The Effects of Smoking-Related Television Advertising on Smoking and Intentions to Quit Among Adults in the United States: 1999–2007

Objectives. We investigated whether state-sponsored antitobacco advertisements are associated with reduced adult smoking, and interactions between smoking-related advertising types.Methods. We measured mean exposure to smoking-related advertisements with television ratings for the top-75 US media markets from 1999 to 2007. We combined these data with individual-level Current Population Surveys Tobacco Use Supplement data and state tobacco control policy data.Results. Higher exposure to state-sponsored, Legacy, and pharmaceutical advertisements was associated with less smoking; higher exposure to tobacco industry advertisements was associated with more smoking. Higher exposure to state- and Legacy-sponsored advertisements was positively associated with intentions to quit and having made a past-year quit attempt; higher exposure to ads for pharmaceutical cessation aids was negatively associated with having made a quit attempt. There was a significant negative interaction between state- and Legacy-sponsored advertisements.Conclusions. Exposure to state-sponsored advertisements was far below Centers for Disease Control and Prevention–recommended best practices. The significant negative relationships between antismoking advertising and adult smoking provide strong evidence that tobacco-control media campaigns help reduce adult smoking. The significant negative interaction between state- and Legacy-sponsored advertising suggests that the campaigns reinforce one another.Cigarette smoking remains the leading cause of preventable death in the United States. State tobacco control programs rely heavily on paid television advertising to promote tobacco control messages, with the goals of influencing attitudes and beliefs about tobacco use, and reducing population smoking. The California Tobacco Control Program, launched in 1990, is the largest and longest-running state-sponsored antismoking media campaign in the United States.1 Massachusetts introduced a campaign in 1994, Arizona in 1997, and Oregon and Florida in 1998.2,3 Between 1998 and 2002, at least 30 other states started antismoking media campaigns. Cigarette excise taxes and earmarked funds from the 1998 Master Settlement Agreement (MSA) have financed the majority of such campaigns4; in recent years, however, many of these state campaigns have been significantly cut, or even eliminated. The American Recovery and Reinvestment Act of 2009 allocated $650 million toward the Communities Putting Prevention to Work initiatives, many of which included significant tobacco control media campaigns.5 This recent infusion of funding represents the largest expansion of state and regional tobacco control media campaigns since 1998. In addition, the US Food and Drug Administration has announced its own sizable tobacco control media campaign scheduled in 2012.6State-sponsored antitobacco advertisements are not the only smoking-related messages seen on television in the United States in recent years. Since 1996, when nicotine replacement therapies were approved for over-the-counter distribution, pharmaceutical companies have used television advertising extensively to promote smoking cessation aids.7 Also as a result of the MSA, the American Legacy Foundation (Legacy) was formed in 1999, and in 2000 introduced “truth,” its national antismoking advertising campaign. In addition, Philip Morris and Lorillard each launched media campaigns in 1998, which included television advertising with putatively antismoking messages.8Early evidence has suggested that public investments in antismoking media campaigns contributed to reductions in smoking among youths.9 Research on the relationship between antismoking advertisements and adult smoking behavior is encouraging but less conclusive.4,10 Most studies have focused on individual media campaigns within a single state or country, and have not controlled for other smoking-related advertising or other tobacco control policies, such as cigarette excise taxes or clean indoor air regulations, which also influence smoking.11 For example, a recent Australian study showed that higher levels of televised antismoking advertising was associated with reduced adult smoking, with control for important concurrent tobacco control policies.12 One multistate study of the relationship between antismoking advertisements and adult smoking in the United States showed that smokers with higher levels of awareness of antismoking media campaigns were more likely to quit, even after control for other tobacco control policies in the 9 states studied.13 However, that study did not explore the impact of other antitobacco or cessation-related advertising, such as Legacy’s truth campaign or advertisements for pharmaceutical cessation aids. Adults in the United States received substantial levels of exposure to ads for pharmaceutical cessation aids, as well as to Legacy’s predominantly youth-targeted antitobacco media campaign.7 Exposure to either or both of these smoking-related messages may therefore have had important effects on adult smoking. To date, there has been no research on the relationship between smoking among US adults and concurrent exposure to smoking-related advertisements produced by various sponsors, or potential interactions among advertising produced by various sponsors.We examined the relationships between US adults’ smoking behaviors and their exposure to smoking-related television advertisements sponsored by state health departments, the American Legacy Foundation, tobacco companies, and pharmaceutical companies promoting their cessation products. We hypothesized that higher levels of exposure to state-sponsored antitobacco advertisements would be associated with reduced smoking. Our models controlled for individual characteristics, as well as state tobacco control policies and, therefore, overcame the limitations of previous research on the effects of antismoking advertising on smoking among adults.     

Florida's "truth" campaign: a counter-marketing, anti-tobacco media campaign.

The "truth" campaign was created to change youth attitudes about tobacco and to reduce teen tobacco use throughout Florida by using youth-driven advertising, public relations, and advocacy. Results of the campaign include a 92 percent brand awareness rate among teens, a 15 percent rise in teens who agree with key attitudinal statements about smoking, a 19.4 percent decline in smoking among middle school students, and a 8.0 percent decline among high school students. States committed to results-oriented youth anti-tobacco campaigns should look to Florida's "truth" campaign as a model that effectively places youth at the helm of anti-tobacco efforts.     

The rise and fall of tobacco control media campaigns, 1967 2006

Extensive research has demonstrated that public education through media campaigns is an effective means to reduce smoking prevalence and tobacco consumption. Aggressive media campaigns that confront the tobacco industry's deceptive practices are most effective and are therefore a prime target for attack. The tobacco industry has attacked public tobacco control media campaigns since 1967, when the first public tobacco control media advertisements ran. Through studying tobacco control media campaigns in Arizona, California, Florida, Massachusetts, Minnesota, and Oregon, and of the American Legacy Foundation, we identified industry strategies to prevent a campaign's creation, limit the target audience and the content of the messages, limit or eliminate the campaign's funding, and pursue litigation against the campaigns. Tobacco control advocates must learn from the past and continue to confront the tobacco industry and its third-party allies to defend antitobacco media campaigns or, despite evidence of their effectiveness, they will be eliminated.     

Advertising health: the case for counter-ads.

Public service advertisements have been used by many in hopes of "selling" good health behaviors. But selling good behavior--even if it could be done more effectively--is not the best goal for using mass media to prevent health problems. Personal behavior is only part of what determines health status. Social conditions and the physical environment are important determinants of health that are usually ignored by health promotion advertising. Public service advertising may be doing more harm than good if it is diverting attention from more effective socially based health promotion strategies. Counter-ads are one communications strategy that could be used to promote a broader responsibility for rectifying health problems. In the tradition of advocacy advertising directly promoting policy rather than products, counter-ads promote views consistent with a public health perspective. Counter-ads set the agenda for health issues, conferring status on policy-oriented strategies for addressing health problems. The primary purpose of counter-ads is to challenge the dominant view that public health problems reflect personal health habits. They are controversial because they place health issues in a social and political context. Advertising strategies for health promotion range over a spectrum from individually oriented public service advertising to socially oriented counter-advertising. The recent anti-tobacco campaign from the California Department of Health Services represents advertisements across the spectrum. Counter-ads that focus on a politically controversial definition for health problems are an appropriate and necessary alternative to public service advertising.     

Getting to the truth: evaluating national tobacco countermarketing campaigns

OBJECTIVES: This study examines how the American Legacy Foundation's "truth" campaign and Philip Morris's "Think. Don't Smoke" campaign have influenced youths' attitudes, beliefs, and intentions toward tobacco. METHODS: We analyzed 2 telephone surveys of 12- to 17-year-olds with multivariate logistic regressions: a baseline survey conducted before the launch of "truth" and a second survey 10 months into the "truth" campaign. RESULTS: Exposure to "truth" countermarketing advertisements was consistently associated with an increase in anti-tobacco attitudes and beliefs, whereas exposure to Philip Morris advertisements generally was not. In addition, those exposed to Philip Morris advertisements were more likely to be open to the idea of smoking. CONCLUSIONS: Whereas exposure to the "truth" campaign positively changed youths' attitudes toward tobacco, the Philip Morris campaign had a counterproductive influence.     

Who's afraid of the truth?

The November 1998 Master Settlement Agreement between tobacco manufacturers and state attorneys general significantly restricted the marketing of tobacco products, made possible markedly expanded tobacco control programs in the states, and provided for the creation of a new foundation whose primary purpose is to combat tobacco use in the United States. This commentary describes the American Legacy Foundation, with particular emphasis on one of its efforts--the "truth" Campaign, a countermarketing effort to reduce smoking among youths. The "truth" Campaign has been well received by the public and is expected to be [corrected] effective in reducing smoking among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry.     

Tobacco control advocacy in Australia: reflections on 30 years of progress.

Australia has one of the world's most successful records on tobacco control. The role of public health advocacy in securing public and political support for tobacco control legislation and policy and program support is widely acknowledged and enshrined in World Health Organization policy documents yet is seldom the subject of analysis in the public health policy research literature. Australian public health advocates tend to not work in settings where evaluation and systematic planning are valued. However, their day-to-day strategies reveal considerable method and grounding in framing theory. The nature of media advocacy is explored, with differences between the conceptualization of routine "programmatic" public health interventions and the modus operandi of media advocacy highlighted. Two case studies on securing smoke-free indoor air and banning all tobacco advertising are used to illustrate advocacy strategies that have been used in Australia. Finally, the argument that advocacy should emanate from communities and be driven by them is considered.     

Characteristics of healthy weight advertisements in three countries

Objective : High rates of population obesity have resulted in the dissemination of mass media campaigns that focus on achieving and maintaining a healthy weight. The aim of the present study was to analyse advertising techniques used in such campaigns to identify common and differential approaches in three countries with similar cultures and rates of obesity (Australia, the United Kingdom and the United States). Methods : An Internet search was conducted to identify healthy weight television advertisements aired in the three countries. Seventy‐two advertisements were located and coded according to the advertising techniques employed. Results : Despite the cultural similarity and comparable obesity rates of the three countries, there were few consistencies in advertising techniques employed. A main focus of the ads was diet, but disparate approaches were used to convey the message in each country. Conclusions : The identified wide variation in advertising techniques may suggest that campaign managers would benefit from greater certainty about which advertising approaches are most effective in encouraging lifestyle behaviours associated with a healthy weight. Implications for public health : A more robust evidence base would be useful to guide the development of healthy weight campaigns.     

Influence of a counteradvertising media campaign on initiation of smoking: the Florida "truth" campaign

OBJECTIVES: The purpose of this study was to assess the short-term effects of television advertisements from the Florida "truth" campaign on rates of smoking initiation. METHODS: A follow-up survey of young people aged 12 to 17 years (n = 1820) interviewed during the first 6 months of the advertising campaign was conducted. Logistic regression analyses were used to estimate the independent effects of the campaign on smoking initiation while other factors were controlled for. RESULTS: Youths scoring at intermediate and high levels on a media effect index were less likely to initiate smoking than youths who could not confirm awareness of television advertisements. Adjusted odds ratios between the media index and measures of initiation were similar within categories of age, sex, susceptibility, and whether a parent smoked. CONCLUSIONS: Exposure to the "truth" media campaign lowered the risk of youth smoking initiation. However, the analysis did not demonstrate that all such media programs will be effective.     

A cost‐effectiveness analysis of online,radio and print tobacco control advertisements targeting 25–39 year‐old males

Objective: To assess the relative cost‐effectiveness of various non‐television advertising media in encouraging 25–39 year‐old male smokers to respond to a cessation‐related call to action. Information about how new electronic media compare in effectiveness is important to inform the implementation of future tobacco control media campaigns. Methods: Two testimonial advertisements featuring members of the target group were developed for radio, press and online media. Multiple waves of media activity were scheduled over a period of seven weeks, including an initial integrated period that included all three media and subsequent single media phases that were interspersed with a week of no media activity. The resulting Quit website hits, Quitline telephone calls, and registrations to online and telephone counselling services were compared to advertising costs to determine the relative cost‐effectiveness of each media in isolation and the integrated approach. Results: The online‐only campaign phase was substantially more cost‐effective than the other phases, including the integrated approach. Conclusions: This finding is contrary to the current assumption that the use of a consistent message across multiple media simultaneously is the most cost‐effective way of reaching and affecting target audiences. Implications: Online advertising may be a highly cost‐effective channel for low‐budget tobacco control media campaigns.     

Sustaining 'truth': changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign

This study examines how the American Legacy Foundation's ‘truth®’campaign and Philip Morris's ‘Think. Don't Smoke’(TDS) campaign have influenced youth's tobacco-related attitudes,beliefs and intentions during the first 3 years of the truthcampaign. We use data from eight nationally representative cross-sectionaltelephone surveys of 35 074 12- to 17-year olds to estimatecross-sectional time series logistic regressions that assessthe association between recall of truth and TDS and attitudes,beliefs, and intentions toward smoking. An alternative measureof exposure to TDS was also used. Findings indicate that exposureto truth advertisements (ads) was associated with steady positivechanges in attitudes, beliefs and intentions to smoke, whereasexposure to Philip Morris ads was associated with more favorablebeliefs and attitudes toward the tobacco industry. Our findingssuggest that well-executed antismoking campaigns can positivelyand consistently change youth's beliefs and attitudes, whereasa tobacco industry-sponsored campaign can have a counterproductiveinfluence. Received on June 18, 2007; accepted on November 4, 2007     

Past lessons and new uses of the mass media in reducing tobacco consumption

A review of mass media response to the smoking issue over the past 25 years reveals that sustained involvement of the broadcast and print media has served significantly to heighten public awareness and reduce smoking rates in the total U.S. population. Public service advertising has been an integral part of the smoking control movement from its outset, but today's intensely competitive media environment has forced health promoters to look beyond public service announcements in the development of total communication programs. Media advocacy--using the media to sharpen public awareness and mold public policy to serve the public interest, a technique derived from political campaigns--is emerging as a powerful tool in the smoking control movement. Its emphasis is on changing the entire social context of tobacco use in America, rather than the smoking behavior of people. Because media advocates' success pivots on their access to the media, they must be able both to create news and to react quickly to breaking news and unexpected events. The opportunistic, risk-taking nature of media advocacy requires that most efforts be waged at the State and local levels. An increasing number of State health departments and other organizations are using paid advertising to improve the frequency and reach of nonsmoking messages. Research verifies that paid media campaigns increase the target audience's exposure to smoking control messages, but planning and making efficient media purchases require sophistication and, of course, the necessary funds. Irrefutable medical evidence linking smoking to disease and addiction, combined with the powerful social force of the nonsmokers' rights movement, offer hope that a smoke-free society is an achievable goal.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gambling advocacy: lessons from tobacco,alcohol and junk food

Objective: To explore the attitudes and opinions of public health experts in gambling and related unhealthy commodity industries towards the tactics used by the gambling industry to prevent reform and the advocacy responses to these tactics. Methods: In‐depth interviews (30–60 minutes) with a convenience sample of 15 public health experts and stakeholders with a public health approach to gambling (n=10), or other unhealthy commodity industries (food, alcohol, tobacco, n=5). Results: Participants described the influences of political lobbying and donations on public policy, and industry framing of problem gambling as an issue of personal responsibility. Industry funding of, and influence over, academic research was considered to be one of the most effective industry tactics to resist reform. Participants felt there was a need to build stronger coalitions and collaborations between independent academics, and to improve the utilisation of media to more effectively shift perceptions of gambling harm away from the individual and towards the product. Conclusions and implications: Gambling industry tactics are similar to the tactics of other unhealthy commodity industries. However, advocacy initiatives to counter these tactics in gambling are less developed than in other areas. The formation of national public health coalitions, as well as a strong evidence base regarding industry tactics, will help to strengthen advocacy initiatives.     

Tobacco advertising and printed mass media in Spain: a fatal attraction

OBJECTIVE: Tobacco advertising is a powerful factor in encouraging smoking initiation. We analyzed tobacco advertising in written mass media in Spain between 2002 and 2005. METHODS: We performed an annual cross-sectional study of advertisements in the 41 most widely disseminated written mass media (nearly 10 million readers). RESULTS: In the period studied, 37% of the media included tobacco advertising (an average of 4.35 million readers). Only 4% of the media included anti-drug campaigns (an average of 0.27 million readers). Tobacco advertising increased from 2.0 to 4.7% (overall) and from 4.3 to 8.0% (in media allowing tobacco advertising). Four out of every 10 readers and one out of eight Spaniards aged 15 years or older were exposed to tobacco advertising. Fifty-six percent of advertisements included young people. CONCLUSIONS: Tobacco advertising remains prominent in written mass media in Spain and was mainly directed at young people.     

A strategy for increasing news media coverage of tobacco and health in Australia

BACKGROUND: In many nations, government fiscal restraint is reducing the ability of public health authorities to mount mass-reach health information advertising campaigns. Strategies for increasing news coverage of health issues, and thereby contributing to policy advocacy, are well recognized, yet under-explored in health promotion research. OBJECTIVE: To increase news coverage of smoking and health issues by issuing media releases about research judged as newsworthy and important in contributing to tobacco control policy debates. METHOD: Research reports selected for their potential newsworthiness were promoted in news releases and their news 'hit rates' in New South Wales (Australia) metropolitan media over 5 weeks were compared with the background coverage of tobacco control issues over the same period. RESULTS: Fifty-eight of 283 (20.5%) news reports on tobacco in the study period were generated by the six media releases. CONCLUSIONS: News reportage of tobacco control and other public health issues can be increased significantly by the strategic use of news releases alerting journalists to research reports that embody recognizable news values. This is an inexpensive strategy with great potential to advance public health objectives.     

A 10-year retrospective of research in health mass media campaigns: where do we go from here?

Mass media campaigns have long been a tool for promoting public health. How effective are such campaigns in changing health-related attitudes and behaviors, however, and how has the literature in this area progressed over the past decade? The purpose of the current article is threefold. First, I discuss the importance of health mass media campaigns and raise the question of whether they are capable of effectively impacting public health. Second, I review the literature and discuss what we have learned about the effectiveness of campaigns over the past 10 years. Finally, I conclude with a discussion of possible avenues for the health campaign literature over the next 10 years. The overriding conclusion is the following: The literature is beginning to amass evidence that targeted, well-executed health mass media campaigns can have small-to-moderate effects not only on health knowledge, beliefs, and attitudes, but on behaviors as well, which can translate into major public health impact given the wide reach of mass media. Such impact can only be achieved, however, if principles of effective campaign design are carefully followed.     

Tobacco control and direct democracy in Dade County, Florida: future implications for health advocates

In 1979 and 1980 in Dade County, Florida, a small grassroots advocacy group, Group Against Smoking Pollution (GASP), attempted to enact a clean indoor air ordinance through the initiative process. The tobacco industry's successful efforts to defeat the initiatives were expensive high-tech media-centered campaigns. Even though GASP's electoral resources were extremely limited for both initiatives, GASP utilized similar media-centered tactics. This approach attempted to defeat the tobacco industry in its own venue, in spite of the tobacco industry's vastly greater resources. Nevertheless, the industry defeated these ordinances by narrow margins because of broad voter support for the initiatives before the industry started its campaigns. Health advocates will never have the resources to match the tobacco industry in expensive high-tech media-centered initiative campaigns. Rather, their power lies in the general popularity of tobacco control legislation and their ability to mobilize broad grassroots efforts combined with an adequately funded media campaign.     

Banning smoking in cars carrying children: an analytical history of a public health advocacy campaign

OBJECTIVE: Framing public health policy reform in ways that attract public and political support is a core skill of advocacy. In this paper we summarise the 12-year Australian history of advocacy for banning smoking in cars carrying children, culminating in the governments of the Australian States of South Australia and Tasmania enacting legislation. METHOD: 'Smoking in cars' was searched on the factiva.com print news media database, with returns limited to Australian newspapers published before 1 June 2007. RESULTS: The issue of smoking in cars received extensive and emotive media coverage, primarily in support of legislating a ban. Invoking the protection of vulnerable children in the debate about smoking in cars was a powerful and persuasive theme. Unlike all other advocacy for smoke-free areas, this debate was not contested by the tobacco industry or other commercial interest groups. CONCLUSIONS: Even in the absence of a co-ordinated advocacy campaign, public opinion studies on support for such legislation have been consistently strong. Communities view the protection of children as paramount and non-negotiable. IMPLICATIONS: Smoke-free cars legislation can and should be fast tracked in order to capitalise on this community support.     

Citizens United, public health, and democracy: the Supreme Court ruling, its implications, and proposed action

The 2010 US Supreme Court Citizens United v Federal Election Commission 130 US 876 (2010) case concerned the plans of a nonprofit organization to distribute a film about presidential candidate Hillary Clinton. The Court ruled that prohibiting corporate independent expenditures for advocacy advertising during election campaigns unconstitutionally inhibits free speech. Corporations can now make unlimited contributions to election advocacy advertising directly from the corporate treasury. Candidates who favor public health positions may be subjected to corporate opposition advertising. Citizen groups and legislators have proposed remedies to ameliorate the effects of the Court's ruling. The public health field needs to apply its expertise, in collaboration with others, to work to reduce the disproportionate influence of corporate political speech on health policy and democracy.