Right Now | Smoke Out
The Resurrection of the Marlboro Man
Battles about the future of smoking have always been waged over children. For tobacco companies, the young represent the next generation of smokers. Public-health advocates like Barry Bloom and Jay Winsten, on the other hand, know that attitudes shaped as early as elementary school will ultimately affect how many youngsters will die prematurely from smoking, the leading cause of preventable death in the United States (each year, smoking claims nearly half a million lives, and leads to five million premature deaths). Now Bloom, formerly dean of the School of Public Health (SPH) and currently Jacobson Research Professor of public health, together with Winsten, Stanton director of SPH’s Center for Health Communication (CHC), are raising the alarm over a disturbing confluence of new enticements to smoking that target the nation’s most vulnerable cohort.
The latest contests are being waged in movies and video games, on social media, and even in middle- and high-school bathrooms, where students are reportedly inhaling flavored tobacco-free products, predominantly those made by JUUL (pronounced “jewel”), which dominates the e-cigarette market, with more than 70 percent of all sales. Like nearly all e-cigarettes, JUUL’s devices deliver nicotine. The company says its products are designed to help adults quit smoking. But the marketing and flavoring (mint, menthol, mango, and fruit), ease of use (the devices are recharged via USB in any computer), and resemblance to a thumb-drive have made JUUL use popular in schools—and easy to conceal.
“The argument,” says Bloom, is “‘Oh, it’s only nicotine that doesn’t have tobacco tars and cancer agents.’ Nicotine is one of the most addictive substances known. And the object of the tobacco companies, if you get addicted to nicotine, the next step is cigarettes.”
Altria, the parent company of tobacco giant Philip Morris, purchased 35 percent of JUUL in 2018. Nicotine use in adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control, according to the Centers for Disease Control (CDC), and may also lead to increased risk of future addiction to other drugs. (Even the second-hand aerosols from e-cigarettes contain substances—including fine particles, chemicals linked to irreversible lung disease and cancer, and heavy metals—that are probably not safe, particularly for children). The average age when young people begin smoking, says Winsten, was 12.4 in the year 2000. (A study of data from 2014-2016 indicated an average age for cigarette smoking initiation of 12.6 years, and for e-cigarettes of 14.1 years.)
Bloom, Winsten, and CHC deputy director Susan Moses are veterans of these battles. In 2007, building on the work of other advocates, they successfully persuaded the Motion Picture Association of America (MPAA), which includes all the Hollywood studios, to include smoking among the criteria used to assign an “R” rating to a film. Dan Glickman, then chairman of the MPAA, had met Bloom while serving as director of the Institute of Politics at the Harvard Kennedy School, and invited him to come speak to the organization. Bloom, Winsten, and epidemiologist Jonathan Samet ’66, S.M. ’77, then at Johns Hopkins, presented the scientific evidence and consensus, after an introduction from Glickman in which he “pointed out that both his parents were smokers and both died of lung cancer,” Bloom recalls. Screenwriters raised objections over First Amendment free-speech rights, but Bloom felt that none of their concerns represented a substantive constraint on artistic freedom and cited the Supreme Court decision Schenck v. United States; Baer v. United States (1919), in which Oliver Wendell Holmes Jr., A.B. 1861, LL.B. ’66, LL.D. ’95, wrote, “The most stringent protection of free speech would not protect a man in falsely shouting fire in a theatre and causing a panic.”
Winsten illustrated for his audience the power of the Hollywood creative community to effect social change for good by recalling its critical role in promulgating the concept of the designated driver in the 1980s, a concept CHC borrowed from Scandinavia that was rapidly adopted in the United States when writers, at Harvard’s request, incorporated the idea into scripts of top-rated television series such as Cheers, L.A. Law, and The Cosby Show. In 2012, the U.S. Surgeon General’s office quantified the effect of MPAA action, concluding in a report that if movies depicting smoking received an “R” rating, that would “reduce the number of teen smokers by nearly 1 in 5 (18 percent), preventing up to 1 million deaths from smoking among children alive today.”
Although there is less smoking overall in films than there was prior to 2007, says Bloom, the incidence of smoking in movies rated PG-13 (containing some material that may be inappropriate for children age 12 and under) “has been creeping up.” And, he adds, “There is more smoking per film than there used to be, and few of those films have been R-rated at the level one might have expected because of that.”
What concerns Bloom and Winsten most, however, are the new contexts in which children are socially conditioned about behavioral norms. Much has changed since 2007, from smartphones, to YouTube, to streaming services, to targeted advertising on social media. “What’s really worrisome is that there are no constraints on streaming films, which is now an increasing part of what kids watch at home; no legal constraints on JUUL other than that the manufacturer has agreed, in principle, not to market to people under 16, or 18, or 21, depending on the state; and no constraints whatsoever on video games, where smoking has become prevalent”—and in some cases is necessary in order to win the game.
The shifting media landscape notwithstanding, are there lessons that can be extrapolated from the 2007 appeal to the MPAA? Bloom and Winsten believe so. The MPAA still has enormous influence on what goes into movies and television shows, they say. Google, which owns YouTube, could restrict smoking messages from reaching children. And companies like Netflix, whose own productions reportedly depict smoking at twice the rate of other studios, they say, must also be persuaded of the imminent harm that smoking in entertainment can exert, years hence. The pair believe it is time for a renewed effort to enlist the entertainment industry’s help, beginning with an appeal to the MPAA through its current CEO, Charles Rivkin, M.B.A. ’88.