A Horse Of The Same Color: Why The Family Smoking Prevention And Control Act Fails To Curb Tobacco Use – Tyler Collins

Smoking is the leading cause of preventable death in the United States (US) (1). It is responsible for approximately one in five deaths annually, with smokers dying on average 13 to 14 years earlier than none smokers (2). Nearly 20% of all US adults are current smokers and 1800 Americans over the age of 18 are added to their ranks daily (2). This is in part due to the fact that the tobacco industry spends $13 billion annually on advertisements and promotions (2). This staggering number can be looked as a partial explanation to why the 70% of smokers, who wish to quit, often fail (2). Not only has the tobacco industry engrained itself into the fabric of society, through its constant barrage of advertisements, but also through the 1998 Master Settlement Agreement (MSA). This arrangement requires the industry to pay 46 states, over the next 25 years, to combat smoking related disease and disability (3). States have come to depend on this settlement money, though, to fill budget deficits. This usage of funds, straying from its original purpose, has allowed big tobacco to influence government agendas (4). As a result, most interventions bent on targeting the industry will fail because of state government ties to tobacco’s success.
Fast forward 11 years and you will find one such intervention that has failed since its inception. This intervention is the Family Smoking Prevention and Tobacco Control Act and was signed by President Barack Obama in 2009. It has been heralded by the media as a “sweeping anti-smoking bill” and praises it for providing critically needed protection to future generations (5). Unfortunately, it falls short of providing the critical care so desperately needed. In a country influenced from the top down, the entanglement of tobacco into the finances of state government sours any chance to change social norms. What has transpired instead is a restoration of previously ineffective plans that completely disregards certain groups. Although many pages of legislation create seemingly groundbreaking advancements, it is merely a charlatan attempting to hoodwink the American public. A true intervention must take place not only to save the government from big tobacco, but also its citizenry.

New Interventions Will Fail Because Government Has Failed

To understand where the United States went wrong requires a look at the historical underpinnings of how the tobacco industry wrapped its tentacles around state budgets. Then a clear distinction can be made between an intervention aimed at the root cause of tobacco’s success and one cast aimlessly out. The research thus starts with the 1998 Master Settlement Agreement between big tobacco and 46 states. The MSA was originally a settlement with these states where the 4 big tobacco companies would pay $206 billion over 25 years to help cover the cost of tobacco related disease and disability (3). But, with few stipulations in the plan as to how the money was to be spent, states have elected to veer the money from its original purpose to more pressing budget deficits (4). In 2007, only 3% of the $24.9 billion available was used in tobacco control programs, with the rest going to fill budget shortfalls (2). As a result, programs have remained underfunded, government has come to rely on tobacco money as a lifeline, and successful programs have been cut so as not to threaten tobacco’s profits too greatly (4). This was seen when the wildly successful “truth” campaign in Florida was cut because it threatened to actually work at curbing tobacco use (6). This campaign was able to retract youth smoking rates from 18.5% to 11.1% among middle school students and from 27.4% to 22.6% among high school students in Florida (7). Sadly, this success became the programs downfall and it was discontinued because it threatened market profitability for the tobacco industry, which threatened MSA settlement payouts to the state of Florida. This clear conflict of interest silences any attempt at government taking meaningful steps to ensure stringent regulation of cigarettes and shows a failure of the system as a whole.
This conflict can be seen through social science models. As shown in the Social Ecological Model, the most overarching determinant of human behavior is the social structure, policy and systems in which one lives (8). If an intervention wants to have a sweeping effect in producing change, a policy or law promoting that change is the surest way to compliance. This understanding is further echoed through the guise of the Social Expectations Model, which dictates that if a social behavior wants to be changed, social norms must be changed (9-10). One way to ensure that change is through government action. This is often in the form of a change in regulations, laws, or policies that affect social behavior (10).
One such example of successful curbing of socially undesirable practices is the implementation of mandated seat belt use in automobiles. Prior to the enactment of seat belt laws, less than 20% of motorists voluntarily buckled up (10). This was in the face of “extensive advertising campaigns and buzzer systems” that attempted to promote buckling up for safety (10). In the first months after the law was enforced in New York State, the first state to require seat belt usage, compliance jumped to between 45% and 60% (10). As is seen in the case of the seat belt, social norms changed only once laws changed. Unfortunately, this will not be the case with the Family Smoking Prevention and Tobacco Control Act.
Through this legislation the Food and Drug Administration (FDA) is going to work closely with the Centers for Disease Control and Prevention (CDC) to “establish contracts with states to support the public health goals of the Tobacco Control Act” (11). This sounds just on the surface, but when states are spending only 3% of their MSA funds on tobacco related issues, collaboration between federal departments and states will only produce minimal benefits (2). The CDC recommends that adequate control of tobacco require 15% of MSA funds to be used for that purpose (2). So, unless more funding is given to tobacco control, no sweeping changes will occur as the law has been heralded to produce (5).

Tobacco Legislation Threatens To Fail To Market Change Properly

The Family Smoking Prevention and Tobacco Control Act plans to increase marketing that informs individuals of the harm posed by smoking cigarettes (11). Sadly, this marketing follows the same mantra of so many failed public health initiatives before it. With this new legislation, “the FDA…intends to propose new graphic health-warning labels to cover 50% of the front and back of each cigarette pack” (11). Furthermore, the FDA believes that many Americans do not truly know the risks of smoking cigarettes and feel that they are often duped into believing that “light” and “low tar” cigarettes are safe to use (11). To combat these misunderstandings, the FDA plans to educate consumers about the true danger of these cigarettes, with the assumption that such understanding will curb usage (11). This belief is bolstered by a 1999 study, which found that the majority of smokers do not believe they are at greater risk of heart disease and cancer than their non-smoking counterparts (12). But, as outlined in Advertising and Marketing Theory, educating consumers and telling them what they should desire is like placing the cart before the horse (13).
The first step in creating a successful marketing campaign is to research what the consumer desires (13). Then, the marketer packages their product to meet those needs (13). Contrary to this theory, the prevailing assumption in public health interventions is to rely on the practitioner’s intuition to judge what society should want and then package their product accordingly (13). This only appeals to those who are conscious of the importance of good health. Regrettably, health is not always a core value in society and is frequently overshadowed by other desires. This is understood by advertisers and marketers, but not by public health practitioners. To illustrate this concept, a study was conducted in 1993 on the rates of smoking cessation after the diagnosis of lung cancer (14). The study found that 21% of smokers diagnosed with lung cancer continued to smoke even after diagnosis (14). These findings are clearly divergent from long held public health assumptions.
According to the FDA and the Family Smoking Prevention and Tobacco Control Act, most smokers do not know the true risk of their habit and if educated, would likely discontinue such habits (11). If this is true, then why would smokers diagnosed with lung cancer, resulting from their cigarette smoking, continue to smoke? The answer can only be that health is not a core value for many individuals and those interventions designed to promote health, through education on the problem, are ineffective. Given this knowledge, interventions like the one proposed in the latest tobacco control legislation continue to follow old, ineffective habits, rather than looking to newer, and more successful ways of producing societal adherence to healthy practices.

The Family Smoking Prevention And Tobacco Control Act Ignores Minority Groups

The Family Smoking Prevention and Tobacco Control Act has established guidelines on how tobacco may market their products and which products may be sold (15). This marketing and removal of certain products may unconsciously allow certain minorities to be targeted by tobacco firms and to an extent borders on institutionalized racism. The group targeted by such racism is primarily black smokers. Currently, nearly 20% of African American adults smoke on a daily basis (2). White and Native American adults are the only two groups to surpass African Americans in smoking percentages (2). Black smokers also tend to prefer a particular type of flavored cigarette; a preference not shared widely by other consumers (16). Luckily, the new legislation mandates the removal of all candy-flavored cigarettes; except for one (11-15). The one flavored cigarette that is not removed from the market is menthol-flavored cigarettes (15). Coincidently, this type of cigarette is the most popular flavor among African American smokers (16). This trend has been noted in numerous studies. One such study conducted a year before the Family Smoking Prevention and Tobacco Control Act found not only that black smokers consume the greatest proportion of menthol cigarettes, but also that menthol cigarette smoking resulted in a higher rate of cigarette consumption overall (16). The study went on to state that any legislation on tobacco control should take into account menthol cigarette usage by blacks and the high consumption such products encourage (16).
As such, it can be inferred that cigarette sales in large part are dependent on the product needs of African American smokers. To this end, menthol cigarettes also comprise a large proportion of cigarette sales in the US. Unlike other candy-flavored cigarettes, which clearly accounts for nearly no sales of cigarettes, menthol is a highly desired flavor. Yet, no restrictions have been placed on their distribution. So, a cigarette that clearly is at the forefront of contributing to major health problems for one particular group, African Americans, has no regulation stemming from this new bill (15).
This is a clear example of one of Camara Jones’ Levels of Racism, which she calls Institutionalized racism. She defines it as the “differential access to the goods, services, and opportunities of society by race” (17). This is undoubtedly what the sale of menthol cigarettes poses to black individuals. Rather than being an inaccessibility of such goods and services, it is an over accessibility to a certain harmful product. Now, this may or may not be a conscious act of racism on the government’s part, but it certainly can be framed as such. It can also be said that some ignoring of scientific findings took place in the drafting of the new tobacco control legislation. Prior to the enactment of this legislation, studies noted the high consumption of menthol flavored cigarettes by black smokers and suggested that legislation curtail this trend (16). The reasoning behind the lack of regulations controlling menthol cigarettes has as much to do with institutionalized racism as it does with the prior criticisms in this paper. This includes the financial ties tobacco firms have to state government budgets (3-4).

Tobacco Control Must Come In The Form Of Effective Legislation

Before any headway can be made on tobacco control, state governments need to get out of the pockets of tobacco firms. Tobacco has state governments right where it wants them by tying settlement payouts to the sale of cigarettes (3-4). Now, state governments have a vested interest in the profitability of tobacco. This is further exacerbated by the current economic downturn and the increasing budget deficits among states. This has allowed money that was intended to curb tobacco related cost and usage to be used to fill gaps (2). Government has since become dependent on these payouts to fulfill the shortcomings in their budgets. Until this trend changes, government will have a stake in how profitable tobacco is. State tobacco control programs could be fully funded to CDC recommended levels if the percent of MSA settlement money used to fund such programs was raised by 12% (2). This would still leave $21.2 billion in settlement funds that states could use for other purposes. This increase from the $747 million currently put toward tobacco control would have a substantial impact on initiation and continuance of smoking by individuals.

Marketing Strategies To Curb Tobacco Usage Should Follow Standard Advertising Practices

Attempts made to market the harms incurred to individuals by smoking must be carefully constructed. It is no easy task to try and stop individuals from partaking in a habit-forming practice. Some basic rules that are commonly followed by advertising agencies can ensure a greater success in interventions aimed at decreasing cigarette consumption. The specific issues with the current legislation is the proposed placement of “graphic health warning” labels on cigarettes (11). Trying to disgust people into giving up cigarettes is not an effective way and would not be recommended by any advertising firm. As described above, smokers know smoking is harmful to their health and even after the effects of the habit have manifested into smoking related disease and disability, many still continue the habit. In order to see meaningful change in the consumption of cigarettes, marketing strategies must be taken to discover what is important to smokers and then market the intervention around those needs and wants. If the current public health practice of using intuition to make an assumption of what average individuals should want, warning labels will be ignored just as other interventions have been.

Greater Emphasis Must Be Taken To Ensure Equality Of Interventions

Interventions regarding tobacco use must encompass all users of tobacco products. Only banning substances that are already not used by individuals helps no one. Considerations must be made to face the full spectrum of the problem, not just pieces. If the objective is to appear as though headway is being made in the fight against the tobacco industry, then a continuation of the status quo is an effective approach. But, if the objective is to truly limit tobacco use, then the proper steps must be taken to limit the use in all groups.
It is clear through multiple studies that menthol cigarettes are used disproportionately by black smokers compared to other smokers (16). It has also been shown that menthol cigarettes lead to a higher consumption of cigarettes in general (16). So not only are African American the highest proportion of menthol cigarette smokers, but they also consume a greater quantity of cigarettes in relation to other groups. This issue must be addressed for the future safety and well being of the black community. Any future legislation should ban the sale of menthol cigarettes just as the current legislation has banned the sale of other candy-flavored cigarettes. Only then will a reduction in the usage of tobacco be evident in the United States.

Conclusion

Tobacco related disease and disability is a worldwide issue. Even so, some aspects of the problem are uniquely American and some problems span the entire spectrum. The newest legislation, the Family Smoking Prevention and Tobacco Control Act does have some merit and may in fact prove effective in some parts. It does have its flaws though, many of which are historical in nature. In order to understand why this legislation is so limited in its scope, one must look the 1998 Master Settlement Agreement for how government finances got so entwined in tobacco sales. Furthermore, a general overhaul in the way public health professionals think and act when implementing interventions should take place. New research shows what is effective in changing behaviors if the profession only looks to them. These new tactics of how to frame issues alone could increase the effectiveness of interventions drastically. This being said, if something does not happen to change the historical tendencies in this country to exclude some groups from the advances of policy and social standards, no intervention will truly be all encompassing. In the case of the newest tobacco legislation, black smokers are passed over in protection from deadly menthol cigarettes. This is not to say that this overlook was intentional, but as Camara Jones illustrates in her analogy of the gardener with the two gardens, the gardener must realize that the problem with some flower’s stunted growth is in its roots (17). Society needs to take all of these tools to cultivate a more prosperous garden for all.

REFERENCES

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-2212.
2. Department of Health and Human Services: Centers for Disease Control and Prevention. Smoking and Tobacco Use. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/
3. Office of the Attorney General. Tobacco Master Settlement Agreement. California: Office of Attorney General.

4. Join Together. Tobacco Settlement Helping to Ensure Profitability of Industry. Join Together. Accessed on April 27, 2010 at
5. Associated Press. Obama Signs Sweeping Anti-Smoking Bill. MSNBC. Accessed on April 27, 2010 at
6. Dietz NA, Westphal L, Arheart KL, Lee DJ, Huang Y, Sly DF, Davila E. Changes in youth cigarette use following the dismantling of an anti-tobacco media campaign in Florida. Preventing Chronic Disease. 2010;7(3):A65. http://www.ncbi.nlm.nih.gov.ezproxy.bu.edu/pubmed/20394704
7. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
8. Gregson, Jennifer, et al. System, Environmental, and Policy Changes: Using the Social Ecological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs with Low-Income Audiences. Journal of Nutrition Education. 2001;33:1.
9. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
10. Weinstein, Neil D. Taking care: understanding and encouraging self-protective behavior. Cambridge, MA: Cambridge University Press, 1987.
11. Deyton, L, Sharfstein, J, Hamburg, M. Tobacco Product Regulation — A Public Health Approach. NEJM 2010. Accessed on April 27, 2010 at
12. Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.
13. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp. 25-41.
14. Richardson GE, Tucker MA, Venzon DJ, Linnoila RI, et al. Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers. Annals of Internal Medicine 1993. Accessed April 27, 2010 at
15. Congress of the United States. H.R. 1256: family smoking prevention and tobacco control act. Govtrack.us 2009. Accessed on April 27, 2010 at
16. Muilenburg, JL, Legge, JS Jr. African American adolescents and menthol cigarettes: smoking behavior among secondary school students. Journal of Adolescent Health 2008; 43(6):570-575.
17. Jones CP. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health 2000; 90:1212-1215.