The use of mass media for tobacco control increased in developed countries in the 1990s, particularly in the United States, Canada, Australia, and the United Kingdom. The emergence of significant funding sources, particularly legal statements with tobacco companies and earmarked tobacco taxes, has allowed the implementation of sustained, mass media campaigns with sufficient audience reach to be effective. Media have been used to promote smoking cessation and smoke-free spaces, to raise awareness of health effects and of unethical tobacco industry behavior, and to create support for various policy measures. Although these campaigns have occurred almost exclusively in developed countries, the lessons learned have been consistent enough to be potentially widely applicable.
THE FAIRNESS DOCTRINE
The first mass media tobacco-control campaign in the United States was the result of a federal court judgment. Under U.S. law until 1988, broadcasters were required under the Federal Communications Commission's Fairness Doctrine "to encourage and implement the broadcast of all sides of controversial public issues over their facilities, over and beyond their obligation to make available on demand opportunities for the expression of opposing views." In 1967, in response to a legal challenge by attorney John Banzhaf, the Fairness Doctrine was interpreted as being applicable to tobacco advertising.
As a result, from 1968 to 1970, health ads about cigarette smoking were carried on the airwaves, with about one health ad broadcast for every three cigarette ads. Per capita cigarette sales declined during this period (they increased both before and after), youth smoking prevalence and self-reported consumption declined significantly, and concern by smokers about their health increased significantly. Although it is impossible to isolate the Fairness Doctrine as the major factor influencing these trends, it is reasonable to assume that it was a major contributor. Perhaps a more telling piece of evidence is that when cigarette advertising was banned on broadcast television in the United States in 1971, the tobacco companies did not challenge the ban. The ban resulted in a 80 percent drop in antismoking ads in the broadcast media.
TOBACCO CONTROL MASS MEDIA IN THE UNITED STATES
Public service announcements (PSAs; advertisements for an issue aired free as a public service) have long been a staple of tobacco control and other health promotion strategies. However, there is very little evidence to support the efficacy of PSAs in reducing tobacco use. The airing of PSAs on a voluntary basis does not guarantee exposure to the public at a level sufficient to change attitudes and behavior on a broad scale.
In 1998, California voters passed Proposition 99, a tax on tobacco products dedicated to funding health promotion and tobacco-control activities. Prop 99, as it is commonly known, has paid for a sustained and comprehensive tobacco-control program that includes a mass media campaign. Several other states, including Massachusetts, Oregon, and Florida, have since used funds from tobacco taxes and from legal settlements with tobacco companies to initiate similar programs.
These programs have been associated with significant reductions in tobacco use. Per capita cigarette consumption declined at a far greater rate in California and Massachusetts than it did nationally after initiation of the state programs. In both states, youth smoking rates held steady as they increased in the country as a whole. Oregon's tobacco tax-funded program was associated with an 11.3 percent decline in per capita consumption over two years, far greater than the national rate of decline. Florida showed even more dramatic results. Following implementation of the Florida tobacco-control program, the prevalence of cigarette use dropped 19 percent among middle school students and 8 percent among high school students in a single year. The centerpiece of the Florida campaign was the aggressive, youth-targeted
"Truth" media and advocacy campaign, which challenged youth to expose the truth behind tobacco marketing and to lead tobacco-control activities in their communities. Further evaluation will be needed to determine whether the Florida declines are sustained.
It is difficult to separate out the effects of mass media relative to other components of these programs, or to broader environmental factors such as the level of spending on tobacco promotion. However, the media campaigns have served to tie together other program components, to raise public awareness of tobacco issues, and to build public support for other tobacco-control measures. In addition, data from California suggest an independent impact of the media campaign. Per capita tobacco sales declined significantly between 1990 and 1992—when the media campaign was the only component of the program that was fully implemented. In addition, consumption declines slowed during a period when spending on media was cut significantly, including the absence of media campaigns for an entire year.
A national paid mass media campaign targeted at youth was launched in 1999 by the American Legacy Foundation. The foundation was established with funds from a 1998 multistate legal settlement and has a mandate to reduce tobacco use through public education and other means. Borrowing from the principles of Florida's Truth campaign, the Legacy campaign has the potential to reduce tobacco use in at least some population segments.
Since 1995, the Campaign for Tobacco-Free Kids has paid for the placement of ads, primarily in the print media, that focus on current political issues. Ads target the public and politicians, and have sometimes focused on one or two individual legislators regarding key decision-making points affecting tobacco-control initiatives. This campaign has not been formally evaluated.
In 1999, the cigarette manufacturer Philip Morris launched a $100 million media campaign ostensibly aimed at discouraging youths from using the products that tobacco companies spend billions of dollars to promote. Focus-group research of youths found that the Philip Morris ads were consistently perceived to be less effective than ads from the successful state campaigns, even before participants were told that the ads were produced by a tobacco company. One of the main points mentioned in the groups was that the ads promoted the choice to smoke or not smoke, but gave no specific reasons why youth should choose not to smoke.
TOBACCO CONTROL AND MASS MEDIA OUTSIDE THE UNITED STATES
Although paid mass media has been used for tobacco control in Canada, Mexico, the United Kingdom, Australia, and Singapore, very few of these campaigns have been evaluated.
In Canada, the federal and provincial governments used paid mass media increasingly in the 1990s to raise public awareness and to promote policy initiatives. The provinces of British Columbia and Ontario received awards for media spots produced as part of a broader tobacco-control strategy. However, none of the recent Canadian campaigns have been evaluated for their effectiveness independently of other policy and program initiatives. These complementary initiatives have been significant.
In Latin America, PSAs remain the most common media tobacco-control tool. There is no evidence to suggest that these campaigns are any more effective that the PSA campaigns in developed countries. Recently, the Pan American Health Organization developed a radio program on smoking cessation in conjunction with radio stations in Columbia and Peru. Although the program has not been formally evaluated, radio listenership and advertising rates increased throughout the broadcast of the multiweek program. Radio is a popular and affordable communication medium in Latin America and has the potential to be a cost-effective tobacco-control tool.
One of the few evaluated campaigns outside of the United States is Australia's 1997 National Tobacco Campaign to promote smoking cessation among adults. The campaign ran for approximately a year with varying levels of intensity, and it utilized graphic images of the physical impact of smoking on the body. The theme, "Every Cigarette is Doing You Damage," aimed to provide smokers with a sense of immediacy about quitting smoking. The campaign also promoted a 24-hour Quitline to give advice and provide references to local resources.
The campaign was associated with increased motivation by smokers to quit and with a 6 percent decline in overall smoking prevalence following a period of little change in smoking prevalence. The lower prevalence was sustained throughout the evaluation period.
Although the campaign was targeted at adults, young teenagers responded more positively to the cessation campaign than to a separate campaign specifically targeted at youth. The campaign has been adapted for use in the United States, Canada, Cambodia, Singapore, Iceland, and Poland.
Tobacco Packages. Although "mass media" usually refers to billboards, magazines and newspapers, and broadcast media outlets, Canada requires that tobacco packages carry health messages that can fairly be described as mass media
messages. Beginning in December 2000, all tobacco packages sold in Canada must carry one of sixteen mandated health messages that cover half of the package. The messages draw upon many of the lessons of mass media campaigns, using color photos and graphic images to demonstrate the negative impacts of tobacco use.
Studies commissioned by the federal government to assess potential impact found that messages with pictures are sixty times more effective than text-only messages in encouraging people to stop, or not start, smoking. The messages were found to be 3.5 times more effective than Canada's previous messages, which convinced hundreds of thousands of smokers to try to quit. Further evaluation of the messages will provide insights into the potential of this innovative medium as an effective mass media tool for tobacco control.
STRATEGIES FOR EFFECTIVE MEDIA CAMPAIGNS
Researchers have attempted to identify the conditions under which media campaigns are most successful, including effective messages and themes. First, media campaigns alone are thought to have limited impact, though they can significantly strengthen the effectiveness of other tobacco-control programs such as school programs, community initiatives, and clean indoor-air campaigns. Second, media campaigns must be professionally developed, should rely on a variety of media (electronic, print, and outdoor), and should contain a mix of target audiences and messages.
There is no single magic bullet for effective messages. However, youth seem to respond well to real-life stories and images of the harmful effects of tobacco use, particularly if harm has affected a loved one, if the individual being profiled started smoking when he or she was young, or if the damage took place at a relatively young age. Messages targeted at adults should not contradict youth-targeted messages. Messages should portray nonsmokers as the majority, present realistic tobacco-free lifestyles, and encourage youth empowerment and control. Further research is needed to investigate whether these guidelines hold true in markets outside of North America and Australia, particularly in developing countries.
Substantial evidence exists to support the value of mass media in tobacco-control programs. Although most evidence comes from the United States, there is no evidence to suggest that these campaigns, given adequate funding, would be any less effective in other developed countries or in developing countries. In fact, mass media may have relatively greater impact in countries where the health effects of tobacco use are less well known. Evaluation of mass media campaigns in developing countries is needed to supplement the body of evidence from developed countries.
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