TO EDUCATE OR NOT TO EDUCATE: IS THAT THE QUESTION?

Norman Giesbrecht makes a compelling case for a dramatic reduction of conventional approaches to alcohol education, reflecting their ineffectiveness in altering the toll of alcohol [1]. The argument is familiar to students of tobacco control, where the empirical evidence on the ineffectiveness of school health education is by now voluminous [2]. Some would argue that the tobacco industry's enthusiasm for and support of educational strategies makes the empirical evidence redundant. The tobacco industry has supported youth antismoking education for over two decades [3]; its web pages now brazenly tout the dangers of smoking [4, 5]; and several companies have devoted hundreds of millions of dollars to their own televised youth antismoking campaigns [6]. Would they do this if they believed such efforts were effective in cutting off the future supply of smokers? Of course not. Indeed, recent research concluded that Philip Morris' ‘Think. Don’t smoke' campaign actually increased youth's propensity to be open to the idea of smoking [6]. Would one expect less from the Masters of the Advertising Universe known as Marlboro? As Giesbrecht observes, not all forms of education and persuasion are born equal. We should devote resources only to those that are demonstrably effective. Some forms clearly work. Substantial, sustained, professionally designed counteradvertising campaigns can reduce smoking (but note the critically important adjectives) [7]. The American Legacy's truth campaign has proved a useful tool to reduce youth smoking, quite possibly second in effectiveness only to increased taxation [8]. The original education and persuasion tools in the antismoking campaign in the United States worked quite well. In the early 1950s, articles in the Reader's Digest (most notably ‘Cancer by the Carton’[9]) drew the public's attention to the seminal research linking smoking to lung cancer [10]; adult per capita cigarette consumption declined sharply for the next 2 years [11]. The first Surgeon General's report on smoking [12], released in January 1964, caused a firestorm of publicity; per capita consumption plummeted 15% during the first 3 months thereafter. The difficulty in quitting smoking (and staying quit), combined with the resourcefulness of the tobacco industry in responding to the threat, diminished the impact. Nevertheless, by the end of the year consumption was 5% below its 1963 level, which proved to be its all-time peak. The televised Fairness Doctrine antismoking advertisements from mid-1967 to 1970 were associated with the first-ever 4-year decline in cigarette smoking [11]. One can find varying levels of effectiveness within a single form of education and persuasion. The warning labels on US cigarette packs go virtually unnoticed by smokers. However, the new warning labels popping up in countries such as Canada, occupying large proportions of the front and back of packs and including graphic illustrations of the damage wrought by smoking, may well be discouraging smoking [13]. Despite the myriad forms, when we speak of education our minds jump to school health education. This is where the research leads many thoughtful, and objective, observers to disparage ‘education’. The best-designed interventions, well-funded and managed by knowledgeable, dedicated researchers, occasionally indicate a positive short-term impact [2]. They do not reflect the greater reality, however: harried, under-resourced teachers, ill-informed about tobacco, challenged with competing educational demands (for which they are better trained), who present antismoking units once, with no ‘booster shots’ in subsequent years. It is hardly surprising that such efforts are ineffective. And yet, abandoning even this least empirically supported form of education could, in some contexts, prove unwise and counter-productive. Giesbrecht warns of the coming storm in India and China, where increasing alcohol and tobacco abuse will undoubtedly accompany increasing affluence. Were I the global tobacco policy czar, would I scrap school health education on tobacco in the developed world? Yes. Would I kill it off in India and China? Probably not. When the definitive sociology of western antismoking campaigns is written, I suspect it will feature something like this: a period of education and persuasion convinced the high-education classes to reject smoking. The political elites, these folks shaped their nation's antismoking norms and, subsequently, laws. As norms and laws changed, the behavior of the lower-education classes followed. Education, in its various forms (quite possibly even including school health education), may have been necessary to set the stage for the ‘more productive’ interventions we in tobacco control have come to know and love. There may well be a necessary (if not sufficient) role for the traditional forms of education in the world's emerging nations in which the worst of the epidemics of tobacco- and alcohol-produced disease and death have yet to be experienced.

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