To the Editor. Despite mounting scientific evidence suggesting a causal relationship between tobacco advertising and increased consumption of tobacco products, particularly among adolescents, promotion of tobacco products by tobacco manufacturers continues to increase

Fischer, P.M.

Goldstein, A.O.

Klein, J.D.

Richards, J.W., Jr

Carolina Digital Repository

packs ofcigarettes sold in 1984, the 1985tobacco HIT would have been 68 centsper pack ($23 billion in direct costs per34 billion packs sold).4 In 1988, therewere 27.7 billion gallons of alcohol soldfor a 1989 alcohol HIT approximating$1.45 per six-pack of beer. A 1990 HITestimate would probably be higher con¬sidering risingmedical care costs.Similar taxes have been proposed orare in effect. Recently, Rep FortneyStark (D, Calif) introduced in Congresslegislation to tax the tobacco companiesdirectly for the Medicaid and Medicarecosts secondary to tobacco-related ill¬nesses, as reported by L. Jones inAmericanMedical News (1990:3). A na¬tional HIT may be more effective,though, by directly taxing the patient-consumer at each purchase. While bothwould reduce consumption, the HITwould also provide a strong educationalmessage, ie, smoking and alcohol con¬sumption contribute to health carecosts.The HIT could then provide funds fora universal access program for the un¬derinsured, estimated by the recentPepper Commission at $24 to $70 billionannually.5 Additional HIT funds couldprovide the $2.2 billion needed to up¬grade and expand the drug treatmentsystem.6 The HIT could also supporttobacco and alcohol disease-related re¬search, programs to stop smoking, andprimary prevention educational pro¬grams. By providing for the financialsupport of the underinsured, all tobac¬co- and alcohol-consuming patientswould have access to medical care forpossible future illnesses, a "pay as yougo" philosophy.Universal access for all Americanswill cost billions of dollars in additionalfunds. Our continued lack of financialdisincentives for these costly human be¬haviors and our inadequate funding ofprimary and secondary treatments maycost us even more. A national HITwould be a large tax increase to manyand face strong opposition from tobaccoand alcohol companies. However, ourbehaviors ofsmoking tobacco and drink¬ing alcohol cost too many lives (anddollars).Rudolph J. Mueller, MDRush Medical CollegeChicago, Ill1. Lundberg GD, Blendon RJ. A special JAMA theme issueon caring for the uninsured and the underinsured. JAMA.1990;264:739.2. Rice DP, Hodgson TA, Sinsheimer P, et al. The economiccosts of the health effects of smoking, 1984. Milbank Q.1986;64:489-547.3. Centers for Disease Control. Alcohol related disease im-pact\p=m-\Wisconsin,1988. MMWR.1990;39:178-187.4. Statistical Abstract of the United States, 1990. 110th ed.Washington, DC: US Bureau of the Census; 1990.5. Rockefeller JO. The Pepper Commission report on com-prehensive health care. N Engl J Med.1990;323:1005-1007.6. Gerstein DR, Lewin LS. Treating drug problems.N Engl J Med.1990;323:844-848.Tobacco Coupons and TeenagersTo the Editor.\p=m-\Despite mounting sci-entific evidence suggesting a causal re-lationship between tobacco advertisingand increased consumption of tobaccoproducts, particularly among adoles-cents,1-3 promotion of tobacco productsby tobacco manufacturers continues toincrease.4,5 The distribution of couponsredeemable for free tobacco products isa major focus for tobacco industry ad-vertising. In 1988, $876 million of the$3 billion spent by US tobacco manufac-turers on tobacco advertising was spenton free coupon promotions.4 This studyaddresses the effects of tobacco couponpromotions on adolescents' ability to ob-tain tobacco products.Study.\p=m-\Two male and two femaleadolescent volunteers (aged 14 and 20years and 15 and 19 years, respectively)were given either seven or eight cou-pons for the discounted purchase of cig-arettes. These coupons had been pro-moted nationally by various tobaccomanufacturers and obtained from localnewspapers. The coupons stated thatthe cigarette discount was restricted to"smokers 21 years of age or older."Georgia state law prohibits the sale oftobacco products to anyone youngerthan 17 years. Each volunteer visitedseven to eight different retail establish¬ments, including supermarkets, phar¬macies, and convenience stores. At eachstore, the volunteer attempted to re¬deem a cigarette coupon at the checkoutcounter. If the clerk began to ringup thepurchase, the purchase attempt wasdeemed successful. If the clerk refusedto make a sale or accept the coupon, theattempt was deemed a failure. No ciga¬rette purchases were actually com¬pleted.The adolescent volunteers attempteda total of 30 tobacco coupon redemp¬tions. The 19- and 20-year-old subjectswere successful in 100% (15/15) of theirpurchase attempts. The 14- and 15-year-old subjects were successful 66%(10/15) of the time (x2 = 6; P<.025). Suc¬cessful redemption attempts occurredin four of four pharmacies, in eightof nine supermarkets, and in nineof 17 convenience stores. When the14- or 15-year-old subjects were refusedtobacco coupon redemption, the mer¬chants stated that state law forbids thesale of tobacco to minors. In no instancewas the volunteer's age questioned inreference to the tobacco manufacturer'sstated criteria that coupon users mustbe at least 21 years of age.Comment.—Tobacco coupon re¬demption programs are intended to pro¬mote increased tobacco consumption ei-ther through reductions in pack cost orby offering two or more packs for a low¬ered price. Adolescents in particularare thought to be most responsive tochanges in cigarette costs; increases ordecreases in the price of cigarettes limitor encourage smoking, respectively.6This price elasticity of demand for ciga¬rettes among adolescents is larger thanthat for adults.' Our findings sug¬gest that tobacco coupon redemptionpromotions may encourage adolescentsmoking.Adolescents have relatively easy ac¬cess to discounts on tobacco productsthrough the use of tobacco promotionalcoupons. While most states have lawslimiting access to tobacco by minors,enforcement is often poor or nonexis¬tent.8 Encouraging more stringent ac¬cess laws and better enforcement ofthem is necessary.9 In addition, free to¬bacco coupon use should be limited tothose aged 21 years or older. However,most states allow 18-year-old persons topurchase tobacco, and such adolescentswere successful in 100% of their couponpurchase attempts in our study. There¬fore, banning the distribution and use oftobacco coupons may be the most effec¬tive way to prevent underage adoles¬cents from gaining access to discountedtobacco products.Adam O. Goldstein, MDJonathan D. Klein, MD, MPHUniversity ofNorth CarolinaChapel HillJohn W. Richards, Jr, MDPaul M. Fischer, MDMedical College ofGeorgiaAugusta1. Public Health Service. Reducing the Health Conse-quences ofSmoking: 25 Years of Progress: A Report of theSurgeon General. Washington, DC: Office on Smoking andHealth; 1989. US Dept ofHealth and Human Services publi-cation 89-8411.2. Goldstein AO, Fischer PM, Richards JW, Creten D.Relationship between high school student smoking and rec-ognition of cigarette advertisements. J Pediatrics. 1987;110:488-491.3. Tye JB, Warner KE, Glantz SA. Tobacco advertisingand consumption: evidence of a causal relationship. WorldSmoking Health. Winter 1988:8-13.4. Davis RM. Current trends in cigarette advertising andmarketing. N Engl J Med.1987;316:725-732.5. Centers for Disease Control. Cigarette advertising\p=m-\United States, 1988. JAMA. 1990;263:2872-2875.6. Warner KE. Smoking and health implications ofa changein the federal cigarette excise tax. JAMA. 1986;255:1028\x=req-\1032.7. Lewit EM, Coate D. The potential for using excise taxesto reduce smoking. JHealth Econ. 1982;1:121-145.8. Centers for Disease Control. State laws restricting mi-nor's access to tobacco. MMWR. 1990;39:349-353.9. Difranza JR, Norwood BD, Garner DW, Tye JB. Legis-lative efforts to protect children from tobacco. JAMA.1987;257:3387-3389.Psychiatric Problems in ObeseChildren Followed up for 10 YearsTo the Editor.\p=m-\The report by Epsteinet al,1 "Ten-Year Follow-up of Behav-ioral, Family-Based Treatment forObese Children," notes long-term posi-tive results with that mode of treatmentapplied to 76 selected patients: obese

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