was killing his stamina. He used to be a serious runner, but he just didn't have the lungs anymore. Bubba was 15 at the time.
The former high school freshman from Plains, Montana, first started smoking when he was 10. "Both of my parents were heavy smokers, and I just picked up on it," he said. He had lots of company. Most of his friends smoked -- Marlboro was the nearly universal choice -- even though none of them was old enough to buy cigarettes. Unfortunately, there were plenty of 18- and 19-year-olds around who were willing to do the kids a favor.
A cloud of smoke
Plains, Montana, is a long way from anywhere, but in some ways it's much like any other place in the country. All across the United States, in small towns and large, kids are living in a haze of smoke. According to the Centers for Disease Control and Prevention (CDC), roughly 16.5 percent of all high school students use tobacco. And each day, Every day, almost 2,500 children under 18 years of age try their first cigarette, and more than 400 of them will become new daily smokers.
Many of them think they're just experimenting -- but the "experiment" often lasts for decades. As the Campaign for Tobacco-Free Kids reports, almost 90 percent of adult smokers started before they were 18. Teenagers tend to underestimate how addictive smoking really is: In one survey, only 5 percent of teen smokers said they expected to be smoking in five years, but eight years later, 75 percent were still smoking, according to Drug Topics journal. "Nicotine addiction is really a pediatric disease," says Ron Todd, MSEd, director of tobacco control for the American Cancer Society.
Everyone from Bubba Ash to the Surgeon General knows smoking is dangerous, so why are so many teens lighting up? You can forget about easy answers such as "peer pressure," says Dan Romer, PhD, research director of the Institute for Adolescent Risk Communication at the University of Pennsylvania's Annenberg Public Policy Center.
According to Romer, today's epidemic is fueled by misunderstandings and misinformation, much of it coming directly from tobacco companies. Research shows that if there were a way to get teens to understand deceptive advertising and the consequences of their smoking, far fewer teens would ever get trapped by the addiction.
Thanks to the warnings on cigarette packs and in magazine ads, just about everyone can recite the risks of smoking: lung cancer, heart disease, emphysema, complications with pregnancy, and so on. But according to research by Romer and others, those risks are practically invisible to teens when they contemplate whether or not to try smoking. "The idea of risk plays almost no role in their decision," he says.
One of Romer's studies, published in the Journal of Adolescent Health, sums up the situation. A survey of 600 teens found that smokers tend to underestimate the danger of smoking, especially their own personal danger. "They think nothing's going to happen to them because they're going to quit," Romer says.
While teens ignore the hazards of smoking, they're well aware of the supposed "benefits." Tobacco companies spend billions on ads promoting cigarettes as the key to a fun and relaxing lifestyle. And teens are getting the message.
In an article for Youth Outlook called "In Defense of Joe Camel," writer Charles Jones praised the cigarette-chomping dromedary -- until recently a representative of RJ Reynolds Tobacco Co. -- as the height of "cool."
Although Jones "watched smoking turn my mother's beautiful smile beige," he began smoking early. He admired Joe Camel, viewing the cartoon figure as in the same league as Bugs Bunny or Wolvie of the X-Men. "When I was a kid, my friends and I would try to find a picture within the shadows of the [cigarette] package," he writes. "Later in life, when the camel started lounging on beaches and playing the saxophone, the last thing we noticed was the cigarette in his mouth. ... The Marlboro Man is dead, but Joe Camel -- a cartoon, not a man -- can never die."
Joe Camel's appeal to kids was hardly accidental. Between 1988 and 1996 millions of teens became addicted to cigarettes through massive tobacco company giveaways of coupons, jackets, and other gear, much of it featuring the cigarette-puffing camel, according to the CDC. More preschoolers recognized Joe Camel, in fact, than Mickey Mouse. Moreover, the CDC discovered, the number of first-time smokers shot up 73 percent in the eight years following 1988, when the cartoon camel made his debut.
RJ Reynolds repeatedly denied targeting adolescents, but its 1990 business plan focused on persuading young adults to smoke Camel cigarettes, the brand most popular with teens. "To ensure increased and longer-term growth for Camel Filter, the brand must increase its share penetration among the 14-24 age group," one of its internal memos stated. Other tobacco companies also targeted kids: a memo from tobacco giant Brown and Williamson noted that "it's a well-known fact that teenagers like sweet products. Honey might be considered [as an additive]."
The stark power of advertising was made still clearer in a survey of 529 young nonsmokers (12- to 15-years-old) conducted by researchers at the University of Massachusetts. As reported in the American Journal of Public Health, young people who were closely tuned in to cigarette advertising -- the ones who owned a promotional item and could describe their favorite ads -- were almost three times as likely as other youngsters to become regular smokers within four to five years of their purchase.
As part of the $200 billion Master Settlement Agreement with the U.S. attorneys general, tobacco companies promised to limit advertising that might appeal to young people. The cartoon spokesman Joe Camel suddenly retired, and many cigarette ads disappeared from magazines with predominantly teenage readerships.
The exit of Joe Camel may have made a difference. According to the Centers for Disease Control and Prevention, rates of teen smoking dropped significantly after the advertising restrictions took effect. However, the decline has stalled in recent years.
If the tobacco companies truly have their hearts set on stopping teen smoking, they have a strange way of showing it, Romer says. Anti-smoking advocates charge that not only are tobacco companies' "anti-smoking" ads aimed at teens ineffective, they may actually promote smoking. To take one example: Lorillard Tobacco, the maker of Newport cigarettes, placed brightly colored ads in kids' magazines proclaiming, "Tobacco is whacko if you're a teen." To Romer, the tag line sounds like it came straight from the marketing department. "The message is that tobacco is cool and interesting," he says. Indeed, confidential documents from Lorillard Tobacco that surfaced in a Justice Department investigation suggested that high school students were the core of its customer base.)
"When it comes to kids, the actions of Big Tobacco speak more loudly than their rhetoric," says John R. Seffrin, PhD, of the American Cancer Society.
Ready to quit
Ads can attract teens to smoking, but no amount of marketing can turn a kid into a lifelong customer. (That's the job of nicotine.) In fact, most young smokers have seriously tried to quit, says Todd of the American Cancer Society. Again, health usually isn't their top concern. "They start to notice that their teeth are yellow and their breath smells bad," he says. "And when they can't get up in the morning without a cigarette, the reality of addiction sets in."
Of course teens, like everyone else, often have trouble shaking that addiction. Romer believes they need help to strengthen their resolve. For starters, cigarette companies could be forced to place more explicit, more graphic warning labels on cigarettes. In his opinion, the Canadian approach of putting pictures of diseased lungs on cigarette packages is a step in the right direction. Such a campaign would make the risks more "emotionally meaningful" and might even discourage some kids from smoking in the first place, he says.
Physicians could also be major allies in the effort to curb teen smoking, but they need more training and support. A study published in the Archives of Pediatric and Adolescent Medicine found that physicians treating children and adolescents need improved smoking cessation counseling skills and practices. An earlier study in the Journal of the National Cancer Institute found that doctors counseled young people about smoking at only 1.7 percent of all office visits.
Parents might also have more influence on teen smoking than they think: a survey of over 1,000 high school students by researchers from the National Institute of Child Health and Human Development found that the more parents were involved in their kids' lives, the less likely the kids were to smoke.
Our brand is truth
Researchers have found that kids are rarely deterred from smoking simply by learning about the risks of tobacco or by school programs to help teens resist peer pressure. What does work, interestingly enough, are campaigns that target the deceptive nature of cigarette advertising.
"You can't tell young people they're going to get sick, because they think they're invulnerable," says Ken August, a spokesman for the tobacco control program for the California Department of Health. "But when you start telling them they're being used by adults -- that really gets through." Other tactics effective in preventing teen smoking include discouraging kids from using any promotional items from tobacco companies and making it harder for everyone to smoke, adults included.
Perhaps it's time, too, for more teens to take the initiative. When young people take a stand against tobacco, their peers tend to listen, says Ursula Bauer, PhD, a researcher with the Florida Department of Health. Bauer and colleagues helped launch a statewide anti-smoking program that included a youth-led advertising campaign. Students created MTV-like television ads and billboards, many accompanied with the slogan "Our brand is truth." The teens also formed SWAT teams -- students working against tobacco -- that conducted letter campaigns and gave anti-smoking presentations in middle schools and elementary schools.
The results of the campaign were remarkable. As reported in the Journal of the American Medical Association, the number of teensmokers plummeted,
Bauer says the program was inspired by similar successful campaigns in California, Oregon, and Massachusetts. "Hopefully other states will start copying us, and we can finally win this war," she says.
For now, the anti-smoking movement is scattered and uncoordinated, in contrast to the cohesive, unrelenting efforts of the tobacco industry, Romer says: "We have 50 states all doing their own thing." While some are using the tobacco settlement windfall to fund anti-smoking initiatives, many are spending their money elsewhere. Until all of the states work together, the cloud around America's teens isn't likely to lift, he says.
Bubba Ash wished he'd never started. After he got hooked, he had two ways to go. The easy route was to keep buying cigarettes and stay away from the track team. But he said he was ready to try the more difficult route. He was ready to quit. Right away.
"When did you have your last cigarette?" a reporter asked.
"About 15 minutes ago," Bubba said.
Sadly, Bubba Ash died in a car crash several years after this article was written.
Telephone interviews with Dan Romer, PhD; Ron Todd, MS Ed.; Steven "Bubba" Ash.
American Cancer Society. Adolescents still confused about the risks of smoking.
Biener, L. and M. Siegel. Tobacco marketing and adolescent smoking: More support for a causal inference. American Journal of Public Health, 90(3):407-411.
Bauer, U.E. et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program. Journal of the American Medical Association, 284(6) 723-728.
Prospective analysis of peer and parent influences on smoking initiation among early adolescents. Simons-Morton BG. Prev Sci, Vol.3(4):275-83
Centers for Disease Control. Cigarette Use Among High School Students -- United States, 1991-2003. http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5323a1.htm
Campaign for Tobacco-Free Kids. Smoking and Kids. http://www.tobaccofreekids.org/research/factsheets/pdf/0001.pdf
Campaign for Tobacco-Free Kids. Did you Know? http://www.tobaccofreekids.org/research
Centers for Disease Control. The Surgeon Generals Report for Kids about Smoking. http://www.cdc.gov/tobacco/sgr/sgr4kids/adbust.htm
Southern Adirondack Tobacco Free Coalition. Coalition in the News. http://www.notobaccoads.org/asp_coalition-in-the-News.asp
Centers for Disease Control and Prevention. Youth and Tobacco Use: Current Estimates.
Kaplan, CP, et al. Smoking cessation counseling with young patients: The practice of family physicians and pediatricians. Archives of Pediatric and Adolescent Medicine, 158 (1): 83-90.