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L E H E R STOBACCO AND ALCOHOLADVERTISING IN TELEVISEDSPORTS:
TIME TO FOCUS ONPOLICY CHANGE
Zwarun' provided additional evidence for the presence of alcohol
and tobacco advertis-
ing during televised sporting events. Her fol-low-up to M adden
and Grube's^ analysis ofalcohol and tobacco advertising in
televisedsports demonstrates that although certaintypes of
advertisements have decreased, thealcohol and tobacco industries
have adaptedto advertising restrictions such as those in-cluded in
the Master Settlement Agreement,the massive lawsuit between state
attorneysgeneral and the tobacco industry.
However, we believe Zwarun did not takeher recommendations far
enough. Althoughthe article mentions the importance of theMaster
Settlement Agreem ent in reducingthe frequency and type of ads, the
authordid not suggest specific policy changes thatare needed to
limit alcohol and tobaccomarketing in televised sports. It has
beenestimated that youths make up 13% of thenational television
viewing audience for alltypes of programming,^ and most youths
re-port watching sporting events on television."*Numerous studies
have provided evidence
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for a connection between tobacco and alco-hol advertising during
sporting events anduse of those products.^'^
On the basis of the growing evidence forthe relationship between
tobacco Eind alco-hol advertising and youth consumption ofthese
products, we suggest that a shift isneeded to focus on policy
change. The sur-geon general and others have described
theconnection b etween policy and behaviorchange and recommend
policies as a behav-ior change strategy.^"^ International
tobaccomarketing standards stipulate that tobaccoads should not "be
of particular appeal toyouth" or be shown at events with morethan 2
5 % young viewers'"; the alcohol in-dustry marketing code"
prohibits ads in-tended to appeal to youths.
Implementation of policies to further re-strict alcohol and
tobacco advertising in tele-vised sports will be challenging;
therefore, itwill be important for alcohol and tobacco
re-secirchers and policy advocates to work col-laboratively. For
examp le, efforts could jointlyfocus on developing policy to
prohibit sportssponsorships for alcohol and tobacco prod-ucts
during televised sporting events with ayouth audience of 15% or
higher, a morespecific and stringent standard for both indus-tries.
By working together on policy chang e,we believe that more
substantive change canoccur to prevent or reduce underage use
oftobacco and alcohol. As clearly illustrated byZwarun, the problem
of alcohol and tobaccoadvertising in televised sports has be en
welldescribed. We are overdue to move to thenext step and devise
effective population-levelsolutions to youths' exposure to tobacco
andalcohol advertising, a
Elizabeth G , Klein, MPHRhonda ffones-Webb, D rPH
A b o u t t h e A u t h o r sElizabeth G, Klein and Rhonda J ,
Jones-Webb are withthe Division of Epidemiotogy and Com munity
Health atthe School of Public Health, University of
Minnesota,Minneapolis,
Requests for reprints should be sent to Elizabeth KlUniversity
of Minnesota, School of Public Health, Divsion of Epidemiology,
1300 S Second Street, Suite 3Minneapolis, MN 55454-1015 (e-mail:
klein_l@epumn,edu),
doi:10,2l05/AfPH,2006,l02566
R e f e r e n c e s1. Zwarun L. Ten years and 1 master
settlementagreement later: the nature and frequency of alcohoand
tobacco promotion in televised spoils, 2000through 2002. Am/Public
Health, 2 0 0 6 ; 9 6 :1492- 1497 .2. Madden PA, Gnib e JW. The
frequency and natof alcohol and tobacco advertising in televised
sport1 9 9 0 - 1 9 9 2 . Am J Public Health, 1 9 9 4 : 8 : 2 9 7 -
2 9 93 . Grover PL, ed. Reducing Tobacco Use AmongYouth:
Community-Based Approaches, Rockville, MdSubstance Abuse and Mental
Health Services Admintration; 19974. Paul P Good sports. Am Demogr,
2001 ;23(1016- 18 .5. Ellickson P, Collins RL, Ham barsoo mian s K,
MCaffrey DE Does alcohol advertising promote adolecent drinking?
results from a longitudinal assessmen[published correction appears
in Addiction, 2 0 0 5 ;100:1201]. Addiction, 2 0 0 5 ; 1 0 0 : 2 3
5 - 2 4 6 .6. Siege! M. Counteracting tobacco motor
sportssponsorship as a promotional tool: is the tobacco stlement
enough? AmJ Public Health, 2001 ; 91 :1100-1106.7. The Health
Consequences of Smoking: A Reporthe Surgeon General, Atlanta. Ga:
U.S. Department Health and Human Services. Centers for Disease
Cotrol and Prevention; 2004.8. Hammond D. Fong GT, McDonald PW,
CameroBrown KS. Impact of the graphic Canadian warninlabels on
adult smoking behaviour. Tob Control. 22 : 3 9 1 - 3 9 5 .9. Wagen
aar AC, Toomey TL. Effects of minimumdrinking age laws: review and
analyses of the literafrom 1960 to 2000, f Stud Alcohol Suppl,
2002; Ma2 0 6 - 2 2 5 .10. Herzog B, Belpedio H. "International
tobaccomarketing standards." New York. NY: Credit SuisseEirst
Boston; 20 01 . Available at:
http://www.ash.oruk/html/advspo/pdfs/csfb.pdf. Accessed November2 0
0 6 .1 1 . Code of Responsible Practices for Beverage
AlcAdvertising and Marketing, Washington, DC: DistillSpirits
Council of the United States; 2003.
Availablhttp://www.discus.org/responsibility/code.asp. Ac-cessed
November 2, 2006.
ZWARUN RESPONDS
I appreciate Klein and Jones-Webb's com-ments that it is
important that the debate
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L E T T I
over alcohol and tobacco advertising intelevised sports move in
the direction ofpolicy recom mendations. The suggestionof
prohibiting the placement of such adsin media vehicles with a
certain percentageof underage people in their audiences isan
especially good one, given the advancesbeing made in audience
measurementmetrics.
However, I would also like to point outthat, given the First
Amendment protectionafforded commercial speech, the most realis-tic
policy solutions will involve the coopera-tion of the alcohol and
tobacco industriesthemselves, I would argue that content analy-es
such as my own are important tools in
eliciting such cooperation for2 reasons. First, the industries
are likely toappreciate debate centered on an accurateand
up-to-date description of current adv ertis-ng and, second, they
are likely to feel pres-wareness of existing loopholes increases.
B
Lara Zwarun, PhD
t t h e A u t h o ris with the Department of Communication,
niversity of Texas, Ariington.Requests for reprints siiouid be
sent to Lara Zwarun,
Texas at
doi:10.2105/AfPH.2006.l02939
COLAOU AND
conclusionsle are m ade on the basis of inac-
misleading use of references. ForInternational Agency
"operational" in developing countries for
to organize screening programs have failed. . . in spite of a
coverage of over 60% ."^'''^'''"Further, the authors cite as
"voluminous evi-dence" of the feasibility of Papanicolaouscreening
in developing countries just 3 refer-ences: a pilot project led by
Suba et al. in acity in Vietnam, a set of guidelines in SouthAfrica
that have yet to be successfully imple-mented, and the same
International Agencyfor Research on Cancer document previouslycited
as evidence that cytology-based pro-grams have been operational
(but not effec-tive) in low-resource countries.
Suba et a l. claim th at successful follow-upof screen-positive
women is feasible, asproven in 6 countries they name, but all
6countries involved limited research studiesdone with external
resources, not routinehealth services where the real-life problemof
poo r follow-up prevails.'''*
On visual "screen and treat," Suba et al,state that use of
visual inspection with aceticadd (VIA) would "require
performingcryosurgery on 18% to 7 1 % of women w hoare
screened,""''''*^* The 3 references theycite for this claim (all
from 2001 or earlier)list screen-positive rates of 28 % , 39% ,
and1 8 % , More recent studies (not cited by Subaet al.) produced
test-positive rates from 7% to3 3 % , with most under 15%.''"^
Althoughsome overtreatment is inevitable (becauseeven cervical
intraepithelial neoplasia identi-fied by cytology will often
regress sponta-neously), VIA would not lead to treatment ofup to 7
1 % of all women screened, as repeat-edly stated by Suba et al.
Contrary to the authors' assertion, visualscreen-and-treat
algorithms by Alliance forCervical Cancer Prevention partners
andothers all call for referring any woman witha lesion suspicious
for cancer to further eval-uation, and VIA studies have missed few,
ifany, cancers.^'" In addition, many propo-nents of visual
inspection for routine servicealso recommend taking a biopsy before
theablative treatment (wherever pathology ser-vices ex ist).'
The drawbacks of cytology are now wellunderstoo d in
resource-poor settings. VIA of-fers a viable alternative that
deserves consid-eration on the basis of the evidence. D
Vivien Davis T s u , P h D , MPH
A b o u t t h e A u t h o rVivien T su is with th e Program for
Appropriate Technoiogyin Health, Seattle, W ash.
Requests for reprints should be sent to D r. Vivien
Tsu,PATH,1455 NW Leary Way, Seattle, WA 98107
(e-maii:[email protected]).
doi:W.2l05/AfPH.2006.102830
R e f e r e n c e s1. Suba EJ, Murphy SK, Donnelly AD, Furia
LM,Huynh ML, Raab SS. Systems analysis of real-world ob-stacles to
successlul cervical cancer prevention in devel-oping countries. Am
f Public Health. 2 0 0 6 ; 9 6 : 4 8 0 - 4 8 7 .2 . International
Agency for Research on CancerCervix Cancer Screening. Lyon, France:
IARC Press;2 0 0 5 . IARC Handbooits of Cancer Prevention, vol 10.3
. Gage JC, Ferreccio C, Gonzales M, Arroyo R,Huivin M, Robles SC.
Follow-up care of women witban abnormal cytology in a low-resource
setting. CancerDetect Prev. 2 0 0 3 : 2 7 : 4 6 6 - 4 7 1 .4 .
Jeronimo J, Morales 0, Homa J, et al. Visual in-spection witb
acetic acid for cervical cancer screeningoutside of low-resource
settings. Rev Panam SaiudPublica. 2 0 0 5 : 1 7 : 1 - 5 .5 . Claeys
P, De Vuyst H, Gonzalez C, Garcia A, BelloR E , Temmerman M.
Performance of tbe acetic acid testwben used in field conditions as
a screening test forcervical cancer Trop Med Int Health. 2 0 0 3 :
8 : 7 0 4 - 7 0 9 .6. Dob AS, Nkele NN, Acbu P, Essimbi F, Essame
O,Nkegoum B. Visual inspection w itb acetic acid andcytology as
screening metbods for cervical lesions inCameroon. Intf Gynaecol
Obstet. 2 0 0 5 : 8 9 : 1 6 7 - 1 7 3 .7. Goel A, Gajidbi G, Batra
S, Bbambhani S, Zutsbi V,Sacbdeva P. Visual inspection of tbe
cervix witb aceticacid for cervical intraepitbelial lesions. Intf
GynaecoiObstet. 2 0 0 5 : 8 8 : 2 5 - 3 0 .8. Sank aranaray anan R,
Basu P, Wesley RS, et al.Accuracy of visual screening for cervical
neoplasia:results from an IARC multicentre study in India
andAfrica. Intf Cancer 2 0 0 4 : 1 1 0 : 9 0 7 - 9 1 3 .9. Sarian
LO, Dercbain SF, Naud P, et al. Evaluationof visual inspection witb
acetic acid (VIA), Lugol's iodine(VILl), cervical cytology and HPV
testing as cervicalscreening tools in Latin America. Tbis report
refers topartial results from tbe LAMS (Latin AMerican Screen-ing)
study, f Med Screen. 2 0 0 5 : 1 2 : 1 4 2 - 1 4 9 .1 0 . Alliance
for Cervical Cancer Prevention. Planningand Implementing Cervical
Cancer Prevention an d ControPrograms: A M anual for Managers.
Seattle, Wasb: Al-liance for Cervical Cancer Prevention: 2004.
"Feasibility" refers to that which is possible,in addition to
that which is operational, suc-cessfiil, or sustained. Papanicolaou
screeningis feasible tmywhere cervical screening is ap-propriate,
because it is not appropriate toscreen for cancer among communities
with-out access to curative treatment services, andbecause
communities with access to curativetreatment will also have access
to cytology
