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EDITORIAL |
The authors are with the Program in the History and Ethics of Public Health, Mailman School of Public Health, Columbia University, New York, NY.
Correspondence: Requests for reprints should be sent to Valeri Kiesig, 523 W 112th St, No. 54, New York, NY 10025 (e-mail: vk2012{at}columbia.edu).
"There is no question that demands more public attention . . . than the prevailing methods of cigarette manufacturers to foster and stimulate smoking among children," an angry New Yorker said in 1888. Tobacco manufacturers seduced the young with promotional prizes like pocket knives and lithograph albums, he said. "At the office of a leading factory in this city you can see any Saturday afternoon a crowd of children with vouchers clamoring for the reward of self-inflicted injury."1
More than a century later, David Kessler, then Food and Drug Administration Commissioner, held a private meeting with President Clinton. Kessler described a similar scene: Adolescents lured by the T-shirts and hats they could buy with Camel cash or Marlboro miles, 6-year-olds taken in by the fun cartoon character Joe Camel, and underage smokers finding easy access to cigarettes in vending machines, in self-service displays, and from lax store clerks. "They all think they can quit," Kessler said, "but then nicotine hooks them."2(pA1) Smoking as he described it was no longer the fault of the young smoker but a "pediatric disease" propagated by the tobacco industry. Kessler said that the president was angry. Clinton reportedly said of those responsible in the tobacco companies, "I want to kill them."2
The instinct to protect children that was present in both the 1880s and the 1990s reflects the central obligation public health has always had to the young and vulnerable. In 1888, though, parents worried largely about the social disease of smoking, how cigarettes might stain childhood purity. Today the desire is to protect children from the disease of addiction, which might lead to grave medical consequences in adulthood. The core of parental and governmental concern has subtly shifted weight from the moral to the medical. Children still garner ethical concerns but not, as in the past, because cigarettes will weaken their character. Instead, the call to protect children is framed by the growing number of tobacco-related deaths. Of course it is not children who are dying. Rather it is the nicotine-addicted adults these children are likely to become.
The moral challenge posed by tobacco use and nicotine addiction in children was stated pointedly by philosopher Robert Goodin: "Being below the age of consent when they first began smoking, smokers were incapable of meaningfully consenting to the risks in the first instance. Being addicted by the time they reached the age of consent, they were incapable of consenting later either."3(p30)
The focus on children and adolescents was also an outgrowth of the epidemiological challenge posed by tens of millions of adult smokers. The 1994 surgeon general’s report Preventing Tobacco Use Among Young People was bold in its assertion: "When young people no longer want to smoke the epidemic itself will die."4 Echoing this perspective the Institute of Medicine declared in the same year, "In the long run tobacco use can be most efficiently reduced through a policy aimed at preventing children and adolescents from initiating tobacco use."5
It was this framing of the issue that informed much of the debate in the 1990s on advertising restrictions and on the imposition of ever-stiffer excise taxes on cigarettes.
When in 1996 the Food and Drug Administration proposed its Supreme Court–thwarted final rule on nicotine, the limits on advertising were solely focused on the protection of those younger than 18 years. Its counteradvertising proposals were justified as a way of undoing "the effects of the pervasive advertising that for decades has influenced young people to begin and continue using tobacco products." Such restrictions would "preserve the component of advertising and labeling which can provide product information to adult smokers" despite the inevitable impact on what adults would be able to see.6 And when Massachusetts sought to implement severe advertising restrictions that ware ultimately overturned by the Supreme Court, it did so in the name of protecting children.7
With cigarette taxes, too, the emphasis on child protection can be seen. When efforts to raise such levies were explicit about their potential public health benefits, the argument in the late 1980s and early 1990s was almost always about making it more difficult for adolescents, with limited disposable income, to buy cigarettes. In Massachusetts, for example, the proponents of a 1992 referendum to impose a 25-cent tax on each pack of cigarettes stated: "We are not after an adult habit—we’re after keeping kids from smoking. . . . Once kids are addicted, they’re trapped for life."8
What can account for the emphasis placed on children in the campaign against tobacco? Certainly those who have devoted themselves to confronting the awful human burden caused by cigarette smoking believe that they can "save" children and the adults they will become by interrupting the uptake of tobacco use. But more is at stake. Just as the emphasis on the innocent victims of environmental tobacco smoke reflects the need to fashion policies that can avoid the taint of paternalism, the focus on children reflects the imperative of fashioning restrictive measures to avoid the charge that adults are being told what to do for their own good. Thus the focus on children demonstrates the constraining influence of American individualism on public health policy.
But what if the focus on children not only represents an ideological dead end but will miss the public health mark that justifies such measures? It may be true that those who begin to smoke as adolescents continue to smoke into their adult years. It may not follow, however, that those who do not smoke as adolescents do not smoke as adults. What if it is untrue that smoking prevented in adolescence is smoking averted? This question is addressed in provocative ways in this issue of the Journal by Sherry Glied, Joyce MoonHoward, and Steven Sugarman. Glied challenges the claims that tax-averted smoking in adolescence results in lifelong tobacco abstinence. Moon-Howard notes that substantial numbers of African American women start smoking in postadolescent years. To the extent that Glied and Moon-Howard are right, it will be necessary to rethink the justification for and practice of tobacco-dependence prevention. It may, in the end, be necessary to say clearly that a public health campaign that does not give great emphasis to limiting adult smoking is doomed.
Accepted for publication November 17, 2002.
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References |
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2. Pringle P. The man who took on tobacco. The Washington Post. April 4, 2001;A1.
3. Goodin R. No Smoking: The Ethical Issues. Chicago, Ill: University of Chicago Press; 1989.
4. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services; 1994:iii.
5. Institute of Medicine. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youth. Washington, DC: National Academy Press; 1994:5.
6. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents; final rule. 61(168) Federal Register 44396 (August 28, 1996).
7. Lorillard Tobacco Co v Reilly, 533 US (2001).
8. Aucoin D. Cigarette tax is hailed, hit at debate. Boston Globe. October 23, 1992:1.
This article has been cited by other articles:
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  S M Carter From legitimate consumers to public relations pawns: the tobacco industry and young Australians Tob. Control, December 1, 2003; 12(90003): iii71 - 78. [Abstract] [Full Text] [PDF]
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