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LEHERS

TOBACCO AND ALCOHOL ADVERTISING IN TELEVISED SPORTS: TIME TO FOCUS ON POLICY CHANGE Zwarun' provided additional evidence for the presence of alcohol and tobacco advertising during televised sporting events. Her follow-up to Madden and Grube's^ analysis of alcohol and tobacco advertising in televised sports demonstrates that although certain types of advertisements have decreased, the alcohol and tobacco industries have adapted to advertising restrictions such as those included in the Master Settlement Agreement, the massive lawsuit between state attorneys general and the tobacco industry. However, we believe Zwarun did not take her recommendations far enough. Although the article mentions the importance of the Master Settlement Agreement in reducing the frequency and type of ads, the author did not suggest specific policy changes that are needed to limit alcohol and tobacco marketing in televised sports. It has been estimated that youths make up 13% of the national television viewing audience for all types of programming,^ and most youths report watching sporting events on television."* Numerous studies have provided evidence for a connection between tobacco and alcohol advertising during sporting events and use of those products.^'^ On the basis of the growing evidence for the relationship between tobacco Eind alcohol advertising and youth consumption of these products, we suggest that a shift is needed to focus on policy change. The surgeon general and others have described the connection between policy and behavior change and recommend policies as a behavior change strategy.^"^ International tobacco marketing standards stipulate that tobacco ads should not "be of particular appeal to youth" or be shown at events with more than 25% young viewers'"; the alcohol industry marketing code" prohibits ads intended to appeal to youths. Implementation of policies to further restrict alcohol and tobacco advertising in televised sports will be challenging; therefore, it will be important for alcohol and tobacco resecirchers and policy advocates to work collaboratively. For example, efforts could jointly focus on developing policy to prohibit sports sponsorships for alcohol and tobacco products during televised sporting events with a youth audience of 15% or higher, a more specific and stringent standard for both industries. By working together on policy change, we believe that more substantive change can occur to prevent or reduce underage use of tobacco and alcohol. As clearly illustrated by Zwarun, the problem of alcohol and tobacco advertising in televised sports has been well described. We are overdue to move to the next step and devise effective population-level solutions to youths' exposure to tobacco and alcohol advertising, a Elizabeth G, Klein, MPH Rhonda ffones-Webb, DrPH
Requests for reprints should be sent to Elizabeth Klein, University of Minnesota, School of Public Health, Division of Epidemiology, 1300 S Second Street, Suite 300, Minneapolis, MN 55454-1015 (e-mail: klein_l@epi, umn,edu), doi:10,2l05/AfPH,2006,l02566

References
1. Zwarun L. Ten years and 1 master settlement agreement later: the nature and frequency of alcohol and tobacco promotion in televised spoils, 2000 through 2002. Am/Public Health, 2006;96: 1492-1497. 2. Madden PA, Gnibe JW. The frequency and nature of alcohol and tobacco advertising in televised sports. 1990-1992. Am J Public Health, 1994:8:297-299. 3. Grover PL, ed. Reducing Tobacco Use Among Youth: Community-Based Approaches, Rockville, Md: Substance Abuse and Mental Health Services Administration; 1997 4. Paul P Good sports. Am Demogr, 2001 ;23(10): 16-18. 5. Ellickson P, Collins RL, Hambarsoomians K, McCaffrey DE Does alcohol advertising promote adolescent drinking? results from a longitudinal assessment [published correction appears in Addiction, 2005; 100:1201]. Addiction, 2005;100:235-246. 6. Siege! M. Counteracting tobacco motor sports sponsorship as a promotional tool: is the tobacco settlement enough? AmJ Public Health, 2001 ;91: 1100-1106. 7. The Health Consequences of Smoking: A Report of the Surgeon General, Atlanta. Ga: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention; 2004. 8. Hammond D. Fong GT, McDonald PW, Cameron R. Brown KS. Impact of the graphic Canadian warning labels on adult smoking behaviour. Tob Control. 2003; 2:391-395. 9. Wagenaar AC, Toomey TL. Effects of minimum drinking age laws: review and analyses of the literature from 1960 to 2000, f Stud Alcohol Suppl, 2002; Mar(14): 206-225. 10. Herzog B, Belpedio H. "International tobacco marketing standards." New York. NY: Credit Suisse Eirst Boston; 2001. Available at: http://www.ash.org. uk/html/advspo/pdfs/csfb.pdf. Accessed November 2, 2006. 11. Code of Responsible Practices for Beverage Alcohol Advertising and Marketing, Washington, DC: Distilled Spirits Council of the United States; 2003. Available at: http://www.discus.org/responsibility/code.asp. Accessed November 2, 2006.

Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in thefoumal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www,ajph,orgfor immediate Web posting, or at submitajpkorg for later print publication. Online responses are automatically consideredfor print publication. Queries should be addressed to the Editor-in-Chief Mary E, Northridge, PhD, MPH, at menll@columbia,edu.

About the Authors


Elizabeth G, Klein and Rhonda J, Jones-Webb are with the Division of Epidemiotogy and Community Health at the School of Public Health, University of Minnesota, Minneapolis,

ZWARUN RESPONDS I appreciate Klein and Jones-Webb's comments that it is important that the debate

198 I Letters

American Journal of Public Healtb | February 2007, Vol 97, No. 2

LETTI

Suba et al. claim that successful follow-up of screen-positive women is feasible, as proven in 6 countries they name, but all 6 countries involved limited research studies done with external resources, not routine health services where the real-life problem of poor follow-up prevails.'''* On visual "screen and treat," Suba et al, state that use of visual inspection with acetic add (VIA) would "require performing cryosurgery on 18% to 71% of women who Lara Zwarun, PhD are screened,""''''*^* The 3 references they cite for this claim (all from 2001 or earlier) list screen-positive rates of 28%, 39%, and About the Author 18%, More recent studies (not cited by Suba Lara Zwarun is with the Department of Communication, University of Texas, Ariington. et al.) produced test-positive rates from 7% to Requests for reprints siiouid be sent to Lara Zwarun, 33%, with most under 15%.''"^ Although Department of Communication, University of Texas at some overtreatment is inevitable (because Ariington, Box 19107, Ariington, TX 76019 (e-maii: zwarun@uta.edu}. even cervical intraepithelial neoplasia identidoi:10.2105/AfPH.2006.l02939 fied by cytology will often regress spontaneously), VIA would not lead to treatment of up to 71% of all women screened, as repeatRECONSIDERING THE FEASIBILITY edly stated by Suba et al. OF PAPANICOLAOU AND Contrary to the authors' assertion, visual ALTERNATIVE SCREENING TESTS screen-and-treat algorithms by Alliance for Cervical Cancer Prevention partners and others all call for referring any woman with Despite the commendable commitment of a lesion suspicious for cancer to further evalSuba et al.' to cervical cancer prevention in uation, and VIA studies have missed few, if developing countries, several key conclusions any, cancers.^'" In addition, many propoin their article are made on the basis of inacnents of visual inspection for routine service curate and misleading use of references. For also recommend taking a biopsy before the example, they cite an International Agency ablative treatment (wherever pathology serfor Research on Cancer document^ as saying vices exist).' that Papanicolaou test-based programs have The drawbacks of cytology are now well been "operational" in developing countries for understood in resource-poor settings. VIA ofmore than 30 years. However, no operational fers a viable alternative that deserves considprograms of any scale were identified in eration on the basis of the evidence. D Africa or Asia. The same document concludes that even in Latin America, "attempts Vivien Davis Tsu, PhD, MPH

over alcohol and tobacco advertising in televised sports move in the direction of policy recommendations. The suggestion of prohibiting the placement of such ads in media vehicles with a certain percentage of underage people in their audiences is an especially good one, given the advances being made in audience measurement metrics. However, I would also like to point out that, given the First Amendment protection afforded commercial speech, the most realistic policy solutions will involve the cooperation of the alcohol and tobacco industries themselves, I would argue that content analyses such as my own are important tools in eliciting such cooperation for 2 reasons. First, the industries are likely to appreciate debate centered on an accurate and up-to-date description of current advertising and, second, they are likely to feel pressured to change that state of affairs as public awareness of existing loopholes increases. B

to organize screening programs have failed . . . in spite of a coverage of over 60%."^'''^'''" Further, the authors cite as "voluminous evidence" of the feasibility of Papanicolaou screening in developing countries just 3 references: a pilot project led by Suba et al. in a city in Vietnam, a set of guidelines in South Africa that have yet to be successfully implemented, and the same International Agency for Research on Cancer document previously cited as evidence that cytology-based programs have been operational (but not effective) in low-resource countries.

About the Author


Vivien Tsu is with the Program for Appropriate Technoiogy in Health, Seattle, Wash. Requests for reprints should be sent to Dr. Vivien Tsu, PATH, 1455 NWLeary Way, Seattle, WA 98107 (e-maii: vtsu@path.org). doi:W.2l05/AfPH.2006.102830

References
1. Suba EJ, Murphy SK, Donnelly AD, Furia LM, Huynh ML, Raab SS. Systems analysis of real-world obstacles to successlul cervical cancer prevention in developing countries. Am f Public Health. 2006;96:480-487. 2. International Agency for Research on Cancer Cervix Cancer Screening. Lyon, France: IARC Press; 2005. 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 witb an abnormal cytology in a low-resource setting. Cancer Detect Prev. 2003:27:466-471. 4. Jeronimo J, Morales 0, Homa J, et al. Visual inspection witb acetic acid for cervical cancer screening outside of low-resource settings. Rev Panam Saiud Publica. 2005:17:1-5. 5. Claeys P, De Vuyst H, Gonzalez C, Garcia A, Bello RE, Temmerman M. Performance of tbe acetic acid test wben used in field conditions as a screening test for cervical cancer Trop Med Int Health. 2003:8:704-709. 6. Dob AS, Nkele NN, Acbu P, Essimbi F, Essame O, Nkegoum B. Visual inspection witb acetic acid and cytology as screening metbods for cervical lesions in Cameroon. Intf Gynaecol Obstet. 2005:89:167-173. 7. Goel A, Gajidbi G, Batra S, Bbambhani S, Zutsbi V, Sacbdeva P. Visual inspection of tbe cervix witb acetic acid for cervical intraepitbelial lesions. Intf Gynaecoi Obstet. 2005:88:25-30. 8. Sankaranarayanan R, Basu P, Wesley RS, et al. Accuracy of visual screening for cervical neoplasia: results from an IARC multicentre study in India and Africa. Intf Cancer 2004:110:907-913. 9. Sarian LO, Dercbain SF, Naud P, et al. Evaluation of visual inspection witb acetic acid (VIA), Lugol's iodine (VILl), cervical cytology and HPV testing as cervical screening tools in Latin America. Tbis report refers to partial results from tbe LAMS (Latin AMerican Screening) study, f Med Screen. 2005:12:142-149. 10. Alliance for Cervical Cancer Prevention. Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers. Seattle, Wasb: Alliance for Cervical Cancer Prevention: 2004.

"Feasibility" refers to that which is possible, in addition to that which is operational, successfiil, or sustained. Papanicolaou screening is feasible tmywhere cervical screening is appropriate, because it is not appropriate to screen for cancer among communities without access to curative treatment services, and because communities with access to curative treatment will also have access to cytology

February 2007, Vol 97, No, 2 | American Journal of Public Heaith

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