Cigarette Advertising and Adolescent Smoking Reiner Hanewinkel, PhD, Barbara Isensee, PhD, James D. Sargent, MD, Matthis Morgenstern, PhD Background: Although most agree that the association between tobacco marketing and youth smoking is causal, few studies have assessed the specifıcity of this association. Purpose: This study aims to examine the specifıcity of the association between cigarette advertising and teen smoking. Methods: A cross-sectional survey of 3415 German schoolchildren aged 10 –17 years was con- ducted using masked images of six cigarette brands and eight other commercial products in 2008. The exposure variable was a combination of contact frequency (recognition) and brand names (cued recall). Sample quartile (Q) exposure to advertisement exposure was calculated in 2009. Outcome variables were ever tried and current (monthly) smoking, and susceptibility to smoking among never smokers. Results: The prevalence of ever smoking was 31.1% and that of current smoking was 7.4%, and 35.3% of never smokers were susceptible to smoking. Ad recognition rates ranged from 15% for a regionally advertised cigarette brand to 99% for a sweet. Lucky Strike and Marlboro were the most highly recognized cigarette brands (with ad recognition rates of 55% and 34%, respectively). After controlling for a range of established influences on smoking behaviors, the adjusted ORs for having tried smoking were 1.97 (95% CI=1.40, 2.77) for Q4 exposure to cigarette ads compared with adolescents in Q1, 2.90 (95% CI=1.48, 5.66) for current smoking, and 1.79 (95% CI=1.32, 2.43) for susceptibility to smoking among never smokers. Exposure to ads for commercial products other than cigarettes was signifıcantly associated with smoking in crude but not multivariate models. Conclusions: This study underlines the specifıcity of the relationship between tobacco marketing and youth smoking, with exposure to cigarette ads, but not other ads, being associated with smoking behavior and intentions to smoke. This fınding suggests a content-related effect of tobacco advertisements. (Am J Prev Med 2010;xx(x):xxx) © 2010 American Journal of Preventive Medicine Introduction S moking typically begins during childhood 1 and will be responsible for more than 1 billion deaths world- wide during the 21st century if current patterns of smoking continue. 2 One way of controlling the smoking epidemic is to prevent youth from taking up the behavior. Adolescents initiate smoking primarily for social rea- sons. 3 Tobacco marketing is one socializing agent linked with youth smoking, and this serves as the basis for con- trols on smoking marketing contained in the WHO Framework Convention on Tobacco Control, 4 in which Article 13 recognizes that a comprehensive ban on to- bacco marketing would reduce consumption. After the Second World War, Germany was a “para- dise” for the tobacco industry, with few effective tobacco control measures in place. 5 The extent of the influence of the tobacco industry over German politics and scientists was profound. 6,7 For example, on two occasions, and partnering with multinational tobacco companies, the German government challenged European Union direc- tives on tobacco advertising and sponsorship in the Eu- ropean Court of Justice in Luxembourg. 8 Nevertheless, advertising restrictions were implemented gradually, be- ginning with a partial ban on tobacco marketing on TV and radio in 1975 and a ban on the distribution of pro- motional packages in 2004. On December 12, 2006, the From the Institute for Therapy and Health Research (IFT-Nord; Hanewinkel, Isensee, Morgenstern), Kiel, Germany; and Dartmouth Med- ical School (Sargent), Cancer Control Research Program, Norris Cotton Cancer Center, Lebanon, New Hampshire Address correspondence and reprint requests to: Reiner Hanewinkel, Institute for Therapy and Health Research (IFT-Nord), Harmsstrasse 2, 24114 Kiel, Germany. E-mail: hanewinkel@ift-nord.de. 0749-3797/00/$17.00 doi: 10.1016/j.amepre.2009.12.036 UNDER EMBARGO UNTIL MARCH 2, 2010, 12:01 AM LOCAL TIME © 2010 American Journal of Preventive Medicine • Published by Elsevier Inc. Am J Prev Med 2010;xx(x)xxx 1