Public Health Magazine: Spring 1996, Vol.4, No.1
Smoke Alarm!-- Keeping Kids from Getting Hooked

By Sharon Lerner

Since it is widely acknowledged that smoking is extremely harmful and hard to shake, what more is there to say? Plenty, as demonstrated by escalating legislative and legal disputes, and by the range of opinions proferred by some Columbia graduate school faculty members. And as President Clinton and the Food and Drug Administration prepare to take action on tobacco regulation, now may be the most important time for voices to be raised against a habit responsible for the premature death of more than 400,000 Americans annually.

At the Columbia School of Public Health, research is targeted at reducing and preventing harm from tobacco. Exploring how people become addicted in the first place, how smoking affects the health of different segments of the population, and which prevention efforts work (and which do not), point toward the same end: protecting the public's health.

However, when scholars at Columbia's law, journalism, and business schools grapple with similar issues, they come up with different questions-and answers. At the same time that a law professor is asking, "What legislative authority does the FDA really have to regulate smoking?" the journalism school's monthly magazine, Columbia Journalism Review, features a cover story about the ABC television network's apology to cigarette-maker Philip Morris for reporting that the company manipulated nicotine levels in its products. Meanwhile, business school students dissect tobacco company conduct in discussions of business ethics.

The Role of Public Health Research

Like many other public health issues, one of the most important functions of smoking research is to trace etiology, in this case, to explore how, why and when more than 46 million adults in this country first light up. Denise Kandel, Ph.D., a professor in SPH's Sociomedical Sciences Division, looks as far back as gestation for one answer.

Anatomical differences between the brains of male and female fetuses may predispose women to tobacco addiction later in life, according to Denise Kandel. Another possibility: a genetic factor related to depression.

In a study of maternal smoking during pregnancy, Kandel found that, while accounting for social influences, girls whose mothers had smoked during pregnancy were four times more likely to smoke during adolescence than those whose mothers didn't smoke during their gestation. Published in the American Journal of Public Health (September, 1994), the study suggested that nicotine may cross the placental barrier and affect nicotine receptors in the brain during a critical period of fetal development. Kandel speculates that hormones or perhaps anatomical differences between the brains of male and female fetuses may play a role in predisposing females to tobacco addiction later in life.

Whatever the exact mechanism of increased risk, Kandel's findings are part of a growing number of newly identified tobacco-related health effects. Along with second-hand or environmental tobacco smoke, knowledge about the effects of in utero exposure may help to deter people from smoking.

Methods for the precise measurement of levels of damage caused by smoking have been developed by Regina Santella, Ph.D., Division of Environmental Health Sciences. These biological markers of smoke exposure in the blood called molecular dosimeters, are being used by Santella and Frederica Perera, Dr.P.H., a molecular epidemiologist, to probe the effects of smoking as well as environmental exposure to tobacco and other carcinogens. In one study using biomarkers (chemical "fingerprints" on DNA) for smoking, differences were found in the umbilical cord blood of babies born to smokers and non-smokers. In another biomarker investigation, levels of the same chemical were found bound to protein in the blood of children of light smokers.

Perera admits that, to some lay people, her findings may fall victim to the "so-what factor." But she and her colleagues are quick to point out that their work has helped to clarify the importance of environmental exposures and genetic susceptibility. It also confirmed that there is a subgroup of the population that is highly sensitive to the effects of both active and passive smoking. Ultimately, Perera hopes that her investigations will magnify the importance of behavior modification and help prevent exposure of youth and adolescents.

Voluntary Versus Involuntary

More often than not, childhood exposure to cigarette smoke is considered to be involuntary. But that definition is clouded by estimates that upwards of 90 percent of smokers start puffing before age 18. Of course, it is illegal to sell cigarettes to anyone under this age, a fact that many vendors and advertisers ignore.

Don Gemson, M.D., M.P.H., co-director of the Harlem Center for Health Promotion and Disease Prevention, recently explored ways to prevent sales of cigarettes to children by vendors in Central Harlem. He found that a startling 98 percent of 176 Central Harlem stores tested sold cigarettes to 12- and 13-year-old volunteers, despite New York's law specifying that people must be 18 years old and look at least 25 years old to buy cigarettes without identification. Not surprisingly, the research indicated that while educational messages helped prevent future sales, those who were fined were even less likely to be caught selling again during subsequent rounds of data gathering.

The Impact of Research

The findings of all three researchers-Gemson, Perera and Kandel-have important policy-making potential that ultimately could fuel anti-tobacco regulation. But the future of smoking hinges not only on public health research evidence, but also on the news media that reports the research, and the legal and political systems that are charged with protecting the public.

Ken Goldstein, a professor in the school of journalism, sees two ways his profession can combat smoking. It can choose not to accept tobacco advertising (such advertising has been shown to influence whether a publication prints information about the negative effects of tobacco), and it can be straight forward in writing about the tobacco issue in general.

Regina Santella (left) and Frederica Perera are working to clarify the effects of genetic susceptibility and environmental exposure to tobacco. They hope that a clearer understanding of in utero risks may discourage people from smoking.

While the new wave of litigation involving personal injury from tobacco holds promise, Grad is more hopeful about legislation that has a direct impact on the industry, such as limiting political campaign contributions. "It's the best way to get at them," he says, referring to politicians who have a stake in, or who support, the tobacco industry. One likely target would be Representative Thomas Bliley (R-VA), chair of the Congressional commerce committee and recipient of more tobacco industry contributions than any other member of Congress.

Grad also predicts that two other tactics will increasingly be employed to bring pressure to bear on cigarette makers. One is further legislative and legal campaigns by states against tobacco companies to recoup health care costs related to cigarette smoking. Another is action by international bodies such as the World Health Organization to restrict tobacco exports to developing countries.

All signs indicate that all these steps will be necessary to eradicate the epidemic of smoking-related diseases, given the strength of the tobacco industry, which has annual revenues of more than $48 billion. Some oppose tobacco regulation on the grounds that measures aimed at limiting people's personal behavior are intrusive. "The logic of a government crusade against cigarettes is tantamount to a second prohibition," says business school professor Bruce Greenwald, adding, "It didn't work very well the first time."

In response, CSPH's Gemson asserts that there is no government crusade per se to prohibit smoking. Furthermore, what little "crusading" the government has engaged in has been effective, he says, as evidenced by the fact that the percentage of Americans who smoke has dropped from about 42 percent in 1964 (the year of the Surgeon General's report), to 25 percent today.

For his part, Greenwald argues that moral suasion, not government intervention, is responsible for the striking drop in smoking rates. Therefore, he maintains, the country should rely on that same moral encouragement, rather than regulation, to further reduce tobacco use.

Casting a harsh economic eye on ideas widely accepted within the public health community, Greenwald holds that the second-hand smoke argument is a diversion from the main point. Namely, he says that health risks to non-smokers are negligible compared to those for smokers.

Such thinking might confound legitimate aspects of the debate, Gemson insists. "There is no controversy about the health effects of tobacco-it is the undisputed number one cause of death in our society."

He asserts that the current debate centers around how best to prevent children and adolescents from becoming addicted to nicotine, and that "regulatory proposals, like those from the FDA, can have a real impact on limiting tobacco advertising aimed at youth, as well as help restrict childrens' access to tobacco. Public health professionals need to keep abreast of the changing political climate as it affects tobacco control so that we can be more effective advocates for the health of the public."