AUDIO
May 19, 2017

Podcast: Using Tobacco Money to Stamp Out Youth Smoking

In 2000, 23 percent of American eighth, 10th, and 12th graders smoked. Today, the figure is 6 percent. "It’s been called one of the most dramatic successes in public-health history, ever," says Robin Koval, CEO of the Truth Initiative.

Her organization has been very much a part of that success. The Truth Initiative was founded in 1999 (as the American Legacy Foundation) with a portion of the landmark $200 billion settlement between major tobacco companies and 46 states and a mission to stamp out youth smoking.

"The wonderful thing about it," Ms. Koval says in this edition of the Business of Giving, "is we get to use the tobacco industry’s money — with no strings attached — to basically say, ‘Let’s put them out of business!’ "

It’s a fight that’s far from over. The tobacco industry still spends $9.6 billion in the United States on advertising and promotion — much of it targeting youth, minorities, and low-income people — and benefits from a business model based on addiction. In this interview, Ms. Koval talks about new fronts in the battle against tobacco, like the prevalence of smoking in video games, and details how the Truth Initiative’s strategies for reaching young people with public-health messages and fostering a tobacco-free culture.

Listen to the full interview on the player below and/or scroll down to read a transcript provided by the Business of Giving.

Transcript

Denver: One of the great public health stories in recent times has been the reduction in teen smoking. Now, there have been a lot of contributing factors to the success of this effort, but no one – and I mean no one – has played a more significant role than the Truth Initiative, formerly known as the American Legacy Foundation. And it is a great pleasure to have with us this evening their President and CEO, Robin Koval. Good evening, Robin, and welcome to The Business of Giving!

Robin: Well, thanks for having me!

Denver: Robin, give us an overview of the mission and goals of the Truth Initiative.

Robin: So our mission is to achieve a culture where youth and young adults reject tobacco – big mission– but very, very achievable. And the way we go about doing it?  We have three major programs: The Truth Campaign, which is our youth public education program, has been around since 2000. It’s where we do most of our work; but we also have a research and policy center where we do a lot of the foundational research in the area; and then our community and youth engagement work where we take what we do with 30,000 feet in the Truth Campaign and really bring it down into the communities. For instance, we have a wonderful tobacco-free campuses program that we’re doing with HBCUs (Historically Black Colleges and Universities) and community colleges.

Denver: How did this organization come into being?

Robin: Well, you might remember, back in 1998, still the largest civil litigation ever in the United States, something called the Master Settlement Agreement came about. It was an agreement between 46 states who sued the four big tobacco companies. There was a settlement for over $200 billion. It’s so much money. It’s hard to–

Denver: Even today!

Robin: Still a lot of money! Most of the money went and still goes to the 46 states that were part of the suit, but part of the agreement in that settlement was to carve out a pot of money to create an organization– It was then called the American Legacy Foundation– to dedicate itself to the education of young people, primarily to advance smoking prevention in the United States. And the wonderful thing about it is we get to use the tobacco industry’s money– with no strings attached– to basically say “Let’s put them out of business!”

Denver: Ain’t that sweet? So let’s take a look back. What was the prevalence of teen smoking back in 2000?  And what would it be today?

Robin: When the Truth Campaign first started… so this is in 2000… 23% of teens… 8th-, 10th-, 12th graders in the United States smoked.

Denver: One out of four.

Robin: That’s pretty incredible, right? I mean, now, we think about that; it’s just mind-blowing. Today, the percent of 8th-, 10th-, 12th graders who smoke is 6%. That’s cigarettes. Now, there are some other things involved there too, but to get from 23% to 6% in 17 years is…It has been called one of the  most  dramatic successes in public health history ever.

Denver: It sure is. Now, are there certain communities where the incidence is higher and where the tobacco industry might be targeting their efforts?

Robin: Yes, for sure. So 6% is an average. But tobacco is not an equal opportunity killer. What the tobacco industry is very clever about is…you know, they would call it targeting; I’d actually call it profiling in terms of singling people out based on who you are, where you live, how much you have, and even whom you love, and marketing their products to them.

So, for example, among LGBT youth, the rates of tobacco use are twice as high as for the general population. Or, if you look at people of lower income, lower education – low SES is what we would say – the rates of tobacco use are incredibly higher. And that’s no accident because you’ll find, like for instance, 10 times more advertising for tobacco in an African-American neighborhood in some cities than in other neighborhoods. And as a person whose background was in marketing, I can tell you, advertising works. If you put 10 times more in the neighborhood, it’s going to have an impact.

Denver: Well, that’s all shameful, but maybe even more so is that they really have targeted those who are suffering from some degree of mental illness.

Robin: Yes. So we know that 40% of the cigarettes actually bought and consumed in the United States are among people with some kind of behavioral health issue – again, not an accident –and that’s people with depression, anxiety, substance abuse users. There’s actually evidence that says for a lot of these people, their ability to recover… and if they’re on medication…would actually be better if they didn’t smoke. But sometimes even the medical community doesn’t know that.

Denver: Well, you know, public health campaigns that have been targeting youth to choose healthy behaviors and healthy lifestyles, they have failed miserably forever and a day. And in fact, Tina Rosenberg, who was on the show recently and writes the “Fixes” column for the New York Times, said that many of these efforts have exactly the opposite effect… and encouraged that unhealthy behavior. So what has the Truth Initiative done that has made this so darn effective in reaching this market and changing their behavior for the better? 

Robin:  Well, you’re absolutely right. So when we first started, there had been campaigns out there trying to get young people not to smoke. Unfortunately, many of those were actually created by the tobacco industry. And, of course, it’s like telling kids: “Don’t do drugs!” They just get more interested. So many of these campaigns…there was one that talked about basically “Don’t smoke right now.” What does that say? And you can’t talk to young people about health effects… they all know tobacco is bad for them. That’s not the reasons they smoke.

So when the Truth Campaign came into being, and it started from some learning that happened actually down in Florida.  Originally, the idea was to not tell kids what to do and act like their parents and wag a finger, but instead, first of all, to trust kids, to give them the facts. And when you give them the facts, they’ll make good decisions.  And also to help them understand how the tobacco industry was manipulating them. Of course, we know that with young people, they want to be in control of their lives. They don’t like to think that a bunch of people in a big skyscraper someplace are trying to control them, and that’s what made the Truth Campaign so effective.

Denver: They kind of punked the tobacco industry in a very clever way, and that caught on. Well, talk about some of these enormously powerful messages that you’ve had both in PSAs and online that have really been successful.

Robin: In 2014, we reintroduced the Truth Campaign for a whole new generation of young people. The original campaign started in 2000, Generation X, maybe the beginning of the Millennials – very, very different mindset. Generation X was rebellious. They didn’t want to join a movement or anything like that. So we spoke to them about rebellion, and that was really successful.

But now, fast forward to a new generation of kids – Generation Z– a lot of people are calling them – they have a whole different mindset. They want to be part of a movement. And so what we did when we relaunched the campaign is we kind of turned the tables. And instead of talking to now the minority of kids who still smoked – when we started in 2014 with this new campaign, it was 9% – we said, “Let’s talk to the majority of kids, the over 90% who don’t smoke, and use them as a wedge really to talk to their peers.”

Because here’s the thing that was really different: In 2000, if you had 100 friends, you were the most popular kid in school, right? There was no Facebook then or Snapchat or any of the things that kids are now, of course, totally immersed in. Fast forward to today, kids have enormous social power. We can put messages out there… and we do… and we think they’re pretty compelling. But when we can get a young person to start internalizing and nodding their head and spreading that message for us, that’s really powerful. So we relaunched our effort, our Truth Campaign with this notion of  “Be the generation to end smoking; you can do it,” with the phrase “Finish it!” And that’s what we’re doing.   

Denver: That’s what you’re doing! That peer-to-peer always does work. Talking about turning the tables, there does seem to be some poetic justice that the tobacco industry– which was really made on the backs of the advertising industry – Joe Camel, the Marlboro Man, I’d Rather Fight Than Switch, and all that… and here, the Truth Initiative is using advertising to deprive the industry of its generation of, let’s say, new customers to replace the old ones who have passed away… mostly from their product. You spent your whole life and career in the  industry– or at least a majority of it– this must be incredibly satisfying for you.

Robin: It is. You hit that nail on the head. I did grow up in the advertising industry, and I loved it. I worked in it for many years. I never, ever worked for a tobacco client; I never would have. But one of the things I always felt about the tobacco industry is—you’re right— advertisers made them. That’s what brought all that success… Joe Camel and all the things you mentioned. So how wonderful—and frankly, I think it’s something that as an advertiser, I felt really compelled to use my talents to do– to take all of those skills and turn the tables and help beat this thing. But let’s not forget—although the Truth Campaign is well-supported, we get our message out there—the tobacco industry still spends $9.6 billion every year just in the United States to promote their product. So, we’re still the David up against the big Goliath.

Denver: You know, I am so glad that you have your foot firmly down on the pedal because I was a little dismayed just this past week or two to see that despite the fact that I think the tobacco industry is selling 37% less cigarettes than it did in 2001, their profits have just soared. They’re up 77% in the last 10 years. So, to your point, they’re far from finished, and we really need to remain vigilant and aggressive.

Robin: We do. Let’s remember the tobacco industry is so successful and so profitable and able to raise prices… even as sales decrease… because they have one of the most unique business models in the world, at least for a legal business – it is called addiction. So they’ve got that working for them.

Denver: Talking about that marketing and advertising, I can remember back to January 1 of 1971 when it went off the airwaves. I thought, “Well, thank goodness, that is it.” But, to your point, $9.6 billion is still being spent in this country, and the lion’s share of that is in-store advertising. Boy, you can’t go by a convenience store without looking at the signs on the window, the displays all beautifully done, the big thing behind the cash register, and things of that sort. What impact is that having on young people? And is there anything we can do to curtail it?

Robin: It has a huge impact, and there’s lots of research that’s been done about that and price discounting… and the fact that that advertising is strategically placed so that there’s more of it in neighborhoods where people are perhaps less able to resist it. In fact, a lot of that advertising… what’s also quite insidious about it, it’s visible there not just for adults. So a child standing there– a 3-year-old, holding their mother’s hand– one of the first things they learn to recognize is a Marlboro box. That’s a very, very powerful symbol. So, yes.

And some cities, primarily localities, are doing things about these retail marketing practices. So for instance, limiting the number of stores in a given geographic area, making sure that cigarettes can’t be overly discounted, setting minimum prices, and things like that because that retail environment is the most powerful advertising environment these cigarette companies have now. If you walk by a convenience store in certain areas, you’ll see that front window absolutely plastered with low-price tobacco sale advertising.

Denver: Right. And I think another thing that you’re probably an advocate of is trying to get them away from schools. Some of these things are very close to schools.

Robin: Yes. And in fact, I hate to tell you that the tobacco industry has actually sued and won at the Supreme Court to prevent localities from passing laws to keep them away. It is a challenge in the United States. We have the First Amendment, which is a wonderful thing and we’re all very protective of it, and I know we’ve been talking a lot about it in the news lately. But that is the same thing also that unfortunately protects the rights of the tobacco industry often to put their advertising wherever they want.

Denver: Well, knowing you were coming in, I did go to a convenience store, and I did shorten myself a little bit to your target market age– or the tobacco industry’s target market age– and I have to tell you, it was absolutely at my eye level. It was incredible.

Robin: So we’ve been talking a lot about cigarettes, which are regulated through the Tobacco Control Act, which was passed in 2009. But what we haven’t really been talking about are things like little cigars, which can be sold in smaller pack sizes. So cigarettes have to be sold in packs of 20; these little cigars can be sold in packs of three and four, and sometimes even in singles. They come in flavors, flavors like cherry and piña colada and wine flavors and all sorts of things that might be appealing to a young person. The display restrictions for them are very different sometimes in some states than they are for cigarettes.  So they can be right there in front of the counter, not even behind the person at the register.

Denver: Yes. Sort of taking that concept of menthol being an easier way to get started, and now they’ve extended it, as you suggest, to all these different flavors. Has there been any impact from what CVS did a couple of years ago when they stopped selling cigarettes in their pharmacy? Is there anything that came of that which is actually measurable?

Robin: Well, we love CVS. I have to just give them so much credit. They have been so brave in taking a leadership stance there. But actually, it’s working. They have research that says that in those areas where they have taken tobacco out of their stores, among people who were primary CVS shoppers who bought their tobacco at CVS, I think they’ve shown that there’s been a 38% increase in quit attempts. So it does make a difference.

Denver: Picking up here on your point about these little cigars and these flavors, let’s get to e-cigarettes. And boy, they have really emerged quite rapidly. In fact, I saw the other day that their biggest market is those between 18 and 24. It’s actually bigger than people who are over 25 years of age. Tell us a little bit about what they are and the concerns you might have– health concerns, around e-cigarettes.

Robin: E-cigarettes are a complicated issue, no doubt. It’s an electronic device that doesn’t combust tobacco. It heats it, and creates this vapor. It is important to remember that most of the terrible, terrible damage that comes from tobacco is through the combustion. While there’s still a lot of controversy about it… and the science isn’t settled, it’s pretty clear that these products are dramatically less harmful than a regular cigarette. We don’t know how much less harmful. But the challenge is these products could be of great benefit to long-term smokers who have tried every other way to quit and can’t quit – this could help them. The evidence isn’t clear yet, but there is some evidence.

However, they’re not the people who are primarily using these products… and they should. What we have is a lot of young people – teenagers, young adults – trying these products, experimenting with them.  The product still, for the most part, contains nicotine. Nicotine is addictive. And until cigarettes really aren’t a factor in the market, which is a long time from now, we have no way of knowing once you start liking nicotine… and your brain starts realizing that you get a benefit– and you do– from it… we know there’s lots of dual usage and kids switch from one thing to another.

So we hope that ultimately every tool that can be used to help long-term smokers quit is put at their disposal.  Half of these people will die if they don’t quit, but we do not want a whole new generation of young people addicted to tobacco. And with flavors out there; a lot of these e-cigarettes come in flavors like gummy bear. One of my favorites is unicorn vomit. I just don’t see those as being targeted to a 40-year-old smoker who’s been smoking for 20 years and now really wants to quit.

Denver: That’s right. Well, a very thoughtful answer. You know, tobacco companies, in this relentless search for replacement smokers, are looking far and wide. And one place they have gone fishing is at the arcade, specifically in video games. Tell us what’s happening with video games.

Robin: Well, this is under the radar for a lot of people; certainly, it was for me as an adult who isn’t necessarily a gamer. But what we found is that there’s a tremendous amount of tobacco imagery in video games, and a lot of it is in games that are rated T for teens– or theoretically, these are games that have been vetted as appropriate for young people. What we also know by the way is that even kids under the age of 18 play plenty of games that are actually rated M for mature. Their parents don’t stop them from doing it. And these games show all the tough guys and the cool people smoking cigarettes.

In some of the games, you can actually get more power, or you can trade a pack of cigarettes to advance in the game. And what that’s doing– and we’ve actually talked to young people about it… this is what they tell us: it sends the message that tobacco is cool; the “badass characters” in these games are the smokers. They’ve even said to us, and you have to really listen to kids to know what they’re really telling you: “Well, that doesn’t influence me.” This might be a 16-year-old speaking, “But I wouldn’t want my 12-year-old brother to see that.” And what that’s really telling you is: Yes, it’s influencing them a lot.

Denver: Yes. Well, we start deceiving ourselves at a very, very early age is what that tells us. Now, when you said “under the radar,” I suppose you mean by that: parents aren’t aware of this, are they?

Robin: No. Parents don’t know. They don’t play these games with their kids. These games, they have very long narratives; it’s hours and hours of play, which is very different in terms of: how do you control this?  A parent might know what’s in a movie or something like that. But we know, and I think we need a lot more research, we know that kids are very influenced by the imagery they see in entertainment. So actually, in the last Surgeon General’s Report, it said that 20% of smoking initiation can be traced back to smoking imagery in the movies. Now, think about it, a movie is a lean-back experience. You see a movie maybe once. A video game? I mean, that’s really immersive. You are a first-person character often in these, and you play the game over and over. There’s some data that says kids spend more time playing video games each day—these are kids who play games—than they do even on social media. And we all know how much time all the young people in our lives spend on that.

Denver: Oh, that’s for sure. Yes. In fact, I think they spend 25 times more on video games than they do in the movies.  So we get somewhat focused on the movies whereas the video games is where the bad action is taking place

Robin: Yes. Games are fun. We want kids to play them. We don’t want to take them away. But we do want the industry to be aware, and you can make a choice to put smoking in or out. The games are just as fun without it.

Denver: You know, Robin, you were the CEO of a very, very successful ad agency right here in New York City.  And then relatively late in your career, you make this move down to Washington D.C.– not to a new job– to a completely new sector, going from the profit to the nonprofit sector. Tell us a little bit about that transition and maybe some of the misconceptions that each sector has of one another.

Robin: It was a big leap off the ledge for me. I left my advertising agency, which I loved and had founded originally many years ago– an agency at the time called the Kaplan Thaler Group and had built up from the ground to a big, big successful business. I left New York. You probably can hear in my voice. I’m a girl who grew up in the Bronx. So to go from there down to Washington D.C. was a big move, and of course moving from the for-profit world to the nonprofit world. This was a huge leap of faith, but I’ve always sort of believed in that in my life… in new adventures, and felt incredibly privileged that at a—well, how shall I put it?—at a mature age in my career… I’ll say it that way… that I was being given this opportunity. But I also felt that I had a lot to bring to it in terms of taking everything I had learned in  my long advertising career to the Truth Campaign, and using all those talents to do something for good, which I just felt in my heart.

And by the way, I was a smoker once in my life. I grew up in a house where my father was a smoker, a pack-a-day Camel, non-filtered smoker. I became a smoker because of that probably. I fortunately was able to quit when I was 28 years old, thanks to my husband who was like a dog with a bone; he was absolutely unbearable, but I’m incredibly grateful to him for that. But I know I’m very lucky. A lot of people try over and over again and are not as fortunate in quitting. So I had great passion for this.

And I would say, I’ve learned a lot. I think there are misconceptions in the for-profit space about how effective nonprofit organizations are, how hard people work, and how much they know about how to engage people and get things done. And I have to say, I learned a tremendous amount. What I think I’ve also realized is that it’s not an either-or situation.

Nonprofits are made better, I think, by some of the things that come naturally to us in the for-profit space – being held accountable for metrics; impact, not just activity, all those things. But I also think the for-profit world could learn a lot from the way the nonprofit space mobilizes and engages people through passion, through mission, through purpose. Many of my clients in my advertising days, I think their businesses would’ve done even better if that sense of purpose, if that sense of “Why are we walking in the door every day?” was infused in the for-profit sector.

Denver: Well, it certainly is with young people these days. That’s what they are all looking for. Let me close with this. You talked a little while ago about finishers, that this was going to be the generation hopefully to end this scourge. If there was one thing that you could see done that would help change the culture to achieve that…and really take this movement to the next level, what would that be?

Robin: There are many, many policy initiatives that would help advance the end of tobacco. We could ban menthol. We could reduce nicotine levels in cigarettes. There are many, many ideas out there. But having spent my life in the marketing communications world, I’m a big believer that things happen in our country, in the world, when people are mobilized to do it. So one of the things that I’m a big believer in is keeping tobacco on the radar screen, keep denormalizing it so that that one day… perhaps not in the too distant future, within this generation’s lifetime, some little kid will be going down the street or digging a hole in the dirt and find a cigarette butt and hold it up and say to their parent, “Mommy, what’s this?” That will be victory.

Denver: Well, for somebody who wants to wake up with purpose every morning, I can’t imagine anybody who has more than you. Robin Koval, the President and CEO of the Truth Initiative, I want to thank you so much for being in this evening. Now, tell us about your website; you talked a little bit about some of the research that you’ve done. You have some of these great public service ads up there.   How can people get involved in these community organizations?  Tell us a little bit about it and what people need to do.

Robin: You can find us at truthinitiative.org. That’s the site for the entire organization. You can see everything we do there, read about all our work, see our research… our fact sheets, a lot of great information for people who want to know more. And then if you want to see our advertising, if you have a young person in your life and want to get him activated and make him a finisher, go to thetruth.com.

Denver: Thank you so much, Robin. It was a real pleasure to have you on the show.

Robin: My pleasure. Thank you for having me here!