Opinion: Cigarette smoking’s growing income gap

By: Peter Orszag

The income gap between smokers and nonsmokers has grown. And it’s something companies may need to address directly in their efforts to help employees kick the habit.

Over the past several decades, smoking rates have fallen sharply among high-income, highly educated Americans and not as much for less educated, low-income people. The result is that, in 2013, the smoking rate exceeded 20 percent for people with a high school degree or less while among those with a graduate degree it was just 5.6 percent. Among people living in poverty, smoking was almost twice as common (29 percent) as among those at or above the poverty line (16 percent).

The good news is that the financial incentives many companies are considering, and some are now using, to help people quit smoking can work, as a new study in the New England Journal of Medicine shows. The researchers randomly assigned employees of CVS Caremark and their relatives and friends to different groups, which were given various financial incentives to stop smoking. This study did two fabulous things that are unfortunately quite unusual in the corporate wellness field: It used a randomized controlled trial (to boost confidence in the causality of its results), and it paid careful attention to the teachings of behavioral economics – testing, for example, whether carrots or sticks were more effective.

The results were encouraging. People who were told they would receive an individual bonus of $800 for quitting stopped at almost three times the rate of those not offered any direct financial inventive. Behavioral theory generally suggests, though, that loss aversion would work even better. In other words, if subjects made an initial deposit that they would stand to lose if they failed to quit, that would provide an even stronger incentive. And that was indeed the case, the researchers found, but people had to be willing to make the deposit in the first place. And because many were not willing to do that, the bonus approach was more effective overall. So unless a company finds a way to force its employees to follow the stick approach, the bonus works better.

These findings were widely reported in the news, but one thing went largely if not entirely unnoticed: A table in the appendix to the study showed that, for each of the four kinds of interventions studied, the share of high-income smokers who quit – those earning $60,000 or more – was larger than that of lower-income smokers. The reason, according to the study’s lead author, is that lower-income smokers were less willing to participate under any of the incentive programs offered. That was true despite the bonus or deposit being the same dollar amount for everyone, and therefore a higher share of income for lower-paid workers.

Reducing smoking among any group of employees is a good thing, and companies should act on this new research. At the same time, it is reasonable to be concerned about the gap in smoking rates by socioeconomic status, which is one of the forces widening the gaps in life expectancy by education and income. To reverse this trend, disproportionately larger dollar bonuses may be needed to get lower earners to quit.

Contact Peter Orszag at porszag3@bloomberg.net

http://www.delawareonline.com/story/opinion/contributors/2015/05/26/cigarette-smokings-growing-income-gap/27977649/

Forum editorial: Minnesota tobacco use down

The anti-tobacco work of ClearWay Minnesota in conjunction with other tobacco cessation efforts has had remarkable results in reducing smoking rates among all age groups in Minnesota. It’s a record worthy of high praise. It’s unambiguous evidence that focused, science-based anti-tobacco campaigns can work.

Numbers released last week by ClearWay show only 14.4 percent of Minnesotans smoke cigarettes, down from 22.1 percent in 1999. The decline through the time period has been steady, and corresponds to increased education and imposition of legal restrictions on smoking in public places. Add new medical research about second-hand smoke, and graphic anti-smoking television advertising, and it appears the multi-faceted message is getting through.

But not to every age cohort.

In ClearWay statistics from 2010 to 2014, smoking hardly dipped at all (1 percent) in the 25-44 year-old group, from 19.7 percent to 18.7 percent. A similar slight improvement was measured in the 45-64 year-old cohort, compared with a huge drop (from 21.8 percent to 15.3 percent) in Minnesotans age 18-24. Which could lead to the conclusion that some Minnesotans don’t get smarter as they age. But whatever the reason, the overall percentages of all Minnesotans who smoke is down over the longer study period, and that’s good news for smokers who quit, non-smokers and reduced impacts on health costs associated with tobacco use. The trends are good.

ClearWay is not resting on its excellent record. In the eight years it has left in its mandate (funded by the national tobacco settlement of a few years back), the agency’s agenda includes raising cigarette taxes, which all studies show discourage young people from purchasing tobacco, and raising the age for tobacco purchases from 18 to 21. Again, research finds that raising the age to beyond high school age contributes to fewer high school students trying tobacco. New York City and Hawaii have already taken that step.

There is still much to be accomplished to achieve as smoke-free a society as possible. A lot has been done, often led by private sector companies that banned smoking from the workplace before cities and states enacted overall smoking bans in buildings and, in many instances, outdoor public spaces. Decades of research into smoking-related illness and death, and the proven health hazards of secondhand smoke, have been the underpinnings of changing public policy. ClearWay’s work and similar complementary efforts have been pivotal in changing the way enlightened Americans view tobacco use.

Forum editorials represent the opinion of Forum management and the newspaper’s Editorial Board.

http://www.inforum.com/opinion/editorials/3751883-forum-editorial-minnesota-tobacco-use-down

Fargo Forum: Anti-tobacco groups eye raising purchasing age to 21 in Minnesota

By Patrick Springer

MOORHEAD – Minnesota tobacco control advocates may propose raising the legal age for buying cigarettes to 21 years old.
Hawaii, New York City and more than 30 municipalities in Massachusetts have raised the legal age for buying tobacco, and the experiment will be closely watched, said Andrea Mowery, vice president of ClearWay Minnesota, a foundation that promotes prevention and cessation of smoking and tobacco use.
ClearWay Minnesota, funded by the state’s share of the 1998 tobacco settlement, will only move ahead with a proposal if a wide consensus of health groups and public health groups agree the approach has merit, Mowery told The Forum editorial board.
“We’re part of a broad coalition,” she said, and listed the American Cancer Society, American Lung Association and American Heart Association as frequent partners. “There’s a very collegial and collaborative process.”
More than 9 of every 10 smokers start before the age of 19 or 20, a reality that is behind the nascent movement to raise the legal age for buying tobacco, Mowery said.
Earlier efforts, which public health officials credit with reducing smoking rates, have centered on raising tobacco taxes and banning smoking in public places.
Teenagers are especially sensitive to price increases spurred by tax increases, which have been shown to be the most effective means to date of curbing youth smoking, Mowery said.
“Youth and young adults are much more sensitive to price,” she said.
Smoking prevalence continues to decline in Minnesota, where the smoking rate stood at 14.4 percent last year, down 35 percent since 1999 and the lowest rate ever recorded, according to the Minnesota Adult Tobacco Survey in 2014.
“So really significant progress,” Mowery said.
The national adult smoking rate is 19 percent. In North Dakota, the adult smoking rate was 21.9 percent in 2011, according to the Centers for Disease Control.
Persistent gaps remain in smoking rates, with those who have less than a high-school education the most likely to smoke, with a rate of 28.6 percent.
Young adult smoking decreased by 6.4 percentage points over the past four years, dropping to 15.3 percent from 21.8 percent, the only noteworthy decline for any age group.
“That is quite a stark departure,” Mowery said.
But that drop coincided with a sharp spike in the use of e-cigarettes, which jumped from a rate of 0.7 percent to 5.9 percent from 2010 to 2014.
The age group most likely to smoke is the 25- to 44-year-old bracket, with a rate of 19.7 percent for men and 18.7 percent for women.
American Indians smoke at a rate that far surpasses the overall population—a rate of 59 percent, quadruple the 14.4 percent overall rate.
“On the whole we’re making good progress,” Mowery said, adding that challenges remain.
http://www.inforum.com/news/3748538-anti-tobacco-groups-eye-raising-purchasing-age-21-minnesota

"Darth Vapor" Sending Students to the Hospital

Reported by Michigan 9 & 10 News

A new form of synthetic marijuana is sending teenagers to the hospital.

A Mason County student is in critical condition after inhaling something called “Darth Vapor”, a substance smoked with an E-cigarette.

School officials at Journey High School in Scottville called 911 yesterday afternoon after the 19-year-old had a seizure.

And it’s not the first problem with the drug in the area.

The sheriff says this is the fourth time since March that they’ve seen an overdose on the vapor. They had it tested, and confirmed it’s a form of synthetic marijuana.

It’s not regulated by the state, which he says, makes it hard to prevent more trips to the ER.

“Just because it’s not regulated by state law doesn’t stop you from being a parent. Your parental rights trump state law as far as I’m concerned,” says Mason County Sheriff Kim Cole.

The sheriff wants parents to help prevent more overdoses on “Darth Vapor”, which put a 19-year-old in critical condition

“The big thing is the parents need to know what these kids are getting into. If you see your child has a e-cig look into that, question why they have it and what they’re putting into it because you mark my words were going to be doing a story on somebody dying,” says Sheriff Cole.

Doctors say smoking vapors is the most dangerous way to ingest something, because the toxins have direct access to your blood.

“It’s almost like taking it in an IV. I mean you just absorb it and it doesn’t go through your liver. So you’re getting the drug directly into the vein, into the circulation,” says Dr. Robert Kowalski, and MD at Munson Healthcare Cadillac Hospital.

And because these vapors are so new and unregulated, treatment can be difficult.

“Most of the treatment for these overdoses is symptomatic. In other words we don’t have a specific antidote for these medications or drugs,” says Kowalski

A business in Ludington has agreed to take the vapor off the shelves, but teens can still manage to get their hands on it.

“I would, you know, tell young adults and children that sell it to you. They’re not pharmacists. They’re not physicians they just want to sell you the drug,” says Kowalski.

All of the overdoses involved students in mason county. The Ludington Schools Superintendent says they’re working with staff and students to prevent problems in the future.

————————-

A 19-year-old is in critical condition after inhaling a substance from an e-cigarette.

The call came in Monday afternoon from Journey High School in Scottville.

The man used an e-cigarette to inhale the substance that caused him to overdose.

The Mason County Sheriff says a 16-year-old was taken to juvenile court for giving the vapor to the 19-year-old.

During the investigation, deputies also found an unloaded rifle in the 16-year-old’s car.

The 19-year-old was airlifted to a Grand Rapids hospital for treatment.

Stay with Northern Michigan’s News Leader throughout the day on air and online for more information on this developing story.

http://www.9and10news.com/story/29102864/19-year-old-in-critical-condition-after-inhaling-e-cigarette-substance

MEDPAGE TODAY: E-Cigs Hamper Ability to Cough

Just one exposure significantly diminished cough reflex sensitivity.

by Nancy Walsh, Senior Staff Writer, MedPage Today

DENVER — Exposure to electronic cigarette vapors significantly diminished cough reflex sensitivity in a group of healthy volunteers, a researcher reported here.

Using a capsaicin cough challenge, the time until the concentration of capsaicin that can induce five or more coughs (C5) was significantly longer after an electronic cigarette “vaping” session, rising from a mean log C5 of 0.50 at baseline to 0.79 15 minutes after exposure (P<0.0001), according to Peter V. Dicpinigaitis, MD, of Albert Einstein College of Medicine in New York City.

“We have previously shown that chronic smokers of tobacco cigarettes have reduced cough reflex sensitivity to capsaicin compared with healthy nonsmokers, presumably on the basis of chronic cigarette smoke-induced desensitization of airway cough receptors,” he said.

“What impressed us in this study what that this was just one exposure, and there was a real effect, a significant effect,” he said in a press conference at the annual meeting of the American Thoracic Society.

Electronic cigarettes are increasingly popular devices that are intended to deliver vapor containing nicotine to the lungs without exposing the lung tissue to the damaging products of tobacco combustion. However, little is known about their effects on the respiratory system, and even less is known about their effects on the sensitivity of the cough reflex.

Cough sensitivity is important in that coughing is a very important protective mechanism for eliminating foreign particles, and suppression of this could render someone more susceptible to respiratory tract infection, he explained.

Capsaicin challenge has become a standard research tool for investigating the effects of various exposures on cough reflex sensitivity, in that the challenge is safe, dose-dependent, and reproducible.

To explore these effects, Dicpinigaitis and his colleagues enrolled 30 lifetime nonsmokers who each underwent a single session of vaping, which consisted of 30 puffs on a disposable device at 30-second intervals. This provided an exposure to nicotine of 1.5 to 1.8 mg, which approximates that of a single tobacco cigarette.

The effects on C5 were transient, as was shown by the fact that 24 hours after the exposure, there was a decline in mean log C5 to 0.55 (P=0.0002).

The clinical significance, if any, of this transient, acute effect and the consequences of chronic exposure remain to be elucidated.

But the take-home messages of the study, he said, were that the vapor in e-cigarettes is not simply a benign, inert vapor, and it may have not only this acute, peripheral effect, but it also may have a delayed central brain effect.

Also, the results raise the question of what might happen with prolonged, chronic exposure, given the physiologic effect of just one exposure, Dicpinigaitis added.

http://www.medpagetoday.com/MeetingCoverage/ATS/51600

TIME Health|Research: 4 Weird Health Effects of E-Cigarettes

Justin Worland

Banana pudding-flavored ecigs disturbed the lungs, one study found

E-cigarette research is heating up, and scientists are starting to show that using e-cigarettes can have some surprising health effects, according to new findings presented at the meeting of the American Thoracic Society.

“Millions of people around the world that are puffing e-cigs,” says Peter Dicpinigaitis, professor at Albert Einstein College of Medicine and one of the authors of new e-cigarette research, “but when you look at the scientific literature about the effects of e-cigs, there’s nothing out there.”

Here are some of the newest findings:

Using e-cigarettes suppresses your ability to cough

Smoking an e-cigarette makes you less likely to cough, even when coughing would benefit your health, according to research by Dicpinigaitis. Researchers asked 30 nonsmokers to puff an e-cigarette 30 times in a 15-minute period. After puffing, people in the study were less sensitive to capsaicin, a component of chili peppers that induces coughing. You might think stopping a cough would be a positive side effect, but coughing keeps you from choking and removes agents that may cause infection, says Dicpinigaitis. He presumes that those the effects would continue throughout the day for someone who uses an e-cigarette frequently.

E-cigarette temperature may affect how many chemicals you’re exposed to

People tend to think about the effects of cigarette smoke or e-cigarette vapor when they consider how the products harm their health. But the mechanics of e-cigarettes may also contribute to how much smoking harms your health, according to new research from University of Alabama School of Medicine professor Daniel Sullivan. His research found a correlation between coil temperature and the creation of harmful chemicals like acrolein, acetaldehyde and formaldehyde in the e-cigarette. There are no configuration standards for e-cigarettes, and Sullivan’s research suggests that the lack of consistency makes it hard to assess uniformly the health effects of smoking e-cigarettes.

E-cigarette flavors may have different effects

Researchers tested the effects of flavored e-cigarette liquid on calcium in the lungs and found that not all flavors had the same effect. Five of 13 flavors tested caused changes to calcium signaling in the lungs, according to a study by University of North Carolina at Chapel Hill researcher Temperance Rowell. Hot cinnamon candies, banana pudding and menthol tobacco were among the flavors that disturbed the lungs.

Evidence is growing that e-cigarettes probably aren’t an effective way to quit smoking

E-cigarettes are a popular tool people use to stop smoking, but they may not be the best way, suggests one research review. Using e-cigarettes improved the likelihood that a smoker would quit smoking cigarettes for the first month on the new technology, but the effect dissipated at 3 and 6-month followups, according to a meta-analysis of four studies by University of Toronto researcher Riyad al-Lehebi. He recommended that people who want to quit smoking consider “other more well-established options.”

http://time.com/3860166/ecigs-research/?xid=emailshare

NPR: Smokers More Likely To Quit If Their Own Cash Is On The Line

Richard Harris

Screen Shot 2015-06-03 at 2.19.15 PM

A new study finds that employer-based programs to help people stop smoking would work better if they tapped into highly motivating feelings — such as the fear of losing money.

This conclusion flows from a study involving the employees of CVS/Caremark. Some workers got postcards asking them if they wanted a cash reward to quit smoking. One card ended up in the hands of Camelia Escarcega in Rialto, Calif., whose sister works for CVS.

Escarcega says she had smoked for many years and wanted to quit, and figured money would be a good incentive. Her sister told her she was welcome to enroll in the study, so she did.

Screen Shot 2015-06-03 at 2.15.01 PMEscarcega didn’t know it at the time, but the study was comparing different financial incentives to help people quit smoking. Hers was straightforward: Over a span of six months, she’d get up to $800 if she quit and didn’t start again.

She did pretty well, she says. “I’ve been smoke-free for a year and a half now.” The program offered her free nicotine patches, but Escarcega says she didn’t even need that added help.

Dr. Scott Halpern, a professor of medicine, epidemiology, medical ethics and health policy at the University of Pennsylvania, worked with colleagues to design the study, as a way of exploring the best way to entice people to quit tobacco, using financial incentives.

“A dollar is not a dollar,” Halpern says, “and how you design smoking cessation programs of the same approximate value goes a long way toward determining how effective these programs will be.”

The researchers compared a few approaches. Some people simply got cash for quitting. Others were offered a carrot-and-stick approach. They’d get a similar financial reward if they quit, but they’d also lose $150 of their own money if they started smoking again.

“People are much more afraid of losing $5 than they are motivated to earn $5,” Halpern says. “And so people’s actions go with their psychology.”

It came as no surprise that the researchers found it a lot harder to convince people to put down a deposit of their own money. But when they did, the results were remarkable.

“The deposit programs were twice as effective as rewards, and five times more effective than providing free smoking cessation aids like nicotine replacement therapy,” Halpern says.

More than half of the people who had money on the line stopped smoking for at least six months. These results are reported Wednesday in the latest New England Journal of Medicine. And Halpern argues the approach is much more effective than what most companies do now.

“Many programs are structured such that employees who stop smoking are rewarded by having less money taken out of their paychecks for insurance premiums the following year,” Halpern notes. “But by bundling the rewards into paychecks they’re relatively invisible to people — and the fact that they occur in the future — makes it less influential than if people were handed the same amount of money more quickly.”

Mercer, a benefits consulting company, reports that 21 percent of large employers currently offer financial incentives to workers who quit smoking or don’t start — primarily by reducing their health-insurance premiums. (An additional 5 percent of those companies offer other incentives). And more than half of the nation’s biggest employers use incentives.

Halpern says insurance premium rebates aren’t the best way to go.

“Employers and insurers could do a whole lot more to curb smoking than they currently are,” he says. “And doing so, they would reduce costs to themselves and improve public health.” Each employee who smokes costs a company more than $5,000 extra a year, due to health care costs and other expenses.

This is potentially tricky ground to navigate, though.

“Companies may have a concern that if they sign people into this kind of a wellness program and [the employees] lose that deposit, they’re going to feel really badly,” says Oleg Urminsky, at the University of Chicago’s Booth School of Business.

The worry is that those bad feelings “may spill into other things,” Urminsky says. “Are they going to resent the employer? Are they going to be complaining? It’s a powerful tool but it’s one that has to be used carefully.”

http://www.npr.org/sections/health-shots/2015/05/13/406459255/smokers-more-likely-to-quit-if-their-own-cash-is-on-the-line?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150513

Opinion: E-cigarettes: Doctors' View: E-cigarette, tobacco smoke enough alike to warrant regulation

By Terry Clark, Mary J. Boylan and Joseph Bianco

What are e-cigarettes? Have you ever seen one? Do you know how they work? Are they as bad for your health as traditional cigarettes?

It is fair to say that three or four years ago these were new questions and we did not know the answers. But now we do, and it is certainly time for you to know — and for our St. Louis County Board of Commissioners to know as they consider a vote to help protect citizens of our county from the “invisible” harm caused by these gadgets if being used indoors.

Details about e-cigarettes and their health effects are well-described in a recent report from the California Department of Health, and even more recent good information on e-cigarettes can be found in the News Tribune’s “Our View” editorial on Friday, headlined, “County up next in quest for clear air.”

E-cigarettes is a good news/bad news story. Are they less toxic than traditional cigarettes? Likely. Are they really safe to use? Not likely.

First, how do they work? With no tobacco or cigarette paper to burn, there’s no smoke. They really are electronic gadgets with several sections, one with a small battery, one with a small amount of fluid usually containing some nicotine as well as flavoring and other chemicals, and a high-temperature chamber that converts the liquid into an aerosol or fog to be inhaled by the user (an action called vaping) and then exhaled where it is readily inhaled by those around the user.

What is in this aerosol emitted by the e-cigarette? At least 10 chemicals known to cause cancer, birth defects or other reproductive harm, including nicotine, formaldehyde, heavy metals and volatile organic compounds, according to the report. It’s not what you or your favorite teenager should be exposed to.

Nicotine, a key ingredient in the aerosol, is highly addictive. Of course, that is why so many users of traditional cigarettes said for years that they could quit whenever they wanted but usually never could.

We should all wonder why the three major tobacco companies purchased start-up e-cigarette companies. What do they know that we do not? One thing is this: Kids who start using purportedly safer e-cigarettes often switch and become traditional smokers or, even worse, dual smokers who use both e-cigs and traditional tobacco cigarettes. They are then addicted to nicotine for decades. Is that what the big tobacco companies are banking on?

Our elected county leaders soon will vote on this simple question: Should e-cigarette use indoors be regulated as a public health hazard just like traditional tobacco smoke? That is, no smoking in indoor places such as worksites, bars, restaurants, stores, arenas, etc.

The city of Duluth and many other communities in Minnesota already have answered this question in the affirmative: Yes, e-cigarette aerosol and tobacco smoke have enough in common to warrant being regulated in the same way under the Minnesota Clean Air Act.

In short, keep them outside.

Terry Clark and Mary J. Boylan are doctors from Duluth. Joseph Bianco is a doctor from Ely.

http://www.duluthnewstribune.com/opinion/columns/3742094-e-cigarettes-doctors-view-e-cigarette-tobacco-smoke-enough-alike-warrant

TIME: San Francisco Bans Chewing Tobacco at Sports Venues

By Olivia B. Waxman

Effective Jan. 1, 2016

On Friday, San Francisco became the first American city to ban smokeless tobacco—chewing tobacco and “moist inhalable snuff”—at sports venues.

The new ordinance, signed by Mayor Ed Lee, goes into effect on Jan. 1, 2016. Violators will be asked to leave the playing fields (where cigarette and cigar smoking is already banned), the Associated Press reports.

Anti-smoking groups argue that a ban on smokeless tobacco—which has been linked to cancer and nicotine addiction—sends the right message to kids who look up to the players. But San Francisco Giants pitcher Matt Cain said the measure may be hard to enforce, noting that coffee pouches resemble tobacco pouches, according to an article on the team’s website.

The state Assembly is still considering a bill banning tobacco use—electronic cigarettes included—wherever there’s a baseball game, the AP reports.

To read more or watch video: http://time.com/3852742/san-francisco-bans-chewing-tobacco/

Reuters Health: Youth who receive tobacco coupons may be more susceptible to smoking

BY KATHRYN DOYLE

(Reuters Health) – Middle and high school students exposed to tobacco coupons were more likely to find smoking “cool” and less likely to feel confident in quitting if they already smoked, according to recent U.S. survey data.

Some kids may encounter the coupons for free or discounted tobacco products passively, via direct mail campaigns aimed at their parents, but the coupons are also often sent by email and are readily available on the Internet.

“In previous studies, my collaborators and I found that exposure to cigarette coupons predicts smoking progression in youth and young adults and reduces likelihood of cessation among general adult smokers from the U.S. upper Midwest,” said the study’s author, Dr. Kelvin Choi of the National Institute on Minority Health and Health Disparities in Bethesda, Maryland.

This new national sample of middle and high school students who were included in the current analysis can be generalized to youth across the United States, Choi told Reuters Health in a statement.

Choi’s opinions do not necessarily reflect those of the National Institutes of Health, Department of Health and Human Services, or the United States Government, the statement added.

Using the National Youth Tobacco Survey 2012, Choi examined questionnaire responses from more than 24,000 middle and high school students, who reported if and where they had received coupons from a tobacco company over the past 30 days.

Almost 10 percent said they were current smokers, 16 percent were experimenters and almost 75 percent were non-smokers.

Thirteen percent of the students had received tobacco coupons over the previous month, most often digitally – by text message, Internet or social networks – and sometimes by paper mail or on tobacco packages themselves.

In the survey, kids who had been exposed to these coupons in any form were less likely to disagree with positive statements about cigarette smoking, such as that it helps young people fit in and have more friends. They were also less likely to agree with negative statements, such as that all tobacco products are dangerous.

The kids who were exposed to the coupons but had never smoked gave survey responses that suggested they were more susceptible to trying smoking, and those who were smokers gave responses suggesting they were less confident in their ability to quit.

Among those who experimented with cigarettes, kids who saw the coupons were more likely to purchase cigarettes over the next month, as reported in Tobacco Control.

“It is well-established that a wide variety of psychosocial factors are associated with smoking and are likely on the causal pathway to smoking,” said Dr. Jennifer O’Loughlin of the department of social and preventive medicine at the University of Montreal in Canada, who was not part of the new study.

“Note that one of the determinants of tobacco use is pricing,” O’Loughlin told Reuters Health by email. “Coupons directly reduce the price and may be a powerful incentive for tobacco use.”

But with a study of only one point in time, like this one, it is difficult to determine which came first, the coupons or the smoking, she said.

Without a long-term study randomizing kids to receive these coupons, it will be difficult to establish that the coupons cause kids to smoke, and therefore difficult to hold coupon distributors responsible, she said.

“In kids especially (who may be particularly vulnerable to advertising and promotion), it is vital to combat anything that contributes to the social norm that tobacco smoking is OK,” O’Loughlin said.

Since kids can download coupons from the Internet easily, they may easily do so without their parents’ knowledge, she said.

“We found that cigarette companies say on their websites that they do not target anyone under the age of 21 with direct mail materials, although their compliance with this self-regulation is unknown,” Choi said. “Interested youth could also potentially bypass the age-verification on cigarette company websites using someone else’s or inaccurate identification.”

On the Internet and in social network channels, it is much harder, if not impossible, to enforce stringent age-verification, he said. “Plus, as we found in a previous study, individuals give coupons to others if they don’t use them,” he said.

http://www.reuters.com/article/2015/05/06/us-adolescent-smoking-coupons-idUSKBN0NR25Q20150506