The Battle for Hearts and Lungs

Read the transcript of a live, online discussion with with Linda C. Hancock, the assistant director of health promotion at Virginia Commonwealth University, about what, if anything, should be done to combat smoking among college students. Printer friendly E-mail article Subscribe Order reprints

By ELIZABETH F. FARRELL

Los Angeles

In the small roped-off area designated for smokers outside of Maloney's bar, students from the University of California at Los Angeles are packed like cattle in a holding pen.

It's a Thursday night in February, and Amara A. Getzell, a 22-year-old senior, stands with her friends amid plumes of cigarette smoke. Taking a drag from her Parliament Light, Ms. Getzell tells a reporter that she is not really a smoker. "It's more of an off and on thing for the past four years," she says, laughing. "I usually only smoke 5 to 10 a day, but when I go out, it's more like 15."

"She's lying! She smokes a pack!" her friend chimes in.

Ms. Getzell rolls her eyes: "Whatever! That's only because I give them out to other people!"

Like many student smokers, Ms. Getzell refuses to call her habit an addiction. Even students who admit they are smokers are hesitant to confess their dependence on nicotine. Of about two dozen students seen lighting up at UCLA last month, only four identified themselves as smokers, and only two said that quitting would be difficult for them.

Smokers who do not think they are addicts are not likely to attempt quitting, and that may explain why some tobacco companies are courting college students more aggressively than ever. Maloney's is one of many popular Los Angeles nightspots frequented by Camel cigarette promoters, according to lists of tobacco-industry promotional events compiled by California's attorney general. Many students here say they have received free lighters and packs of cigarettes from marketing representatives.

Such promotions are not unique to Los Angeles. Tobacco companies are effectively reaching college students throughout the nation: A study published by the American Journal of Public Health in 2004 revealed that students at all but one of 119 colleges surveyed had attended a tobacco-sponsored social event at a fraternity, bar or club, or campus venue in the previous year.

Those marketing efforts are paying off. Despite a litany of anti-tobacco education efforts at the elementary- and secondary-school level, the number of young adults who smoke is on the rise. In 2004 the Centers for Disease Control and Prevention reported that tobacco use among all age groups had decreased, with the exception of 18- to 24-year-olds, 28.5 percent of whom reported that they were smokers, up from 24.5 percent in 1990.

Other evidence also suggests that college students in particular are picking up the habit. UCLA's 2004-5 survey of 300,000 incoming college freshmen found that only 6.4 percent had smoked in high school, but the 1999 Harvard School of Public Health College Alcohol Study, which surveyed more than 10,000 college students, found that 32.9 percent had smoked in the previous 30 days. At UCLA, the rate was slightly lower in a recent study, at 25 percent.

The Masters Settlement Agreement, a landmark agreement in 1998 between 11 tobacco companies and 46 states, 5 territories, and the District of Columbia, placed restrictions on marketing tobacco to children. The industry responded to the new rules by spending more on marketing to "entry level" smokers -- those ages 18 to 24. In 2002 alone, the marketing budgets of the 11 companies exceeded $12.5-billion, a 81-percent increase from the $6.9-billion they spent in the year before the settlement, according to the Federal Trade Commission.

The Masters settlement also gave college health centers the resources to fight back against big tobacco like never before. One stipulation of the settlement requires the 11 tobacco companies to pay more than $200-billion to the 46 states over a 25-year period as compensation for the costs of tobacco-related deaths and injuries. That money has trickled down to colleges in the form of a record number of grants for campus smoking-prevention and smoking-cessation programs. In Pennsylvania alone, each college in the state-university system is eligible for up to $18,000 in grant money for its anti-tobacco efforts through Students Working Against Tobacco, a program established in 2003. Before the program, state colleges relied on small grants of $100 to $1,000 for their smoking-prevention campaigns.

While some colleges are attempting to develop innovative anti-smoking efforts, other institutions, including UCLA, view smoking as a minor health concern relative to the others that strain their limited budgets. "Colleges tend to regard it as a low priority because they find low smoking rates," says Tess Boley Cruz, an assistant professor of research in preventative medicine at the University of Southern California. "But it may be that they're not paying close enough attention."

Hitting the Bars

At a popular college nightclub in Hollywood on a recent Thursday night, three young representatives for Camel cigarettes, an R.J. Reynolds Tobacco Company brand, work their marketing magic inside a large green tent called the Smokers Lounge. One sits at a small card table with a sign that bears a discreet Camel logo as the other two, a clean-cut man in khakis and a woman in a newsboy cap, mingle with patrons and offer them free cigarettes.

In exchange for letting the promoters scan their driver's license for their name and address, and the bar code on their own pack of cigarettes, customers can choose from a boxful of cartons containing assorted Camel brands: lights, regulars, menthols, and Turkish Gold. Some receive free lighters, too.

Although they are friendly to the strangers here, all three Camel representatives decline to give their names to a reporter. When asked about their promotional strategies, one insists that Camel does not market specifically to college students. "We're not soliciting new smokers, we're just trying to get existing smokers to switch brands," he says. "They have to have a pack already for us to scan if they want to get free samples."

His colleague tells a different story, though. "We would probably give them cigarettes anyway if they didn't already have a pack," he says. "It's all about the numbers."

The process of becoming a smoker is gradual, and for many college students, the smoking habit begins as something they do only when drinking. Free giveaways at bars, providing students with more cigarettes than most will smoke in an evening, ensure that they will have cigarettes around when they are sober, making them more likely to start smoking regularly, college health experts say.

Tobacco companies, aware that smoking habits change gradually, are constantly on the lookout for opportunities to convert casual smokers into habitual ones. A 1994 internal memorandum from Philip Morris's advertising consultants, Young & Rubicam, released as part of the tobacco settlement, describes students as an opportune market because of the stress they may feel in response to all the changes happening in their lives: "During this stage in life, some younger adults will choose to smoke and will use smoking as a means of addressing" these transitions. The memo notes that an entering college student, "away from the regiment of high school and his home," is likely to take up the habit or, if he is already a smoker, to start smoking more frequently.

As part of a new policy introduced in 2002, California requires all tobacco companies to register their promotional events with the state. Even though smoking is now banned from bars and clubs in the state, tobacco companies registered more than 35,000 events in 2004 alone. "It's a great way for them to promote their product while students' inhibitions are lowered by alcohol," says Ms. Cruz.

Despite the restrictions on youth marketing and billboard advertising stipulated in the tobacco settlement, "adult-only facilities" were explicitly exempted from any of the marketing limitations placed on other venues. Once promoters reach potential customers at such locations, there are few regulations on how they can hawk their products.

R.J. Reynolds did not respond to requests for comment on its marketing practices. But at least one rival company insists it refrains from pushing cigarettes to students. Dana Bolden, a spokesman for Philip Morris USA, said his company never gives out free samples and avoids doing anything that "could be perceived as an attempt to market to them." As one example, Mr. Bolden mentions that Philip Morris has voluntarily adopted a policy forbidding it to advertise its tobacco products in college newspapers.

Yet U.S. Smokeless Tobacco, which owns such popular chewing-tobacco brands as Skoal and Copenhagen, acknowledges that it goes after the college-student market by sponsoring promotional parties at fraternities and hiring college students to distribute free samples. "The reason we have any presence there is because it's an adult environment," says Jon Schwartz, a company spokesman. "It's a legal practice, and we register events in states that require us to."

Mr. Schwartz says he is not sure if fraternities are compensated for holding events. But according to a report by the Bacchus & Gamma Peer Education Network, a national association of college health educators, fraternities often receive cash or prizes for distributing a specified amount of chewing tobacco. For instance, the organization reports that U.S. Smokeless Tobacco approached a fraternity at the University of Colorado at Boulder in the fall of 2003 and offered the members a chance to win a 42-inch plasma television in exchange for filling a three-foot tall container with empty chewing-tobacco tins (the fraternity declined).

At a recent marketing event at the University of California at Davis, the Alpha Gamma Rho fraternity hosted a "South of the Border" theme party at which U.S. Smokeless representatives handed out free samples of Skoal and Copenhagen chewing tobacco.

Contests for expensive electronics and pool tables are especially popular at fraternities because members of Greek organizations tend to smoke at much higher rates than their non-Greek counterparts.

Some tobacco companies also hold spring-break promotions, with drawings for lavish prizes, as well as promotional giveaways -- T-shirts, caps and sunglasses bearing the companies' logos -- at college vacation destinations like Shasta Lake, Calif., and Daytona Beach, Fla.

Students "have to give out their addresses to get these prizes, which allows the tobacco companies to send them even more stuff through direct mail," says Olivia R. Senn, associate director of health promotion at Bacchus & Gamma. "It's a very effective way for them to stay in contact with the smoker and develop a personal relationship with them. They send them free things at least once a month."

Reaching Beyond Restrictions

As some tobacco companies focus intensely on student smokers, many colleges are attempting to discourage tobacco use on their campuses. In the past few years, measures such as banning cigarette sales at campus stores, forbidding smoking in dormitories, and instituting policies against smoking inside a particular radius around campus buildings have become popular means of clamping down on puffers in academe.

Attempting to regulate smoking at parties and bars, where students are much more inclined to smoke, is far more challenging. But students at the University of Nevada at Las Vegas are trying to do just that with the help of a statewide program called "Urban Fuel."

The students convince top clubs in Las Vegas to go smoke-free for one night while they host an event called "Nasty Habits."

"Our goal is to change the association between drinking and smoking," says Malcolm Alho, who founded the group under a different name while a student at the University of Nevada at Las Vegas.

Since 2002 Mr. Alho has expanded his efforts as a health educator for Nevada's Clark County Health District. He relies on a network of 2,200 young club-hoppers, including many Las Vegas students, to promote the "Nasty Habits" parties.

During those events, volunteers take surveys on their laptop computers, asking attendees if they would prefer a smoke-free nightclub to a smoke-filled one. Typically, about 80 percent say they would come to the club more often if it did not allow cigarettes. Mr. Alho provides club owners with the data after each outing.

Despite the popularity of the events, Mr. Alho says the tobacco companies have many advantages over his group. "We won't go into bars or clubs if their reps are present," says Mr. Alho. "We can't compete with them. They have more money and cooler stuff."

Raffles, Challenges, and Cash

Although they cannot build the hip image that tobacco companies spend billions to create, college health professionals are trying to make their smoking-prevention and smoking-cessation programs more fun than they were in the past. Their main strategy: avoid scare tactics.

"Students think they're invincible, so there's really no point to putting up pictures of black lungs and saying they're going to die," says Ms. Senn, with Bacchus & Gamma. "Those methods obviously didn't work on them in the last 18 years, so they're not going to work now."

Some college health professionals have ditched lectures on the evils of cigarettes in favor of promotional campaigns about the advantages of quitting.

Michael P. McNeil, senior coordinator of health services at Temple University, prefers to help students focus on the things they could buy -- like more CD's -- if they did not spend money on cigarettes. "A lot of them are struggling to pay for school, so we try to use the cost of the habit to motivate them not to smoke," Mr. McNeil says.

Quit-smoking programs tied to cash prizes and raffles for big-ticket items, including DVD players and televisions, are other popular ways to pique students' interest in kicking the habit. To make that challenge less of a drag, some health professionals have created contests in which students compete with other smokers who want to quit.

At Eastern Washington University in 2001, for instance, students received $250 each to participate in the "tobacco-survivor challenge," a weekly contest that tested their ability to resist smoking in situations that were most likely to tempt them.

Some college health officials have found that proactive strategies work, too. At Temple, Mr. McNeil used part of a $29,000 grant he received from Pennsylvania this year to put each member of the university's health-services staff through a training program on nicotine cessation.

After that, staff members started confronting more students about their smoking habits, even if they had come to the health center for unrelated illnesses. The following month, the number of students who came to his office seeking quit-smoking materials tripled.

"There's good research evidence to show that simply asking them if they smoke and providing brief interventions can really help with quit rates," says Jane M. Croeker, director of health promotion at the University of North Dakota at Grand Forks.

Generally, health centers that eschew the traditional approaches, like group-support sessions, and offer individualized services -- such as one-on-one counseling sessions to determine what triggers nicotine cravings -- have the most success.

"First, we have to figure out where they are in their love-hate relationship with this habit," says Linda C. Hancock, the assistant director of health promotion at Virginia Commonwealth University. Last fall Ms. Hancock helped 200 students quit smoking; in previous semesters, programs that relied on a group approach attracted only a handful of students at best. "It's crucial to approach them with the assumption that different things work for different people."

Setting Priorities

Despite the increase in innovative programs at some universities, tobacco prevention often takes a back seat to other student-health problems, including alcohol abuse, depression, and eating disorders. Many college health professionals are stretched too thin to focus on smoking.

At UCLA's student health center, brochures about sexually transmitted diseases, mental illness, and body-image workshops abound, but pamphlets on smoking are absent. The university does not offer any quitting programs for students, and its pharmacy does not stock nicotine-replacement-therapy drugs, like the nicotine patch.

"We don't think it's a huge priority," says Rena Orenstein, heath educator at UCLA's student health center. "These students have grown up with smoking restrictions and the State of California does a really good job with their prevention efforts, so it's not a big health issue we need to address."

Indeed, while eating disorders and excessive drinking pose immediate dangers to students' health, it is unlikely that a college student will drop dead of lung cancer before graduating. Yet the 25-percent smoking rate among UCLA students is significantly higher than the 17.8-percent state average for 18- to 29-year-olds, suggesting that current state efforts are not enough to keep students from becoming addicted to cigarettes.

When California officials announced in January that they were planning to cut $500,000 of the state's $77.2-million budget for anti-tobacco efforts, local and national tobacco researchers warned that history could repeat itself. Previous cuts in anti-tobacco education in California and other states have resulted in higher smoking rates among teens and young adults, according to the national Campaign for Tobacco-Free Kids, based in Washington D.C.

Some campus health officials worry that failing to reach out to student smokers now will cause more students to light up in the future. "The cigarette companies are only more than happy to pick up the slack," says Ms. Cruz at USC. "And they show no sign of stopping."