摘要：Antismoking efforts often target teenagers in the hope of producing a new generation of never smokers. Teenagers are more responsive to tobacco taxes than are adults. The author summarizes recent evidence suggesting that delaying smoking initiation among teenagers through higher taxes does not generate proportionate reductions in prevalence rates through adulthood. In consequence, the impact of taxes on smoking among youths overstates the potential long-term public health effects of this tobacco control strategy. CONTEMPORARY TOBACCO control policy has concentrated its fire on reducing smoking initiation among teenagers. According to Donna Shalala, former secretary of health and human services, the rhetoric used to justify measures designed to control adolescent smoking emphasizes that, “among children living in America today, 5 million will die an early preventable death because of a decision made as a child.” 1 This focus is operationalized in the terms of the 1998 master settlement agreement between the state attorneys general and the tobacco industry; many of the agreement’s clauses concern restrictions on tobacco advertising, promotion, and sales to young people. The focus is similarly reflected in the close attention tobacco use analysts pay to changes in annual data on patterns of cigarette smoking among youths. Educating young people and helping them to make rational decisions in regard to smoking is sound and appropriate public policy. Yet, from a public health perspective, the harms of cigarette smoking are—with the important exception of the effects of smoking during pregnancy on fetal health 2 —only distantly connected to the smoking behavior of teens. Most of the health effects of smoking occur later in life, after years of exposure. Quitting can reverse many of the ill health consequences of earlier smoking. 3 Thus, the main purpose of programs designed to reduce smoking among teens is instrumental: to reduce smoking among adults. The public health logic of concern over youth smoking is primarily that reducing youth smoking is the best way to reduce smoking overall. The principal conclusion of the 1994 surgeon general’s report on smoking was that “[n]early all first use of tobacco occurs before high school graduation; this finding suggests that if adolescents can be kept tobacco free, most will never start using tobacco.” 4(p543) While quitting smoking is very difficult, focusing on teens may, as Elders et al. 4 have suggested, produce a new generation of never smokers. Antismoking efforts focused on teenagers may be not only more politically saleable, but also more effective, than broader efforts. Teenagers are more susceptible than are adults to a range of inducements toward curbing smoking. For example, they respond more strongly to tobacco taxes. The price elasticity of demand for smoking—the standard measure of responsiveness to taxation—is 2 to 3 times as high among teenagers as it is among adults. 5, 6 Similarly, marketing analysts believe that teens are more responsive to advertising because their tastes have not yet been fully formed. As David Verklin, CEO of Cara International (a media buyer), stated recently in a National Public Radio report, younger buyers “haven’t made all their brand choices . . . and if you could reach them and get them to be users of your brand at an early age, you’ll have them for a lifetime.” For this reason, a 30-second commercial on The Late Show with David Letterman produces 38% more revenue than a similar commercial on Nightline, although the Nightline audience is only 4 years older, and about 10% larger, than Letterman’s audience. The literature on responsiveness thus suggests that targeting teen smokers will generate a larger reduction in smoking for a given cost than targeting adults. Reducing smoking among teens is a necessary condition for a program aimed at young people to have an effect on adult smoking rates. But it may not be a sufficient condition. The smoking rate among adults in the United States is lower than the corresponding rate among youths. 7, 8 Many factors intervene between youth and adulthood in terms of the decision to smoke. A complete evaluation of the effects of antismoking efforts cannot assume that delaying smoking initiation among teenagers will generate persistent reductions in prevalence through adulthood. The effects of programs designed to reduce smoking among youths may remain constant, intensify, or diminish over time. Programs that discourage smoking may educate even those who do begin smoking. As these smokers grow older, such programs may increase later quit rates. Or it may be that tobacco control programs are most effective among those who are most susceptible to long-term addiction. If late initiators find quitting easier (as some evidence suggests), programs that delay smoking may also increase quitting behavior. 9 In these cases, the program’s effects intensify over time. Alternatively, adults who were discouraged from smoking by a program may change their minds as their incomes increase or they join new peer communities. In such cases, the program’s effects diminish over time.
