Causal Relationship: Cigarette Advertising and Smoking Report

This report analyzes a study by Hanewinkel et al. examining the association between cigarette advertising and adolescent smoking initiation. The study revealed a dose-response relationship, with higher exposure to cigarette advertisements correlating with increased smoking initiation. The report evaluates the study based on Hill's criteria, highlighting strengths like the strong association and consistency, while also acknowledging limitations such as sample bias and recall bias. The analysis emphasizes the need for additional information, including socioeconomic background, individual characteristics, and peer behaviors, to establish a definitive causal relationship. The report concludes that while the study suggests a link, further investigation is needed to account for confounding variables and biases, ultimately determining the extent to which cigarette advertising influences the initiation of smoking among young people. The report also includes details of a similar study on television watching and smoking.

1. A discussion on cigarette smoking
Hanewinkel et al carried out an epidemiological cohort study to examine the association
between cigarette advertising and adolescent smoking initiation among 2102 adolescents who do
not smoke and aged between 10 and 17 in 2008. The results of the study showed a dose-response
relationship which increased by 10% when the adolescents were exposed to cigarette
advertisements in the low, 12% when they were exposed in the medium and 19% when they
were exposed in the high. Also, the study showed that other advertisements did not predict
smoking initiation. However, even though other advertisements did not predict smoking
initiation and high exposure to smoking advertisements was the main predictor of smoking
initiation (19%), the study still reserves judgment since it did not mention the confounding
variables, for example, family members who smoke, peer pressure and stress.
2. The following are Hills criteria which have been identified from this study
Strength: analysis of the data of this study showed that there is a strong association between
exposure to cigarette advertisement and smoking initiation. This is so because exposure to high
cigarette advertisements remained the main predictor (19%) of smoking initiation while other
advertisements did not predict smoking initiation and statistically significant that the p-value =
0.05. Also, the confidence interval of 95% was quite wide (1.08-179) proving that the association
was strong.
Consistency: the results of the study showed consistency since exposure to cigarette
advertisement in the low increased smoking initiation by 10%, exposure in the medium increased
smoking initiation by 12% and exposure in the high increased by 19%.
Specificity: The results of the study revealed that other advertisements did not predict smoking
initiation which means that cigarette advertisements are the only advertisements that predicted

smoking initiation. However, the findings did not measure other causal variables, for example,
peer pressure, stress and family members who smoke.
Temporality: In this study, the exposure to cigarette advertisements was measured one year
before smoking initiation. The study, therefore, satisfies the criterion of temporality.
Biological gradient: The results of this study demonstrated the biological gradient since the
increased exposure to cigarette advertisement increased smoking initiation among the
adolescent.
Plausibility: This study critically analyzed the content related effect of cigarette advertisements.
For example, when young people see their idols, such as musicians being used on cigarette print
ads, they get motivated to start smoking. This learning phenomenon confirms that the association
makes sense thus, plausibility is satisfied.
Coherence: This study established that coherence is not independent but rather it depends on the
social learning theory.
Analogy: This study established that various associations are similar to the association in this
study. For example, the association between alcohol advertisements and alcohol consumption.
Experiment: This study didn’t include any experimental data.
Potential Biases:
Sample bias: The study randomly selected the subjects from 120 schools in only 3 states of
Germany mainly SchleswigHolstein, Brandenburg and Humburg. Therefore, the sample did not
involve the general population in the country.
Recall bias: this is another bias in this study especially since the subjects involved in the study
depended on their memory to report the number of times they were exposed to cigarette
advertisements.

Information bias: This study failed to report other causes of initiation of smoking, for example,
behavioral factors like stress, peer pressure and the content of advertisement exposed to.
3. What additional information would you need to be satisfied that a causal relationship
exists between smoking advertisment and smoking?
After critically analyzing the Hills criteria above, I don’t believe that it was satisfied. This
is so because there is a need to access additional information before a final judgment on the
causal relationship between cigarette advertisements and the initiation of smoking is made. Aside
from addressing the mentioned cofounders and biases, factors such as individual characteristics
and the socioeconomic background will provide vital information that will be relevant in making
a sound decision.
1. Socio-economic background
Young adults from lower socio-economic backgrounds are subject to disparities mostly
regarding education. This makes them together with their families less informed about the
dangers of smoking. As a result, such young people are given the freedom to smoke at an early
age which negatively affects their health.
4. Individual characteristics
At the adolescent stage, young people are undergoing a lot of challenges because this is the stage
that they begin to discover their potential. However, stressing life situations especially at school
is known to be problematic to these young people. As a result, some of them will want to find
things that will make them forget their challenges. That is when they start smoking.
5. Peer behaviors

At the adolescent stage, people are very curious since they will want to try everything that comes
their way. Therefore, if they find their friends smoking, they will like to try it and see how it
feels. A simple try leads to the initiation of smoking.

Reference
Hanewinkel, R., Isensee, B., Sargent, J.D. and Morgenstern, M., 2011. Cigarette advertising and
teen smoking initiation. Pediatrics, 127(2), pp.e271-e278.
Lovato, C., Watts, A. and Stead, L.F., 2011. Impact of tobacco advertising and promotion on
increasing adolescent smoking behaviours. Cochrane database of systematic reviews, (10).
Morgenstern, M., Sargent, J.D., Isensee, B. and Hanewinkel, R., 2013. From never to daily
smoking in 30 months: the predictive value of tobacco and non-tobacco advertising
exposure. BMJ open, 3(6), p.e002907.