Accessibility of Tobacco Products

Accessibility of tobacco products is an important environmental factor that influences smoking initiation by adolescents (Lynch and Bonnie 1994; USDHHS 1994; Forster and Wolfson 1998). In numerous surveys conducted since the late 1980s, youth often self-reported that their most common source of cigarettes was purchase from retail stores (Lynch and Bonnie 1994; USDHHS 1994; Centers for Disease Control and Prevention [CDC] 1996a,b; Forster and Wolfson 1998). Since the early 1990s, noncommercial or social sources (other minors, parents, older friends) have also been studied (Cummings et al. 1992; CDC 1996b; Forster et al. 1997). Evidence suggested, however, that much of the tobacco provided by minors to other minors was initially purchased from commercial sources by the adolescent donor (Wolfson et al. 1997). Some of these self-report surveys have found that adolescent girls may be less likely than boys to report usually purchasing their own cigarettes (CDC 1996b; Kann et al. 1998). Additionally, results from the Memphis Health Project (Robinson and Klesges 1997) indicated that girls were less likely than boys to view cigarettes as affordable and easy to obtain. Field research concerning minors' access began in the late 1980s and has generally concentrated on assessing rates of illegal sales of tobacco to minors from retail stores during compliance checks in which underage youth attempt to purchase tobacco products (DiFranza et al. 1987; USDHHS 1994; Forster and Wolfson 1998; Forster et al. 1998). Compliance check studies in which both girls and boys participated generally found that retailers were more likely to sell cigarettes to girls than to boys of the same age (Forster and Wolfson 1998).

Pricing of Tobacco Products

Although considerable research has been done on the effect of price on smoking among smokers (Wasserman et al. 1991; Hu et al. 1995b; Chaloupka and Grossman 1996; CDC 1998), little empirical research exists on the effect of price on smoking initiation. Lewit and Coate (1982) used cross-sectional survey data and found that a price increase appeared to affect the decision to become a smoker rather than the decision to smoke less frequently. They also found that the smoking behavior among young adults (20 through 25 years old) was more sensitive to price changes than that among older persons and that male smokers, particularly those aged 20 through 35 years, were quite responsive to price, whereas female smokers were essentially unaffected by price. Chaloupka (1990, 1991a,b) also found that women were much less responsive to price than were men, but, in contrast with the findings of Lewit and Coate (1982), Chaloupka found that adolescents and young adults (aged 17 through 24 years) were less responsive to price than were older age groups. In a CDC (1998) study, data analyzed from 14 years of the National Health Interview Survey showed that a 10-percent increase in price led to a 2.6-percent reduction in the demand for cigarettes among males and a 1.9-percent reduction among females. Thus, females were less responsive to price, as other studies have also found.

Mullahy (1985) found that both the decision to smoke and the quantity of cigarettes consumed by smokers were negatively related to cigarette prices among both men and women. As in the Lewit and Coate (1982) study, Mullahy (1985) found that cigarette prices had a greater effect on the decision to smoke than they did on cigarette consumption. Similarly, he found that men were somewhat more responsive to price than were women (average elasticities of -0.56 and -0.39, respectively). Of the studies that examined price in relation to initiation, two (Lewit et al. 1997; Dee and Evans 1998) found a significant inverse relationship between price and smoking initiation, and one (DeCicca et al. 1998) found no significant relationship. Dee and Evans (1998) estimated the price elasticity of smoking initiation to be in the range of -0.63 to -0.77. This finding implied that for every 10-percent increase in the price of cigarettes, a 6.6- to 7.7- percent reduction in the onset of smoking would be expected. Lewit and colleagues (1997) found that a 10-percent increase in price reduced the onset of smoking by 9.5 percent.

Chaloupka (1992) explored whether differences existed in the impact of clean indoor air laws on cigarette demand among women and men. The results for women and men showed dramatic differences in their response to both clean indoor air laws and cigarette prices. Men living in states with clean indoor air laws were found to smoke significantly less, on average, than their counterparts living in states with no restrictions on smoking. The smoking behavior among women, however, was found to be virtually unaffected by restrictions on cigarette smoking. Increased cigarette prices were found to lower the average cigarette consumption among men, whereas cigarette prices had no impact on smoking among women.

Advertising and Promotion of Tobacco Products

Defining a self-image is an important developmental task during adolescence (French and Perry 1996). Attractive images of young smokers displayed in tobacco advertisements are likely to "implant" the idea of initiation of smoking behavior in adolescent minds as a means to achieve the desired self-image. Therefore, it is not surprising that adolescents generally notice and respond to messages in tobacco advertising and promotion. A study by Pollay and colleagues (1996) found that brand choices among adolescents were significantly related to cigarette advertising and that the relationship between brand choices and brand advertising was stronger among adolescents than among adults.

Gilpin and Pierce (1997) suggested that the tobacco industry's expanded budget for marketing and increased emphasis on marketing tactics that may be particularly pertinent to young people influenced rates of smoking initiation among adolescents. Results from the statewide California Tobacco Survey led Evans and associates (1995) to conclude that tobacco advertising and marketing may have a stronger effect on smoking initiation among adolescents than does exposure to peers and family members who smoke. On the basis of a study of 7th and 8th graders, Botvin and colleagues (1993) reported that exposure to tobacco advertising was predictive of current smoking status. A study performed in rural New England showed that one-third of 6th through 12th graders possessed cigarette promotional items (e.g., T-shirts, hats, and backpacks) (Sargent et al. 1997). Students who owned such items were 4.1 times as likely to be smokers as students who did not own these items. One study revealed that ownership of and willingness to use cigarette promotional items were less common among girls than among boys (Gilpin et al. 1997).

Although advertising is thought to influence smoking initiation, information about differential gender effects of tobacco advertising and promotion on smoking initiation is limited. For a more detailed discussion of the relationship between historic trends in tobacco marketing targeted to women and time trends in smoking among girls and young women, see "Influence of Tobacco Marketing on Smoking Initiation by Females" later in this chapter.

Parental Hostility, Strictness, and Family Conflict

Study results on the effect of parental strictness on smoking initiation among adolescents have been conflicting. Some studies found that strictness and hostility of parents toward their children increased the risk for smoking initiation among adolescent boys (e.g., Chassin et al. 1984). However, other studies concluded that perception of parental strictness by adolescent children did not contribute to smoking initiation (e.g., McNeill et al. 1989).

Biglan and coworkers (1995) studied a sample of 643 adolescents at three time intervals. Family conflict at time 1 predicted inadequate parental monitoring at time 2, and inadequate parental monitoring, association with deviant peers, parental smoking, and peer smoking at time 2 predicted smoking at time 3. The model was the same for girls and boys, and no significant differences were found in the path coefficients. These findings suggested that family conflict influences tobacco use indirectly and that the mechanism among girls and boys is similar.

Level of Parental Supervision, Involvement, or Attachment

Parents who closely supervise their children know where their children are and monitor what they are doing. Results of some studies suggested that close supervision deters smoking among adolescents (Chassin et al. 1986; Mittelmark et al. 1987; Radziszewska et al. 1996; Jackson et al. 1997), and findings in two studies suggested that parental supervision may be a greater deterrent among girls than among boys (Skinner et al. 1985; Krohn et al. 1986). This pattern might be explained by the finding that girls are generally monitored more closely than are boys (Cohen et al. 1994). One study revealed that authoritative parenting styles influenced children's smoking initiation independently of parental smoking status (Jackson et al. 1994). However, other studies showed no link between parental supervision and adolescent smoking (e.g., Krohn et al. 1983).

Parental involvement implies the active participation of parents in their children's lives. A longitudinal study of fifth and seventh graders found lower rates of smoking initiation among children who reported that their parents spent more time with them and communicated with them more frequently (Cohen et al. 1994). Girls tended to have better communication with their parents than did boys, but the relationship between interaction with parents and smoking initiation was not reported separately by gender. In one study, parental involvement in their children's school, religious, and athletic activities decreased the risk for smoking among both girls and boys (Krohn et al. 1986). In another study, children who perceived their parents as generally unconcerned about their social activities were slightly more likely to increase their smoking over a one-year period (Murray et al. 1983). The results of two other studies suggested, however, that this relationship may exist for boys only (Mittelmark et al. 1987; Stanton et al. 1995).

Longitudinal studies have reported that the risk for smoking among adolescents increases as their emotional bonds and sense of attachment to parents weaken (Conrad et al. 1992). Findings in several studies suggested that weak attachment to parents and risk for smoking do not differ by gender (Ensminger et al. 1982; Krohn et al. 1986; Kumpfer and Turner 1990-91). One study of female college students found that poor father-daughter relationships (e.g., spending little time together or poor communication) correlated with the daughters' smoking (Brook et al. 1987).

Parental Smoking

Parents who smoke are more likely than those who do not to have children who smoke (Conrad et al. 1992; Jackson et al. 1997). Studies found that children in grades four through six (mean age, 11 years) were almost three times as likely to have smoked cigarettes in the past 30 days if they lived with an adult smoker (Morris et al. 1993) and that adolescents were about two times as likely to have smoked daily if one or both parents smoked (Green et al. 1991). One study found that adolescents whose parents had stopped smoking were about one-third less likely to have ever smoked than were those with parents who still smoked (Farkas et al. 1999). Several studies reported that girls and boys are equally susceptible to the effects of parental smoking (Chassin et al. 1984; Santi et al. 1990-91; Green et al. 1991; Glendinning et al. 1994) and to parental attitudes toward smoking (Ary and Biglan 1988). However, some researchers found differences in receptivity to parental smoking among girls and boys. One study showed that boys were more influenced by parental smoking than were girls (Sussman et al. 1987), but most of the studies suggested that girls may be more influenced than boys (Chassin et al. 1986; Charlton and Blair 1989; Swan et al. 1990; van Roosmalen and McDaniel 1992; Flay et al. 1994; Kandel et al. 1994; Hu et al. 1995a; Robinson et al. 1997).

The effects of maternal smoking may differ among girls and boys. In three studies, maternal smoking tended to have a slightly greater effect on subsequent smoking among girls than among boys (Ahlgren et al. 1982; Pulkkinen 1982; Bauman et al. 1992). This finding was confirmed in a study of 201 parent-child triads that used independent reporting of smoking status from each member of the domestic group (Kandel and Wu 1995), unlike the majority of studies, which used the child's report about parents' smoking. Stanton and Silva (1992) reported that recent smoking cessation among mothers apparently helped to delay and perhaps deter smoking among daughters but not among sons. Thus, adolescent girls may be more likely than adolescent boys to model their smoking on their mothers' smoking behavior. In one study, however, maternal smoking significantly predicted smoking among sons but not among daughters (Skinner et al. 1985).

Sibling Smoking

One study reported that smoking among older siblings had little or no influence on smoking among their younger sisters and brothers (Ary and Biglan 1988), but other evidence suggested that young siblings are influenced by sibling smoking (Swan et al. 1990; Conrad et al. 1992; Daly et al. 1993). The effect was equal among girls and boys in one study (Santi et al. 1990-91). In other studies, the effect was stronger among girls (Chassin et al. 1984; Mittelmark et al. 1987; van Roosmalen and McDaniel 1992; Pierce et al. 1993) or among boys (Brunswick and Messeri 1983-84; Stanton and Silva 1991). The pattern may vary by race or ethnicity (Hunter et al. 1987); in particular, African American girls appeared to be less susceptible than white girls to the influence of siblings, other family members, and peers who smoked. At present, no conclusion can be drawn about the comparative susceptibility of girls and boys to sibling smoking.

Peer Smoking

In many studies, one of the strongest risk factors for smoking is exposure to peers, especially close friends, who smoke (USDHHS 1994; Meijer et al. 1996; Gritz et al. 1998). Friends' smoking was predictive of some phase of smoking in all but 1 (Newcomb et al. 1989) of 16 longitudinal studies reviewed by Conrad and associates (1992). Results of many studies suggested that involvement with peers who smoke has a similar effect among girls and boys (Palmer 1970; McCaul et al. 1982; Pulkkinen 1982; Chassin et al. 1984), 1986; Gottlieb and Baker 1986; Krohn et al. 1986; Mittelmark et al. 1987; Sussman et al. 1987; Santi et al. 1990-91; Stanton and Silva 1992; Urberg 1992; van Roosmalen and McDaniel 1992; McGee and Stanton 1993; Pierce et al. 1993; Glendinning et al. 1994). Findings in other studies suggested that peer smoking affects adolescent girls and boys somewhat differently. In a few studies, boys who smoked had more friends who were smokers (Morris et al. 1993) and were more influenced by the smoking-related attitudes (Chassin et al. 1984) and behaviors of their peers than were girls who smoked (Urberg et al. 1991). However, most of the studies that reported gender-specific differences suggested that girls are more influenced by peer smoking than are boys (Semmer et al. 1987; Charlton and Blair 1989; Pirie et al. 1991; Waldron et al. 1991; Rowe et al. 1992; Sarason et al. 1992; Skinner and Krohn 1992; Hu et al. 1995a). Akers and colleagues (1987) reported that adolescent girls were more influenced in their smoking behavior by their boyfriends than adolescent boys were influenced by their girlfriends. However, Skinner and associates (1985) found that the initiation of smoking among girls tended to coincide with increasing involvement with other girls who smoked but not with boys who smoked.

Bauman and Ennett (1994) contended that the examination of simple peer associations may be less revealing than the exploration of social networks among peers. These researchers and their colleagues pointed to the homogeneity of adolescent friendship cliques with regard to smoking and noted that, in a formal network analysis of 87 such cliques, most were composed entirely of nonsmokers (Ennett et al. 1994). The study results suggested that cliques may contribute more to the maintenance of nonsmoking status than to the initiation of smoking. These findings were strongest among all-female and among all-white cliques. In another analysis of the same data, the authors pointed out that adolescents who did not belong to a clique had a higher probability of smoking than did adolescents who belonged to a clique (Ennett and Bauman 1993).

Perceived Norms and Prevalence of Smoking

Adolescents whose close peers smoke tend to perceive that smoking is far more normative than it actually is (Conrad et al. 1992; USDHHS 1994). One study revealed that seventh-grade girls estimated the overall incidence of smoking among their peers at significantly higher levels than did seventh-grade boys (Robinson and Klesges 1997). At least three studies have examined gender-specific differences in perceived social norms of adolescent smoking and smoking initiation. In two studies, significantly more females than males reported social norms as a reason for experimenting with cigarettes or beginning to smoke (Botvin et al. 1992; Sarason et al. 1992). In the third study, the opposite gender-specific effect was observed (Chassin et al. 1984).

Perceived Peer Attitudes Toward Smoking

In one study of a multiethnic sample of adolescents, perceived approval of smoking by one's three best friends was significantly associated with susceptibility to smoking and ever smoking (Gritz et al. 1998). In other studies, even though boys reported more often than girls that their friends' approval of smoking was an important influence on their smoking, peer smoking appeared to be an equally strong risk factor for smoking among girls and boys (Pierce et al. 1993; Flay et al. 1994).

Strong Attachment to Peers

Among adolescents, strong bonds with parents tend to deter smoking, and strong bonds with peers tend to promote smoking. Indeed, Conrad and colleagues (1992) found that in nine longitudinal studies, adolescents were more likely to experiment with cigarettes or to start smoking regularly if they had developed close emotional attachments to other adolescents, spent more and more time with friends, had a large number of close friends, reported that agreement with peers was increasingly important, or had a boyfriend or girlfriend (Kellam et al. 1980; Ahlgren et al. 1982; Krohn et al. 1983; Murray et al. 1983; Chassin et al. 1984; Skinner et al. 1985; Semmer et al. 1987; Sussman et al. 1987; McNeill et al. 1989). Several studies have reported no gender-specific differences in the effects of peer bonds on smoking (McNeill et al. 1989; Swan et al. 1990; Sussman et al. 1994). One study among African Americans, however, showed that the number of close friends an adolescent reported having was a predictor of smoking initiation for boys only (Brunswick and Messeri 1983 -84). In another study, positive social events and peer support increased the likelihood of smoking among more girls than boys (Wills 1986), and Best and colleagues (1995) suggested that among adolescents for whom peer approval is especially important, girls may be more likely than boys to smoke.

Interaction of Social Influences

Flay and associates (1994) tested a model that examined how the following factors interact to influence smoking initiation among adolescents: (1) friends' smoking, (2) parental smoking, (3) expectation of negative outcome from smoking, (4) perceived friends' approval of smoking, (5) perceived parental approval of smoking, (6) refusal self-efficacy (i.e., confidence in one's ability to resist temptations to try smoking), and (7) intention to smoke or not to smoke. The findings showed that friends' smoking influenced smoking initiation both directly and indirectly and that friends' smoking was a stronger influence than parental smoking. Parental smoking had a stronger effect among girls than among boys, but this gender-specific influence was tempered by parental approval or disapproval of smoking. Disapproval mediated the influence of parental smoking among girls but not among boys, and parental approval was an important predictor that girls would start to smoke. These results are consistent with other findings that girls may be more susceptible than boys to social influences, especially parental influences (see "Parental Smoking" earlier in this chapter). No significant gender-specific differences were observed in how the pathways from self-efficacy and expectations of negative outcome affected smoking initiation.

Previous research suggested that parental influence, in general, remains constant or decreases but that the influence of peers increases as adolescents develop (e.g., Krosnick and Judd 1982). A more recent study indicated that the pattern of change in parental and peer influences on smoking may differ among girls and boys (Hu et al. 1995a). In this longitudinal study, data were collected at four time points from grades seven through nine. Smoking status was predicted by using previous smoking status and the effects of time, friends' smoking, and parental smoking. In general, the effects of friends' smoking were stronger than the influence of parental smoking, and the effects of friends' smoking appeared to increase over time, whereas the influence of parental smoking remained fairly constant. Although parental smoking predicted initiation and escalation of smoking equally, friends' smoking was more predictive of initiation than of escalation. The effects of friends' smoking were stronger among girls than among boys, and the tendency for the influence of friends to increase with time was also more noticeable among girls.

Pederson and colleagues (1998) examined the dose-response relationships between various social variables (e.g., maternal smoking, parental approval of smoking, sibling smoking, and friends' smoking) and smoking status among eighth-grade students. The study revealed strong dose-response relationships between these social variables and smoking status for the entire group and, in most cases, among females and males when data were analyzed separately.

Socioeconomic Status and Parental Education

Several studies have shown that low socioeconomic status puts adolescents at higher risk for smoking (Conrad et al. 1992; USDHHS 1994). At least three studies have examined whether the risk for smoking among daughters and sons is affected differently by the socioeconomic status of their parents. Findings in two studies suggested that low socioeconomic status places girls at higher risk than boys (Chassin et al. 1992; Glendinning et al. 1994). The third study produced a contrary finding, but it was conducted among college students, a group in which low socioeconomic status may have been underrepresented (Gottlieb and Baker 1986).

National surveys consistently showed that education (number of years of schooling) is inversely related to cigarette smoking among women and men (see Chapter 2). However, data from the Monitoring the Future Surveys provided little evidence of a gender-specific effect of parental education on risk for smoking among high school seniors for the period 1994-1998. Among seniors whose parents had not graduated from high school, females were more likely than males to smoke, but in general the prevalence of current smoking among both females and males differed little across level of parental education (see "Relationship of Smoking to Sociodemographic Factors" in Chapter 2 and Table 2.11).

Ferrence (1988) proposed a model of diffusion of innovations (Rogers and Shoemaker 1971) to help elucidate gender-specific differences in relation to initiation and cessation of smoking. In general, persons with better economic resources, more education, and greater power adopt new ideas and behaviors and accumulate material goods earlier than those with fewer such resources. This fact may explain why men historically started smoking before women did. Gender-specific differences in relation to economic resources, education, and power have changed over time in concert with changes in the roles of women in society. The first women to smoke were those who, by virtue of their resources, were considered avantgarde. Similarly, in recent decades, the reduction in smoking prevalence occurred first among persons having greater resources. This explanation is supported by theories on social roles (Dicken 1978, 1982; Deaux and Major 1987; Eagly 1987; Waldron 1991).

Behavioral Control

Theories on smoking and drug use (Petraitis et al. 1995) contend that persons may be unable to resist temptations to smoke if they are unable to control certain other behaviors, including tendencies to be impulsive, easily distracted, or aggressive or to exhibit type A behavior. Studies have shown that smoking was more common among (1) adolescents who reported getting into trouble at school (Krohn et al. 1986); (2) young adults who had been aggressive, quarrelsome, and impatient at age 8 years (Pulkkinen 1982); (3) young adults who as children did not solve problems reasonably, did not negotiate with others, and were not conciliatory toward others (Pulkkinen 1982); and (4) adults who demonstrated type A behavior (Forgays et al. 1993).

Results in several studies suggested that a lack of behavioral control plays a larger role in smoking among girls than among boys. Aggressive behavior may put girls at significantly higher risk than boys for succumbing to peer pressures to smoke (Stanton et al. 1995). In one study, young women, but not young men, were more likely to initiate smoking as adolescents if they focused more on short-term goals than on long-term goals (Brunswick and Messeri 1983-84).

Sociability

Adolescents who are shy or lack social skills may find it especially difficult to resist peer pressure to smoke. Studies indicated that adolescents may view smoking as a vehicle for entering a desired friendship group (e.g., Aloise-Young et al. 1994), but two studies suggested that this is true only among boys (Gottlieb and Green 1984; Allen et al. 1994). In a study of girl and boy smokers and nonsmokers, Allen and coworkers (1994) concluded that adolescent boys may have used smoking to cope with social insecurity, whereas adolescent girls who smoked were more socially competent and self-confident than were girls who did not smoke. Killen and colleagues (1997) also found that sociability was related to smoking initiation among adolescent girls.

Fatalism and External Locus of Control

Persons who have an external locus of control generally believe that their lives are controlled by external forces (e.g., fate or God) and may believe that they can do little to prevent negative events from affecting them. In one study, investigators found no link between locus of control during adolescence and smoking during adulthood (Winefield et al. 1992). Other studies, however, suggested that fatalism and an external locus of control are associated with smoking initiation (Brunswick and Messeri 1984; Chassin et al. 1984).

Intelligence, Academic Performance, and Commitment to School

In their analysis of data from the 1990 California Youth Tobacco Survey, Hu and colleagues (1998) found that students who reported their performance in school as below average were more likely than better-than-average students to be current or former smokers. They found no gender-specific differences in the likelihood of being a former smoker or in attempts to stop smoking. An earlier study found that scores on tests of intelligence and readiness for school during first grade were not related to smoking among 16- and 17-year-old African American girls or boys (Kellam et al. 1980). Another study of adolescents reported that poorer academic achievement increased the risk for smoking among girls and boys, but that the importance of two achievement measures differed; reading test scores were stronger predictors among girls, whereas grade point average better predicted smoking among boys (Brunswick and Messeri 1983-84, 1984).

Weak commitment to school consistently predicts the initiation and progression of smoking among adolescents (Conrad et al. 1992). In one longitudinal study, investigators found no gender-specific difference in the effect of weak school bonds on subsequent smoking (Ensminger et al. 1982). However, three other studies suggested that commitment to school affects girls more strongly than it affects boys (Hibbett and Fogelman 1990; Waldron et al. 1991; Skinner and Krohn 1992), and one study reported the reverse (Chassin et al. 1984). Because of these conflicting findings, no conclusion can be drawn about gender-specific differences in relation to school bonds and adolescent smoking.

Rebelliousness, Risk Taking, and Other Health-Related Behaviors

Longitudinal studies of smoking consistently have shown that adolescents are at risk for smoking if they previously rebelled against rules, teachers, or adults in general (Mittelmark et al. 1987); opposed disciplinary rules at school (Murray et al. 1983); or tolerated deviant behavior in others (Chassin et al. 1984). Although adolescent rebelliousness appears to be less common among girls than among boys (Robinson and Klesges 1997), findings in some longitudinal studies suggested that rebelliousness and tolerance for unconventional behavior may affect smoking initiation among girls and boys equally (Skinner and Krohn 1992; Simon et al. 1995). However, several studies have shown that smoking was more highly correlated among girls than among boys in regard to the following characteristics: rebelliousness (Pierce et al. 1993), feelings of being decreasingly bound by laws and parental rules (Skinner et al. 1985), higher levels of both rebelliousness and rejection of adult authority (Best et al. 1995), and tolerance of deviant behavior (Chassin et al. 1984). Stanton and colleagues (1995) found that delinquency significantly increased the risk for smoking among girls but was not related to smoking among boys. One study found that 17-year-old girls were more likely than boys the same age to smoke experimentally if they went to bars, taverns, or nightclubs; had been in trouble with the police; or had been involved in fights (Waldron et al. 1991). Findings from this study paralleled earlier reports about rebelliousness (Sussman et al. 1987).

Sensation seeking has been defined as willingness to take risks for the sake of stimulation and arousal (Zuckerman et al. 1987). Sensation seeking and risk taking appear to be related to smoking among adolescents (Simon et al. 1995; Petridou et al. 1997; Wahlgren et al. 1997; Coogan et al. 1998).

Clustering of smoking and other unhealthy behaviors suggested the formation of a "risk behavior syndrome" during adolescence (Escobedo et al. 1997). This syndrome may emerge as early as elementary school (Coogan et al. 1998). Data from the National Health Interview Survey indicated that smoking aggregates with marijuana use, binge drinking, and fighting among African Americans, Hispanics, and whites of both genders (Escobedo et al. 1997). Other U.S. national survey data also showed a strong relationship between smoking and use of other substances, including alcohol, among girls and young women (see Chapter 2). A British study examined smoking status, exercise, and dietary behaviors among 14- and 15-year-old adolescents (Coulson et al. 1997). Smoking was associated with lower levels of exercise, lower consumption of fruits and vegetables, and greater consumption of high-fat foods. In addition, evidence from the Youth Risk Behavior Survey suggested that participating in interscholastic sports inhibits the development of regular and heavy smoking among adolescents (Escobedo et al. 1993). Furthermore, some studies reported that the more physically active and fit adolescent girls were, the less likely they were to initiate smoking (e.g., Waldron et al. 1991; Aaron et al. 1995). A British study found that girls who had a teenage pregnancy were more likely to smoke cigarettes than were girls who had not been pregnant (Seamark and Gray 1998).

Results from the longitudinal Minnesota Heart Health Program provided evidence that smoking, physical inactivity, and poor dietary preferences cluster in childhood and tend to endure through adolescence (Kelder et al. 1994; Lytle et al. 1995). Similar clustering of smoking and other unhealthy behaviors were reported in an Australian study with follow-up on a cohort of persons aged 9 years through early adulthood (Burke et al. 1997). At age 18 years, smoking, excessive alcohol use, and poor dietary preferences were clustered among both women and men; physical inactivity was also part of the cluster among women.

Religiousness

Most studies on the relationship between religiousness and smoking suggested that religious beliefs are important in the decision of some persons not to smoke. After age 17 years, young women who attended church only occasionally were more than twice as likely to start smoking as were those who attended regularly (Daly et al. 1993). In general, more women than men report religious commitment, which appears to be associated with a lower rate of smoking among women (Reynolds and Nichols 1976; Brook et al. 1987; Grunberg et al. 1991; Waldron 1991). Study data indicated that among high school seniors of both genders, the prevalence of smoking is inversely related to the self-reported importance of religion (see "Relationship of Smoking to Sociodemographic Factors" in Chapter 2). In three studies that examined gender-specific differences in religious attitudes among adolescents, religion deterred smoking among females more than it did among males, and a lack of religious commitment contributed to smoking among females more than it did among males (Gottlieb and Green 1984; Krohn et al. 1986; Waldron et al. 1991). In contrast, Skinner and colleagues (1985) found that religiousness had no effect on smoking by either gender.

Self-Esteem

Adolescents who have poor self-esteem may have difficulty resisting pressures to smoke, especially if they believe that smoking will enhance their image. In some longitudinal studies, adolescents with low self-esteem were significantly more likely than those with high self-esteem to start smoking within the next year (Ahlgren et al. 1982; Simon et al. 1995). Other longitudinal studies, however, detected no link between self-esteem and subsequent smoking (Brunswick and Messeri 1983 -84; Winefield et al. 1992). One study showed that girls who scored high on personal dissatisfaction (e.g., desire to have more friends, be thinner, or be less socially anxious) were more likely to smoke than were girls who appeared to be more personally satisfied (Best et al. 1995). This relationship between personal dissatisfaction and smoking was not observed among boys. Similar findings from another study suggested that self-esteem may be a factor in the smoking behavior among girls in grades six through eight but not among males in any grade (Abernathy et al. 1995).

Emotional Distress

Theories of smoking and drug use have suggested that persons may have difficulty resisting temptations to smoke if they are anxious, hostile, irritable, depressed, or psychologically distressed (Petraitis et al. 1995). Evidence of a link between emotional distress and smoking is mixed, however. Many of the studies have focused on adults, so it is not clear to what extent the findings can be extrapolated to smoking initiation, which generally occurs among adolescents. Some investigators have found no association between smoking, hopelessness, stress, nervousness, negative mood, psychological disturbances, or level of anxiety (Winefield et al. 1992; Simon et al. 1995). Others have found links between smoking and anger (Modrcin-McCarthy and Tollett 1993); stress (Wills 1986); stressful life events (Frone et al. 1994); depression (Pederson et al. 1998); and anxiety levels, physical complaints, and hostility (Forgays et al. 1993; Schifano et al. 1994). A study by Johnson and Gilbert (1991) reported that the intense feelings of anger and irritability were related to both smoking initiation and maintenance among African American adolescents, whereas among white adolescents these emotions were associated only with smoking initiation. One qualitative investigation reported that the most frequent reasons for smoking among girls in grades 10 and 11 were stress reduction and relaxation (Nichter et al. 1997). Although exceptions have been reported (Oleckno and Blacconiere 1990; Allen et al. 1994; Frone et al. 1994), findings in several studies suggested that symptoms of distress are more strongly associated with smoking among females than among males (Brunswick and Messeri 1984; Gottlieb and Green 1984; Knott 1984; Semmer et al. 1987; Lee et al. 1988; Waldron et al. 1991; Pierce et al. 1993).

Coping Styles

Two studies have examined whether there are gender-specific differences in the link between smoking levels and the way persons cope with their problems, but such differences do not appear to exist. In one study, MacLean and coworkers (1996) found no connection between smoking level during the past month and the frequency with which 17-year-old girls and boys used various strategies (e.g., getting angry) to cope with problems. In a study of 12-year-olds, Wills and Vaughan (1989) examined the relationship between current smoking and earlier tendencies to seek adult or parental help with problems, but they found no differences by gender in this relationship. These researchers did find that, among adolescents who had previously relied on peers for help with problems, girls were far more likely than boys to smoke, but it is unclear whether this effect related primarily to coping styles or to peer attachments.

Perceived Refusal Skills

Adolescents who are confident of their ability to resist pressures to smoke may be better able to avoid smoking than those who are not confident. Although girls may have stronger doubts about avoiding cigarette smoking in the future than do boys (van Roosmalen and McDaniel 1992), attempts to reduce those doubts appear to have the same effect among girls and boys. Findings in experimental studies suggested that refusal skills can be taught effectively to both girls and boys (Sallis et al. 1990), and results of longitudinal studies suggested that self-doubts about the ability to refuse offers to smoke affect girls and boys equally (Lawrance and Rubinson 1986; Flay et al. 1994). In one study, however, this finding was not true among all racial and ethnic groups; for 13-year-old Asian children who one year earlier had doubted their ability to refuse an offer of a cigarette, the prevalence of smoking was higher among boys than among girls (Sussman et al. 1987).

Previous Experimentation with Tobacco and Intention to Smoke

Findings in three longitudinal studies suggested that girls and boys who experiment with cigarettes during adolescence are at generally similar risk for progression from experimentation to regular smoking. In two of these studies, the investigators found no gender-specific differences in the link between experimental smoking during adolescence and regular smoking during early adulthood (Chassin et al. 1990; McGee and Stanton 1993). In the third study, the researchers found that the amount smoked at ages 10 through 13 years was strongly related to the amount smoked at ages 14 through 17 years and that the link between previous and current smoking may have been stronger among boys than among girls (Skinner and Krohn 1992). Two studies showed that girls and boys were equally likely to smoke if at least one year earlier they had thought they might smoke in the future (Ary and Biglan 1988; McNeill et al. 1989). In a large study of 4,500 adolescents, the lack of a firm decision not to smoke was a strong baseline predictor of both experimentation and progression to regular smoking (Pierce et al. 1996). However, intention was not as important as exposure to other smokers in influencing the transition from experimentation to regular smoking. No gender differences were found.

Susceptibility to Smoking

As smoking prevention moves toward use of more tailored and individualized programs, identifying precursors of smoking initiation becomes increasingly important. The ability to classify adolescents as being at higher or at lower risk for smoking initiation is critical to the development of appropriate intervention techniques.

Two theoretical concepts appear to be particularly useful for identifying adolescents at risk for smoking initiation: the transtheoretical model of change (Prochaska et al. 1992; Pallonen 1998; Pallonen et al. 1998) and susceptibility to smoking (Pierce et al. 1996). The transtheoretical model of change postulates gradual progression through a series of discrete stages of cognitive and behavioral change, simultaneously integrating constructs such as stages of change, decisional balance (pros and cons of smoking behavior), situational temptations to try smoking (Hudmon et al. 1997), and self-efficacy. Pallonen and colleagues (1998) proposed integration of the stages of adolescent smoking initiation and cessation. The four stages of smoking initiation are (1) acquisitionprecontemplation, (2) acquisition-contemplation, (3) acquisition-preparation, and (4) recent acquisition. These stages have been validated in a sample of high school students. The scores for perceived advantages (pros) of smoking and temptations to try smoking were closely related to the stages of smoking initiation. The continuum based on the four stages of change appears to provide a concise and theoretically sound approach to smoking initiation in adolescent populations.

Susceptibility to smoking is a measure of intention to smoke. According to this concept, "susceptible" adolescents exhibit a lack of firm commitment not to smoke in the future. The construct of susceptibility to smoking has been used in the California Tobacco Survey and other studies; its rationale and validation have been extensively presented in the literature ( Pierce et al. 1995, 1996; Unger et al. 1997; Jackson 1998). Adolescents are susceptible to smoking if they have made no determined decision not to smoke in the next year or if offered a cigarette by a friend. The susceptibility measure integrates intentions and expectations of future behavior; therefore, it identifies persons with a cognitive predisposition to smoking. Longitudinal studies have demonstrated that susceptibility is a stronger predictor of smoking experimentation among both females and males than are other well-established predictors, such as exposure to smokers in the immediate social environment (Pierce et al. 1996; Jackson 1998). A recent study reported that the susceptibility construct can predict who among adolescent experimental smokers will become established smokers (Distefan et al. 1998).

Beliefs About Effects on Image and Health

In several longitudinal studies of smoking among adolescents, smoking was more common among persons who lacked knowledge of the health consequences of smoking, doubted that nicotine is addictive, and had mostly positive beliefs about smoking (Conrad et al. 1992). Attitudes that put adolescents at risk for smoking included (1) having tolerance for smoking by others, (2) believing that smoking makes people look good and enhances their image, (3) having the opinion that smoking is fun or pleasant, (4) expecting generally positive consequences from smoking, and (5) placing more value on the perceived positive results of smoking than on the negative consequences. The belief that smoking makes people have an unpleasant smell, look silly, or feel sick reduced the risk for smoking.

Evidence suggested that some attitudes about smoking are especially important among girls. In some studies, girls were found to be at higher risk than boys for smoking if they thought the harmful effects of smoking had been exaggerated (Waldron et al. 1991) or if they dismissed the health hazards of smoking (Swan et al. 1990). In a study of persons 18 through 23 years old, thoughts about health were an important deterrent to smoking among women but not among men (Brunswick and Messeri 1983-84). However, another study showed that boys expected more benefits from smoking than did girls and that the relationship between the expected number of benefits and susceptibility to smoking was stronger among boys than among girls (Pierce et al. 1993).

Findings have been inconclusive on genderspecific differences in whether smokers are perceived to be mature, confident, and self-reliant. In one study, this image was positively associated with smoking among both girls and boys (McGee and Stanton 1993), but in two other studies, such an image was more important among girls than among boys (Mittelmark et al. 1987; Waldron et al. 1991), while in another study such an image was more important among boys than among girls (Dinh et al. 1995).

Concerns About Weight Control

Many girls believe that smoking helps to control weight by suppressing appetite (USDHHS 1980; Klesges et al. 1989, 1997). Findings in several crosssectional studies suggested that concerns about body weight and dieting are related to smoking status among adolescent girls (Charlton 1984; Gritz and Crane 1991; Pirie et al. 1991). Among 1,915 students in grades 10 through 12 in one school district in Mississippi, girls who smoked were more likely than girls who did not smoke to perceive themselves as fat (Page et al. 1993). This association was not found among boys. Both girls and boys who smoked were less satisfied with their weight than were nonsmokers. A study of Catholic high school students in Memphis, Tennessee, found that among white students who smoked more than once a week, girls (39 percent) were significantly more likely than boys (12 percent) to use smoking in an attempt to control weight (Camp et al. 1993). A longitudinal study of 1,705 students in grades 7 through 10 indicated that concerns about weight and dieting behaviors (e.g., constant thoughts about weight and trying to lose weight) were positively related to smoking initiation among girls but not among boys (French et al. 1994). At baseline, fear of gaining weight, the desire to be thin, and trying to lose weight were also positively related to current smoking among girls.

Although most of these studies reported a relationship between smoking status and concerns about weight, investigators in only one study (Camp et al. 1993) controlled for many other known correlates of smoking: age, race and ethnicity, number of smoking models (e.g., peers who smoke), perceived value of smoking, degree of social support, risk-taking behavior, rebelliousness, and pharmacologic and emotional reactions to early experimentation with smoking. In that study, being female predicted smoking for weight control reasons.

Most of these studies on adolescents' beliefs about smoking and weight control were conducted primarily or exclusively among white study participants. The processes of smoking initiation may be different across racial and ethnic groups (Flay et al. 1994; Klesges and Robinson 1995). For example, according to a school-based survey conducted in the early 1980s, concerns about weight and dieting may have been less important among African American girls than among white girls (Sussman et al. 1987). In a survey of 6,967 seventh-grade adolescents in an urban school system, Robinson and colleagues (1997) found that African American adolescents who knew about the weight-suppressing effect of smoking were less likely to experiment with cigarettes than were those who believed that smoking had no effect on weight. Among white adolescents, weight control beliefs were not associated with cigarette experimentation. No gender differences were reported.

Beliefs About Mood Control and Depression

The belief that smoking can control negative moods and produce positive moods is important among many girls. One study showed that girls were no more likely than boys to smoke for relaxation or relief from problems or anxieties (McGee and Stanton 1993). However, at least two studies showed that females were more likely than males to say that they smoked to control negative emotions (Semmer et al. 1987; Novacek et al. 1991). Pirie and associates (1991) also found that young women who smoked were significantly more likely than young men who smoked to say that they would be tense and irritable if they stopped smoking.

Depression in adolescence predicts depression in young adulthood (Kandel and Davies 1986) and may have an important interrelationship with smoking. Among adults, major depression is strongly related to smoking (Anda et al. 1990; Glassman et al. 1990; Kendler et al. 1993), although neither the directionality of the association nor its gender-specific effect is completely understood. Findings in a large cross-sectional study suggested that depression and anxiety were associated with smoking among teenage girls of all ages but only among younger teenage boys (Patton et al. 1996). Astudy in Atlanta of 1,731 youths aged 8 through 14 years who were assessed at least twice from 1989 through 1994 found that antecedent tobacco smoking was associated with an increased risk for subsequent depressed mood but that antecedent depressed mood was not associated with risk for subsequently initiating smoking (Wu and Anthony 1999). Findings were not presented separately by gender, but gender was included in multivariate analyses and was not an independent predictor of smoking initiation. (See "Depression and Other Psychiatric Disorders" in Chapter 3.)

Attempts to Stop Smoking

In 1987, among those who have ever smoked, only 18.5 percent of men and 19.5 percent of women in the United States reported they had never tried to quit (USDHHS 1990). In 1998, an estimated 39.2 percent of current daily smokers had stopped smoking for at least a day during the preceding 12 months because they were trying to quit (CDC 2000). However, only a small percentage of persons who try to quit in any given year remain abstinent.

Rose and colleagues (1996) examined the natural history of smoking from adolescence to adulthood and evaluated predictors of attempts to stop smoking in the previous five years. The category "quit attempt" included two groups: those who had stopped smoking but started again within six months or fewer, and those who abstained for more than six months. The study participants, females and males in grades 6 through 12 in a midwestern county school system, were first surveyed during a three-year period (1980-1983) and again for follow-up periods in 1987 and 1994. The study assessed changes in smoking status as of 1994 among participants who were smokers in 1987. The primary focus was on cognitive factors (e.g., confidence, health beliefs and values, and motivations for smoking) and personal characteristics (e.g., demographics, f status and education, employment status, social role, and negative affect).

In analyses based on the combined data for females and males, Rose and colleagues (1996) determined that smokers who reported an attempt to stop smoking were more likely to be women, to be married, to have more social roles, and to use smoking to control negative affect. Smokers who reported an attempt to stop smoking also gave higher ratings to the value of health and the perceived likelihood of not smoking in one year than did those who had made no attempt to stop smoking. Female smokers with lower sensory motivation (e.g., less enjoyment in handling a cigarette) were more likely to have attempted to stop smoking, whereas the opposite was true among male smokers. The view that smoking has a negative effect on personal health was related to attempts to stop smoking among heavy smokers but not among light smokers.

Although females were more likely than males to attempt to stop smoking, no gender-specific differences were observed in the success of these attempts (Rose et al. 1996). Because study participants were of childbearing age, pregnancy may have increased the number of attempts among women to stop smoking. The number of cigarettes smoked daily did not affect attempts to stop smoking when other factors were controlled for, but it did affect the success of these attempts. In general, both females and males who attempt to stop smoking may be cognitively more ready to stop (i.e., have higher perceived likelihood of not smoking and higher perceived value of health) than do smokers who do not attempt to stop (Rose et al. 1996). These findings are difficult to generalize, however, because the study population was relatively well educated, white, young, and from the Midwest. In addition, some potentially relevant predictors among women (e.g., motives to control weight and spousal support) were not assessed.

Smoking Cessation

Because all 13 studies in this overview (Table 4.2) investigated predictors of smoking cessation, considering smoking cessation among young persons, pregnant women, young and middle-aged adults, and older adults separately is possible.

Advertising

The considerable resources devoted to advertising and promotion are placed in the service of techniques with extraordinary power to sell products. Advertising builds a brand's image (Kotler 1991; Mark and Silverman 1992; Bissell 1994), raises the salience of a brand, and conditions consumers to form the attitudes needed to purchase the product (Percy and Rossiter 1992). Attitudes include a cognitive or logical component (e.g., beliefs about benefit) and an affective component (e.g., emotions that energize behavior) (Percy and Rossiter 1992). Consumers often buy products because of the psychological and social meaning the products represent to them (Kindra et al. 1994). Advertising of cigarette brands uses specific themes to suggest distinctive identities (Chapman and Fitzgerald 1982). A classic example is the Marlboro man, who projects a sense of adventure, freedom, and being in charge of his own destiny (Trachtenberg 1987). Smokers and potential smokers may identify with the projected images and purchase the brand as a surrogate for adopting the portrayed behavior (Solomon 1983; Botvin et al. 1993). Brand images may pose solutions to identity problems and appeal to persons who are socially insecure (Chapman and Fitzgerald 1982; Trachtenberg 1987). The theme of a cigarette advertisement (e.g., adventure, glamour, and independence) evokes an enhanced self-image (Solomon 1983), and consumers may feel they are purchasing enhancement along with the product. Typically, the ads use attractive, youthful models and portray smoking in socially pleasing circumstances and surroundings. Repeated exposure to such ads may have a strong influence on the brand selection of consumers who identify with the lifestyles and images used (Bearden and Etzel 1982). For some consumers, cigarette smoking may actually contribute to their structuring of social reality, selfconcept, and behavior (Solomon 1983).

Advertising is also used to reduce fear of the health risks from smoking (Botvin et al. 1993) by presenting facts and figures (e.g., information on nicotine and tar content) or by using positive imagery (e.g., clear blue skies and white-capped mountain peaks). For example, many modern ads have shown models engaged in exercise (Pollay and Lavack 1993). In addition, advertising is used to encourage brand loyalty by reinforcing preferences rather than encouraging brand switching (Raj 1985; Tellis 1988). Image reinforcement attracts repeat purchasers. In one market research study, Marlboro customers were offered half-priced Marlboro cigarettes packaged in generic brown boxes; only 21 percent of customers were attracted to the offer (Trachtenberg 1987)

Promotions

An effective marketing strategy uses both advertising and promotions. Promotions are typically used to convince people to try a product, to increase purchase volume, to encourage brand switching, to win customer loyalty, and to enhance corporate image (Gagnon and Osterhaus 1985; Warner et al. 1986; Levin 1988; Tellis 1988; Kotler 1991; Mark and Silverman 1992; Zinn 1994). Retail value-added promotions stimulate short-term sales (Kotler 1991). Because women and youth are sensitive to low prices, reduced prices may be an especially effective tool for reaching them (Lynch and Bonnie 1994; Townsend et al. 1994; Chaloupka and Warner 1999). Promotional allowances paid to retailers help to ensure prominent placement of a product in high-volume areas or near products such as candy or liquor (Kotler 1991; Lynch and Bonnie 1994).

Point-of-sale promotions influence consumers when they are making purchase decisions and, thus, also build support among retailers (Gagnon and Osterhaus 1985; Lynch and Bonnie 1994). Such promotions allow targeted marketing, are easy to evaluate with sales data, and are relatively inexpensive (Gagnon and Osterhaus 1985). Women are an especially lucrative target for promotions because they make about 80 percent of the purchase decisions in the marketplace (E. Janice Leeming, Executive Director, Marketing to Women, letter to Sharon Dean, Corporate Fact Finders, April 12, 1993).

Specialty items that contain brand names or logos, such as clothing and accessories, often serve as walking ads and enhance the perception that tobacco use is the norm (Lynch and Bonnie 1994). For cigarettes, these items do not carry the health warning required for other forms of advertising and promotion (Slade et al. 1995). Coupon redemption helps to create databases of millions of smokers for further promotions (Lynch and Bonnie 1994; Zinn 1994), and these databases also provide demographic information for marketing and for encouraging smokers to become politically involved in issues related to tobacco policy.

Tobacco companies have also used innovative promotional campaigns by offering discounts on common household items unrelated to tobacco. For example, Philip Morris has offered discounts on turkeys, milk, soft drinks, and washer detergent with the purchase of tobacco products (Slade 1994). If tighter restrictions on tobacco advertising and promotion were implemented, more of this type of marketing may occur. Consumer products that women are more likely than men to purchase will be prime candidates for such an approach to product promotion.

Sponsorship

Brand or corporate sponsorship of public entertainment, sporting events, or organizations that promote specific causes provides multiple benefits to the corporations. Sponsors spend money to achieve commercial objectives; sponsorship is economical because it allows a company to reach a niche market without wasting resources and provides "embedded advertising," which links product attributes or lifestyle images to an active event (IEG 1995a, p. 5). Sponsorship also promotes audience loyalty. For example, for the cost of a 30-second spot during a Super Bowl broadcast, a company can sponsor a team in the NASCAR Winston Cup series and receive more than 30 hours of television coverage. Companies also use sponsorship to drive sales, through discounted tickets and point-of-purchase display ads (IEG 1995a).

Sponsorship associates a brand with prestigious events and may make the brand appear more credible than its competitors (Kotler 1991; IEG 1995a). Tobacco industry sponsorship may also lend an aura of social legitimacy to smoking, create gratitude from the recipient institutions, gain allies, or encourage neutrality toward industry activities and thereby soften public criticism of the industry (Elkind 1985; Ernster 1986; Levin 1988; Williams 1991).

Product Packaging

The packaging of a brand of cigarettes, including name, logo, and colors, presents an image that cues attitudes toward the brand and affects its attractiveness (Britt 1978; Beede and Lawson 1992; Health Canada 1995). When repeated in advertising copy, the attributes of the brand become familiar stimuli that enhance recall and retention (Beede and Lawson 1992). Brand images may be used to attract women and men or to counteract negative stereotypes, such as the idea that smoking is inappropriate for women (Elkind 1985). These images may be particularly important among young female smokers. Brand is an important component of consumer decisions among children (Ward et al. 1977), and minors can successfully recall tobacco brand images and slogans (USDHHS 1994). Cigarette advertising may have predisposing and reinforcing effects among children (Aitken et al. 1991).

Tobacco is the ultimate "badge product" (Bissell 1994, p. 16) for tobacco marketing generally and for product packaging specifically. For product packaging, it is a badge product because it is used frequently, is displayed in social settings, and shows its package design and brand every time it is used (Trachtenberg 1987; Bissell 1994; Pollay 1994). Color, design, and shape symbolically convey the image of the brand. Because visual image alone often stimulates the purchase of a brand (Percy and Rossiter 1992), consumer recall of the brand name at the time of purchase is not necessary.

Packaging influences the attitude of a consumer toward a product and the choice of a brand (Opatow 1984; Gordon et al. 1994). Graphics and color convey nonverbal messages. For example, blue and white signify cleanliness and purity and are frequently used for health products (Opatow 1984). Light blue signifies calm and coolness. Red connotes excitement, passion, strength, wealth, and power (Gordon et al. 1994; Kindra et al. 1994) and is frequently used for male-oriented products. Red is a popular color for tobacco packaging because it demonstrably aids recall of the product (Beede and Lawson 1992; Health Canada 1995). Green suggests coolness, restfulness, nature, cleanliness, and youthfulness. Pastels are associated with femininity: light purple suggests freshness, springtime, and flowers; pink suggests innocence and relaxation; and light yellow suggests freshness and intelligence (Gordon et al. 1994; Kindra et al. 1994).

In recent years, internal tobacco industry documents have become available and are easily retrievable from various Web sites. A good inventory of tobacco industry Web sites is available through the CDC's Office on Smoking and Health Web site at http://www.cdc.gov/tobacco. A few examples from tobacco industry documents are provided below to illustrate how the tobacco companies have viewed women. These excerpts were obtained from the report "Big Tobacco and Women," available at the following Web site: http://www.ash.org.uk.

An RJR document titled "Women's Response to Advertising Imagery" noted: "With the exceptions of career women and single women who work to support themselves, all female segments in the present study reacted positively to advertising imagery associated with the following dimensions: intimacy and closeness, tenderness and gentleness, loving, caring, and sharing."

An RJR document from 1983, summarizing focus groups held with women, noted: "There is greater agreement as to how and why women began smoking in the first place. Beyond the easily recognized pressure of peers, women smoke to indicate passage into adulthood and as part of this transitional period, to exhibit anti-authoritarian behavior."

The internal tobacco industry documents also contain evidence that children were explicitly targeted with promotional campaigns. For example, a handwritten letter from a parent sent to RJR in 1981 noted: "Dear Sirs, You are sending Christmas Cards and Coupons to encourage my 15-year-old daughter to smoke. Please remove my daughter from your mailing list."

In a 1981 report titled "Social Trends Among Female Smokers," British American Tobacco commented on women's attitudes toward smoking: "(1) concern about smoking too much, (2) actively looking for new brands of cigarettes to smoke, (3) believe there should be different cigarettes for men and women, (4) report using, at least occasionally, cigarettes for enjoyment, (5) acceptable if used moderately, cigarettes for enjoyment, (6) low tar and nicotine cigarette represent a major step in the direction of making smoking less harmful to the health" (http://www.ash.org.uk).

Making Cigarettes Glamorous

The best known advertising campaign of the American Tobacco Company urged women to "Reach for a Lucky Instead of a Sweet" (Wagner 1929, p. 344; Wallace 1929; Journal of the American Medical Association [JAMA] 1930) (Figure 4.4). Once the association of smoking with slimness was well established, the ads counseled women to "avoid that future shadow" and featured silhouettes of women with large double chins or fat ankles behind images of svelte young women (JAMA 1930; Tyler 1964, p. 100) (Figure 4.4). This positioning of Lucky Strike as an aid to weight control led to a 312-percent increase in sales for this brand in the very first year of the advertising campaign, despite the protests of sugar and candy interests (Gunther 1960).

Figure

Figure 4.4. The best known advertising campaign of the American Tobacco Company appealed to the desire of women to be slim, as shown by 1920s and 1930s Lucky Strike ads. Source: Tobacco Industry Promotion Series, History of Advertising Archives, Faculty (more...)

During this time, Bernays (1965) pursued the emphasis on slimness for the American Tobacco Company by "flooding fashion editors with photographs of thin Parisian models in haute couture dresses" (Bernays 1965, p. 383). After research showed the green Lucky Strike package was unpopular with some women because it clashed with clothing, Bernays worked with clothing manufacturers, department stores, magazine fashion editors, and interior decorators and sent out press releases describing the psychological benefits of the color green as "the color of spring, an emblem of hope, victory (over depression) and plenty" (Bernays 1965, p. 390).

In the late 1930s, testimonials claiming benefits of cigarettes to the throat were reinstated. Ads describing Lucky Strike cigarettes as a light, gentle smoke that offered "throat protection" included testimonials from "leading artists of radio, stage, screen and opera, whose voices are their fortune" (Pollay 1993, p. 5), including Miriam Hopkins, Carole Lombard, Joan Crawford, Myrna Loy, Dolores Del Rio, and Claudette Colbert. By 1940 and continuing through the years of World War II, Chesterfield ads regularly featured glamour photographs of a Chesterfield girl of the month, primarily from the world of fashion models and Hollywood starlets. Some endorsers were famous stars, including Rita Hayworth, Rosalind Russell, and Betty Grable (Pollay 1993). From 1943 through 1946, ads for the Regent brand of cigarettes featured drawings of celebrities, including Diana Barrymore, Joan Blondell, Jinx Falkenberg, Merle Oberon, Jane Wyatt, Arlene Francis, Celeste Holm, and June Havoc (Pollay 1993). The trend continued after World War II, with Chesterfield endorsements from women show business celebrities, such as Jo Stafford, Ann Sheridan, Virginia Mayo, Ethel Merman, and Dorothy Lamour (Pollay 1993). In 1946, one of the now famous "More doctors smoke Camels…" ads featured a female physician, who is identified as the 1946 version of the "Lady with a Lamp" (Figure 4.5). In the early 1950s, Camel cigarettes, too, were endorsed by celebrities, including opera star Nadine O'Connor and movie star Joan Crawford, in ads claiming "Not one single case of throat irritation due to smoking Camels" (Starch 1951; Starch 1953, p. 73).

Figure

Figure 4.5. A 1946 Camel ad featured a female physician-one of the testimonials claiming benefits of cigarettes and the throat. Source: Life 1946.

Recognition of Power of Advertising

The trade presses of both the advertising and tobacco industries were unequivocal in giving credit to advertising for the growth of cigarette sales, especially among women. "The growth of cigarette consumption has, itself, been due largely to heavy advertising expenditure…. It would be hard to find an industry that better illustrates the economic value of advertising in increasing consumption of a commodity" (Weld 1937, p. 70). Advertising was viewed not only as a vehicle for increased sales, but also "as an educator of public opinion…. The cigarette companies were instrumental in destroying the fetters of an outmoded convention [against women smoking'…. The advertising appropriations of the cigarette companies have been truly large and truly productive…." (Tobacco Retailers' Almanac 1938, p. 18).

Fueled by past successes in encouraging ever more women to take up cigarette smoking, industry insiders remained confident that the post-World War II period offered even more untapped potential. "Women can be converted and there are a lot of them- particularly through the Middle and Far Western States-that have not had that comforting experience of smoking a cigarette" (Dunhill 1949, p. 32). Responding to a survey, cigarette industry leaders agreed that "a massive potential market still exists among women and young adults" and acknowledged that recruitment of these millions of prospective smokers was "the major objective for the immediate future and on a long-term basis as well" (United States Tobacco Journal 1950, p. 3). Even after the health scare that started in December 1952 with the publication in Reader's Digest of a brief article entitled "Cancer by the Carton" (Reader's Digest 1952), optimism about recruiting female nonsmokers was publicly expressed. In 1953, an article in the United States Tobacco Journal (1953) claimed that "more than three-fifths of the nation's women comprise a potential new market for the cigarette industry" (United States Tobacco Journal 1953, p. 3). This estimate was based on a survey of 16 cities where only "40.53 percent of the women in these markets now smoke cigarettes" (United States Tobacco Journal 1953, p. 3).

Links of Fashion to Advertising

Fashion was prominent in cigarette advertising during the 1950s. R.J. Reynolds' "elegant swashbuckling" Cavalier (Tide 1950, p. 53), a brand and trade character, was used for many fashion tie-ins in 1950. The Cavalier lapel pin was acquired by thousands of women, and adaptations of his hat and shoes were sold in women's clothing stores. Cavalier was also connected with a new women's raincoat, a housecoat, a fall suit, and a sleeve cuff. Amilliner sold a Cavalier hat in 24 colors and gave buyers free packs of Cavalier cigarettes. Sample packs of cigarettes had long been distributed to hotel fashion shows, women's society meetings, bridge clubs, airlines, secretarial schools, and companies with employee lounges (Tide 1950).

Ads for the Parliament brand were "drenched in fashion appeal," by using "a haut [sic] monde tone" (Printers'Ink 1955, p. 87). Another ad, showing a woman wearing gloves and placing L&M cigarettes in her purse, declared, "Just Where You'd Expect to Find L&M" (Gerry 1956, p. 23). Lorillard developed nationwide promotional campaigns that linked the company's Kent and Newport brands with such fashion magazines as Vogue and Mademoiselle, department stores, specialty stores, and several prominent fashion houses. Six dresses were designed exclusively for the Kent brand. Meanwhile, Newport's "Refreshing Change" promotional drive featured chemise dresses, sportswear, and swimsuits created by a range of designers to appeal to young women (United States Tobacco Journal 1958, p. 20). In announcing these campaigns, Lorillard's vice president and director of advertising commented, "It will enable us to reach the fashion pace-setters in many important communities, and psychologically, we think our use of this special avenue for women's attention-an indirect sell-will be appreciated by the more fashion-conscious sex" (United States Tobacco Journal 1958, p. 20). In addition, 200 of the department stores involved in this promotion used point-of-sale merchandising to promote Kent and Newport cigarettes (Printers'Ink 1958). Also targeting fashion-conscious women, Liggett & Myers developed designer packaging for king-sized Lark, L&M, and Chesterfield (Advertising Age 1968b). Even some ads having a health protection theme used fashion variants, such as Pall Mall's 1952 "Guard Against Throat-Scratch" ad featuring a fashionable woman (Figure 4.6).

Figure

Figure 4.6. In a 1952 ad, Pall Mall used the image of a fashionable woman as part of a health protection theme. Source: Life 1952.

In the early 1950s, the Chicago Tribune hired the firm Social Research, Inc. to study the habits and attitudes of cigarette purchasers. The findings indicated that people had brand preferences even though they could not differentiate among cigarettes when they were blindfolded. Participants believed that each brand had certain qualities and that some brands were more or less appropriate for either men or women. In particular, the novel king-sized and cork- and filter-tipped brands were considered feminine at that time. A motivation researcher in the 1950s described smoking as an expression of freedom and worldliness among women, an idea he believed could be exploited and reinforced by advertising (Martineau 1957).

James Bowling of Philip Morris USA (subsidiary of Philip Morris Companies, Inc.) commented, "The ladies have led every major cigarette trend in the past 15 years…. Our studies show that they were the first to embrace king-sized cigarettes, menthol, charcoal, and recessed filters" (Sanchagrin 1968, p. 26). By 1953, the wave of new product introductions for king-sized and filter-tipped versions of both traditional and new brands had begun, and women smokers accepted the "new and improved" products (Advertising Age 1953). Sellers of traditional brands also continued to target their advertising to women.

Influence of Tobacco Marketing on Smoking Initiation Among Females

This section reviews the evidence linking tobacco marketing to smoking initiation. Because not all studies have focused on females, this topic is reviewed rather broadly here, including tobacco marketing that specifically targeted girls and women and marketing that was not necessarily gender specific. When comparisons between females and males are available, they are reported.

As described earlier in this chapter, the tobacco industry changed its marketing strategy over the years to build and maintain its customer base. Marketing efforts were directed particularly to women in the 1920s and 1930s and again in the late 1960s, when niche brands were introduced. In this section, temporal trends in smoking initiation among females, compared with trends among males, are examined with respect to marketing campaigns. (For in-depth discussion of trends among females, see "Trends in Current Smoking Among Women" in Chapter 2.) The focus is on adolescents and young adults, because most people begin smoking before they reach mature adulthood (USDHHS 1994).

The earliest nationally representative U.S. data on smoking initiation were from the 1955 Current Population Survey (Haenszel et al. 1956). In this survey, respondents were asked about smoking history, and those who had ever smoked were asked the age at which they started to smoke regularly (Haenszel et al. 1956). Very few females born between 1890 and 1899 had ever smoked (Figure 4.7). Only 7.5 percent of the females in the cohort born in 1900-1909 had started to smoke regularly by age 21 years, and 14.9 percent had by age 30 years-the midpoint age of that cohort when the tobacco industry campaign to recruit female smokers was in full swing. However, 19.6 percent of the females in the cohort born in 1910-1919, who were teenagers during at least the early part of the campaign, began smoking by age 21 years. By comparison, 51.2 percent of males in the cohort born in 1900-1909 started smoking by age 21 years, and 61.3 percent of them had begun by age 30 years. Aslight increase was noted in the proportion of males who smoked by age 21 (to 56.9 percent) for the cohort born in 1910-1919.

Figure

Figure 4.7. Cumulative percentage of females who had become regular smokers, by birth cohort. Source: Haenszel et al. 1956.

Data collected as part of the National Health Interview Survey beginning in 1970 presented a similar picture. In each of six surveys (1970, 1978, 1979, 1980, 1987, and 1988), respondents who had ever smoked were asked the age at which they started to smoke regularly. Data for adults aged 20 years or older were combined to analyze smoking initiation patterns over time among females and males at ages 14 through 17, 18 through 21, and 22 through 25 years for the periods 1910-1925 and 1926-1939 (Pierce and Gilpin 1995). Smoking initiation among women aged 18 through 25 years began to increase significantly in the mid-1920s, the same time that the tobacco industry mounted the Chesterfield and Lucky Strike campaigns directed at females. The trend was most striking among women aged 18 through 21 years; smoking initiation increased from 0.5 percent in 1910-1911 to more than 1.5 percent in 1924-1925, and reached nearly 5 percent in 1938-1939. Among women aged 22 through 25 years, smoking initiation was near zero in 1910-1911, then increased to about 0.5 percent in 1924-1925 and to 1.8 percent in 1938-1939. Among girls aged 14 through 17 years, smoking initiation was low in 1910-1925 (<1 percent), increased after 1925, and reached about 2.5 percent by 1938-1939. It is unlikely that smoking initiation among females would have increased during that time had the tobacco industry not stimulated the demand. The two brands of cigarettes most heavily pitched to women during the campaign were Lucky Strike and Chesterfield. The Lucky Strike campaign of the mid-1920s that encouraged women to "Reach for a Lucky Instead of a Sweet" resulted in a dramatic increase in sales; Lucky Strike went from being the third-ranked brand in 1925, with sales of 13.7 billion cigarettes, to the first-ranked brand in 1930, with sales of more than 40 billion (Pierce and Gilpin 1995).

Patterns of smoking initiation from the postWorld War II period through the mid-1980s were examined in relation to the introduction of brands targeted primarily to females (Pierce et al. 1994). The results indicated that incidence of smoking initiation among girls aged 17 years or younger was stable or declined slightly from the mid-1950s through the mid-1960s. After 1967, initiation of smoking among girls climbed dramatically, especially for girls aged 14 through 17 years, although increases were apparent even for girls as young as 11 years old. This upward trend in smoking initiation among adolescent girls continued until the mid-1970s. The increases from 1967 to the peak observed in the 1970s were approximately 110 percent for age 12 years, 55 percent for age 13 years, 70 percent for age 14 years, 75 percent for age 15 years, 55 percent for age 16 years, and 35 percent for age 17 years. Initiation rates among girls aged 14 through 17 years rapidly increased in parallel with the combined sales of the leading women's niche brands during this period (Virginia Slims, Silva Thins, and Eve) (Figure 4.8) (see text box "Virginia Slims: A Case Study in Marketing Success"). In contrast, smoking initiation among men aged 18 through 20 years declined abruptly after World War II, plateaued during the 1950s and early 1960s, then fell sharply. Among boys 16 and 17 years of age, initiation of smoking showed a steady downward trend throughout the study period, and for those 15 years of age or younger, it either decreased slightly or remained fairly constant.

Figure

Figure 4.8. Smoking initiation rates for 14- to 17-year-old girls, 1966-1979, and expenditures for three cigarette brands targeted to women, 1967-1978 . Sources: Pierce et al. 1994; Pierce and Gilpin 1995.

Virginia Slims: A Case Study in Marketing Success

In the late 1960s, after more than a decade of substantial success with repositioning Marlboro as a masculine brand, Philip Morris decided to appeal to women through a new brand of cigarettes. Spurning strategies based on traditional feminine imagery, the tobacco company launched advertising for Virginia Slims in 1968, touting the 100-mm "slimmer than the usual" cigarette with the slogan "You've come a long way, baby" (Advertising Age 1968a, p. 33; Advertising Age 1968c, p. 2) (Figure 4.9). This advertising strategy showed canny insight into the importance of the emerging women's movement and enlisted several themes of that movement in its approach. The success of Virginia Slims and its advertising relative to competitive products and their advertising demonstrated the importance of image-based advertising in establishing an attitude and persona for the brand. It also made clear the greater appeal of ads that suggest attitudes of independence over those that emphasize frilly fashion-ability. The switch in the mid-1990s to the slogan "It's a woman thing" in ads for Virginia Slims cigarettes is a logical marketing response to the evolution of the women's movement-a theme the brand has always attempted to use to its advantage (Figure 4.9). In 1999, Philip Morris launched the Virginia Slims "Find Your Voice" campaign featuring women of diverse racial and ethnic backgrounds, including African Americans, Asians, Hispanics, and whites (Figure 4.10). The appearance of the models in the advertisements and the accompanying copy suggested that women in different ethnic and cultural groups have unique needs for self-expression, and the ads' slogan attempted to associate the Virginia Slims brand with fulfilling such needs: "Virginia Slims/ Find Your Voice."

Underlying the initial advertising campaign to launch the brand was the finding of motivation research that "cigarettes are either masculine r feminine but never successfully neuter" (Weinstein 1970, p. 4). After toying with several combinations of names and product variations, the advertisers focused on variants of "Virginia," because it was the home state of Philip Morris, the name of the marketing director's wife, and a "great name for a cigarette with a feminine personality. It not only has traditional tobacco overtones, but it romantically suggests moonlight, gentle breezes, and green hills" (Weinstein 1970, p. 4). The creation of brand personality would be achieved by using aspects of style, tone, music, and visuals, rather than information, because the advertising team believed that "in cigarette advertising… 90 percent of what you communicate is non-verbal" (Weinstein 1970, p. 13). This task, pursued by a staff that was initially all male, was described as "15 Guys in Search of a Feminine Identity" (Weinstein 1970, p. 1).

The advertising agency sought to capitalize on the product's distinctive thinness, which provided "visual intrigue," "tactile distinctiveness," and "style and grace" (Weinstein 1970, p. 2). The team also believed that the success of the pioneering king-sized Pall Mall cigarettes was due in part to how it flattered women-that is, "the extra length made their noses look shorter. Maybe this thin cigarette similarly could be liked because it makes your hand look slimmer and more graceful" (Weinstein 1970, p. 2).

However, the team rejected an overtly cosmetic appeal, such as a gold package or naming the product Vanity or Tiffany and promoting it in Vogue, for fear that this approach would make the brand a novelty product and appeal to too few women. They finally settled on a "fun personality for the brand- a lively, sparkly, happy cigarette" (Weinstein 1970, p. 13). They described the brand as "The first cigarette for women only,… designed slimmer for a woman's slimmer hands and lips; designed with the kind of flavor women like; and packaged in a slim purse pack" (Weinstein 1970, p. 7).

The advertising team created the concept of exploiting the issue of women's rights, which had reemerged in the late 1960s. They used the slogan "You've come a long way, baby" and ran copy that contrasted women's historical lack of rights with the modern situation in which women could have everything, even "a cigarette brand for [their] very own" (Weinstein 1970, p. 16). "Congratulations on your success" (Weinstein 1970, p. 20). The year that Virginia Slims was launched, its advertising was carried on 9 network television programs, on local television and radio, and in 16 women's publications and Sunday supplements (Sanchagrin 1968). Television programs that carried Virginia Slims ads included Mission: Impossible, Family Affair, Hogan's Heroes, Mayberry R.F.D., The Red Skelton Show, Green Acres, Thursday and Friday night movies, and the CBS Evening News. Print ads to launch Virginia Slims appeared in American Home, Cosmopolitan, Ebony, Family Circle, Glamour, Harper's Bazaar, Ladies' Home Journal, Life, Look, Mademoiselle, McCall's, the True Story group, TV Guide, Woman's Day, Vogue, and Women's Wear Daily (Advertising Age 1968c).

The Virginia Slims campaign was very successful (Advertising Age 1970), and its slogan may have resonated with the rhetoric of the burgeoning women's movement of the late 1960s. However, one advertising trade column described the campaign as featuring a "rebellious but unliberated woman"(Advertising Age 1973, p. N8), and the inclusion of the word "baby" in the slogan resulted in some criticism from feminists (Kluger 1996). For more than two decades, ads in the campaign showed variations on the theme of a strikingly dressed, contemporary woman contrasted with unappealing background images of women in the past. But rarely, if ever, were the contemporary women portrayed as carrying out responsibilities; they were portrayed merely as very slim models wearing trendy styles. The ads mocked the older generation's experience, attitudes, and behavioral constraints, in part by contrasting new fashions with the old fashioned. Advertising agency personnel later explained that the agency wanted to avoid "the obvious trap of being too feminine" (Advertising Age 1968d, p. 2), but fashion was an important element in this campaign. In fact, Philip Morris placed an ad in Women's Wear Daily to thank the fashion trade for providing designs for its 1973 Virginia Slims campaign. The list of contributors included top designers Bill Blass, Pierre Cardin, and Halston (Advertising Age 1974a).

After January 2, 1971, when cigarette advertising was no longer permitted on broadcast media, the volume of advertising in women's magazines increased dramatically-threefold to fourfold from the first quarter of 1970 through 1971. For example, the number of pages devoted to cigarette advertising rose from 5 to 22 pages per quarter in Ladies' Home Journal, from 7 to 21 pages in Redbook, from 5 to 19 pages in Woman's Day, from 6 to 24 pages in Cosmopolitan, and from 7 to 21 pages in Family Circle (Revett 1971). This intensity of advertising in women's magazines continued into the 1980s. Regular readers of Glamour, House & Garden, Ladies' Home Journal, Mademoiselle, McCall's, Metropolitan Home, Vogue, and Woman's Day were exposed to about 100 cigarette ads annually in each magazine (Whelan 1984). Readers of Better Homes and Gardens, Cosmopolitan, Family Circle, and Redbook were exposed to 200 cigarette ads annually in each magazine, and reading Newsweek, People, TV Guide, or Time meant exposure to more than 400 ads per year. In 1974, Virginia Slims alone was supported by $8.3 million in advertising in magazines, newspapers, and Sunday supplements (Advertising Age 1974b).

Virginia Slims ran an award-winning premium promotion in 1977-the Ginny Jogger jogging suit. Persons who wanted to obtain the outfit were required to submit cash receipts and proof of Virginia Slims purchase (Robinson 1979). Some 30,000 sweat suits were distributed, 50 percent more than expected. In the mid-1970s, about 400,000 additional items were distributed, including 200,000 T-shirts bearing the slogan "You've come a long way, baby," 110,000 jerseys, and 70,000 sweaters. By the mid-1980s, the mix of promotional items had changed. The items were more likely to contrast the "then-and-now" choices of women and to highlight the availability of previously all-male goods (e.g., a little black book for telephone numbers, jogging suits, rugby shirts, and boxing shorts). A promotional history was introduced, the Book of Days, a hardbound appointment calendar noting dates in history, including the date when Virginia Slims were launched in 1968; historical anecdotes; and sexist quotations. It was reported that one million books were printed annually (Robinson 1985).

Virginia Slims started sponsoring women's professional tennis in 1970, and a full season of tournaments was played in 1971. That year, events were held in 20 cities and featured eight professionals, including Billie Jean King and Rosemary Casals (Brinkman 1976). Free samples of Virginia Slims were given away at stadium entrances (Ernster 1985), and contract players were not allowed to take public positions against cigarette sponsorship (Brinkman 1976). The brand's public relations firm developed a program for reaching the media with "stories and angles of interest that extended far beyond match results and sports pages…. The Virginia Slims media guide, published annually… became the encyclopedia of women's tennis" (Harris 1991, p. 208). Media luncheons were held at the start of the season in New York and before each event in every tournament city, where charity tie-ins created more publicity. Although cigarette advertising was banned from television, the Virginia Slims Tournament was covered by the networks (Harris 1991). A Philip Morris marketing vice president explained, "Virginia Slims gets worldwide publicity and an opportunity to sample adult audiences and to spin off retail promotions" (Harris 1991, p. 209). The company also gained grateful allies: in 1990, when the U.S. Secretary of Health and Human Services, Louis Sullivan, M.D., called for an end to sports sponsorships by cigarette firms, Zina Garrison and Billie Jean King supported the industry in press interviews (Harris 1991). In 1995-1996, Philip Morris ended its $5 million annual sponsorship of the Virginia Slims professional women's tennis tour, replacing it with the annual Virginia Slims Legends Tour, at a cost of approximately $3 million. This six-stop event combined a tournament of former tennis greats (e.g., Billie Jean King, Chris Evert, and Martina Navratilova) and a concert featuring prominent female singers (e.g., Barbara Mandrell and Gladys Knight). The stated intention of the new tour was to reach older women (IEG 1995b).

Figure 4.9. Philip Morris launched advertising of Virginia Slims in 1968 with the slogan "You've come a long way, baby" and switched in the 1990s to "It's a woman thing"

Sources: From top to bottom: Playboy 1971; Time 1978; Glamour 1999.

Figure 4.10. Ads from the multicultural "Find Your Voice" campaign

Sources: From top to bottom: Glamour 2000b; Ladies' Home Journal 2000a;Glamour 2000a.

By the early 1980s, smoking initiation among both male and female adolescents aged 14 through 17 years was decreasing significantly (Gilpin and Pierce 1997). This downward trend was also observed among young adults aged 18 through 21 years. Although the decline in initiation of smoking continued among young adults, a parallel decline was not observed among adolescents aged 14 through 17 years. Smoking initiation among adolescents decreased from 5.4 percent in 1980 to 4.7 percent in 1984, then increased to 5.5 percent in 1989, possibly reflecting increased tobacco marketing expenditures between 1984 and 1989 CDC 1995). The incidence of smoking initiation and the prevalence of smoking among adolescents continued to increase during a time of increased expenditures on new marketing strategies for promoting tobacco use. The prevalence of current smoking among female high school seniors increased from 25.8 percent in 1992 to 32.4 percent in 1996. The proportional increase among boys was similar (Johnston et al. 1996; University of Michigan 1996). This period includes the observed peak (1993) of advertising and promotion by the tobacco industry. (See Table 2.9 in Chapter 2 for prevalence rates of smoking among high school seniors, 1976-2000.)

The Joe Camel character debuted in January 1988, before the marked rise in the initiation of smoking among adolescents that occurred in 1993. The Teenage Attitudes and Practices Surveys indicated that brand preference for Camel increased from 8.1 percent in 1989 to 13.3 percent in 1993 (CDC 1994). Among adolescents who purchased their own cigarettes in 1993, 10.3 percent of girls and 16.1 percent of boys bought Camel cigarettes. During the same period, Marlboro cigarettes decreased in popularity (from 68.7 to 60.0 percent) but nonetheless continued to be the market share leader among adolescents; nearly the same percentages of girls and boys bought Marlboro (60.7 and 59.2 percent, respectively). It is possible that the Joe Camel campaign affected the popularity of Marlboro.

The trends in smoking initiation among adolescents suggested a relationship between tobacco marketing campaigns and smoking initiation but were not direct proof of cause and effect. One Australian survey of 5,686 schoolchildren aged 10 through 12 years used a "semantic differential" measure of approval or disapproval of cigarette advertising in general (Alexander et al. 1983). Children who approved of cigarette ads were more than twice as likely to adopt smoking at a follow-up of 12 months. In another Australian study of 2,366 children and adolescents (modal age, 12 years), respondents were asked whether cigarette ads made them think that they would like to smoke a cigarette (Armstrong et al. 1990). Youth indicating that the ad had some influence on them were about three times as likely to use cigarettes at the 2-year follow-up as were those who indicated that the ad had no influence. The magnitude of the effect was nearly the same among girls and boys and about the same as having a sibling of the same sex who smoked.

A study conducted in schools in England and Wales in 1986-1988 among 3,694 children aged 11 through 15 years sought detailed information on recall of common cigarette ads in magazines (Goddard 1990). Students were shown ads without any print identifying the brand and were asked to rate them as beautiful, quite nice, not very nice, or disgusting. Scores were constructed for recognition (number correct) and for liking (number called beautiful or quite nice). Although girls generally scored lower than boys on both measures, baseline scores were significantly higher among girls who smoked at the time of follow-up than among girls who did not; this difference was not apparent among boys.

In another British study, 2,338 boys and girls aged 12 and 13 years who had never smoked were surveyed and then surveyed again four months later, with similar results (Charlton and Blair 1989). The participants were asked to name a cigarette brand and whether they had a favorite brand. For girls, being able to name a cigarette brand was among the four factors, of nine possible factors, significantly related to smoking during the period between the surveys; none of the factors was significant for boys. Another British study, a longitudinal study of 9- and 10-year-old children followed for several years, found that among girls, those aware of the most heavily advertised cigarette brands (Benson and Hedges, Silk Cut) were significantly more likely to start smoking than were those who named other brands (While et al. 1996). A longitudinal study of more than 1,000 Massachusetts youth found that exposure to brand-specific cigarette advertising in magazines was associated with later smoking initiation of these brands (Pucci and Siegel 1999). Among girls, the top seven brands were Marlboro, Camel, Newport, Winston, Capri, Virginia Slims, and Kool.

A number of other studies have investigated advertising awareness, self-image, and perceived attributes of smokers (USDHHS 1994). One of these studies showed that more than 90 percent of 6-year-olds tested in day-care settings in Atlanta and Augusta, Georgia, were able to match the Old Joe (Camel) logo to cigarettes, about the same percentage that could link Mickey Mouse to the Disney channel (Fischer et al. 1991). The tobacco industry attacked this study and funded research in Australia designed to replicate the study and to eliminate some of its alleged shortcomings (Mizerski 1995). Study results confirmed that, in Australia too, recognition of Old Joe was high and increased with age (72 percent of 6-year-olds). The study also assessed, in a matching exercise, the children's liking for products by having them point to a picture of a smiling or frowning face. Forty percent of 3-year-olds but fewer than 5 percent of 5-year-olds demonstrated a liking for cigarettes. The author concluded that, because a high level of recognition was not associated with positive affect, advertising did not encourage children to smoke. This study, however, like the others cited, was not designed to examine the association between early recognition of a cigarette brand logo and later initiation of smoking. Perhaps the more significant observation in all these studies was the high level of recognition of the Joe Camel icon and its association with cigarettes, even among young children.

Whatever children's view of smoking may be, as they approach the middle-school years, they become increasingly concerned with self-image, and messages contained in tobacco advertising and promotions likely play a role in changing their attitudes and behaviors (Arnett and Terhanian 1998; Feighery et al. 1998). Using data from the youth portion of the 1993 California Tobacco Survey, a study from California (Evans et al. 1995) identified an association between receptivity to tobacco marketing and susceptibility to smoking. (A separate longitudinal study identified susceptibility to smoking at baseline as being predictive of future cigarette use [Pierce et al. 1996]). Beside naming a favorite tobacco ad or believing in the benefits of smoking promoted by tobacco advertising, the index of receptivity to tobacco marketing in the California study included possession of a tobacco promotional item, such as a key chain, lighter, or T-shirt with a tobacco brand logo on it. The association between possession of a tobacco promotional item and susceptibility to smoking (Evans et al. 1995) was verified in two other cross-sectional studies, one that involved a national sample of adolescents (Altman et al. 1996) and one that included students in rural New England (Sargent et al. 1997).

Promotional items are typically obtained at the point of sale as a premium or from coupon redemption. However, many adolescents also obtain them as gifts from family or friends (Gilpin et al. 1997; Sargent et al. 1997). In 1993, a national study of U.S. girls and boys aged 12 through 17 years showed that 35 percent had collected tobacco coupons (e.g., Camel Cash and Marlboro Adventure Miles), had a promotional catalog, or owned a promotional item (Coeytaux et al. 1995). More than 1 in 10 of the girls and boys (10.6 percent) reported having owned at least one tobacco promotional item. Extrapolating to the entire population of U.S. girls and boys aged 12 through 17 years, the authors estimated that 7.4 million had participated in a tobacco promotional campaign. The amount of the tobacco marketing budget devoted to promotions of this sort, in contrast to traditional print advertising, has increased substantially since 1985 (Gilpin et al. 1997; Redmond 1999). The deviation from observed prevalence and prevalence predicted by a diffusion model of daily smoking among ninth graders nation-wide (based on a series of cross-sectional surveys) was correlated with the upswing in tobacco promotional expenditures (Redmond 1999).

A recent longitudinal study further demonstrated the relationship between tobacco promotional items and smoking initiation among youth. In 1996, youth who participated in the 1993 California Tobacco Survey were contacted again for a study funded by The Robert Wood Johnson Foundation. Among those who were not susceptible to smoking and who had never smoked in 1993, receptivity to tobacco marketing predicted those who became susceptible to smoking or who smoked by 1996 (Pierce et al. 1998). Receptivity to tobacco promotional items (having a promotional item or being willing to use one) carried 2.89 times the risk for progression toward smoking than did minimal receptivity. Receptivity to tobacco advertising (having a favorite tobacco ad, but not owning or being willing to use a promotional item) carried a 1.82 increased risk. Minimally receptive adolescents had no promotional items, would not be willing to use one, had no favorite cigarette ad, and could or would not name a brand as being the most advertised. No interaction of advertising receptivity with gender was observed, and the analysis adjusted for demographics, school performance, and parental and peer smoking. From this study, it was estimated that 34 percent of adolescent experimentation with cigarettes can be attributed to tobacco advertising and promotions. Another longitudinal study of 529 Massachusetts teens aged 12 through 15 years, interviewed in 1993 and again in 1997, produced very similar findings (Biener and Siegel 2000).

Restrictions on Brand Name Sponsorships

• Prohibits brand name sponsorship of concerts, events with a significant youth audience, and team sports (football, basketball, baseball, hockey, or soccer).
• Prohibits sponsorship of events where the paid participants or contestants are underage.
• Limits tobacco companies to one brand name sponsorship per year, after current contracts (in effect as of August 1, 1998) expire or after three years, whichever comes first.
• Provides a special exception to the prohibition of the sponsorship of concerts for the Brown & Williamson company by permitting it to sponsor either the GPC country music festival or the Kool jazz festival (formerly both were annual events). The agreement also permits the company to sponsor one other brand name event that was part of a contract in existence before August 1, 1998, for a period not to exceed three years.
• Allows corporate sponsorship of athletic, musical, cultural, artistic, or social events as long as the corporate name does not include the brand name of a domestic tobacco product.
• Bans the use of tobacco brand names in stadiums and arenas.
• Limits the duration and restricts the placement of advertising for sponsored events.

General Advertising and Marketing Restrictions

• Bans use of cartoon characters, but not human subjects (e.g., the Marlboro Man), in the advertising, promotion, packaging, or labeling of tobacco products, effective May 22, 1999.
• Bans payments to promote tobacco products in movies, television shows, theater productions or live performances, videos, and video games.
• Bans distribution and sale of nontobacco merchandise with brand name logos (e.g., caps, T-shirts, backpacks), effective July 1, 1999.
• Prohibits tobacco companies from authorizing third parties to use or advertise brand names.
• Requires tobacco companies to designate a contact in each state that will respond to Attorney General complaints of prohibited third-party activity.
• Exempts licensing agreements or contracts in existence as of July 1, 1998, but does not permit the licensing agreements or contracts to be extended.
• Bans future cigarette brands from being named after recognized nontobacco brand or trade names (e.g., Harley-Davidson, Yves Saint Laurent, Cartier) or nationally recognized sports teams, entertainment groups, or individual celebrities.

Restrictions on Outdoor Advertising

• Bans all transit and outdoor advertising (including billboards, signs, and placards larger than a poster) in arenas, stadiums, shopping malls, and video game arcades. Poster-sized signs and placards can be placed in arenas, stadiums, shopping malls, and video game arcades, but must conform to the overall agreement regarding the targeting of advertising to children.
• Requires tobacco billboards and transit ads to be removed by April 22, 1999.
• Allows states to substitute, at industry expense and for the duration of billboard lease periods, alternative advertising that discourages smoking among youth.
• Bans tobacco companies from entering into agreements that would prohibit advertising discouraging tobacco use.

These provisions of the MSA primarily addressed tobacco marketing to youth and have yet to be evaluated as to how they affect tobacco companies' patterns of marketing to women. The first study attempting to document the effect of the MSA marketing and advertising restrictions found that tobacco companies were shifting advertising dollars into point-of-sale promotions and advertising instead of billboards (University of Illinois at Chicago 2000).

Marketing on the Internet

The future of tobacco advertising and promotion may lie in cyberspace. The World Wide Web on the Internet offers endless possibilities for promoting tobacco use and marketing tobacco products. For users of the Web, hundreds of smoking-related Web sites can be found. (No Web sites are listed here because addresses change so frequently.) These include sites selling smoking clothing and novelty items, such as Smoke magazine, and sites providing photographs of women smoking, some of which are pornographic. The Web also offers lists of and information about female celebrities who smoke, as well as photographs of celebrities smoking. Smoking chat rooms and even an interactive novel, Jack Tar, which features background photographs of women smoking, are available. There is a smokers' resource site, and many sites are supported by purveyors of cigarettes, cigars, and smokeless tobacco. Using the keywords "smoke," "smoking," "tobacco," and other related terms in any Web site browser will yield many Web site hits.

Historical Overview

It was not until about 1930 that ads targeting women were first published in Europe. Although women had appeared in British ads earlier, they were purely decorative, the aim being to attract the attention of male smokers. Only in the late 1920s and early 1930s, following changing social attitudes, was it acceptable for women to be seen smoking in public.

During the 1940s and 1950s, the images and messages used in ads aimed at women expanded. Smoking was promoted as enhancing relaxation. One example is a 1947 ad that read "Afternoon off. Is anything more pleasant or soothing than pottering in the garden on a fine afternoon?… And nothing completes your peace of mind more than an ‘Embassy’" (Woman's Own 1947). Similarly, a Craven ‘A’ advertisement of 1951 stated that "One can let the world go by, as Craven ‘A’ smokers do" (Sphere 1951). Other themes reflected a woman's "flair for quality" (e.g., a Gold Flake ad in 1950) (Woman's Own 1950), her intelligence (e.g., in ads in Minor in 1952 and 1953; Picture Post 1952, 1953b), or the sporty life (e.g., a Kensitas ad in 1953) (Illustrated 1952) and outdoor pursuits (e.g., in ads for Players Navy Cut in 1953 and 1956) (Woman and Home 1953; Picture Post 1956). Cigarettes were also portrayed as a passport to sexual attractiveness and success. The copy for a 1952 Craven ‘A’ ad read "When two young people share the same taste, their hearts are one" (Woman 1952), and an advertisement for the same brand in 1953 stated that "When two's company and three is infinitely too many, the pleasure of Craven ‘A’ completes the perfect understanding between young people together" (Picture Post 1953a). Similar ads also started to appear in other European countries, later than in the United Kingdom, reflecting a slower change in social and cultural attitudes toward women in these countries. For example, tobacco companies in Sweden did not start to advertise directly to women until the 1950s, when smoking was portrayed as glamorous and as a way for women to gain admission to the world of men. During the 1960s, ads in Sweden promoted smoking as a symbol of female liberation and equality (Haglund 1988).

The targeting of women in many Western countries entered a new phase in the 1970s and 1980s, after the 1968 launch of Virginia Slims in the United States. The number of women in the labor force had increased, a key factor in the decision of tobacco companies to develop a range of marketing strategies to appeal to women. The strategies included altering the product and its price, availability, and image through innovative packaging and promotion (Ernster 1986).

In the 1980s, concern over the large number of men who had stopped smoking may have played a part in prompting the tobacco industry to increase its emphasis on women. This phenomenon was reflected in the British trade journal Tobacco, which carried articles with such titles as "Suggesting that Retailers Should ‘Look to the Ladies'" (Reisman 1983), "Women-A Separate Market" (Cole 1988b), and "Creating a Female Taste" (Gill and Garrett 1989).

Until the 1980s, little tobacco marketing took place in developing countries. National tobacco monopolies in these countries generally either did not promote their products or did so only minimally. Beginning in the 1980s, however, when young women in some countries were becoming more economically independent and began to copy Western fashion and trends, transnational tobacco companies introduced tobacco ads into developing countries. Many of the initial ads had a masculine focus (e.g., the Marlboro man), but gradually a range of ads was produced, including gender-neutral ads (e.g., a pleasant mountain scene or a blue lagoon), ads that showed both women and men (e.g., enjoying the outdoors in a group), and ads in which only women were shown (e.g., ads for Virginia Slims). Designer cigarettes then appeared. In 1989, the brand Yves Saint Laurent, its elegant package designed to appeal to women, was launched in Malaysia and other Asian countries. Some of the national tobacco monopolies and companies, such as those in Indonesia and Japan, began to copy this promotional targeting of women (Mackay and Crofton 1996).

The precise amount of money spent on advertising, sponsorship, and other promotion throughout the world is not known, but the fragmented information available suggested that the amount is considerable. In the mid-1980s, the combined annual tobacco advertising expenditures for 10 Latin American countries totaled $116.7 million (USDHHS 1992).

Advertising Age reported data for 1989 on advertising in 38 countries, based on media totals provided by research companies, media tracking services, marketing publications, and advertising agencies in each country. The reliability of available data varied by country, but Philip Morris ranked 1st in advertising in Argentina, Hong Kong (China), and Pan-Arabia (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). It ranked 5th in Germany and the United Kingdom, 7th in Canada, and 10th in Mexico (Advertising Age 1990). Since that time, enormous increases in marketing expenditures by U.S. tobacco companies have occurred in China, the countries of Eastern Europe, and other developing countries (Amos 1992; Hille 1995).

In 1994, Marlboro was the biggest advertiser among cigarette brands in China (US$5.2 million), followed by State Express 555 (US$3.1 million) (Hille 1995). Expenditures were expected to continue to grow, and media directors predicted that any restrictions or bans on tobacco advertising in the electronic and print media would be unlikely to affect tobacco companies' expenditures because the companies could use other forms of advertising to which restrictions did not apply (Hille 1995).

Marketing Strategies

The ways in which tobacco companies target women vary across countries. Factors that influence marketing strategies include (1) the current prevalence of smoking among women, (2) restrictions on tobacco marketing, which vary from no restrictions to complete bans, (3) cultural norms, and (4) women's access to different media. However, strategies generally mirror those used in the United Kingdom and the United States, which is not surprising, because British and U.S. companies are the main exporters of cigarettes and have become increasingly involved in new markets (Chapman and Wong 1990; Kholmogorova and Prokhorov 1994). When doing business abroad, tobacco companies often apply business standards different from and less stringent than those they use in their own country. Ads that are either not allowed or would be ethically or culturally unacceptable in the United States (e.g., religious images of the Madonna) are used in other countries (Chapman and Stanton 1994), and many countries do not require health warnings in ads.

Media Censorship

Very few studies have examined the effect that advertising outside the United States may have on editorial policies. However, at least one British magazine that accepted cigarette ads admitted finding it difficult to endorse positions that contradicted its advertising (Jacobson and Amos 1985). In a study conducted during 1989-1990, investigators found that, of 71 women's magazines published in 13 European countries, 69 percent accepted cigarette ads and 54 percent allowed photographs of persons smoking (Amos and Bostock 1992a). Responses to a question on coverage of smoking and health were received from 63 of the magazines; only 22 percent had published an article of one page or more on the health effects of smoking, 37 percent had given more minor coverage to smoking and health, and 41 percent had not covered the topic at all. Magazines that accepted cigarette ads were less likely to have carried articles on smoking and health than were those that did not publish cigarette ads. A more recent study of 111 women's magazines in 17 European countries in 1996 and 1997 found that 55 percent of the magazines that responded accepted cigarette ads, but only 31 percent had published an article of one page or more on smoking and health in the previous 12 months; only 4 of the magazines had a policy of voluntarily refusing cigarette advertising (Amos et al. 1998). Magazines that accepted tobacco advertising seemed less likely to give coverage to smoking and health. Indeed, 1 German magazine stated that it informed tobacco companies if it was going to publish material on nonsmoking and that the companies could stop their ads for that issue. In a study of four popular women's magazines published in Ireland in 1989-1993, the proportion of space devoted to tobacco ads and articles that conveyed the positive attributes of smoking or that were critical of tobacco control interventions was 1.95 percent of total magazine space (Howell 1994). This amount of space was 14.5 times greater than the space devoted to articles about the risks from smoking. Many magazines throughout the world appear to promote smoking among women by showing fashion photographs of models smoking and photographs of well-known personalities smoking that accompany editorial articles. In South Africa, one tobacco company refused to pay for a cigarette ad in a women's magazine after the ad appeared opposite a letter criticizing articles that promoted smoking (Yussuf Saloojee, National Council Against Smoking, fax to Amanda Amos, October 11, 1995).

Bans and Restrictions on Tobacco Advertising and Promotion

Many countries have banned all tobacco advertising and promotion (e.g., Australia, Finland, France, Norway, Singapore, Sweden, and Thailand). In 1998, the European Union adopted a directive on tobacco promotion. This directive will ban most tobacco advertising and sponsorship in the 15 countries of the European Union by July 30, 2006. Other countries have banned direct advertising, and still others have instituted partial restraints. Such bans are often circumvented by tobacco companies through various promotional venues such as creation of retail stores named after cigarette brands or corporate sponsorship of sporting and other events. Moreover, national bans on tobacco advertising may be rendered ineffective by tobacco promotion on satellite television, by cable broadcasting, or via the Internet, because no international laws regulate these venues (Solberg and Blum 1995).

Even in countries with strong regulations restricting tobacco advertising, attempts are constantly made to bypass the spirit of these bans (Solberg and Blum 1995; Weir 1995). In 1994, after a ban on direct ads for tobacco on television in China, Reuters reported that Philip Morris had staged an "unprecedented marketing coup" by showing ads "dressed up as public affairs shows" (Hong Kong Standard 1994, p. 94). Moreover, implementation of bans may be poor, despite the excellence of some bans on paper, as evidenced in Eastern European countries and Mongolia, or it may be undermined by cross-border advertising. For example, Singapore has a comprehensive ban on tobacco marketing, but tobacco-sponsored television programs reach Singapore from Malaysia.

Several countries, such as Japan and the United Kingdom, have generally adopted a nonlegislative approach to tobacco control in which marketing is governed by voluntary codes or agreements. (This position will change in the United Kingdom as it implements the European Union's directive on tobacco promotion described here.) These codes often contain specific regulations designed to reduce or prevent the targeting of women, especially young women. However, these voluntary agreements often fail to achieve their aims (Jacobson and Amos 1985; Amos et al. 1989; Toxic Substances Board 1989; Naett and Pollitzer 1991a; Mindell 1993). For example, the Tobacco Institute in Japan has advertising codes prohibiting the use of models younger than 25 years old, the promotion of sales to women, the depiction of women smoking in ads, and the placement of advertising in women's magazines. However, both Virginia Slims and Capri are advertised in Japan. Ads for Frontier Menthol Slims have featured young female models, and tobacco vending machines have shown Virginia Slims videotapes of young women dancing-all of which violate the codes. Indeed, the government of the United Kingdom concluded in its 1998 report "Smoking Kills-A White Paper on Tobacco" that little evidence existed that indicated previous voluntary agreements on tobacco advertising in the United Kingdom had worked (Secretary of State for Health et al. 1998, p. 47-48). The government therefore decided to enact legislation to implement the 1998 Directive of the European Union that will ban most tobacco advertising and promotion.

Members of the public health community argue that tobacco advertising and promotion activities increase consumption of tobacco products by increasing demand via new recruits. The tobacco industry, on the other hand, argues that advertising and promotional activities serve only to maintain consumer brand loyalty or cause current tobacco users to switch brands. Advertising and promotion activities, they contend, do not contribute to recruitment. Studies have generally shown a modest positive effect or no effect of advertising on consumption (Jha and Chaloupka 1999). These conclusions must be interpreted cautiously, because the studies have generally used highly aggregated data for all advertisers, in all media, and often over large populations. Use of such aggregated data hides small changes and thus minimizes the possible impact of an additional dollar of advertising expenditure on tobacco consumption (Jha and Chaloupka 1999). In other words, small changes that may be discernible in an analysis of less aggregated data would be lost or obscured in an analysis of aggregated data. Studies that use less aggregated data have shown larger positive effects of advertising on consumption; however, such studies are very costly (Jha and Chaloupka 1999) and therefore few, if any, have been conducted.

An indirect and less costly method of discerning the impact of tobacco advertising on consumption is examination of the effects of restrictions and bans on tobacco consumption (Saffer and Chaloupka 2000). The Toxic Substances Board of New Zealand, which examined the relationship between government policies on tobacco promotion and tobacco consumption trends in 33 countries between 1970 and 1986, concluded that the abolition of tobacco promotion was an essential part of a comprehensive policy to lower tobacco consumption (Toxic Substances Board 1989). The Regional Office for the Western Pacific World Health Organization called for a region free of tobacco advertising by the year 2000 to protect Asian children from commercial pressure to smoke (Warner 1986). The debate on the impact of such policy actions has been lively and partisan. Studies have examined the impact of partial cigarette advertising bans on consumption and the impact of total bans. The evidence suggested that partial bans have little or no effect on reducing tobacco consumption, whereas total advertising bans covering all media prove to be most effective in reducing tobacco consumption. Partial bans are ineffective because tobacco companies can substitute nonbanned media for banned media without reducing the amount of dollars spent on advertising. When advertising via all media is banned, the industry's opportunity to substitute among media is effectively constrained. Thus, advertising expenditure must be adjusted up or down. Using data from 1970 through 1992, a recent study of 22 high-income countries concluded that comprehensive bans on cigarette advertising and promotion can reduce smoking but that more limited partial bans have little or no effect (Saffer and Chaloupka 2000). The study concluded that if the most comprehensive advertising bans were in place, tobacco consumption would fall by more than 6 percent in high-income countries. Another study (Jha and Chaloupka 1999) of 100 countries compared consumption trends over time among those with relatively complete bans on advertising and promotion and those with no such bans. In the countries with nearly complete bans, the downward trend in consumption was much steeper. Because it was not possible to control for all factors in every country, other factors could have contributed to the decline in consumption in some countries. In a review of the effects of various interventions on adolescent smoking, Willemsen and De Zwart (1999) concluded that advertising bans lead not only to decreased consumption among adults but also contribute to reductions in initiation among adolescents; gender-specific effects were not reported.

Protests Against Targeting of Women

Until recently, most of the challenges to the tobacco industry's targeting of women have been restricted to countries with the longest history of wide-spread smoking among women, including Australia, Canada, Finland, Sweden, and the United Kingdom (Jacobson 1992; Canadian Ministry of Health 1993). However, organizations in both developed and developing countries are beginning to protest tactics used to target women. In 1990, the International Network of Women Against Tobacco was formed by women from about 60 countries. One of the organization's three main goals is to counter the marketing and promotion of tobacco to women throughout the world (see "Tobacco Control Advocacy Programs by and for Women" in Chapter 5). Women's Action on Smoking is now active in many nations, including Japan, where smoking prevalence has been low among women but high among men (World Smoking and Health 1994). Women's Action on Smoking in Japan instituted a hotline to provide health advice to workers, mostly women who are exposed to cigarette smoke, and sent to callers information on the health effects of environmental tobacco smoke, advice on how to avoid exposure, and suggestions on advocating for workplace restrictions on smoking. In India in 1990, when Golden Tobacco Company began targeting women with a new brand, MS Special Filter (Gupta and Ball 1990), protests quickly followed. Ads for the brand featured Indian women wearing Western clothing in affluent settings, which are symbols of liberation for Indian women who are gaining financial and professional independence. A group of medical school professors and health workers wrote to newspapers urging them not to accept advertising for the cigarette (Crossette 1990). Members of Bailancho Saad, a little-known group of women activists, objected to the brand name as an inappropriate use of the prefix Ms., called for bans on advertising and a boycott of the cigarette, and defaced billboards advertising the product (Alvares 1990).