In this paper, we review the history of the use of mass media campaigns to reduce tobacco use, outline the current status of mass media antismoking campaigns in the United States, review evidence of the effectiveness of these campaigns, explain the major problems with the implementation of these campaigns, outline the factors that influence the effectiveness of mass media antismoking campaigns, and make recommendations for the effective use of future mass media campaigns for tobacco control.

History, Current Status, and Effectiveness

The use of advertising to counter tobacco use dates back to 1967, when John Banzhaf successfully petitioned the Federal Communications Commission (FCC) to consider cigarette advertising under the Fairness Doctrine, a 1949 FCC policy that required broadcasters to air both sides of all controversial public issues [2]. Beginning on 1 July 1967, the FCC required broadcasters to air one antismoking message for every three cigarette commercials; this amounted to $75 million of advertising time per year from 1968 through 1970 [2]. The spots were so effective that in 1970, the tobacco industry agreed to congressional legislation to ban tobacco advertising on television and radio (and thus to eliminate the free antismoking ads).

Subsequent research has shown that the Fairness Doctrine antismoking advertisements resulted in a decline in per capita cigarette consumption of at least 5% [2-6] and a reduction in the prevalence of teenage smoking of 3 percentage points [6]. In fact, the antismoking advertisements were found to have had an effect that was nearly six times that of cigarette advertising during this period [4].

The potential effectiveness of mass media anti-smoking campaigns in preventing smoking has now been established on the basis of well-evaluated research and demonstration projects in Vermont [7, 8] and Minnesota [9]. These field experiments show that community- and school-based interventions highlighted by a prominent mass media campaign can reduce the initiation of smoking in adolescents. Under the most favorable circumstances, the prevalence of smoking in young persons has been reduced by 40% [7, 8].

Before 1988, mass media campaigns to prevent tobacco use or encourage smoking cessation were sporadic and relied on free advertising (public service announcements) or short-term funding for specific campaigns. For example, from 1983 to 1990, the Office on Smoking and Health (part of the Centers for Disease Control and Prevention) ran a series of televised antismoking spots directed at youth, but these were public service announcements that relied on donation of advertising time by broadcasters [10]. Public service announcements are not usually aired during prime time and therefore reach a far smaller audience than do paid advertisements [11]. In 1987, the National Cancer Institute ran a paid, radio antismoking campaign featuring radio personality Casey Kasem, but this project lasted only a year [10].

The use of the mass media in tobacco control changed substantially in 1988, when voters in California approved Proposition 99. This ballot initiative increased the state cigarette tax by 25 cents and allocated 20% of the revenue to establish a comprehensive, statewide tobacco education and prevention program that includes a state-of-the-art anti-tobacco media campaign [12]. Massachusetts (1992), Arizona (1994), and Oregon (1996) established similar programs [13], and Minnesota (1986) and Michigan (1994) initiated limited tax-funded media campaigns [10, 14]. During the past 4 years, the annual expenditures for these statewide antitobacco media campaigns have been approximately $12 to $16 million for California, $13 to $16 million for Massachusetts, $5 to $6 million for Arizona, $0.5 to $2 million for Michigan, and $50 000 to $300 000 for Minnesota [14].

The effects of these media campaigns, especially those in California and Massachusetts, have been striking. The California tobacco control program was associated with a 10% to 13% long-term decline in cigarette consumption; approximately 21% of this decline was estimated to be due to the media campaign [15, 16]. This translates into a media campaign-related reduction of cigarette sales by 232 million packs in California between 1990 and 1992 alone [16]. Goldman and Glantz [17, 18] showed that cigarette consumption decreased in association with waves of the media campaign and that the decline in consumption nearly halted when Governor Pete Wilson suspended the media campaign in late 1991 and early 1992 [17, 18]. Popham and colleagues [19] surveyed adult smokers who quit smoking during 1990 and 1991 and found that in response to uncued questions, 6.7% (representing 33 000 former smokers in the state) cited the anti-smoking commercials as an influence in their decision to quit [19]. When asked directly, an additional 34.3% (representing 173 000 former smokers in the state) indicated that the media campaign had influenced their decision to quit smoking.

The Massachusetts tobacco control program was also associated with a substantial decline in cigarette consumption that seems to be attributable in part to the antismoking media campaign [18, 20]. In addition, 1997 telephone surveys of a random sample of young persons from Massachusetts and throughout the United States revealed that Massachusetts youth were more likely to agree that smoking is an addiction, that tobacco companies lie to kids, that smoking inhibits athletic performance, and that smoking causes permanent wrinkles [21]; all of these were themes of specific antismoking advertisements aired in the state during the previous year.

Problems with Implementation

Despite the successes of these media campaigns, their implementation has not been without problems. In 1992, Governor Wilson suspended California's media campaign by diverting its funding for other purposes [13, 18, 22]. The campaign resumed only because of a successful lawsuit brought by the American Lung Association against the Wilson administration [18]. More recently, the Wilson administration has censored the antismoking campaign's commercials; in 1995 and 1996, it pulled three anti-tobacco-industry advertisements from use and weakened several other anti-tobacco-industry commercials [13]. State legislators have also attempted to weaken the campaign; in 1996, Assembly Speaker Curtis Pringle introduced a bill that would have restricted the media campaign to messages dealing with health and disallowed spots attacking the tobacco industry. Only a concerted and unified effort by public health advocates has maintained the existence and integrity of the media campaign.

William Weld, then governor of Massachusetts, attempted to undermine the state's antismoking media campaign by proposing to divert $10 million of funding from the tobacco control program in 1995, but public health advocates successfully prevented this action [23]. In Arizona, the Department of Health Services has ordered the media campaign to focus specifically on preadolescents, adolescents, and pregnant women and has forbidden commercials that attack the tobacco industry or focus on the issues of secondhand smoke or cigarette addiction [24]. However, these forbidden themes are precisely the ones that have been most effective with adolescents in focus group research [18, 25].

Factors That Influence Effectiveness

Not all antitobacco advertising is effective. Focus group research has suggested that commercials that expose the tobacco industry's manipulation of young persons [25] or focus on themes of secondhand smoke and cigarette addiction are the most effective strategies for reducing tobacco use [18]. Campaigns based on the short-term or long-term health effects of smoking are less effective [18].

Ironically, media campaigns like the one in Arizona, which focuses exclusively on encouraging youths not to smoke, are likely to be ineffective [26-29]. The message that "kids shouldn't smoke" actually reinforces the tobacco industry's marketing of the cigarette as "one of the few initiations into the adult world" and as a symbol of the "growing-up, maturity process" [26]. Furthermore, focusing on tobacco use as a problem only among young persons may undermine other facets of a comprehensive approach to tobacco control by counteracting efforts to change broader societal norms regarding tobacco use [26, 29]. Framing the epidemic of tobacco-related disease only as a problem of under-age smoking may also have other unintended effects: It may strengthen the social acceptance of adult tobacco use and may reinforce the perceived legitimacy of promoting this deadly product to adults [26-29].

More generally, the health communication literature suggests that public health messages based on the adverse health consequences of a behavior are only moderately effective in changing the behavior of adolescents [30-36]. Austin [31], for example, argued that a "common mistake in campaign design has been to assume that portraying a behavior as bad or unhealthy will cause children to reject it." In fact, the prohibition of behaviors may enhance their appeal to adolescents [30]. DiFranza and McAfee [34] found that public service announcements that portrayed smoking as an adult behavior made smoking more appealing to youths. The Institute of Medicine suggested that "as adolescents venture more and more into the community, their perceptions that certain norms seem to apply only to them and not to adults may promote health-compromising behaviors" [35]. Behaviors that are restricted for adolescents but not adults can become symbols of adult status [35, 36]. Thus, directing kids not to smoke without challenging the acceptability of smoking among adults may reinforce adolescents' perceptions of smoking as a symbol of maturity.

The consistency of a health campaign message with messages from other sources also generally affects the success of a public communication campaign [31, 37]. Austin [31] argued that to be effective, public communication campaigns must "provide consistent messages from a variety of sources and over a long period of time." Mixed messages from parents, communities, and health officials may lead adolescents to be skeptical of adult advice [31]. Adolescents are more likely to imitate observed behavior than to do what they are told, especially when the two conflict [37]. Thus, campaigns that focus exclusively on deterring young persons from smoking without challenging the social acceptability of smoking itself (and aiming to reduce tobacco use among everyone, adults and children alike) are unlikely to be effective.

Dorfman and Wallack [11] have explained that the most effective counter-advertisements are those that

"challenge the legitimacy and credibility of the industry marketing the product. These are counter-ads, because they represent a clear transfer from the personal to the policy environment and focus on the corporate entity or public policy as a major player in that environment."

By definition, these advertisements are likely to be controversial. Nevertheless, "the power of counterads may be in the controversy they generate" [11].

Advertisements that directly attack the tobacco industry as the source of the tobacco problem; expose the way in which the industry manipulates, deceives, seduces, and addicts children and adolescents; and highlight the way the industry maintains adult smokers as life-long drug addicts to make profits are effective in challenging the legitimacy and credibility of the industry. Moreover, these themes frame tobacco as a problem because it kills people, not because those younger than 18 years of age use it. The theme of tobacco industry manipulation also demonstrates and reinforces the concept that smoking is a behavior that undermines adolescents' independence, reduces their control over life decisions, and makes them victims of the industry's deceit. Rather than mobilizing young persons to rebel against directives not to smoke, campaigns based on these themes empower them to rebel against an industry that is making its profits by deceiving them; seducing them; manipulating them; addicting them; and, ultimately, killing them.

The tobacco industry knows that messages aimed solely at changing individual behavior and focused mainly on health-related themes are ineffective in challenging social norms and are therefore unlikely to be effective in reducing tobacco use. When they were unsuccessful at eliminating mass media anti-smoking campaigns, the industry and its supporters instead attempted to control the content of the campaigns, ensuring that the result is a program that will have little ultimate impact. The tobacco industry's appreciation of this fact is illustrated by the settlement of Florida's Medicaid suit against the industry. The industry agreed to provide $200 million for an antitobacco campaign but specifically forbade advertisements attacking the industry [18].

Conclusions

To be effective, mass media antismoking campaigns should 1) provide consistent messages from many sources, repeatedly and over a long period; 2) portray tobacco as a product that is deadly for everyone, not as a drug whose use is inappropriate only for young persons; and 3) work in concert with other interventions to promote social policies that aim to change societal norms regarding tobacco.

To deliver consistent messages over a long period, the public health community must find a way to institutionalize counter-advertising campaigns. These programs need a consistent source of funding that is not subject to legislative diversion. They also need an aggressive, unrelenting strategy for marketing nonuse of tobacco that is protected from erosion by political forces. The recent settlement of a state lawsuit against the tobacco industry in Minnesota may have established a model for how this can be accomplished. Interest on a permanent endowment will fund a wide variety of tobacco control interventions, including a mass media campaign. A nonprofit health foundation, rather than a government agency, will develop, implement, monitor, and evaluate the campaign.

To adequately portray tobacco as a lethal product whose use is socially unacceptable for both adults and children, mass media campaigns may need to broaden their scope. A continued focus on the inappropriateness of smoking among youths may reinforce the image of smoking as a behavior that is acceptable for adults.

Counter-advertisements should be used as part of a broader program to promote social policies that change societal norms regarding tobacco. Examples of appropriate interventions are those that challenge the legitimacy of tobacco advertising and promotion, reduce the prevalence of smoking among adults, restrict smoking in public places, eliminate smoking in entertainment programming, and counteract the promotion of tobacco through corporate sponsorship of highly visible events and organizations. For example, Massachusetts and California have both used their media campaigns effectively to support smoke-free bar and restaurant laws.

Antitobacco media campaigns can be a powerful tool for reducing tobacco use, and earmarking cigarette tax revenue to run such campaigns has been a useful strategy for ensuring sustained funding. To be effective, however, the campaigns must be protected from political attempts to divert funding or limit their scope to themes that do not challenge the "normality" of tobacco use. The most aggressive media campaigns generate the most controversy, but they are also likely to be the most effective.