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By Stacie Crozier

Are all tobacco control materials and resources created equal?

That's a question that researchers, public health officials, health care professionals and even The New York Times are raising as tobacco companies produce and distribute tobacco prevention and smoking cessation materials to the health care community and the public.

"It seems incongruent with the mission of a dental office to display or use materials provided by companies who produce a product that when used as intended can kill you," says Cathy Backinger, Ph.D., acting chief, Tobacco Control Research Branch, National Cancer Institute.

She cautions dentists to carefully evaluate the entities that produce tobacco control resources and materials. "Is it a trusted source?"

Materials available from the National Cancer Institute, she adds, have been shown through scientific research to be effective tools in helping smokers quit.

Smokers who want to quit and parents who want to prevent their children from smoking have a variety of resources at their disposal proven to be effective tools, she says.

"There are some 45 million smokers and we need to have a variety of ways to help them quit," Dr. Backinger says. "Brochures are helpful for some; interactive phone quitlines and online resources provide support; physicians and dentists can provide counsel and, consistent with applicable state law, prescription medications to help. Not every individual responds to one method, but there are a variety of choices out there, and we hope they choose materials from a trusted source."

In November 2006, when Dr. Backinger heard reports of dental offices displaying and distributing QuitAssist materials produced by Philip Morris USA, she sent a letter to ADA President Kathleen Roth.

"Dental offices are a prime location to promote the health importance of both tobacco prevention and cessation. The implied endorsement of the Philip Morris QuitAssist materials is incompatible with the aims of dental offices that are concerned with patients' oral health," she wrote. "The tobacco industry markets a product that is both highly addictive and lethal under normal conditions of use. Thus, dental professionals' goal of oral health and those of the tobacco industry are fundamentally different and irreconcilable."

Philip Morris USA spokesman David Sutton says health care providers and consumers can request free QuitAssist materials from the company or obtain them on the PMUSA Web site.

The company in 2006 also distributed 2.4 million guides to U.S. dental offices through a third-party vendor. Since the QuitAssist program was launched in 2003, its Web site has logged more than 1.5 million visits and it has been promoted through "onserts" on more than 750 million packs of the company's cigarettes.

"We want to make health care professionals and the public aware of the resources we offer and the opportunity for them to obtain more," says Mr. Sutton. "We are trying to raise awareness of our smoking cessation efforts."

In her letter to Dr. Roth, Dr. Backinger said tobacco products are responsible for more than 440,000 American deaths each year.

"Because tobacco use is responsible for about 30 percent of all cancer deaths, efforts to prevent and control tobacco use are a very high priority for the National Cancer Institute. Recently, some tobacco companies have sought to portray themselves as interested in helping to prevent youth smoking, or in helping adults to quit. … Some individuals may benefit from cessation information provided by Philip Morris. However, many more will suffer, so long as the company's aggressive marketing efforts continue."

According to the Campaign for Tobacco-Free Kids, the tobacco industry spent $15.1 billion to market and promote tobacco products in 2003—a 21.5 percent increase from the 2002 figure of $12.47 billion and a 125 percent increase since tobacco companies and states reached tobacco settlement agreements in November 1998 that placed restrictions on tobacco industry marketing.

(The 1998 Master Settlement Agreement was signed with 46 states, five U.S. territories and the District of Columbia. Florida, Minnesota, Mississippi and Texas had previously signed settlement agreements. All the agreements combined are known as the state Tobacco Settlement Agreements.)

The Centers for Disease Control and Prevention has set recommended levels that states should spend on tobacco control activities—about 8 percent of approximately $20 billion in settlement funds received each year. According to CDC data, only three states currently fund tobacco prevention programs at recommended levels. Less than half (22 states) fund programs at less than 25 percent of recommended levels—with five states spending none of their settlement funds on such programs.

"State legislatures decide how to use tobacco settlement funds," says Dr. Backinger. "They can and do use them for a variety of things not related to tobacco control."

A study published in the December 2006 issue of the American Journal of Public Health showed "little relation" between exposure to tobacco company-sponsored, youth-targeted ads and youth smoking outcomes. But ads targeted to parents but viewed by older teens may actually increase teen smoking and reduce their perceptions of danger about smoking, researchers concluded.

The study focused on parent-directed ads from Philip Morris USA and youth-directed ads from Phillip Morris and Lorillard Tobacco Co.

"Adolescents need accurate information about the serious health consequences of smoking, and they should be wary of tobacco marketing that portrays smoking as cool and glamorous," says Melanie Wakefield, Ph.D., lead researcher and author of the study. "An important thing that parents can do to prevent their kids from smoking is to set a good example and quit smoking themselves. Or, if they don't smoke, make their homes and cars smoke-free."

Dr. Wakefield, a behavioral scientist, is director of the Centre for Behavioural Research in Cancer for the Cancer Council Victoria, in Melbourne, Australia. The study was supported by grants from the National Cancer Institute State and Community Tobacco Control Initiative, the National Institute on Drug Abuse and the Robert Wood Johnson Foundation.

"Parents can also support smoke-free laws, tobacco tax increases, tobacco advertising bans and funding for real tobacco prevention and quitting programs sponsored by state and federal governments," Dr. Wakefield adds.

A statement on PMUSA's Web site regarding the AJPH study and its television ad campaign, "Talk. They'll Listen," says, "Based on June 2006 research, 61 percent of parents of kids 10 to 17 years old reported being aware of at least one ad from the campaign. Of those aware, 61 percent reported having talked to their child about not smoking as a result of seeing the ad."

Philip Morris USA established its Youth Smoking Prevention Program in April 1998—about seven months before tobacco companies signed the Master Settlement Agreement.

Since the YSP program's inception, PMUSA has pumped about $1 billion into the program, over and above the $30 billion it has sent to the states during the last eight years through Tobacco Settlement Agreements, says Mr. Sutton.

"We believe that kids should not smoke," says Mr. Sutton. "This is a product intended for adults only, and we put our money where our mouth is."

YSP encompasses a variety of activities, including research and research reviews on youth behavior and smoking rates, parent communications, grant programs, and a variety of strategies designed to prevent youth from gaining access to tobacco products, Mr. Sutton says.

The program's parent resources were created in conjunction with an advisory board of psychologists, psychiatrists and public health professionals, chaired by Lawrence Kutner, Ph.D., clinical psychologist; lecturer, Harvard Medical School Department of Psychiatry; and president, Health Communications Consultants Inc. Dr. Kutner is a former columnist on child development and parent-child communication for The New York Times and Parents magazine, and author of five books on those topics.

"Our advisory board is an independent group that works to ensure the scientific accuracy and developmental appropriateness of the print and online materials for parents funded by the PMUSA Youth Smoking Prevention program," says Dr. Kutner. "Our goal is to provide accurate, practical and effective resources that parents can use to help prevent kids from using tobacco in any of its forms."

Dr. Kutner says that in addition to the health consequences of smoking he's seen clinically, he works in youth smoking prevention and smoking cessation for a more personal reason.

"Both of my parents were smokers," he notes. "Both died from smoking-related cancers by the time I was 18 years old. I know the health consequences of smoking. No child should have to deal with that."

The advisory board, he says, has no involvement in television campaigns for PMUSA print and online materials.

"We're providing our expertise to parents," Dr. Kutner adds. "PMUSA is getting the same advice and counsel we would provide to any youth smoking prevention group. As independent consultants, each of us would walk away from the project if we ever feel that our advice is being either ignored or misused. I was initially concerned that this effort at youth smoking prevention might be a ruse, and that our advice would be ignored. Other members of the advisory board initially had the same concerns—indeed, I'd be suspicious of any health care professional who did not."

PMUSA's financial resources, he says, have served to "distribute approximately 70 million co pies of our brochures through a variety of channels—numbers that most youth smoking prevention programs can only dream about."

Philip Morris has placed paid advertisement inserts promoting the free parent brochures and tip sheets in their "Raising Kids Who Don't Smoke" series in a variety of health trade publications, including the November 2006 Journal of the American Dental Association.

Dr. Scott L. Tomar raised an objection to the insert in a letter to JADA Editor Michael Glick.

"Philip Morris' advertising campaign focuses on peer influence, parental factors and commercial access being the primary influences on youth smoking initiation, rather than tobacco industry marketing, inaccurate risk appraisal, price and other factors known to influence youth smoking," wrote Dr. Tomar, professor and chair, Department of Community Dentistry and Behavioral Science, University of Florida College of Dentistry. He opined that, "The available evidence suggests that not only is this tobacco industry campaign not effective in reducing youth smoking, it was associated with lowering youths' perceived harm of smoking."

Even The New York Times has weighed in recently on the issue. An editorial in its Nov. 27, 2006, issue, states, "Philip Morris says it has spent more than $1 billion on its youth smoking prevention programs since 1998 and that it devised its current advertising campaign on the advice of experts who deem parental influence extremely important. But the company has done only the skimpiest research on how the campaign is working. …

"Philip Morris, the industry's biggest and most influential company, is renowned for its marketing savvy," the Times editorial adds. "If it really wanted to prevent youth smoking—and cut off new recruits to its death-dealing products—it could surely mount a more effective campaign to do so."

In a published response to the editorial, Jennifer Hunter, vice president, Youth Prevention and Corporate Responsibility Programs for Philip Morris USA, said, "We understand the skepticism regarding how a tobacco company can be serious about preventing youth from smoking, but our business is grounded in competing for the largest share of the adult tobacco market. As a business and as parents, we don't want kids to smoke, and when society feels that we behave otherwise, it actually harms our business. … While we have serious concerns about the design and conclusions of the study cited in your editorial, the study does highlight the need for continued understanding of how parent-directed youth smoking prevention advertising affects youth. We intend to pursue this issue and to engage with relevant experts to identify opportunities to improve all youth smoking prevention efforts, especially our own." 

For more information on smoking cessation resources, visit www.ada.org/goto/quitsmoking.