Legislators and public health officials in the USA are currently debating the expenditure of millions of dollars flowing into their state coffers from the national tobacco settlement. In these debates, it should be recognised that anti-smoking advertising has the potential to be a viable and cost effective deterrent to youth smoking. When the Fairness Doctrine was applied to tobacco related broadcast speech from 1967 to 1970, broadcasters were required to donate an estimated $298 million per year (in 1996 dollars) in free airtime for anti-smoking advertising messages. Research indicates that per capita cigarette consumption, and both adult and adolescent smoking prevalences, fell significantly during this period.1-5
More recently, controlled experiments comparing “test” (intervention) and “control” (non-intervention) communities found that anti-smoking advertising can significantly reduce youth smoking prevalence, particularly when combined with synergistic school and community based activities.6-8 Additional supportive evidence comes from controlled laboratory experiments in which adolescents have been exposed either to anti-smoking or control (smoking unrelated) advertisements, and then asked to complete surveys that assessed their smoking related knowledge, perceptions, and behavioural intentions. Middle school students who viewed anti-smoking (versus control) advertising reported significantly less favourable perceptions of smokers.9 Likewise, showing an anti-smoking advertisement before a feature film significantly diluted the impact of the film's pro-smoking imagery on high school students.10
These prior studies indicate that anti-smoking advertising can work well under fairly controlled circumstances. However, like other advertising, it carries no guarantees. Indeed, several tobacco use prevention media campaigns have been documented failures because of inadequate length, funding or other factors.11-14Officials planning anti-smoking advertising are faced with an array of challenging planning and implementation tasks. The goal of this study is to provide guidance in planning effective anti-smoking advertising campaigns targeting youth, based on an analysis of past campaigns initiated by five US states (Arizona, California, Florida, Massachusetts, and Minnesota), a different country (Canada), and researchers from the University of Vermont who initiated a multicommunity trial.
Overview of study
The current study is an offshoot of work that we conducted in 1997-98 on adolescents' impressions of anti-smoking advertisements.15 At that time, we obtained copies of all English language television advertisements that had been used in major North American anti-smoking campaigns from 1985 to 1997. All campaigns had identified adolescents as either a primary or sole target audience. In total, we obtained 167 advertisements from six of the campaigns listed above. The Florida initiative had not yet started. We arranged for each advertisement to be viewed by approximately 50 adolescents, half seventh graders (age 12–13 years), half 10th graders (age 15–16 years). The adolescents then completed surveys that were designed to assess each advertisement's message content, the level of agreement (clarity) or disagreement (confusion) over the message content, and the consistency of messages within a campaign (that is, the proportions of advertisements containing the same message). In addition, adults content analysed each advertisement to determine whether the spokesperson appeared to be youthful (under 25 years old) and whether smoking behaviour was depicted. Prior research had indicated that these variables might potentially influence the effectiveness of anti-smoking advertisements targeting youths.16-18
We found that the campaigns differed rather substantially on the advertising message variables (content, clarity, and consistency) and on the executional variables (youthful spokespeople and depictions of smoking). We believed that, based on published reports or data, we could determine which campaigns had been relatively more effective than others at reducing adolescent smoking prevalence. Campaign costs could also be assessed. Hence, we decided to embark on a study to examine whether higher rankings on any of the advertising variables seemed to be associated with greater cost effectiveness. We were able to identify several factors that appeared to improve campaign cost effectiveness as measured by significant reductions in adolescent smoking prevalence. We present our study below, beginning with an explanation of the advertising variables and tentative research hypotheses, followed by our method and findings, and ending with a discussion of limitations and implications.
Advertising variables studied because possible associations with cost effectiveness
In our initial 1997-98 study,15 we reviewed the anti-smoking advertisements that had been provided by campaign sponsors and developed a checklist of messages used. As our adolescent subjects viewed each advertisement, they placed a checkmark next to each message they felt it contained. If 80% or more of the adolescents agreed that an advertisement contained a message, it was put into that message category. Categories with 12 or more advertisements were formally labelled. We identified seven such mutually exclusive categories. These categories are listed below.
Long term effects—advertisements that discuss the long term health effects of smoking, such as cancer and lung disease.
Short term effects—advertisements that highlight the short term cosmetic effects of smoking, such as smelly breath, and related outcomes such as romantic rejection.
Marketing practices—advertisements that describe relatively innocuous tobacco marketing practices, such as the use of glamorous models and the distribution of free promotional items.
Deceptive portrayal of lethal product—advertisements that highlight the deceptive tactics used to sell what is essentially a lethal and addictive product, such as illegally targeting minors and falsely claiming that cigarettes are nonaddictive.
Second hand smoke—advertisements that stress the negative impact of second hand smoke on family members and other people, particularly infants and children.
Smoker as negative role model—advertisements that depict smokers as people who have unwisely chosen a lifestyle that is both unappealing and unhealthy.
Refusal skills—advertisements that feature attractive, personable individuals and show these individuals refusing to smoke.
We relied on prior research to assess the potential efficacy of each message in terms of dissuading adolescents from smoking.15In our own research, hundreds of adolescents were randomly assigned to view advertisements of a particular type and the effects of this exposure (versus exposure to unrelated-to-smoking or control messages) on intentions to smoke were statistically assessed.15Another study examined the transcripts of innumerable focus groups that were convened to evaluate anti-smoking advertisements and looked for consensus as to which advertisements seemed to be the most convincing.19
Both studies concluded that second hand smoke messages work well with adolescents.1519 In addition, the focus group study found that youths responded well to advertisements disclosing the deception used to sell what is essentially a lethal and addictive product.19 Finally, our own experimental study indicated that adolescents were persuaded by social norm appeals, meaning advertisements that portrayed a smoker's lifestyle negatively (as unappealing and unhealthy) or advertisements that showed attractive people refusing to smoke. Other messages were found to be relatively ineffective with adolescents, including those stressing long term effects only,1519 short term effects only,1519 or relatively innocuous tobacco marketing practices.15 Thus, for the current study, we tentatively predicted that the more cost effective prevention campaigns would make greater use of the following messages: deceptive portrayal of lethal product, second hand smoke, smoker as negative role model, and/or refusal skills.
Advertising for most products and services is designed to communicate a single persuasive message for an extended period of time (for example, Crest fights cavities, Listerine kills germs).20-22 The goal is to remind consumers continually of the brand name and its unique selling proposition (positioning) such that, when making consumption or purchase decisions, consumers will immediately think of the brand and remember why to choose it. Also, consumers frequently do not attend to or process advertisements because they are busy or distracted.22 Hence, advertisers rely on repetition, the “oft referred to soul of persuasion” to increase the likelihood of changing behaviour.23 To avoid boring or irritating consumers with repetitive information, advertisers use multiple advertisement executions, that is, variations on the theme (such as different settings).22
Message repetition or consistency should be beneficial for anti-smoking advertising as well. If a campaign has a large budget, it perhaps has more flexibility in terms of conveying multiple messages. However, even cigarette advertisers with substantial budgets tend to utilise single themes. The Marlboro Man (male autonomy) and Virginia Slims (liberated female) campaigns are just two examples of this.24Therefore, we tentatively predicted that an anti-smoking campaign's cost effectiveness would be enhanced by a focus on a single efficacious theme.
In consumer advertising, it is widely recognised that messages can be either poorly comprehended or mistakenly comprehended.2526 Despite advertisers' best efforts, consumers frequently misunderstand the specific claims that are made, the general conclusions reached, and/or the sponsors of the advertisements.2728 Hence, it is commonplace for advertisers to test consumers' comprehension of advertisements in rough cut and/or final form, to rectify any problems that might arise.1829 Subtle changes in wording or dramatisation can make a substantial difference in whether a message is generally understood by target audience members.
There are some who believe that people can be subliminally persuaded by advertisements, independent of message awareness or comprehension.30 However, numerous studies by psychologists and consumer researchers have found no link between subliminal messages and consumer behaviour. It appears that subliminal advertising simply does not have the power attributed to it by its advocates.31 As one advertising agency executive put it, “We have enough trouble persuading consumers using a series of up front 30 second advertisements—how could we do it in 1/300th of a second?”.21 The rare instances of documented subliminal advertising effects have been produced in highly contrived and artificial settings that have little relevance to marketers.2232
Anti-smoking messages can be quite complex—for example, those that argue that tobacco marketers use deception to sell a deadly and addictive product. If youths fail to understand what an advertisement is saying, it is unlikely to have the intended effects. At least one study found that an anti-smoking advertisement that was carefully crafted by adult professionals, but subtle in its approach rather than hard hitting, was poorly understood by the adolescents for whom it was intended.33 Hence, we predicted that anti-smoking campaigns with a higher proportion of readily comprehended and strong messages would tend to be more cost effective.
AGE OF SPOKESPERSON
In general, people are more likely to be influenced by a persuasive appeal if they perceive it as coming from a spokesperson with whom they feel a sense of similarity.21 When audiences identify with a spokesperson, they are more likely to accept that person's opinions and recommendations as credible and relevant to their own lives.2234 Advertisers typically try to ensure that target audience members feel a sense of similarity or identification with the spokesperson by using a person that is similar to the audience in age, sex, race and/or lifestyle.161735-37
When advertisers court adolescents, they generally make a concerted effort to use youthful spokespeople who will be believed and respected by the youth subculture.3839 Some cigarette advertisers apparently feel that it is important to use youthful spokespeople as well.1738 According to studies, tobacco advertisers frequently violate their voluntary code to rely on models that look to be at least 25 years old.1740 One study examined magazines that accept cigarette advertisements and are popular with 12–15 year olds (for example, Sports Illustrated and People) and reported that four out of six cigarette models appeared to be under 25, with the median age being 19.40 Adolescents also reportedly prefer younger cigarette models.17 Often the implied message seems to be that, by smoking, they will become like the attractive young people in the advertisements.36 Experts have opined that the Marlboro Man appeals to youth, despite his age, by symbolising autonomy and freedom from authority, two dominant developmental goals for adolescents.35
The general rule of thumb is that, when targeting adolescents, spokespeople should be just slightly older than the target group and hence aspirational.38 Models can sometimes be too young, because teens are looking for images of “independence, adventure seeking, social approval, and sophistication.”35Since the advertising campaigns that we analysed targeted a diverse group of youths from roughly 9–19 years old, we could not address the issue of whether some of the spokespeople might have been too young for some audiences. Instead, we tentatively predicted that campaigns that made greater use of youthful spokespeople would be more effective at lowering adolescent smoking prevalence, holding other factors constant.41
DEPICTIONS OF SMOKING BEHAVIOUR
We also felt that it was important to consider the use of advertisements that depicted people smoking cigarettes. We were concerned that if a campaign depicted smoking too frequently, it might inadvertently imply that the behaviour is prevalent, normal, and accepted and thus convey a contradictory message.4142Adolescents already overestimate smoking rates among both peers and adults, and the more extreme the overestimate the higher the risk of smoking initiation.43 It may sometimes be appropriate to depict smokers to illustrate the negative aspects of tobacco use, model refusal skills, portray tobacco executives or the like. However, many experts feel that depictions of smoking in anti-smoking advertisements should be minimised because of the potential for unintended adverse effects.18
Turning to our research method, we first ranked each focal campaign on each advertising variable that we speculated might be related to cost effectiveness. Next, we obtained data on campaign costs and effects and developed cost effectiveness rankings. Then, we tested our tentative predictions regarding the relation between each advertising variable and cost effectiveness by comparing how the campaigns ranked on each dimension. For instance, we compared how the campaigns ranked in terms of message content versus cost effectiveness. If the rankings seemed to be associated and in the expected direction (for example, positively), we concluded that there was some support for our predictions.
ASSESSMENT OF ADVERTISING VARIABLES
To rank the campaigns on each advertising variable, we relied on the materials submitted by campaign officials. Officials assured us that they provided a complete or virtually complete set of advertisements from 1985 to 1997. Florida advertisements were not included because we completed this phase of the work in 1998 and their campaign started later. Adolescents provided the data used for ranking each campaign on the message variables: content, clarity, and consistency. We felt that adolescents would be the best judges—particularly regarding message clarity—of whether the messages would be comprehended by other youths. We believed that the executional variables (use of youthful spokespeople and depictions of smoking) could be readily assessed by adults trained in content analysis so we used that approach.
Data were collected from adolescents as follows. We recruited 1128 seventh and 10th graders in California from middle class, ethnically diverse school districts.15 The advertisements from the various sponsors were randomly divided into small pods of 8–9. Each adolescent was randomly assigned to evaluate one pod of advertisements. Immediately after viewing each advertisement twice, subjects answered a series of closed ended questions about the advertisement.
We used the data from adolescents in several ways. To assess the extent to which a campaign employed messages that research suggests may be especially efficacious for youth, we did the following. If at least 80% of subjects agreed that an advertisement contained a certain message, it was classified into that category (see earlier discussion). Then, for each campaign, we calculated the total percentage of advertisements that fell into the efficacious categories (deceptive portrayal of lethal product, second hand smoke, smoker as negative role model, and refusal skills). Vermont's score on efficacious message content, for instance, was 79% because 58% of its advertisements were classified as refusal skills, 13% as deceptive portrayal of lethal product, and 8% as smoker as negative role model.
To assess message consistency, we relied on the percentage of advertisements that fell into the most commonly used efficacious category. In the case of Vermont, since the most commonly used efficacious message was refusal skills and 58% of the advertisements used it, the consistency rating was 58%. To judge message clarity, we relied on the percentage of advertisements rated unclassifiable, meaning that fewer than 80% of the adolescents could agree on the message conveyed.
Additionally, three trained adults content analysed each advertisement to assess if the spokesperson (main character) appeared to be under 25 years of age and if any person was shown to be smoking cigarettes.3644 Inter-rater reliability was 81%. Researchers consider reliabilities over 80% to be acceptable.45 For each campaign, we then computed the percentages of advertisements that contained youthful spokespeople and depicted smoking behaviour.
ANALYSES OF CAMPAIGN COSTS
Information on anti-smoking advertising expenditures was obtained from officials in each US state (Arizona, California, Florida, Massachusetts, Minnesota), Canada (Health Canada), and Vermont. We also consulted published sources and the internet. For each campaign, an average expenditure across all available years was computed and then converted to per capita amounts by dividing by the 1996 USA census population estimate for the relevant geographic area. The per capita amount provides a control for differences in population sizes. For instance, since California is a more populated state, it needs a larger advertising budget to reach everyone who is to be targeted.
For California4647 (telephone conversation with Curt Fallor, California Tobacco Control Section, December 1999), Massachusetts4748 (email correspondence with Mark LaPlante, Massachusetts Department of Health Services, February 2000), Florida,4749 Canada,50 and Arizona (telephone conversation with Robert Suiter, Arizona Tobacco Education and Prevention, February 2000)4751 the per capita figure reflects the average annual budget from campaign inception to 1999. The per capita cost for Minnesota reflects the average annual budget for the complete campaign that occurred from 1986 to 1990. This figure was then adjusted to 1996 dollars using the consumer price index.4752-54 The Vermont campaign was conducted in communities across several states in the USA between 1985 and 1989. The researchers estimated that it would cost $84.5 million, in 1996 dollars, to replicate nationally. We divided this amount by the 1996 USA population to obtain a per capita estimate.4755
Figure 1 shows, for each campaign, the estimated per capita cost for all anti-smoking advertising, across all audiences. Information about the money spent strictly on youth was generally not available and thus not reported. We do not report how campaign expenditures changed over the years, because of incomplete data, but this issue is discussed in relevant places in the text. Figure 1 further illustrates the minimum and optimal per capita funding levels recommended by the Centers for Disease Control and Prevention (CDC) (in 1999 dollars),56and the estimated value of the anti-smoking advertisements run during the Fairness Doctrine Era ($1.12 in 1996 dollars).145As a basis for comparison, tobacco firms currently spend over $7 per capita per year in the USA on advertising, promotional items, and sponsorships.53
Comparison of adjusted per capita anti-smoking advertising expenses, 1985 to present. For California, Massachusetts, Florida, Canada, per capita expenditures were calculated from average annual budget allocated from campaign inception to 1999 and 1996 population estimates.46-51 Per capita cost for Minnesota reflects the average annual budget from the entire campaign (1986 to 1990) and 1996 population estimates, adjusted to 1996 dollars.475253 Costs for Vermont were calculated from published estimates for replicating the campaign at national level (in 1996 dollars) and 1996 national population estimate.4754Funding level during Fairness Doctrine was calculated from estimated expenditures of $298 million (in 1996 dollars) divided by 1996 US population estimates.414754
ANALYSES OF CAMPAIGN EFFECTIVENESS
Reports on the Minnesota and Vermont campaigns have appeared in academic journals, so we relied on those publications to assess the effects.7852 Both campaigns were evaluated by tracking weekly smoking prevalences over time in intervention and control communities using school based surveys. In Canada, current (last 30 day) adolescent smoking prevalences have been tracked since 1970 using personal and confidential home surveys. The data, and trends over time, have been reported in an academic article so we relied on that article.50
To evaluate the remaining campaigns, we used data from the sponsoring state and an appropriate comparison area (see below) to provide a baseline or control group.57 Since multiple data sources were available, we used the following selection criteria to minimise potential bias. First, we relied on academic journals or official government or university reports. Second, we used sources with two or more years of data so that we could assess changes in smoking prevalence. Third, the intervention and control (baseline) data pertained to youth in the same grade in school, collected in the same year, using the same measure: 30 day prevalence or current smoking (that is, any smoking within the past 30 days). Finally, we used surveys completed by random pools of subjects from randomly selected schools. We relied on school based surveys because, in phone surveys, youth generally report substantially less smoking behaviour.58 It seems that youths are hesitant to respond honestly about illicit tobacco use over the phone because they fear being overheard by family members.5859
Following these criteria, in virtually all cases, we relied on data collected by the states in cooperation with the CDC and its Youth Risk Behavior Survey (YRBS). The single exception was California where state specific data from Monitoring the Future were available and where the state's own surveys were phone based. Monitoring the Future also provided regional comparison data for Massachusetts and Florida, and US comparison data for California. California uses national (versus regional) data as its benchmark since the state represents roughly 69% of the western region, according to the US census.47 For Arizona, there was only one state specific data point available, stemming from a phone survey conducted more than two years after the campaign had commenced.51 Hence, we do not report on the effects of Arizona's campaign.
Tables 1 to 6 indicate the changes in adolescent smoking prevalence in the campaign and control (baseline) areas across relevant comparison years. Results for the Vermont study, Minnesota, and Canada are summarised as published.85052 Vermont researchers used a stepwise regression procedure to assess treatment effects between the intervention and control groups.78 Minnesota evaluators analysed that state's results using a hierarchical ANCOVA that compared the mean square effect for the state by year interaction against the mean square effect for school within state by year.52 This approach, while appropriate, was conservative and could possibly have underestimated the effects for Minnesota. The Canadian data were fit to stochastic models that estimated coefficients for trends, changes in trends, and random fluctuations in prevalences, by sex.50 If the Canadian advertising campaign had lowered adolescent smoking prevalence, a significant change in trend would have been observed.
For California, Massachusetts, Florida, and each selected comparison area, we calculated relative risk ratios using the PROC FREQ function in SAS. The ratios reflect between year comparisons of the proportions of adolescents who reported smoking within the past 30 days, with the uncertainty in each estimate being expressed by the 95% confidence interval (CI). The higher the ratio, the higher the smoking prevalence (risk). A confidence interval that does not contain 1.00 indicates a significant change (increase or decrease) in the risk of smoking over time.60
For example, the relative risk from 1997 to 1999 among Massachusetts 10th graders was 0.82. This value is significant because the 95% CI of 0.72 to 0.92 does not contain 1.00. The value also indicates that the overall risk for 30 day smoking prevalence was significantly lower in 1999 than in 1997. Absolute changes in prevalence are also reported in tables 1 to 6 and significant effects are flagged. Tests of absolute changes were conducted using the z statistic, but the results are identical to those using relative risk. All comparisons controlled for grade in school and geographic area—for example, Massachusetts 10th graders in 1997 were compared to that state's 10th graders in 1999, and so forth. Table 7 contains the estimated sample sizes used for the calculations in tables 1 to 6. For details on the sample sizes, see notes at the foot of table 7.
We concluded that an advertising campaign lowered adolescent smoking prevalence from time t to t+n (for example, 1997 to 1999) if (a) the focal area showed a significant decrease in prevalence and there was either no significant change or a significant increase in the comparison area, or (b) the prevalence was flat in the focal area and increased significantly in the comparison area. If there was no significant difference between the focal and comparison areas (that is, if both experienced increases in, decreases in, or constant prevalences), we concluded that the campaign had no effect during that period for that grade. In a few cases smoking prevalence significantly increased in the intervention (versus comparison) area. Factors extraneous to the campaign (for example, societal norms) or conceivably the campaign itself could have contributed to the increase. Since we could not distinguish between these competing explanations, we do not interpret these results.
Figure 2 provides data about each sponsor on each advertising message variable—namely, content, efficacious content, clarity, and consistency. For each sponsor, we used SPSS to compute crosstabs and χ2 tests comparing the frequency (prevalence) of use of different message content. The results of these within sponsor analyses are included in fig 2. The messages shown by black bars were used by the sponsor significantly more than the messages designated by white bars (p < 0.05). The messages depicted by grey bars were not used significantly more or less than any other messages.
Messages used in advertisements as identified by middle school and high school students (within campaign comparisons). Solid black and white bars within each figure differ significantly (p < 0.05). Grey bars do not differ significantly from each other or from black and white bars.
Figure 3 contains data about each sponsor on each advertising execution variable, namely, use of youthful spokespeople and depictions of smoking. We used SPSS crosstabs and χ2 tests to make the between sponsor comparisons shown. A black (versus white) bar indicates significantly greater use of the designated executional device by one sponsor versus another (p < 0.05). Grey bars indicate no significant differences.
Use of youthful spokespeople and depiction of people smoking (across campaign comparisons). Solid black and white bars within each figure differ significantly (p < 0.05). Grey bars do not differ significantly from each other or from black and white bars.
Trends in youth smoking prevalence: Vermont campaign, 1985 to 1989
Trends in youth smoking prevalence: California campaign, 1990 to present
Trends in youth smoking prevalence: Massachusetts campaign 1993 to present
Trends in youth smoking prevalence: Florida campaign 1998 to present
Trends in youth smoking prevalence: Minnesota campaign 1986 to 1990
Trends in youth smoking prevalence: Canada 1985 to present
Approximate sample sizes for youth smoking prevalence results
Detailed results for each advertising campaign
COST EFFECTIVENESS RANKINGS
Table 8 ranks the advertising campaigns from best to worst in terms of their cost effectiveness at dissuading youth from smoking. The findings indicate that one campaign was highly cost effective, three achieved modest effects at varying funding levels, two did not work, and the results for Arizona are unknown. Vermont's campaign worked very well by achieving significant effects inexpensively ($0.32 per capita).55 California is ranked after Vermont on cost effectiveness because its campaign resulted in modest effects at a low per capita cost ($0.4646; telephone conversation with Curt Fallor, California Tobacco Control Section, December 1999). Massachusetts and Florida rank next because they attained modest effects while spending substantially more per capita ($2.1648; email correspondence with Mark LaPlante, Massachusetts Department of Health Services, February 2000 and $1.2949 respectively). Minnesota's campaign was inexpensive ($0.51 per capita)53 but did not achieve any significant effects. Canada's campaign, with a per capita budget of $0.47,50 was not successful either. Arizona spent $2.35 per capita but a lack of behavioural outcome data prevents an analysis of cost effectiveness (telephone conversation with Robert Suiter, Arizona Department of Tobacco Education and Prevention, February 2000)51 (see both fig 1 and table 8).
PREDICTORS OF COST EFFECTIVENESS
Table 8 further ranks the campaigns on each advertising variable that was measured due to its potential association with cost effectiveness (in terms of lowering adolescent smoking prevalence). All but one of the variables does seem to be associated with cost effectiveness. The more cost effective campaigns generally utilised a larger percentage of messages that, based on prior research, seem to be especially efficacious at dissuading youth from smoking. Typically, the more cost effective campaigns showed greater consistency in terms of emphasising a single efficacious message. Campaigns that ranked higher on cost effectiveness generally avoided unclear messages and employed youthful spokespeople more often. The frequency of depictions of smoking behaviour did not seem to be associated with cost effectiveness, however (table 8).
Summary of case study findings: advertising cost effectiveness and possible predictors
The campaign that was undertaken by Vermont researchers sought to stress the positive consequences of non-smoking, model refusal skills, convey the immediate social and physical problems associated with smoking, and teach adolescents about cigarette marketing.761 It ranks as the most cost effective because it achieved significant reductions in smoking prevalence with a low per capita budget.61 The campaign ran from 1985 to 1989 as a part of a multi-community experimental trial.55
The two intervention communities received mass media advertisements and a school program; the two control communities received only the school program. At the onset, the students were in grades 6 and their weekly smoking prevalence was less than 2%. By the time they had reached grade 8, the intervention group was smoking significantly less than the control group (intervention 5.0%, control 9.3%; p < 0.05). Two years later, smoking prevalence in the intervention group remained significantly lower (intervention 12.8%, control 19.8%; p < 0.05).861 The effects were sustained for at least two years after the campaign ceased (intervention 16%, control 24%; p < 0.05).8
PREDICTORS OF COST EFFECTIVENESS
It appears that the success of the Vermont campaign can be attributed to a variety of factors. Based on our results, 79% of the advertisements communicated message content that prior research found to be efficacious with youth. Advertisements with the refusal skills theme comprised 58% of the campaign which indicates a very high degree of consistency over time. Two other efficacious themes were used: deceptive portrayal of lethal product (13%) and smoker as negative role model (8%). Only 4% of Vermont's messages were deemed unclassifiable (meaning low agreement on message).
Executional factors may have also contributed to Vermont's success. In particular, 70% of Vermont's advertisements featured youthful spokespeople which may have enhanced the campaign's relevance to its target audience. While 46% of the advertisements depicted smoking, apparently the depictions were unflattering and reinforced the anti-smoking messages. Overall, the Vermont researchers mounted a homogeneous and effective campaign that can serve as a model for states considering anti-smoking advertising.
California chose to emphasise the health effects of second hand smoke and to attack the tobacco industry for selling a lethal and addictive product and targeting kids.6263 The campaign, started in 1990 after voters approved a tobacco excise tax hike, has had moderate success.1964 Since the campaign was relatively inexpensive, it ranks second in terms of cost effectiveness.
Our findings indicate that from 1993 to 1995 the California campaign realised some positive results. Although smoking prevalences among California eighth and 10th graders remained flat during this time, nationally there were significant increases in smoking prevalences in both grades (for eighth graders: California relative risk 1.00, 95% CI 0.74 to 1.35; US relative risk 1.14, 95% CI 1.05 to 1.25; for 10th graders: California relative risk 1.00, 95% CI 0.78 to 1.29; US relative risk 1.13, 95% CI 1.05 to 1.21). From 1995 to 1997, there is little indication that California's campaign was impacting youth. For grades 8 and 10, while smoking prevalences continued to be flat in California, nationally the prevalences were flat as well.6566 One reason may be that the California advertising budget was cut; it has also been speculated that the California advertisements became less hard hitting.4667
PREDICTORS OF COST EFFECTIVENESS
There are several reasons why California seems to have had some success. First, 58% of its advertisements used message themes that prior research identified as being efficacious with adolescents. One such theme—deceptive portrayal of lethal product—was used in 32% of the advertisements. This indicates a relatively high degree of consistency over time. California used additional efficacious themes: second hand smoke (14%), smoker as negative role model (7%), and refusal skills (5%). Only 17% of California's advertisements were rated as unclassifiable, meaning that the majority were readily comprehended. Executionally, 50% of the California advertisements featured youthful spokespeople which was about average across the sponsors. Smoking behaviour was modelled in 42% of the California advertisements which was also about average.
Convincing 9 to 17 year olds not to smoke is one of three major objectives of the Massachusetts campaign.68 A primary message is to communicate the “harsh medical realities of the effects of smoking”.6269 Additional messages include second hand smoke, cosmetic effects, and testimonials from ex-employees and former supporters of the tobacco industry.6270 The surtax funded campaign started in 1993 and has had modest success.71 Similar to California, there is evidence that adolescent smoking prevalence decreased in some instances, but the per capita spending to achieve this result was higher. As such, we rank Massachusetts third (tied with Florida) on cost effectiveness.
|World No Tobacco Day|
Ash trays with fresh flowers are a common symbol of World No Tobacco Day
|Observed by||All UN Member States|
|Next time||31 May 2018 (2018-05-31)|
World No Tobacco Day (WNTD) is observed around the world every year on May 31. It is intended to encourage a 24-hour period of abstinence from all forms of tobacco consumption around the globe. The day is further intended to draw attention to the widespread prevalence of tobacco use and to negative health effects, which currently lead to nearly 6 million deaths each year worldwide, including 600,000 of which are the result of non-smokers being exposed to second-hand smoke. The member states of the World Health Organization (WHO) created World No Tobacco Day in 1987. In the past twenty nine years, the day has been met with both enthusiasm and resistance around the globe from governments, public health organizations, smokers, growers, and the tobacco industry.
WHO and World No Tobacco Day
WNTD is one of eight official global public health campaigns marked by the WHO, along with World Health Day, World Blood Donor Day, World Immunization Week, World Tuberculosis Day, World Malaria Day, World Hepatitis Day, and World AIDS Day.
- In 1987, the WHO's World Health Assembly passed Resolution WHA40.38, calling for April 7, 1988 to be "a world no-smoking day". The objective of the day was to urge tobacco users worldwide to abstain from using tobacco products for 24 hours, an action they hoped would provide assistance for those trying to quit.
- In 1988, Resolution WHA42.19 was passed by the World Health Assembly, calling for the celebration of World No Tobacco Day, every year on May 31. Since then, the WHO has supported World No Tobacco Day every year, linking each year to a different tobacco-related theme.
- In 1998, the WHO established the Tobacco Free Initiative (TFI), an attempt to focus international resources and attention on the global health issue of tobacco. The initiative provides assistance for creating global public health policy, encourages mobilization between societies, and supports the World Health Organization Framework Convention on Tobacco Control (FCTC). The WHO FCTC is a global public health treaty adopted in 2003 by countries around the globe as an agreement to implement policies that work towards tobacco cessation.
- In 2008, on the eve of the World No Tobacco Day, the WHO called for a worldwide ban on all tobacco advertising, promotion, and sponsorship. The theme of that year’s day was ″Tobacco-free youth″; therefore, this initiative was especially meant to target advertising efforts aimed at youth. According to the WHO, the tobacco industry must replace older quitting or dying smokers with younger consumers. Because of this, marketing strategies are commonly observed in places that will attract youth such as movies, the Internet, billboards, and magazines. Studies have shown that the more youth are exposed to tobacco advertising, the more likely they are to smoke.
- In 2015, WNTD highlighted the health risks associated with tobacco use and advocated for effective policies to reduce tobacco consumption, including ending the illicit trade of tobacco products.
- In 2016, on World No Tobacco Day, held on 31 May, the World Health Organization (WHO) called on governments to get ready for plain packaging of tobacco products.
- In 2017, WNTD is focusing on tobacco as "a threat to development." The campaign aims to demonstrate the threats that the tobacco industry poses to sustainable development, including the health and economic well-being of citizens in all countries.
Each year, the WHO selects a theme for the day in order to create a more unified global message for WNTD. This theme then becomes the central component of the WHO’s tobacco-related agenda for the following year. The WHO oversees the creation and distribution of publicity materials related to the theme, including brochures, fliers, posters, websites, and press releases. Videos were created as a part of the 2008 WNTD awareness campaign for the theme ″Tobacco-free youth″ and published on YouTube, and podcasts were first used in 2009.
In many of its WNTD themes and related publicity-materials, the WHO emphasizes the idea of "truth." Theme titles such as "Tobacco kills, don't be duped" (2000) and “Tobacco: deadly in any form or disguise” (2006) indicate a WHO belief that individuals may be misled or confused about the true nature of tobacco; the rationale for the 2000 and 2008 WNTD themes identify the marketing strategies and “illusions” created by the tobacco industry as a primary source of this confusion. The WHO's WNTD materials present an alternate understanding of the “facts” as seen from a global public health perspective. WNTD publicity materials provide an "official" interpretation of the most up-to-date tobacco-related research and statistics and provide a common ground from which to formulate anti-tobacco arguments around the world. The theme for World No Tobacco Day 2017 is "Tobacco – a threat to development."
The WHO serves as a central hub for fostering communication and coordinating WNTD events around the world. The WHO website provides a place for groups to share news of their activities, and the organization publishes this information online by country.
Since 1988 the WHO has presented one or more awards to organizations or individuals who have made exceptional contributions to reducing tobacco consumption. World No Tobacco Day Awards are given to individuals from six different world regions (Africa, Americas, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific), and Director-General Special Awards and Recognition Certificates are given to individuals from any region.
Groups around the world — from local clubs to city councils to national governments — are encouraged by the WHO to organize events each year to help communities celebrate World No Tobacco Day in their own way at the local level. Past events have included letter writing campaigns to government officials and local newspapers, marches, public debates, local and national publicity campaigns, anti-tobacco activist meetings, educational programming, and public art.
In addition, many governments use WNTD as the start date for implementing new smoking bans and tobacco control efforts. For example, on May 31, 2008, a section of the Smoke Free Ontario Act came into effect banning tobacco "power walls" and displays at stores in this Canadian province, and all hospitals and government offices in Australia became smoke-free on May 31, 2010.
The day has also been used as a springboard for discussing the current and future state of a country as it relates to tobacco—for example in India which, with 275 million tobacco users, has one of the highest levels of tobacco consumption in the world.
For some, WNTD is seen as a challenge to individual freedom of choice or even a culturally acceptable form of discrimination. From ignoring WNTD, to participating in protests or acts of defiance, to bookending the day with extra rounds of pro-tobacco advertisements and events, smokers, tobacco growers, and the tobacco industry have found ways to make their opinions of the day heard.
There has been no sustained or widespread effort to organize counter-WNTD events on the part of smokers. However, some small groups, particularly in the United States, have created local pro-smoking events. For example, the Oregon Commentator, an independent conservative journal of opinion published at the University of Oregon, hosted a "Great American Smoke-in" on campus as a counter to the locally more widespread Great American Smokeout: "In response to the ever-increasing vilification of smokers on campus, the Oregon Commentator presents the Great American Smoke-in as an opportunity for students to join together and enjoy the pleasures of fine tobacco products." Similarly, "Americans for Freedom of Choice", a group in Honolulu, Hawaii, organized "World Defiance Day" in response to WNTD and Hawaii's statewide ban on smoking in restaurants.
Historically, in America the tobacco industry has funded state initiatives that provide resources to help smokers quit smoking as per the Master Settlement Agreement regulated by the U.S. government. For example, Phillip Morris USA operates a website that acts as a guide for those who choose to quit smoking.
World No Tobacco Days have not induced a positive vocal response from the tobacco industry. For example, a memo made publicly available through the Tobacco Archives website was sent out to executives of R.J. Reynolds Tobacco Company in preparation for the third annual World No Tobacco Day, which had the theme of “Childhood and Youth Without Tobacco.” The memo includes a warning about the upcoming day, a document that explains the arguments they anticipate the WHO making, and an explanation of how the company should respond to these claims. For example, in response to the anticipated argument that their advertisements target children, the company’s response includes arguments that claim their advertisements are targeted towards adults by using adult models, and that advertisements lack the power to influence what people will actually purchase. In Uganda, since the World No Tobacco Day is the one day that the media is obligated to publicize tobacco control issues, the British American Tobacco company uses the eve of the day to administer counter-publicity. In 2001, their strategy included events such as a visit with the President of the International Tobacco Growers Association.
Unlike the tobacco industry, some big pharmaceutical companies do publicly support WNTD. For example, Pfizer was a large sponsor for many WNTD events in the United Arab Emirates in 2008. At the time, Pfizer was preparing to release its drug Chantix (Varenicline) into the Middle Eastern market. The drug was “designed to activate the nicotinic receptor to reduce both the severity of the smoker's craving and the withdrawal symptoms from nicotine.”
Many tobacco growers feel that anti-tobacco efforts by organizations such as the WHO jeopardize their rights. For example, the International Tobacco Growers Association (ITGA) argues that poor farmers in Africa may suffer the consequences if WHO anti-tobacco movements succeed. They also argue that these efforts may gang up on manufacturers of tobacco and be an attack on the industry, therefore hurting the growers.
- ^World Health Organization. Tobacco. Fact Sheet N°339, Updated May 2017. Geneva. Accessed 6 January 2015.
- ^World Health Organization, WHO campaigns. Geneva, 5 January 2015.
- ^Centres for Disease Control. 1990. ″MMWR Weekly″ (April 6, 1990). World No-Tobacco Day. Atlanta.
- ^World Health Organization. Tobacco Free Initiative (TFI). Geneva. Accessed 5 January 2015.
- ^Chan, Margaret. 2008. ″WHO calls for banning all tobacco advertising, promotion.″ Nation’s Health. 38(6):21.
- ^World Health Organization. World No Tobacco Day 2015: Stop illicit trade of tobacco products. Geneva. Accessed 5 January 2015.
- ^"World No Tobacco Day 2016: Get Ready for Plain Packaging".
- ^World Health Organization. World No Tobacco Day 2017: Tobacco – a threat to development. Geneva. Accessed 26 May 2017.
- ^ abWorld Health Organization. World No Tobacco Day 2010. Geneva.
- ^World Health Organization. World No Tobacco Day 2009: Campaign Materials. Geneva.
- ^World Health Organization. Tobacco multimedia centre. Geneva. Accessed 5 January 2015.
- ^World Health Organization. Register your World No Tobacco Day 2010 event. Geneva.
- ^World Health Organization. World No Tobacco Day 2009 Awards – The winners. Geneva.
- ^For examples, search “celebrations around the world” within each theme’s page of the World Health Organization’s website. Try World Health Organization, World No Tobacco Day activities – 31 May 2008 to get started.
- ^CBC News. 2008. Cigarette display ban begins in Quebec, Ontario. Ottawa.
- ^Health Life. Smoking to be Banned on Public Hospital Grounds. Adelaide, 25 September 2009. Accessed 5 January 2015.
- ^Campaign for Tobacco-free Kids. Global Epidemic: India. Washington. Accessed 5 January 2015.
- ^The Oregon Commentator. OC to host Great American Smoke-in. November 26, 2007.
- ^Zimmerman, Malia. Defiance—one puff at a time. Hawaii Reporter. July 6, 2007.
- ^Cummins, Sharon E et al., Tobacco cessation quitlines in North America: a descriptive study. Tobacco Control. Dec 2007; 16(Suppl 1): i9–i15.
- ^Phillip Morris USA. Quit Assist. Accessed 6 January 2015.
- ^Tobacco Archives. www.tobaccoarchives.com
- ^R.J. Reynolds Tobacco Company Online Litigation Document Archive. 1990. Infotab. WHO World No-Tobacco Day, 31 May 1990: Growing up without tobacco, The Industry Response.
- ^The Environmental Action Network. 2002. Tobacco Industry Tactics in Uganda.
- ^UAS Interact. 2007. Today’s News Stories: World No Tobacco Day is “Critically Important” for the Middle East.
- ^Yach, Derek and Douglas Bettcher. 2000. Globalisation of tobacco industry influence and new global response. Tobacco Control. 9:206–219.