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Cigarette Continuity Programs and Social Support for Smoking
Walton Sumner II, MD;
Michael Dunaway, MD;
D. Gene Dillman II, MD
Arch Fam Med. 1998;7:264-268.
ABSTRACT
Objective To describe smokers' participation in cigarette continuity programs and the prevalence and structure of cooperative teams of smokers.
Methods Cross-sectional survey of smoking histories and continuity-program participation by individuals and their family members in a convenience sample of 176 current smokers at the University of Kentucky Chandler Medical Center, Lexington. Fisher exact test or  2 tests were used to compare proportions.
Results One of 3 smokers collected coupons for a continuity program. Three quarters of the collectors redeemed their own coupons, and one quarter gave coupons to another collector. Coupon collectors reported an average team size of more than 2 members. One fifth of collectors were teammates with another generation of family members, and one quarter of collectors aged 24 to 35 years were teammates with their children. Smokers were often aware of their relatives' coupon-collecting habits.
Conclusions Continuity programs have been a popular means of reinforcing smoking, especially within families and groups of friends. Continuity programs are novel in encouraging smoking and brand loyalty between generations. Continuity-program participants need to be aware of the risk of promoting smoking initiation by their children. Health advocates could use similar strategies to promote smoking cessation and prevention within families and other social groups.
INTRODUCTION
IN A CIGARETTE continuity program, smokers save some part of cigarette packages as proof of purchase. Participants redeem this "proof" for merchandise, such as sporting goods, clothing, electronics, and even cigarette advertisements. These items are frequently "branded" with a cigarette-brand emblem.1 The proofs of purchase are often a universal product code (UPC); a modified UPC, such as Philip Morris' Marlboro UPCs specially marked with "5 Miles" and the name of a program, eg, "Adventure Team" or "Unlimited"; or a special coupon, such as R. J. Reynolds' Camel Cash. Between 1992 and 1993, industry expenditures rose from $340 million to $756 million for this type of promotion.2 Observers estimated that Philip Morris spent $325 million on its 1993 Adventure Team program alone.3 Philip Morris stated that nearly 12 million smokers participated in its Adventure Team and Country Store promotions.4 The industry claims that these programs promote brand loyalty,5 recruit new and existing smokers to the brand,6 provide a novel advertising theme, and identify customers for political and marketing purposes.3
In addition, continuity programs may be able to create or reinforce social support for smoking. In 1994, Philip Morris' Marlboro Country Store promotion encouraged groups of smokers to collect Marlboro Miles together. The company promised pool tables to 10000 teams of 10 or more smokers who committed to collecting 25000 Marlboro Miles (5000 coupons) during approximately 8 months. All of the pool tables were reserved within 2 hours on May 16, 1994, when Philip Morris began accepting orders. Informally questioning smokers in our practice, we found that our patients often formed teams to acquire less costly merchandise. In one memorable encounter, a patient lamented that her 5-member team would have more difficulty collecting Marlboro Miles since her husband had stopped smoking, at his physician's advice, following his first myocardial infarction.
Cigarette advertising in general raises concerns regarding effects on children, teenagers, and young adults,7-9 and continuity programs add to those concerns.10-12 In an observational study,13 children exposed to these programs were more susceptible to smoking initiation than their unexposed peers. The introduction of the Marlboro continuity program in 1993 coincides with a reversal in national trends of smoking by teenagers.14 Because promotional merchandise is durable and conspicuously displays brand emblems, families involved in continuity programs could view cigarette advertisements in their homes for years to come. In response to concerns that continuity programs recruit new, underaged smokers, the Food and Drug Administration issued regulations15 to ban cigarette continuity programs in the United States. In April 1997, a federal judge ruled that the Food and Drug Administration lacked authority to regulate any cigarette advertising, and the federal government planned to appeal this ruling.
In our practice, we found that adult smokers sometimes involved their children in continuity programs. A 50-year-old man acquired "Camel–the game" playing cards for his grandson, but advised the boy not to smoke. A 16-year-old girl spent "quality" time with her stepfather collecting Adventure Team miles. A 14-year-old girl saved miles with her mother to obtain a leather jacket priced at 1 pack-year of Marlboros.
These encounters led us to question the magnitude of the risk that continuity programs pose to our patients and their families. If the risk is large and modifiable in a clinical encounter, specific countermeasures might be worthwhile. We began to investigate these questions with an exploratory survey of continuity-program participation. This article reports (1) the prevalence of continuity-program participation among patients, visitors, and medical staff who smoke, (2) the number and size of continuity-program teams, and (3) the prevalence of multiple-generation (eg, father and son) teams.
METHODS
At the University of Kentucky Family Medical Center and the University Hospital, Lexington, Ky, 3 interviewers surveyed 176 adult inpatients, outpatients, and staff who smoke. We used a questionnaire of our own design, with open-ended questions intended to assess current smoking habits, past smoking habits, current cigarette brand smoked, past cigarette brands smoked, current coupon-collecting habits, and basic demographic information. A genogram indicating each family member's smoking habits, cigarette brands, and continuity-program participation was obtained. Teams (groups of  1 smokers collecting coupons together) and the team leaders (individuals who redeemed coupons for merchandise) were identified on the genograms. Teams could then be examined to determine the number of individuals and generations represented. Unrelated team members were also noted on the genograms. The questionnaire was tested with 6 individuals who smoke and revised for clarity. The study was approved by an institutional review board as an anonymous survey.
In February 1995, one interviewer surveyed 57 outpatients who smoke. Between June 20, 1995, and July 13, 1995, another interviewer surveyed 106 individuals in outdoor smoking areas. Between February 17, 1995, and May 6, 1995, a third interviewer surveyed, in a hospital practice, 13 patients who smoke. Seven potential outpatient subjects were recognized after departure from the clinic and could not be surveyed. Two potential hospital subjects were too ill to survey. Eight subjects did not complete the survey because of time constraints. No subjects refused.
The data were analyzed using a commercially available software program (Statview 4.5, Abacus Concepts, Berkeley, Calif). Fisher exact test was used to compare proportions between 2 groups. The 2 tests were used to compare proportions among multiple groups.
RESULTS
The Table 1 describes demographics of the sample and univariate analyses of the proportions of subjects participating in continuity programs. Neither sex nor volume of smoking was a significant predictor of participation in continuity programs. Being white, younger than 31 years, and a hospital patient were univariate predictors of higher rates of participation in continuity programs.
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Demographic Characteristics and Subgroup Participation in Continuity Programs*
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Fifty-nine subjects (33.5%) collected coupons for 11 continuity programs, including 37 Marlboro-coupon collectors (21% of smokers and 63% of collectors), 11 Winston-coupon collectors (6.3% of smokers and 19% of collectors), and 1 Camel-coupon collector. Forty-five subjects (25.6%) were team leaders, and 14 subjects belonged to teams led by someone else. Seven of the 45 team leaders collected a brand's coupons other than the cigarette brand they regularly smoked, usually a second-choice brand or one smoked by another household member.
The subjects' 59 teams ranged in size from 1 to 8 members, with a mean of 2.4 members. The mean size of the subjects' 37 Marlboro-coupon teams was 2.6 persons (median, 2; mode, 2; range, 1-7). The subjects' teams included 18 single-person teams (30%), 29 teams (50%) confined to 1 generation, 11 teams (19%) involving 2 generations, and 1 team involving 3 generations of family members. Of 9 teams in which the subject was younger than age 24, none involved a member of a younger generation. Of 23 teams in which the subject was between the ages of 24 and 35 years, 6 teams included 1 or 2 individuals from a younger generation, eg, a child, nephew, or niece of the subject. Five of these teams collected Marlboro Miles, 2 collected Winston proofs of purchase, and 1 collected both.
The 59 subjects who participated in continuity programs also identified 28 (6.4%) of their 437 relatives who smoked as members of 15 other teams within their families, with a mean size of 1.8 persons per team. The 117 subjects who did not participate in continuity programs identified 29 (3.8%) of their 767 relatives who smoked as members of 24 teams, with a mean size of 1.7 persons per team.
COMMENT
Participation in continuity programs was quite common in this survey and tended to involve social units. One third of these subjects who smoke had participated in a continuity program at the time of this survey, and more than half of these participated in Marlboro programs. Cigarette continuity programs created incentives for individuals who smoke to recruit others into teams of 2 or more. If individuals who smoke in other states form teams of similar size, then industry reports of the numbers of individuals participating in these programs could significantly underestimate the true figure.
Information about continuity programs was shared within families. Whether subjects who smoked participated in a continuity program or not, they were often aware of relatives who did participate. The relatively low prevalence of participation and small team sizes reported for the subjects' relatives who smoke suggest that our subjects had incomplete information about their relatives' participation.
In 1 of 5 teams, 2 or more generations of relatives, typically parents and their children, cooperated in collecting cigarette proofs of purchase. One of 10 teams was composed of adults and their relatives who probably were too young to legally purchase cigarettes. The potential of these intergenerational teams for extending brand loyalty from one generation to the next is unknown. It is worth noting that Camel, Chesterfield, Lucky Strike, Philip Morris, and Winston have each been market-leading brands, but none for more than 1 generation of smokers. The Marlboro continuity programs encourage older adults who smoke to advocate smoking Marlboro cigarettes to younger adults. Thus, the programs enable Philip Morris to exploit current market leadership among adults who smoke to maintain a dominant market share among the next generation.
If continuity programs use persons with an established smoking habit to recruit new participants or reinforce smoking within groups, then smoking prevention and cessation efforts might be bolstered by counteracting the prosmoking messages inherent in these programs. For instance, merchandise from most continuity programs will promote a cigarette brand to children long after any ban on continuity programs. Parents who sincerely do not want their children to smoke will want to consider disposing of this merchandise or, at least, removing the brand emblems. Although we do not have formal evidence of parents' receptiveness to such advice, we have seen responses ranging from denial to full acceptance of the suggestion in our practice. Whether disposing of this merchandise will prevent smoking initiation is unknown, but plausible at present.
More abstractly, if some individuals can recruit their friends and families to form teams for continuity programs, perhaps some individuals can also lead friends and families in smoking cessation or prevention. Rather than limiting organized smoking-cessation support groups to congregations of strangers who are coincidentally simultaneously interested in smoking cessation, it might be possible to equip individuals to proactively assist their friends. These individuals might act as local opinion leaders and might learn to sympathetically assist friends through stages of change16 and withdrawal symptoms or give nicotine-replacement advice. Studies17-18 of social support for smoking cessation and other chronic disease management suggest that support organized around existing social networks can reduce the prevalence of smoking. The Neighbors for a Smoke-Free North Side, in St Louis, Mo, is a social-support intervention that resembles a continuity program in many ways. Careful research allows the sponsor to tailor health messages to resonate with its target audience. Messages emphasize personal benefits rather than authoritative advice. Messages are disseminated through brochures, clothing, parties, and advertising. Small groups of friends convene to disseminate messages to group members, who pass these messages along to other friends and relatives. The Neighbors-for-a-Smoke-Free-North-Side experiment differs from a continuity program in only a couple of respects: it promotes health, not tobacco use, and it lacks a token reward scheme.
We should note several limitations of this study. This is a small cross-sectional study of a convenience sample of individuals who smoke in a state with a strong protobacco tradition. Causal mechanisms are not proven by cross-sectional studies. Legislation restricting these programs can create natural experiments that suggest causal mechanisms. For instance, continuity-program brochures carried a notice that the offer was void in Kansas in 1993 and 1994, but not in 1995. Effects of these programs on smoking should be delayed in Kansas relative to its neighboring states.
These results might not represent national participation in these programs, although they are consistent with available information about continuity-program participants nationally. The 12 million participants in Marlboro's Adventure Team and Country Store programs account for approximately 25% of the estimated 47.5 million adults who smoke in the United States in 1995. Marlboro continuity-program participants similarly composed 21% of this sample (P=.3, 2 test). Nevertheless, the composition of continuity teams in Lexington may not be representative of teams nationally. A national random telephone survey would be more easily generalized.
We did not specifically ask subjects to confirm illegal cigarette purchasing by underaged individuals.18 Consequently, intergenerational teams involving minors are strongly suspected, but not decisively demonstrated, here. This survey of adults who smoke could not detect teams of minors who collect cigarette coupons without any adult contribution. This also prevents us from comparing youth participation in Marlboro and Camel programs. A national survey that focused on youth participation would clarify these issues.
Our data contain an internal inconsistency. If the average team size is 2 or more individuals, then the ratio of team leaders to other team members should be 1:1 or less in a random sample (eg, 29 team leaders and 30 other team members in this size sample). We encountered 45 team leaders and 14 other team members, or a 3:1 ratio (P<.002, 2 test). This could indicate that our sample was enriched for team leaders, that individuals will collect for more than 1 team leader, that the questionnaire did not detect changes in team leadership over time, or that these reports are inaccurate. The correct mean team size could be as low as 1.3 persons.
Finally, although this survey showed that teams of continuity-program participants were common in our practice, it could not demonstrate that any particular intervention would reduce the impact of these programs. While we believe that discussing patients' participation in continuity programs can be enlightening for the physician, we do not have evidence that the effort tangibly improves patient care.
CONCLUSION
Cigarette continuity programs have been a popular form of tobacco advertising. Teams formed in response to these programs bridge generations within families and engage friends in long-term cooperative smoking activities. The prosmoking responses seen in the context of these programs may provide insights for designing interventions that promote other behaviors. Similarly structured programs might help friends and families to support one another in avoiding tobacco-related diseases. Specific advice for practicing physicians should await further studies.
AUTHOR INFORMATION
Accepted for publication June 11, 1997.
This study was supported by Minority High School Research Apprenticeship grant 5R25RR10088-02 from the National Institutes of Health, Bethesda, Md, and by Faculty Development Grant in Family Medicine 5D15PE50040-03 from the Department of Health and Human Services, Public Health Service, Washington, DC.
We thank Joy Gonsalvez for conducting numerous interviews.
Corresponding author: Walton Sumner II, MD, Division of General Medicine Sciences, Department of Medicine, Washington University, St Louis, MO 63110.
From the Division of General Medical Sciences, Washington University, St Louis, Mo (Dr Sumner), and the Department of Family Practice, University of Kentucky, Lexington (Drs Dunaway and Dillman).
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14. Giovino GA, Schooley MW, Zhu BP, et al. Surveillance for selected tobacco-use behaviors: United States, 1900-1994. MMWR CDC Surveill Summ. 1994;43(SS-3):1-43.
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