The increase in rates of smoking initiation among adolescents during 1985–1989 may reflect increased real expenditures for cigarette advertising and promotion. The increase in rates occurred during a period when real expenditures for total cigarette advertising and promotion† doubled, and expenditures for cigarette promotion more than quadrupled (7 ) (Figure 2): from 1980 to 1989, total annual advertising and promotional expenditures (in 1993 dollars) increased from $2.1 billion to $4.2 billion, while promotional expenditures alone increased from $771 million (37% of total expenditures) to $3.2 billion (76%) (Figure 2). Promotional efforts have been highly effective among adolescents. For example, among persons aged 12–17 years in 1992, approximately 50% of smokers and 25% of nonsmokers reported having received promotional items from tobacco companies (1 ).

An association between overall cigarette marketing expenditures and initiation
rates for smoking among adolescents is plausible for at least four reasons. First, brand loyalty is usually established with the first cigarette smoked (8 ); therefore, cigarette companies have an economic incentive to encourage first-time smokers to smoke their brands. Second, adolescents are exposed to cigarette advertising and promotions that employ themes and images that appeal to young persons (1 ). Third, advertising directly influences brand awareness and attitudes toward smoking among adolescents (1 ). Specifically, adolescents smoke the most heavily advertised brands, and changes in brand preferences among young persons are associated with changes in brand-specific advertising expenditures (9 ). For example, the Joe Camel campaign introduced nationally in 1988 was associated with an increase in the market share of that specific brand among adolescents (1,9 ). Finally, consumer research suggests that younger persons (i.e., aged 14–17 years) aspire to be young adults (10 ); therefore, advertising and promotional efforts targeted toward young adults may have greater appeal to adolescents because of their age aspirations.

Although current estimates of smoking initiation rates among adolescents are not
available, from 1991 through 1993, the national prevalence of smoking increased
among eighth- and 10th-grade students (6 ). To reverse the trend of increasing smoking initiation rates among adolescents and to achieve the national health objective for the year 2000 of reducing the initiation of cigarette smoking by youth (no more than 15% should become regular smokers by age 20) (objective 3.5) (4 ), prevention efforts that focus on young persons should be intensified. Such efforts could include making cigarettes less affordable by either increasing their real price (1 ) or by limiting sales to cartons rather than individual packs, enforcing laws prohibiting the sale and distribution of cigarettes to young persons (4 ), conducting mass media campaigns to discourage tobacco use (1 ), and eliminating or severely restricting all forms of tobacco product advertising and promotion to which young persons are likely to be exposed (4 ).