Longitudinal studies consistently suggest that exposure to tobacco advertising and promotion is associated with the likelihood that adolescents will start to smoke. Based on the strength and specificity of this association, evidence of a dose-response relationship, the consistency of findings across numerous observational studies, temporality of exposure and smoking behaviours observed, as well as the theoretical plausibility regarding the impact of advertising, we conclude that tobacco advertising and promotion increases the likelihood that adolescents will start to smoke.
Effect of cigarette promotions on smoking uptake among adolescents.
The purpose of this study was to evaluate the association between receptivity to cigarette promotions and smoking uptake in a cohort of adolescents.
                This was a prospective cohort study of 480 4th- to 11th-grade students conducted in three rural Vermont K-12 schools. Cigarette use was determined by self-report at baseline, 12 months (survey 2), and 21 months (survey 3). Proportional odds models were used to evaluate smoking uptake as a function of baseline measures of cigarette use, receptivity to cigarette promotions, and confounding factors, including grade, parental education, peer smoking, and family smoking. Adolescents were receptive to cigarette promotions if they owned or were willing to use a personal item bearing a cigarette brand logo [cigarette promotional item (CPI)]. Smoking status was measured using a 6-point ordinal index that combined experience and attitudes: 0 = never smoker/not susceptible to smoking, 1 = never smoker/susceptible to smoking, 2 = puffer (1 cigarette or less in lifetime), 3 = non-current experimenter (2-99 cigarettes in lifetime/none in past 30 days), 4 = current experimenter, and 5 = smoker (> or =100 cigarettes in lifetime).
                The 480 students were equally distributed across grade at baseline. Environmental exposure to smoking was high, and 30% were receptive to cigarette promotions at baseline. Higher levels on the smoking index at baseline were associated with higher grade in school, peer smoking, and receptivity to cigarette promotions. One hundred eighty-five students (38.5%) had moved to a higher category on the smoking index by survey 3, of whom 30 had become smokers. Receptivity to cigarette promotions at baseline was significantly associated with higher smoking uptake, with 48.7% of receptive students moving up one or more categories on the smoking index [adjusted proportional odds 1.9 (95% CI 1.3, 2.9)]. Acquisition of receptivity to cigarette promotions was also associated with increased smoking uptake, with those becoming receptive in surveys 2 or 3 having significantly higher odds of progression [3.6 (1.8, 7.0) and 2.9 (1.5, 5.5), respectively] compared with those who did not change. Conversely, those who were receptive at one point but became non-receptive in surveys 2 or 3 had lower odds of progression [0.4 (0.2, 0.9) and 0.5 (0.3, 1.1), respectively].
                This study supports a close linkage between tobacco promotional activities and uptake of smoking among adolescents beyond baseline descriptions of receptivity to cigarette promotions. Over time, the likelihood of smoking uptake is increased when an adolescent acquires a CPI or becomes willing to use one and is decreased when an adolescent who owns a CPI loses it or becomes unwilling to use it. This provides strong evidence that elimination of cigarette promotional campaigns could reduce adolescent smoking.
                Copyright 2000 American Health Foundation and Academic Press.