19

NCI TOBACCO CONTROL MONOGRAPH SERIES

U.S. DEPARTMENT 

OF HEALTH AND 

HUMAN SERVICES

National Institutes 

of Health

National Cancer Institute

The Role of

the Media in 

Promoting and 

Reducing

Tobacco Use

Executive Summary

iii

Foreword

When I fi rst started TV work with the ABC affi liate in Boston in 1972, broadcast television 

was king, with a realm dominated by only ABC, CBS, and NBC. Even though I got into the 

business by accident and had no formal training in media, I quickly understood the power 

of the airwaves to infl uence the minds and hearts of viewers. I also became very conscious of 

the attendant responsibility to be accurate and understandable, remembering Mark Twain’s 

admonition (loosely phrased) to beware of reading health books because mistakes can kill you.

Perusing the information in this enormously informative volume, I was once again reminded 

of those elemental emotions: exhilaration about the opportunities offered by media and 

anxiety about the potential for misuse. Any phrase or sound bite can affect millions of 

people. In dealing with tobacco, I think the power of this potential must never be forgotten. 

Tobacco captivates people when they cannot rationally resist its siren call and can unleash 

a slow, deadly disease that can kill them even as they try to escape the tenacious trap of 

addiction. So those of us given the privilege of access to media should be aware of our own 

responsibilities in the fi ght against tobacco use—including the need to choose words and 

images to counter misinformation and temptation aimed at the young entrusted to our care. 

I have come to believe that unless we think and feel that we are fi ghting a lethal battle against 

tobacco use, we will not succeed in stemming the forces that would promote it. This volume 

contains a wealth of information about how tobacco companies use media to their benefi t. 

I predict that, like me, even though you have seen them in action, you will be amazed by 

the tactics used to promote tobacco. Tobacco use is a social phenomenon largely propelled 

by mass media over the past century, led by tobacco industry professionals who constantly 

change strategies to reach their goals. They combine the resourcefulness of a profi t-making 

industry with a changing media and regulatory landscape to sell a product that remains our 

greatest public health challenge. We will not remove tobacco from our society unless we are 

willing to understand the industry’s constantly changing tactics.

But this volume provides encouragement—information about successful efforts to fi ght back. 

Again I was surprised by what can work and stimulated to think about new ways to take a 

stand and make a difference.

I invite you to consider this volume a valuable reference for understanding how media can 

be used in the war against tobacco. Keep it handy for wise counsel, strategic encouragement, 

and a partner in a noble cause.

Tim Johnson, M.D., M.P.H.

Medical Editor, ABC News

June 2008

v

Message from the Series Editor

This volume is the 19th of the Tobacco Control Monograph series of the National Cancer 

Institute (NCI). This series began in 1991 with a visionary blueprint for public health action 

on tobacco prevention and control. In the years since, it has disseminated important crosscutting research in areas such as the effectiveness of community-based and population-level 

interventions, the impact of tobacco control policies, the risks associated with smoking 

cigars and low-tar cigarettes, and systems approaches to tobacco control.

The subject matter of this monograph stands at the confl uence of three major trends of the 

past century: the growth of mass media, the concomitant rise in cigarette smoking as a social 

phenomenon, and more recently, research to understand and to decrease the disease burden 

caused by tobacco use. Cigarettes are a product of the mass media era; the art and science of 

mass communications and mass marketing were critical to the growth of tobacco use in the 

past century. At the same time, however, the media have contributed signifi cantly to the roughly 

50% decline in smoking prevalence that took place over the past four decades, by increasing 

public knowledge of the health hazards of cigarette smoking, helping to change social norms 

about cigarette smoking, and increasing public acceptance of tobacco control policies.

This monograph summarizes what we have learned about the ability of the media to encourage 

and discourage tobacco use. There has been much interest in and study of media, and several 

government publications document the impact of advertising on tobacco use. This publication 

provides the most comprehensive and critical review and synthesis of the current evidence base 

in this area, drawing on work from many disciplines and research traditions. There is growing 

interest in applying what we have learned in tobacco prevention and control to other public 

health areas (such as dietary behavior). This monograph has important messages for public 

health researchers, practitioners, and policymakers as well as those in the communication 

science and media studies communities.

This monograph provides a comprehensive assessment of the literature on developing 

effective pro-health media messages and on policies to control tobacco marketing, both in 

the United States and abroad. This information is critical to support efforts to reduce the use 

of tobacco and the morbidity and mortality associated with its use. The evidence presented 

in this volume also underscores the need to continue to study and understand the ability of 

protobacco forces to change media strategies to adapt to a changing tobacco control policy 

environment. 

We are pleased that Dr. Timothy Johnson, Medical Editor for ABC News, has provided the 

Foreword to this volume. As a physician who began working in television in 1972, he has 

a long-standing record of communicating the harmful effects of smoking to the public. 

His background and commitment provide invaluable perspectives about the power of the 

media and why this monograph is so important for tobacco prevention and control.

Stephen E. Marcus, Ph.D.

Monograph Series Editor

June 2008

vii

Preface

The work presented in the National Cancer Institute’s Tobacco Control Monograph 19, 

The Role of the Media in Promoting and Reducing Tobacco Use, is the most current and 

comprehensive distillation of the scientifi c literature on media communications in tobacco 

promotion and tobacco control. This ambitious effort to synthesize the science bridged 

the disciplines of marketing, psychology, communications, statistics, epidemiology, and 

public health and represents the combined efforts of fi ve scientifi c editors, 23 authors, 

and 62 external peer reviewers.

The six main parts of this monograph deal with aspects of media communications relevant 

to tobacco promotion and tobacco control. Part 1, an overview, frames the rationale for 

the monograph’s organization and presents the key issues and conclusions of the research 

as a whole and of the individual chapters. This section describes media research theories 

that guided this assessment of the relationship between media and tobacco use, which can 

be viewed as a multilevel issue ranging from consumer-level advertising and promotion to 

stakeholder-level marketing aimed toward retailers, policymakers, and others.

Part 2 further explores tobacco marketing—the range of media interventions used by 

the tobacco industry to promote its products, such as brand advertising and promotion, 

as well as corporate sponsorship and advertising. This section also evaluates the evidence 

for the infl uence of tobacco marketing on smoking behavior and discusses regulatory and 

constitutional issues related to marketing restrictions.

Part 3 explores how both the tobacco control community and the tobacco industry have 

used news and entertainment media to advocate their positions and how such coverage 

relates to tobacco use and tobacco policy change. The section also appraises evidence of the 

infl uence of tobacco use in movies on youth smoking initiation. Part 4 focuses on tobacco 

control media interventions and the strategies, themes, and communication designs 

intended to prevent tobacco use or encourage cessation, including opportunities for new 

media interventions. This section also synthesizes evidence on the effectiveness of mass 

media campaigns in reducing smoking. Part 5 discusses tobacco industry efforts to diminish 

media interventions by the tobacco control community and to use the media to oppose state 

tobacco control ballot initiatives and referenda. Finally, Part 6 examines possible future 

directions in the use of media to promote or to control tobacco use and summarizes research 

needs and opportunities.

Key lessons from this volume can inform policymakers as well as scientists and practitioners. 

Most critical from a policy standpoint is the conclusion, supported by strong evidence, that 

both exposure to tobacco marketing and depictions of tobacco in movies promote smoking 

initiation. A fundamental theme throughout this monograph is the dynamic interplay 

between tobacco promotion and tobacco control, whereby action in one area produces change 

in the other. For example, when limits have been placed on tobacco promotion, the tobacco 

industry typically has resisted, evolving alternative strategies to effectively reach current and 

potential smokers with media messages that promote its products.
viii

In the United States in 2005—the same year in which 2.7 million American adolescents 

aged 12 to 17 used cigarettes in the past month1 and 438,000 Americans died prematurely 

from diseases caused by tobacco use or secondhand smoke exposure2—the tobacco industry 

spent $13.5 billion (in 2006 dollars) on cigarette advertising and promotion,3 an average 

of $37 million per day. The tobacco industry continues to succeed in overcoming partial 

restrictions on tobacco marketing in the United States, and tobacco marketing remains 

pervasive and effective in promoting tobacco use. Efforts to curb the depiction of tobacco 

use in movies have increased in recent years, and the evidence reviewed here indicates 

that progress in this area could be expected to translate into lower rates of youth smoking 

initiation in the future.

Strong evidence indicates that media campaigns can reduce tobacco use. This underscores 

the importance of adequately funding mass media campaigns and of protecting them from the 

tobacco industry’s efforts to impede them. The monograph provides guidance about the types 

of media campaign messages that are most and least likely to perform well.

This volume highlights the complexities of assessing the media’s infl uence on tobaccorelated attitudes and behavior. The ubiquity of the media means that randomized controlled 

trial designs are typically not feasible, so other study approaches must be used to assess 

causality of associations between exposures and outcomes. Accordingly, a vast range of 

research—from experimental forced-exposure studies in the laboratory to survey and cohort 

studies of populations—is reviewed.

The monograph editors hope that the evidence gathered and synthesized in this volume 

will facilitate progress in tobacco control in the United States and throughout the world. 

This review should be a valuable resource for those seeking to understand the effects of 

tobacco promotion and tobacco control media campaigns in their own jurisdictions as well as 

those charged with implementing aspects of the Framework Convention on Tobacco Control. 

Finally, this monograph contributes to a broader understanding of the media’s past and 

potential roles to exacerbate or ameliorate other major public health problems of our time.

The Scientifi c Editors of Monograph 19

R.D., E.G., B.L., K.V., and M.W.

References

1. Substance Abuse and Mental Health Services Administration. 2005. Results from the 2005 National 

Survey on Drug Use and Health. Offi ce of Applied Studies, NSDUH Series H-27, DHHS Publication 

no. SMA 05–4061. Rockville, MD. http://oas.samhsa.gov/nsduh/2k5nsduh/2k5results.pdf.

2. Centers for Disease Control and Prevention. 2006. Smoking and tobacco use fact sheet: Tobaccorelated mortality (updated September 2006). http//www.cdc.gov/tobacco/data_statistics/Factsheets/

tobacco_related_mortality.htm.

3. Federal Trade Commission. 2007. Federal Trade Commission cigarette report for 2004 and 2005. 

http://www.ftc.gov/reports/tobacco/2007cigarette2004-2005.pdf.

Preface
ix

Monograph Series Editor

Stephen E. Marcus, Ph.D.

Epidemiologist

Tobacco Control Research Branch

Behavioral Research Program

Division of Cancer Control and Population 

Sciences

National Cancer Institute

Bethesda, MD 

Scientifi c Editors

Ronald M. Davis, M.D.

Senior Scientifi c Editor

Director

Center for Health Promotion & Disease 

Prevention

Henry Ford Health System

Detroit, MI 

Elizabeth A. Gilpin, M.S.

Clinical Professor of Biostatistics

Cancer Prevention & Control Program

University of California, San Diego

Moores Cancer Center

La Jolla, CA 

Barbara Loken, Ph.D.

Professor

Department of Marketing

Carlson School of Management

University of Minnesota

Minneapolis, MN

K. Viswanath, Ph.D.

Associate Professor

Department of Society, Human Development 

& Health

Harvard School of Public Health

Department of Medical Oncology

Dana Farber Cancer Institute

Boston, MA 

Melanie A. Wakefi eld, Ph.D.

Senior Scientifi c Editor

Director and NHMRC Principal Research 

Fellow

Centre for Behavioural Research in Cancer

Cancer Control Research Institute

The Cancer Council Victoria

Victoria, Australia

Contributing Authors, Reviewers, and Other 

Contributors are listed in the monograph.

This monograph was developed by the National Cancer Institute under the general direction 

of Stephen E. Marcus, Monograph Series Editor. The Scientifi c Editors Ronald M. Davis,

Elizabeth A. Gilpin, Barbara Loken, K. Viswanath, and Melanie A. Wakefi eld were responsible 

for the editorial content of the monograph. The editors also drafted original chapters or 

sections of chapters for this monograph. Contributing authors drafted chapters or sections of 

chapters. Reviewers with relevant expertise provided critical reviews of the content by section, 

chapter, and/or volume. 

Acknowledgments

1

This Executive Summary should not 

be considered a substitute for the 

comprehensive monograph. Although 

the Executive Summary provides a useful 

synopsis of the purpose, organization, and 

conclusions of the monograph, it is only 

meant as a starting point for researchers, 

practitioners, and policymakers in tobacco 

control and other areas of public health. 

Readers are encouraged to refer to the full 

monograph for an in-depth, peer-reviewed 

synthesis of the scientifi c evidence, as 

well as supporting references and other 

documentation.

Tobacco use is the single largest cause of 

preventable death in the United States. 

According to the Centers for Disease 

Control and Prevention, cigarette 

smoking is responsible for more than 

400,000 premature deaths per year and 

reduces the life expectancy of smokers by 

an average of 14 years. This total exceeds 

the death toll of HIV/AIDS, substance 

abuse, motor-vehicle collisions, suicide, 

and homicide combined.1

In 1964, the fi rst Surgeon General’s report 

on smoking and health raised the alarm 

about the dangers of cigarette smoking.2

Four decades later, despite a rapidly 

growing evidence base on the impact of 

tobacco use, 1 in 5 American adults continue 

to smoke3 and more than 4,000 young 

people smoke their fi rst cigarette each 

day.4 Illnesses caused by smoking cost 

the nation more than $160 billion per 

year in health care expenditures and lost 

productivity. While tobacco use continues, 

evidence implicating the number of illnesses 

caused by tobacco continues to mount. 

Smoking plays a key role in the causation 

of lung, oral, laryngeal, and pharyngeal 

cancers. It has also been implicated in 

other cancers, such as those of the cervix, 

pancreas, and kidney, and has a substantial 

impact on the prevalence of heart disease, 

emphysema, and pneumonia, among other 

health problems.5,6

Yet, the proportion of adults who are current 

smokers has declined from 42% in 1965 

to 21% in 2006,3 and the percentage of 

ever smokers (aged 18–35 years) who have 

quit was 34% in 2006.7

 More important 

for the future, youth smoking prevalence 

has declined substantially; between 

1976 and 2006, the 30-day prevalence 

of current smoking (smoking on one or 

more occasions during the past 30 days) 

among high school students decreased 

from 39% to 22%.8 Given these promising 

trends, how does one explain the paradox 

of millions who successfully quit tobacco 

use while millions more initiate tobacco 

use and continue to smoke? 

The history of tobacco control efforts 

to date ranges from educational and 

community-based efforts directed at 

smoking prevention and cessation to 

policy interventions such as tobacco 

tax increases, clean indoor air laws, and 

stricter enforcement of laws restricting 

youth access to tobacco products.9 Against 

this backdrop, the monograph focuses on 

what remains one of the most important 

phenomena in both tobacco promotion and 

tobacco control: mass communications. 

A uniquely twentieth-century development, 

mass communications are the product of 

enterprises that are explicitly organized 

to produce and distribute information 

products such as news, entertainment, 

and advertising to inform, amuse, and/or 

sell commodities to the public. Analogous 

to the agent-vector-host-environment 

model for transmission of infectious 

diseases, mass media became a powerful 

vector that carried tobacco—the agent—

to a growing number of susceptible hosts 

throughout the country. Mass media have 

Executive Summary
2

also changed the fabric of the environment 

in ways that facilitate the movement of that 

agent (for example, by infl uencing social 

norms surrounding tobacco). At the same 

time, media play a critical role in tobacco 

control, helping to counterbalance the 

protobacco cues in the environment.10

The infl uence of the media and their role 

in product marketing represent one of 

the key developments of modern society. 

Effective advertising and promotion 

through media channels have created 

entire categories of human product and 

service needs beyond basic survival, 

which, in turn, have fueled the economic 

growth of communication media that 

include newspapers, magazines, radio, 

and television. Today, these media have 

evolved to become part of a global virtual 

society linked by channels such as the 

Internet, text messaging, and interactive 

gaming. As mass communications have 

bridged societies around the world, they 

have also magnifi ed the impact of media 

on global public health. Over 80% of the 

more than 1 billion smokers worldwide live 

in developing countries, and the impact of 

globalization has led to an increase of more 

than 250% in cigarette exports from the 

United States alone in the decade preceding 

2002.1,11 Moreover, smoking prevalence in 

the developing world is rising as prevalence 

among developed nations continues to 

decline, with the United Nations projecting 

a 1.7% net global annual increase between 

1998 and 2010. If current trends continue, 

more than one-half billion of the world’s 

current inhabitants are predicted to lose 

their lives to tobacco use,12,13 underscoring 

the urgency of examining the media’s role 

in global tobacco marketing. 

At the same time, the media have an equally 

powerful role in infl uencing individuals 

and policymakers and have made critical 

contributions to the cause of tobacco 

control. Media channels hold the power 

to frame conceptual models, infl uence the 

evolution of these models in the public’s 

perceptions, and ultimately guide these 

perceptions toward the implementation 

of policy.14 Tobacco control interventions 

have been inherently intertwined with 

the media, ranging from the antitobacco 

public service announcements broadcast 

on television under the Federal 

Communications Commission’s (FCC’s) 

Fairness Doctrine in the late 1960s15,16 to the 

advertising restrictions of the 1998 Master 

Settlement Agreement and the advertising 

restrictions contained in the World Health 

Organization’s (WHO’s) Framework 

Convention on Tobacco Control.17 Annual 

adult per capita cigarette consumption 

in the United States has declined from 

its peak level of 4,345 cigarettes in 1963 

to a preliminary estimate of 1,654 in 

2006,18,19 a process that started with the 

media publicity surrounding the 1964 

Surgeon General’s report and continues 

through today’s media advocacy efforts on 

behalf of tobacco control.

Despite these successes, tobacco use still 

accounts for nearly one-third of cancer 

deaths worldwide. As a result of growing 

international tobacco use, WHO predicts 

that deaths caused by tobacco will increase 

to 6.4 million per year by 2015, representing 

10% of all deaths worldwide.10,20 These 

trends, combined with the interrelationships 

between tobacco and media, mean that it 

is critical to understand how exposure to 

media infl uences tobacco use and to explore 

ways to effectively leverage the media to 

improve the overall state of public health.

This Executive Summary provides 

a framework for understanding the 

relationship between tobacco and the media, 

methodological issues in researching mediarelated issues in tobacco, and an overview 

and summary of the specifi c areas addressed 

in the monograph. Subsequent sections 

present the conclusions of individual 

chapters, followed by the major conclusions 

of the volume.

Executive Summary
3

Monograph 19. The Role of the Media

Tobacco and the 

Media: A Multilevel 

Perspective

A complete and comprehensive 

understanding of the role of mass 

communications in tobacco control and 

tobacco promotion requires a multilevel 

approach. At the individual level, one 

must examine how individual-level factors 

such as knowledge, beliefs, and attitudes 

infl uence and are infl uenced by tobaccorelated media messages and the channels 

in which the messages occur. At the 

organizational level, attention needs to be 

focused on (1) how the structure of mass 

media organizations and the practices of 

media practitioners lead to the production of 

media messages in the form of advertising, 

news, and entertainment; (2) how advocates 

for both the tobacco industry and tobacco 

control attempt to infl uence the news and 

entertainment media; and (3) the role of 

regulation and public policy in infl uencing 

tobacco communications. Finally, at the 

population level, it is important to consider 

the larger cultural environment that is 

shaped by the interplay of the tobacco 

industry, mass media, tobacco control 

researchers, advocates, and policymakers.

The media also function at several levels, 

and the levels at which stakeholders on both 

sides of tobacco issues interact with media 

can be seen as a nested relationship, as 

shown in the fi gure on the next page. Each 

level from 1 through 4 represents a broader 

and more indirect level of marketing effort, 

and at the same time, a more powerful 

one. For example, although the ultimate 

impact of media efforts may be felt most 

clearly by direct consumer response to 

advertising or marketing communications, 

interventions at the stakeholder level often 

have broad-reaching effects on promotional 

efforts, social attitudes toward an issue or 

product, or even policies and regulation. 

The monograph attempts to examine 

the dynamics of tobacco-related media 

interventions at each of these levels, within 

a systemic framework.

The relationships among these levels and 

stakeholders on either side of the tobacco 

debate, and their relationships with chapters 

in the monograph, can be seen as follows:

Advertising. Cigarette advertising and 

promotion in the United States totaled 

more than $13.5 billion in 2005 (in 2006 

dollars),21 with effects that included 

recruiting new smokers, especially young 

smokers, as well as expanding the market for 

tobacco products by reinforcing smoking, 

discouraging quitting, and appealing 

to health concerns. Chapter 4 provides 

an overview of tobacco advertising and 

promotional efforts throughout modern 

history, while chapters 3 and 8 examine 

the rationales for and legal issues faced in 

regulating such efforts. Chapter 11 provides 

a detailed look at the strategies and themes 

of media efforts used by tobacco control 

advocates. Finally, chapter 14 explores how 

the tobacco industry uses media advertising 

and promotion to defeat state tobacco 

control referenda and ballot initiatives.

Marketing communications. Tobacco 

advertising forms part of an integrated 

marketing communications strategy 

combining sponsorship, brand 

merchandising, brand stretching, 

packaging, point-of-sale promotions, and 

product placement, across a broad range 

of channels ranging from event marketing 

to the Internet.22,23 Chapter 3 explores 

key aspects of the branding process, and 

(along with chapter 4) defi nes these terms 

and strategies as they relate to tobacco. 

Chapter 6 examines tobacco manufacturers’ 

corporate sponsorship efforts—i.e., those 

carried out in the name of the company 

but not connected to a specifi c tobacco 

product brand. Chapter 15, the monograph’s 

concluding chapter, examines future issues 
4

in tobacco promotion, including pointof-sale displays, discounting, and brand 

marketing, in the context of the current 

regulatory and social environment.

Consumer marketing. Consumer-product 

marketing efforts, including pricing, 

distribution, packaging, and product 

design, are aimed at the development of 

tobacco product brand identities that often 

are targeted toward specifi c demographic, 

psychographic, or ethnic markets.24,25

Chapter 3 examines key principles of 

targeted marketing and communicating 

brand image, while chapter 5 looks in 

detail at common marketing themes used 

by tobacco companies to reach their target 

audiences. An even more important issue 

is the effectiveness of such media efforts 

on targeted consumers. Chapters 7 and 12 

review the impact of media interventions 

by tobacco industry and tobacco control 

advocates, respectively, on smoking behavior, 

while chapters 9 and 10 explore the role 

of the news and entertainment media in 

infl uencing tobacco use among consumers.

Stakeholder marketing. Image- and 

relationship-building initiatives aimed at 

stakeholders, such as retailers, the hospitality 

industry, and policymakers, range 

from personal outreach to mass media 

Executive Summary

The Nested Relationships among Advertising, Marketing Communications, Consumer 

Marketing, and Stakeholder Marketing in Tobacco Promotion

Television

Billboards 

Radio

Cinema 

Press

Sponsorship 

Merchandising 

Point-of-sale

promotions

Internet Product

placement

Brand

stretching

Loyalty

schemes

Free samples 

Packaging 

Product

design 

Pricing 

Distribution 

Youth

prevention

Health

warnings

Corporate social

responsibility

Media

training

Relationship

building

Scientific

seminars

Other Marketing 2 Communications

Consumer 3 Marketing

Stakeholder 4 Marketing

Mass Media 1 Advertising
5

Monograph 19. The Role of the Media

organizations and public relations efforts 

around broad themes such as corporate social 

responsibility, youth smoking prevention, and 

providing information on health risks.26–28

Chapters 6 and 9, discussed previously, 

explore corporate advertising and news media 

advocacy as tools to create an image among 

stakeholders, while chapter 13 addresses 

how the tobacco industry uses stakeholder 

marketing efforts in an attempt to mitigate 

the impact of tobacco control media 

interventions on tobacco product sales.

These integrated levels of marketing and 

promotion pose a challenge to the goals 

of tobacco control and public health and 

underscore the need to further examine 

appropriate policy interventions to address 

the role of media efforts by the tobacco 

industry. Moreover, as direct advertising 

channels have become increasingly 

restricted by policy interventions on both 

the domestic and global levels, promotional 

expenditures for tobacco continue to 

increase in areas such as point-of-purchase 

displays, promotional allowances, and 

viral, or “stealth,” marketing.21,24,25,29,30

Given these trends and the realities of a 

digitally interconnected age, public health 

stakeholders must continue to monitor the 

relationship between media and tobacco use 

as both evolve in the twenty-fi rst century.

Studying the Media 

and Tobacco

As is the case with most social science 

research, assessing causality is a 

signifi cant challenge—in this instance, 

in determining the relationship between 

mass communications and tobacco-related 

outcomes. Establishing causality is even 

more challenging in the case of mass 

communications, given their ubiquity, the 

complex nature of communication effects, 

and the limitations of research designs.31,32

Major challenges in assessing causality in 

media studies include the following:

■ Media effects are complex and 

multidimensional:32 (1) media can have 

short-term effects such as the impact of 

a short burst of advertising on consumer 

attitudes and behaviors—for example, 

on sales of cigarettes—and long-term 

effects that are stable and sustained, 

such as on social norms and values; 

(2) media infl uence may be at the micro 

level, such as on individual cognitions, 

affect, and behavior, or at the macro 

level, infl uencing social policies, social 

movements, and social actors; (3) some 

effects may alter norms or opinions, such 

as changing norms regarding tobacco 

use, while others may stabilize and 

reinforce existing norms on smoking; 

(4) the effects of media can accumulate 

after sustained exposure to messages or 

be noncumulative; (5) media infl uence 

may range from effects on individual 

cognitions or attitudes to direct behavior; 

(6) some media effects are direct and 

others conditional; and (7) media effects 

can be as diffuse as general exposure to 

media or can be content specifi c. 

■ It is diffi cult to establish control groups. 

In epidemiology, some consider the 

randomized clinical trial as a gold 

standard that can clearly establish 

the difference in “exposures” between 

control and treatment groups. The 

fundamental assumption behind the idea 

of a control group is that the members of 

this group are not exposed to “treatment,” 

in contrast to an intervention group 

that is exposed to treatment.5 In the case 

of media, it is often diffi cult to confi ne 

the spread of messages to specifi ed 

geographic areas, control for prior 

exposure or “background” exposure to the 

messages, blunt the impact of competing 

messages, and achieve suffi cient exposure 

to messages in the treatment group so 

that it can be distinguished from controlgroup exposure.

■ As noted above, media effects, particularly 

in the complex domain of health, 
6

may take longer to establish, whereas 

most research designs may not have 

observations for a suffi ciently long 

duration to document the effects.31

A research design with observations 

over a short duration may not be able to 

document media effects adequately. 

■ Media effects can be selective for certain 

population subgroups; that is, not all 

groups are equally infl uenced by the 

media. For example, evidence shows that 

information campaigns or diffusion of 

information could potentially benefi t 

some groups more than others.10,33

■ Media effects are not always direct but 

instead may be diffused through others.31

For example, a campaign to promote a 

tobacco quitline may reach a smoker 

only through a family member or 

friend who is exposed to the campaign 

and shares messages with the smoker. 

If the observations are limited to those 

receiving quitline services, one might 

underestimate the effectiveness of 

the campaign.

■ Last, the all-pervasive nature of the media 

environment includes both messages of 

interest as well as background “noise.”

Given these challenges, no single study 

method or design is likely to provide the 

weight of evidence necessary for causal 

inferences regarding the infl uence of 

mass communications on tobacco control 

or tobacco promotion. What is needed 

is a combination of methods, designs, 

interpretive techniques, and judgments 

that provides a body of evidence to enable 

an overall assessment of the relationship 

between media and outcomes pertaining 

to tobacco use.34 In assessing the impact of 

media, studies should examine how media 

messages are generated (e.g., interplay 

between journalistic practices and 

tobacco industry efforts to infl uence 

news coverage), the nature of the media 

environment (how news on tobacco use 

and its effects are covered or the depiction 

of tobacco use in entertainment media), 

and the impact of the media environment 

on a range of tobacco-related outcomes. 

The phrase “range of tobacco-related 

outcomes” is worth underscoring here. 

Unlike epidemiological studies in many 

other fi elds of research—in which 

exposure-outcome relationships are more 

straightforward—it is not always easy to 

establish a direct causal link between media 

messages and behavior. Often, as discussed 

above, media effects could be on antecedents 

to behavior such as beliefs, norms, and 

intentions. Focusing on behavior alone 

could lead one to falsely conclude that media 

effects are weak. 

The monograph reviews studies based on 

multiple research designs and methods 

including surveys, fi eld and laboratory 

experiments, and analyses of media content 

and tobacco industry documents. Studies 

based on surveys of population groups or 

subgroups have the advantage of observing 

people in their natural environment, do 

not interrupt or disrupt their routines, 

and are generalizable. What is gained in 

external validity, however, is traded against 

internal validity in the form of controlling 

for extraneous factors. The choice of 

these control variables is often important. 

Surveys can be single or repeated crosssections, or they can be longitudinal (or 

panel) designs in which the same persons 

are interviewed at different points in time. 

The latter method can be quite effective in 

measuring change over time and can be an 

important contributor to providing evidence 

of causality.

Experiments, particularly laboratorybased experiments, provide the advantage 

of internal validity and are helpful in 

confi rming causal relationships. These 

experiments, however, are often limited 

in terms of the rather forced nature of 

exposure, unnatural viewing situations, 

and the limitations of the experimental 

Executive Summary
7

Monograph 19. The Role of the Media

populations, which are often college 

students. Field experiments have the 

potential to increase external validity, while 

maintaining a degree of internal validity, but 

are subject to a number of sources of error, 

as discussed by Cook and Campbell in their 

classic work on quasi-experimental designs.35

Analyses of media content can be both 

quantitative and qualitative. The analysis 

of news content on tobacco for example, 

as reviewed in chapter 9, demonstrates how 

systematic analysis of news coverage can 

provide an understanding of the news to 

which consumers are likely to be exposed. 

This facilitates the interpretation of the 

impact of news content on audiences exposed 

to news. Systematic content analyses 

require that the criteria for classifying media 

content be explicit and formal and that the 

classifi cation, or coding, be done by more 

than one coder. Documentary analysis 

(e.g., the analyses of tobacco industry efforts 

to infl uence media) may not be “systematic” 

but may rely more on expert judgment. This 

analysis can be considered valid as long as 

the criteria for interpretation are transparent 

and the inferences are plausible in light of 

the evidence from other methods.

In summary, the monograph relies on 

the totality of evidence from multiple 

studies using a variety of research designs 

and methods to understand the effects 

of media on tobacco promotion and 

tobacco control. The evidence is based on 

consistency, strength of associations, and 

theoretical plausibility.5,34

Preparation of the 

Monograph

The National Cancer Institute’s Tobacco 

Control Research Branch invited fi ve 

experts representing the domains of 

medicine, public health, communications, 

marketing, epidemiology, and statistics 

to serve as editors of the monograph. 

This ambitious effort to synthesize the 

science included the contributions from 

23 authors selected for their individual 

expertise. The monograph was subjected 

to a rigorous review process, which began 

with a review of the monograph outline. 

As each chapter was drafted, the chapter 

was reviewed by multiple peer reviewers 

with expertise on the individual topic. 

When the entire volume was complete, 

the full draft was submitted to expert 

reviewers who evaluated the monograph 

as a whole, who related one chapter to 

another, and who ensured that the volume 

level conclusions were supported by the 

monograph’s content. The National Cancer 

Institute conducted the fi nal review before 

the monograph was printed. Comments 

from 62 expert reviewers formed the basis 

of revisions the authors and volume editors 

made to the monograph. All of these efforts 

have culminated in a monograph that 

includes nearly 2,000 references, 44 tables, 

15 fi gures, and numerous illustrative 

examples used in the media to promote 

and to discourage tobacco use. 

The monograph is supported by its Web 

page, http://www.cancercontrol.cancer.gov/

tcrb/monographs/19/index.htm, where 

supplemental materials for the monograph 

(fact sheets and presentation slides) and 

links to additional resources on the media 

and tobacco are located. 

Monograph 

Organization

The monograph refl ects a comprehensive 

examination of how mass media have been 

used in both tobacco promotion and tobacco 

control by various stakeholders and the 

consequences of such use. This examination 

included reviewing 

■ different types of media, such as news, 

television, advertising, movies, and 

the Internet;
8

■ strategies to infl uence the content of 

media products, such as public relations 

and strategic communications; and 

■ the effects of media communications on 

tobacco initiation and use.

Part 1—Introduction, frames the discussion 

of media and tobacco use. This fi rst chapter 

provides an overview of the topic of the 

monograph. It also includes volumelevel conclusions and chapter-by-chapter 

synopses and conclusions. The second 

chapter summarizes the theoretical 

underpinnings of media research that 

support the rationale and methodology 

for the subsequent examination of specifi c 

areas of interest surrounding tobacco 

and media.

Part 2—Tobacco Marketing, explores 

issues related to the media interventions 

used by the tobacco industry to promote 

its products. Its chapters focus on areas 

that include several aspects of tobacco 

advertising and promotion, the use of 

media by the tobacco industry for corporate 

sponsorship and advertising, the infl uence 

of tobacco marketing on smoking behavior, 

and the regulatory and constitutional issues 

surrounding policy interventions directed 

at tobacco marketing.

Part 3—Tobacco in News and 

Entertainment Media, looks at two media 

channels that go beyond traditional paid 

advertising and promotion to play a key 

role in shaping public opinion on smoking. 

Its chapters explore how news media 

coverage infl uences tobacco use and the role 

that entertainment media play in attitudes 

toward tobacco use.

Part 4—Tobacco Control Media 

Interventions, focuses on how media efforts 

are used in support of tobacco cessation and 

prevention, including an overview of the 

strategies and themes in tobacco control 

media interventions and efforts to assess the 

effectiveness of mass media campaigns in 

reducing smoking.

Part 5—Media, Tobacco Control 

Interventions, and Tobacco Industry 

Mitigation Efforts, discusses two separate 

aspects of tobacco industry counterefforts 

and the media: the industry’s efforts to 

weaken tobacco control media interventions 

and its use of the media in the political 

realm to attempt to defeat state tobacco 

control ballot initiatives and referenda.

Part 6—Future Directions, examines 

possible future trends in the use of media 

for both tobacco promotion and tobacco 

control, as a summary of the issues 

discussed throughout the previous sections.

Major Conclusions

These conclusions are based on the scientifi c 

evidence and evaluation provided in the 

monograph.

1. Media communications play a key 

role in shaping tobacco-related 

knowledge, opinions, attitudes, and 

behaviors among individuals and within 

communities. Media communications 

on tobacco include brand-specifi c 

advertising and promotion, news 

coverage, depictions of tobacco use 

and tobacco products in entertainment 

media, public relations, corporate 

sponsorship, corporate advertising, 

political advertising for ballot initiatives 

and referenda, and media campaigns 

for tobacco control.

2. Cigarettes are one of the most heavily 

marketed products in the United States. 

Between 1940 and 2005, U.S. cigarette 

manufacturers spent about $250 billion 

(in 2006 dollars) on cigarette advertising 

and promotion. In 2005, the industry 

spent $13.5 billion (in 2006 dollars) on 

cigarette advertising and promotion 

Executive Summary
9

Monograph 19. The Role of the Media

($37 million per day on average). 

Currently, most of the cigarette 

industry’s marketing budget is allocated 

to promotional activities, especially 

for price discounts. Price discounts 

accounted for 75% of total marketing 

expenditures in 2005 ($10.1 billion in 

2006 dollars). Less than 1% of cigarette 

marketing expenditures are now used for 

advertising in traditional print media.

3. Tobacco advertising has been 

dominated by three themes: providing 

satisfaction (taste, freshness, mildness, 

etc.), assuaging anxieties about the 

dangers of smoking, and creating 

associations between smoking and 

desirable outcomes (independence, 

social success, sexual attraction, 

thinness, etc.). Targeting various 

population groups—including 

men, women, youth and young 

adults, specifi c racial and ethnic 

populations, religious groups, the 

working class, and gay and lesbian 

populations—has been strategically 

important to the tobacco industry.

4. The total weight of evidence—from 

multiple types of studies, conducted by 

investigators from different disciplines, 

and using data from many countries—

demonstrates a causal relationship 

between tobacco advertising and 

promotion and increased tobacco use.

5. The depiction of cigarette smoking 

is pervasive in movies, occurring in 

three-quarters or more of contemporary 

box-offi ce hits. Identifi able cigarette 

brands appear in about one-third of 

movies. The total weight of evidence 

from cross-sectional, longitudinal, 

and experimental studies indicates a 

causal relationship between exposure 

to depictions of smoking in movies and 

youth smoking initiation.

6. Evidence from controlled fi eld 

experiments and population studies 

shows that mass media campaigns 

designed to discourage tobacco use 

can change youth attitudes about 

tobacco use, curb smoking initiation, 

and encourage adult cessation. The 

initiation effect appears greater in 

controlled fi eld experiments when 

mass media campaigns are combined 

with school- and/or community-based 

programming. Many population studies 

document reductions in smoking 

prevalence when mass media campaigns 

are combined with other strategies 

in multicomponent tobacco control 

programs.

Chapter Summaries 

and Conclusions

Part 1—Introduction

Chapter 1. Overview and Conclusions

Chapter 1 provides an introduction and 

framework for the monograph, describes 

how it is organized, and includes major 

volume conclusions and individual 

chapter conclusions. 

Chapter 2. Theoretical Underpinnings 

of Media Research in Tobacco Control 

and Tobacco Prevention

This chapter examines the history and 

theory of conceptual models currently 

used in media research. It looks at three 

broad levels of theories and analysis for 

media studies in tobacco—the individual, 

organizational, and societal levels—

and how these levels affect the framing 

of research efforts and their fi ndings. 

This chapter lays the groundwork for 

understanding some of the important 

theoretical and methodological differences 

underlying the media studies discussed 

in the monograph and their impact on 

tobacco control efforts.
10

Executive Summary

Part 2—Tobacco Marketing

Chapter 3. Key Principles of Tobacco 

Promotion and Rationales for 

Regulation

This chapter explores the use of advertising 

and promotion by the tobacco industry 

to create demand for its products, 

including market segmentation to target 

consumers by demographic, geographic, 

behavioral, and psychographic factors, 

as well as branding strategies to create a 

consistent product identity and message.

Conclusions

1. The promotion of tobacco products 

involves sophisticated targeting and 

market segmentation of potential 

customers. Common market 

segmentation dimensions include 

demographics (e.g., age, gender, race/

ethnicity), geography (e.g., market 

density, regional differences within 

a domestic or international market), 

behavioral characteristics (e.g., occasions 

of cigarette use, extent of use, user’s 

smoking status), and psychographics 

(lifestyle analysis). 

2. Internal tobacco company documents 

reveal that two key typologies of 

cigarette consumers used by cigarette 

fi rms are “starters” (who frequently 

initiate smoking during adolescence) 

and “pre-quitters” (i.e., existing smokers 

who need reassurance).

3. The brand image of most tobacco 

products represents the end result of a 

multifaceted marketing effort involving 

brand identity, logos, taglines and slogans, 

pictorial elements, and the use of color. 

The development, enhancement, and 

reinforcement of this brand imagery are 

primary objectives of tobacco promotion. 

4. Tobacco companies have designed 

their communications of brand image 

to use principles relating to message 

repetition, consistency, and relevance to 

a contemporary audience. The brand’s 

image is built slowly and collectively by 

all of the accumulated associations and 

images of the communications strategy, 

such as social status, sophistication 

and social acceptance, athleticism and 

healthfulness, glamour and fashion, 

rewarded risk-taking and adventure, 

and masculinity or femininity. 

5. The key rationales cited for 

implementing a comprehensive ban 

on tobacco advertising and promotion 

include (1) the health consequences 

of tobacco use (including addiction); 

(2) the deceptive or misleading nature of 

several tobacco promotional campaigns; 

(3) the unavoidable exposure of youth to 

these campaigns; (4) the role of tobacco 

advertising and promotion in increasing 

tobacco use in the population, especially 

among youth; (5) the targeting of 

“at-risk” populations, including youth, 

women, and ethnic and racial minorities, 

through advertising and promotion; 

(6) the failure of the tobacco industry 

to effectively self-regulate its marketing 

practices; and (7) the ineffectiveness of 

partial advertising bans. 

6. Substantial evidence exists from the United 

States and several other countries that the 

tobacco industry does not effectively selfregulate its marketing practices.

7. Substantial evidence exists from the 

United States and several other countries 

that tobacco companies typically respond 

to partial advertising bans in ways that 

undermine the ban’s effectiveness. These 

responses include shifting promotional 

expenditures from “banned” media to 

“permitted” media (which may include 

emerging technologies and “new” 

media), changing the types and targets 

of advertising in permitted media, 

using tobacco-product brand names 

for nontobacco products and services, 
11

Monograph 19. The Role of the Media

and availing themselves of imprecise 

clauses in the legislative text of the bans 

that allow them to continue to promote 

their products.

Chapter 4. Types and Extent of 

Tobacco Advertising and Promotion

This chapter examines the scope of 

tobacco advertising and promotion in the 

United States and its evolution over time. 

Areas discussed include a taxonomy of past 

and present channels used in advertising 

and promoting tobacco products; emerging 

promotional channels such as packaging, 

viral marketing, and the Internet; and 

recent trends in tobacco advertising and 

promotional expenditures, including the 

shift from traditional print advertising to 

promotional activities.

Conclusions

1. Cigarettes are one of the most heavily 

marketed products in the United States. 

Between 1940 and 2005, U.S. cigarette 

manufacturers spent about $250 billion 

(in 2006 dollars) on cigarette advertising 

and promotion. In 2005, the industry 

spent $13.5 billion (in 2006 dollars) on 

cigarette advertising and promotion 

($37 million per day on average).

2. Most of the cigarette industry’s 

marketing budget is allocated to 

promotional activities, especially for 

price discounts, which accounted for 75% 

($10.1 billion in 2006 dollars) of total 

marketing expenditures in 2005. From 

1970 to 2005, the pattern of marketing 

expenditures shifted dramatically; the 

proportion of expenditures allocated 

for advertising in “measured media” 

decreased from 82% in 1970 to almost 

none in 2005. Measured media include 

television, radio, newspapers, magazines, 

and billboards. Correspondingly, the 

proportion of marketing expenditures 

devoted to promotional activities 

increased from 18% to almost 100%.

3. During the past three decades, 

Philip Morris has consistently 

committed more than $100 million per 

year (in 2006 dollars) to advertising 

for Marlboro, the industry’s dominant 

brand, which currently has 40% of the 

U.S. market share. In 2006, the Marlboro 

brand was the 12th most highly valued 

brand worldwide, with an estimated 

$21.4 billion in brand equity.

4. Expenditures for smokeless tobacco 

advertising and promotion reached 

$259 million (in 2006 dollars) in 2005. 

The fi ve largest categories of expenditure 

were price discounts (40%), coupons 

(11%), sampling (11%), point of sale 

(8%), and magazines (8%).

5. Cigarette advertising and promotion 

are heavy in volume and high in 

visibility at the point of sale, particularly 

in convenience stores. Cigarette 

marketing at the point of sale increased 

substantially after the 1998 Master 

Settlement Agreement, which included 

a ban on cigarette advertising on 

billboards. About 60% of all cigarettes 

sold in the United States are purchased 

in convenience stores, where cigarettes 

are the top in-store product category in 

terms of consumer sales.

6. As cigarette advertising is being curtailed 

in some traditional media, cigarette 

companies are exploring the use of new 

or nontraditional media for distributing 

protobacco messages and images, 

including the Internet and cigarette 

packages. In addition, cigarette fi rms 

(like other companies) are experimenting 

with viral (stealth) marketing to create a 

“buzz” about a product.

Chapter 5. Themes and Targets of 

Tobacco Advertising and Promotion

This chapter provides an overview of specifi c 

themes and population targets used in 

tobacco advertising and promotion on the 
12

Executive Summary

basis of studies of marketing materials and 

tobacco industry documents. It examines 

key themes for tobacco marketing efforts 

such as taste and satisfaction, implied harm 

reduction, social affi nity, brand loyalty, and 

“smokers’ rights.” It also discusses efforts 

to market tobacco products to specifi c 

populations—most of which are defi ned by 

age, gender, race or ethnicity, and sexual 

orientation—and the implications of these 

targets for marketing themes and brand 

identity.

Conclusions

1. Tobacco advertising has been dominated 

by three broad themes: providing 

satisfaction (taste, freshness, mildness, 

etc.), assuaging anxieties about the 

dangers of smoking, and creating 

associations between smoking and 

desirable outcomes (independence, social 

success, sexual attraction, thinness, etc.).

2. Targeting various population groups—

including men, women, youth and 

young adults, specifi c racial and ethnic 

populations, religious groups, the 

working class, and gay and lesbian 

populations—has been strategically 

important to the tobacco industry. 

3. The tobacco industry has become 

increasingly sophisticated in applying 

market research to population segments 

in order to design products, messages, 

communication channels, and 

promotions more aligned with the needs 

and susceptibilities of particular market 

segments. This research results in more 

effi ciency, greater reach, and increased 

effectiveness for marketing activities 

aimed at targeted populations.

4. Little attention has been paid to 

understanding tobacco marketing 

aimed at American Indians and Alaska 

Natives, despite their high prevalence 

of tobacco use.

5. Targeted marketing of tobacco products 

to specifi c groups such as youth, women, 

and minorities has become a focus for 

monitoring and protest by antitobacco 

advocates and community groups.

Chapter 6. Tobacco Companies’ 

Public Relations Efforts: Corporate 

Sponsorship and Advertising

This chapter examines corporate public 

relations activities that can have an 

important impact on public perceptions 

of and attitudes toward individual tobacco 

companies. Such activities include 

corporate sponsorship activities targeting 

core customer groups, corporate advocacy 

advertising in areas such as youth smoking, 

and corporate image advertising designed 

to highlight charitable work or create a 

new corporate brand identity.

Conclusions

1. Corporate sponsorship of events and 

social causes represents a key public 

relations strategy for major tobacco 

companies, which spent more than 

$360 million on these efforts in 2003. 

Key targets included sporting events, 

antihunger organizations, and arts and 

minority organizations. These efforts 

have been used, in certain cases, to 

infl uence opinion leaders who benefi t 

from such sponsorship. 

2. Corporate image campaigns by tobacco 

companies have highlighted their 

charitable work in the community 

and have promoted their youth 

smoking prevention programs; 

at times, corporate spending on these 

campaigns has vastly exceeded the 

amount actually given to the charities. 

These campaigns have reduced 

perceptions among adolescents and 

adults that tobacco companies are 

dishonest and culpable for adolescent 

smoking, and among adults, have 

increased perceptions of responsible 

marketing practices and favorable 

ratings for the individual companies.
13

Monograph 19. The Role of the Media

3. Tobacco industry youth smoking 

prevention campaigns have been 

generally ineffective in reducing youth 

smoking. Moreover, they may even have 

increased smoking in some subgroups 

of youth. 

4. Tobacco industry public relations efforts 

such as corporate sponsorship and 

advertising may make audiences more 

resistant to criticism of the industry, 

may mitigate jurors’ negative views 

toward the industry, and may weaken 

public or legislative support for tobacco 

control policies. 

5. Systematic monitoring and descriptions 

of tobacco companies’ activities and 

expenditures for corporate sponsorship 

and advertising are needed to better 

understand the impact of these 

activities on the public image of tobacco 

companies, on consumers’ smoking 

intentions and behaviors, and on the 

image of sponsored events and causes. 

Chapter 7. Infl uence of Tobacco 

Marketing on Smoking Behavior

This chapter examines the evidence base 

for how tobacco marketing efforts affect 

tobacco use by adolescents as well as tobacco 

consumption across the general population 

by using results from numerous studies 

as well as fi ndings from tobacco industry 

documents. Areas examined include the 

relationship between cigarette advertising 

and adolescent needs and self-image, the 

effects of marketing exposure on adolescent 

smoking, and the relationship between 

tobacco marketing expenditures and overall 

tobacco consumption.

Conclusions

1. Much tobacco advertising targets the 

psychological needs of adolescents, 

such as popularity, peer acceptance, 

and positive self-image. Advertising 

creates the perception that smoking 

will satisfy these needs.

2. Adolescents who believe that smoking 

can satisfy their psychological needs or 

whose desired image of themselves is 

similar to their image of smokers are 

more likely to smoke cigarettes.

3. Experimental studies show that even 

brief exposure to tobacco advertising 

infl uences adolescents’ attitudes and 

perceptions about smoking and smokers, 

and adolescents’ intentions to smoke.

4. The vast majority of cross-sectional 

studies fi nd an association between 

exposure to cigarette advertising, 

measured in numerous ways, and 

adolescent smoking behavior, measured 

in numerous ways, indicating a robust 

association.

5. Strong and consistent evidence from 

longitudinal studies indicates that 

exposure to cigarette advertising 

infl uences nonsmoking adolescents to 

initiate smoking and to move toward 

regular smoking.

6. Many econometric studies have used 

national time-series data to examine the 

association between tobacco advertising 

expenditures and tobacco consumption. 

Some of these studies found a small 

positive effect of advertising on 

consumption. Other studies failed to fi nd 

a positive effect, probably because the 

data used had little variance and were 

measured at a high level of advertising 

expenditure at which changes in the 

volume of advertising have little or no 

marginal effect.

7. The evidence from three cross-sectional 

econometric studies using disaggregated 

local-level data indicates a positive effect 

of advertising on tobacco consumption.

8. The studies of tobacco advertising 

bans in various countries show that 

comprehensive bans reduce tobacco 

consumption. Noncomprehensive 

restrictions generally induce an 

increase in expenditures for advertising 
14

Executive Summary

in “nonbanned” media and for other 

marketing activities, which offset the 

effect of the partial ban so that any net 

change in consumption is minimal 

or undetectable. 

9. The total weight of evidence from 

multiple types of studies, conducted by 

investigators from different disciplines, 

using data from many countries, 

demonstrates a causal relationship 

between tobacco advertising and 

promotion and increased tobacco use, 

as manifested by increased smoking 

initiation and increased per capita 

tobacco consumption in the population.

Chapter 8. Legal and Constitutional 

Perspectives on Tobacco Marketing 

Restrictions

This chapter explores legal and 

constitutional issues surrounding regulation 

of tobacco promotion within the context 

of legislative efforts in the United States as 

well as WHO’s Framework Convention on 

Tobacco Control. 

Conclusions

1. The First Amendment to the U.S. 

Constitution, as the Supreme Court 

has interpreted it in recent years, 

grants broad protection for commercial 

speech, including speech about tobacco 

products. The Court has precluded 

regulation of tobacco products by the 

U.S. Food and Drug Administration 

(FDA) on the basis of the Court’s analysis 

of existing authorities under the FDA’s 

governing statute and the complex 

balance that Congress has struck 

between protecting and promoting 

trade in tobacco products and informing 

consumers of their dangers.

2. The Federal Trade Commission has 

authority to prevent “unfair or deceptive 

acts or practices in or affecting 

commerce.” However, the agency’s 

efforts to prevent tobacco advertisements 

that are false or misleading have been 

limited. 

3. Canada and the European Union 

have imposed limitations on tobacco 

advertising and promotion, but these 

policies were weakened as a result of 

legal challenges. Nevertheless, Canadian 

and European restrictions on tobacco 

marketing are stronger than those 

currently in place in the United States.

4. The Framework Convention on 

Tobacco Control (FCTC), the fi rst treaty 

ever negotiated by the World Health 

Organization, calls on each party to the 

treaty to “undertake a comprehensive 

ban of all tobacco advertising, promotion 

and sponsorship ... in accordance with its 

constitution or constitutional principles.” 

As of April 2008, 154 countries were 

parties to the FCTC. The United States 

signed the treaty in May 2004 but has 

yet to ratify it. 

Part 3—Tobacco in News and 

Entertainment Media

Chapter 9. How the News Media 

Infl uence Tobacco Use

This chapter examines news media 

coverage of tobacco issues and its ultimate 

relationship with both individual tobacco 

use outcomes and policy interventions. 

It looks at the nature and volume of tobacco 

issue coverage and provides a content 

analysis of news media items referring to 

tobacco. It also examines common framing 

issues for tobacco-related news items as 

well as relationships with outcome measures 

and tobacco industry efforts to infl uence 

media coverage.

Conclusions

1. The news media represent a key source 

of health information for the general 

public. More important, they serve 
15

Monograph 19. The Role of the Media

as a framing mechanism for issues 

surrounding tobacco control. As a 

result, news coverage is a frequent aim 

of stakeholder activity on both sides of 

tobacco-related issues. However, only 

a small proportion of tobacco control 

research has been devoted to news media 

issues to date.

2. News coverage that supports tobacco 

control has been shown to set the agenda 

for further change at the community, 

state, and national levels. Despite this, 

organized media advocacy efforts on 

behalf of tobacco control issues remain 

an underutilized area of activity within 

public health.

3. Key issues covered as news stories 

include secondhand smoke, tobacco 

policies, and the health effects of 

smoking. Studies of tobacco-related news 

coverage often show that the majority of 

stories favor tobacco control progress, 

including opinion pieces. Other studies 

have shown the tobacco industry to be 

successful in gaining consistent coverage 

for selected issues.

4. Content analyses of tobacco-related 

news articles have revealed some trends 

that remain favorable to protobacco 

interests. These trends include the 

underrepresentation of tobacco farming 

diversifi cation in the farming press, 

a tendency of articles to challenge the 

science behind secondhand smoke 

issues, and positive coverage of the 

growth in cigar smoking.

5. Numerous factors can affect the 

volume and nature of tobacco 

news coverage. The American Stop 

Smoking Intervention Study found 

more support for tobacco control in 

letters to the editor in participating 

states, and editors largely support 

tobacco control efforts. However, news 

coverage often focuses on specifi c areas 

such as tobacco control policies, the 

outcomes of tobacco lawsuits, or the 

disbursement of Master Settlement 

Agreement funds.

6. Large-scale studies have yet to be 

undertaken investigating associations 

between tobacco-related news 

coverage and attitudes, behaviors, 

and outcomes related to tobacco 

use. These studies face challenges in 

separating the effects of news coverage 

from those of the interventions or 

policy changes they describe. Research 

shows potential evidence for such 

an impact, including a drop in per 

capita cigarette consumption after 

news coverage of the 1964 Surgeon 

General’s report on smoking and 

health, a relationship between 

tobacco-related news coverage and 

cessation, and a link between news 

coverage of specifi c tobacco control 

efforts and lower adolescent smoking 

prevalence and consumption.

7. Paid tobacco advertising tends to 

suppress or reduce news coverage of 

tobacco-related issues, particularly in 

magazines. However, bans on tobacco 

advertising that accompany ratifi cation 

of the World Health Organization’s 

Framework Convention on Tobacco 

Control may impair the tobacco 

industry’s ability to exert editorial 

control over published content.

Chapter 10. Role of Entertainment 

Media in Promoting or Discouraging 

Tobacco Use 

This chapter looks at the impact of media 

channels for entertainment on attitudes 

and outcomes related to smoking in an 

environment in which American youth are 

exposed to more than fi ve hours per day of 

media from television and other sources. 

It describes portrayals of tobacco products 

and tobacco use in the movies together 

with a discussion of other channels such 

as television, music, magazines, and the 
16

Executive Summary

Internet. It also looks at the infl uence of 

such portrayals on social attitudes and 

behaviors related to smoking, as well as 

current strategies for reducing media 

exposure to tobacco products.

Conclusions

1. Children and adolescents in the 

United States have heavy exposure to 

entertainment media, with an average 

of 5.5 person-hours of media use per 

day. Tobacco use often is integrated into 

entertainment media programming, 

especially in movies.

2. Portrayals of tobacco in movies include 

images of tobacco use and images of 

tobacco product brand names and logos. 

Depictions of smoking are pervasive in 

movies, occurring in three-quarters or 

more of contemporary box-offi ce hits. 

Cigar use also is commonly depicted in 

movies, but use of smokeless tobacco 

is not. Smoking is more common in 

movies rated for adults (i.e., R-rated), but 

depiction of smoking is not related to boxoffi ce success. Identifi able cigarette brands 

appeared in about one-third of movies 

released during the 1990s. In contrast to 

its frequent depiction in movies, tobacco 

use is found in about 20% of television 

shows and 25% of music videos.

3. Smoking prevalence among contemporary 

movie characters is approximately 25%, 

about twice what it was in the 1970s and 

1980s. In contrast, smoking in the general 

population has declined since the 1970s. 

Smokers in movies differ from smokers 

in the general population: the former 

are more likely to be affl uent and white. 

The health consequences of smoking are 

rarely depicted in movies.

4. Cross-sectional studies show that, 

among adolescents, exposure to smoking 

in movies is associated with initiation of 

smoking, independent of several other 

factors such as smoking by friends and 

family. Cross-sectional studies also 

indicate that among adolescent never 

smokers, exposure to smoking in movies 

is associated with more positive attitudes 

toward smoking.

5. Two longitudinal studies demonstrate 

that adolescents with higher exposure to 

smoking in movies at baseline are 2.0 to 

2.7 times more likely to try cigarette 

smoking in the future. More studies are 

needed on the role exposure to smoking 

in movies plays in adolescents’ smoking 

beyond the initiation phase. 

6. Experimental studies show that 

images of cigarette smoking in fi lm 

can infl uence adolescent and adult 

viewers’ beliefs about social norms for 

smoking, beliefs about the function 

and consequences of smoking, 

and their personal intentions to 

smoke. Protobacco movie content 

(e.g., stars smoking, absence of health 

consequences portrayed) appears 

to promote prosmoking beliefs and 

intentions. The effects observed for 

experimental studies of smoking in 

movies on viewers’ smoking-related 

beliefs are of a similar magnitude 

as those observed in experimental 

media research on other health topics 

(e.g., effects of media violence on 

viewers’ aggression).

7. Experimental studies indicate that 

antitobacco advertisements screened 

before fi lms can partially counter the 

impact of tobacco portrayals in movies. 

8. The total weight of evidence from 

cross-sectional, longitudinal, and 

experimental studies, combined with the 

high theoretical plausibility from the 

perspective of social infl uences, indicates 

a causal relationship between exposure 

to movie smoking depictions and youth 

smoking initiation. 

9. One longitudinal study indicates that 

parental steps to reduce the exposure 

of never smokers (aged 10–14 years) 
17

Monograph 19. The Role of the Media

to R-rated movies, which have higher 

numbers of smoking events, produced 

a corresponding reduction in their 

smoking initiation. 

10. Efforts to reduce media exposure to 

tobacco include restrictions on tobacco 

advertising and product placements, 

advocacy targeted to entertainment 

providers, media literacy interventions 

aimed at the general public, continued 

dialogue with key stakeholders in the 

entertainment industry, and proposed 

self-regulation by the movie industry 

(e.g., tobacco-related ratings).

Part 4—Tobacco Control Media 

Interventions

Chapter 11. An Overview of Media 

Interventions in Tobacco Control: 

Strategies and Themes

This chapter examines current and future 

trends in media interventions for tobacco 

control, including the evolution of media 

efforts from their start under the FCC’s 

Fairness Doctrine for television advertising, 

to recent initiatives funded by state 

authorities and the 1998 Master Settlement 

Agreement. It also discusses examples of 

advertising themes used in tobacco control 

programs, research on factors in effective 

tobacco control advertising campaigns, 

and the potential for “new-media” channels 

such as interactive health communications 

using the Internet.

Conclusions

1. From their beginnings with the successful 

1967–70 application of the Fairness 

Doctrine to cigarette advertising in the 

broadcast media, media interventions for 

tobacco control have evolved to become a 

key component of tobacco control efforts. 

These interventions have been aided by 

funding from the 1998 Master Settlement 

Agreement.

2. Media channels commonly used for 

tobacco control advertising include 

television, radio, print, and billboards. 

Much research on tobacco control media 

interventions revolves around television, 

regarded as the most powerful medium.

3. Public-health-sponsored antitobacco 

advertising has included themes such 

as the health risks of smoking, exposure 

to secondhand smoke, questioning 

the accuracy of tobacco industry 

communications, and the declining 

social acceptability of smoking. Other 

forms of smoking-relevant advertising 

include advertisements for commercial 

smoking cessation products as well as 

the tobacco industry’s youth smoking 

prevention and adult cessation programs. 

4. Numerous studies have shown 

consistently that advertising carrying 

strong negative messages about health 

consequences performs better in 

affecting target audience appraisals and 

indicators of message processing (such as 

recall of the advertisement, thinking 

more about it, discussing it) compared 

with other forms of advertising, such 

as humorous or emotionally neutral 

advertisements. Some of these negative 

advertisements also portray deception 

on the part of the tobacco industry. 

Advertisements for smoking cessation 

products and tobacco-industry-sponsored 

smoking prevention advertising have 

been shown to elicit signifi cantly 

poorer target audience appraisals than 

do advertisements based on negative 

health consequences.

5. Studies have shown that particular 

characteristics of advertisements 

(such as those eliciting negative 

emotion) are more important than 

demographic factors (such as race/

ethnicity, nationality, and age group) 

in driving immediate advertising-related 

appraisals and indicators of message 

processing.
18

Executive Summary

6. Because many smokers search the 

Internet for help to quit, interactive 

Web-based health communications may 

have potential for assisting smoking 

cessation. However, these services need 

to be informed by smoking cessation 

theory and research and structured to 

expose users to appropriate information.

Chapter 12. Assessing the 

Effectiveness of the Mass Media in 

Discouraging Smoking Behavior

This chapter studies the use of mass media 

in tobacco control and health promotion, 

and examines research results relative to 

changing smoking behavior in light of 

their methodological challenges. Specifi c 

areas covered include (1) controlled fi eld 

experiments involving antismoking mass 

media campaigns aimed at youth and adults, 

often only one part of multicomponent 

interventions; and (2) population-level 

studies, including both longitudinal 

and cross-sectional evaluation studies 

of national- and state-level tobacco 

control mass media campaigns conducted 

either alone or as one component of a 

multicomponent tobacco control program.

Conclusions

1. Several evaluations of the antismoking 

public service announcements required 

under the Fairness Doctrine between 

1967 and 1970, the fi rst large-scale 

U.S. national mass media campaign, 

indicate that there were discernible 

reductions in tobacco consumption, 

smoking prevalence, and smoking 

initiation. This natural experiment 

spurred research into the use of media 

to infl uence health behaviors.

2. Evidence from controlled fi eld 

experiments suggests that antitobacco 

mass media campaigns conducted in 

conjunction with school- or communitybased programming can be effective in 

curbing smoking initiation in youth and 

promoting smoking cessation in adults. 

This evidence has provided the impetus 

for antitobacco mass media campaigns 

to become important components of 

tobacco control programs.

3. The few population-based studies of 

antitobacco mass media campaigns, 

in which the media campaign was the 

only antitobacco program, demonstrate 

that the media campaigns were effective 

in reducing smoking in the youth and 

adult target populations.

4. Population-based studies of antitobacco 

mass media campaigns that were only 

one component of multicomponent 

tobacco control programs provide 

considerable evidence for reduced use 

of tobacco by youth and adults. The 

antitobacco mass media campaign and 

the other program components together 

may have reduced smoking more 

than did any single component alone. 

The relative contributions of various 

components to program effectiveness 

are diffi cult to determine, but some of 

the controlled fi eld experiments showed 

a dose-response relationship between 

reduced smoking and an increased 

number of program components.

5. Evidence from controlled fi eld 

experiments and population studies 

conducted by many investigators in 

many countries shows that antitobacco 

mass media campaigns can reduce 

tobacco use.

Part 5—Media, Tobacco Control 

Interventions, and Tobacco 

Industry Mitigation Efforts 

Chapter 13. Tobacco Industry Efforts 

to Infl uence Tobacco Control Media 

Interventions

This chapter examines how tobacco 

interests and their allies work to impede 
19

Monograph 19. The Role of the Media

antitobacco media efforts by using 

techniques such as diverting funding to 

other causes, lobbying elected offi cials, 

restricting antitobacco media content 

through negotiated settlements, and fi ling 

legal challenges. Examples are given from 

state-level media campaigns in Minnesota, 

California, Arizona, and Florida.

Conclusions

1. Tobacco industry efforts to impede 

tobacco control media campaigns 

include attempts to prevent or reduce 

their funding. Examples include 

opposition to a tobacco tax increase 

intended to fund media campaigns in 

California and claims that a “budget 

crisis” precluded spending on tobacco 

control media campaigns in Minnesota. 

2. Efforts to weaken the messages or 

reduce the size of the target audience 

in tobacco control media campaigns 

include restricting the scope of 

Arizona’s Proposition 200 initiative to 

address specifi c topics such as nicotine 

addiction and to target only children and 

pregnant women and, in the American 

Legacy Foundation’s “truth” campaign, 

disallowing public policy advocacy and 

vilifi cation of the tobacco industry. 

3. The tobacco industry has cited its 

own media campaigns—such as 

“Helping Youth Decide,” “Think. 

Don’t Smoke,” and “Tobacco Is 

Whacko if You’re a Teen”—to argue 

that government-funded campaigns 

duplicate these efforts and waste 

taxpayer dollars. This strategy was seen 

fi rst in Minnesota and leading up to 

and following the 1998 signing of the 

Master Settlement Agreement.

4. Increasing consumer awareness of 

tobacco industry activities to counteract 

public-health-sponsored campaigns 

designed to reduce tobacco use can be 

an important component of effective 

media interventions. 

Chapter 14. Tobacco Industry Media 

Efforts to Defeat State Tobacco Control 

Ballot Initiatives and Referenda

This chapter examines tobacco industry 

efforts to use media to counter ballot 

initiatives and referenda for a sample of 

the 42 state-level tobacco control measures 

put before voters between 1988 and 2006. 

This chapter discusses media campaigns 

in several states, together with primary 

themes used by the tobacco industry in 

these efforts, such as unfair taxation, 

diversion of funds, personal choice, and 

wasteful government spending.

Conclusions

1. Within those states that allow these 

processes, ballot initiatives and referenda 

have served as an effective tool for 

enacting tobacco control legislation by 

direct vote. Tobacco industry interests 

frequently have used media channels 

(such as radio, television, print media, 

and direct mail) to defeat these ballot 

measures.

2. Despite the tobacco industry’s media 

efforts, it has generally not prevailed, 

losing in 32 (76%) of 42 state initiatives 

and referenda from 1988 to 2006. 

Given the industry’s lack of success in 

defeating tobacco control state initiatives 

and referenda at the state level, holding 

tobacco control initiatives or referenda is 

an important, though expensive, option 

if a state legislature has blocked tobacco 

control legislation.

3. The tobacco industry consistently has 

used several primary themes to defeat 

state tobacco tax increase initiatives. 

These include suggestions that the 

measures would impose unfair taxes 

and that tax revenues would not be 

spent on health care or tobacco control 

programs as intended. Secondary themes 

used consistently over an 18-year time 

span include that the measures would 
20

Executive Summary

increase “big government” and wasteful 

spending, discriminate against smokers, 

and increase crime and smuggling. 

Other, less frequent themes were that the 

measures would be a tax cut for the rich, 

impede economic growth, fail to solve 

state budget problems, restrict personal 

choice, and violate antitrust laws.

Part 6—Future Directions

Chapter 15. Future Directions

This chapter examines the future of media 

as they relate to both tobacco promotion and 

tobacco control. Issues discussed relative 

to tobacco promotion include point-ofpurchase marketing, packaging, the use of 

entertainment media, and public relations. 

Tobacco control media issues include news 

and media advocacy, measurement of news 

media effectiveness, media interventions, 

and the potential for newer alternate 

media channels.
21

Monograph 19. The Role of the Media

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