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TOBACCO USE PREVENTION 

MEDIA CAMPAIGNS: 

LESSONS LEARNED FROM YOUTH IN NINE COUNTRIES

Sponsored by the Centers for Disease Control and Prevention 

Authors

Elizabeth Schar, Marketing Consultant 

Karen Gutierrez, Marketing Consultant

Rebecca Murphy-Hoefer, PhD, MPH, Health Communications Specialist, Office on Smoking and Health/CDC

David E. Nelson, MD, MPH, Senior Scientific Advisor, Office on Smoking and Health/CDC

March 2006
Suggested citation: Schar E, Gutierrez K, Murphy-Hoefer R, Nelson DE. Tobacco Use Prevention Media 

Campaigns: Lessons Learned from Youth in Nine Countries. Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health; 2006. Available at www.cdc.gov/tobacco.
Table of Contents

Executive Summary v

1 Introduction 1

2 Methodology 3

3 Comprehensive Tobacco Control Programs 5

4 Target Audiences: Youth Only or General Population? 7

Targeting adults and youth 7

Targeting youth only 7

5 Emotional Appeal 11

Research findings on the importance of emotional appeal 11

Research findings on emotional appeal of ads in media campaigns 12

6 Message Content 15

Health effects 16

Tobacco industry deceptive practices 21

Social approval/disapproval or refusal skills 26

Secondhand smoke 28

Cosmetic effects 29

Addiction 30

Athletic performance 30

Individual choice 31

Effectiveness of different message themes 32

7 Message Format 35

Testimonials 35

Graphic depiction 36

Celebrities 36

8 Message Tone, Frequency, and Reach 39

Humorous versus sad or serious tone 39

Preachy tone 40

Ad frequency, reach, and duration 40

Integration of message elements 42

9 Evaluation 43

Acknowledgments 45

References 47

Appendix 1: Case Histories of Campaigns with Effective Media Presence 51

Appendix 2: List of Advertisements by Country and U.S. State 53

Appendix 3: Research Summary 73

EXECUTIVE SUMMARY 

EXECUTIVE SUMMARY

Based on this review of material on youth tobacco 

use prevention campaigns from nine countries, the 

research literature, and extensive marketing program 

experience, we have drawn several conclusions about 

successful mass media campaigns. 

In general, successful youth tobacco use prevention 

mass media campaigns: 

• Are most effective when they are part of broader, 

comprehensive tobacco control programs designed 

to change a community’s prevailing attitudes concerning tobacco use. 

• Include ads with strong negative emotional appeal 

that produce, for example, a sense of loss, disgust, 

or fear. 

• Introduce persuasive new information or new 

perspectives about health risks to smokers 

and nonsmokers.

• Use personal-testimony or graphic-depiction 

formats that youth find emotionally engaging 

but not authoritarian.

• Feature multiple message strategies, advertising 

executions, and media channels to consistently 

attract, engage, and influence diverse youth with 

varying levels of susceptibility to smoking. 

• Provide adequate exposure to media messages over 

significant periods of time.

• Incorporate comprehensive formative, process, and 

outcome evaluation plans.

Specific conclusions and recommendations from each 

section of the report are provided below. 

Comprehensive Programs

Mass media advertising to prevent youth tobacco use 

is most successful when it is part of a broader, comprehensive tobacco control initiative that includes such 

elements as taxes on tobacco products, curriculumbased school programs, cessation services, and grassroots activism. 

Mass media ads contribute to the synergy produced 

by different campaign elements working together to 

change a community’s prevailing attitudes toward 

tobacco use. 

Targeting Youth Versus the 

General Population

No clear consensus exists on whether ad campaigns that 

target youth audiences only or those directed at both 

adults and youth are more effective; both have been 

successful in changing youth attitudes and behaviors.

Some evidence indicates that older teens and youth 

who are most susceptible to smoking initiation may 

need specific, targeted tobacco counter-marketing 

messages. Those planning youth-targeted campaigns 

should consider developing messages that appeal to a 

broad range of youth, including high-risk youth and 

older teens who are more difficult to reach. Although 

evidence suggests that age-targeted messages can 

improve effectiveness, messages have been successfully 

developed to appeal to all ages, including adults.
Emotional Appeal

• Ads with strong and credible negative emotional 

appeal—leading the viewer to feel a sense of personal loss, sadness, anger, disgust, or fear—increase 

the attention to, and recall of, ads among youth 

audiences and enhance the ads’ effectiveness.

• Emotionally compelling ads (such as personal testimonies) and those with strong graphic depictions run 

the risk of emotionally exhausting certain audience 

members if these ads are broadcast for significant 

periods of time. This has the potential to produce 

a defensive response to the message. Media schedules 

need to be designed to avoid emotional burnout.

Message Content 

• Health effects: Ads that portray the serious health 

consequences of tobacco use in a credible manner 

can be effective. Health-effects information must 

be presented in innovative ways that engage 

viewers emotionally. 

• Tobacco industry deceptive practices: Ads that communicate information on tobacco industry deceptive 

practices can be effective, but audiences probably 

need to be exposed over time to several different 

messages regarding tobacco industry behavior. To 

effectively communicate this message, the ads must 

educate the audience about tobacco industry marketing practices that attract youth to an addictive habit 

and do not reveal the serious negative consequences 

of smoking. These ads may be misunderstood by 

some youth, who question why a tobacco company 

should be treated differently from any other company 

because of its marketing practices. Only broadcast 

media campaigns conducted in the United States that 

use tobacco industry deceptive-practices ads have 

outcome evaluation results to date. 

• Social approval/disapproval or refusal skills: Ads 

stressing that not smoking is socially acceptable or 

that smoking is negatively perceived by peers, and 

ads that introduce refusal skills, can be effective in 

increasing awareness of tobacco-related issues and 

reducing intention to smoke. However, the research 

indicating that these types of messages can be 

successful is limited primarily to controlled community trials. Results from one large-scale tobacco 

control program did not show success in changing 

behavior or attitudes toward smoking despite high 

awareness of campaign messages. 

• Secondhand smoke: Secondhand-smoke ads inform 

youth about the potential for personal harm from 

exposure to the tobacco smoke of others. Limited 

data indicate that these ads can be effective among 

youth, but they have rarely been used as the only 

or major type of ad in a youth campaign. As a 

result, the influence of these types of ads has rarely 

been measured among youth.

• Cosmetic effects, addiction, athletic performance: 

Research on ads focusing on the short-term cosmetic 

effects of smoking, the addictive nature of tobacco, 

and the effects of smoking on athletic performance 

is limited. Available data suggest that ads emphasizing these themes are less effective among youth 

than ads that address the health effects of tobacco 

use or the deceptive practices of the tobacco industry.

• Individual choice: Individual-choice messages, 

which emphasize that youth have the choice of 

whether to smoke, have not been shown to be 

effective. Available data indicate that emphasizing 

the choice of whether to smoke without offering 

persuasive reasons not to smoke is not an effective 

strategy for preventing youth from using tobacco. 

Message Format

• The testimonial, the personal story of someone 

who has experienced negative tobacco-related 

health or emotional consequences, is an effective 

message format. The testimonial format tends to 

elicit a strong emotional response in youth audiences, provides credible information about the 

negative effects of smoking, and has the added 

benefit of not telling the viewer what to do. 

• Graphic depictions of the health effects of smoking are effective with youth audiences because 

these images can induce a strong emotional reaction (e.g., disgust or fear). But to be perceived as 

credible, the ads must depict the actual effects of 

smoking graphically and must present youth with 

information on the risks of smoking that they may 

not have considered before.

vi TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 
• The celebrity format should be used with caution. 

Although ads using celebrities are usually successful in attracting attention, they can create credibility concerns or other complications. Moreover, 

subsequent revelations of celebrity misdeeds can 

damage the impact of ad campaigns. The most 

effective celebrity ads seem to be those based on 

personal testimonials concerning the negative 

impact of tobacco use on the lives of celebrities 

or members of their families. 

Message Tone, Frequency, 

and Reach

Youth respond more strongly to messages that produce 

negative emotions—feelings of loss, anger, sadness, 

fear, or disgust—than to humorous messages. Ads with 

a “preachy” tone that tell youth what to think and 

how to behave should be avoided. When ads offer advice 

and direction to youth, they may lead the audience to 

rebel against the message and produce the opposite of 

the desired result. 

Messages will only be effective if audiences are 

adequately exposed to them. The messages must 

appear often enough for audiences to notice them, 

internalize them, and develop relevant attitude and 

behavior changes. Campaigns must maintain a strong 

and consistent presence in broadcast media to achieve 

program goals.

It is difficult, if not impossible, to disentangle the 

unique contribution of each message element (content, 

format, tone) to ad effectiveness. Careful attention to 

all message elements and ad execution (how the ad is 

created and presents the message) is essential; these 

elements must be integrated effectively to produce the 

desired impact. 

Evaluation

Different aspects of youth tobacco use prevention 

mass media campaigns should be evaluated for these 

campaigns to succeed over time. Formative, process, 

and outcome evaluation activities need to be integrated into campaigns at each stage of ad development 

and implementation so that managers can develop 

the optimal communication strategies and respond 

to changes in target audience response over time. 

EXECUTIVE SUMMARY vii

INTRODUCTION 

INTRODUCTION 

Globally, 4.9 million deaths a year are attributed to 

tobacco-related diseases (World Health Organization, 

2005). If tobacco use continues unchecked, this rate 

is projected to rise to 10 million deaths annually by 

2020. To help stem this alarming increase in tobaccorelated mortality, governments should help reduce 

the number of young smokers because most smokers 

initiate tobacco use in their youth. One way to reduce 

the number of young smokers is to help youth make 

a commitment to not smoking (U.S. Department of 

Health and Human Services, 1994). 

Mass media provide effective tools for convincing 

youth not to smoke, because they can communicate 

prevention messages directly to young people and 

influence their knowledge, attitudes, and behaviors 

(Hopkins et al., 2001). By using mass media as part 

of a comprehensive tobacco control program, several 

countries have been successful in reaching and influencing youth with messages that encourage a commitment to not smoking.

As part of its overall goal of reducing tobacco use, 

the Office on Smoking and Health of the Centers for 

Disease Control and Prevention (CDC) has prepared 

this report to build awareness of what the tobacco 

control community has learned about effective youth 

tobacco use prevention media campaigns. By combining field-based information with published research 

results, we aim to provide a collection of practical 

findings in a resource for those charged with developing and implementing effective mass media campaigns 

to reduce youth tobacco use.

Approach

We reviewed evaluation data on campaigns from Australia, Canada, England, Finland, the Netherlands, 

Norway, Poland, Scotland, and the United States. We 

summarize the elements of paid media campaigns in 

these countries that, based on available information 

from both published and unpublished sources, appear 

to have been most effective in changing youth attitudes about smoking, encouraging youth to commit to 

not smoking and, in some cases, reducing tobacco use. 

We focus on lessons learned about ad message content, format, and tone, as well as how often and how 

long ads should be aired. We also discuss the role of 

evaluation in developing effective media campaigns.

This is not a meta-analysis or a comprehensive review 

of the scientific literature on media campaigns in 

tobacco control. Rather, it is a review of selected studies 

and campaign information provided by researchers and 

practitioners in tobacco control programs who responded 

to a request for information or were identified through 

our efforts to find others involved in youth tobacco use 

prevention media campaigns in various countries. 

We recognize that mass media are only part of the total 

plan needed to reduce youth tobacco use. Schoolbased education and youth empowerment programs, 

and cessation programs, for example, can play important roles in the overall effectiveness of youth tobacco 

use prevention programs. However, evaluations of paid 

mass media campaigns, especially those focused on 

television ads, have produced the most consistent data 

available regarding message effectiveness. Therefore, 

in this review, we focus on findings from evaluations of 

television ads used in paid mass media campaigns. 
 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

We do not review other elements or types of comprehensive tobacco counter-marketing campaigns 

here. However, excellent reviews of the literature on 

tobacco use prevention and cessation and on overall 

tobacco control campaign effectiveness in the United 

States are available elsewhere (National Cancer Institute, 2000; CDC, 2000; Hopkins et al., 2001). 

We also recognize that data on youth tobacco use 

prevention campaigns are too disparate and limited for 

drawing firm conclusions. We therefore highlight message strategies that, based on available data, generally 

appear to be most effective. 

As states, national organizations, and countries develop 

their media campaigns, they need to choose the campaign elements that they expect will work most effectively with their target audiences and in their unique 

environments. These decisions should be based on their 

own message research and media campaign evaluations, 

as well as findings and recommendations from this and 

other reviews, such as those of Farrelly and colleagues 

(2003) and Wakefield and associates (2003).

This report has several limitations. First, cultural and 

ethnic differences are not explored; we draw conclusions only about the audiences targeted by the campaigns that we assessed. Second, additional evaluation 

data that we were unable to identify probably exist 

on youth tobacco use prevention campaigns in these 

and other countries, particularly developing countries. 

Third, we focused on summarizing practical recommendations for program managers as well as research 

findings from published literature; we did not attempt 

a comprehensive review of the scientific literature 

on youth tobacco use prevention campaigns. Fourth, 

although we attempted to identify materials from 

youth tobacco use prevention media campaigns for all 

types of tobacco, the vast majority of the information 

we obtained pertained to cigarette smoking only. As 

a result, we do not specifically address prevention of 

the use of other forms of tobacco, such as smokeless 

tobacco or cigars.

A list of the campaigns and ads, including descriptions of the ad content and key messages, and a summary chart of the studies discussed in this report, are 

included as appendices to this document. For further 

information regarding the ads, please contact the 

CDC Office on Smoking and Health Media Campaign 

Resource Center at 770-488-5705, or send an e-mail 

to mcrc@cdc.gov.

Request

If you have conducted a youth tobacco use prevention 

media campaign and are willing to share lessons learned, 

please contact the Chief of the Health Communications 

Branch, Office on Smoking and Health, Mail Stop K-50, 

Centers for Disease Control and Prevention, 4770 Buford 

Highway NE, Atlanta, GA, USA 30341-3724. 
METHODOLOGY 

METHODOLOGY 

In June 2001, CDC and the World Health Organization (WHO) sent an international request through 

the Globalink listserv, whose members included 

approximately 2,000 tobacco control advocates from 

80 countries, for information on youth tobacco use 

prevention mass media campaigns with documented 

results among youth. As part of this request, CDC and 

WHO asked for published and unpublished data from 

campaigns, such as consumer insight research; awareness, recall, and attitude evaluations; and data on 

smoking prevalence and cigarette consumption. 

On behalf of CDC and WHO, we contacted people 

recognized by the tobacco control community as being 

involved in developing, implementing, or evaluating 

youth tobacco use prevention programs in one or more 

countries. A list of people who provided information for 

this report is included in the Acknowledgments, p. 45. 

From June 2001 to August 2002, we collected campaign 

evaluation information from tobacco control organizations and researchers in Australia, Canada, England, 

Finland, Germany, the Netherlands, Norway, Poland, 

and the United States. Information on U.S. campaigns 

was contributed by the American Legacy Foundation and state organizations from Arizona, California, 

Florida, Massachusetts, Minnesota, Mississippi, Montana, New York, Oregon, Texas, Utah, and Vermont. 

We included unpublished, so-called “gray” literature 

in this review because many useful tobacco control 

campaign evaluations are not published in the scientific literature and have much to offer. 

Information on each of the mass media campaign 

evaluations reviewed in this report is available in 

Appendix 3.

We reviewed all of the information collected to identify the tobacco counter-advertising media campaign 

elements most commonly deemed effective in reaching and influencing youth audiences. 

We based our conclusions on a synthesis of four types 

of information sources: 

• Message research—studies in which participants 

rated the perceived effectiveness of ad content 

themes or actual ads (e.g., focus groups or classroom settings). 

• Media campaign evaluations—quantitative, 

population-based studies of people exposed to ads 

aired in broad-scale tobacco counter-advertising 

campaigns targeted to specific geographic regions 

(states, provinces, countries) or broadcast in controlled community-based trials.

• Expert opinion—information gathered through 

interviews with people closely involved with ad 

campaigns and our own extensive public health, 

commercial marketing, and advertising experience.

• Selected aspects of the research literature that are 

relevant to the practical aspects of mass media 

anti-tobacco public health ad campaigns.

Each of the conclusions in this report is based on results 

from more than one geographic area. Data are limited 

in many cases, highlighting the need for more tobacco 

control programs to thoroughly evaluate their campaigns. Statistical significance of data (e.g., p values, 

95% confidence intervals) was available from some 

sources and not others; such information is included 

when available. The methods and rigor of the campaign 
 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

evaluations and the data and information sources used 

varied widely, preventing a formal empirical comparison of findings, such as a meta-analysis. As a result, the 

recommendations should be regarded as the perspectives of the authors, based on a careful review of available information from experienced campaign managers. 

The conclusions are intended to provide those responsible for developing media campaigns with practical 

suggestions for conducting effective youth tobacco use 

prevention advertising campaigns.

We judged message strategies to be most effective 

if their evaluations had several of the following 

characteristics:

• Results showing statistically significant differences 

in perceived effectiveness, awareness, beliefs and 

attitudes, and behavioral intent or reported behavior 

among youth using random sampling methodologies. 

• Indications of an association between campaign 

ads and reduced smoking prevalence among youth.

• Similar results achieved in more than one geographic area. 

• Direct comparisons showing that one message 

strategy was more effective than another.
Nearly all mass media campaigns that have achieved 

long-term success were implemented as part of a comprehensive tobacco control program. Campaigns in Finland, 

California, and Massachusetts were able to reduce smoking prevalence among adults and youth over time through 

this comprehensive approach (Biener et al., 2000; California Department of Health Services, 2000; Massachusetts Department of Public Health, 2000; Puska, 1999). 

Several U.S. government and WHO reports note that 

mass media have played an important role in effective 

tobacco control programs when they were supported by 

other components of these programs, such as a mix of 

environmental and policy changes, educational programs, 

cessation treatment programs, and grassroots activism 

(U.S. Department of Health and Human Services, 2000; 

CDC, 1999; Hopkins et al., 2001; Institute of Medicine, 

2000; WHO, 2001). When diverse tobacco control 

program elements work together to change the overall 

environment, they create a synergy that contributes to the 

success of mass media tobacco use prevention campaigns.

Specifically, mass media campaigns are most successful 

when they target people who are surrounded by antitobacco messages from several sources. For example, 

a mass media campaign is more likely to be effective 

with someone who frequents bars or restaurants that 

no longer allow smoking because of a community-wide 

clean air policy, is aware that the price of cigarettes 

has risen because of a tax increase, and has been told 

by a doctor about the dangers of tobacco use during 

a regular checkup, than with someone who has had 

none of these additional influences. The combined 

impact of these interventions is likely to cause a teen 

to think about the impact of tobacco use in his life 

and to make different decisions about tobacco use 

than if he had received only one of these messages. 

COMPREHENSIVE TOBACCO CONTROL PROGRAMS 

COMPREHENSIVE TOBACCO

CONTROL PROGRAMS

We found that comprehensive tobacco control programs 

are necessary for success in youth-focused mass media 

campaigns as well. In several U.S. states, youth tobacco 

control programs were mandated by the legislatures or 

Master Settlement Agreement restrictions based on U.S. 

lawsuits against the tobacco industry. These states include 

Florida (Bauer et al., 2000; Bauer and Johnson, 2001), 

Minnesota (Minnesota Department of Health, 2002), 

Mississippi (Partnership for a Healthy Mississippi, 2001), 

and Texas (Texas Tobacco Prevention Initiative, 2001). 

These youth-targeted tobacco use prevention campaigns were able to influence youth, effectively 

reducing uptake through strong media campaigns 

supported by community- and school-based programs, 

youth access policy enforcement and, in some cases, 

smoking cessation promotion. The media campaigns 

built awareness and delivered the message that youth 

needed to seriously consider not smoking, while the 

other tobacco control program elements provided 

additional incentives not to smoke, such as excise 

taxes that increased the cost of smoking, clean indoor 

air policies in schools and restaurants, and regulations 

that prohibited the sale of tobacco products to youth. 

Conclusions 

Research from several countries has consistently 

shown that tobacco counter-marketing campaigns are 

most successful when they are part of broader, comprehensive tobacco control activities in communities. 

These efforts may include such elements as environmental and policy changes, taxation, curriculum programs, cessation treatment programs, and grassroots 

activism. A key contributor to successful mass media 

campaigns is the synergy resulting from the different 

program elements working together to change society’s 

prevailing attitudes about tobacco use. 

TARGET AUDIENCES: YOUTH ONLY OR GENERAL POPULATION? 

A frequent debate in the tobacco control field centers 

on the choice of whom to target with tobacco counter-marketing programs. Experts agree on the need to 

decrease smoking among youth (National Blueprint 

for Action, 2000), but not on the effectiveness of 

counter-marketing programs and messages directed 

toward youth compared with those that target the 

general population, including adults and youth.

Tobacco use usually begins in adolescence. For example, in the United States, about 70% of adult smokers 

report that they started smoking by the time they were 

18 (CDC, 1994). Based on data from 131 countries, 

the Global Youth Tobacco Survey reports that 9% of 

13- to 15-year-old students around the world currently 

smoke cigarettes (Warren et al., 2006).

Because most smokers begin using tobacco in adolescence, many program managers believe that tobacco 

use prevention campaigns should target youth. But 

other experts believe that targeting youth with prevention messages without communicating messages 

to the whole population drains resources from the 

real fight, which should focus on reducing and denormalizing tobacco use among both adults and youth. 

These experts also believe that youth-oriented campaigns in isolation communicate a “forbidden fruit” 

message to youth, increasing their desire to engage in 

an activity that is prohibited for them but is acceptable for adults (Ling and Glantz, 2002; Atkin, 2000). 

Targeting Adults and Youth 

Campaigns in Australia, England, U.S./California, 

and U.S./Massachusetts were able to influence youth 

through comprehensive tobacco counter-marketing 

efforts targeting youth and adults (Biener et al., 2000; 

BMRB Social Research, 2002; California Department of Health Services, 2000; Hassard, 2000; Massachusetts Department of Public Health, 2000). Even 

though messages were not targeted specifically to 

them, youth reported equal or higher awareness of the 

campaigns compared with adults. They also reported 

learning new information, identifying with the ad 

messages, changing key attitudes and, in some cases, 

changing their smoking behaviors.

Targeting Youth Only 

Tobacco control programs in U.S./Florida, U.S./Minnesota, and U.S./Mississippi, as well as the national 

program of the American Legacy Foundation, were 

able to change youth attitudes and behaviors associated with tobacco use by pursuing a strategy that 

targeted youth exclusively.

One of the challenges in developing effective antitobacco messages is achieving awareness and behavior 

change in youth who are most susceptible to smoking 

initiation (based on the number of friends and family 

members who smoke and the youths’ attitudes toward 

tobacco and tobacco companies), including older 

youth. Several programs, including those of U.S./Arizona (Burgoon et al., 2000) and U.S./Florida (Sly, 

1998), have found that older youth and those at higher risk of smoking initiation showed the least awareness of, and receptivity to, their messages. However, 

the American Legacy Foundation has been successful 

in creating messages that appealed equally to all 

youth (Farrelly MC, et al., 2002); responses to 

the messages from susceptible and older youth were 

similar to responses from younger and less susceptible 

youth. In Florida, the Legacy truthsm ads evaluated 

in the same study were more influential across all 

TARGET AUDIENCES: 

YOUTH ONLY OR 

GENERAL POPULATION?
 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

youth, susceptible and non-susceptible, than any of 

the tobacco industry-sponsored youth prevention ads 

(RTI International, 2002). (For descriptions of the 

ads used in the campaigns described in this report, 

see Appendix 2.)

Those seeking to reach youth are well aware of the 

challenges of developing messages that communicate 

effectively to young people. Youth often discount 

messages that appear to speak to younger age groups, 

preferring to align themselves with an older age group 

that they perceive as being in a more desirable stage 

of life (Zollo, 1999). Young people are typically more 

responsive to ads that show people who are perceived 

as attractive and “cool” and are several years older 

than themselves. Programs such as the Target Market 

campaign in U.S./Minnesota have found that using 

teen members of the Target Market network (youth 

who voluntarily joined the state’s counter-marketing 

initiative) as spokespeople in television ads was not 

successful (Ergo International, 2001). Other teens 

were not interested in watching or listening to youth 

who looked to be their own age or younger.

Targeting youth in general may not be enough to 

ensure campaign success among youth; campaigns 

may need to target specific segments of the youth 

population. For example, although Florida’s program 

resulted in declines in smoking uptake and increased 

commitment to never smoking among middle school 

and high school audiences, the middle school students 

were the most responsive to certain program elements 

(Sly, 1998). The Minnesota Target Market campaign 

evaluation showed that campaign effectiveness among 

middle school students was much greater than among 

high school students (Ergo International, 2001). As a 

result, different strategies or messages from those used 

for middle school students may be needed to produce 

more significant changes in tobacco-related attitudes 

among high school students. 

U.S./Mississippi decided to develop ads targeted to 

youth of different ages instead of trying to develop 

ads that would appeal to all youth (Partnership for 

a Healthy Mississippi, 2001). These ads capitalized 

on attitude differences between age groups that were 

identified through qualitative research. The ages of 

6–11 years were defined as the “age of reason,” when 

youth willingly accept information about the risks of 

tobacco use and directions to speak with those they 

love about quitting. The ages of 12–17 years were 

defined as the “age of rebellion,” when youth resist 

advice from authority figures but accept factual information to consider when making their own independent 

decisions. The Partnership developed “age of reason” 

ads that gave younger viewers advice and direction on 

how to avoid the effects of tobacco-related diseases 

on their lives. “Age of rebellion” ads gave older youth 

facts about smoking and tobacco industry behavior 

that would encourage them to question the value of 

using tobacco. Mississippi youth behavior risk surveys found that smoking in both age groups declined, 

indicating that targeting by age could be an effective 

strategy (Partnership for a Healthy Mississippi, 2000).

However, some programs have been successful in 

developing messages that appeal to youth of different ages. The advertising messages of the American 

Legacy truthsm campaign resonated well with youth 

aged 12–17 years as well as with young adults aged 

18–24 years (Farrelly MC, et al., 2002). Aided awareness, participants’ ability to remember an ad when it 

is described to them, was slightly higher among youth 

than young adults, but levels among both populations 

were high. However, receptivity, or message appeal 

and acceptance, declined among both audiences 

(although it declined slightly more among young 

adults) as the message focused less on tobacco industry 

deceptive practices and long-term health risks and 

more on short-term health effects and individual choice. 

Conclusions

No clear consensus exists on whether to target youth 

only or the general population with tobacco use 

prevention campaigns. Some research indicates that 

youth-targeted tobacco control programs in general, 

and youth-targeted mass media campaigns specifically, 

can be successful in developing awareness and changing attitudes and behaviors associated with tobacco 

use. However, other research indicates that campaigns 

targeted to the general population can also reduce 

smoking among youth. 

Some evidence indicates that older teens and youth 

who are most susceptible to smoking initiation are 

less responsive to typical tobacco counter-advertising 
TARGET AUDIENCES: YOUTH ONLY OR GENERAL POPULATION? 

messages than other youth (Hassard, 2000; Sly et al., 

2001). Messages need to appeal to youth of all ages, 

including subgroups that are harder to reach. Tobacco 

counter-advertising messages should either target 

different age groups separately or use themes that 

resonate broadly with youth of different ages. 

EMOTIONAL APPEAL 

EMOTIONAL APPEAL 

Decades of research in communication, behavioral science, advertising, and marketing have shown that the 

most effective ads generate some level of emotional 

response among audiences. According to the Elaboration 

Likelihood Model of persuasion (Petty and Cacioppo, 

1986), ads must first gain the attention of the audience, most of whom have a low level of involvement 

or interest in the topic (in this case, tobacco use 

prevention or cessation) before the communication 

process can begin. Emotional messages are better 

remembered than non-emotional ones (Lang, 1995), 

and emotional appeals, which engage the viewer on 

a personal level, tend to be more effective in gaining 

audience attention than strictly cognitive appeals that 

rely on a rational, directive approach (e.g., providing 

tobacco health facts or encouraging viewers to “just 

say no” to smoking) (Petty and Cacioppo, 1986). 

Evidence increasingly shows that engaging viewers 

emotionally in the tobacco use prevention message is 

important to an ad’s overall effectiveness (Biener et 

al., 2002). The need to engage viewers emotionally 

has been an accepted tenet of consumer advertising 

for some time, but research demonstrating its applicability to tobacco control has lagged behind research 

focusing on message content (Biener et al., 2004). 

Although the emotional approach traditionally used 

in tobacco control and other public health ad campaigns has been based on fear, it is the ability to arouse 

any one of a number of negative emotional responses—

such as anger, sadness, disgust, loss, or fear—that 

increases a message’s effectiveness (Biener et al., 

2002). Negative emotions that an effective tobacco 

prevention ad may arouse include fear of the health 

consequences of smoking, a sense of personal loss or 

sadness due to the death or illness of a loved one, or 

anger at tobacco companies because of their deceptive 

marketing practices (Biener et al., 2002). 

Research Findings on the 

Importance of Emotional Appeal

Several studies have examined the role and effectiveness of generating an emotional response in youth 

tobacco counter-marketing messages. In the Teen 

Research Unlimited (TRU) multistate focus group 

study, for example, youth rated a series of tobacco use 

prevention ads according to whether the ads would 

make them “stop and think about not using tobacco” 

(Teen Research Unlimited, 1999). Three of the 

four ads rated by youth as most likely to make them 

consider not using tobacco generated strong negative 

emotional responses focused on a sense of loss or fear 

associated with smoking-related illnesses. 

The highest rated ads were those that highlighted 

the health consequences of tobacco use, typically in 

a dramatic or emotional way, by portraying smokers 

with tobacco use-related diseases describing their fear 

of not being able to breathe, or the grief of losing a 

loved one to a tobacco-related disease. The ads with 

the lowest ratings were tobacco industry-sponsored 

tobacco use prevention ads, such as the Philip

Morris Company’s Think. Don’t Smoke. ads, which 

have been characterized by researchers as having low 

emotional engagement because they do not challenge or 

engage the viewer’s beliefs or feelings (Teen Research 

Unlimited, 1999; Wakefield, 2002). These Philip

Morris ads, which have a personal-choice theme, 

present smoking as a rational choice young people can 

make, but they do not include information about the 

serious negative consequences of tobacco use. 
12 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

In the Youth Appraisal of Anti-smoking Advertising study, 278 8th-, 10th-, and 12th-grade students 

in Boston and Chicago appraised a broad range of 50 

anti-smoking ads produced in the United States from 

1997 to 2001. The students rated the ads produced by 

the tobacco companies as less engaging, less confrontational, and having less negative emotional content 

than ads produced by state and national tobacco control programs. As a result, youth would be less likely to 

think about the message content of these ads in a personal way that would affect their attitudes or behavior 

regarding tobacco use (Wakefield et al., 2002). 

The participants in this study were also asked 1 week 

after seeing the ads to identify the ads that they 

recalled best, had discussed with others outside of the 

rating session, and had thought most about. Ads that 

included personal testimonials or that had a negative 

visceral element (inducing an “ugh” response) were 

significantly more likely to be recalled, discussed, and 

identified as making youth “stop and think” at followup (Wakefield, 2003).

In an extension of this study to Australia and Great 

Britain using the same protocol, youth in these countries rated the ads similarly to youth in the United 

States (Wakefield et al., 2003). Consistent with the 

Elaboration Likelihood Model (Petty and Caccioppo, 

1986), ads that included moving personal testimonials 

and graphic negative elements were consistently more 

likely to be recalled and discussed, and to make youth 

“stop and think” than ads presenting personal-choice 

messages (the type of ad typically developed by the 

tobacco industry).

Tobacco company-sponsored tobacco use prevention 

ads, such as the Philip Morris Think. Don’t Smoke. 

ads (see Appendix 2 for descriptions of these and 

other ads discussed in this report), have not been 

found effective in changing youth beliefs, attitudes, 

and behavior associated with tobacco use (see individual-choice discussion, page 31). The Youth Appraisal 

of Anti-smoking Advertising research suggests that 

the low impact of industry-sponsored tobacco use prevention ads is probably due to a lack of characteristics 

that engage youth emotionally and promote processing 

of information contained in the ad (Wakefield, 2002; 

Wakefield et al., 2003). 

Research Findings on 

Emotional Appeal of Ads 

in Media Campaigns

Several researchers have assessed the effectiveness 

of anti-smoking ads designed to evoke an emotional 

response in adolescents in actual campaigns. These 

studies have found that campaigns using ads with strong 

emotional appeals are effective in influencing tobaccorelated beliefs, attitudes, and behaviors among youth.

The Norway Youth Provocative Appeals campaign 

evaluation was a longitudinal study from 1992 to 1995 

that targeted adolescents aged 14–15 years living 

in southeastern Norway. Researchers developed 

provocative anti-smoking messages designed to prevent the onset of smoking among adolescents. They 

communicated these messages through mass media 

and evaluated the effectiveness of these messages in 

preventing smoking and encouraging cessation among 

adolescents (Hafstad et al., 1997). The researchers 

based their work on a mass communication theory 

that supports the use of emotional appeals when 

awareness of a problem is high, interest is low, and no 

new information is available to offer on the subject 

(Rothschild, 1987). 

Although some public health communication experts 

discourage messages that could be perceived as “blaming the victim,” the Norwegian researchers began 

their media campaign with a message that, “Girls are 

stupid because the more we know about the health 

risks of smoking, the more Norwegian girls start to 

smoke.” They decided to target girls because, although 

smoking prevalence was decreasing overall in Norway, it was higher among adolescent girls and young 

women than among boys and young men. In its second year, the campaign focused on young females with 

a message that smoking was due to poor self-control 

and endangered the environment. The message in the 

third year targeted young men and women, suggesting 

that smokers had less successful lives than nonsmokers 

(Hafstad et al., 1997).

The researchers found that among nonsmokers, a significantly lower percentage of boys and girls exposed to 

the mass media campaign started to smoke (8.6%) than 

in the control area (12.4%). Also, significantly more 

girls exposed to the campaign who had been smokers
EMOTIONAL APPEAL 

at the beginning of the study had stopped smoking 

(25.6%) than girls in the control area (17.6%). The 

Norwegian researchers concluded that provocative messages that emotionally engage adolescents were effective in preventing the onset of smoking among young 

females in southeastern Norway, but cautioned that this 

approach could be rejected by the target audience in 

other cultures (Hafstad et al., 1997). 

In the U.S./Massachusetts tobacco surveys, 8 ads were 

chosen for study from approximately 100 ads used in 

the state mass media campaign (Biener et al., 2004). 

The ads used a broad spectrum of messages, including normative behavior or social acceptance, illness 

related to tobacco use, and the deceptive practices of 

the tobacco industry. The ads also ranged in emotional 

tone from humorous to serious. An independent panel 

of youth had previously sorted the ads into groups 

according to message type and emotional tone (Table 1). 

A second group of youth evaluated the ads according 

to the extent to which they could recall the ad after 

hearing a description of it, as well as the ad’s perceived 

effectiveness (Table 2). 

In the follow-up surveys, youth were more likely to 

recall and perceive as effective anti-smoking ads that 

generated negative emotions (fear, sadness) than ads 

that generated positive emotions (happiness, humor, 

amusement) (Table 2). The four ads rated as most 

effective scored highest on the negative-emotion scale 

(sad and frightening) and highest on cognitive quality 

(interesting, thought-provoking, and believable). All 

of these ads depicted illness and suffering resulting 

from smoking, and three of the four ads criticized the 

tobacco industry’s practices.

Table 1

Characteristics of Eight Anti-Tobacco Ads Broadcast in U.S./Massachusetts, 1993–1998

Ads Negative Emotion* Positive Emotion*

Strength of 

Emotional Appeal*

Cognitive 

Quality*

Happy Birthday 4 2.4 5.0 5.2

Pam Laffin 4.9 1.8 5.3 5.4

Janet Sackman 4.7 1.7 5.0 5.3

Cowboy 4.6 1.8 4.9 5.1

Camel 1.4 4.5 2.6 3.2

Lung/Dinner 2.7 4.7 3.4 3.5

Monica 2.0 2.6 3.1 3.9

Models 1.4 2.7 2.9 3.8

* Mean scale values as rated by panel of 104 youth judges (1 = low, 7 = high)

Note: Differences in strength of emotional appeal and cognitive quality scores were statistically significant for each of the illness ads compared 

with all the humorous and normative or social acceptance ads based on non-overlapping 95% confidence intervals. (Biener et al., 2004)
14 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

Although emotional appeal can be a very important 

component of effective anti-tobacco ads for youth, 

invoking too much emotion can limit the length of 

time for which an ad can be used. An internal agency 

memo from Arnold Communications, Boston, cited 

by the U.S./Massachusetts tobacco control program 

staff, indicated that the testimonial Pam Laffin and 

Rick Stoddard ads achieved saturation (the point at 

which the viewing audience no longer paid attention 

to the ads or received any additional benefit from their 

messages) after being broadcast for only 7–11 weeks 

(Brogdon, oral communication, 2000). Viewers contacted the tobacco control program to request that the 

ads be discontinued because of their intense emotional 

content. Those who complained about the Pam Laffin

and Rick Stoddard ads said that they could not bear to 

watch them anymore; they had quickly understood the 

strong message and did not need or want to see the 

ads again and again. These highly emotional ads were 

found to build high levels of awareness among audiences much more quickly than other ads (Brogdon, 

oral communication, 2000). Subsequent media schedules shortened the number of weeks for which these 

ads were broadcast to avoid emotionally exhausting 

audiences and reducing ad effectiveness.

Similarly, researchers in Poland used the Every Cigarette Is Doing You Damage campaign to provide mass 

media support for the Great Polish Smokeout program 

in 1999. Television stations reported that viewers called 

to complain that they were distressed by the graphic 

nature of the ads, especially when the ads were aired 

during the dinner hour. After the tobacco control programs shared data with the television stations indicating that these ads were effective in influencing youth 

audiences, the television station managers allowed the 

ads to stay on the air (Przewozniak et al., 2002). 

Conclusions

Generating a strong negative emotional response 

can be an effective component of youth tobacco use 

prevention ads. The research reviewed for this report 

confirms findings from a substantial body of literature showing that strong negative emotional appeals 

increase the attention to, and recall of, ads among 

youth audiences as well as overall effectiveness. But 

while emotionally compelling ads (especially those 

with personal testimonies about the negative impact of 

tobacco-related illness and death of loved ones) can be 

effective, they run the risk of emotionally exhausting 

certain audience members. Adjustments may need to 

be made to ad placement schedules, such as airing them 

for shorter periods of time, to avoid this problem. 

Table 2

Recall and Perceived Effectiveness of Anti-Tobacco Ads Broadcast in U.S./Massachusetts, 1993–1998, 

by Message Type

Message Type Overall Recall (%)* Perceived Effectiveness†

Illness Ads 68.4 8.2

Humorous Ads 69.3 6.8

Normative or Social Acceptance Ads 42.2 6.4

* Survey respondents who recalled seeing an ad when given a brief description of it.

† Based on recall, where 0 = not a good ad and 10 = a good ad.

Note: Differences were statistically significant at p < 0.05, when overall results for illness ads were compared with those of normative or 

social acceptance ads, and when overall recall for the humorous ads was compared with that of normative or social acceptance ads. Scores 

for perceived effectiveness were statistically significant at p < 0.05 for the illness ads compared with both humorous and normative or 

social acceptance ads. (Biener et al., 2004)
The research community has not reached consensus on 

how the messages most commonly communicated by 

tobacco use prevention ads should be categorized (Farrelly et al., 2003; Wakefield et al., 2003; Goldman and 

Glantz, 1998). We have chosen to categorize the message content of the ads reviewed using groupings most 

commonly employed by researchers, while recognizing 

that some ads may belong to more than one category. 

In this report, we discuss only content themes for which 

data on effectiveness in youth are available. 

In the following sections, we review the results of 

evaluation research on ads whose messages focus on 

one of the following themes:

• Health effects: The most common content of 

youth tobacco use prevention ad messages is the 

adverse health effects of smoking. These ads typically attempt to communicate one or more of 

the health problems associated with smoking, 

often presenting information that viewers are 

unlikely to know or perspectives that viewers are 

unlikely to have considered previously. These ads 

typically portray the negative consequences of these 

health effects on smokers and their loved ones. 

• Tobacco industry deceptive practices: Ads providing information on the deceptive practices of the 

tobacco industry, such as denying the health effects 

of tobacco use, were first introduced in California in 1990 as part of a tobacco de-normalization 

strategy intended to reduce the societal acceptance 

of tobacco use. These ads are designed to reduce 

the glamour associated with smoking and to make 

audiences aware of how the tobacco industry is 

misleading consumers into addiction. Such messages

typically portray the industry as composed of 

uncaring, greedy, and manipulative corporations 

willing to sell hazardous and addictive products for 

financial gain. 

• Social approval or disapproval and refusal skills:

Some messages about social approval of not smoking 

or disapproval of smoking, as well as refusal-skills 

messages, emphasize that instead of increasing the 

popularity of youth, smoking has just the opposite 

effect. Other ads address ways to respond to peer 

pressure to smoke. 

• Secondhand smoke: Secondhand-smoke messages 

stress the effects of cigarette smoke on nonsmokers 

or steps that can be taken to reduce exposure to 

secondhand smoke. 

• Adverse cosmetic effects: Messages about adverse 

cosmetic effects emphasize the short-term effects 

of smoking on appearance, such as bad breath or 

discolored teeth. These ads typically stress the 

disapproval of peers that results from these effects 

of smoking on one’s appearance. 

• Addiction: Addiction messages stress the potential 

for youth to become addicted to tobacco use.

• Athletic performance: Athletic-performance messages address the adverse impact of smoking on a 

youth’s performance in a sport. 

• Individual choice: Individual-choice messages 

emphasize that youth can make independent decisions about whether to smoke. 

MESSAGE CONTENT 

MESSAGE CONTENT 6
6 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

Health Effects

Mass Media Campaign Evaluations

Australia

The Australia National Tobacco Campaign survey 

results demonstrated that young audiences were, in 

some cases, more receptive to graphic portrayals of 

newly understood health risks of smoking than adults. 

Although the Every Cigarette is Doing You Damage 

(ECIDYD) campaign targeted adults, follow-up 

surveys showed that, for some measures, the response 

of teenagers (aged 14–17 years) was greater than that 

of adults (Hassard, 2000).

• Awareness of the campaign was greater among teenaged smokers and teenaged recent quitters (96%) 

than adult smokers and adult recent quitters (87%). 

• Teenaged smokers and recent quitters who had 

viewed the campaign ads showed similar levels of 

agreement with the basic messages of the campaign 

to those of adult smokers and adult recent quitters. 

Regarding the basic campaign message that, “Every 

cigarette is doing you damage”:

• 97% of teenaged smokers and recent quitters agreed 

that the message represented the truth, compared 

with 81% of adult smokers and recent quitters. 

• 82% of teenaged smokers and recent quitters believed 

the statement “smoking causes strokes” to be true, 

compared with 77% of adults. 

• Teens and adults had similar belief ratings about 

smoking causing blood clots in the brain (73% and 

71%, respectively) and decay in the lungs (94% 

and 94%, respectively). 

• 85% of teenaged smokers and recent quitters 

believed that smoking blocks arteries with fatty 

deposits, compared with 76% of adults. 

Note: Conclusions should be evaluated as directional because of 

the relatively small number of teenagers who were recent quitters.

Researchers compared youth responses to the national 

ECIDYD campaign with results from the Australia 

Health Omnibus Survey, which evaluated the Stressing Out campaign created for a youth audience by the 

South Australian Smoking and Health Project (Hassard, 2000). Although awareness of the two campaigns 

was similar, teenagers were more influenced by the 

ECIDYD campaign, which focused on health risks, 

than the Stressing Out campaign, which focused on 

short-term consequences of smoking. Almost 54% of 

the youth surveyed strongly agreed with the message 

presented in the ECIDYD campaign, but only 35% 

agreed with the short-term–consequences message 

in the Stressing Out campaign. About 61% of youth 

smokers surveyed reported that the ECIDYD ads made 

them more likely to quit, compared with only 31% of 

youth for the Stressing Out ads (Hassard, 2000).

Canada/British Columbia

Results from the Canadian Tobacco Use Monitoring 

Survey showed that the prevalence of current smoking in British Columbia among people aged 15 years 

or older dropped from 26% in 1997 to 20% in 1999 

(Lavack, 2001). This decrease followed the conclusion 

of a 2-year, multi-level anti-smoking campaign in British Columbia that used a mix of messages in the broadcast media primarily focused on the health risks of 

smoking (British Columbia Ministry of Health, 2000). 

Several of the ads were produced by U.S. states and 

featured people who had suffered from the negative 

health effects of smoking; one ad discussed the number of British Columbians affected by tobacco-related 

illnesses. The media campaign was also supported by 

Critics’ Choice, a school-based program that reached 

approximately two thirds of British Columbia students 

aged 10–17 years, and by the secondhand-smoke workers’ compensation board regulation, enacted in 1998 to 

eliminate smoking in workplaces. The smoking prevalence for youth aged 15–19 years continued to drop, 

declining from 20% in 1999 to 18% in 2000 (British 

Columbia Ministry of Health, 2000).

Poland

Poland used the Australia-developed ECIDYD campaign for the mass media portion of the Great Polish 

Smokeout program in 1999. The post-campaign evaluation of adult and youth (aged 13–15 years) audiences 

showed that youth had higher awareness of the ads 

than adults, and higher levels of agreement about the 

ads’ relevance and thought-provoking ability; their 

level of agreement about the ads’ believability was 

almost as high (Table 3) (Przewozniak et al., 2002).
MESSAGE CONTENT 

England

England’s Testimonials campaign encouraged smokers to quit by showing emotional pain of smokers 

and their families due to smoking-related illness and 

death. After viewing the ads Stephen and Rebecca,

which featured two people who had suffered health 

consequences from smoking, more youth than adults 

reported learning about the health effects of smoking. Of youth surveyed in the England Anti-smoking 

Advertising Tracking Survey, 84% realized that not 

only old people suffer from smoking-related illnesses, 

compared with 75% of adults. Ninety percent of 

youth agreed that it is important to keep trying to quit 

smoking, compared with 76% of adults. Although the 

campaign targeted adults, 38% of youth stated that 

they could identify with the people and situations in 

the ads, compared with 70% of adults (BMRM Social 

Research, 2002).

U.S./Arizona

The University of Arizona conducted the Arizona 

Tobacco Education and Prevention Program (TEPP) 

media campaign evaluation to determine the effectiveness of an ad called Doesn’t Kill. They also gathered 

data on participant awareness of, and reactions to, the 

American Legacy Foundation’s truthsm campaign ads, 

which focused mainly on tobacco industry deceptive practices and were aired during the same period. 

In the Doesn’t Kill ad, several teenagers announce 

that tobacco did not kill their parents or friends as 

everyone thought it would; the ad then shows that 

each parent or friend suffered major negative physical consequences from tobacco use. A description of 

the truthsm ads is available in Table 4 (University of 

Arizona, 2000). 

Although the intent of the Arizona TEPP research 

was not to compare the efficacy of the two types of 

ads, comparisons are possible. Teens did not like the 

Doesn’t Kill ad as well as most of the truthsm ads, but 

significantly more respondents agreed that the Doesn’t 

Kill ad was more likely to make teenagers think about 

quitting smoking than any of the other ads or groups 

of ads (Table 5) (University of Arizona, 2000).

Table 3

Poland ECIDYD Campaign Youth and Adult Responses

Ad

Awareness (%) Believability (%) Relevance (%)

Thought 

Provoking (%)

Youth Adult Youth Adult Youth Adult Youth Adult

Lung 66 43 88 96 70 62 75 62

Tumour 75 40 87 92 68 58 75 62

Artery 67 32 86 90 67 63 72 69

Brain 66 19 83 94 66 61 73 65

(Przewozniak et al., 2002)
18 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

Table 4

truthsm U.S./National Campaign Ad Descriptions

Ad Ad Description

truth 1 A series of ads portraying a teenager reading e-mail messages sent to the truth.com Web site 

that address some of youths’ questions about truthsm and the tobacco issue. 

truth 2

A series of ads portraying teenagers holding electric counters flashing numbers pertaining 

to important tobacco issues, such as tobacco industry spending on marketing and number 

of deaths from tobacco. 

truth 3

A series of ads portraying teens trying a variety of experiences and products, such as bungee 

jumping, slam dunking a basketball, and driving rental cars. A narrator says that tobacco is 

the only product or experience that kills one out of three people who use it. 

truth 4 An ad portraying teenagers driving around a wealthy neighborhood trying to hypnotize 

people who work for tobacco companies to make them feel better about their unethical work. 

truth 5 An ad portraying teenagers piling hundreds of body bags outside a large building to 

illustrate the number of people who die every day from tobacco.

(University of Arizona, 2000) 

Table 5

U.S./Arizona Youth Response to Doesn’t Kill and truthsm Ads

Response

Ads Reviewed (% who agree or strongly agree)

Doesn’t Kill truth 1 truth 2 truth 3 truth 4 truth 5

I like this ad or 

series of ads. 79.8 88.3 85.6 85.8 85.0 92.7

The people who 

made this ad are 

smart.

93.4 90.6 93.5 90.6 83.3 94.5

This ad will make 

teenagers think 

about quitting 

smoking.

95.7 88.2 87.2 77.0 59.1 85.4

I like this ad more 

than most others 

I have seen.

69.7 72.4 73.7 74.7 57.6 70.3

(University of Arizona, 2000)
MESSAGE CONTENT 19

U.S./Massachusetts

The Massachusetts Department of Health’s tobacco 

control program used a comprehensive tobacco 

de-normalization approach instead of a targeted 

youth campaign. University of Massachusetts Boston 

researchers used the Massachusetts tobacco surveys to 

evaluate the recall and persuasiveness of anti-smoking 

mass media messages aired by the Massachusetts Department of Health in 1999. Before the survey, small 

panels of teens categorized the ads based on message 

content (See Appendix 3 for specifics) (Biener, 2002).

Respondents to the survey rated the ads on a scale 

of 0 to 10, with 0 indicating that the ad was a poor 

anti-smoking ad and 10 indicating that it was a good 

anti-smoking ad. Mean ratings for ads depicting illness (8.3) and tobacco industry deceptive practices 

(8.1) were significantly higher than ratings for the 

ads focused on sports performance, social acceptance, 

and being cool (7.0). Ads aired by the Philip Morris 

Company that focused on individual choice received 

the lowest average rating (5.8) (Biener, 2002).

The Massachusetts researchers reported that youth 

smoking prevalence for high school students dropped 

from 36% in 1995 to 30% in 1999 (Abt Associates, 

2000). The researchers concluded that, “Youth prevention programs should not shy away from tobacco 

counter-advertising ads that feature the serious [health] 

consequences of smoking.” These types of ads are 

the ones perceived as most effective by teenagers, 

regardless of their smoking status, age, gender, or 

ethnicity (Biener, 2002). 

U.S./Utah

In 1998, the Utah Department of Health used four 

television ads produced in other states as well as several 

new locally produced ads in its youth anti-tobacco 

media campaign. Results from the Utah Tobacco Media 

Campaign evaluation indicated that VoiceBox/Debi (a 

health effects ad) had the greatest influence on teens’ 

decisions not to smoke, and had the second highest 

level of recall (Table 6). The most recognizable ad was 

one produced locally that depicted Utah teenagers and 

prominent young adults near familiar local landmarks. 

But this local message, which featured positive testimony about reasons not to smoke, had about half the 

impact of the VoiceBox/Debi ad in influencing youths’ 

intent not to smoke (Neiger et al., 2002). 

Message Research 

Canada/British Columbia

A youth education program in Canada, Critics’ 

Choice, offered students the chance to view a series 

of anti-smoking ads and vote for the ad that was most 

likely to prevent them from starting to smoke or to 

encourage smokers to quit (perceived effectiveness) 

(British Columbia Ministry of Health, 2000). In all 4 

years of the program, students chose ads that graphically portrayed the health consequences of smoking as 

those most likely to influence youth to avoid smoking or consider quitting. In 1997, participants chose 

Table 6

Recognition and Impact Comparison of Anti-Smoking Ads by U.S./Utah Youth

TV Ad % Recognition % Influenced

Debi 72 43

Teenagers in local Utah settings talk about why they do not smoke 91 23

Pam Laffin 67 8

Cowboy 57 7

Teenagers at Great Salt Lake talk about why they started smoking 60 5

Janet Sackman 35 5

Note: Percentage influenced by Debi ad was significantly higher than for all other ads. (Nieger et al., 2002)
20 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

VoiceBox/Debi as most likely to influence their smoking-related behaviors; in 1998, Artery; in 1999, Stroke; 

and in 2000, Tar Lung (British Columbia Department 

of Health, 2000).

U.S./National 

In 1997, the CDC sponsored U.S./National quantitative copy testing that compared the Cowboy ad, which 

depicts the health effects of smoking, with Models, in 

which players on the women’s U.S. Olympic soccer 

team communicate about the ability to perform better 

in sports if one does not smoke. The ad scores were also 

compared with the average scores of thousands of other 

ads previously tested by consumer products companies 

using the same methodology. Results indicated that ad 

recall, main message recall, and key measures, such as 

ability to convince or engage the viewer, were better for 

Cowboy than for Models, and that Cowboy scored above 

average on most key measures. When the verbatim 

comments were analyzed to determine the reasons for 

Cowboy’s popularity, the emotional story about the 

cowboy’s death and the loss to his brother, as well as the 

graphic images of the cowboy’s last days in a hospital 

bed, were the elements of the ad most often mentioned 

by respondents (Gutierrez, personal communication, 

1998). 

U.S./Multistate 

In 1999, four state tobacco control programs joined 

CDC to evaluate 10 anti-smoking ads, including two 

produced by the tobacco industry, for their impact 

on youth audiences. The Teen Research Unlimited 

(TRU) multistate focus groups consisted of 20 at-risk 

youth focus groups conducted in Massachusetts, California, and Arizona. Participants indicated which of 

10 ads would most make them “stop and think about 

not using tobacco.”

Three of the ads with the highest ratings by the focus 

groups presented stories about the negative consequences of smoking on real people and all four of these 

ads graphically showed the consequences of smoking 

(loss of larynx, emphysema, hospitalization, seizures, 

death). The adolescents appeared to have been more 

strongly affected by the idea of living with the negative consequences of tobacco than by the idea of dying 

from them (Teenage Research Unlimited, 1999). 

U.S./North Carolina

Researchers at the University of North Carolina 

conducted four focus groups in that state using the 

same methodology and the same set of ads as in the 

multistate research. The North Carolina Anti-smoking 

Ad Focus Groups findings in 2000 were virtually identical to those of the TRU study (University of North 

Carolina, 2002). 

Another study by the University of North Carolina 

(2002) showed that teens were becoming increasingly aware and critical of tobacco counter-marketing 

messages. However, the messages that described the 

serious health consequences of tobacco use, including 

the impact of secondhand smoke, were perceived by 

teens as most likely to cause viewers to stop and think 

about the dangers of tobacco use (University of North 

Carolina, 2002). 

U.S/California

The 1998 Protection Motivation Theory Message 

Study by University of California, Irvine researchers 

found that ads focusing on the serious health consequences of tobacco use could have the reverse of the 

intended effect in certain audiences. The researchers 

showed 2,800 7th- and 10th-grade students 194 antismoking television ads in use from 1986 to 1997 

to evaluate the impact of the ads on intentions to 

smoke and on smoking-related beliefs (Pechmann et 

al., 2003). Messages about the serious health effects of 

smoking strengthened beliefs that smoking poses severe 

health risks, but failed to reduce intentions to smoke. 

When data from the teens who felt most invulnerable 

to health risks were examined separately, the researchers found that the stronger the teens’ perceptions that 

smoking poses severe health risks, the stronger their 

intent to smoke, apparently due to the appeal of 

tobacco as “forbidden fruit” (Pechmann et al., 2003).

This study also found that health-risk and addiction 

ads can lessen the intention to smoke, but only if they 

stress the fact that youth are susceptible to the health 

risks of smoking. To emphasize health risk vulnerability, the researchers recommended that ads tell true-life 

stories of younger victims, stressing how quickly these 

victims became addicted to smoking, and show how 

much they have suffered from their illness or from the 

illnesses of those they love (Pechmann et al., 2003). 
MESSAGE CONTENT 21

U.S./Utah

In 1998, the Utah Department of Health conducted 

formative message research using tobacco prevention 

ads developed in other tobacco control programs to 

evaluate which messages might be most effective among 

Utah youth. The results indicated that Utah youth aged 

11–18 years were most interested in, and persuaded by, 

ads that used a real-life format, such as testimonials from 

people who had experienced tobacco-related health 

effects. In follow-up focus groups, the youth were not 

shocked or offended by the new information shared in 

the ads about how tobacco companies were targeting 

them. The youth also dismissed ads that depicted what 

they perceived as unlikely events. For example, they 

responded, “that would never happen,” after viewing 

an ad showing cigarettes raining down out of the sky 

to communicate that tobacco companies are targeting 

youth (Murphy, 2000).

Tobacco Industry Deceptive Practices 

Mass Media Campaign Evaluations

U.S./National—American Legacy Foundation

The American Legacy Foundation’s truthsm campaign 

is a national U.S. media effort that began in 1999 to 

prevent tobacco use among youth (aged 12–17 years), 

particularly those most susceptible to tobacco use. The 

campaign is based on research indicating that at-risk 

youth often begin to smoke because this behavior communicates a level of freedom, risk-taking, and defiance 

that they find attractive (U.S. Department of Health 

and Human Services, 1994). The Legacy ads show 

authority-defying youth from diverse ethnic and socioeconomic backgrounds uncovering facts about tobacco 

industry activities and actions. Many of these ads also 

address the adverse health consequences of tobacco 

use. Probably one of the best known Legacy ads is Body 

Bags, in which youth place 1,200 bags representing 

human bodies outside the headquarters of a tobacco 

company to demonstrate the daily death toll in the 

United States from smoking. While the Legacy ads 

were airing, the tobacco industry aired youth tobacco 

use prevention ads with an individual-choice theme. 

Through the Legacy Media Tracking Surveys (LMTS), 

the Foundation evaluated the target audience response 

to the broadcast campaign. The Legacy ads were rated 

highly for receptivity (based on whether the ad was 

perceived as convincing, captured viewers’ attention, 

or gave good reasons not to smoke, and on whether 

viewers talked to a friend about the ad) among smoking and nonsmoking youth, and across races and ethnicities, with nearly 90% of youth aged 12–17 years 

reporting that the ads were convincing and gave them 

good reasons not to smoke (Farrelly et al., 2002). 

Comparisons of the Legacy ads to individual-choice 

ads produced by the tobacco industry showed that 

the industry-sponsored ads were significantly less well 

received by youth who were current smokers or most 

susceptible to smoking (Table 7). Of the five message types tested, the ads combining messages about 

tobacco industry deceptive practices with health-risk 

information had the highest receptivity and unaided 

recall ratings (the ability to remember the ad without 

assistance) among youth and young adults. 

The recall numbers identified through the LMTS are 

especially striking because respondents were more 

than six times more likely to remember the Legacy 

ads than tobacco industry-sponsored ads (Farrelly et 

al., 2002). Furthermore, nearly 75% of respondents in 

this study could remember seeing at least one Legacy 

ad compared with 66% for any of the tobacco industry 

ads, even though the tobacco industry spent considerably more money purchasing broadcast ad placements 

than the Legacy Foundation (Farrelly et al., 2002). 

Analyses of the nationally representative U.S. Monitoring the Future (MTF) adolescent surveys showed 

significant declines in current smoking prevalence 

among students in grades 8, 10, and 12 from 1999 

through 2002 that were associated with exposure 

to the truthsm campaign (Farrelly et al., 2005). The 

relative decline in smoking prevalence was 3.2% 

annually from 1997 to 1999, increasing to 6.8% annually from 2000 to 2002. Overall, an estimated 22% of 

the decline in adolescent smoking was attributable 

to the truthsm ad campaign. The findings from these 

analyses demonstrated a dose-response relationship, 

with those students with higher estimated levels of exposure to campaign ads experiencing a larger relative 

decline in smoking prevalence compared to those with 

lower estimated levels of ad exposure. The dose-response findings were more consistent among 8th grade 

students compared to those in 10th and 12th grades.
22 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

Researchers cautioned, however, that direct causal 

connections cannot be established; the results of ad 

effectiveness evaluations based on ad recall may be 

compromised by differences in the attitudes of those 

who are able to recall the ads. For example, those who 

already have strong anti-smoking attitudes may pay 

more attention to the ads regardless of the specific 

message content (Farrelly et al., 2002).

U.S./California

The California Department of Health Services 

Tobacco Control Section has aired tobacco industry 

deceptive-practices ads for more than a decade. Many 

researchers in that state and elsewhere believe that 

these types of ads played a role, as did other messages, in 

contributing to the decline in youth smoking prevalence 

in the state among those aged 12–17 years, from 8.7% 

in 1992 to 5.9% in 2001 (Balbach and Glantz, 1998; 

Goldman and Glantz, 1998). In a review of broadcast 

messages from 1994 to 2000, the Independent Evaluation 

Consortium for the State of California Department of 

Health Services Tobacco Control Section found that 

40% of these ads focused on prevention and cessation, 

32% on tobacco industry deceptive practices, and 

22% on secondhand smoke (Independent Evaluation 

Consortium, April 2003).

This study found that youth and adults who had seen 

more of the California campaign’s tobacco countermarketing television ads emphasizing the deceptive 

practices of tobacco companies were more likely to 

believe that tobacco advertising and promotions influence youth to smoke (Independent Evaluation Consortium, 1998). The evaluation of four television ads 

showed that ads focusing on the harm caused to others 

by tobacco use and exposing tobacco industry deceptive practices had the highest combination of recall 

and accuracy of recall (the ability to correctly describe 

the ad). Ads with the highest scores for both recall 

and accuracy of recall among youth were Victim/Wife,

Table 7

Receptivity and Unaided Awareness for Legacy and Philip Morris U.S./National Youth Tobacco Use 

Prevention Ads

Ad Description

Receptivity Rating by Respondents*

Youth

(12–17)

Young Adults

(18–24)

Legacy

Body Bags

Industry deceptive practices with 

health risks 3.1 3.0

Legacy

Daily Dose

Industry deceptive practices with 

health risks 3.0 2.8

Legacy

Beach Industry deceptive practices, humor 2.9 2.7

Philip Morris

Karate Kid

Short-term health effects, shortness of 

breath, affecting physical performance 2.8 2.5

Philip Morris

Boy on the Bus Individual choice 2.4 2.2

*Ads were rated based on four factors, with one point given for each factor considered to be present: convincing, grabbed attention, gave 

good reasons not to smoke, talked to friends. Differences between the Individual Choice and Industry Deceptive Practices ads were 

statistically significant at 95% confidence intervals. (Farrelly et al., 2002)

Note: 47% of respondents were able to recall the Legacy Body Bags, Daily Dose, and Beach ads without assistance, compared with 6.5% for 

the Philip Morris Think. Don’t Smoke. Karate Kid and Boy on the Bus ads. 
MESSAGE CONTENT 23

which featured a man whose wife had died from an illness caused by his cigarette smoke, and Hooked, which 

suggested that tobacco companies use addiction to 

achieve their business goals. 

U.S./Florida 

The Florida state tobacco control program first developed the Truth campaign concept, later adopted by 

the American Legacy Foundation, in which a series 

of ads inform youth about tobacco industry deceptive marketing practices. Florida’s youth-targeted 

anti-smoking campaign included grassroots activism, 

public relations activities, school-based programs, and 

a strong mass media presence. 

From 1998 to 2000, when the campaign received 

strong funding support from the state legislature 

through the Florida Department of Health, cigarette 

smoking among middle school students dropped 

from 18.5% to 11.1% (a relative decline of 40%) and 

among high school students from 27.4% to 22.6% (a 

relative decline of 18%) (Bauer and Johnson, 2001).

The Florida Anti-Tobacco Media Evaluation (FAME) 

found that the more tobacco industry deceptive-practices 

ads Florida teens, especially younger teens, saw during 

the campaign, the less likely they were to begin smoking 

(Sly et al., 2001). The FAME longitudinal study 

assessed recall of specific tobacco counter-marketing 

ads in Florida’s Truth campaign and actual changes in 

smoking behavior. Confirmed awareness of the Truth 

advertising campaign correlated strongly with reduced 

likelihood of becoming a smoker and with increased 

likelihood of quitting. Teens who agreed strongly with 

statements about tobacco industry deceptive practices 

had smoking initiation rates that were 7.3 times lower 

than those of teens who agreed less strongly with the 

statements, and more than two times lower than those of 

teens with medium levels of agreement (Sly et al., 2001).

A direct causal relationship between reported ad 

exposure and smoking prevalence, initiation, or 

cessation cannot be confirmed because of selective 

recall and pre-existing attitudes. The ads were part 

of a larger effort to reduce smoking, making it difficult to determine which component of the tobacco 

counter-marketing effort had the greatest influence on 

smoking initiation rates. Nevertheless, the reductions 

in smoking prevalence were extremely impressive, 

especially given the short duration of the campaign 

(Sly et al., 2001). 

Table 8

Beliefs Among Teens in U.S./Florida and in a U.S./National Sample Regarding Tobacco Industry Behavior

Belief Statement

% of Florida Teens 

in Agreement

% of Teens 

Nationally in 

Agreement

Cigarette companies lie. 87.3 81.5

Cigarette companies deny that cigarettes cause cancer. 65.9 56.8

Cigarette companies try to get teens to start smoking. 88.1 82.1

I would like to see cigarette companies go out of business. 83.3 77.1

Value differences between Florida teens and the national sample were statistically significant based on nonoverlapping 95% confidence 

intervals. (RTI International, 2002)
24 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

The FAME findings regarding the effectiveness of 

tobacco industry deceptive-practices ads on youth in 

Florida were confirmed by the American Legacy Media 

Tracking Surveys, which gauged the effectiveness of 

the national truthsm campaign (RTI International, 

2002). The LMTS included a relatively large number 

of participants in Florida to allow assessment of the 

incremental effect of the in-state Truth campaign. 

The researchers found that Florida teens were more 

likely to have unfavorable beliefs about the tobacco 

industry than their peers in other parts of the country, 

possibly because they had been exposed to the messages of both campaigns and to the tobacco industry 

deceptive-practices theme for a longer period of time 

(Table 8). 

U.S./Minnesota

Beginning in 1999, the Minnesota Department 

of Health initiated the Target Market campaign to 

increase knowledge and levels of emotion about 

tobacco industry deceptive practices by educating 

Minnesota youth about the industry and encouraging 

them to join a youth anti-tobacco movement. The 

campaign included ads featuring youth speaking out 

against the tobacco industry that had targeted them as 

potential consumers. 

After 1 year of the campaign, the Minnesota Target 

Market campaign evaluation indicated that the Target 

Market message had affected smoking behavior and 

teen attitudes about the tobacco industry. Youth aged 

12–13 years showed the most growth in confidence 

in their ability to fight back against tobacco industry messages that encourage smoking, along with a 

new level of interest in, and enhanced knowledge of, 

tobacco industry deceptive practices (Table 9) (Ergo 

International, 2001). 

Minnesota youth also reported changes in smoking 

behavior and anti-tobacco beliefs following the Target 

Market campaign’s first year (Table 10). In the 2001 

Target Market campaign evaluation study, the number 

of Minnesota youth who reported using tobacco in the 

last 21 days dropped from 3% to 1% among those aged 

12–13 years, and from 30% to 23% among those aged 

16–17 years. These declines were statistically significant (Ergo International, 2001). 

Table 9

Beliefs About the U.S./Minnesota Target Market (TM) Advertising Messages Among Youth Who 

Recalled Seeing or Hearing TM Ad(s)

Belief Statements

Youth Responses (%)

12- to 13-year-olds

Before/After Campaign

14- to 15-year-olds

Before/After Campaign

16- to 17-year-olds

Before/After Campaign

Like you have the power 

to fight back 80/92 80/86 79/82*

That you learned something new 54/73 47/67 33/63

Motivated you 48/65 41/57 37/57

Inspired you 47/68 37/58 23/51

* All differences in values pre-campaign and post-campaign (before and after viewing the ads) were statistically significant based on 

nonoverlapping 95% confidence intervals, except for the belief statement “Like you have the power to fight back” for 16- to 17-year-olds. 

Numbers in parentheses indicate numbers of participants in each cell. (Ergo International, 2001)
MESSAGE CONTENT 25

Target Market annual funding was reduced from $23.7 

million to $4.6 million in 2003, eliminating all broadcast presence (CDC, 2004). Within 6 months of the 

reduced media presence, the percentage of adolescents 

who reported susceptibility to smoking increased from 

43% to 53%. 

Message Research

Canada/British Columbia

In British Columbia, students who participated in the 

Critics’ Choice school program found tobacco industry deceptive-practices ads difficult to understand and 

uninteresting (British Columbia Ministry of Health, 

2000). Ads that included a tobacco industry message 

were not rated in the top 5 or 6 of the 12 ads viewed 

each year, based on youth perceptions of the ads’ ability to encourage cessation or discourage smoking initiation. The exception was Body Bags, ranked second 

in 2000, which reported the number of deaths caused 

annually by tobacco-related diseases and used graphic 

visuals of body bags (British Columbia Ministry of 

Health, 2000). The strong response to Body Bags may 

indicate the value of blending a health-effects message 

with a tobacco industry deceptive-practices message. 

A consultant to the British Columbia Ministry of 

Health’s advertising agency that managed the Critics’ Choice program proposed that the lack of positive 

response to the tobacco industry deceptive-practices 

ads was probably due to two factors (Kim Sanderson, 

unpublished data, June 2001):

• The cigarette brand names used in the ads, such as 

Marlboro, and company names, such Philip Morris, 

were not very familiar to Canadian youth because 

these brands and companies’ products were not 

sold in that part of Canada.

• Because of tobacco advertising restrictions, the 

tobacco industry’s presence was less prominent in 

Canada than in other countries. 

Table 10

Changes in Anti-Tobacco Beliefs Associated with the Mass Media Campaign Among 

U.S./Minnesota Youth Aged 12–17 Years

Cigarette companies try to cover up all of the bad things 

they have done.

Belief Statements

Youth Response (%)

Before seeing the ads After seeing the ads

I don’t want to be the target of big tobacco companies. 71 7

I feel strongly against smoking. 6 75

It annoys me that tobacco companies are targeting kids. 57 6

Knowing how much money tobacco companies are 

making off of kids makes me mad. 5 6

Cigarette companies are trying to get young people to smoke. 52 66

48 55

I can fight back against tobacco companies. 42 57

It doesn’t matter to me if other kids smoke or not. 22 19

All differences were significant at the 95% confidence level. (Ergo International, 2001) 
26 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

U.S./Multistate

In 1999, CDC sponsored a multistate focus groups 

study in Massachusetts, California, and Arizona. 

Tobacco industry deceptive-practices messages were 

better understood and received among respondents 

who lived in states where these messages had already 

been communicated extensively, such as California. 

Youth in states where tobacco industry deceptivepractices messages had not been extensively aired did 

not understand the ads and lacked interest in them 

(Teen Research Unlimited, 1999). 

U.S./California

To review the effectiveness of anti-smoking television 

ads developed or in development for youth and adults, 

researchers at the University of California, San Francisco conducted a national anti-smoking campaign 

focus group analysis. They studied results from 186 

focus groups that evaluated eight advertising themes 

(industry deceptive practices, secondhand smoke, 

addiction, cessation, youth access, short-term effects, 

long-term health effects, and romantic rejection). The 

researchers concluded that tobacco industry deceptivepractices and secondhand-smoke messages were the 

most effective for de-normalizing smoking and reducing cigarette consumption (Goldman and Glantz, 

1998). Other researchers, however, took issue with the 

findings of this study, noting that because of methodological limitations, the research did not necessarily 

support these conclusions (Worden et al., 1998; Balch 

and Rudham, 1998). 

The University of California, Irvine Protection 

Motivation Theory Message Study investigated 

several types of approaches used in tobacco industry 

deceptive-practices ads with students in middle and 

high school. The students compared these ads, which 

included a range of messages such as tobacco industry 

marketing tactics, deaths caused by such tactics, and 

youth activism against tobacco marketers. None of the 

tobacco industry deceptive-practices approaches were 

found to lessen youths’ intent to smoke. Respondents 

did, however, have favorable opinions about the ads, 

and the ads increased their knowledge about tobacco 

industry marketing (Pechmann et al., 2003).

U.S./North Carolina 

In the North Carolina anti-smoking ads focus groups 

conducted among students living in this tobaccogrowing state, ads with a tobacco industry deceptivepractices theme were rated considerably lower than ads 

with other themes in their ability to cause the viewer 

to stop and think about tobacco use. The students who 

gave low ratings to the industry deceptive-practices ads 

commented that the decision whether to smoke is up 

to youth, and the tobacco industry has a very limited 

impact on youth decisions. Others noted that tobacco 

companies have a right to make money. Participants 

rated the ads with a tobacco industry deceptive-practices 

message as more effective in making them stop and 

think when the ads included health risk information 

(University of North Carolina, 2001). 

Social Approval/Disapproval 

or Refusal Skills

Mass Media Campaign Evaluations

The Netherlands

The Netherlands DEFACTO campaign conducted 

from 1998 to 2000 included mass media (television 

and radio ads and publicity about the campaign), a 

road show, a Web site, and cessation services (Frissen, 

2002). The objective of the campaign was to decrease 

smoking and exposure to secondhand smoke in Dutch 

society. The ads showed that youth do not need to 

smoke to be independent and popular and that nonsmokers are cool. 

The television ads featured obnoxious, rebellious 

behavior, such as burping in a classroom, as a way to 

express the coolness of a nonsmoker. The Netherlands 

DEFACTO tracking study, conducted 10 weeks after 

the campaign began, found that 72% of those surveyed understood the ads and 71% appreciated them 

(Frissen, 2002). The percentage of youth who had 

strong intentions to continue not to smoke increased 

from 32% to 42% during this campaign. Those who 

had weaker intentions to continue not to smoke 

decreased from 42% to 33%. During this period, the 

percentage of youth who reported that they did not 

have smoking friends increased from 17% to 23% 

(Frissen, 2002). 
MESSAGE CONTENT 27

 U.S./Vermont, Montana, New York 

In 1986, researchers at the University of Vermont 

began a multistate combined school and mass media 

study, developing television ads that reached youth in 

grades 5–10 with social-disapproval, refusal-skills, and 

smoking-consequences messages (Flynn et al., 1995). 

The ads were developed based on feedback from focus 

groups, testing of creative ideas, and reviews of completed ads by the target audiences to help ensure that 

the ads would provide youth with a positive view of not 

smoking, a negative view of smoking, improved skills 

for refusing cigarettes, and a clearer understanding that 

most youth their age do not smoke. These researchers 

did not develop or test ads with messages about the 

long-term health effects of smoking or tobacco industry 

deceptive-practices messages for comparison. The ads 

were broadcast on television in Vermont, Montana, and 

south central New York State communities.

The researchers measured the impact of a mass media 

campaign in conjunction with a typical school tobacco use prevention program. Students who participated 

in the school program and saw the ads smoked fewer 

cigarettes per week (2.6) following the campaign than 

students who participated only in the school program 

(4.4). Moreover, only 13% of students who participated 

in the school program and saw the ads had smoked a 

cigarette in the previous week, compared with 20% 

of those who participated in the school program 

only (Flynn et al., 1995). The reductions in smoking 

prevalence among youth exposed to the campaign 

lasted up to 2 years after the campaign had stopped. 

The multistate school mass media campaign follow-up 

study calculated that the odds ratio for being a weekly 

smoker after exposure to both mass media and schoolbased programs was 0.6, indicating a reduced risk 

(Flynn et al., 1994). 

U.S./Minnesota

The Minnesota Department of Health developed 

and implemented a comprehensive tobacco countermarketing campaign from 1986 to 1990 designed to 

discourage tobacco use among schoolchildren (Murray et al., 1994). Annual spending for the mass media 

portion of the campaign was about $2 million. The 

campaign used a social approval-disapproval and 

refusal-skills approach. The campaign developers 

sought to present not smoking in a positive light and 

smoking as negative behavior, and to provide training 

on how to refuse invitations to smoke. 

The campaign was evaluated annually through the 

Minnesota-Wisconsin Adolescent Tobacco Use 

Research Project. Evaluation results based on Arbitron 

data, which measure household television viewing 

patterns, indicate that while the target audience was 

aware of the messages (95% of the 3,600 9th-grade 

students surveyed annually had seen an anti-smoking 

message at least 50 times per year), no measurable 

changes in attitudes or smoking behavior occurred as a 

result of the 4-year campaign. Researchers believe that 

the lack of change may have been due to less than full 

support of schools in providing a strong anti-smoking 

curriculum (Murray et al., 1994). 

Message Research

U.S./California

The University of California, Irvine Protection 

Motivation Theory Message Study found that the 

ads students rated as most likely to strengthen their 

intentions not to smoke addressed social-norms 

themes, conveying that smoking may cause severe 

social disapproval by peers. Anti-smoking messages 

rated as effective in increasing youth intentions not 

to smoke, compared with control-group messages that 

focused on drunk driving, discussed smokers’ negative 

life circumstances (disheveled “losers” who had taken 

the wrong path in life and as a result had unattractive life situations), role modeling to enhance viewers’ refusal skills, and information on how smoking 

endangers the lives of others. The perceived lack of 

appeal of smoking due to the severity of social disapproval risks appeared to have the greatest effect on 

students’ intentions not to smoke. Message themes 

that were rated as less effective included disease and 

death (health effects), cosmetics (effects of smoking 

on appearance, such as bad breath), selling disease and 

death (tobacco companies influencing consumers to 

purchase products that cause illness and death), and 

tobacco industry marketing tactics (powerful tobacco 

companies targeting children, women, and minorities) 

(Pechmann et al., 2003). 

U.S./Massachusetts

The Massachusetts tobacco surveys measured recall 

and perceived effectiveness of eight ads used in the 
28 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

Massachusetts Department of Health tobacco control 

media campaign. The lowest recall rate was for ads 

in the normative category, which delivered messages 

about social approval of not smoking and disapproval 

of smoking (Biener, 2004). 

Secondhand Smoke

Mass Media Campaign Evaluations

U.S./California

Since 1993, reducing secondhand-smoke exposure has 

been one of the major goals of the California tobacco 

control program. The California Independent Evaluation Research Consortium conducted surveys from 

1989 to 1995 to evaluate many aspects of the California state tobacco control program and to provide 

information on which media ads were most highly 

associated with attitude changes. Exposure to secondhand-smoke messages was associated with an increase 

in the number of adults and youth who believed that 

breathing secondhand smoke was bad for one’s health, 

and an increase in the likelihood of respondents asking another person not to smoke around them (Independent Evaluation Consortium, 1998) (Table 12). 

The Independent Evaluation Consortium found that 

the Victim Wife ad, which featured a man whose wife 

had died from extensive exposure to secondhand 

smoke, achieved the highest recall and accuracy of 

recall of any ad in the study for both adults and youth 

(Independent Evaluation Consortium, 1998).

A review of all messages broadcast in California from 

1994 to 2000 found that 22% of the television spots 

aired addressed concerns about secondhand smoke, 

40% focused on prevention and cessation, and 32% 

provided information on tobacco industry deceptive practices (Independent Evaluation Consortium, 

2003). Smoking prevalence among California youth 

remained flat at 11.2% from 1994 to 1997, followed 

by a large 1-year decline of 10.7% to 6.9% from 1998 

to 1999. This decrease corresponded with a significant 

increase in media campaign spending, from $13.3 

million in 1998 to $19.5 million in 1999. The decline 

in California youth smoking prevalence continued, 

dropping to 5.9% in 2001 (California Youth Tobacco 

Survey, 2002).

Table 12

Effect of Viewing U.S./California Secondhand Smoke Messages on Beliefs and Behaviors

Belief/Behavior

Number of Secondhand-Smoke Ads Viewed

None 1–2 2+

10th-Grade 

Youth (%)

Adults

(%)

10th-Grade 

Youth (%)

Adults

(%)

10th-Grade 

Youth (%)

Adults

(%)

Believe that secondhand 

smoke is a health risk 92 87 97 91 100 93

Likely to ask someone not 

to smoke around them 41 38 47 42 48 48

(Independent Evaluation Consortium, 1998)
MESSAGE CONTENT 29

Canada/Ontario

The Ontario, Canada, Ministry of Health launched 

a media campaign to communicate the dangers of 

secondhand smoke. The campaign was designed to 

reduce the social acceptability of smoking in public 

places and to affect public policy by communicating 

the health risks of secondhand smoke to nonsmokers. 

Television advertising that addressed the health risks 

of secondhand smoke succeeded in raising awareness 

and interest in the topic (Lacey, 2002). The postcampaign Ontario tobacco media campaign tracking 

survey showed that awareness of the Victim/Wife ad 

was slightly higher for youth (81%) than for adults 

(76%), and that 96% of youth believed that secondhand smoke was a danger to others besides smokers. 

Overall, youth tended to hold similar views about 

secondhand smoke to those of the adults, but were 

more accepting of smokers in social situations. Youth 

were supportive of government regulations to control 

smoking in public places (87%, compared with 85% 

of adults) and more likely than adults to agree that 

smoking should be illegal (56%, compared with 49% 

of adults) (Lacey, 2002). 

Message Research 

U.S./California, U.S./Massachusetts, U.S./Michigan

The University of California, San Francisco’s national 

anti-smoking advertising campaign focus-group analyses 

found that secondhand smoke and tobacco industry 

deceptive practices were the two most effective message 

themes of the eight tested for de-normalizing smoking and reducing cigarette consumption (Goldman 

and Glantz, 1998). However, as mentioned earlier, 

this study’s methods and assumptions were questioned 

by some members of the tobacco control community 

(Balch and Rudham, 1998; Worden et al., 1998). 

U.S./California

The University of California, Irvine Protection 

Motivation Theory Message Study found that ads that 

discussed the negative effects of smoking and secondhand smoke on family members and other people 

weakened youths’ intent to smoke. In particular, students rated the perceived effectiveness of secondhandsmoke ad messages as higher than that of messages 

concerning health risks to smokers or tobacco industry 

deceptive practices (Pechmann et al., 2003). According 

to the authors, the ads worked because they implied 

that people do not appreciate living or working with 

smokers, or they see the behavior as inconsiderate, 

harmful to them, and socially unacceptable. 

U.S./North Carolina

Youth participants in the North Carolina Antismoking Ads Focus Groups study rated secondhandsmoke messages as the second most effective theme 

of those tested, with only messages on adverse health 

effects to smokers rated higher. Participants indicated 

that ads using this theme raised awareness of the dangers of secondhand smoke, which appeared to be new 

information to some participants (University of North 

Carolina, 2002). 

Cosmetic Effects 

Mass Media Campaign Evaluations

U.S./Arizona

The Arizona TEPP ad campaign included a focus on 

the short-term effects of smoking on a teen’s breath, 

teeth, and skin, and how these effects can interfere 

with a teen’s desired appearance. With a tagline of 

“Tobacco. Tumor causing, teeth staining, smelly puking habit,” these ads presented a range of unattractive 

and humorous scenarios, often exaggerating the effects 

of tobacco on the health, appearance, and social acceptance of youth who smoke. 

The in-school evaluation of the Arizona TEPP prevention ads studied youth response to the television ads 

used in 1999 to determine which emotions were most 

influential in generating disapproval of smoking and 

the intention not to smoke. The research showed that 

the most effective ads tested among Arizona youth were 

those rated as the most disgusting (i.e., generating a 

negative emotional response); messages of social disapproval were rated as less effective (Hendricks et al., 

2001). Researchers tested reactions to ads created and 

used in Arizona only and did not examine the impact of 

any of the graphic health-effects or testimonial ads that 

have been shown to be effective elsewhere.

U.S./Massachusetts

The Massachusetts tobacco surveys of high school students evaluated the effectiveness of various ad executions. The researchers found that ads presenting the 

impact of cigarette smoking on appearance were more 

effective than ads using humor, in that more youth 
30 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

were able to recall the appearance-focused ads and 

were more receptive to the messages. However, these 

ads were less effective than those described as sad or 

frightening by youth respondents (Biener, 2002). 

Message Research

U.S./California

The University of California, Irvine Protection Motivation Theory Message Study of school-based groups 

found that ads showing the effects of smoking on appearance and attractiveness (e.g., bad breath, yellowed 

teeth, smelly clothes) did not influence respondents’ 

intentions to smoke, apparently because the youth felt 

that appearance problems could be easily remedied 

with cosmetic products (Pechmann et al., 2003). 

Addiction

Message Research

U.S./Multistate 

Most young people do not understand the addictive 

characteristics of tobacco use and mistakenly believe 

that they can quit using tobacco whenever they please 

(CDC, 1994). However, smoking cessation is much 

harder than most youth perceive it to be (CDC, 

2001). Creating messages about the power of nicotine 

addiction that are comprehensible and relevant to 

the viewer is difficult. One of the most powerful ads 

addressing addiction (along with health effects) is the 

Debi/Voice Box ad. However, the TRU multistate focus 

group research indicated that youth audiences named 

health effects, not addiction, as the main message of 

the Debi ad (Teenage Research Unlimited, 1999).

U.S./Massachusetts

According to an account executive from the advertising agency that developed the U.S./Massachusetts 

tobacco counter-marketing campaign, the program’s 

efforts to communicate messages about addiction using 

the testimonial format did not achieve the impact 

of testimonials portraying illness and personal loss 

(Miller, unpublished data, 2000). In one set of Massachusetts ads, teenagers talked remorsefully about how 

they wished they had never started to smoke. These 

ads did not achieve nearly the awareness and recall 

ratings of the personal-loss ads. 

Another Massachusetts ad that attempted to communicate the power of addiction was the Breathe ad. 

It featured a swimmer underwater needing to take 

a breath in an attempt to compare the need for a 

cigarette to the basic need to breathe. Many Massachusetts youth did not understand the connection to 

smoking (Miller, oral communication, October 2000).

Athletic Performance 

Mass Media Campaign Evaluations 

U.S./National

The Philip Morris Karate Kid ad, which was designed 

to communicate the message that smoking causes 

shortness of breath and can affect athletic performance, was evaluated in the Legacy Media Tracking 

Surveys (LMTS) for awareness and receptivity compared with the American Legacy Foundation’s ads 

addressing health effects or tobacco industry deceptive 

practices. The Karate Kid ad received a lower rating 

than any of the Legacy ads reviewed (See Table 7) 

(Farrelly et al., 2002). 

U.S./Massachusetts

The Models ad, which featured members of the U.S. 

women’s Olympic soccer team, was one of eight ads 

from the Massachusetts Department of Health tobacco 

control media campaign evaluated for emotional tone 

and message content through Massachusetts tobacco 

surveys with Massachusetts youth aged 12–17 years. In 

the ad, the soccer players talked about being able to 

perform better in sports because they did not smoke. 

The ad received lower ratings for recall and effectiveness than health-effects messages and humorous messages aired in the Massachusetts campaign and tested 

in the research (Biener, 2004). 

Message Research

U.S./National 

The 1998 CDC-sponsored National Quantitative 

Copy Test compared recall among youth audiences of 

the Cowboy ad, which addressed the serious negative 

health effects of smoking, with the Models ad, in which 

members of the U.S. women’s soccer team talked about 

being able to perform better in sports by not smoking. 

The Models ad featured a celebrity role model cautioning the audience about tobacco industry messages 

glamorizing smoking, versus the reality of the effects 
MESSAGE CONTENT 31

of smoking on athletic performance. Recall of the 

Models ad was below average compared with hundreds 

of other consumer product ads tested, in both ability 

to recall seeing the ad 3 days after the first research 

interview and being able to recall the main message 

of the ad. Only 19% of respondents could recall a key 

element of the ad, and only 8% of female respondents 

aged 13–19 could state that the message of the ad was 

about improving athletic performance by not smoking 

(Gutierrez, personal communication, 1998).

Individual Choice

Mass Media Campaign Evaluations

U.S./National

Most tobacco industry-sponsored, youth-focused ads 

have stressed individual-choice messages, emphasizing 

that youth can make decisions independently about 

whether to smoke, and encouraging them to choose 

not to smoke. The Philip Morris ad campaign, which 

focused on individual choice, was launched in 1998, 

with annual spending reported to be in excess of $100 

million for mass media alone. This media expenditure 

was substantially higher than that of the American 

Legacy Foundation for its ad placement campaign 

(Farrelly et al., 2002).

When the Legacy ads were compared with the Philip 

Morris individual-choice ads in the Legacy Media 

Tracking Study, the individual-choice ads were rated as 

less effective than the Legacy ads in building awareness 

and being positively received by the target audiences. 

Nearly 75% of respondents could confirm awareness of 

at least one Legacy ad, versus 66% of any Philip Morris 

individual-choice ad (Farrelly et al., 2002). 

Analysis of the LMTS data allowed comparisons of 

the Legacy ads to individual-choice ads produced by 

Philip Morris and Lorillard (Tobacco Is Whacko 

campaign), all of which aired in 2000. Results showed 

that the industry-sponsored ads were significantly less 

well received by youth who were current smokers or 

most susceptible to smoking (based on the number of 

friends and family members who smoked and their 

attitudes toward tobacco and tobacco companies). 

Of the five message types tested, the ads combining 

tobacco industry deceptive-practices messages with 

health-risk information received the highest receptivity 

ratings among youth and young adults. The recall numbers are especially striking because respondents were six 

times more likely to remember the Legacy ads than the 

tobacco industry ads (Farrelly et al., 2002).

Message Research

Scotland

The Center for Tobacco Control Research at the University of Strathclyde conducted focus groups among 

respondents aged 12–17 in Scotland in November 

2001 to determine youth reactions to the tobacco 

industry-sponsored Youth Smoking Prevention (YSP) 

ads aired on MTV (Devlin et al., 2002). Results from 

the Scotland YSP ads focus groups indicated that ads 

emphasizing individual choice did not help persuade 

youth participants not to smoke. In addition, the 

youth failed to relate to the campaign, feeling that the 

messages were not relevant to their lives. Participants 

described the television ads as unrealistic and lacking 

credibility. In addition, the campaign ads appeared to 

reinforce young smokers’ decisions to smoke by implying that both smoking and not smoking were acceptable, and the ads did not address any serious negative 

consequences of tobacco use (Devlin et al., 2002). 

U.S./Multistate

The TRU multistate focus groups study addressed 

several individual-choice ads, including the Stairs and

Bus ads from Philip Morris and the I Decide ad from 

U.S./Arizona. The ads that focused on individual 

choice (i.e., encouraged viewers to make their own 

decisions about smoking or stated that one does not 

need to smoke to be cool) were consistently rated 

lowest by participants in their likelihood of making 

participants “stop and think about not using tobacco.” 

Participants stated that the ads did not have enough 

substance because they did not include good reasons 

not to smoke and did not provide any compelling 

information about the consequences of smoking 

(Teenage Research Unlimited, 1999). 

U.S./California

The University of California, Irvine Protection Motivation Theory Message Testing study was designed, 

in part, to examine the effects of the Philip Morris 

Think. Don’t Smoke. campaign individual-choice ads. 

The researchers found that these ads did not have any 

effect on youth intentions to smoke (Pechmann et al., 
32 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

2003). According to the researchers, many of the 

Philip Morris ads seemed to imply that both smoking and not smoking are socially acceptable choices, 

which does not constitute a clear anti-smoking message. 

Effectiveness of Different 

Message Themes

Based on our review of ad themes and media campaigns 

stressing each of these themes, we have classified the 

effectiveness of each message theme into one of four 

categories: effective, effective but with limited research 

data, inconclusive, or not effective.

Effective: Health Effects

Media campaign and message evaluation research has 

consistently shown that portraying the serious negative consequences of smoking in a credible manner 

is effective in influencing youth; in some instances, 

these messages were shown to have a positive influence on attitudes or behaviors concerning not using 

tobacco. Adult-targeted messages that portray personal loss and present information on health risks that 

was not previously known or previously considered 

can be effective among youth, even when the messages are not targeted to youth audiences (Hassard, 

2000). These findings about the power of new health 

information in reaching audiences effectively are consistent with those from a meta-analysis of 48 health 

campaigns in the United States (Snyder, 2001). In 

that study, researchers found that the most effective 

campaigns were those that provided the audience 

with new information (not previously considered or 

known) on health effects.

Simply presenting health information is not enough. 

New information or new perspectives need to be presented in ways that engage viewers emotionally. For 

example, the Australian Every Cigarette Is Doing You 

Damage ads and the Janet Sackman, Cowboy, VoiceBox/Debi, and Doesn’t Kill ads from the United States 

demonstrate the importance of health-effects message 

content delivered in formats that are engaging 

to viewers (e.g., graphic display of health effects, 

testimonials about personal loss and suffering) (University of Arizona, 2000; Biener, 2002; Hassard, 2000; 

Murphy, 2000; Teenage Research Unlimited, 1999). 

Effective: Tobacco Industry Deceptive Practices

The effectiveness of messages in a mass media campaign 

emphasizing the deceptive practices of the tobacco 

industry has been assessed mainly in the United States. 

Effectiveness of this approach in other countries is not 

known. Many, but not all, of the studies on these ads 

found that tobacco industry deceptive-practices ads 

can successfully influence youth knowledge about the 

tobacco industry, attitudes toward smoking and the 

tobacco industry and, in some cases, smoking behaviors. 

Combining messages about the deceptive practices of 

the tobacco industry with health-effects messages has 

been shown to be effective in changing youth attitudes 

and influencing behaviors (Balbach and Glantz, 1998; 

Independent Evaluation Consortium, 1998).

The youth-focused tobacco industry deceptivepractices message strategy requires audience preparation and may be misunderstood by audiences unfamiliar 

with tobacco industry strategies and behaviors. Youth 

audiences may need a clear explanation of why the 

tobacco industry should be viewed differently than 

other legal businesses, and they probably need exposure 

to many different messages over time to fully understand this relatively complex subject.

Effective but with Limited Research Data: Social 

Approval/Disapproval or Refusal Skills

Messages addressing social approval of not smoking or 

social disapproval of smoking or that introduce refusal 

skills have been found in some studies to be effective 

in increasing awareness of tobacco prevention issues 

among youth and reducing intentions to smoke. One 

study found that when such ads are used in conjunction with a school-based educational intervention, 

they contribute to a decline in smoking prevalence 

(Flynn et al., 1995). Ads that communicate the social 

approval or disapproval theme or refusal skills have 

been effective in changing attitudes and behavior in 

different countries. However, the number of evaluations available for this review was small and results 

available from one large-scale broadcast campaign 

evaluation did not indicate that this message strategy 

was effective in changing attitudes or behavior, even 

though the audience was aware of the messages (Murray et al., 1994). As a result, we classified these ads as 

effective in limited controlled research environments. 
MESSAGE CONTENT 33

Effective but with Limited Research Data: 

Secondhand Smoke

Research results on the effectiveness of secondhandsmoke message content are positive, but the secondhand-smoke message has rarely been used as a sole or 

major focus in a youth tobacco use prevention campaign. As a result, data on this theme are very limited.

Inconclusive: Cosmetic and Short-Term Effects

Findings on cosmetic and short-term–effect ads 

were available for this review from only three studies conducted in the United States, and results were 

inconclusive. Additional research is needed before any 

conclusion can be reached about the effectiveness of 

this type of message content. 

Inconclusive: Addiction

Research on this type of message content is limited. 

However, the results that are available suggest that 

this theme is less effective among youth than other 

message themes. 

Inconclusive: Athletic Performance

Research on this type of message content is limited. 

However, the results that are available suggest that 

messages with this theme are less effective among 

youth than other message themes. 

Not Effective: Individual Choice

Research indicates that the individual-choice message 

is not effective in preventing youth from using tobacco. 

MESSAGE FORMAT 

MESSAGE FORMAT 

Message format refers to the method or creative 

approach used to present message content to audiences. 

Although many formats have been used in tobacco 

use prevention ads, research data and campaign lessons compiled for this review focus on the three most 

commonly used:

• Testimonials—real people speaking about their 

losses, pain, and suffering due to the consequences 

of smoking.

• Graphic depiction—visual images showing the 

adverse health effects of smoking in novel, 

credible ways.

• Celebrities—well-known people from the entertainment, sports, or political fields presenting antitobacco messages.

Testimonials 

England

The Stephen and Rebecca testimonial ads evaluated in the 

England anti-smoking ad tracking survey received higher 

agreement among youth than adults that older people 

are not the only ones who suffer from smoking-related 

illnesses and that continuing to try to quit is important 

regardless of age (BMRB Social Research, 2002).

U.S./Massachusetts

A representative from Arnold Communications, the 

advertising agency that created the Massachusetts Pam 

Laffin and Rick Stoddard testimonial ad series, noted 

in an internal agency memo that real-life stories tend 

to resonate across multiple target audiences (Brogdon, 

oral communication, 2000). The agency learned 

through conversations with youth that the Pam Laffin 

ads, originally targeted to adult smokers, seemed to 

resonate well with teens because of Pam’s own youth 

and the startling photos in the ad of Pam before and 

after she developed emphysema. 

The Pam Laffin pre- and post-campaign telephone 

surveys for the Massachusetts 1997 ad tracking study 

found that 94% of youth aged 9–17 years who recalled 

the ad believed that it provided good reasons not to 

smoke. When responses from youth who had seen 

the ad were compared with responses from youth who 

could not recall seeing the ad, 16% more youth who 

had seen the ad reported believing that “smoking was 

not a way to look cool,” and 12% more agreed that 

“smoking was not a way to look and feel independent” 

(Massachusetts Department of Public Health, 1997). 

In the Janet Sackman ad, a former cigarette ad model 

who has lost her vocal cords to cancer describes the 

addictiveness of smoking and how she was misled by 

the tobacco companies she had once worked for as a 

highly visible spokeswoman. Massachusetts youth rated 

this ad as effective in evoking strong negative emotions 

about the effects of smoking in the Massachusetts Tobacco 

Surveys and longitudinal studies. Youth described this 

ad as sad and frightening, and they considered ads that 

evoke such emotions to be more effective than ads 

rated as funny or neutral (Biener, 2004). 

U.S./Arizona

In the Doesn’t Kill ad, teenagers report that their parents and friends had been told that tobacco would kill 

them, but this did not happen. When their parents’ 

and friends’ faces are revealed, the viewer sees their 

current health conditions caused by smoking-related 

diseases; for example, one father’s jaw and cheek have 

been removed, one mother has a stoma in her throat 

resulting from losing part of her larynx, and part of 
6 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

another woman’s mouth is missing. The Arizona 

TEPP media campaign evaluation results indicated 

that youth were more likely to remember the Doesn’t 

Kill ad than other ads reviewed in the research. In 

addition, significantly more respondents agreed that 

the Doesn’t Kill ad would make teenagers think about 

quitting smoking than any of the other ads or groups 

of ads (University of Arizona, 2000).

U.S./Multistate

The TRU multistate and University of North Carolina 

focus group studies found that ads that graphically, 

dramatically, and emotionally portrayed the serious 

negative consequences of smoking were rated as the 

most effective by participants in making them “stop 

and think about not using tobacco.” Three of the four 

most highly rated ads (Voicebox/Debi, Pam Laffin, and

Cowboy) used a testimonial format to deliver their messages. The real stories of personal loss and the impact 

on the smokers’ families were messages that youth 

reported identifying with, in part because virtually all 

of them knew someone who had died or suffered from a 

tobacco-related disease. Participants who had seen the 

ads also claimed that they would never want to be like 

the smokers in the ads who suffered physically from 

tobacco (Teenage Research Unlimited, 1999; University of North Carolina, 2001). 

U.S./Utah

The Utah Department of Health tobacco media campaign formative message research demonstrated that, 

of all the ads tested, testimonial-format ads illustrating 

the suffering caused by the health effects of using 

tobacco were most likely to interest and persuade 

youth (Neiger et al., 2002).

Graphic Depiction 

Australia

The developers of the Australian Every Cigarette is 

Doing You Damage campaign found new ways to show 

audiences exactly what cigarette smoking can do to 

the human body. The ads showed how tobacco-related 

diseases develop, presenting the viewer with previously 

unknown information about the health effects of smoking. The Australia national tobacco campaign surveys 

showed that the Artery ad achieved a higher rate of 

youth recall (73%) than the Lung ad (60%), which 

conveyed a message about a health risk, lung damage, 

with which smokers are more familiar. The Tumour ad, 

which showed how smoking can damage cells and lead 

to tumor growth, also achieved higher recall (64%) 

than the Lung ad (Hassard, 2000). 

U.S./Arizona

The Arizona prevention ads in-school evaluation was 

designed to evaluate the appeal and impact of emotion in anti-tobacco ad messages. The researchers 

tested a variety of ads that had been used in the state’s 

youth-targeted tobacco counter-advertising campaign. 

The ads were rated for their ability to elicit emotional 

reactions of disgust, humor, fear, and guilt. Ads rated 

as disgusting were perceived as most effective in causing these reactions; these ads had a strong element of 

graphic display, such as the repulsive characteristics of 

spit tobacco juice (Hendricks et al., 2001). 

Celebrities

U.S./National

The CDC-sponsored National Quantitative Copy Test 

compared two ads, Models and Cowboy, that featured 

celebrities. The Models ad, which featured the women’s U.S. Olympic soccer team, had low recall among 

the target audience of females aged 13–19 years. 

The testimonial ad Cowboy, which shows the suffering from smoking-related disease of the actor who 

played the Marlboro Man, had much higher recall 

levels than the Models ad across all audiences tested. 

The researchers believed that this was because the ad 

evoked more emotion and presented realistic, negative 

consequences of smoking (Gutierrez, personal communication, 1998). 

Celebrities can help build awareness by generating media coverage at events and news conferences 

(Zollo, 1999). In addition, celebrities can attract the 

attention of policy makers to the importance of youth 

tobacco use prevention. 

Celebrity personal testimonial ads involve both a 

testimonial and a celebrity format. Examples of ads 

using celebrities include ads featuring U.S. supermodel 

Christy Turlington, who quit smoking after many 

attempts and who lost her father to lung cancer caused 

by smoking, and Rick Bender, a U.S. semi-professional 

baseball player whose jaw and cheek were removed 

because of cancer caused by chewing tobacco.
MESSAGE FORMAT 

The most credible celebrity spokespeople for tobacco 

counter-advertising messages seem to be those who 

have experienced firsthand the effects of tobacco use, 

such as former smokers who speak from experience 

about the negative health consequences of smoking 

or the difficulty of quitting or who have lost a family 

member because of tobacco use. 

Several potential concerns must be considered before 

using celebrities as spokespeople in youth countermarketing campaigns. Youth are media savvy and 

highly aware that celebrities are often paid to tout 

product messages, potentially compromising celebrities’ credibility (Zollo, 1999). In addition, some program managers have found that in their desire to be 

involved in the development of the advertising, celebrities may overestimate their value and influence and 

may direct a campaign’s communication in ways that 

are not supported by best practices. Furthermore, a 

campaign may lose its credibility if a celebrity smoker 

who quits begins using tobacco again, abuses another 

substance (such as drugs or alcohol), or becomes 

involved in a scandal (Johnson, 1992; Zollo, 1999). 

Several campaigns have benefited when people who 

were not famous presented personal testimonies in 

anti-tobacco ads and became celebrities in their hometowns, states, or countries. Pam Laffin, a U.S./Massachusetts spokeswoman who suffered from smoking-related 

illnesses, talked to youth audiences around that state, 

testified at legislative hearings in several states, and 

was featured in an MTV documentary before her 

death in October 2001. Debi Austin, the smoker who 

lost her voice box to cancer, was asked to carry the 

Olympic torch in her home state of California. 

Conclusions

Good evidence indicates that testimonials are an 

effective ad format for youth. They provide a strong 

emotional appeal because they are based on stories of 

real people who have suffered from the consequences 

of their tobacco use or the tobacco use of loved ones. 

This finding is consistent with an extensive body of 

research in communication, psychology, and advertising about the impact of testimonial messages on audiences (Dillard and Pfau, 2002; Slater, 2002). 

Although less research is available on their effectiveness, graphic depictions of the health effects of smoking also are an effective format with youth audiences. 

As with testimonials, strong graphic displays can 

induce strong negative emotional reactions (e.g., disgust, fear), which probably contributes to their effectiveness. Graphic displays, however, must be credible 

and based on health information that was previously 

unknown or unconsidered to influence viewers. 

Quantitative evaluation data are lacking, but program 

managers have learned that celebrities can increase 

awareness of a campaign message. This format must be 

used with caution, however, because credibility concerns and unexpected revelations of celebrity misdeeds 

can damage the effectiveness of ad campaigns using 

celebrities (Zollo, 1999). The most effective celebrity 

ads seem to be those that use a testimonial format, 

based on the celebrity’s personal negative experiences 

with tobacco. 

MESSAGE TONE, FREQUENCY, AND REACH 

Message tone refers to the overall manner in which 

messages are delivered to and perceived by audiences. 

To a large extent, message tone is based on a number of perceived characteristics of message text and 

delivery. Message tone can have a strong impact on 

a viewer’s reaction to an ad. Tone can also make ads 

emotionally draining and therefore difficult to continue watching. 

Adequate media presence that ensures sufficient audience exposure to messages for substantial periods of 

time can be as important to ad effectiveness as the 

content and execution of the campaign’s ads. Awareness of messages is often directly attributable to the 

media presence—a combination of the length of time 

ads are shown, the frequency of campaign messages, 

and the percentage of the target audience that they 

reach (Snyder, 2001). 

Tobacco use prevention ads are aired in distinct cultural 

and media environmental contexts that can strongly 

influence their potential effects on audiences. For 

example, youth living in tobacco-growing communities 

may reject or ignore a tobacco counter-advertising message because smoking is an accepted behavior among 

their families and friends; in contrast, youth living in 

communities with strong tobacco control programs may 

have already been educated on the dangers of tobacco 

use and the industry’s role in marketing tobacco products 

in ways that appeal to youth and therefore may be more 

inclined to accept anti-tobacco messages. As a result, 

the same messages could be received very differently by 

each audience. 

How ads are executed (designed, edited, and produced) 

plays an important role in advertising effectiveness 

because potential effectiveness can be compromised 

by executing ads in ways that hinder communication 

or persuasiveness (Stevens, California Department of 

Health Services, oral communication, November 2000; 

Connolly, formerly of the Massachusetts Tobacco Control Program, oral communication, November 2000). 

Humorous Versus Sad or Serious Tone 

U.S./Utah 

Formative research conducted by the Utah Department of Public Health showed that humorous ads got 

the attention of Utah youth, but these ads were not 

as persuasive as other ads tested with more serious and 

sad themes (Murphy, 2000).

U.S./Massachusetts

Researchers evaluated the role of message tone in 

U.S./Massachusetts anti-tobacco ads using the Massachusetts tobacco surveys. In 1997, 100 independent 

Massachusetts youth judges rated a group of antitobacco television ads for perceived effectiveness. The 

youth characterized the ads as sad or frightening (Pam 

Laffin, Janet Sackman, Happy Birthday, and Cowboy), 

funny (Camel and Dinner), or neutral (Monica and

Models). The ads classified as sad or frightening were 

rated by the youth judges as more effective in causing them to think seriously about whether to smoke 

cigarettes than ads rated as funny or neutral (Biener, 

2000). Some of the very sad and serious testimonial 

ads that aired in U.S./Massachusetts were perceived 

as too emotionally draining and therefore difficult to 

continue watching by some viewers (Brogdon, oral 

communication, October 2001). 

MESSAGE TONE, FREQUENCY, 

AND REACH
0 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

U.S./Arizona 

The Arizona prevention ads in-school evaluation 

tested the appeal and effect of emotion on the impact 

of anti-tobacco messages conveyed in ads aired in 

Arizona’s youth-targeted tobacco counter-marketing 

campaign. The ads were rated for their ability to elicit 

emotional reactions. Ads rated as humorous, although 

well liked by youth, were perceived as less effective 

than other ads, especially those with more serious or 

sadder tones (Hendricks et al., 2001). 

Preachy Tone

Scotland

Scottish youth reacted negatively to the tone actors 

used in the tobacco industry’s European youth smoking prevention campaign. Describing the actors as 

“snobby,” “bitchy,” and “too perfect,” participants in 

the Scotland MTV YSP Ads Focus Groups said that 

they found it difficult to identify with, and relate to, 

these ads (Devlin et al., 2002).

U.S./Florida and U.S./Minnesota

Programs in Florida and Minnesota, which featured 

industry deceptive-practices ads developed with the 

assistance of youth, found that ads needed to avoid 

“preaching” to audiences, telling youth how to think, 

feel, or act with respect to tobacco use (Ergo International, 2001; Sly, 1998). Because avoiding preachy 

messages was considered critically important to the 

Minnesota program managers, they included a measure of “preachiness” in the Target Market campaign 

evaluations. A quantitative study (a “brand audit”) 

was designed to measure youth perceptions of the 

Target Market brand. The brand audit, conducted 

after the initial airing of Target Market ads, found that 

46% of viewers who recalled the ads described them as 

“preachy,” and this was considered a negative tone by 

youth (Ergo International, 2001). Program managers 

in Florida had a similar experience, reporting that ads 

featuring youth questioning authority became tiresome to youth audiences over time (Sly, 1998).

U.S./Mississippi and U.S./North Carolina

Formative message research by the Partnership for a 

Healthy Mississippi found that preachy messages are 

viewed cynically by youth (Partnership for a Healthy 

Mississippi, 2001). Youth focus-group participants 

warned the creative team that developed the tobacco 

use prevention ads in Mississippi against using a 

preachy tone in presenting tobacco information because 

this would cause them to ignore the message. As a 

result of these warnings, the Mississippi team developed ads conveying indisputable facts about tobacco 

that avoided telling viewers what to do. Researchers 

attending the University of North Carolina antismoking ads focus groups found that ads with adultdriven messages (e.g., featuring celebrities pitching a 

healthy lifestyle) were not viewed as credible by youth 

participants, partly because they contained an element 

of preachiness (University of North Carolina, 2001). 

Although humorous ads may be appealing to youth, 

youth repeatedly rated ads as more effective in making 

them consider not smoking when the ads had a more 

serious or sad tone than when they had a humorous 

tone. This does not mean that ads with an ironic or 

sarcastic tone cannot be effective; these are common 

features of tobacco industry deceptive-practices ads. 

Ads with a preachy tone, especially those featuring 

adults telling youth what to do, should probably be 

avoided because youth audiences seem to especially 

dislike this tone. 

Ad Frequency, Reach, and 

Duration

Mass media are the most efficient and effective means 

of reaching the youth audience (Zollo, 1999). Mass 

media generally include television, radio, print, direct 

mail, Internet, and billboard or other outdoor advertising. The mass media provide an important impetus 

for building awareness and understanding that helps 

other program elements effectively influence the 

target audience. Program developers have learned 

that using broadcast messages to increase awareness of 

tobacco issues can increase the impact of school- and 

community-based tobacco use prevention curricula 

(Flynn et al., 1995). 

For example, U.S./Minnesota’s youth tobacco use 

Target Market prevention program experienced a significant drop in awareness (from 85% to 57%) among 

youth aged 12–17 years surveyed just 6 months after 

annual funding was reduced from $23.7 million to 

$4.6 million in 2003, eliminating all broadcast presence (CDC, 2004). Over the same period, the percentage of adolescents susceptible to smoking (based 
MESSAGE TONE, FREQUENCY, AND REACH 

on the number of friends and family members who 

smoke and the youths’ attitudes toward tobacco and 

tobacco companies) increased from 43% to 53%. 

Achieving media levels necessary to reach a large 

percentage of audiences with messages over long time 

periods is challenging. A meta-analysis of health 

campaigns in the United States found that, on average, 

only 40% of community-based intervention target 

audiences were exposed to the messages of these 

campaigns (Snyder, 2001). Insufficient media presence 

may explain why some large-scale experimental media 

campaigns have had little or no impact on behavior 

change (Hornik, 2002). Exposure to advertising needs 

to be sufficient to influence awareness, knowledge, 

attitudes, and behaviors. Even ads with strong and 

effective content that are delivered with an appropriate tone will not be effective unless a sufficient percentage of the target audience sees these ads regularly 

over a long period of time (Hornik, 2002). 

A strong, consistent media presence is possible when 

media plans follow well-established industry guidelines 

developed over years of experience in evaluating media 

placement results for hundreds of products and services. 

These guidelines, which continually evolve over time 

as audience viewing habits change, are based on reach 

(estimated percentage of target audience exposed to 

ads), frequency (estimated number of times target audience members are exposed to the ads during a certain 

time period), and duration (length of time that a campaign continues to broadcast ads) of exposure. 

Jeff McKenna, former Chief of the Health Communications Branch of CDC’s Office on Smoking and 

Health for 12 years, developed recommendations 

regarding the reach, frequency, and duration of ads 

based on the scientific and advertising literature and 

CDC’s experience in working with U.S. states and 

media experts on tobacco counter-marketing campaigns 

for adults and youth. Because these recommendations 

are based on experiences in the United States, they 

may not be applicable in all countries. The recommendations are:

• Ads should reach approximately 75%–85% of the 

target audience each quarter during the campaign.

• Managers should air ads as frequently as their budgets allow once this level of reach is achieved. 

• Four-week target rating points (TRPs), which are 

the product of reach times frequency, should average 400 TRPs or more during the campaign’s introductory phase and 200 TRPs or more after that. For 

example, if during the introductory phase 80% of 

the target audience is exposed to an ad an average 

of five times per 4-week period, the 4-week TRPs 

would be 400 (5 x 80), which should be sufficient. 

• During the first 12 months of a campaign, ads 

should be aired as often as possible to establish the 

campaign themes and brand identity (if relevant). 

• Ads should be aired for at least 6 months to affect 

awareness, 12–18 months to have an impact on 

attitudes, and 18–24 months to have an impact 

on behavior. 

Note: A more in-depth discussion of guidelines for effective media 

planning can be found in Advanced Calculations and Measurements, 

Advertising Media Planning (Baron et al., 2002).

Tobacco companies spend billions of dollars on advertising each year, altering their marketing and advertising 

strategies and their messages in response to changing 

market conditions (Ling and Glantz, 2002). To counter 

the effects of this heavy marketing and to continue to 

influence target audience attitudes and behaviors over 

time, tobacco use prevention advertising must be continuously present in target audiences’ minds. 

Experienced media planners can provide valuable 

guidance in avoiding the pitfalls of spending too little 

money and reaping no benefit from messages heard 

sporadically by small numbers of people. In the case 

of extremely limited funds, program planners may 

need to pursue other interventions in addition to mass 

media, such as grassroots advocacy, to achieve desired 

environmental and policy changes. 

Case histories showing the lessons learned from media 

campaigns in U.S./California, U.S./Massachusetts, 

and U.S./Florida, as well as a national U.S. campaign 

made possible through compliance with the Fairness 

Doctrine in the late 1960s and early 1970s, are included 

in Appendix 1. All of these campaigns involved a 
42 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

strong media presence over an extended period of 

time, and they are good examples of programs that 

changed attitudes and influenced behaviors, according 

to a variety of measures. Sufficient spending for ad 

placement and carefully developed creative messages 

contributed greatly to the success of these campaigns. 

When funding was reduced, limiting or eliminating 

media placement, campaign effectiveness was diminished (Balbach and Glantz, 1998; Abt Associates, 

1999; Sly et al., 2002).

Ensuring sufficient audience exposure to messages may 

be as important as developing effective ads. Audiences 

must be exposed to messages enough times over long 

enough periods to be influenced by them. The results 

of research on tobacco counter-marketing campaigns 

support well-established media industry guidelines 

concerning the need to maintain a strong and consistent presence in broadcast media to achieve program 

goals. A long-term commitment to communicating 

counter-advertising messages through the mass media 

is essential to the long-term success of any campaign 

to prevent youth tobacco use.

Integration of Message 

Elements

Outstanding message content with high emotional 

appeal is not enough. Every aspect of an ad’s development (format, tone, actors, setting, pace, etc.) must 

be done well. Airing several ads over the same time 

period, rather than just one ad (even one that has 

been found to be effective), is also essential to keep 

messages fresh and to prevent the ads from becoming 

so familiar to audiences that they do not pay attention 

to them (Stevens, California Department of Health 

Services, oral communication, November 2001; Connolly, Massachusetts Tobacco Control Program, oral 

communication, November 2001). 

It is difficult, if not impossible, to distinguish the 

effects of each message element (content, format, 

tone) and environmental influence (Farrelly et al., 

2003; Wakefield et al., 2003). 

Two recent reviews of the scientific literature on media 

campaigns to prevent youth smoking highlight the 

need for further study of the many elements involved 

in creating an effective mass media campaign targeting 

youth. Farrelly et al. (2003) cited the need for research 

on the effects of message type, emotional content, and 

production values simultaneously to help determine 

precisely which campaign elements work most effectively to reduce smoking. These researchers pointed out 

the need to evaluate message effectiveness over time—

messages currently known to be effective may wear 

out or only delay the onset of smoking. The review by 

Wakefield et al. (2003) shows that, although some campaigns have reduced smoking prevalence among youth, 

no single recipe appears to be the definitive approach. 

These researchers suggest that inconsistent findings 

within and between campaigns may be due to the difference in methodologies, the fact that tobacco counteradvertising messages compete with many other broadcast 

messages for attention, the role of creative production 

factors, the extent of audience exposure to messages, 

message wear-out, and audience sophistication. 
Evaluation is critical to the effectiveness of tobacco 

control media campaigns (Atkin and Freimuth, 2001; 

Valente, 2002). But in too many cases, no evaluation 

is conducted, evaluation is done only as an afterthought, or evaluation is underfunded and thus not 

conducted properly or sufficiently. Tobacco control 

program managers need evaluation data to gauge 

whether campaign elements are being executed as 

planned and whether the target audience is seeing, 

hearing, and remembering the tobacco countermarketing messages. Evaluation is also needed to 

assess whether messages are affecting audience knowledge, attitudes, and beliefs, and ideally, whether the 

messages are contributing to behavior changes. 

Evaluation must be planned from the beginning of 

any media campaign effort because it provides valuable information on how well campaign elements are 

being developed, how well the campaign is proceeding 

(while in progress), what the outcomes are over time, 

and whether changes to the campaign are needed. 

In addition, funders of tobacco counter-marketing 

campaigns generally require data to show that their 

funds were used to produce the desired effect. Without 

evaluation data, program planners will find it difficult 

to justify their tobacco counter-marketing activities. 

The primary types of evaluation that should be 

included in media campaign planning include formative research and evaluation, process evaluation, and 

outcome evaluation. Examples of all three types of 

evaluation were reviewed in this document. 

Formative research and evaluation are used to help 

develop advertising and other campaign materials. 

Formative research is typically qualitative and might 

include focus groups, observations, or one-on-one 

interviews. This type of research is used to discover key 

target audience insights that can be used to develop 

engaging and persuasive ad concepts. Once the ad 

concepts are developed, formative evaluation can be 

used to assess whether the proposed content, format, 

and tone of the ad concepts communicate the desired 

message clearly and persuasively to the target audiences. However, ads found to be successful in formative evaluation in one country or one region will not 

necessarily be successful elsewhere. (Note: Formative 

research and evaluation findings are reviewed under 

the “message research” sections of Chapter 6.) 

Process evaluation helps managers determine whether 

a campaign’s elements have been executed as planned. 

One typical use of process evaluation in a mass media 

campaign is to determine the level of audience exposure 

to ads during the period they were aired. Data from 

process evaluation are important not only for assessing exposure to ads, but also for identifying which ads 

are most or least remembered by, and compelling to, 

target audiences. This feedback can be used to make 

adjustments to certain ads or to the mix of ads used in 

the rest of the campaign.

For youth tobacco use prevention campaigns, process 

evaluation regarding the execution of the mass media 

placement plan is typically conducted in one of the 

following ways: 

• Estimates of the size and makeup of the viewing 

audiences (often available from television and 

radio stations based on ratings for shows) and the 

number of times ads aired during a given period.

• Surveys of audience members, often by telephone, 

during or after an ad campaign to assess audience 

E VALUATION 

EVALUATION 
44 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

awareness of the ads. Typically, questions assess 

participants’ potential level of exposure to ads, 

confirmed awareness of ads, and main message 

recall. Questions also address how engaging or 

persuasive the ads were to the viewers.

Outcome evaluation gauges changes in audience 

knowledge, attitudes, or intended or actual behavior. 

It is used to assess the effects of one ad or a whole 

campaign on a target audience. Achieving relevant 

outcome measures, such as increasing the percentage 

of the target audience that reports a strong commitment not to begin smoking or reducing the percentage 

of audience members reporting previous 30-day 

tobacco use, is the ultimate goal for many youth 

tobacco use prevention media campaigns. 

Program managers recognize that outcome evaluations 

have some limitations. Behavior change at the population level is difficult to achieve over short periods of 

time and may not become evident for many months 

or years after a campaign begins. This underlines the 

need to continue to measure outcomes after a campaign ends. In addition, any observed behavior change 

cannot necessarily be attributed to a single tobacco 

control program element, such as a mass media advertising campaign.
ACKNOWLEDGMENTS 

ACKNOWLEDGMENTS

The authors wish to acknowledge the support and 

contributions of the tobacco control program managers and researchers in many countries, listed below, 

who so willingly provided their data and insights for 

this review. We thank Jeff McKenna, former Chief 

of the Health Communication Branch in the Office 

on Smoking and Health (OSH) at the Centers for 

Disease Control and Prevention, for his thoughtful 

insights and support. We also thank Terry Pechachek, 

PhD, Associate Director for Science at OSH, and 

Corinne Husten, MD, MPH, Acting Director of OSH, 

for their thoughtful comments and suggestions.

Jane Allen, MA/American Legacy Foundation, Washington, 

DC, USA

Eusebio M. Alvaro, PhD, MPH/Claremont Graduate University, 

Tucson, AZ, USA

Lois Biener, PhD/University of Massachusetts Boston, USA

Cindy Borgen/Minnesota Department of Health, St. Paul, USA

Mary Brogden/formerly with Arnold Communications, Boston, 

MA, USA

Greg Connolly, PhD, DDS/Harvard School of Public Health, 

Cambridge, MA, USA

Bill Coyne/Department of Health, London, England

Elinor Devlin/University of Strathclyde, Glasgow, Scotland

Matthew C. Farrelly, PhD/RTI International, Research Triangle 

Park, NC, USA

Kurt Fowler/Department of Health Services, Sacramento, 

CA, USA

Danielle Frissen/Defacto, The Hague, Netherlands

Stanton A. Glantz, PhD/University of California, 

San Francisco, USA

Anne Hafstad, PhD/National Institute of Public Health, 

Oslo, Norway

Kate Hassard/Anti-Cancer Council of Victoria, Canada

Natalie Lacey/Ipsos-Reid, Toronto, Canada

Anne Lavack, PhD/University of Regina, Canada

Mary Lee/Partnership for a Healthy Mississippi, Jackson, USA

Claudia Machado/Crispin Porter & Bogusky, Miami, FL, USA

Tim McGloin, MSPH/University of North Carolina at Chapel 

Hill, USA

Anne Miller/formerly with Arnold Communications, Boston, 

MA, USA

Cornelia Pechmann, PhD/University of California, Irvine, USA

Barbara Pizacani, PhD, MPH/Department of Human Services, 

Portland, OR, USA

Krzysztof Przewozniak, MA/Health Promotion Foundation, 

Warsaw, Poland

Kim Sanderson/Consultant with Many Hats, South Surrey, 

British Columbia, Canada

David F. Sly, PhD/University of Miami, FL, USA

Colleen Stevens, MSW/Department of Health Services, 

Sacramento, CA, USA

Paula Traffas/Texas Department of Health, Austin, USA 

Melanie Wakefield, PhD/Centre for Behavioral Research in 

Cancer, Victoria, Canada

John K. Worden, PhD/University of Vermont, 

Burlington, USA

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U.S./California

When Proposition 99 was enacted, funds were set 

aside for the development and implementation of a 

statewide tobacco counter-marketing campaign. The 

first wave of California’s media campaign ran from 

April 1990 through September 1991 and cost $28 million. The media placement plan followed the generally recognized principles outlined in this report and 

achieved the recognized industry standards for media 

reach, frequency, and duration. 

The California Tobacco Survey documented a 17% 

drop in the percentage of adults smoking during this 

period, which was attributed to the effects of a tax on 

tobacco products, educational efforts, and the media 

campaign (Balbach and Glantz, 1998). Before California’s media campaign, cigarette consumption in the 

state had dropped by 45.9 million packs per year from 

1981 to 1988. This rate of decline tripled to 164.3 

million packs per year during the tobacco counteradvertising campaign, but decelerated to 19.4 million packs per year when the mass media portion of 

the campaign was withdrawn in 1992 (Balbach and 

Glantz, 1998). 

A lawsuit by the American Lung Association restored 

funding for the media campaign from May 1992 

through June 1993. The 1994–1995 budget was 

$12 million, but funding for the campaign was again 

reduced in 1995–1996, when only $6.5 million was 

spent. The reduced spending levels affected the 

intensity of the campaign, and the increase in adult 

smoking prevalence from 17.3% in 1994 to 18.4% in 

1998 was attributed to the inadequate levels of media 

presence (Balbach and Glantz, 1998). 

Per-capita spending on tobacco counter-advertising 

and promotions continued to decline in California 

from $5.73 in 1997–1998 to $3.42 in 1999–2000 

(California Department of Health Services, 2002). 

During this period, overall smoking rates remained 

stable and media spending was below recommended 

CDC levels. At the same time, tobacco industry percapita spending increased from $24.30 in 1997–1998 

to $34.01 in 1999–2000 (California Department of 

Health Services, 2002). 

Evaluators monitoring trends in California cigarette 

consumption and adult smoking prevalence from the 

early 1980s concluded that a substantial proportion of 

the decrease in cigarette consumption was attributable 

to the paid media campaign. The overall evaluation 

provides evidence that California’s tobacco countermarketing campaign was responsible for a substantial proportion of the observed declines in cigarette 

consumption and adult smoking behavior. The use of 

multiple data sources and evaluation approaches lends 

further support to this conclusion (Pierce et al., 1998; 

Glantz, 1993; Hu et al., 1995).

U.S./Massachusetts

The 1994–1998 Massachusetts tobacco control 

program budget averaged just under $40 million 

annually, with an annual media campaign budget 

of approximately $13 million in the initial launch 

period. The media budget declined to $11.09 million in 1999. Media placement planning followed the 

general guidelines provided in Chapter 8 of this report 

for reach, frequency, and duration, as recommended 

by the advertising agency of record, Arnold Communications. During this time, total per-capita cigarette 

purchases in Massachusetts declined by approximately 

APPENDIX 

APPENDIX

CASE HISTORIES OF 

CAMPAIGNS WITH EFFECTIVE 

MEDIA PRESENCE

APPENDIX

1
52 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

30%. Youth smoking prevalence declined slightly from 

1995 to 1997 and the smoking rate among Massachusetts 

high school students declined again from 1997 to 

1999, even though national rates were rising (Abt 

Associates, 1999).

U.S./Florida 

The American Legacy Foundation’s Media Tracking 

Survey results indicated that the more truthsm ads a 

youth viewed, the less likely he or she was to become 

a smoker. In the national tracking study, the Legacy 

Foundation surveyed Florida youth more frequently 

than youth in other states to fully examine the effect 

of their longer exposure to tobacco counter-advertising 

messages there, since Florida’s Truth campaign had been 

conducted for several years before the national truthsm

campaign was launched (RTI International, 2002).

Researchers evaluated the Florida Truth campaign by 

documenting the number of different ads that young 

respondents could describe. They found that the likelihood that a young nonsmoker would remain a nonsmoker increased with the number of Florida Truth 

anti-tobacco ads viewed. The researchers suggested 

that another valuable measure would be the number 

of times each ad had been viewed (Sly et al., 2002).

Although the Florida Truth campaign was adequately 

funded in its first year, it suffered funding cuts in subsequent years. During the well-funded year, smoking 

rates dropped 40% among middle school students and 

18% among high school students. Once funding was 

cut, changes in smoking prevalence among youth leveled off. However, when the Legacy national truthsm

campaign was launched (using a message focus similar 

to that of the Florida Truth campaign), it may have 

been able to compensate for the drop in Florida Truth 

campaign media levels (Sly et al., 2002).

U.S. Fairness Doctrine Campaign

A valuable field example of the power of sustained 

media campaigns is offered by the Fairness Doctrine 

campaign in the United States from 1967 to 1970. This 

campaign was the result of an agreement between the 

broadcast industry in the United States and the U.S. 

Federal Communications Commission, the agency that 

regulates the use of broadcast air waves. According to 

this agreement, the television networks were to donate 

placement of one anti-tobacco message as a public 

service announcement (PSA) for every three protobacco ads paid for by the tobacco industry. As a 

result, sufficient levels of reach, frequency, and duration 

were achieved nationally for the first time to produce 

a high level of anti-tobacco message awareness. 

The campaign was associated with declines in adult 

and teen smoking rates in the United States from 

1968 to 1970 (U.S. Department of Health and 

Human Services, 1989). Smoking prevalence for all 

U.S. adults was 42.6% in 1966, the year prior to the 

Fairness Doctrine ruling, and had declined to 37.4% 

by 1970 when the PSAs ended. Per-capita cigarette 

consumption declined from 4,280 cigarettes in 1967 

to 3,985 cigarettes in 1970, a relative decline of 7% 

(U.S. Department of Health and Human Services, 

1989). During the period of anti-tobacco PSAs, teenaged smoking declined by 3% (Lewit et al., 1981). 

Per-capita cigarette sales increased by 4% from 1971 

to 1973 after the Fairness Doctrine PSAs ceased, rising from 3,985 to 4,148 cigarettes (U.S. Department 

of Health and Human Services, 1989). 

APPENDIX

1
APPENDIX 

APPENDIX

LIST OF ADVERTISEMENTS BY 

COUNTRY AND U.S. STATE

APPENDIX

2

Note: Some ads mentioned in this document were developed for research purposes only and were not part of an ongoing media campaign. 

These ads are listed under the relevant study in the research summary table (Appendix 3). 

Australia

Campaign Every Cigarette Is Doing You Damage

Origin Country Australia, aired nationally

Sponsoring Organization National Tobacco Campaign

Strategy/Objective

Motivate smokers to try to quit by:

• Putting quitting on today’s agenda.

• Showing damage in a new way.

• Tying damage to the act of smoking.

Primary Target Smokers aged 18–40 years 

Message Every cigarette you smoke causes damage, so the sooner you quit, the better off you’ll be.

Executions

Each spot is an empathetic portrayal of a slightly awkward but typical moment in the 

eeryday life of a smoker. In some executions, the iewer journeys with cigarette smoke as 

it is inhaled, traeling down into the trachea and lungs, where the smoke begins its deadly 

work. In other executions, other facts are shared and other body parts are emphasized.

• Artery—Fatty deposits, squeezed from the aorta. 

• Lung—Emphysematous damage. 

• Tumour—The recently discoered mechanism by which smoking damages the 

p tumor suppressor gene. 

• Brain—The mechanism of smoking-related strokes. 

• Eye—The impact smoking can hae on eyesight and the fact that smoking is one 

of the leading causes of blindness.

• Tar Lung—The amount of tar that collects in a smoker’s lungs oer time.

• Call for Help—Cessation help line.

Elements TV, radio, outdoor, print (including poster), and bus and tram ads; Web site www.

quitnow.info.au; fold-out information sheets; launch events

Duration June 1997–January 1999

Media Weights
 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

Canada/British Columbia

Campaign Name Critics’ Choice Program (Ads produced in other countries were compared to the 

ad produced in Canada.)

Origin Country Australia, British Columbia, Canada, U.S./American Legacy Foundation, U.S/Arizona, 

California, Massachusetts

Sponsoring Organization British Columbia Ministry of Health

Strategy/Objective Motiate youth to reject smoking by engaging them in discussion about antitobacco messages

Primary Target Middle school and high school students

Message

The messages aried. For example, some ads focused on social consequences, some 

on stories of the impact of smoking on smokers and their families, and some on 

industry deceptie practices.

Executions

The executions tested or aired that are mentioned in this document are:

• Voicebox/Debi—See description under U.S./California ads.

• Artery—See description under Australia ads.

• Stroke—See description under Australia ads.

• Tar Lung—See description under Australia ads.

• Body Bags—See description under U.S./American Legacy Foundation ads.

• Scary Math—The number of Canadians affected by smoking-related illnesses.

Elements In-school curriculum, TV

Duration After the ads were tested in the Critics’ Choice in-school program, one ad each year 

was selected to air in British Columbia. Durations of ad broadcasts are unknown.

Media Weights Unknown
Canada/British Columbia

Campaign Name Protecting Kids from Tobacco

Origin Country British Columbia, Canada; U.S./California, Massachusetts

Strategy/Objective Motiate adults and youth to reject tobacco

Primary Target Primary target: Adults; Secondary target: Youth

Message Smoking has consequences that cause pain and loss to both smokers and their loed ones. 

Executions

Examples are listed below:

• Voicebox/Debi—See description under U.S./California ads.

• Pam Laffin—See description under U.S./Massachusetts ads.

• Janet Sackman—See description under U.S./Massachusetts ads.

• Victor Crawford—A former lobbyist for the tobacco industry says that tobacco 

companies target children because they know that 0% of smokers start as 

children. He then apologizes for his role, and the tag reeals that he died of 

throat cancer.

• Scary Math—Discusses the number of British Columbians affected by 

tobacco-related illnesses. 

Elements In-school curriculum, youth adisory committee and network, 

posters, magazine ads 

Web site, TV ads, 

Duration June –00

Media Weights Unknown

Canada/Ontario

Campaign Name Secondhand Smoke Educational Campaign (An ad produced outside Ontario 

was aired with ads produced in Ontario.)

Origin Country Ontario, Canada

Sponsoring Organization Ontario Ministry of Health (managed by Heart and Stroke Foundation and Ontario 

Lung Association)

Strategy/Objective Educate the general public about the dangers of secondhand smoke to build 

support for clean indoor air policies

Primary Target Adult oters and opinion leaders

Message Secondhand smoke can endanger those you loe and care about.

Executions

• 

• 

• 

Victim/Wife—See description under U.S./California ads.

Don—Description not aailable.

Bernice—Description not aailable.

Elements TV, radio ads

Duration April–July 000 and December 000–March 00

Media Weights Two TV flights lasting 6 weeks each

APPENDIX 

APPENDIX

2
56 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

United Kingdom/England

Campaign Name Testimonials

Origin Country England

Strategy/Objective Encourage smokers to quit by showing emotional pain of smokers and their families 

due to smoking-related illness and death

Primary Target Adult smokers

Message

Smoking has consequences that cause pain and loss to both smokers and the nonsmokers who care about them. The implied message is that smokers should quit. The 

ads were tagged with a toll-free quitline number.

Executions

Each execution was a real-life testimonial of a smoker or nonsmoker who had suffered 

from the consequences of smoking or losing someone to a smoking-related illness.

• Stephen—A young man describes his illness caused by smoking.

• Rebecca—A young woman describes the changes in her father due to his illness 

from smoking.

• Christy Turlington—An American supermodel talks about losing her father to lung 

cancer 6 months after he quit smoking. She also shares how difficult it was for her 

to quit but iews it as her biggest accomplishment.

• Byron, Colleen, Kay—Testimonials.

• Pharmacist—Asian chemist talks about using nicotine replacement therapy and 

refers the iewer to an undertaker standing nearby pointing out the alternatie to 

not quitting, death.

• Relationships—Family of smokers who hae suffered smoking-related problems.

• Facts—The number of people who die from smoking-related illnesses; 

proides quitline phone number.

Elements TV, radio, and print ads

Duration January–March 

Media Weights Unknown
APPENDIX 

APPENDIX

2

Finland

Campaign Name Youth-Targeted Campaign Within North Karelia Project

Origin Country Finland

Sponsoring Organization National Public Health Institute

Strategy/Objective Motiate youth to reject smoking by helping them resist social pressures to smoke

Primary Target Youth

Message You can quit too; you can resist smoking in social situations.

Executions

TV programming showing real-life experiences of North Karelians as they stopped smoking.

School and community programs focused on building skills to resist smoking in 

social situations.

Elements School and community-leel programs, TV programming, adult cessation programs

Duration –

Media Weights – TV shows oer the years, 0– minutes each
58 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

The Netherlands

Campaign Name “. . . but I don’t smoke.”

Origin Country The Netherlands

Sponsoring Organization DEFACTO

Strategy/Objective Encourage youth to be nonsmokers by presenting nonsmokers in a positie light

Primary Target Youth

Message

Nonsmokers can be cool, edgy, and rebellious.

to be cool.

Young people do not need to smoke 

Executions

• Restaurant—Teenaged waiter,tired of requestsfor different itemsfrom older woman 

in restaurant,seres her urine in a glass.

• Classroom—Teenaged boy burps in front of an entire classroom of students,

including the teacher.

• Auto Shop—Teenaged girls see auto mechanic working under a car and grab him 

in the crotch.

• Home—Teenaged boy drinks milk directly from the carton and then punches his 

father when his father irritates him.

• Game Show—Two teenaged girls spell names of genital organs and other 

sexually related words in a simulated game show.

• Bathroom—Teenaged boy makes drunk, obnoxious man next to him in bathroom 

fall into urinal.

• Car—Teenaged boy buys sexy women’s underwear and places it in his father’s car 

where his mother finds it and is horrified.

Each execution ends with the teen saying, “. . . but I don’t smoke.”

Elements TV ads

Duration Unknown

Media Weights Unknown
APPENDIX 2 59

APPENDIX

2

Norway

Campaign Name Provocative Appeals Campaign

Origin Country Norway

Sponsoring Organization Cancer Registry of Norway; Research Center for Health Promotion, Uniersity of 

Bergen; Norwegian Women’s Public Health Association

Strategy/Objective Motiate youth, particularly girls, to reject smoking through proocatie appeals

Primary Target Teenaged girls (–); Teenaged boys and girls ()

Message

: Girls must be stupid because they know how bad smoking is for them but 

they still smoke.

: Smoking means lack of self-control and it conflicts with enironmental concerns.

: Smoking means a lack of success in education and work.

Executions One TV ad was produced and aired each year; print ads and posters were also deeloped.

Elements TV, moie, and full-page newspaper ads; school posters

Duration –

Media Weights Each TV ad was aired 6 times oer  weeks; each newspaper ad ran once in each of 

fie newspapers; ,0 posters were sent to schools and youth organizations each year.

Poland

Campaign Name Every Cigarette Is Doing You Damage

Origin Country Australia

Sponsoring Organization Health Promotion Foundation

Strategy/Objective

Motiate smokers to try to quit by:

• Putting quitting on today’s agenda.

• Showing damage in a new way.

• Tying damage to the act of smoking.

Primary Target Adult smokers

Message Eery cigarette you smoke causes damage, so the sooner you quit, the better 

off you’ll be.

Executions

• 

• 

• 

• 

Artery—See description under Australia ads.

Stroke—See description under Australia ads.

Tar Lung—See description under Australia ads.

Brain—See description under Australia ads.

Elements TV ads and accompanying posters were part of comprehensie efforts related to the Quit 

and Win program, a promotion that encourages smokers to quit smoking and win prizes.

Duration Unknown

Media Weights Unknown
60 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

European Countries (38)

Campaign Name Youth Smoking Prevention Initiative 

Origin Country Various European countries

Sponsoring Organization British Tobacco, Japan Tobacco International, and Philip Morris

Strategy/Objective Reduce youths’ interest in smoking by showing them “cool” teens who do not smoke

Primary Target Youth

Message You can be cool and not smoke.You can hae many interests other than smoking.

Executions

Each execution focuses on a teenager who has distinct interests but does notsmoke.The 

copy saysthat he orshe“does X,does Y,does Z, and doesn’tsmoke.”The examples below 

are from Russia and Portugal:

• Silvia—A teenage girl shops at a mall, trying on clothes, etc.

• Jaou—A teenaged boy dances in clubs.

• Rodrigo—A teenaged boy surfs.

• Katya—A teenaged girl tries on clothes and then alters them to her own style.

• Lioha—A teenaged boy plays in a rock band.

• Dimon—A teenaged boy plays soccer.

Elements TV ads

Duration 00

Media Weights Unknown. Aired in  European countries on the MTV network
APPENDIX 2 61

APPENDIX

2

U.S./American Legacy Foundation

Campaign Name truthsm

Origin Country United States

Strategy/Objective

Motiate youth to reject smoking by proiding information on the tobacco industry’s 

deceptie marketing practices

Primary Target Youth aged – years who are most at risk of smoking

Message

Messages ary by sub-campaign and execution, but the main messages are that 

tobacco companies make money by addicting youth to cigarettes, lying about the 

dangers of tobacco use, and manipulating the contents of cigarettes to make them 

more appealing while also making them more addictie and deadly.

Executions

Sample executions include:

• Body Bags series—Body bags represent all of the people who die from smokingrelated illnesses.The first and most famous execution shows teenagers unloading 

and piling up stacks of body bags in front of a tobacco company’s headquarters 

while shouting that ,00 people die eery day from tobacco-related illnesses.

The other executions show body bags on the beach, in bars, and on horseback to 

contrast the attractie images of smokers portrayed in cigarette ads with the 

reality of the death they cause.

• Daily Dose series—Each execution focuses on one fact related to tobacco use or 

the behaior of the tobacco industry. In each ad, a teen holds up an electronic 

counter that lights up with the correct answer.

• Only One Product series—Each ad portrays the typical use of a product; howeer,

the third person to use the product in each ad is killed.The text reads that only 

one product kills one third of its users—tobacco.

Elements TV and radio ads,Web site

Duration Ongoing campaign that began in 000 

Media Weights Ad-industry–recommended media weights to achiee awareness goals
62 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Arizona

Campaign Name Tobacco Education and Prevention Campaign (TEPP) 

Origin Country U.S./Arizona

Sponsoring Organization

Strategy/Objective

Primary Target

Message

Executions

Elements

Duration

Media Weights

Tobacco Education and Preention Program, Arizona Department of Health Serices

Motiate youth to reject tobacco by showing disgusting and graphically intense 

tobacco-related images and situations in humorous ways to engage youth

Youth aged – years 

Although the messages aried throughout the many executions, the main message 

was that smoking is disgusting. A few notable exceptions include two ads about 

deciding whether to smoke, and one execution whose message is that tobacco does 

not always kill its users but it harms them in ways that may be just as bad.

Although executions ary greatly,each ad ends with the tagline,“Tobacco.Tumor-causing,

teeth-staining,smelly,puking habit.”Some sample executions are:

• Theater Snacks—A boy and a girl are on a date in a moie theatre. He spits his 

chewing tobacco into his cup and then she takes his cup, drinks from it, and 

is horrified.

• Maggots—A teenaged girl is preparing to go out and is smoking. As she continues to look in the mirror, her image turns into a witch and maggots come out of 

her mouth.

• I Decide—Dierse teensstate confidently that they decide what to do with their 

lies,they decide whether or not to smoke, and they choose not to smoke.

• Doesn’t Kill—Seeral teenagers say that tobacco did not kill their parents and 

friends as eeryone thought it would.Then each parent or friend is shown and is 

clearly ery ill.

TV, print, and radio ads; public relations eents;Web site; merchandise

August –00

-week flights airing periodically
APPENDIX 2 63

APPENDIX

2

U.S./California

Campaign Name California Tobacco Control Program

Origin Country U.S./California

Sponsoring Organization California Department of Health Serices,Tobacco Control Section

Strategy/Objective

De-normalize tobacco use by proiding information about the tobacco industry’s 

deceptie practices, health effects of tobacco use, dangers of secondhand smoke, and 

quitting resources

Primary Target Adult smokers and nonsmokers

Message

Messages ary based on the themes stated aboe (industry deceptie practices,

health effects of tobacco, health effects of secondhand smoke, quitting resources).

Executions

Examples of the many executionsinclude:

• Voicebox/Debi—A woman with a hole in her throat (stoma) tells her story of 

nicotine addiction. As she describes her unsuccessful attempts to quit, she inhales 

cigarette smoke through the stoma and questionsthe tobacco industry’s unwillingness to admit that tobacco is addictie.The ad is tagged with the helpline 

phone number.

• Victim/Wife—An older man recounts his wife’s request that he quit smoking.

Resentful of her interference, he had refused to quit, claiming that it was his life 

that was affected, not hers. In a broken oice, he explains that she died from the 

consequences of secondhand smoke.

• Hooked—A fisherman dressed as a business executie is fishing.The oiceoer 

discusses how the tobacco industry triesto“hook”youth with its addictie product.

• Quitting Takes Practice—This animated spot depicts a sad and frustrated character 

who has tried unsuccessfully to quit smoking.The narrator points out that it took 

him a long time to start to smoke so it will probably take a more than a few tries 

to quit; quitting takes practice. By the end of the commercial, the smoker builds 

confidence in his ability to quit, using the helpline as a resource.The ad is tagged 

with the helpline phone number.

Elements TV, radio, and print ads; billboards; public relations eents

Duration –

Media Weights Minimum leels to achiee awareness goals and call olumes
64 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Florida

Campaign Name Truth

Origin Country U.S./Florida

Sponsoring Organization Florida Department of Health, Office of Tobacco Control

Strategy/Objective Motiate youth to reject tobacco by informing them of deceptie tobacco industry practices

Primary Target Youth aged – years

Message

Messages ary by execution; the main message is that the tobacco industry deceies 

people to make money from a deadly product.

Examples of the many executions include:

• Deaths Planned—Simulating a motion picture trailer, this ad builds drama around 

a plot to kill millions of people and reeals at the end that it is the tobacco industry that is planning the deaths.

• Publishing—An unscripted ad in which two teenaged boys call a magazine and 

ask why it accepts tobacco adertising, since the product kills. They then ask if 

the magazine would be willing to place anti-smoking ads for free. The magazine 

executie says “no” and hangs up.

• Director—Two young men attempt to call a moie director to conince him not to 

hae the characters in his film smoke. When one of the callers is unable to speak with 

the director personally, he leaes a detailed message with the secretary.

• Secrets—Simulates an ad for a moie with scenes from the corporate life of a 

tobacco executie. This pseudo-moie trailer builds suspense and anticipation 

as the executie plots to gain the trust of young people to replace dying older 

cigarette smokers.

• Grim Reaper—In a conference room filled with tobacco smoke, executies are 

discussing the profitability of filtered cigarettes. Suddenly, the Grim Reaper enters 

the room and complains that so many people are dying as a result of smoking 

that he cannot keep up with the workload. Eentually, security guards eject him 

from the room.

• Thanking Patient—In a hospital room, a patient near death lies on a bed attached 

to a ariety of medical deices. He is isited by two joial tobacco executies who 

hae come to thank him for his loyal business oer the years, seemingly obliious 

to the fact that the patient is in distress. When they notice a teenager in the hall 

who can replace the dying patient, the executies quickly approach her as if to 

begin the cycle oer again.

• Fun with Statistics—A laugh track plays in the background of actual footage of 

congressional hearings on the tobacco industry. This addition makes the testimony appear comical and embarrassing.

Executions

Elements TV and print ads, billboards, public relations eents, school curriculum

Duration –000

Media Weights Unknown
APPENDIX 2 65

APPENDIX

2

U.S./Massachusetts

Messages aried based on the key themes, including health-risk information, impact on 

smokers and their families, cessation resources, and tobacco industry deceptie practices.

Campaign Name Massachusetts Tobacco Control Program

Origin Country U.S./Massachusetts

Sponsoring Organization Massachusetts Department of Public Health

Strategy/Objective

De-normalize smoking by communicating new health-risk information about smoking and secondhand smoke, emphasizing the toll taken by tobacco-related illnesses 

on smokers and their families, proiding quitting information, and exposing the 

deceptie marketing practices of the tobacco industry

Primary Target Smokers; Secondary targets: youth, general population, and opinion leaders

Message

Executions

Examples of the many executionsinclude:

• Pam Laffin Documentary series—Pam speaks of the tremendous toll smoking 

has taken on her life. She started smoking at age 0 to look older. At age , she 

deeloped emphysema and had a lung remoed. Indiidual executions focus on 

the pills that make her look bloated, the surgery, the failed lung transplant, the 

inability to breathe, her 0% chance of surial, and the impact on her children.

• Rick Stoddard series—Rick talks about losing his wife (aged 6 years) to lung cancer caused by smoking. Each spot focuses on a different aspect of her illness, such 

as her addition to nicotine, her youth at the time of her death, and the pain she 

suffered as she died.

• Get Outraged series—Each ad shows a preious disaster that concerned the U.S.

public (e.g., poisoned grapes that killed a few people, a plane crash that killed 

hundreds of people), and then contrasts the reaction to these eents to the 

relatie lack of concern about tobacco, despite the fact that tobacco kills ,00 

people eery day.The tag is, “Where is the outrage?”

• Youth Consequences series—Each ad focuses on one negatie consequence of 

smoking that is releant to young people, such as wrinkles, high cost, compromised athletic performance, and social rejection, including by members of the 

opposite sex.

• Models—Members of the U.S. women’s soccer team talk about the adantages of 

not smoking, despite the messages from the tobacco industry that smoking will 

make a person glamorous or popular.

• Cowboy—A man relates how his brother was one of the original Marlboro men in 

cigarette ads and how the tobacco companies wanted people to think that they 

could gain freedom and independence from smoking.The man’s brother died of 

lung cancer from smoking.The man asks how someone can feel independent while 

hooked up to so many tubes and pieces of hospital equipment.

Elements TV ads

Duration Ongoing campaign began in January .Ealuation results were reported through 000.

The Pam Laffin series ran for  weeks and the Rick Stoddard series ran for  weeks.

Media Weights ,00 Gross Rating Points each for Pam Laffin and Rick Stoddard series
66 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Minnesota

Campaign Name Target Market

Origin Country U.S. /Minnesota

Sponsoring Organization Minnesota Department of Health

Strategy/Objective

Motiate youth to reject tobacco by making them aware that tobacco companies 

target them with messages encouraging tobacco use

Primary Target Youth aged – years

Message

Tobacco companies are targeting us, so let’s target them by uncoering and rejecting 

their marketing practices.

Executions

Sample executions are below:

• Thank You—Indiidual teens speak to the camera, saying “thank you” to the 

tobacco industry in a sarcastic oice for conincing kids to smoke, killing family 

members, deceiing people about their products, and other acts.

• Light It Up—Youth construct a giant cowboy out of tobacco ads ripped from magazines (meant to symbolize the Marlboro Man) and burn it, while the oiceoer 

says that tobacco companies still spend millions of dollars on ads in the magazines that youth read.

• Bigger Than Ever—Teenagers rip up all of the tobacco ads they can find in magazines and create a sign that reads,“They’re Still Targeting Us.”

Elements TV, print, and radio ads

Duration 000–July 00

Media Weights Unknown
APPENDIX 2 67

APPENDIX

2

U.S./Mississippi

Campaign Name Question It

Origin Country U.S./Mississippi

Sponsoring Organization Partnership for a Healthy Mississippi

Strategy/Objective

Motiate youth to reject tobacco by proiding information about the deceptie marketing practices of the tobacco industry and facts about the health risks of smoking

Primary Target Youth (smokers and nonsmokers) aged – years 

Messages ary by execution and include the following themes: tobacco industry 

deceptie marketing practices, the role addiction plays in new-customer acquisition, 

dangers of tobacco use compared with other negatie life experiences, and shortterm health effects. 

Message

Sample executions include: 

• Cheerleader—A cheerleader coughs and drops a fellow cheerleader in a 

cheering competition.

• Car Contest—An endurance contest for a car is lost by a teenager who coughs just 

as the opposition is weakening. 

• Barber—A teenaged boy sits in a barber chair for a haircut. The barber gies him 

a comb-oer hair style, mimicking the style used for older men waiting in the 

room. The oiceoer asks, ”You wouldn’t want their haircut, why would you want 

their lungs?”

• Dentist—A teenaged girl in the dentist’s chair has all of her teeth remoed and 

replaced with diseased-looking teeth. The oiceoer says, “You wouldn’t want 

their teeth, why would you want their lungs?”

• License—A strutting teenager receies his drier’s license and backs his car into 

a patrol car as he exits the parking lot. A oiceoer says, “That’s one way screw up 

your life early. Smoking is another.”

• Cow-tipping—Teenagers playing pranks tip oer cows in the field, but one cow 

tips oer on top of a kid. The oiceoer says, “That’s one way screw up your life 

early. Smoking is another.”

• Prisoner—A prisoner is being led to the electric chair as the oiceoer describes 

how many people he has killed. At the end, it is reealed that the “killer” is a 

tobacco industry executie.

• It’s Legal—The head drug dealer tells a group of street-wise drug dealers that it 

is time to focus on a drug that is just as addictie as other drugs but is easier to 

push because it is legal—tobacco. 

All of the ads end with the tagline, “Question It.”

Executions

Elements TV, radio, and outdoor ads; contests; Web-based reality programs; school curriculum; 

public relations eents; posters

Duration Ongoing campaign that began in March 

Media Weights Unknown
68 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Mississippi

Campaign Name Reject All Tobacco (R.A.T.) 

Origin Country U.S./Mississippi

Sponsoring Organization Partnership for a Healthy Mississippi

Strategy/Objective

Motiate youth to reject tobacco by teaching them about the health effects of 

smoking and secondhand smoke; empower them to speak up to adults to protect 

themseles from secondhand smoke and promote quitting in those they care about

Primary Target Youth aged 6– years 

Message Smoking is dangerous to smokers and nonsmokers. Make sure you tell someone about it.

Executions

Humorous presentations of the dangers of tobacco use and secondhand smoke to youth 

and adultsin their lies, including:

• Goldfish—A woman’s pet fish shows its loe for her by blowing bubbles in the 

form of hearts and then extinguishes her cigarette, while the oiceoer admonishes the audience to tell someone to quit smoking today so that they will be 

around tomorrow.

• Robot—A scientist training a robot to show emotion issurprised when the robot 

cares enough to take a cigarette out of his mouth.A oiceoer tellsthe audience to 

help someone quitsmoking today so that they will be around tomorrow.

• Fly—A fly attempts to escape the dangers of secondhand smoke from the cigarette of a woman driing with her daughter in the car. A oiceoer talks about the 

number of toxic chemicals in secondhand smoke.

• X-Ray Goggles—A boy with x-ray glasses sees the insides of his father’s lungs,

which are filled with tar from smoking.The oiceoer discusses the number of 

deaths from cancer due to smoking.

• Aunt Edna—A young boy experiences a iid dream in which a bizarre aunt 

becomes responsible for his care after the death of his parents from smokingrelated diseases.The next morning the boy sees his parents prepare to smoke 

at the breakfast table and tells them to quit smoking so they will be around in 

the future.

• Foosball—A foosball game begins and the cigarette smoke from the boys playing 

the game makes the players sick.The oiceoer describes the health effects 

of secondhand smoke, such as lung cancer, asthma attacks, and reduced 

physical performance.

• Toy Soldier—Animated toy soldiers mourn the loss of the toy soldier who was 

smoking a cigarette; the oiceoer points out that  million people a year die 

from smoking-related illnesses around the world.

Elements

TV, radio, and outdoor ads; contests;Web site; performance troupe; school curriculum;

public relations eents; posters; merchandise

Duration Ongoing campaign that began in May 

Media Weights Unknown
APPENDIX 2 69

APPENDIX

2

U.S./Oregon

Campaign Name Tobacco Use Prevention Program 

Origin Country Ads were produced by U.S./California and U.S./Massachusetts and aired in U.S./Oregon

Sponsoring Organization Tobacco Control Program, Oregon Department of Health

Strategy/Objective Motiate smokers to try to quit

Primary Target Smokers

Message Message aried by ad execution, but most focused on the pain and suffering smokers 

and their family members suffered because of smoking-related illnesses and death.

Executions

• 

• 

• 

• 

• 

Voicebox/Debi—See description under U.S./California ads.

Cowboy—See description under U.S./Massachusetts ads.

Pam Laffin—See description under U.S./Massachusetts ads.

Janet Sackman—See description under U.S./Massachusetts ads.

Victim/Wife—See description under U.S./California ads.

Elements TV ads

Duration Unknown

Media Weights Unknown

U.S./Philip Morris

Campaign Name Think. Don’t Smoke.

Origin Country United States

Strategy/Objective Motiate youth to reject smoking by giing them the choice about whether to smoke

Primary Target Youth aged 0– years 

Secondary target: Parents of youth aged 0– years

Message You can decide whether to smoke, and you don’t hae to smoke to be cool or popular. In addition, some ads focused on the short-term health effects of smoking on 

athletic performance.

Executions

The campaign included many executions; those mentioned in this document are:

• Bus—An African American teenaged boy says that he does not want to smoke 

and that it is stupid.

• Stairs—Racially dierse teens talk about their decisions not to smoke.

• Karate Kid—A preteen in a karate class finds that smoking affects endurance.

Elements Primarily TV ads

Duration 000–00

Media Weights Unknown
70 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Texas

Campaign Name Tobacco Is Foul

Origin Country U.S./Texas

Strategy/Objective Motiate youth to reject tobacco

Primary Target Youth aged – years

Message Short-term health effects

Executions

• 

• 

• 

Gotta Light—An animated character introduces a smoker who desperately needs 

to light a cigarette. An athlete carrying a torch runs by and the smoking character 

runs to catch the flame. He is not able to catch the runner because of his smokedamaged lungs.

 First-Time Smokers—Two animated characters try smoking an abandoned cigarette butt they discoer on the playground. Inhaling the smoke causes them to 

choke and gag. An x-ray of their lungs shows the impact of smoking on their ability to breathe. The first-time smokers decide that smoking is not for them.

Tobacco Show Off—An animated character sets up a fight between animated 

characters who are chewing and smoking tobacco. The fighters collapse from 

weakness due to smoking and the grossness of chewing tobacco. 

Elements TV ads, school and community preention programs, and adult cessation programs

Duration Spring–Fall 000

Media Weights Unknown
APPENDIX 2 71

APPENDIX

2

U.S./Utah

Campaign Name The Truth About Tobacco

Origin Country U.S./Utah

Sponsoring Organization Utah Department of Health

Strategy/Objective

Motiate youth to reject tobacco by exposing the myths about the positie aspects 

of smoking

Primary Target Youth

Message

Many myths are out there. Find out the truth about smoking by calling a toll-free 

phone number.

Executions

Sample executionsinclude:

• Pam Laffin—See description under U.S./Massachusetts ads.

• Janet Sackman—See description under U.S./Massachusetts ads.

• Voicebox/Debi—See description under U.S./California ads.

• Cowboy—See description under U.S./Massachusetts ads.

• Negative Role Models—Utah teenagers at the Great Salt Lake explain why they 

started smoking.

• Positive Role Models—Utah teenagers at arious Utah locations explain why they 

do not smoke.

Elements TV, radio, magazine, and newspaper ads; school programs

Duration Ongoing campaign that began in 

Media Weights Unknown
72 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

2

U.S./Vermont, New York, Montana

Campaign Name University of Vermont Northeastern States Study

Origin Country U.S./Vermont

Sponsoring Organization Uniersity of Vermont

Strategy/Objective

Motiate youth to reject tobacco by proiding such information as the negatie social consequences of smoking and the positie social consequences of not smoking, 

and refusal skills

Primary Target Youth

Message

Executions focused on the negatie social consequences of smoking, positie social 

consequences of not smoking, short-term and long-term health effects of smoking, 

cost of smoking, and how to refuse an offered cigarette.

Executions

Examples of the many executions include:

• Beautiful Lady—An attractie woman enjoying an eening of leisure experiences 

wrinkled skin, discolored teeth, and other effects of smoking.

• Billy—A young boy encourages his friends to smoke with him, but is repeatedly 

rebuffed by those who think that smoking is wrong, including his dog.

• Don’t Worry—Teenagers discoer that they can perform better at singing, swimming, and other pursuits than competitors who smoke.

• Break Away—Teens enjoy the positie aspects of not smoking, encouraged to 

“break away” by a rock band performing the song “Breakaway.”

• Nicoflame—An animated segment features a young boy learning about the shortterm and long-term consequences of smoking—dizziness, bad breath, yellow 

teeth, tar in lungs, and high blood pressure. The oiceoer encourages him to say, 

“No, I don’t smoke.” 

• Drag Race—An animated segment introduces the addictie aspects of smoking 

and encourages youth to say, “No, I don’t smoke.”

• Viewpoints of Ex-Smokers—Ex-smokers offer testimonials about the additie 

nature and short-term health effects of smoking.

• Viewpoints of Nonsmokers—Nonsmokers share testimonials about the health 

effects and costs of smoking, and reasons not to smoke.

Elements TV ads, school curriculum 

Duration January–April 6–

Media Weights

Aerage annual paid media presence oer -month period was 0 spots on network 

TV and 0 spots on cable TV in each market. Media outlets also donated public 

serice airtime, increasing the number of broadcasts up to 0%. 
APPENDIX 

RESEARCH SUMMARY

APPENDIX

APPENDIX

3
 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

Smokers and recent quitters aged –0 years(n = ,): pre-campaign May  (n = ,): post-campaign Noember Telephone sureys

Commonwealth Department of Health 

and Family Serices

Australia National Tobacco 

Campaign Sureys

Australia National Tobacco 

Campaign Sureys

Lung, Artery, Tumour

Youth and adults aged  years and older (n = ,0)– years (n = 60)–0 years (n = ,00)

+ years (n = ,)Face-to-face interiews in participants’ homes

Ads from Stressing Out—You’re Smarter Than That campaign 

(ads unknown)“Eery Cigarette Is Doing You Damage”: Lung, Artery, Tumour

Australia South Australian Health 

Omnibus Surey 

South Australian Health Omnibus Surey 

South Australian Smoking and Health Project

Canada National Tobacco Use 

Monitoring Surey 6, , , 000, 00 

Health Canada National Population 

Health Surey

Canadian Tobacco Use Monitoring Surey 

Youth aged – years (n = ,0) Telephone sureys Unknown

1997

—Voice Box, Pee Pee, Janet 

Sackman, Ice, Dinner, Pam Laffin, 

Victor, Scary Math, Joy, Cattle, Attractiveness, Mosh Pit1998

—Aorta, Maggot, Christy, Ashes, 

Cigar, Tumour, Date, Smoke, Mascot, I Decide, Truth, Subliminal, Spoiled1999

—Stroke, Cocktail, Best Memory, Joanne, Can’t Breathe, Airplane, 

Talk Show, Tea Party, Scary Math, Grasshopper, War, Cowboy2000—Tar, Body Bags, Eye, Breathe, Splode, Ironic Quotes, Theater Snacks, Rid-A-Zit, Fish Out of Water, Parachute, Larc, Voice

Elementary, middle, and secondary schools, classroom 

oting after iewing  anti-tobacco adsNumber of Participants by Year ,000 , 6,0000 60,000

Canada/British ColumbiaCritics’ Choice

, , , 000

Critics’ Choice School Program

British Columbia Ministry of Health

1 Hassard K, editor. Australia’s National Tobacco Campaign, Evaluation Report. Volume 1. Canberra: Commonwealth Department of Health and Aged Care; 1999.2 British Columbia Ministry of Health. Critics’ Choice Post Analysis. Victoria, BC; 2000.
APPENDIX 

 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

Canada/OntarioOntario Tobacco Media Campaign Tracking Surey—Youth 00

Ontario Tobacco Media Campaign Tracking Surey—Youth

Ontario Proincial Goernment 

Youth (n = 0)Adults (n = ,000)Telephone surey

Beautiful Lady, Billy, Breakaway, Don’t Worry, Drag Race, Jennifer, Magazine Ad, Mindy, Nicoflame, Older Girl, VP Ex-Smokers, VP Nonsmokers

Central Office of Information, on behalf of the Department of Health, England; BMRB Social Research

England Anti-Smoking Adertising Tracking, Surey Wae 6

Anti-Smoking Adertising Tracking Surey

Youth aged – years (n = 0)Face-to-face interiews

Stephen, Rebecca, Christy, Kay, Byron, Colleen, Pharmacist, Relationship, Facts

Men aged 0– years (n = ,6)Women aged 0– years (n = 0,6) Sureys to assess cardioascular disease risk following a comprehensie community-based inter-ention initiated in  to reduce coronary heart disease mortality rate in - to 6-year-old males 

FinlandNational FINRISK Study, , , , , 

Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki

Messages were primarily deliered through TV programming

North Karelia Project

International Global Youth Tobacco Surey 00

Global Youth Tobacco Surey 

Centers for Disease Control and Preention; World Health Organization

Students aged – years  sites in  countries and the Gaza Strip/West BankSchool-based surey

No ad ealuation

3 BMRB Social Research, COI Communications, Department of Health. Tobacco Education Campaign Evaluation, Young People and Pregnant Smokers. London: Department 

of Health; 2002.

4 Puska P. The North Karelia Project: from community intervention to national activity in lowering cholesterol and CHD risk. European Heart Journal 1999;suppl 1:59–513.
76 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

Youth smokers or susceptible nonsmokers (n = 6) • U.S. grades , 0, or  

(n = )

 • Australia grades , 0, 

or  (n = 6)

 • United Kingdom  British equialent to 

grades , 0, or  (n = )

Participants iewed and ealuated 0 ads. A follow-up phone call  week later ealuated recall and engagement.

InternationalYouth Appraisal of Anti-Smoking Adertising 000, 00,6,

NCI Youth Appraisal of Anti-Smoking Adertising 

State and Community Tobacco Control Initiatie of the National Cancer Institute

0 ads representing a range of messages produced by tobacco control agencies (), tobacco companies (), and pharmaceutical companies ()

Netherlands The DEFACTO Tracking Study –00

Netherlands DEFACTO Tracking Study DEFACTO Youth aged –6 years (n = 600)

“. . . but I don’t smoke.” campaign (see Appendix  for descriptions of ads)

Cancer Registry of Norway; Institute for Epidemiological Cancer Research, Oslo; Research Center for Health Promotion, Uniersity of Bergen; Norwegian Women’s Public Health Association

NorwayProocatie Appeals in Adolescent-Targeted Mass Media Campaigns,  and 

Norway Youth Proocatie Appeals Campaign Ealuation

Adolescents aged  and  years in interention county (n = ,)Adolescents aged  and  years in control county (n = ,)Surey questionnaire completed in classrooms

Ads unknown Main message was that girls must be stupid because they know the risks of smoking and still smoke

5 Wakefield M, Durrant R, Terry-McElrath Y, Ruel E, Balch G, Anderson S, et al. Appraisal of anti-smoking advertisements by youth at risk for regular smoking: a comparative study 

in the United States, Australia and Britain. Tobacco Control 2003;12(Suppl ii):ii82

–ii86.

6 Wakefield M, Balch GI, Ruel EE, Terry-McElrath Y, Flay B, Szczypka G, et al. Youth appraisal of anti-smoking advertisements from tobacco control agencies, tobacco companies 

and pharmaceutical companies. Journal of Applied Social Psychology 2005;35:1899–1916.

7 Terry-McElrath Y, Wakefield M, Ruel E, Balch GI, Emery S, Szczypka G, et al. The effect of anti-smoking advertisement executional characteristics on youth comprehension, appraisal, recall and engagement. Journal of Health Communication 2005;10:127–143.8 Hafstad A, Aaro LE, Engeland A, Anderson A, Langmark F, Stray-Perersen B. Provocative appeals in anti-smoking mass media campaigns targeting adolescents—the accumulated

effect of multiple exposures. Health Education Research, Theory and Practice 1998;12:227–236.
APPENDIX 

3 77

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

Poland Ealuation of –00 Media Campaigns

Poland Media Campaign Ealuation

Great Polish Smokeout Campaign

Youth aged– years (n = ,)Youth aged6 years (n = ,00)Telemetric Measurement Systemby Centre of Research on Public Opinion

Great Polish SmokeoutCampaign, using the Eery Cigarette Is Doing You Damage campaign ads

Poland Poland (Urban) Global Youth Tobacco Surey 

Poland (Urban) Global Youth Tobacco Surey 

Centers for Disease Control and Preention; World Health Organization

Youth aged – years (n = ,6)School-based surey Ads unknown

ScotlandEaluation of Tobacco Industry-Funded MTV Youth Smoking Preention Campaign—Focus Groups, 00

Tobacco IndustryFunded MTV Youth Smoking Preention Campaign—Scotland Focus Groups

Uniersity of Strathclyde Youth aged – years Eight focus groups

Main message of campaign was, “You can be cool and not smoke” (see Appendix  for descriptions of ads)

U.S./Arizona Ealuation of the Tobacco Education and Preention Program Media Campaign

Arizona Tobacco Education and Preention Program Media Campaign Ealuations

Communication Research Section,Arizona Cancer Center, Uniersity of Arizona

Smokers and nonsmokers aged – years (n = )Telephone sureys

Chuck’s Mom, Doesn’t Kill, Truth ad series – (see Appendix  for descriptions of ad series)

U.S./ArizonaEaluation of the Tobacco Education and Preention Program Media Campaign0

Arizona Tobacco Education and Preention Program Media Campaign Ealuations

Communication Research Section, Arizona Cancer Center, Uniersity of Arizona

Youth aged – years (n = 0)Exposure and recall ratesTelephone sureysCompared data from  and 00

Media schedule was not actie during this period. Recall measures were for national truthsm spots, 

Ammonia, Rat Suit, and BioSphere.

9 University of Arizona. Evaluation of the TEPP Media Campaign. Report 17, year 2, quarter 4: youth. Tucson, AZ; 2000.

10 University of Arizona. Evaluation of the TEPP Media Campaign. Report 29, year 4, quarter 1: youth comparisons. Tucson, AZ; 2002.
78 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./Arizona Impact of Preention Ads on Tobacco Attitudes and Intentions

Arizona Preention Ads In-School Ealuation

Arizona Cancer Center, Uniersity of Arizona 

Students in grades 6– (n = ,)In-school surey

Theater Snack, Maggots, Grasshopper, Bucking Bronco, Smoked Meat, I Would Rather, Rapunzel, Frank, Pee Pee, Mosh Pit, Rodeo Rider, Basketball, Lady Bug, Runner, I DecideThe 6 ads tested were randomly selected from among  compiled from all known Englishlanguage sponsors of antismoking ads and represented the themes of disease and death, endangerment of others, cosmetic effects, smokers’ negatie life circumstances, refusal-skills role models, marketing tactics, selling disease and death

U.S./CaliforniaProtection Motiation Theory Message Testing , 000 

Protection Motiation Theory Message Study, Uniersity of California, Irine

California TobaccoRelated Disease Research Program, Uniersity of California, Irine 

th-grade students (n = )0th-grade students (n = )Participants completed a written surey after iewing a ideotape of eight ads in a classroom setting 

U.S./California Independent Ealuation Consortium 6–, 

, –000

California Gallup Independent Ealuation Consortium

Gallup Organization;Stanford Uniersity; Uniersity of Southern California

Adults from  focal counties (n = 6,6)Telephone interiewsStudents from  focal counties (n = 6,) School-based sureys

A broad range of ads with messages about health risks, tobacco industry deceptie practices, secondhand smoke, and cessation resources

11 Burgoon M, Miller C, Alvaro E, Denning V, Willey P, Grandpre J. Adolescents’ responses to tobacco prevention TV ads. Poster presented at World Conference on Tobacco or 

Health; August 6

–11, 2000; Chicago, IL.

12 Pechmann C, Zhao G, Goldberg ME, Reibling ET. What to convey in anti-smoking ads for adolescents? The use of protection motivation theory to identify effective message 

themes. Journal of Marketing 2003;67:1–18.

13 Independent Evaluation Consortium. Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program. Wave 1 data, 1996–1997. 

Rockville, MD: California Department of Health Services; 1998.
APPENDIX 

3 79

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./CaliforniaCalifornia Tobacco Sureys (CTS) 0–,,,6,, and 00.In addition to the 6 basic CTS surey, a –6 Teen Longitudinal Surey was released.

California Tobacco Sureys 

The California Department of Health Serices contracted with the Uniersity of California, San Diego;Westat Corp.

Sureys of attitudes, behaiors,and media exposure regarding smoking and tobacco use

Ealuated recall of all program elements, including teleisions ads presenting health risk,tobacco industry deceptie practices, secondhand smoke,and cessation messages

U.S./Florida Anti-Tobacco Media Ealuation,,6,, 000

Florida Anti-Tobacco Media Ealuation 

Center for the Study of Population, College of Social Sciences, Florida State Uniersity

Youth aged –0 years (n = ,0)Telephone sureys conducted eery 6 months between October  and October 000

Broad ariety with focus on messages about tobacco industry deceptie practices, including Director, Producer, Publishing,Who Are You, Congrats, Agency,Vending,That’s the Problem, Lucky, Lungs,I’m an Actor

U.S./Florida Youth Tobacco Surey , , 000,

Florida Youth Tobacco Surey 

Bureau of Epidemiology,Florida Department of Health

Public middle school (grades 6–) and high school (grades –) studentsSelf-administered schoolbased sureysYear Gr 6–8 Gr 9–12 # schools ,6 0,6  , , 000 ,6 , 

Broad ariety, primarily with messages about tobacco industry deceptie practices 

14 Sly DF. Florida Anti-Tobacco Media Evaluation, Report on September 1998 Survey Results. Tallahassee, FL: Florida State University; 1998.15 Sly DF, Heald G, Ray S. Florida Anti-Tobacco Media Evaluation Follow Up Report. Tallahassee, FL: Florida State University; 2001.16 Sly DF, Trapido E, Ray S. Evidence of the dose effects of an anti-tobacco counter advertising campaign. Preventive Medicine 2002;53:511–518.17 Bauer U, Johnson T. Assessing the Impact of Florida’s Pilot Program on Tobacco Control 1998–2000: A Comprehensive Analysis of Data from the Florida Youth Tobacco Survey. Volume 3, 

Report 2. Tallahassee, FL: Florida Department of Health; 2001.

18 Bauer U, Johnson TM, Hopkins RS, Brook RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program. Findings from the Florida 

Youth Tobacco Survey, 1998–2000. JAMA 2000;284:723–728. 
80 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

Students from Massachusetts (n = 600) and New Hampshire (n = 00) female,  male respondents per grade per cellQuasi-quantitatie tracking study ia in-school interiews among students aged – years (grades –)

U.S./Massachusetts Department of Public Health Adertising Tracking Study 

Massachusetts Ad Tracking Study 

Arnold Communications; Millersille Uniersity Opinion Research Center

Pam Laffin and Break Free campaignsTeen panels assigned ads to the following categories: . Massachusetts ads depicting 

illness, in which people told their stories about health consequences of smoking and loss

. Massachusetts Get Outraged

campaign, a series of messages about deaths caused by tobacco and the tobacco industry’s targeting of youth

. Massachusetts ads that focused 

on sports performance, social acceptance, and being cool, with no mention of health consequences

. Philip Morris’s Think, Don’t 

Smoke. youth campaign, which communicated that youth are free to choose whether to smoke

Adults in  (n = ,00) Re-interiew of participants in 6Youth aged – years (n = ) Random-digit–dialed telephone surey in , identified in earlier adult surey process Telephone sureyBehaioral Risk Factor Sureillance System dataTobacco Institute Reports

U.S./Massachusetts Tobacco Sueys in , 6, ,0,,,,

Massachusetts Tobacco Sureys

Center for Surey Research, Uniersity of Massachusetts, Boston

19 Biener L. Adult and youth response to the Massachusetts anti-tobacco television campaign. Journal of Public Health Management & Practice 2000;6:40–44.20 Biener L. Anti-tobacco ads by Massachusetts and Philip Morris: what teenagers think. Tobacco Control 2002;11(Suppl II):ii43–46.21 Biener L, Harris JE, Hamilton W. Impact of the Massachusetts Tobacco Control Programme: population based trend analysis. BMJ 2000;321;351–354.22 Biener L, Ji M, Gilpin E, Albers A. The impact of emotional tone, message and broadcast parameters in youth anti-smoking advertisements. Journal of Health Communications

2004;9:259–274.

23 Biener L, Taylor TM. The continuing importance of emotion in tobacco control media campaigns: a response to Hastings and MacFadyen. Tobacco Control 2002;11:75–77.24 Massachusetts Department of Public Health. Adolescent Tobacco Use in Massachusetts: Trends Among Public School Students, 1996–1999. Boston; 2002.
APPENDIX 

3 81

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./Minnesota Minnesota-Wisconsin Adolescent Tobacco Use Research Project

Minnesota-Wisconsin Adolescent Tobacco Use Research Project

Uniersity of Minnesota; Minnesota Department of Health; National Research Centre for Preentie Medicine, Moscow, Russia

th-grade students (n = ,00) sureyed annually in –6 community units roughly equialent to school areas 

Variety of ads with themes of social disapproal of smoking due to negatie social consequences of tobacco use, bad breath and smelly clothes, and social approal of nonsmoking

U.S./Minnesota Target Market Campaign Ealuation Pre/Post Research Results 000, 00, 00, 00

Minnesota Target Market Campaign Ealuations

Minnesota Department of Health; Surey Research Center, Uniersity of Florida

Youth aged – years (n = ,000) Telephone surey 

Variety of ads, primarily with theme of tobacco industry deceptie practices (see Appendix  for descriptions of selected ads)

U.S./Minnesota Minnesota Youth Tobacco Surey 000, 006

Minnesota Youth Tobacco Surey 

Minnesota Department of Health

Students in grades 6– in 0 middle and high schools (n = ,)

No ad ealuation

Reject All Tobacco ads:Aunt Edna, Barber, Bingo, Car Contest, Cheerleader, Cow Tipping, Fly, Foosball, Frances, Goldfish, License, Prisoner PHM, Robot, Teeth, Toy Soldier, VJ, X-Ray Goggles Question It ads:Cheerleader, Car Contest, Barber,Dentist, License, Cow-Tipping,Prisoner PHM, It’s Legal

U.S./Mississippi Mississippi Youth Benchmark Study Ad Tracking Surey Wae  00

Mississippi Youth Ad Tracking Benchmark Surey

Partnership for a Healthy Mississippi, Southern Research Group 

Students in grades –Cell phone surey conducted at schools (n = ,0)

25 Ergo International, Inc. Target Market Campaign Evaluation: Pre-Post Research Results. Minneapolis: Minnesota Partnership for Action Against Tobacco; 2001.26 Minnesota Department of Health. Teens and Tobacco in Minnesota: Results from the Minnesota Youth Tobacco Survey. Available at 

http://www.health.state.mn.us/divs/hpcd/tpc/TobaccoReports.html.

27 Partnership for a Healthy Mississippi. 2000 Ad Tracking Survey, Wave 4. Jackson, MS: Southern Research Group, Mississippi State Department of Health, Mississippi State 

University Social Science Research Center; 2001.
82 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./Mississippi Youth Behaior Risk Sur-ey , , , 

Mississippi Youth Behaior Risk Sureys 

Diision of Adolescent and School Health, Centers for Disease Control and Preention

Students in grades – (n = approximately ,00 annually)Self-administered questionnaire 

No ad ealuation

U.S./MississippiYouth Behaior Risk Sur-ey Middle Schools 00

Mississippi Youth Behaior Risk Surey of Middle Schools 

Mississippi State Department of Health

Students in grades 6– (n = ,0)Self-administered in-school questionnaire

No ad ealuation

U.S./Mississippi Youth Risk Behaioral Surey 00

Mississippi Youth Risk Behaioral Surey 00

Mississippi State Department of Health

Middle school students in  schools (n = ,00) No ad ealuation

U.S./MississippiYouth Tobacco Surey, 

Mississippi Youth Tobacco Surey

Mississippi State Department of Health

Students in grades 6–Self-administered schoolbased surey

Public high school students (n = ,0)Priate high school students (n = ,)Middle school students (n = ,)

No ad ealuation

U.S./Multistate Meta-Analysis of Health Campaigns

Meta-analysis of  health campaigns Uniersity of Connecticut 

Total (n = 6,)Meta-analysis of  health communication campaigns in the United States promoting a wide range of health behaiorsCampaigns included at least one form of mass media and were community-based

No ad ealuation

U.S./Multistate Literature Reiew ofYouth Tobacco Use Preention Media Campaigns 00

Literature Reiew of Youth Tobacco Use Preention Media Campaigns

Research Triangle Institute Literature reiew of youth tobacco use preention mass media campaigns No ad ealuation

28 Snyder L. How effective are mediated health campaigns? In: Rice R, Atkins C, editors. Public Communication Campaigns. 3rd edition. Thousand Oaks, CA: Sage Publications; 

2001:181

–190.

29 Farrelly MC, Niederdeppe J, Yarsevich J. Youth tobacco prevention mass media campaigns: past, present and future directions. Tobacco Control 2003;12(Suppl I):i35–47.
APPENDIX 

3 83

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./Multistate Teen Research UnlimitedFocus Groups0

Teen Research UnlimitedMulti-State Focus Groups

State health departments in Arizona, California, and Massachusetts; Centers for Disease Control and Preention

At-risk youth aged –6 years (n = 0)0 focus groups in six cities in three states

Pam Laffin, Cowboy,Voicebox/Debi,Industry Spokesman, I Decide, Pee Pee, Publishing, Cinema: Deaths Planned, Bus, Stairs

Youth aged – yearsYoung adults aged – yearsPre-campaign (n = 6,)0 months after campaign started (n = 0,6)Telephone sureys

Variety of ads including the American Legacy Foundation’s Body Bagsand seeral ads from the Philip Morris Think. Don’t Smoke. campaign (see Appendix  for descriptions of indiidual ads)

U.S./NationalLegacy Media Tracking Sureys,

Legacy Media Tracking Sureys 

American Legacy Foundation

U.S./NationalQuantitatie Copy Testing 

National Quantitatie Copy Testing

Centers for Disease Control and Preention

Youth aged – years (n = )ARS quantitatie copy testing in eight U.S. cities

Cowboy/Will McLearn, Models

U.S./NationalEaluation of Anti-Smoking Adertising Campaigns Focus Group Analysis 

National Anti-Smoking Campaign Focus Group Analysis

Uniersity of California,San Francisco

Youth and adults (n = ,00)6 focus groups 

 ads produced for California,Massachusetts,and Michigan tobacco counter-adertising campaigns

U.S./NationalNational Youth Tobacco Surey 00

National Youth Tobacco Surey 

American Legacy Foundation

Middle schoolstudents(n = ,)High school students (n = ,)School-based surey 

No ad ealuationPam Laffin, Lab Monkey, Injuries, Rick Stoddard series—Heart in the Sky; Target Market series—Thank You; American Legacy Foundation truthsm series—Barrio Marketing, 

Venus, Gwen, Ribbons, 1 in 3, 2nd Hand

U.S./North Carolina Focus Groups 00

North Carolina AntiSmoking Ads Focus Groups Uniersity of North Carolina Youth aged – years (n = ) 0 focus groups

30 Teenage Research Unlimited. Counter-Tobacco Advertising Exploratory, Summary Report. Prepared for the States of Arizona, California, and Massachusetts Public Health Anti-Tobacco Media Campaigns. Northbrook, IL; 1999.31 Farrelly MC, Davis KC, Yarsevich JM. Getting to the truth: assessing youths’ reactions to the truthsm and Think. Don’t Smoke. tobacco counter-marketing campaigns. First Look 

Report 9; 2002. Available at http://www.americanlegacy.org.

32 RTI International. Confirming the Truth: More Evidence of the Success of the Truth Strategy in Florida. Results from the Legacy media tracking survey. Durham, NC; 2002. Available at 

http://tobacco.rti.org/data/lmts.cfm.
84 TOBACCO USE PRE VENTION MEDIA CAMPAIGNS 

APPENDIX

3

Study Common Name Research Sponsor Methods Ads Involved

U.S./North CarolinaAnti-Smoking AdsFocus Groups 000

North Carolina AntiSmoking Ads Focus Groups

Uniersity of North Carolina at Chapel Hill

Youth aged –6 yearsFour focus groups

Pam Laffin, Cowboy, Voicebox/Debi, Industry Spokesman, I Decide, Pee Pee, Publishing, Cinema: Deaths Planned, Bus, Stairs

Participants identified top 0 preferred ads focusing on preention from pool of  ads: Voice Box/Debi, Cowboy, Bad Influence, Janet Sackman, Cattle, Pam Laffin, Smart Dog, Movie, Camel, Girlfriend, Maggots

U.S./UtahTobacco Preention Media Campaign Formatie Message Research

Utah Tobacco Media Campaign Formatie Message Research

Utah Department of Health

Youth aged – years (n = ) Theater testing of  radio and TV adsEight focus groups throughout Utah

U.S./UtahTobacco Preention Media Campaign Ealuation

Utah Tobacco Media Campaign Ealuation

Utah Department of Health

Nonsmokers aged – years (n = 6)Telephone sureys before and after the campaign

Pam Laffin, Janet Sackman, Cowboy, Debi/Voicebox, Teenagers at Great Salt Lake, Teenagers Why I Don’t Smoke, The Truth About Tobacco

Students in grades – (n = ,) initiallyStudents in grades 0– (n = ,) by end of campaignSix in-school sureys in four matched study communities in Vermont, New York, and Montana

U.S./VermontMultistate School and Mass Media Combination Interentions

Multistate School and Mass Media Campaign Combination Ealuations 

Uniersity of Vermont

Broad range of ads (see Appendix , Vermont for descriptions of selected ads)

33 Murphy RL. Development of a low budget prevention media campaign. Journal of Public Health Management & Practice 2000;6:45–48.34 Neiger BL, Barnes MD, Merrill RM, Murphy R, Thackeray R, Giles RT, et al. Measuring the effect of a tobacco media campaign among nonsmoking children and adolescents. 

International Electronic Journal of Health Education (serial online) 2002;5:35–40. Available at http://www.iejhe.org.

35 Flynn BS, Worden JK, Secker-Walker RH, Badger GJ, Geller BM. Cigarette smoking prevention effects of mass media and school interventions targeted to gender and age groups. 

Journal of Health Education 1995;26(Suppl):45–51. 
APPENDIX 

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APPENDIX

3

6 teleision ads deeloped and produced by six creatie agencies in seeral formats: situation comedy, rock ideo, cartoon, testimonial, and drama. Spots included Beautiful Lady, Billy, Don’t Worry, Break Away, Nicoflame, Drag Race,and View Points (see Appendix  for descriptions of indiidual ads)

U.S./Vermont Mass Media and School Interentions for Cigarette Smoking Preention Follow-Up6

Multistate Mass Media and School Interentions Follow-Up

Uniersity of Vermont

Students in grades 0–(n = ,60) assessed in the 6–0 cigarette smoking preention study Primary outcome was cigarette smoking in the past week

36 Flynn BS, Worden JK, Selker-Walker RH, Pirie PL, Badger GJ, Carpenter JH, et al. Mass media and school interventions for cigarette smoking and prevention: effects 2 years after 

completion. American Journal of Public Health 1994;84:1148–1150.