Within the next fe\v bceeks, representatilres of
the Women vs. Smoking Network appeared on NRC
Nic~17fl!/ NLTIT, CBS 771is Mov/I~u~, CBS Ew~I~II;; N<~i~~~,
the Ml~cNril-Lchwr Ncw~Horl~, Ni~l7tmfcl7, and
Nightli77e. Representatives Lvere also interviewed by
major national newspapers, including L/S,4
Todny; by numerous local papers; by CBS Radio
Network, the Black Radio Network, and National
Public Radio; and by local talk S~OM'S. Last, repre-
sentatives were asked to testify on the topic at con-
gressional hearings. The network follolved up on
the publicity bv spotlighting several different
projects, including a petition to the tobacco compa-
nies to adhere to their o\\`n \roluntarv code of cor-
porate ethics.

  Even the cigarette's proposed name dre\V criti-
cism. Groups in North Dakota and South Dakota
objected to the name, as did Sioux tribal organiza-
tions, because "Dakota" means "friend" or "allv"
in the Sioux language. These groups formed a coa-
lition of more than 4U organizations and collected
25,000 signatures on a petition objecting to the USC
of the word and demanding that R.J. Revnolds cease

chairman Joe Garagiola by lawmakers and Secretary
of Health and Human Services Donna Shalala. >lore
than S70 million in electronic media coverage has been
generated directly from NSTEP efforts. In addition,
NSTEP activities appear to have substantially in-
creased the coverage of smokeless tobacco issues in
the print media. Before NSTEP there were approxi-
mately 500 print articles annually devoted to smoke-
less tobacco; since NSTEP that number has climbed to

Components of Community Programs

Community Advocacy and Mobilization
Electronic Networking

  Interactive communication technologies, such as
computer networks, have been used extensively by
advocacy groups for reducing tobacco use. For ex-
ample, daily communications played an important

selling the cigarette, rvhich had been test-marketed,
as planned, beginning in April 1YYO. The Women
VS. Smoking Nettvork provided strategic counsel-
ing and technical support to the grassroots coali-
tion and \vas instrumental in helping arrange a press
conference in Washington, DC, in June 1990, which
featured then Surgeon General Antonia Novello,
Senator Larry Pressler (R-SD), and others objecting
to the marketing plan.

  Although advocacy groups \vere able to gen-
crate considerable community and media mobili-
zation, R.J. Reynolds continued test-marketing.
Advocates felt they had raised national concern
about the targeting of cigarette advertising, al-
though this impression was not directly verified
through survey research. Dakota cigarettes were
\vithdra\vn trvo years later, however, because the
brand did not sell as well as officials had hoped
04~77c~icn77 Mcrlit-111 iV~w 1992). In this instance, al-
though ad\,ocates might attribute the end result to
the effective use of the media to promote the agenda
for reducing tobacco use, the demise of the Dakota
brand \vas probably more attributable to market
forces.

more than 5,000. One article alone appeared in more
than 800 netzspapers on a given Meekend, and NSTEP
estimated the value of this media coverage at $15 mil-
lion. A recent survey of major league baseball players
and coaches found that more than 44 percent of smoke-
less tobacco users want to quit in the next six months,
perhaps attributable to NSTEP's active participation
in educating ballplayers during spring training.

part in the response to Philip Morris' Bill of Rights Tour
(see the text box later in this chapter). Many active,
functioning networks now provide communication
services to assist in efforts to reduce tobacco use.

  The Institute for Global Communications, based
in San Francisco, \vas an early provider of issue-
specific networks to the general public. PeaceNet and


EcoNet, which were dev~eloped in 1 YH6, are among the
most widelv used and well known of the institute's
networks. As of October 1994, the institute reported a
combined membership of 12,000 people from 130 coun-
tries (Moore 1994). Within these networks, and others
like them, are smaller groups focused on a specific as-
pect of an issue or a particular policy. For instance,
among HandsNet's 2,500 member organizations,
which span the nonprofit sector, is a forum linking 200
community coalitions on substance abuse. This forum,
managed by the Boston-based group Join Together and
supported by the Robert Wood Johnson Foundation,
provides on-line technical assistance to these coalitions.
The forum also provides news summaries and infor-
mation available on funding opportunities and
proposed legislation.

  Several networks link people who work in health-
related areas. In 1993, the Public Health Network pro-
vided forums, e-mail service, and databases for
its membership, which was composed of nearly 600
users from state and local health agencies and of
program directors who were members of the CDC's
Public Health Leadership Institute. In 1998, this
network was replaced by the Information Network for
Public Health Officials. Established by the CDC's Pub-
lic Health Practice Program Office, the network links
the public health community to the Internet and pro-
vides access to on-line information. Planned l'arent-
hood Federation of America hosts PI'XNet, a network
for its affiliates in regional and national offices, pri-
marily for communication within the organization
itself. During the lYYOs, the CDC offered the electronic
resource WONDER to public health officials, acade-
micians, and others so that thev were able to commu-
nicate via e-mail with and ha;,e access to the CDC's
databases of health data.  The advent of the Internet,
including Web-based e-mail and list serv technology,
has facilitated the exchange of public health informa-
tion for health professionals and the public. CDC now
offers its health data, materials, databases, electronic
journals, and other resources on its Web site at
www.cdc.gov.

  In 1990, the Advocacy Institute founded
SCARCNet, a multiuser interactive bulletin board that
served the tobacco control community. (The history
of the bulletin board's sponsoring organization-the
resource center known by the acronym SCARC-is
discussed in "Impact of Direct Ad\;ocacy," later in this
chapter.) When SCARCNet ceased in January 2000, it
had more than 1,000 subscribers and was circulated to
thousands of readers throughout the wrorld on vari-
ous networks. SCARCNet's most popular feature \~as
the "Daily Bulletin," which each day summarized

major newspaper and journal stories on reducing to-
bacco use (Advocacy Institute 1994). The "Daily Bul-
letin" was accompanied by a "Morning Briefing,"
which put these news stories in perspective for the
tobacco control community. The contents of the "Dailv
Bulletin" stories were retained and stored in a data-
base that is currently available for searching at
\vww.tobacco.org.  Another notable feature of
SCARCNet was the publication of "Action Alerts."
These two-page summaries of current issues requir-
ing immediate action included objectives for action,
suggested actions, media bites, quotes, and talking
points and were sent to SCARCNet as needed (on av-
erage, twice per month). The conferencing section on
SCARCNet, called the "Strategy Exchanges," provided
a forum for planning, counseling, and experience
sharing. The technology allowed for concurrent but
separate discussions on discrete issues, such as clean
indoor air, tobacco advertising and promotion, tobacco
pricing policies, and minors' access to tobacco prod-
ucts. Since its inception in 1990 to its final edition on
January 31, 2000, SCARCNet, along with its global
counterpart GLOBALink, became an important re-
source for the tobacco control community. In Febru-
ary 2000, the American Legacy Foundation began its
support of a newly designed and enhanced news ser-
vice system that harnesses advances in Web technol-
ogy to build on SCARCNet's valued features. This
system provides users with the leading national news
stories and also includes a news service that allows
users to receive a customized selection of other stories
based on their geographic location and specialty
areas of greatest personal interest (e.g., advertising, en-
forcement, etc.).

  SCARCNet has served as a model for other pub-
lic health advocacy networks. Examples include Safety
Net (an advocacy network for violence prevention) and
the Marin Institute's ALCNet (a network for alcohol
control advocates), which is modeled closely after
SCARCNet. ALCNct has been used for media advo-
cacy as Lvell, particularly to facilitate strategy devel-
opment to counteract certain alcohol products and
promotions.

  As with other modalities used for social change,
the precise role of on-line networks-one element in a
multifaceted approach-is difficult to define. Al-
though process measures are available (e.g., frequency
of interactions and message traffic), they do not assess
the basic value of computer links in furthering the
agenda for reducing tobacco use, nor is it likely (as is
noted at the beginning of this chapter for social inter-
ventions overall) that their efficacy can be precisely
estimated. Current enthusiasm for the mechanism,


however, rvill probably ensure its continuation, and
accrued anecdotal experience-to date, quite positive-
\vill provide the ultimate judgment.

Direct Advocacy

History md Actizlitirs

  National-level activities, including the lz'ork of
the Coalition on Smoking OR Health (see "Further
Regulatory Steps" in Chapter 5; see also "Communitv
Mobilization," earlier in this chapter) and others (see
Chapter 2 and USDHHS lYHYb), have played a promi-
nent role in the evolving policy changes concerning
the reduction of tobacco use. Of equal interest, from
the point of vie\v of the potential impact of ad\.ocacy,
are decentralized grassroots organizations.

  The nonsmokers' rights movement originated in
the early 1970s (see "From Antismoking to Nonsmok-
ers' Rights" in Chapter 2). It consisted of individuals
acting on their own and of small grassroots organiza-
tions of people irritated bv ETS or con\,inced that theil
health suffered from it. &ring this period, the docu-
mented adverse health effects of ETS were first being
brought to the public's attention (Steinfeld 1972; U.S.
Department of Health, Education, and Welfare 1972).
As research documenting these health hazards accu-
mulated, nonsmokers' rights organizations gre\v in
number and strength.

  Many of the early grassroots organizations used
the acronym GASP to represent similar titles, includ-
ing the Group Against Smokers' Pollution, the Group
Against Smoking Pollution, the Group to Alleviate
Smoking in Public Places, and Georgians Against
Smoking Pollution. Other acronyms w-ere also used,
including FANS (Fresh Air for Nonsmokers), TAPS
(Texans Against Public Smoking), and ANSR-
pronounced "answer"- (Association for Nonsmokers
Rights). Organizations were small, poorly funded, and
often run from home by volunteers.

  Initially, many nonsmokers' rights organizations
simply provided a forum for nonsmokers to express
their concerns about smoking and ETS. These groups
helped legitimize their members' complaints and em-
power them to take protective actions. Such actions
required courage, assertiveness, and no small measure
of tact, since smoking in public areas was normative
at the time. Group members might thus learn how to
politely ask people to refrain from smoking; or to ob-
viate direct confrontation with smokers, groups might
provide members with signs, cards, or buttons asking
people not to smoke in their presence.

  Early in the movement, nonsmokers' rights
associations adopted public policy change as an

important goal. Groups began to work for passage of
measures to restrict public smoking. Such regulations
are often referred to as clean indoor air laws (see "Clean
Indoor Air Regulation" in Chapter 5). To encourage
these measures, an early GASP organization produced
a "Bill of Rights" that stated, in part, that

Non-Smokers have the right to breathe clean air,
free from harmful and irritating tobacco smoke.
This right supersedes the right to smoke when the
tlvo conflict. Non-Smokers have the right to
express-firmly but politely-their discomfort
and adverse reactions to tobacco smoke. . Non-
Smokers have the right to take action through
legislativ-e channels, social pressures or any other
legitimate means-as individuals or in groups-
to pre\:ent or discourage smokers from polluting
the atmosphere and to seek the restriction of
smoking in public places (Group Against Smokers'
Pollution, n.d.1.

  O\rer time, manv organizations moved to encom-
pass broade r policy goals for reducing tobacco use-
in particular, thev sought M-ays to decrease tobacco use
by minors. Lariely as a consequence of those efforts,
direct advocacy and public policy change became im-
portant parts of these organizational strategies.

  In some communities, nonsmokers' rights orga-
nizations Marked in isolation. In others, they formed
associations lvith medical societies, voluntary health
associations, and other organizations; the result was a
more intense effort to ensure passage of desired legis-
lation. Despite initial obstacles, in many communities
nonsmokers' rights associations were a driving force
in moving their allies toward a legislative approach to
reducing tobacco use. For example, one of the earliest
and most influential nonsmokers' rights organizations
was California GASP, founded in 1976, which eventu-
ally became Americans for Nonsmokers' Rights
(ANR). ANR is now the principal national-level
tobacco control group devoted primarily to promot-
ing legislation for clean indoor air. In California, ANR
helped support the passage of such ordinances in many
localities. Partly as a result of ANR's work, California
has more local ordinances for clean indoor air than any
other state. ANR has served as a national consultant
to other groups pursuing such legislation.

Impact of Direct Adz~ocncy

  In retrospect, the grassroots organirations can bc>
seen as ha\.ing -\lorked to diminish the Iegitimacv of
tobacco use in the txye3 of the public anJ the crt~dibil-
it\, of the tobacco indu~tr\. Tht> passage ofordinanct~s


c3gainst public smoking (see "Clean Indoor Air Regu-
lation" in Chapter 5) occurred over se\~eral years, dur-
ing cvhich a shift in public opinion about smoking
became evident. During the 1960s and 197Os, the right
to smoke was largely unquestioned. In more recent
vears, declining smoking prevalence and public opin-
ion polls have indicated an increasing intolerance for
public smoking (USDHHS lY8Yb). The work of non-
smokers' rights organizations is coeval with these
legal, epidemiologic, and social changes. Sorting out
cause and effect is difficult, but the nonsmokers' rights
movement seems to have contributed to the changing
social norm (Glantz 1987).

  There were, however, some important exceptions
to the emerging nonsmoking norms. By the mid-lY80s,
it was apparent that both the traditional educational
efforts and the passage of ordinances to protect non-
smokers from ETS had a limited effect on young
people's smoking-related attitudes and behaviors
(USDHHS 1994). Efforts to reduce smoking appeared
unable to reduce the prevalence of smoking among
teenagers (Lynch and Bonnie 1994), and smoking
prevalence among white females began increasing
sharply during the 197Os, as did the prevalence of
smokeless tobacco use among males.
  The failure to decrease smoking among young
people is as difficult to assess as is the success observed
among adults (particularly among adult men). Ana-
lyzing the effect of prevention activities on young
people must include weighing the hampering effects
of advertising and promotional efforts backed bv the
tobacco industry's enormous marketing budget (see
"Advertising and Promotion " in Chapter 5; DiFranza
et al. 1991; Pierce et al. 1991; Lynch and Bonnie 199-I;
USDHHS 1994). Whate\.er the interplay of the forces
involxred, the result is that protobacco actixitv directed
at those entering the market has been generaIl\, suc-
cessful. An exception is the continued decline in pre\`a-
lence among young African Americans, particularly
among young women (USDHHS lY98).
  Perhaps some of the shortfall in grassroots efforts
to reduce tobacco use is associated Lvith the earlv iso-
lation of these groups from the established naiional
advocacy organization. Anecdotally, there is evidence
of a culture clash. When the nonsmokers' rights move-
ment emerged in the 197Os, many medical and volun-
tary health organizations decried \vhat they perceived
as the unprofessional, indecorous, confrontational ap-
proach that these activists took to an issue that had
previously fallen in the domain of the traditional pub-
lic health structure. Some traditional organizations in
the public health arena may also have felt that

grassroots organizations were infringing on their
"turf" and their fund-raising base.
  For their part, nonsmokers' rights associations
objected to lvhat they saw as the overly cautious, mea-
sured approach of researchers, medical associations,
and volunteer health associations, whose efforts
seemed to have done little to solve the problems ot
day-to-day exposure to ETS. The grassroots organi-
zations urged voluntary health organizations to exam-
ine their mission statements and dedicate appropriate
resources to cost-effective solutions to reducing to-
bacco use.

  In time, both approaches acknowledged that the
lack of coordination and cohesion was a significant
barrier to their efforts. The groups noted that, in con-
trast, the tobacco industry operated as a monolith
through the coordinated efforts of the Tobacco Insti-
tute, a lobbying and public relations organization
representing the industry. This insight led to the emer-
gence of several groups-somewhat disparate in their
approaches-that attempted to bridge some of the dis-
tance between the grassroots and national approaches
to reducing tobacco use.

  Among the oldest of these groups is DOC (Doc-
tors Ought to Care), which was founded in 1977 as a
national coalition of health professionals, students, and
concerned individuals. DOC groups take an activist
approach to public health problems and sponsor com-
munity projects and events on reducing tobacco use
and other issues. From the outset, members chose COP
trontational programs, such as counteradvertising and
picketing industry-sponsored sports events, to
delegitimize the tobacco industry and focus attention
on its acti\-ities bv involving both physicians and
voung people in advocacy activities. DOC groups use
&tire, ridicule, and parody in their work to appeal to
children and teenagers (Blum 1982); for example, they
have sponsored "Emphysema Slims" tennis matches
featuring appearances by "Martina Nosmokanova."
DOC also maintains a large archive of activities related
to the tobacco industry, including past advertising
campaigns and marketing strategies (Mintz 1995). The
acti\+ties of DOC are similar in style, if not content, to
those of the Australian organization Billboard Utilising
Graffitists Against Unhealthy Promotions (BUGA-UP),
which was founded in 1979. BUGA-UP members,
some of whom are physicians, have used unconven-
tional tactics, such as spray-painting billboards that
advertise tobacco products (Jacobson 1983).

  Another group is Stop Teenage Addiction to To-
bacco (STAT), which \vas founded in 1985 with the aim
of reducing tobacco use among minors. From its
inception, STAT aimed to unite the medical and


scientific arm and the grassroots arm of the movement
to reduce tobacco use. Although STAT frequently ap-
proaches tobacco issues from the activist perspective,
the organization has long included key members
of the medical and public health establishment in
its leadership. DOC, STAT, and other groups have
attempted to make the activist, confrontational ap-
proach to reducing tobacco use acceptable to the more
conservative medical and voluntary health organiza-
tions. Partly because of these efforts, an activist
approach is now an important component of the move-
ment (see the text box "Bill of Rights Tour").

  Another impetus for a more unified movement
\vas the establishment of the Smoking Control Adlro-
cacy Resource Center (SCARC) at the Advocacy Insti-
tute in 1987. The Adlrocacy Institute's mission-to
study, analvze, and teach public interest advocacy-
included a'focus on smoking reduction as a model
public interest movement. The institute received fund-
ing from the Henry J. Kaiser Family Foundation to
establish SCARC. Rather than be a frontline organ-
Tation, SCARC proposed to help build the mo\,ement's
infrastructure. As such, SCARC \vould be v-ielved as
a neutral player and \t,ould not vie I\Tith the
movement's other organizations in seeking media,
voluntary, or funding sources. Since its formation,
SCARC has served three important roles as convener,
tobacco industry monitor, and center for strategic
development, training, and counseling (Butler 1990).

Media Advocacy

  Media advocacy for reducing tobacco use was
developed during the lY8Os by a small number of ac-
tivists working primarily in the United States, Canada,
Australia, and the United Kingdom. The attendees at
the September 1985 International Summit of Smoking
Control Leaders resolved to produce a handbook that
would provide guidance on using the media to sup-
port tobacco control. The resulting document, Smoke
Si~rlals: T/V .S~~lr~kirl;~ Corlfvol Mcdin Hnr2itEook Pertschuk
19871, describes many of the important themes and
skills needed for using what would later be dubbed
"media advocacy." In January 1988, the Advocacy In-
stitute convened a t\vo-day consensus workshop,
sponsored bv the NCI, that produced a second hand-
book on media advocacy, M&i17 SfrntL><yies ,f<~ .S~&ill~q
Co77frol: Glrirlrlirzc~.~ (USDHHS 198Ya), which formally
recognized the importance of media advocacy in re-
ducing tobacco use (and in which the term "media
advocacy" was first employed).

  Media advocacv has been defined as the strate-
gic use of mass media to advance a social or public

policy initiative (NC1 1YYl). In contrast to the goal of
traditional health communications efforts, the goal of
media advocacy is to change public policy and thereby
generate a broader impact on tobacco use by creating
an environment in which smoking is not normative.
S777ok Si~~~~~ls articulates six critical tasks the media
must perform to help accomplish this goal: (1) edu-
cate the public about the severity of the risks of smok-
ing, the susceptibility of every smoker, and the health
benefits of quitting; (2) educate the public about the
health risks of ETS; (3) alert citizens and policymakers
to injurious public policies that promote smoking, in-
cluding insufficiently regulated advertising and pro-
motion of cigarettes, as well as unrestricted smoking
in public areas and the workplace; (4) respond to and
counteract the propaganda and disinformation cam-
paigns of the tobacco industry; (5) counter the eco-
nomic and political influence of the tobacco industry,
\vhich th\z,arts the adoption of remedial policies; and
(6) reinforce e\.olving social nonsmoking norms
(I'ertschuk 1987).

  Media ad\,ocacy campaigns have been likened
to political campaigns "in lvhich competing forces con-
tinuouslv react to unexpected events, breaking news,
and opportunities" (Pertschuk et al. 1991, p. 3). Such
campaigns require both presenting the public health
side of an issue and negating the opposing side. Like
political campaigns, media advocacy campaigns re-
quire quick reactions that contrast with the carefully
planned, fixed agendas of traditional media programs.

  Media advocacy recognizes the pokential of the
press to place on the public agenda issues concerning
the reduction of tobacco use and to either advance or
retard progress toward policy goals. Successful me-
dia influence requires gaining access to the news and
framing or shaping coverage of the resulting story.
These strategies are interrelated, since the framing of
a story helps determine whether a journalist will agree
to cover it.

  The use of media advocacy has two daunting limi-
tations: it is a new technique that requires complex
skills and an understanding of the news media, and it
demands a large investment in time (Wallack 1990). But
another apparent barrier-the reliance on an outside
party (the media) to achieve program goals-is also a
source of considerable strength: media advocacy is a
means by which public health practitioners can indi-
rectly confront and compete with forces that are tradi-
tionally beyond their policy and financial reach. These
forces represent powerful vested interests-the tobacco
industry, advertising industry, retail establishments that
sell tobacco, and others. The financial and political
influence of these entities can limit the ability of public


I n fall 1989, Philip Morris, the largest U.S. manu-
facturer of cigarettes, contracted with the U.S.
National Archives and Records Administration to
sponsor a commemoration of the 200th anniversary
of the Bill of Rights. The commemoration involved
a national advertising campaign, including com-
mercials on prime-time television and full-page
advertisements in major newspapers, asking Ameri-
cans to "Join Philip Morris and the National Archives
in celebrating the 200th anniversary of the Bill of
Rights" (cited in Advocacy Institute 1989, p. 1). Philip
Morris soon announced plans to transport Virginia's
copy of the Bill of Rights to all 50 states in coopera-
tion with the Virginia State Library and Archives.
  Advocates for reducing tobacco use inter-
preted Philip Morris' effort as an attempt to link
smoking with the national freedoms guaranteed by
the Bill of Rights. These groups believed that Philip
Morris would use its association with the Bill of
Rights Tour, which highlighted themes of liberty
and freedom of expression, to gain public support
for the company's claim of a First Amendment right
to advertise. Philip Morris' project \tTi.ith the National
Archives raised concern in the C.S. House of Rep-
resentatives, which held hearings on the issue but
did not intervene. Advocates for reducing tobacco
use began using the l&month tour schedule to
coordinate local efforts to counter what they con-
sidered to be a tobacco-marketing plan.
  The Washington state chapter of Doctors
Ought to Care (DOC) built a countersymbol, the
"Statue of Nicotina," to travel with the tour. At a
press conference, comments from the president of
the chapter, Dr. Robert Jaffe, captured the flavor of
the symbol's proposed use:

Nicotina is modeled [on] the Statue of Liberty.
She's holding a cigarette in her upheld hand,
instead of a torch, and her eyes are closed, the
symbol of shame that she's been made a
symbol of tobacco. The chains from her ciga-
rettes in the pack help to illustrate to all of the
children who are going to see the Bill of Rights
Tour that this is a dangerous, addictive drug.
At her feet are the words, "Give me your poor,
your tired, your women, your children yearn-
ing to breathe free .I' (quoted in Wallack et al.
1993, p. 185).

  The Advocacy Institute published an advance
schedule of the national tour, including dates and
specific locations for each of the tour's stops. The
institute also tracked activities in various states and
disseminated strategic information through Action
Alcrfs posted on SCARCNet, the institute's com-
puter network dedicated to sharing information on
reducing tobacco use. SCARCNet (see "Electronic
Networking," earlier in this chapter) was a key
mechanism for advocates to share information and
develop strategies. In addition, the American Lung
Association and the American Medical Association
provided materials and strategic support to its in-
terested affiliates.

  Initially, Philip Morris responded to protests
at tour sites by establishing a "speaker's corner"
that restricted protesters to a site away from the
exhibit hall. At first, this strategy successfully
muted attacks and deflected positive attention from
protesters. Indeed, by appearing to encourage
protesters, Philip Morris was portrayed by some me-
dia reports as being faithful to the spirit of the Bill
of Rights. As the tour continued, however, groups
opposed to the sponsorship learned from experience
in other states. The groups refined their message,
learned 110~. best to respond to Philip Morris'
spokespersons, discussed public reaction to their
protests, and modified their tactics appropriately.
They developed a simple slogan, "Bill of Rights Yes/
Philip Morris No" (cited in Wallack et al. 1993, p.
1861, to clarify the theme of their protests.
  With the changed approach, advocates re-
ported improved media coverage of the protests.
At almost everv tour stop, advocates staged press
conferences beiore the opening of the exhibit and
displayed the Statue of Nicotina, which was trans-
ported from state to state. By February 1991, five
months into the tour, Philip Morris scaled down
the number of scheduled stops. The tour, accom-
panied by advocates for reducing tobacco use,
continued through its conclusion in Richmond,
Virginia, in December 1991.

  The ultimate effectiveness of this advocacy
effort is difficult to judge, but the effort played an
obvious role in muting the public relations benefits
to the tobacco industry. At the very least, the re-
sources invested by the industry did not appear to
bring the expected return.


Ralucirlg Tohcco Use

(as well as private) agencies to use confrontational tac-
tics. In addition, many communities prefer consensus
building to confrontation with powerful opposition
parties. However, because the visible products of me-
dia advocacy-the media reports themselves-emerge
from a disinterested party (the media) rather than from
parties for or against reducing tobacco use, this new-
est form of social intervention can be successful in pre-
viously problematic areas.

  As with other social interventions, the precise
contribution of media advocacy to the effort to reduce
tobacco use is difficult to judge. Events like those sur-
rounding the marketing of the cigarette brands Up-
town, X, and Dakota and the Philip Morris-sponsored
Bill of Rights Tour demonstrate the role that media
advocacy can plav in the overall effort.

Countermarketing

Mass Media in ToOacco Corrtrol

  In contemporary society, the mass media are the
most important means of educating and informing the
public and, through public response to media, policy-
makers. By design or not, the media plays an enor-
mous role in influencing the smoking behavior of
individuals and the actions of policymakers in both the
public and the private sector (Pertschuk 1987). Public
health programs have used various health communi-
cation programs to inform and influence the behavior
of the general public. Traditionally, communication
programs intended to reduce tobacco use have tried
to influence the behavior of individuals. Most such
media campaigns have focused on influencing the
behavior of adult smokers-and hence have focused
more on smoking cessation than on prevention. Flay
(1987) describes three prominent types of mass media
programs and campaigns designed to influence
smoking-related knowledge, attitudes, and behavior:
(1) those that inform the public of the negative health
consequences of cigarette smoking and try to motivate
smokers to quit, (2) those that promote specific smok-
ing cessation actions to those smokers motivated to
quit (e.g., smokers are encouraged to call a help line
or to request specific materials, such as a tip sheet or a
self-help manual), and (3) those that promote smok-
ing cessation self-help clinics for those smokers who
desire to quit. A smaller number of campaigns have
focused on youth, either encouraging young people
to avoid using tobacco products or convincing young
people who smoke to try to quit (USDHHS 1994).

  A factor that has limited the success of traditional
mass media campaigns is the small size of the cam-
paign budgets compared with the advertising and

marketing budgets of the tobacco industry (Flay 1987;
USDHHS 1994). In addition, these campaigns to re-
duce tobacco use have experienced drawbacks because
of their traditional reliance on public service announce-
ments (PSAs). Although PSAs have been an integral
part of such efforts for many years, the number of PSAs
on any subject provided to broadcasters has increased,
whereas the amount of donated air time available for
PSAs has decreased. Also, the advent of cable tech-
nology, which has increased the number of channels
through lvhich people can be reached and therefore
has diffused the audience, has further hampered
efforts to reach targeted groups efficiently. By the mid-
198Os, it had become apparent that the role of the
media in the effort to reduce tobacco use required re-
evaluation. In the following sections, the uses of mass
media approaches for tobacco control are summarized.

Effects of Protobacco Advertising amI Promotion

  The effect of tobacco advertising and promotion
activities on both adult consumption and youth ini-
tiation has been the subject of considerable research
over the past decade (see "Advertising and Promo-
tion" in Chapter 5). While noting that existing evi-
dence suggests that tobacco marketing increases the
level of tobacco consumption, the 1989 Surgeon
General's report Rcducillg the Health Co~~sequcnces
of Sl?lokirl~: 25 Ytvrs of Progress concluded that the
issue is so complex that a sufficiently rigorous study
capable of providing definitive scientific evidence is
not available and that "none is likely to be forthcom-
ing in the foreseeable future" (USDHHS 1989b, pp.
516-7). The 1994 Surgeon General's report Prezw~ti~zg
Tr&ncco Use Amor~g Youug Peo,& similarly noted the
absence of a definitive longitudinal study of the direct
relationship of tobacco advertising to adolescent smok-
ing. However, acknowledging the value of recent
nonlongitudinal studies focused on young people, the
report offered this major conclusion: "Cigarette
advertising appears to increase young people's risk of
smoking by affecting their perceptions of the perva-
siveness, image, and function of smoking" (USDHHS
1994, p. 6). Also in 1994, the Institute of Medicine con-
cluded that the preponderance of evidence suggests
that tobacco marketing encourages young people to
smoke (Lynch and Bonnie 1994).

  In its rule to restrict the access and appeal of to-
bacco products to young people, the Food and Drug
Administration (FDA) reviewed the quantitative and
qualitative evidence and concluded that cigarette ad-
vertising is causally related to the prevalence of smok-
ing among voung people (Fcdcrnl Register 1996). The


agency also cited statements from internal documents
of the tobacco industry to sho\~ the importance of the
vouth market segment to the industry's continued
success. More recently, a 1998 Report to the United
Kingdom's Chief Medical Officer by the Scientific
Committee on Tobacco and Health concluded unani-
mously that tobacco advertising and promotion influ-
ence young people to begin smoking (Scientific
Committee on Tobacco and Health 1998).

   Survey data sho\v that among children who
smoke, most use the most heavily advertised brands
of cigarettes, whereas many adult smokers buy generic
or value category brands, which have little or no im-
age advertising (CDC 1994). A major econometric
marketing study found that young people are three
times more affected by advertising than are adults
(Pollay et al. 1996). Research has also pointed to the
impact of other tobacco promotional activities, such
as sponsorship of public entertainment events and dis-
tribution of specialty or premium items. These activi-
ties constitute the largest (and an increasing) share of
tobacco marketing expenditures. The CDC has esti-
mated that today's U.S. teens already have been ex-
posed to more than 520 billion in imagery advertising
and promotions since age 6, creating a "friendly fa-
miliarity" for tobacco products and an environment
in which smoking is seen as glamorous, social, and
normal (Eriksen 1997). Although the effect of this ex-
posure is difficult to quantify, especially nation\\.ide,
one study has estimated that 3-l percent of all youth
experimentation with smoking in California betIvecn
1993 and 1996 can be attributed to tobacco promotional
activities (Pierce et al. 1998). A recent study found that
teenagers who can readily name a cigarette brand and
who own a tobacco-company-sponsored promotional
item are more than tlvice as likely to become estab-
lished smokers than adolescents ~`110 do neither
(Biener and Siegel 2000).

Effects of Tobacco Couzzterwzarketizzg

  In light of ubiquitous and sustained protobacco
messages, countermarketing efforts of comparable in-
tensity and duration are needed to alter the social and
environmental context of tobacco use. Evidence of
effectiveness comes from three main sources: (1) the
natural experiment of the counteradvertising cam-
paign that occurred during the late 1960s as the result
of a Fairness Doctrine ruling (also discussed in "Broad-
cast Advertising Ban" in Chapter 5), (2) school and
community intervention studies incorporating mass
media approaches (see "Supplemental Programs" in
Chapter 3), and (3) recent experience with large paid

media campaigns in several U.S. states and with a na-
tionwide campaign funded by the FDA. Because of
the special sensitivity of young people to tobacco mar-
keting and the high rates of tobacco use among teen-
agers, the subsequent review in this chapter will focus
on countermarketing media campaigns that include
prominent youth-targeted components. The literature
provides strong evidence of the value of mass media
campaigns to inform the public at large-including
young people-about the hazards of smoking, to pro-
mote specific cessation actions and services (such as
telephone help lines), and to provide cessation clinics
to adult smokers (Flay 1987; Pierce 1995).
  The Fairness Doctrine campaign. In 1967, the
Federal Communications Commission (FCC) applied
the Fairness Doctrine (discussed in "Broadcast Adver-
tising Ban" in Chapter 5) to cigarette advertising and
required broadcasters to provide a significant amount
of airtime to antismoking messages-a requirement
interpreted by the FCC at that time to be about one
antismoking message per three tobacco advertising
messages). This requirement resulted in the onlv sus-
tained nationwide tobacco control media campaign
to date. From mid-1967 through 1970, roughly $200
million in commercial airtime (in 1970 dollars) or $75
million per year w'as donated for antismoking mes-
sages on television and radio (Warner 1986; USDHHS
1989b).

  The campaign produced significant reductions
in both adult and youth smoking behaviors (Hamilton
IY72). For the first time in the 20th century, adult per
capita cigarette consumption fell for more than three
consecutive vears. Teenage smoking prevalence was
3 percentage- points smaller during the Fairness Doc-
trine period than it was in the 16 months before the
campaign, and the campaign was associated overall
\vith a 3.4-percentage point reduction in teen smoking
prevalence. Perhaps the ultimate indicator of the
campaign's impact was a change that followed the
campaign's end: with the 1971 enactment of congres-
sional legislation banning tobacco commercials from
television-and with them, the Fairness Doctrine-
mandated counteradvertisements-per capita
cigarette consumption immediately resumed its
upbvard trend (see "Broadcast Advertising Ban" in
Chapter 5).

  Hamilton (1972) suggested that during the Fair-
ness Doctrine period, the antismoking campaign mes-
sages had an effect that was nearly six times that of
cigarette advertisements. Warner (1979) noted that the
government's broadcast ban-and the consequent end
of the countermarketing campaign-was especially
detrimental to the ongoing effort to pre\rent young


people from smoking. Cigarette promotion remained
highly visible in the print media and in tobacco com-
panies' sponsorship of sporting events at the same time
the broadcast ban "virtually eliminated mass promo-
tion of the antismoking cause" (p. 445).

  Community intervention studies. As described
in "Research on Multifaceted Programs" in Chapter 3,
multicomponent youth-directed programs that include
a prominent mass media component have shown long-
term success in postponing or preventing smoking
onset in adolescents. In the University of Vermont
School and Mass Media Project, the study featuring
the most intensive paid counteradvertising campaign,
the preventive effect actually increased during the two-
vear intervention period among the adolescents at
iligher risk for smoking (Flynn et al. 1997)-a rare
outcome for most campaigns trying to change health
behaviors. The authors noted that counteradvertising
can effectively reach higher-risk youth because of their
greater exposure to the mass media, particularly ra-
dio and television. It is also likely that higher-risk
youth make their decisions about tobacco use earlier
in life than lower-risk vouth; mass media influences
can be especially powerful in shaping attitudes and
normative perceptions at early ages.

  State-based media campaigns. Mass media cam-
paigns are standard components of the well-funded,
ongoing tobacco control programs in California, Mas-
sachusetts, Arizona, Florida, and other states recei\,-
ing money for counteradvertising programs from state
excise tax increases or tobacco settlement allotments
(as was discussed in "Example of Major State Pro-
grams," earlier in this chapter). Although it is diffi-
cult to sort out the effectiveness of media campaigns
from other program components, evaluations of these
statewide public education programs, particularly in
California and Massachusetts (see "Supplemental Pro-
grams" in Chapter 3), have shown their success in re-
ducing tobacco use among adults, slowing the uptake
of tobacco among youth, and protecting children from
exposure to ETS (CDC 1996). A recent study of the
Massachusetts media campaign in 1993 and 1997 found
that among younger adolescents (those aged 12-13
years in 1993), those who had been exposed to the
counteradvertising campaign on television were about
half as likely to have become smokers as those who had
not been able to recall campaign advertisements (Siegel
and Biener 2000).

  Food and Drug Administration campaign. In
1998, the FDA launched a national advertising
campaign to help retailers comply with the age and
photo identification provisions of the FDA's rules to
prevent tobacco sales to children and adolescents. The

campaign began with a test in Arkansas and by year's
end was active in 42 states. Funded annually at about
$9 million, the campaign featured radio spots, bill-
boards, newspaper advertisements, posters, and store
signage. The overall approach was to use humor to
relieve the discomfort clerks may feel when checking
young people's identification/proof-of-age cards and
to increase awareness of the rule provisions among re-
tailers, underage youth, and the general population.
One counter card, for example, reads, "Our cashier
really stinks at guessing ages. So if you want ciga-
rettes, can we see some I.D.?"

  A campaign tracking survey (Market Facts 1998)
in nine states with test and control sites found that
during the first year of the campaign, knowledge of
age 27 as the cutoff age for checking identification
increased from 34 to 54 percent in test sites and from
31 to 40 percent in control sites. Most important was a
small but significant decline in the average number of
times minors tried to buy tobacco. According to re-
tailer self-reports, this number declined from 3.4 times
each day before the campaign to 2.8 times daily after
the media effort. In control sites, the frequency of un-
derage purchase attempts did not decrease from be-
fore (2.4 times daily) to after (2.7 times daily) the time
of the campaign. For customers from whom identifi-
cation was requested in the test sites, retailers reported
that the proportion of those who were "often" or "al-
ways" irritated declined from 34 percent to 28 percent.

  Counteradvertising and entertainment media.
The increase in movie depictions of tobacco use is a
powerful media influence promoting use among teens
(Stockwell and Glantz 1997). In focus groups, young
people are not able to recall antismoking messages on
television or in the movies, but they recall specific
movies that portray smoking and can identify actors
and actresses who smoke in their entertainment roles
(Crawford et al. 1998). Counteradvertising holds
promise for helping denormalize and deglamorize
these portrayals in the entertainment media. In an
experimental study, Pechmann and Shih (1999) found
that placement of a 30-second California Department
of Health Services tobacco counteradvertisement
before the popular movie Rmlify Bites served to inocu-
late teenagers against the movie's pervasive
prosmoking cues without detracting from their enjoy-
ment of the film. Because paid advertising in movie
theaters is a highly efficient method of reaching
adolescents, the authors recommend this tactic as a
nationwide cost-effective prevention strategy.

  Research on best practices. Although produc-
ers of counterad\.ertising campal, `011s use formative re-
search techniques to de\,elop products, inconsistent


testing methods hinder comparison of the eftecti\,e-
IWSS of different messages. This situation has helped
create the impression that there is little agreement
over "what works" in tobacco counteradvertising, as
typified by this Wd7i77,@r7 Pnrt headline: "The Anti-
Smoking Campaign's a Many Splendored Thing, and
That's the Problem" (Teinowitz 1998).
  Goldman and Glantz (1998), using available fo-
cus group data and research reports obtained from a
number of states, concluded that t\vo message strate-
gies, industry manipulation and the hazards of ETS,
are the most effective for denormalizing smoking
among young people and reducing consumption
among adults. The researchers reported that addic-
tion and cessation messages can also be effective, but
that four strategies are not effective: youth access,
short-term health effects, long-term health effects, and
romantic rejection.  They also characterized
California's counteradvertising campaign as more
"confrontational with the industry" (p. 772) than Mas-
sachusetts' "more youth-oriented approach" (p. 772),
citing this difference as a major reason for their find-
ing that the California media campaign was relativelv
more cost-effective. This paper elicited some strong
responses. The University of Vermont School and Mass
Media Project investigators (Worden et al. 1998) em-
phasized the limitations of focus group results and the
importance of audience age in reactions to messages.
They argued that for young people aged 10 to 12 years
(the age group in which they recommended starting
prevention efforts), presenting messages that foster
positive social influence and social norms have proved
most effective in reducing tobacco use among youth.
Balch and Rudman (1998) responded that young
people participating in 110 focus groups in five differ-
ent states considered numerous concepts and judged
five to be more credible, relevant, and persuasive:
addiction, short-term health effects, athletic perfor-
mance, role model for vounger siblings, and effects on
family. From Massachusetts, Connolly and Harris
(1998) noted that industry manipulation and ETS
themes constituted 32 percent of all youth-targeted
messages and 37 percent of all messages in the Massa-
chusetts tobacco control media campaign and that on
a per capita basis, the state actually outspent Califor-
nia on these messages. Moreover, the researchers re-
ported that Massachusetts experienced a larger decline
in per capita cigarette consumption than did Califor-
nia for the period 1990-1996.

  To obtain data in a more quantitative way,
Pechmann and Shih (1999) created a typology based
on 196 youth-oriented antismoking television adver-
tisements. They identified three main types-fear

appeals, peer norms, and tobacco marketing-and
further subdivided these into seven main messages:
(1) smokers may face serious health problems, (2) to-
bacco company deception results in disease and death,
(3) smokers endanger their family members, (4) smok-
ing is unattractive, (5) smokers are perceived by peers
as misguided, (6) most young people choose not to
smoke, and (7) advertisement shows how tobacco corn-
panies market their products. The investigators tested
a sample of 56 of their advertisements in a group of
ethnically diverse 7th, 9th, and 10th graders. After
viewing a selection of test and placebo advertisements,
study participants completed an evaluation survey to
assess the effect of each category on their intent to
smoke and on other pertinent measures, such as atti-
tudes toward smoking and knowledge of tobacco
marketing tactics. Results showed that only three of
the seven messages were highly effective in reducing
teenagers' intent to smoke: those that conveyed that
smokers endanger their family members, that smok-
ers are perceived by peers as misguided, and that most
young people choose not to smoke.
  In the Massachusetts campaign study (Siegel and
Biener 2000), the authors tested eight smoking-related
knowledge and attitude variables corresponding to
campaign themes. Only one variable, perceived youth
smoking prevalence, changed significantly with expo-
sure to the media campaign at baseline and was asso-
ciated with the reported reduction in tobacco uptake.
Exposed youths were more than twice as likely than
their unexposed peers to have an accurate perception
at folloll--up that fewer than half of the students at their
high school were smokers. Variables that did not
change were kno\vledge and attitudes related to low-
tar cigarettes, environmental tobacco smoke, chem-
cals, rvrinkles, tobacco company tactics, dating, and
sports. This finding points to the power of the mass
media, especially television, to set social norms and
supports the effectiveness of counteradvertising mes-
sages that denormalize tobacco use.
  As part of a three-year study exploring racial/
ethnic and gender differences in teen tobacco use, a
group of 11 CDC-funded university-based Prevention
Research Centers conducted a series of focus groups
during 1996-1997 to explore potentially effective
counteradvertising strategies and messages. Six of the
11 centers used television spots from CDC's Media
Campaign Resource Center for Tobacco Control to elicit
reactions and stimulate discussion. For the most part,
different centers used different advertisements, and
they did not attempt to "test" the advertisements in
any standardized way to determine relative effective-
ness. Nevertheless, the conclusions that emerged from


Teen Focus Group Response to Counteradvertising Messages
      (Findings from 11 Prevention Research Centers)

o  Without an overall context provided by ongo-
ing advertising and other program elements, the
message that tobacco companies are manipu-
lating young people to smoke ("they're lying
to you") has relatively low interest and salience
among teens and may be miscomprehended.

.  Attempts to explain the concept of nicotine ad-
diction and make it personally relevant for
young nonsmokers is difficult because most
have not experienced the physical cra\,ings of
addiction and tend to take messages literally.

o  The television spot shorvn to the most iocus
groups (about physical performance and fea-
turing the U.S. Women's National Soccer Team)
was easily understood, attention getting, and
credible and may be generalizable (with some
  effort) to nonathletic endeavors.

.  Young people did not like advertisements that
  feature text.

o  Young people, particularly whites, were sharply
critical of any advertisement they perceived as
  corny, "cute," staged, or unhip.

this research (Tobacco Network, unpublished data) give
some indication of the complexity of people's response
and the considerable challenges to crafting effective
messages (see the text box "Teen Focus Group Response
to Counteradvertising Messages").

  Audience targeting. The use of counteradver-
tising aimed only at young people rather than the use
of a general marketing approach has been controver-
sial. Glantz (1996) criticized the public health
community's "preoccupation with youth" (p. 157),
particularly youth access campaigns, as an ineffective
strategy and one that diverts energy from reducing
adult smoking and creating a smoke-free society.
Cummings and Clarke (1998) warned that campaigns
focused exclusively on young people may be counter-
productive if the messages make smoking more ap-
pealing to youth by promoting it as somethi?; that is

As advertising professionals have reported in
the research literature, humor was found to be
a double-edged sword: it can be very effec-
tive, but if used inappropriately can be seen
as tri\.ializing the issue. In some focus groups,
humorous advertisements obtained both the
highest and the IoM-est scores.

Young people reacted emotionally and favor-
ably to true, nonpreachy stories about the im-
pact of smoking on a person's or family
member's life (such as a television spot from
California featuring a man whose wife had
died from exposure to his smoking).

Cartoons tend to have low "stopping power"
because teens have seen so many, whereas the
use of surprising characters like animals (such
as the "Animals" and "Butts" spots from Min-
nesota) can rivet attention. These attention-
getting spots do not necessarily communicate
an effective countermessage, however.

Messages that portray the negative social effects
of tobacco use perform well among teens; mes-
sages that focus on health effects can be effec-
ti\,e if they are presented dramatically but
realistically (such as a California spot featuring
a laryngectomy patient smoking a cigarette).

not for them. Indeed, a chief criticism of the tobacco
industry-funded booklet Tohcco: Hclyir~~ Youth Say No
was that it portrayed tobacco use as a forbidden fruit
and a badge of maturity, thereby increasing its attrac-
tion to youth (DiFranza and McAfee 1992). The Insti-
tute of Medicine noted 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" (Lynch and Bonnie 1994, p. 87). Young
people participating in focus groups conducted dur-
ing the third year (1997-1998) of the CDC-funded
Tobacco Network project reported that they respect
and regard policies targeted to the public at large, such
as clean indoor air laws, but resent policies specific to
them, such as youth access restrictions. They also
resented the inconsistent enforcement of general


Tips for Success in Health Promotion Campaigns

.  Target yourlgpeople in grades six ard rlilre (ages
22 a~ln 15). These years define critical periods
in most children's social development, times
when many young people change schools and
  peer groups.

.  Target adults with comylementary, uorrcontra-
dictoq messages. In a comprehensive strategy,
media messages that inevitably spill over from
one audience to another can be mutually rein-
forcing and synergistic. Clean indoor air mes-
sages can provide added motivation for adults
to quit smoking. Cessation messages for adults
can affect young people's perception of norms
and highlight the problem of addiction. Pre-
vention messages for young people can increase
the salience of the tobacco issue among parents
and community leaders.

.  Highlight rlonsmoking as the majority behavior.
Most young people overestimate the number
of their peers who use tobacco. Campaigns
should not seek to correct this misperception
nrrti highlight an increasing "problem" of kids
  who smoke.

.  Present realistic tobacco-free lifestyles as prac-
ticed bv diverse, appealing, and interesting per-
sons. \iouth behaviors are driven bv how, young
people perceive the behaviors oi people like
them. Having a repertoire of social choices is a
fundamental need for teens, \~ho are going
through a period of profound social and envi-
  ronmental transition.

policies, such as allowing teachers but not students to
smoke on school property.

  Worden (in Cummings and Clarke 1998), referring
to the research literature on multifaceted education cam-
paigns, noted that reducing the demand for tobacco
among young people requires a combination of direct
(to youth) and indirect (to adults) messages and careful
attention to audience segmentation. He stressed that
young people and adults need separate media cam-
paigns that do not contradict each other. For example,
a youth-directed television spot that communicates the

.  Provide constructive alternatives to tobacco
use and discourage destructive alternatives.
Sports and other youth-oriented activities as-
sociated with the tobacco-free lifestyle can pro-
vide some of that positive social repertoire.

o  Commw~icate the relevant dangers of tobacco.
Certain dangers of tobacco, if explained in a
creative and memorable manner, resonate with
young people-for example, addiction por-
trayed as a loss of control, the carcinogenicity
of environmental tobacco smoke, the toxic
chemicals in tobacco products and smoke, and
the tangible suffering and visible disfigurement
  from tobacco-related diseases. Communicate
health messages through personal testimonies
(tell a story) and creative executions that break
through young people's sense of immortality
  and their (and adults') resistance to traditional
health messages.

.  Encourage youth empowerment ad control.
  Teens need to be offered information and anec-
dotal experience from lvhich they can begin to
understand the world and take control of their
  o~`ii lives.

o  Abaiidori the serzrch for the "magic-bullet"
message. There is no single best motivator for
pre\renting or reducing tobacco use. Campaign
messages for both voung people and adults
should feature a \.ariety of themes, appeals (fear,
humor, satire, testimonials, etc.), and execu-
tional styles. Maximize the number, variety,
and novelty of messages rather than communi-
cating a fe\V messages repeatedly.

message "most kids don't smoke" can be neutralized
by an adult-aimed but youth-vielved spot that says
"more and more kids are smoking e\rery day."

Chflrflcteristics of Successful Campaigns

  Though debate continues over the relative effec-
tiveness of strategies employing specific messages, the
experience rel-ieived in preceding sections suggests
ca~stns~s that counteradvertising campaigns must
have sufficient reach, frequency, and duration to be


.

.

Use multiple noq)reachy voices. Not only do
different teens require different appeals and
creati\re executions, but diversitv of messages
is itself a sophisticated message. Teens
strongly reject attempts by anyone to domi-
nate or direct them. Messages about indus-
try manipulation, if they are to be relevant and
acceptable to youth, should be delivered by
nonauthoritarian sources (such as Florida's
"Truth" campaign teenagers), not \vith melo-
dramatic appeals. A\-oid highlighting a single
theme, tagline, identifier, or sponsor.

Use a completneiftar~y, reirlforciilg inis of tele-
zGsiorf, radio, print, arid outdoor adzlertising.
The campaign should also csplore the \-al-i-
0~1s alternnti\,e media options a\.ailable (e.g.,
mo\ie trailers, the Internet, other computer
resources, \,ideo games, materials for schools
and community groups). The media mix is
especially important in \,ie\l- of todav't; pro-
liferating fragmented media market.-

Iffuoluepareifts andfamilics in acti\.itics that
\vill reduce risk factors and promote protec-
tive factors for voung people at risk for to-
bacco use. Parents and other family members
ha\Te substantial influence on the perceptions
and behaviors of young people.

successful. The 1967-1970 media campaign, enabled
by the Fairness Doctrine, achieved high frequency (one
antismoking advertisement per three cigarette adver-
tisements), extended reach (virtually complete audi-
ence penetration through three [pre-cable television]
national networks), and long duration (three and a half
years). The youth-aimed media campaign of the Uni-
versity of Vermont School and Mass Media Project
exposed 50 percent of the target population to each
television and radio spot about 6 times each year over
a four-year period (about the midpoint in the recom-
mended exposure range of 3 to 10 times per year). This
level of exposure is possible only through paid media
placement.

  Another lesson from health promotion campaigns
is the need for research at every phase of campaign
planning and implementation. Campaigns should be
grounded in the extensive literature on psychosocial
risk factors for initiating, continuing, and stopping
tobacco ust and should be guided by expertise in

o  Maximize use of existing high-quality media
materials produced bv the government, volun-
tary agencies, and a n&nber of individual states.
(A new, high-quality television spot commonly
costs more than SlOO,OOO to produce.) A large
collection of advertisements is currently avail-
able through the CDC's Media Campaign Re-
  source Center for Tobacco Control. The cost of
placing an advertisement will vary significantly
by state and media market.

.  Include grassroots promotions, local media ad-
z~ocacy, evertt spomorshiys, and other com-
mauit?y tie-ins to support and reinforce the
counterad\rertising campaign (see "Media Ad-
\.ocacy," earlier in this chapter). Work in con-
cert 14th other interventions to promote policies
that aim to change social norms regarding to-
bacco. A local "look" for local media messages
(e.g., featuring people of ethnic or geographic
representation similar to the viewing audience)
appears to be more important for adults than
for youth, because young people tend to share
and be shaped by a more universal, multiethnic
  vouth "media Ivorld."

communications theory and practice. Media materials
should undergo rigorous audience pretesting to ensure
they achieve predetermined communication objectives
with their target audiences. Ongoing measurement of
the communications' impact is needed to evaluate the
effectiveness of the campaign and to guide midcourse
corrections.

  Through the Columbia University Preventior
Research Center in New York City, the CDC convened
a panel of youth marketing and research experts in 1996
to advise the agency on effective countermarketing
approaches to prevent tobacco use among young
people. Over two years, the expert panel reviewed the
literature, interviewed experts in tobacco control and
health promotion, and drew on their private-sector
experience and resources to develop a set of strategic
guidelines for such a campaign (McKenna et al. 2000).
This work, supplemented by other reviews of
counterad\)ertising campaigns (USDHHS 1994;
I'echmann I 997; Siegel 1998; Teenage Research


Unlimited 1909; I'echmann and Reibling 20001,
yielded recommenddti~)lis for cftecti\,e media can-
paigns to prevent tobacco use (see the text box "Tips
for Success in Health Promotion Campaigns").

  These recommendations serve as general guidance
for tobacco counteradvertising efforts, but further
research is needed to refine our understanding of the
role and effects of mass media. Relevant areas for fur-
ther investigation include determining the impact of

Summary

counterad\,ertising on tobacco use behaviors, on readi-
ness to quit, on attitudes toward tobacco advertising
and tobacco use, and on other predictors of initiation
and cessation; identifying the most effective themes,
techniques, and messages; tailoring messages to high-
risk groups; exploring the role of new communication
tools, such as the Internet; attributing impact; and ex-
amining the interaction of media campaigns with pri-
vate and public tobacco control policies.

  The conceptual framework described at the start
of this chapter defines the basic components of the health
promotion intervention model. The statewide tobacco
control programs being funded either bv increases in
cigarette excise taxes or settlements lvith the tobacco in-
dustry are creating a ne\v laboratory to test many of these
conceptual models for comprehensive tobacco control.
Recently, both the Institute of Medicine (IOM) and re-
searchers have released reviews of the emerging data
from these statewide tobacco control efforts. In their
report, the IOM (2000) noted that it is difficult to at-
tribute a reduction in tobacco use to any single factor;
nevertheless, they conclude that "multifaceted state
tobacco control programs are effective in reducing to-
bacco use"(p. 1). In a review focusing more specificall!,
on the effectiveness of these ne\v statewide tobacco con-
trol programs on teenage smoking, Wakefield and
Chaloupka (1999) conclude that "There is consistent
evidence the programs are associated \vith a decline in
adult smoking prevalence"(p. 6), but they are some\\,hat
more cautious about the impact of these programs on
vouth smoking. Nevertheless, thev do conclude that
%otwithstanding these cautions; \ve find that the
weight of evidence falls in fa\,or of comprehensi\~e
tobacco control programs being able to reduce teenage
tobacco use" (p. 6).

  In the consideration of the emerging data from
these statewide tobacco control programs, it is impor-
tant to note that many programmatic elements of the
comprehensive tobacco control program frame\vork
are still being refined and evaluated. Thus, no current
statewide program serves an ideal or model program.
Wakefield and Chaloupka (1999) conducted a careful
re\rie\v of the \rarious elements of the statelvide

programs in Arizona, California, Florida, Massachu-
setts, and Oregon. They placed special attention on
the strengths of the "inputs'`-"namely, what was
nct~lnl/!/ i~~plwwltrd as part of the programs." Addi-
tionally, they assessed how "actual implementation of
program strategies may differ substantially from in-
tended implementation" and noted that "the extent of
disparity may vary over time and between programs."
Much more evaluation research is needed in order to
sort out the efficacy of individual components of these
evolving comprehensive programs and to refine the
comprehensi\re program structure.

  Finally, although the data from these statewide
tobacco control programs are encouraging, these results
need to be considered in the perspective of the less fa-
\,orable results from the community trials. The concep-
tual frame\vork for the comprehensive tobacco control
programs shares many elements with the theoretical
models used to de\,elop the community trial interven-
tions. Hoivever, as Wakefield and Chaloupka (1999)
noted, the programs actually implemented may differ
substantiallv from the intended implementation. There
has been sbme effort to analyze how the program
components Lvithin the emer& statewide tobacco
control programs may differ from interventions tested
\\,ithin the community trials (Green and Richard 1993;
Schmid et al. 1995), but much more M.ork is needed in
this area. As the IOM (2000) and Wakefield and
Chaloupka (1999) concluded, the results from the state-
\vide tobacco control programs are favorable. However,
both revielvs emphasize the importance of continued
sur\,eillance and evaluation efforts to monitor program
performance, to provide accountability for the use of
public funds, and to improve program efforts.


Conclusions

The large-scale interventions conducted in com-
munitv trials have not demonstrated a conclusi\.e
impact on preventing and reducing tobacco use.

Statewide programs ha\re emerged as the new
laboratory for de\vAoping and evaluating comprc-
hensive plans to reduce tobacco use.

3.  Initial results from the statewide tobacco control
programs are favorable, especially regarding
declines in per capita consumption of tobacco
products.

1.  Results of statelvide tobacco control programs sug-
gest that vouth behaviors regarding tobacco use are
more difkcult to change than adult ones, but initial
results of these programs are generally favorable.


Abramson JH, Gofin R, Hopp C, Gofin J, Donchin M,
Habib J. Evaluation of a community program for the
control of cardiovascular risk factors: the CHAD pro-
gram in Jerusalem. lsra~/ ]olrrrlnl of Medico/ S'cicr~ccs
1981;17(2-3):201-12.

Abt Associates Inc. for the Massachusetts Department
of Public Health. Irlrlependcllf Evnluatiorz (lf t/w Massa-
clrusctts 7oEncco Co,ztuo/ Progrnn~. First Annual Report:
Fiscal Year 1994. Cambridge (MA): Abt Associates Inc.,
1995.

Abt Associates Inc. for the Massachusetts Department
of Public Health. Indcper~rlcrlf Ezw/mfio/l of fhr Mmsn-
clmsetfs Tobacco Cor7fd Pro`yrtlrrl. Fourth Annual Report.
Cambridge (MA): Abt Associates Inc., 1997.

Abt Associates Inc. for the Massachusetts Department
of Public Health. I,zc-lepetrncrlt Ezlnlunfiorz of the Mnsw
cllllsrtts Tohncco Co17tvol Plogrnrll. Fifth Annual Report:
Summary. Cambridge (MA): Abt Associates Inc., 1999.

Advocacy Institute. Plli/ip Morris Car-pornfr~ lump Ari-
oertisilzg Canzpaipr. Action Alert. Washington: Advo-
cacy Institute, Smoking Control Advocacy Resource
Center (SCARC), Nov 3,1989.

Advocacy Institute. T/w S/rloliirlx CojlfwI ,%fwcilc!/ Rc-
jot~rc~ Chtcr Nctzclork: Ezwl~mfio~~ of SCARCNtTf. Wash-
ington: Advocacy Institute, 1994.

Allison KR, Rootman I. Scientific rigor and commu-
nity participation in health promotion research: are
they compatible? Hr~/th I)rofll~fjofl 1rltcrrli7tirjrlill 1996;
11(4):333-40.

Altman DG, Flora JA, Fortmann SP, Farquhar JW.
The cost-effectiveness of three smoking cessation
programs. Anwr-imu ]o~lvrlnl f~f Plrblir Hrnlfh 1987;77(2):
162-5.

American Medical Association. Sl~lokELt~Sj State Nn-
tiorzn/ Tobacco Pvfwcnfio77 at7d Cor~trol Pqrf7t77: Five Yfsrs
of Mnkirlg n Di@wrzce. Chicago: American Medical As-
sociation, 1998.

Amcricarl Mcdicnl NtTitls. No more Dakotas. Auwric~~rz
Medical News, Apr 13, 1992; Roundup Sect:18 (co1 3).

American Public Health Association. lntrmnfional No+
;oork of Ww~t~~~ Apirrsf Tobacco Mmbrr Directory I 994.
Washington: American Public Health Association,
1994.

,4nwictrjs for Nor7sn7okcrs' Rights u. The Stntc of Califor-
rlin, 31 Cal. App. 4th 743, 1996 Cal. App. LEXIS 1165,
59 Cal. (Cal. Ct. App., Third App. Dist. 1996).

Anantha N, Nandakumar A, Vishwanath N, Venkatesh
T, fallad YG, Manjunath I', Kumar DR, Murthy SGS,
Shivashankariah, Dayananda CS. Efficacy of an anti-
tobacco community education program in India. Car7-
cf'r Calrws nrlcl Coflfrol 1995;6(2):119-29.

Aravanis C, Corcondilas A, Dontas AS, Lekos D, Keys A.
Coronary heart disease in seven countries. IX. The
Greek islands of Crete and Corfu. Cirrlrlnfiorz 1970;41(4
supp1):188-1100.

Arizona Cancer Center, Behavioral Sciences Section, for
the Arizona Department of Health Services. Emlunfh
of t/r 7ihrco Edr~cafior~ ar7d Prmwfim Pvfym7~ Mcdin
Ci7r7rp7igrz. Tucson (AZ): Arizona Cancer Center, 1998.

Arizona Department of Health Services. 1999 Avtorzn
Adult 7olwrco Slrrw!/ Rcporf. Phoenix (AZ): Arizona
Department of Health Services, Bureau of Public Health
Statistics, 2000.

Bal DG, Kizer KW, Felten MA, Mozar HN, Niemeyer D.
Reducing tobacco consumption in California: devel-
opment of a statewide anti-tobacco use campaign. ]ulrv-
,~nl of fh Americnrf Mdicn1 Asociafiorl 1990;264(12):
1570-4.

Balch GI, Rudman G. Antismoking advertising cam-
paigns for youth [letter]. ]o~rr,la/ of fhc Amerirnrl Mcdi-
till A~~ociat;m 1998;280(4):323-4.

Bandura A. Sucin/ LL~~rllj~~~ Theory. Englewood Cliffs
(NJ): Prentice-Hall, 1977.

Bauer RL, Heller RF, Challah S. United Kingdom Heart
Disease Prevention Project: 12-year follow-up of risk
factors. Al7rc~uirn,~ ]olrrrla[ of E/~iilo7~io/o~~/ 1985;121(4):
563-9.

428 Cllapfcr 7


Baum F. Researching public health: behind the
qualitative-quantitative methodological debate. Social
Scicrlcc ord Mtdicilw 1995;40(4):339-68.

Begay ME, Traynor M, Glantz SA. The tobacco indus-
try, state politics, and tobacco education in California.
AnIt~~ic~u ~01~um1 of Publiz HOI/~/I 1993;83(9):1214-21.

Biener L, Siegel M. Tobacco marketing and adolescent
smoking: more support for a causal inference. A,lrcr-i-
ii711 ]o~~ml of P~rblic Hcoltlr 2000;90(3):407-11.

Blackburn H. Research and demonstration projects in
community cardiovascular disease prevention. ]oli~jrnl
of Pliblic Htwlfll Policy 1983;4(4):398-421.

Blackburn H, Taylor HL, Keys A. Coronary heart dis-
ease in seven countries. XVI. The electrocardiogram
in prediction of fiv,e-year coronary heart disease inci-
dence among men aged fortv through fifty-nine. Cir-
<liltlfitlll 1970;41(4 Suppl):I154-161.

Blum A. Medical activism. In: Taylor RB, Creda JR,
Denham JW, editors. Htw/t/7 PJ~~rJmtior~: Prillrijdtrs nrfd
Clirrirnl App/icobiorrs. Norwalk (CT): Appleton-Centurv-
Crofts, 1982:373-91.

Bracht N, Finnegan JR Jr, Rissel C, Weisbrod R, Gleason
J, Corbett J, Veblen-Mortenson S. Community owner-
ship and program continuation following a health
demonstration project. Htwlth Edt~mfior~ Rtwnrclr 1994;
9(2):243-55.

Briton NJ, Clark TW, Baker AK, Posner J, Soldz S,
Krakow M. Atio/escci~t TO~OCCO Uw ifr Mnssachusetts.
Trtwds A~~KJu~~ Public Scl~ool Sflldt>lltj 1981-1996. BOS-
ton: Health and Addictions Research, 1997.

Butler J. The "Dakota Papers." Paper presented at the
Seventh World Conference on Tobacco and Health; Mar
30, 1990; Perth (Australia).

Buzina R, Keys A, Mohacek I, Marinkovic M, Hahn A,
Blackburn H. Coronary heart disease in seven coun-
tries. V. Five-year follow-up in Dalmatia and Slavonia.
Circzrlntion 1970;41(4 Suppl):I40-151.

Carleton RA, Lasater TM, Assaf AR, Feldman HA,
McKinlay S, and the Pawtucket Heart Health Program
Writing Group. The Pawtucket Heart Health Program:
community changes in cardiovascular risk factors and
projected disease risk. Amv+can ]ourm/ of Public Htwlth
1995;85(6):777-85.

Centers for Disease Control. State coalitions for pre-
vention and control of tobacco use. Morbidity nd Mor-
tdity Weekly RqJorf 1990;39(28):476-84.

Centers for Disease Control and Prevention. Changes in
the cigarette brand preferences of adolescent smokers-
United States, 1989-1993. Morbidity ard Mortnlity Weekly
Report 1994; 43(32):577-81.

Centers for Disease Control and Prevention. Cigarette
smoking before and after an excise tax increase and an
antismoking campaign-Massachusetts, 1990-1996.
Morbidity nut1 Mar-fnlify Weekly Report 1996;45(44):
966-70.

Centers for Disease Control and Prevention. Tobacco
tax initiativre-Oregon, 1996. Morbidity ad Mortality
h'wkly Report 1997;46(11):246-8.

Centers for Disease Control and Prevention. 7998 Pvo-
SYI~/!~ RricfirIS Rook. Atlanta: Centers for Disease Control
and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking
and Health, 1998.

Centers for Disease Control and Prevention. Best PI.~c-
tim ftw Colllp,,t~/It~rfsii~t~ Tth~co Corztm-ol Progmzs-August
2999. Atlanta: Centers for Disease Control and Preven-
tion, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health,
1999a.

Centers for Disease Control and Prevention. Decline
in cigarette consumption following implementation of
a comprehensive tobacco prevention and education
program-Oregon, 1996-1998. Morbidity md Mortal-
ity Wefkly Report 1999b;48(7):140-3.

Centers for Disease Control and Prevention. Tobacco
use among middle and high school students-Florida,
1998 and 1999. Morbidity nr~ll Mortnlify Weekly Report
1999c;48(12):248-53.

Chaloupka FJ, Grossman M. Price, tobacco corlfrol /JO/~-
tics 01111 youfh making. Working paper no. 5740. Cam-
bridge (MA): National Bureau of Economic Research,
1996.

COMMIT Research Group. Community Intervention
Trial for Smoking Cessation (COMMIT): summary of
design and intervention. ]ozir1rfl/ CJf tl?e Notioml Carzcer
Iustitutc 1991;83(22):1620-8.


COMMIT Research Group. Community Intervention
Trial for Smoking Cessation (COMMIT): I. Cohort re-
sults from a four-year community intervention. Amrri-
c11n Juurnal of Public Henlfh 1995a;85(2):183-92.

COMMIT Research Group. Community Intervention
Trial for Smoking Cessation (COMMIT): Il. Changes
in adult cigarette smoking prevalence. Amkcnr~ \our-
tm2 of Public Health 1995b;85(2):193-200.

Connolly GN, Harris JE. Evaluating antismoking ad-
vertising campaigns [letter]. jourrznl qf the Amricarz
Medical Associatiotz 1998;280(11):964-5.

Crawford M, Headen S, Luke D, McGloin T. Latest re-
search: youth and teens. Presented at the National
Conference on Tobacco and Health; Ott 26-28, 1998;
St. Paul (MN).

Cummings KM, Clarke H. The Use of Counter-Advertisiizg
as II Tobacco USC Dctrrrel~t md Annlysis of Pem'ir~g Federal
Tobacco Legislation. Policy Analysis No. 8. Washington:
Advocacy Institute, Health Science Analysis Project,
1998.

DiFranza JR, McAfee T. The Tobacco Institute: help-
ing youth say "yes" to tobacco. ]mrrm/ of Fnnzily Pmc-
fice 1992;34(6):694-6.

DiFranza JR, Richards JW, Paulman PM, Wolf-Gillespie
N, Fletcher C, Jaffe RD, Murray D. RJR Nabisco's car-
toon camel promotes Camel cigarettes to children. ~oI[,,~
llal of the Americalz Mrdicnl Associntiorl 1991;266(22):
3149-53.

Downie RS, Tannahill C, Tannahill A. Hcflltll Pronto-
tion: Models a& Vnl~rcs. 2nd ed. Oxford: Oxford Uni-
versity Press, 1996.

Dwyer T, Pierce JI', Hannam CD, Burke N. Evaluation
of the Sydney "Quit. For Life" anti-smoking campaign.
Part 2: changes in smoking prevalence. Mcnicnl ]our-
tzal of Austmlia 1986;144(7):344-7.

Egger G, Fitzgerald W, Frape G, Monaem A, Rubinstein
I', Tyler C, McKay B. Results of large scale media anti-
smoking campaign in Australia: North Coast "Quit for
Life" programme. British Mrdic171 ]ourml 1983;287
(6399):11254X

Elder JP, McGraw SA, Rodrigues A, Lasater TM,
Ferreira A, Kendall L, Peterson G, Carleton RA. Evalu-
ation of two community-wide smoking cessation ~011.
tests. Preuentiue Medicine 1987;16(2):221-34.

Elder JP, Schmid TL, Dower I', Hedlund S. Commu-
nity heart health programs: components, rationale, and
strategies for effective interventions. Iollrrzal of Pub/ii
Henltl7 Policy 1993;14(4):463-79.

Eriksen MP. Social forces and tobacco in society. Pa-
per presented at the Robert Wood Johnson Founda-
tion Conference, New Partnerships and Paradigms
for Tobacco Prevention Research; May 6-9, 1997;
Sundance (UT).

Farquhar JW. The community-based model of life style
intervention trials. Anrerican [our& of Epidemiology
1978;108(2):103-11.

Farquhar JW, Fortmann SP, Flora JA, Taylor B, Haskell
WL, Williams PT, Maccoby N, Wood PD. Effects of
communitywide education on cardiovascular disease
risk factors: the Stanford Five-City Project. Journal of
the Auwicarl Medical Associatiun 1990;264(3):359-65.

Farquhar JW, Fortmann SI', Maccoby N, Haskell WL,
Williams PT, Flora JA, Taylor CB, Brown BW Jr,
Solomon DS, Hulley SB. The Stanford Five-City Project:
design and methods. America/l ]ourml of Epidemiology
1985;122(2):323-34.

Farquhar JW, Maccoby N, Wood I'D, Alexander JK,
Breitrose H, Brown BW Jr, Haskell WL, McAlister AL,
Meyer AJ, Nash JD, Stern MI? Community education
for cardiovascular health. Lnrmt 1977;1(8023):1192-5.

Farquhar JW, Magnus PF, Maccoby N. The role of pub-
lic information and education in cigarette smoking
controls. Candiiztr ]our/m/ of Public Hrnlfh 1981;72(6):
412-20.

Fcdcrnl Register. US Department of Health and Human
Services, Food and Drug Administration. Regulations
restricting the sale and distribution of cigarettes and
smokeless tobacco to protect children and adolescents
(21 CFR Parts 801,803,804,807,820, and 897), 61 Fed.
Reg. 44396 (1996).

Fidanza F, Puddu V, Imbimbo AB, Menotti A, Keys A.
Coronary heart disease in seven countries. VII. Five-
year experience in rural Italy. CircuIntioH 1970;41
(4 Suppl): 163-175.


Reduciirg Tobmco Use

Fisher EB Jr. The results of the COMMIT trial [edito-
rial]. Amt>ricnn Iorrrr~nl of Public Hrnlt11 1995;85(2):
159-60.

Fisher EB, Auslander WF, Munro JF, Arfken CL,
Brownson RC, Owens NW. Neighbors for a Smoke Free
North Side: evaluation of a community organization
approach to promoting smoking cessation among Af-
rican Americans. Am~ricn~7 ]ourrml ofPublic Hcwlfh 1998;
88(11):1658-63.

Florida Department of Health. 2000 Florida Youth To-
bacco Survey results. f`loridn l'oi/th TP/JL~L.~-o S177wy
2000;3(1).

Flynn BS, Worden JK, Seeker-Walker RH, Pirie PL,
Badger GJ, Carpenter JH. Long-term responses of
higher and lower risk youths to smoking pre\.ention
interventions. P~~`ilc~)7tiilc .Medicij~t, 1997;26(3):389-94.

Fortmann SP, Tay!or CB, Flora JA, Jatulis DE. Changes
in adult cigarette smoking prevralence after 5 vears of
community health education: the Stanford Fivre-City
Project. An7cvicc7~7 ]01rrr7nl of E~`ill~,~lfiol~,~!/ 1993;137(1):
82-96.

Gail MH, Byar DP, Pechacek TF, Corle DK, for the
COMMIT Study Group. Aspects of statistical design
for the Community Intervention Trial for Smoking
Cessation (COMMIT). Co17f~ol/~`d Clirlical Triclls
1992;13(1):6-21.

German Cardiovascular Prevention Study Group. The
German Cardiovascular Prevention Study (GCP): de-
sign and methods. E~~vcI[J~~~ Henrf /OUYI~R~ 1988;9(10):
1058-66.

Giovino GA, Schooley MW, Zhu B-P, Chrismon JH,
Tomar SL, l'eddicord JP, Merritt RK, Husten CG,
Eriksen Ml? Surveillance for selected tobacco-use
behaviors-United States, 1900-1994. Morbidity 1717d
Mortality Weekly Report 1994;43(SS-3):1-43.

Glantz SA. Achieving a smokefree society [editorial].
Circulation 1987;76(4):746-52.

Glantz, SA. Preventing tobacco use-the youth access
trap [editorial]. A1~7~k717 ~mrrrznl of P~hlic Hrnlfl7 1996;
86(2):156-S.

Glantz SA, Begay ME. Tobacco industry campaign con-
tributions are affecting tobacco control policymaking
in California. /onr)znl of tl7e ~4mericnr7 Medim Associu-
tio~ 1994;272(15):1176-82.

Glasgow RE, Cummings KM, Hyland A. Relationship
of worksite smoking policy to changes in employee
tobacco use: findings from COMMIT. Community In-
tervention Trial for Smoking Cessation Tobacco Con-
Irol 1997;6(2 Suppl):S44-8.

Glasgow RE, Klesges RC, Mizes JS, Pechacek TF. Quit-
ting smoking: strategies used and variables associated
w,ith success in a stop-smoking contest. Journal of Corr-
sulfir7<q nr~d Clinicnl Psycl7olo<43 1985;53(6):905-12:

Gofin J, Gofin R, Abramson JH, Ban R. Ten-year evalu-
ation of hypertension, overweight, cholesterol, and
smoking control: the CHAD program in Jerusalem.
Priwr~tiiv~ Medic-i77r 1986;15(3):304-12.

Goldman LK, Glantz SA. Evaluation of antismoking
advertising campaigns. 10111.)1171 of tl7c America77 Medical
Associntiilr7 1998;279(10):772-7.

Goodenow C. Tobacco Use Among High School Stu-
dents: 1999 Massachusetts Youth Risk Behavior Sur-
vey Results, Massachusetts Department of Education;
<http://www.doe.mass,edu/news/november99/
112299yrbs,html>; accessed June 6,200O.

Green LW, Kreuter MW. Hcnlflz Prmuotior~ Pln,717ing: At7
Eil7rcatioml nrrd Ewiuorzn7entrrl A~~Jvo~I. 2nd ed. Moun-
tain View (CA): Mayfield Publishing Company, 1991.

Green LW, Richard L. The need to combine health edu-
cation and health promotion: the case of cardiovascu-
lar disease prevention. P~on7otion 1717d Educatiofz Dee
1993:11-7.

Group Against Smokers' Pollution. Norr-Smokers' Bill
of Rights. College Park (MD): Group Against Smokers'
Pollution, n.d.

Gutzwiller F, Nater B, Martin J. Community-based
primary prevention of cardiovascular disease in Swit-
zerland: methods and results of the National Research
Program (NRP 1A). Prc~~nfizlc Medicirlr 1985;14(4):
482-91.

Hamilton JL. The demand for cigarettes: advertising,
the health scare, and the cigarette advertising ban.
RcTijil,itl c)f Ecor7mrii.s (711d Statistics 1972;54(4):401-11.


Hcnlfh I'r'olrloticirr I,ltc~rrrnric~,lnl. The Jakarta Declaration
on leading health promotion into the 21st century.
Hen/t/r ~I-O~JlOfiOl7 ~/~frr~u?tiot~a~ 1997;12(4):261-4.

Heller K. The slow burn: cigarettes, cancer and blacks.
T/zr PI7iladclpl~ia Irlquiwr Mngxir~c, May 20, 1990:14, 1%
20, 30, 32-34, 36.

Hoffmeister H, Mensink GBM, Stolzenberg H, Hoeltz
J, Kreuter H, Laaser U, Nussel E, Hullemann K-D, v.
Troschke J. Reduction of coronary heart disease risk
factors in the German Cardiovascular Prevention
Study. PrCr?CjrfiDc Medicirlc 1996;25(2):135-45.

Hu T-w, Sung HY, Keeler TE. Reducing cigarette
consumption in California: tobacco taxes vs an anti-
smoking media campaign. Amrricar~ ]our1m1 (!f Public-
HcDI~Jz 1995;85(9):1218-22.

Independent Evaluation Consortium. Firm/ Report OIL
the I~zdepfvd~~7t Emluatiorl of f/w Califorr2in 7rh7cro Cofl-
trol Prezwrfiorr and Edw~fiorr Prqram: W17w I D0fa, 1996-
1997. Rockville (MD): The Gallup Organization, 1998.

Institute of Medicine. Sfnfc Plnp~rm Cn11 Rdli<r Tohc-c-cl
L/SC. A Report of the National Cancer Policy Board.
Washington: National Research Council, 2000.

International Network of Women Against Tobacco.
Herstories. World .Sj?rclki,lg fi Hralflr 1994;19(2):1-16.

Interreligious Coalition on Smoking OR Health. PI/~-
/lose. Takoma Park (MD): Interreligious Coalition on
Smoking OR Health, 1993.

Interreligious Coalition on Smoking OR Health. Honor
roll. Rdigimr 0 Tubncco Crvlfrol Jan 1994:l.

Jacobs DR Jr, Luepker RV, Mittelmark MB, Folsom AR,
Pirie PL, Mascioli SR, Hannan I'J, Pechacek TF, Bracht
NF, Carlaw RW, et al. Community-wide prevention
strategies: evaluation of the Minnesota Heart Health
Program. ]ol/r11i71 of Chrorlic Dismscs 1986;39(10):
775-88.

Jacobson B. Smoking and health: a new generation of
campaigners. British? Mrdicnl Jo~~rm?/ 1983;287(6390):
483-4.

Kann L, Kinchen SA, Williams BI, Ross JG, Lowry R,
Hill CV, Grunbaum JA, Blumson I'S, Collins JL, Kolbe
LJ. Youth risk behavior surveillance-united States,
1997. Morbidity arid Morfalify Weekly Reporf 1998;47
(SS-3):1-89.

Kickbusch I. Approaches to an ecological base for pub-
lic health. Hcnltlr Promotion 1989;4(4):265-8.

Kimura N, Keys A. Coronary heart disease in seven
countries. X. Rural southern Japan. Circul&ion 1970;
41(4 suppl):Ilol-I12.

King AC, Flora JA, Fortmann SP, Taylor CB. Smokers'
challenge: immediate and long-term findings of a com-
munity smoking cessation contest. Anwicarr Jourrml of
Pllblic Hcolfh 1987;77(10):1340-1.

Korhonen HJ, Niemensivu H, I'iha T, Koskela K, Wiio
J, Johnson CA, Puska I? National TV smoking cessa-
tion program and contest in Finland. Prrzwztizw Medi-
cine 1992;21(1):74-87.

Korhonen HJ, Puska I', Lipand A, Kasmel A. Combin-
ing mass media and contest in smoking cessation: an
experience from a series of national activities in Fin-
land. H!/gic 1993;12(1):14-8.

Kornitzer M, Dramaix M, Kittel F, De Backer G. The
Belgian Heart Disease Prevention Project: changes in
smoking habits after two years of intervention. Pre-
ZYII~~ZY Mdici,~i~ 1980;9(4):496-503.

Koskela K. .4 Cvrl2nlrlrlif!/-Basl'il Autisndi~~g Pvoxr~n~t??~~
i7.i 17 Part iit n Co,lfprclirizsiilc Cardiozlascirlar Progmv7nle
IT/P h'orfll K7wlin Projr~rfl. Kuopio (Finland): Research
Institute of Public Health, University of Kuopio, 1981.

Lando HA, Loken B, Howard-Pitney B, Pechacek T.
Community impact of a localized smoking cessation
contest. ilrrlcric-arr ]o~rrr~nl of Public Henlflz 1990;80(5):
601-3.

Lando HA, Pechacek TF, Pirie PL, Murray DM,
Mittelmark MB, Lichtenstein E, Nothwehr F, Gray C.
Changes in adult cigarette smoking in the Minnesota
Heart Health Program. Amcricarz Jourml of Pddic Healfh
1995;85(2):201-8.

Lando HA, Pirie PL, McGovern PG, Pechacek TF, Swim
J, Loken B. A comparison of self-help approaches to
smoking cessation. Addictive Brlraviors 1991;16(5):
183-93.


Lefebrve RC, Lasater TM, Carleton FA, Peterson G.
Theory and delivery of health programming in the
community: the Pawtucket Heart Health Program.
Pvez~eutizle Medicirze 1987;16(1):80-95.

Lichtenstein E, Thompson B, Nettekoven L, Corbett K
for the COMMIT Research Group. Durability of to-
bacco control activities in 11 North American commu-
nities: life after the Community Intervention Trial for
Smoking Cessation (COMMIT). Hcnltlz Educatioll Rc-
sear& 1996;11(4):527-34.

Lichtenstein E, Wallack L, Pechacek TF for the COM-
MIT Research Group. Introduction to the Community
Intervention Trial for Smoking Cessation (COMMIT).
Illterllatiollal Quarterly of Comml~~fify Health Edllcatiorf
1990-91;11(3):173-85.

Luepker RV. Community trials. Prwer~tiw Mcdicirlt)
1994;23(5):602-5.

Luepker RV, Murray DM, Jacobs DR Jr, Mittclmark MB,
Bracht N, Carlaw R, Crow R, Elmer I', Finnegan J,
Folsom AR, Grimm R, Hannan PJ, Jeffrey R, Lando H,
McGovern I', Mullis R, Perry CL, Pechacek T, I'irie I',
Sprafka JM, Weisbrod R, Blackburn H. Community
education for cardiovascular disease prevention: risk
factor changes in the Minnesota Heart Health Program.
Americar1 ~OLmal of PllbliC Hea2fh 1994;84(9):1383-93.

Lynch BS, Bonnie RJ, editors. GrozoinX U/J Tclbacco Free:
Prezlel7tiug Nicotirre Addiction irk Childw17 arzd Yoz~ths.
Washington: National Academy Press, 1994.

Macaskill I', Pierce JP, Simpson JM, Lyle DM. Mass
media-led antismoking campaign can remove the edu-
cation gap in quitting behavior. A??lericarr \o~rrrnl 4f
Public Health 1992;82(1):96-8.

Maccoby N, Farquhar JW, Wood I'D, Alexander J. Re-
ducing the risk of cardiovascular disease: effects of a
community-based campaign on knowledge and be-
havior. ]o~r~nl of Comrnu~~ity Health 1977;3(2):100-14.

Macdonald G, Veen C, Tones K. Evidence for success
in health promotion: suggestions for improvement.
Health Educatiolz Research 1996;11(3):367-76.

Madonna MG. Getting key players to work together
and defending against diversion-Arizona. Carlcer
1998;83(12 Suppl):2708-12.

Manley M, Lynn W, Epps RF', Grande D, Glynn T,
Shopland D. The American Stop Smoking Interven-
tion Study for cancer prevention: an overview. Tobacco
Coutml 1997a;6(Suppl 2):53-511.

Manley MW, Pierce JP, Gilpin EA, Rosbrook B, Berry
C, Wun L-M. Impact of the American Stop Smoking
Intervention Study on cigarette consumption. Tobacco
Colztrol 1997b;6(Suppl 2):S12-S16.

Market Facts. Tobacco Retailer Study. Prepared for the
Food and Drug Administration, 1998. Boston: Arnold
Communications, 1998.

McAlister A, Puska I', Salonen JT, Tuomilehto J, Kos-
kela K. Theory and action for health promotion:
illustrations from the North Karelia Project. Amevicarl
jof/r~ml of Plrblic Health 1982;72(1):43-50.

McAlister AL, Farquhar JW, Thoresen CE, Maccoby N.
Behavioral science applied to cardiovascular health:
progress and research needs in the modification of risk-
taking habits in adult populations. Health Education
MOIIO~X~~IS 1976;4(1):45-74.

McGuire WJ. Persuasion, resistance, and attitude
change. In: Pool I, Frey FW, Schramm W, Maccoby N,
Parker EB, editors. Handbookof Comnzurzicafion. Chicago:
Rand McNally College Publishing Company;1973:
216-52.

McKenna J, Gutierrez K, McCall K. Strategies for an
effective youth counter-marketing program: recom-
mendations from commercial marketing experts. ]our-
real of Public Hcalfh Managemerlt Practice 2000;6(3):7-13.

McMillen RC, Ritchie LA, Robertson AA, Frese W,
Cosby AG. The 2 999 Mississippi Social Climate Survey of
Tobacco Corlfrol atld Tobacco Use: Establishilzg a Ben&
mark for Mississippi. A Report to the Mississiy,vi State
Deportnle1zt of Health. Mississippi State (MS): Missis-
sippi State University, Social Science and Research
Center, 1999.

Meister JS. Designing an effective statewide tobacco
control program-Arizona. Cancer 1998;83(12 Suppl):
2728-32.

Meyer AJ, Nash JD, McAlister AL, Maccoby N,
Farquhar JW. Skills training in a cardiovascular health
education campaign. IoLlrllnl of Cotiszrltirlg at7d Clinical
Psycho/o<~y 1980;48(2):129-42.


Minnesota Department of Health. T/X, Mi/lmwta P/n/7
for Nousmokilzg 0170' Hmltll: Rc;wrt arid Rr~c-c)rrrrllt'rrtfatj~~~~s
of the Techrlical Advisory Cor?lrlliffce o/z Norlsrnokirlg (7r1il
Health. Minneapolis: Minnesota Department of Health,
1984.

Minnesota Department of Health. 7heMir117esotn Tobacco-
Use Prezwtio~~ Ifzitiative ]af?uary 1987-Drcrndwr 2988: A
Report to the 1989 Legislature. Minneapolis: Minnesota
Department of Health, 1989.

Minnesota Department of Health. Minrwofa Tobacco-
Use Preventiorl Initiative 1989-1990: A Report to the 7991
Le$slature. Minneapolis: Minnesota Department of
Health, 1991.

Minnesota Department of Health. Mirrrrcsota Youth To-
bacco Prevetrfiorz Initiative: Stratqic Pla~z. Septmtw 2999-
Ilily 2002. St. Paul (MN): Minnesota Department of
Health, 1999.

Mintz M. Where there's smoke. T/w Wnsl7irzgtor7 Post
Magazille, Dee 3, 1995:20-g, 46-8.

Mississippi State Department of Health. Mississippi's
1999 Youth Risk Behazjior Surzley: Sur7lrmry c$ Fidir7p.
Jackson (MS): Mississippi State Department of Health,
2000.

Mittelmark MB, Hunt MK, Heath GW, Schmid TL.
Realistic outcomes: lessons from community-based
research and demonstration programs for the preven-
tion of cardiovascular diseases. jourrml oiPl,blic Hen/f/~
Policy 1993;14(4):437-62.

Moon RW, Males MA, Nelson DE. The 1990 Montana
initiative to increase cigarette taxes: lessons for other
states and localities. ]ou~nnl of Public Health Policy
1993;14(1):19-33.

Moore J. Non-profit advocates' latest tool: technology.
Chronicle of Phila~zfhropy 1994;6(24):1, 40-2.

Mullan F. Don Quixote, Machiavelli, and Robin Hood:
public health practice, past and present. Amevicarz ]our-
nal of Public Health 2000;90(5):702-6.

Murray DM, Hannan PJ, Jacobs DR, McGovern PJ,
Schmid L, Baker WL, Gray C. Assessing intervention
effects in the Minnesota Heart Health Program. Ameri-
cats journal o,f Epidemiology 1994;139(1):91-103,

Murray DM, Perry CL, Griffin G, Harty KC, Jacobs DR
Jr, Schmid L, Daly K, Pallonen U. Results from a state-
wide approach to adolescent tobacco use prevention.
Prevc/ltiz~e Medicine 1992;21(4):449-72.

National Cancer Institute. ASSlST Program Guidelil7es
for Tobacco-Free Communities. Bethesda (MD): National
Cancer Institute, Division of Cancer Prevention and
Control, Cancer Control Science Program, Public Health
Applications Research Branch, 1991.

National Cholesterol Education Program Expert Panel.
Report of the National Cholesterol Education Program
Expert Panel on detection, evaluation, and treatment
of high blood cholesterol in adults. Archives of Internal
Medicilw 1988;148(1):36-69.

Nicholl J. Tobacco Tax Campaipz Guide. Atlanta: Ameri-
can Cancer Society, 1996.

Nicholl J. Tobacco tax initiatives to prevent tobacco use:
a study of eight statewide campaigns. Cancer 1998;
83(12 Suppl):2666-79.

Novotny TE, Siegel MB. California's tobacco control
saga. Health Affairs 1996;15(1):38-72.

Nutbeam D. Achieving "best practice" in health pro-
motion: improving the fit between research and prac-
tice. Health Ed~lcafiou Research 1996;11(3):317-26,

Nutbeam D. Evaluating health promotion-progress,
problems and solutions. Health Promotiotz lrltematiorlal
1998;13(1):27-44.

Ockene JK, Lindsay EA, Hymowitz N, Giffen C, Purcell
T, Pomrehn I', Pechacek T, for the COMMIT Research
Group. Tobacco control activities of primary-care
physicians in the Community Intervention Trial for
Smoking Cessation. Tobacco Colzfrol 1997;6(Suppl
2):S49-S56.

Oregon Health Division. Tobacco Prezwfiol~ atzd Educa-
tion Props Report-1 999. Portland (OR): Department
of Human Resources, Oregon Health Division, 1999.

Orzechowski and Walker. The Tax Burden 011 Tobacco:
Historical Cornpilntiorl 1999. Arlington (VA): Orzechowski
and Walker. 2000.

Pechacek TF, Lando HA, Nothwehr F, Lichtenstein E.
Quit and Win: a community-wide approach to smok-
ing cessation. Tobacco Control 1994;3(3):236-41.

424 Ch~JtU' 7


Rrducijzg Tohncco Use

Pechmann C. Does antismoking adlrertising combat
underage smoking? A review of past practices and re-
search. In: Goldberg ME, Fishbein M, Middlestadt SE,
editors. Social M~rkefi~z;;: Theorrfic~l nrld Prncticol Per-
specfiws. Mahlvah (NJ): Lawrence Erlbaum Associates,
1997:189-216.

Pechmann C, Reibling ET. Planning an effective anti-
smoking mass media campaign targeting adolescents.
]OILVII~T/ of P~/b/ic- Hc~lth Mnr7u,yc~n7cr7t Prnrticc 2000;
6(3):80-94.

Pechmann C, Shih CF. Smoking scenes in movies and
antismoking advertisements before mo\?es: effects on
youth. jol/rjlnl ofM&i+il7~ 1999;63(3):1-13.

Perry CL, Kelder SH, Murray DM, Klepp KI. Commu-
nitywide smoking prevention: long-term outcomes of
the Minnesota Heart Health Program and the Class of
1989 Study. A177~~ic7717 ]017r17~71 c$Piiblir Hmlfl7 lYY2;82(9):
1210-6.

Pertschuk M. St77okc SiS,rllls: 71~~ S,llr)kirlg Cor7ird MP
dig Hnrldhook. Atlanta: American Cancer Society, 1987.

I'ertschuk M. SCARC: the Smoking Control Advocacy
Resource Center. Developing a system for undergird-
ing health policy advocacy. Paper presented at Progress
Toxvards a Smokefree Society-National, State and
Local Tobacco Control Initiatives, the American Pub-
lic Health Association Annual Meeting; Nov 11, 1992;
Washington (DC).

I'ertschuk M, Erickson A. Smoke Ficyhtij7g: A Smokirzg
Corztrol MozjenIejlt Bui/iiirz,o Guide. Atlanta: American
Cancer Society, 1987.

Pertschuk M, Wilbur I', O'Keefe AM. Medin Adz~ocacy:
Re@nzillR Public Debate. Washington: Benton Founda-
tion, 1991.

Pierce JP. International comparisons of trends in ciga-
rette smoking prevalence. American ]07tvt7nl of Public
Health 1989;79(2):152-7.

Pierce JP. Mass media and tobacco control. In: Slama
K, editor. Tobacco nrzd Health. New York: Plenum Press,
1995:335-40.

Pierce JI', Choi WS, Gilpin EA, Farkas AJ, Berry CC.
Tobacco industry promotion of cigarettes and adoles-
cent smoking. /o7iv?7n/ qf the Americnrl Medicnl Associn-
fiotl 1998;279(7):511-5.

Pierce JP, Dwyer T, Frape G, Chapman S, Chamber-
lain A, Burke N. Evaluation of the Sydney "Quit. For
Life" anti-smoking campaign. Part 1. Achievement of
intermediate goals. Medica/ [ourunl of Austrnlin
1986;144(7):341-4.

Pierce JP, Evans N, Farkas AJ, Cavin SW, Berry C,
Kramer M, Kealey S, Rosbrook B, Choi W, Kaplan RM.
Tobacco Use in Cnliforllia: AIZ Evaluations of the Tobircco
Coutro1 Propmz, 7 989-l 993. La Jolla (CA): University
of California, San Diego, 1994.

Pierce JI', Gilpin E, Burns DM, Whalen E, Rosbrook B,
Shopland D, Johnson M. Does tobacco advertising tar-
get young people to start smoking? Evidence from
California. ]ourm2 of tl7e Anwricalz Medical Association
1991;266(22):3154-8.

Pierce JP, Gilpin EA, Emery SL, Farkas AJ, Zhu SH,
Choi WS, Berry CC, Distefan JM, White MM, Soroko
S, Navarro A. Tobncco Collfrol i~r Colifornin: Who's
WirzrlirfS the Wfir? At7 Emluntiorz of the Tobacco Coufrol
P logrnrr7, 1989-7 996. La Jolla (CA): University of Cali-
fornia, San Diego, 1998a.

Pierce JP, Gilpin EA, Emery SL, White MM, Rosbrook
B, Berry CC. Has the California Tobacco Control Pro-
gram reduced smoking? ]ozlrrzn/ of the Americnrl Medi-
ml Associotioll 1998b;280(10):893-9.

Pierce JP, Macaskill I', Hill D. Long-term effectiveness
of mass media led antismoking campaigns in Austra-
lia. Anwimj7 Jourml of Public Health 1990;80(5):565-9.

Pollay RW, Siddarth S, Siegel M, Haddix A, Merritt
RK, Giovino GA, Eriksen MP. The last straw? Ciga-
rette advertising and realized market shares among
youths and adults, 1979-1993. ]ournn/ of Marketing
1996;60:1-16.

Puska I', Nissinen A, Salonen JT, Toumilehto [sic] J.
Ten years of the North Karelia Project: results with
community-based prevention of coronary heart dis-
ease. Scnndimoiau Jourtlal of Social Medtcine 1983a;
11(3):65-8.

Puska I', Nissinen A, Tuomilehto J, Salonen JT, Koskela
K, McAlister A, Kottke TE, Maccoby N, Farquhar JW.
The community-based strategy to prevent coronary
heart disease: conclusions from the ten years of the
North Karelia project. An,zual Review of Public Healtl7
1985;6:147-93.


[`~~ska I`, S`llonen JT, kissinen A, Tuomilehto J, Varti-
aintn E, Knrhonen H, Tanskanen A, R6nnqvist P,
Koskela K, Huttunen J. Change in risk factors for coro-
nary heart disease during 10 years of a community
intervention programme (North Karelia project). Bvif-
is/~ Medical /oumnl 1983b;287(6408):1840-4.

Puska I', Tuomilehto J, Nissinen A, Vartiainen E. T/w
North Karelin Project: -70 Yeor Results olld E.xperielrces.
Helsinki (Finland): The National Public Health lnsti-
tute (KTL), 1995.

Puska I', Tuomilehto J, Salonen J, Neittaanmaki L, Maki
J, Virtamo J, Nissinen A, Koskela K, Takalo T. Changes
in coronary risk factors during comprehensive five-
year community programme to control cardiovascu-
lar diseases (North Karelia project). Blitisll Medim
/ourr7nl 1979;2(6199):1173-8.

Riester T, Linton M. Designing an effective counter-
advertising campaign-Arizona. Clljlcrr 1998;83(12
Suppl):2746-51.

Robert Wood Johnson Foundation. Nineteen states re-
ceive $10 million to fight tobacco use [press release].
Princeton (NJ): Robert Wood Johnson Foundation, Aug
15,1994.

Robinson RG, Orleans CT, James DA, Sutton CD. Pntll-
z~~ay.5 to Freedom: h'ir777i17y f/w Figl7t Agi7i17sf Tubaico.
Philadelphia: Fox Chasi Cancer Center, 1992. Re-
printed with permission by the Centers for Disease
Control and Prevention and the National Medical
Association.

Rogers EM. Diffi~-siw~ o,f 1njmwfioj7s. 3rd ed. New York:
Free Press, 1983.

Rose G. Strategy of prevention: lessons from cardio-
vascular disease. Bvifidr Mcdical]o~~rr7al Clir7ical Rrsc~1d7
Editiurl 1981;282(6279):1847-51.

Rose G, Heller RF, I'edoe HT, Christie DGS. Heart
disease prevention project: a randomised controlled
trial in industry. British Medicnl ]111/rr7nl 1980;280
(6216):747-51.

Ross M. Tohacro Tas C11777pi~~75: ,4 Case Study of Tzo
States. Washington: Advocacy Institute, 1996.

Rothman J. Three models of community organization
practice, their mixing and phasing. In: Cox FM, Erlich
JL, Rothman J, Tropman JE, editors. Sfmkyies of Con7-
ruzrnity Orpuixtioll. 3rd ed. Itasca (IL): Peacock Pub-
lishers, !979:25-45.

Sallis JF, Flora JA, Fortmann SI?, Taylor CB, Maccoby N.
Mediated smoking cessation programs in the Stanford
Five-City Project. Addictiz~e Behaviors 1985;10(4):441-3.

Salonen JT, Puska P, Kottke TE, Tuomilehto J. Changes
in smoking, serum cholesterol and blood pressure lev-
els during a community-based cardiovascular disease
prevention program-the North Karelia Project. Ameui-
0712 /ourru7l of Epidemiology 1981;114(1):81-94.

Sanson-Fisher R, Redman S, Hancock L, Halpin S,
Clarke I', Schofield M, Burton R, Hensley M, Gibberd
R, Reid A, Walsh R, Girgis A, Burton L, McClintock A,
Carter R, Donner A, Green S. Developing methodolo-
gies for evaluating community-wide health promotion.
Health Promotions Interrmfiorznl 1996;11(3):227-36.

Schmid TL, Pratt M, HoMJze E. Policy as intervention:
environmental and policy approaches to the preven-
tion of cardiovascular disease. Anwicnr7 ]ourunl of Pub-
lit Hrnlfh 3995;85(9):1207-11.

Scientific Committee on Tobacco and Health. Report o,/
flrc .%iu7fific Corur77iffee 017 Toh~cco arrd Henlfh. London:
The Stationery Office, 1998.

Shea S, Basch CE. A review of five major community-
based cardiovascular disease prevention programs.
Part I: rationale, design, and theoretical framework.
A/7wict7/7 ]olir,mI ofHealth Pvor77nfior7 1990a;4(4):203-13.

Shea S, Basch CE. A review of five major community-
based cardiovascular disease prevention programs.
Part II: intervention strategies, evaluation methods,
and results. Auwricnr7 jo7,r77al nfHcaltl7 Pror?wfior7 1990b;
4(3):279-87.

Shultz JM, Moen ME, Pechacek TF, Harty KC, Skubic
MA, Gust SW, Dean AG. The Minnesota Plan for Non-
smoking and Health: the legislative experience. ]o~r-
17171 of P~lhlic Henlfh Policy 1986;7(3):300-13,

Siegel M. Mass media antismoking campaigns: a pow-
erful tool for health promotion. Alzrrals oflr7frrrlalMedi-
cirzr 1998;129(2): 128-32.


Siegel M, Biener L. The impact of an antismoking me-
dia campaign on progression to established smoking:
results of a longitudinal youth study. Amvim ]culrrml
of P~tblis Henlth 2000;90(3):380-6.

Siegel M, Mowery I'D, Pechacek TF, Strauss WJ,
Schooley MW, Merritt RK, Novotny TE, Giovino GA,
Eriksen MI'. Trends in adult cigarette smoking in Cali-
fornia compared with the rest of the United States,
1978-1994. Amclicn~~ ]ourufl/ of P~iblic Hcwlth 2000;
90(3):372-9.

Specter M. Marketers target "virile female": R.J.
Reynolds plans to introduce cigarette. T/71, lMz.s/~i~~gtc~r~
Post, Feb 17, 1990;Sect A:1 (co1 4).

State of Arizona, Office of the Auditor General. PP@P
~fln/lc(' ilrldit. Department of Health Ser\?ces' Tobacco
Education and Prevention Program. Report to the Ari-
zona Legislature. Phoenix (AZ): State of Arizona, Of-
fice of the Auditor General, 1999. Report h`o. 99-17.

Steenkamp HJ, Jooste PL, Jordaan PCJ, S~~anepoel ASP,
Rossouw JE. Changes in smoking during a community-
based cardiovascular disease intervention programme:
the Coronary Risk Factor Study. .%lrt/l Af~irn~~ Medim/
~mir/7n/ 1991;79(5):250-3.

Steinfeld JL. II: The public's responsibility: a bill of
rights for the non-smoker. Rhode lslnrzd Medic-n/ ]o~rrrml
1972;55(4):124-6, 138.

Stockwell TF, Glantz SA. Tobacco use is increasing in
popular films. x$wco Corzfrol 1997;6(4):282-4.

Substance Abuse and Mental Health Services Admin-
istration. Sylzor Regulatiorz: Report fo Cotrgrcss (III FFY
1997 Sfntc Compliance. Rockville (MD): US Department
of Health and Human Services, Substance Abuse and
Mental Health Services Administration, Center for
Substance Abuse Prevention, 1998a. DHHS Publica-
tion No. (SMA) 97-3143.

Substance Abuse and Mental Health Services Admin-
istration. Synar Regdnfim: Report fo Ccvzgress ofz FFY
2 997 Stafc &71ylia7rce: Sunr~nnr.~/. Rockville (MD): US
Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration,
Center for Substance Abuse Prevention, 1998b. DHHS
Publication No. (SMA) 98-3185.

Susser M. The tribulations of trials-intervention in
communities [editorial]. A777crimr7 [o~~rml of Public
Hen/f/z 1995;85(2):156-8.

Taylor HL, Blackburn H, Keys A, Parlin RW, Vasquez
C, Puchner T. Coronary heart disease in seven coun-
tries. IV. Five-year follow-up of employees of selected
U.S. railroad companies. Circl//nfion 1970a;41 (4 Suppl):
120-139.

Taylor HL, Menotti A, Puddu V, Monti M, Keys A.
Coronary heart disease in seven countries. XI. Five
years of follo\v-up of railroad men in Italy. Circulation
197Ob;41(4 Suppl):Il13-122.

Taylor SM, Ross NA, Cummings KM, Glasgow RE,
Goldsmith CH, Zanna MP, Corle DK. Community In-
ter\,ention Trial for Smoking Cessation (COMMIT):
changes in community attitudes toward cigarette
smoking. Health Edumfim Research 1998;13(1):109-22.

Teenage Research Unlimited. Co~~ufer-Tc7hrrcco Adrrrfisiq
E.\-/~lornt(?~~/. Summary Report, January-March 1999.
xorthbrook (IL): Teenage Research Unlimited, 1999.

Teinowitz I. After the tobacco settlement; take the
money & run (ads); the anti-smoking campaign's a
many splendored thing, and that's the problem. The
Wnsbi~l~qfor~ Post, Dee 6, 1998; Outlook Sect: Cl.

Texas InterAgency Tobacco Task Force. Le~islafiz~e Plan.
Austin (TX): Texas Department of Health, 1998.

Texas Department of Health. 1998 Texas Youth Tobacco
Survey. Report 1: Current Tobacco Use; <http:/ /www.
tdh.state.tx/us/otpc>; accessed June 6,200O.

Thompson B, Corbett K, Bracht N, Pechacek T. Com-
munity mobilization for smoking cessation: lessons
learned from COMMIT. Hcnlth Prow&w Iflternnfiorzal
1993;8(2):69-83.

Tobacco Education and Research Oversight Commit-
tee. Tosum a Tobacco-Free California: Mastering the Chal-
Iclzges, 199_5-1997. Sacramento (CA): Tobacco Education
and Research Oversight Committee, 1995.

Tobacco Education Oversight Committee. Toward II
Tnbncco-Fwc Cnliforrlia: A Master Plafz to Red~cr Calif~r-
rlirrrls' U.$r @ %b~cm. Sacramento (CA): Tobacco Edu-
cation Oversight Committee, 1991.