30

II. Mass-Reach Health 

Communication Interventions 

Justification 

Mass-reach health communication interventions 

can be powerful tools for preventing the initiation 

of tobacco use, promoting and facilitating cessation, and shaping social norms related to tobacco 

use.1,2 The Community Preventive Services Task 

Force recommends mass-reach health communication interventions on the basis of strong evidence 

of effectiveness in: decreasing the prevalence 

of tobacco use; increasing cessation and use of 

available cessation services such as quitlines; 

and decreasing initiation of tobacco use among 

young people.3

Mass-reach health communication refers 

to the various means by which public health 

information reaches large numbers of people. 

The term “mass-reach” has been added to the 

description of health communication interventions 

in this edition of Best Practices because the 

available evidence suggests that the use of massreach vehicles, in particular television, is required 

to make meaningful changes in population-level 

awareness, knowledge, attitudes, and behaviors.3

Impact of Tobacco Advertising and 

Promotion

Billions of dollars are spent annually by tobacco 

companies to make tobacco use more affordable 

and attractive, as well as an accepted and established part of American culture.4,5 Young people 

are particularly vulnerable to social and environmental influences to use tobacco. Messages 

and images that make tobacco use appealing to 

them are everywhere.2,6 For example, youth and 

young adults see smoking in movies, video games, 

Web sites, in their social circles, and throughout 

the communities where they live. Tobacco marketing portrays smoking as a social norm, and 

young people exposed to these images are more 

likely to smoke. Nonsmoking adolescents exposed 

to tobacco advertising and promotional campaigns are significantly more likely to become 

young adult smokers.2,7,8 Youth who are exposed 

to images of smoking in movies are more likely to 

smoke. Those with the most exposure to onscreen 

smoking imagery are about twice as likely to begin 

smoking as those with the least exposure.2

 Evidence also indicates that tobacco purchase and 

cessation behaviors among adult smokers are influenced by tobacco promotion, particularly at the 

point of purchase.9–11 Because youth and adults 

continue to be heavily exposed to pro-tobacco 

media, advertising, and promotion, public education campaigns are needed to prevent tobacco use 

initiation and to promote cessation.

Despite the 1998 Master Settlement Agreement 

(MSA) between 46 states and several major 

tobacco companies that established restrictions 

on tobacco marketing and some types of outdoor 

advertising, tobacco product promotion remains 

prevalent. In 2011, tobacco companies spent more 

than $8.3 billion, or approximately $23 million 

per day, to market cigarettes in the United States;4

this level of spending exceeded spending on 

tobacco prevention and control efforts by all of the 

states and territories by a ratio of approximately 

18 to 1.4,12 In addition, marketing expenditures 

for smokeless tobacco exceeded $452 million 

in 2011—more than double the spending in 

2000.5 Although the majority of current tobacco 

marketing comprises price discounts, which 

offset the impact of excise taxes on tobacco use, 

traditional tobacco company advertising and 

marketing spending, at more than $700 million in 

2011, still far exceeds the $175 million spent on 

public health-sponsored antitobacco campaigns 

by the states and CDC.4,5,13 Since the MSA, tobacco 

promotions have shifted away from traditional 

media (e.g., billboards and magazines) and 

moved toward digital media and retail outlets,2,14–17

and tobacco companies are increasingly using 

tobacco product packages (e.g., shapes, colors, 

text) as a form of marketing.18,19 In addition, 

tobacco companies are re-entering the television 

market as they acquire or introduce electronic 

cigarette (e-cigarette) products and advertise these 

products.20 For example, Lorillard, Inc. acquired 

the e-cigarette manufacturer blu eCig® in 2012 

and was among the first companies to advertise 

an e-cigarette product nationally on television.21
31

Section A: Mass-Reach Health Communication Interventions

Tobacco advertising and promotion are 

real threats to public health. The 2012 Surgeon 

General’s report stated, “The evidence is sufficient 

to conclude that there is a causal relationship 

between advertising and promotional efforts of 

the tobacco companies and the initiation and 

progression of tobacco use among young people.”2

The National Cancer Institute’s (NCI’s) Monograph 

19 concluded that a causal relationship exists 

between tobacco advertising and promotion and 

increased tobacco use, including both increased 

smoking initiation and increased per capita 

tobacco consumption in the population.19 Evidencebased strategies, including mass-reach health 

communication interventions, are needed to 

counter the negative impact of tobacco industry 

marketing efforts and protect public health.19

Effectiveness of Tobacco 

Countermarketing

The research literature provides ample evidence 

that tobacco countermarketing, which is the use of 

commercial marketing tactics to reduce the prevalence of tobacco use, can be a valuable tool in 

reducing smoking.19,22 The NCI Monograph 19

reviewed the available literature from 1970 through 

2007 and found extensive evidence that tobacco 

countermarketing campaigns curbed smoking initiation in youth and promoted smoking cessation in 

adults, particularly in the context of comprehensive 

tobacco control programs.19 A 2012 review further 

confirmed the efficacy of mass-media campaigns 

in reducing smoking among adults.23 In addition, a 

2013 study found that greater exposure to tobacco 

control mass-media campaigns may reduce the 

likelihood of relapse among quitters.24

Media campaign research and evaluations 

have shown that advertising that elicits negative 

emotions through graphic and personal portrayals 

of the health consequences of tobacco use is 

especially effective in motivating smokers to 

quit.19,23,25 There is also evidence that this kind of 

approach to advertising messages reduces tobacco 

use among youth and young adults.2,26 CDC’s 

Tips From Former Smokers (Tips) campaign, the 

first federally funded, nationwide, paid-media 

tobacco education campaign in the United States, 

is an example of this approach. The first Tips

campaign was conducted during March–June 2012 

and featured former smokers talking about their 

experiences and their families’ experiences living 

with diseases caused by smoking and secondhand 

smoke exposure.27 In addition to a comprehensive 

earned media component, the Tips campaign 

included advertising on national and local television, 

local radio, online media, and billboards as well 

as in movie theaters, transit venues, and print 

media. A subsequent evaluation of Tips found that 

an estimated 1.6 million smokers attempted to quit 

smoking because of the campaign and that more 

than 100,000 of them would likely quit smoking 

permanently.26 Additionally, the 2012 Tips campaign 

and a subsequent 2013 Tips campaign resulted in 

immediate and significant increases in state quitline 

call volumes, which rapidly declined to baseline 

levels upon completion of these campaigns.26,27

There have been fewer studies examining 

the effectiveness of tobacco countermarketing 

campaigns among population subgroups that 

bear a disproportionate burden of tobaccorelated disease and death. However, some studies 

have assessed the potential differential impact 

of mass-media campaigns by socioeconomic 

status (SES). A 2012 review found evidence to 

suggest that general-population campaigns may 

be effective for encouraging quitting in low 

SES smokers if the campaigns have sufficient 

reach, frequency, and duration.23 A 2012 study 

in New York state found increased quit attempts 

among both the general population and low-SES 

groups who were exposed to strongly emotional 

and graphic antismoking advertisements.25

Over the past decade, states have 

remained an important source of innovative 

countermarketing content; however, many have 

also found that they can save time, money, and 

the risks associated with new advertisement 

development by adapting existing advertisements 

from other states, cities, national governmental 

agencies, or other countries. For example, 

New York City has used advertisements from 

Australia, England, Massachusetts, California, 

and Minnesota; Florida has used advertisements 

from Australia, California, Washington State, 

and New York City; and Minnesota has used 

advertisements from Canada, California, 

Vermont, Ohio, Arizona, and CDC.28 Many of 

the advertisements were found in CDC’s Media 

Campaign Resource Center (MCRC) database.28

In addition to the importance of effective 

messaging strategies, research from many sources 

shows that tobacco countermarketing campaigns 

must have sufficient reach, frequency, and 
32

Section A: Mass-Reach Health Communication Interventions

duration to be successful.24,27,29–31 A key goal for 

tobacco control campaigns is to reach a defined 

target audience with attention-getting messages 

in the most efficient and effective way possible. 

Media buying, which typically includes how 

placements are purchased, the channels selected, 

and how the budget is allocated across channels, 

is an integral part of an overall strategy.

Evidence also suggests that earned media, 

which is the process of securing free news 

placements in a variety of media outlets through 

dedicated efforts to communicate key messages, 

can contribute to tobacco countermarketing 

campaign effectiveness. Local and statewide 

earned media campaigns have been shown to 

effectively support key tobacco control goals, 

including increasing calls to a state quitline, 

influencing smoking knowledge, attitudes, 

and behavior among youth, and implementing 

changes in local tobacco control policy.32–35

Digital media, including electronic delivery 

of information via Web sites, mobile applications, 

and social networking sites, are emerging and 

promising vehicles for reaching and influencing key 

target audiences. However, there is not yet sufficient 

evidence to draw conclusions or to make formal 

recommendations on the efficacy or ideal use of 

these media at this time. The measurement and 

evaluation of digital media interventions are critical 

to help build an evidence base, to gauge their 

effectiveness, and to optimize future digital media 

interventions. Given that the tobacco industry is 

allocating significant funding to these media,4,5

use of digital media is likely a promising 

area for states to consider.

Recommendations

An effective state mass-reach health communication intervention delivers strategic, 

culturally appropriate, and high-impact messages via sustained and adequately funded 

campaigns that are integrated into a comprehensive state tobacco control program effort. 

Typically, effective health communication interventions and countermarketing strategies 

employ a wide range of efforts, including:22

 Paid television, radio, out-of-home (e.g., 

billboards, transit), print, and digital 

advertising at the state and local levels

 Media advocacy through public relations/

earned media efforts (e.g., press releases/

conferences, social media, and local events), 

which are often timed to coincide with holidays, 

heritage months, and health observances 

 Health promotion activities, such as working 

with health care professionals and other 

partners and promoting quitlines 

 Efforts to reduce or replace tobacco industry 

sponsorship and promotions as well as 

to decrease movie smoking imagery

Innovations in health communication 

interventions include the ability to target and engage 

specific audiences through multiple communication 

channels, such as online video, mobile Web, and 

smartphone and tablet applications (apps). Social 

media platforms, such as Twitter and Facebook, 

have facilitated improvements in how messages 

are developed, fostered, and disseminated in order 

to better communicate with target audiences and 

allow for relevant, credible messages to be shared 

more broadly within the target audiences’ social 

circles. However, these platforms are complements 

to, not substitutes for, traditional mass media. 

Because data on the contribution of digital media 

efforts to reaching tobacco countermarketing 

campaign goals are still emerging, evaluation 

of digital media efforts can help determine 

effectiveness and establish an evidence base.22

Behavior theory, audience insight research, pretesting of campaign materials, and surveillance and 

evaluation are grounded in communication science 

and are used to develop interventions that target 

specific audiences with messages that can change 

awareness, knowledge, attitudes, and behaviors. 

Examples of these audiences include adult tobacco 

users, youth, and high-risk populations such 

as members of the lesbian, gay, bisexual, and 

transgender (LGBT) communities, those with lower 

socioeconomic status, and certain races such as 

American Indians. These methods are often used 

to identify key strategies, influential messages, and 

the most effective communication channels and 

media options to reach specific audiences. However, 

ensuring that messages resonate with specific 

population subgroups does not require that unique 

materials be developed for each audience. Evidence 

has confirmed that strong ads, such as those that 

graphically or emotionally portray the serious 

consequences of smoking, resonate well with a 
33

Section A: Mass-Reach Health Communication Interventions

wide variety of audiences.19,23 Advertising concepts 

and advertisements can be tested among specific 

target audiences to ensure that they communicate 

persuasively, and media buying can be tailored, 

when feasible, to ensure appropriate reach of 

those audiences.

Effective media planning works within the total 

framework of a mass-reach health communication 

campaign’s goals. For an overall campaign, it is 

estimated that advertisements should reach 75% 

to 85% of the target audience each quarter of the 

year, with a minimum average per quarter of 1,200 

gross rating points (GRPs) during the introduction 

of a campaign and a minimum average of 800 

GRPs per quarter thereafter.22,23,29,36 GRPs track 

the total reach and frequency of the campaign. A 

campaign is expected to run at least 3 to 6 months 

to achieve awareness of the issue, 6 to 12 months to 

influence attitudes, and 12 to 18 months to influence 

behavior,22,29 although some campaigns, including 

CDC’s Tips campaign, have influenced behavior 

within a 3-month time frame.26,27 Campaigns need to 

overcome pro-tobacco marketing influences; thus, 

it is important to set reasonable expectations of 

effectiveness. In addition, campaigns must run as 

continuously as possible because their impact can 

diminish over a relatively short time period.26,27,37–39

For more information regarding the media 

planning process, consult CDC’s countermarketing 

manual, Designing and Implementing an Effective 

Tobacco Countermarketing Campaign.22

The experiences of many states, including 

New York, California, Florida, Massachusetts, 

and Minnesota; the national organization Legacy 

(formerly the American Legacy Foundation); and 

CDC emphasize that message content of tobacco 

control campaigns is very important. Messages that 

elicit strong emotional response, such as personal 

testimonials and viscerally negative content, 

produce stronger and more consistent effects on 

audience recall, knowledge, beliefs and quitting 

behaviors.2,22,25,26,40 Aggressive state and national 

countermarketing campaigns that have more 

directly confronted the tobacco industry’s marketing 

tactics have also demonstrated effectiveness, but 

have often become targets for budget cuts.41–43

Resources such as CDC’s countermarketing 

manual and the MCRC database can be used to 

develop effective communications plans and to 

acquire effective advertisements cost efficiently.22,28 

The countermarketing manual is a toolkit with 

chapters on all major aspects of campaign 

development, and MCRC is a clearinghouse of 

tobacco-related media campaign materials produced 

by states and other organizations that other states 

can adapt and reuse. Evidence suggests that it 

is not necessary to develop new advertising,44–46

particularly considering the availability of existing 

advertisements in the MCRC—many of which have 

been used with very effective results.28 Typically, 

new advertising should be developed only when a 

campaign objective is unique enough that existing 

advertisements may not address it, when a campaign 

needs to publicize a local event (e.g., a quitting 

program or implementation of a new smokefree 

law), or when another unique situation arises.

Comprehensive earned media efforts are an 

essential part of the strategic plan, regardless of 

the size of one’s media campaign budget, but 

especially when funds are limited. Additionally, 

each major campaign element and activity should 

have an earned media component. Although 

paid media benefits from the ability to control 

the message and the placement, news media 

coverage is important because it can help set the 

public agenda, influence what people are talking 

about, and further broaden and add credibility to 

paid messages. Examples of earned media tactics 

include: establishing relationships with journalists to 

become a trusted, responsive, and knowledgeable 

resource; issuing press releases; scheduling editorial 

board briefings; holding events to generated 

media coverage; writing letters to the editor; and 

training spokespeople for interviews.22,28,32–34

In addition to providing sufficient reach, frequency, and duration, effective media and mass-reach 

health communication intervention efforts will benefit from the activities identified in the following box. 
34

Section A: Mass-Reach Health Communication Interventions

 Audience insight research to determine the 

current knowledge, attitudes, and behaviors 

of target audiences, as well as the motivations 

and behavioral theory that can best influence 

change among specific audiences.

 Formative research to identify promising 

messages and concepts.

 Formative evaluation to pretest campaign 

materials to ensure that they are clear, credible, and 

persuasive and that they motivate the audience 

to change their attitudes and behaviors.

 Surveillance to understand pro-tobacco messaging, 

media placements, and marketing tactics.

 Local media promotion, event sponsorships, and 

other community collaboration tie-ins to support 

and reinforce the statewide campaign, increase 

awareness about policies that protect and promote 

health, and shift social norms related to tobacco use.

 Digital technologies, such as text/SMS 

messaging, social media, Web sites, and blogs 

to generate messages that can be further 

disseminated by the target audience.

 Process and outcome evaluation of a 

comprehensive communication effort, as well 

as specific evaluations of new and innovative 

approaches, including the use of digital media.

 Promotion of available services, including the state’s 

telephone cessation quitline number or the quitline 

portal numbers (1-800-QUIT-NOW, 1-855-DÉJELO-YA), 

as well as quitting Web sites and social media pages.

Beneficial Activities for Effective Media and Mass-Reach 

Health Communication Intervention Efforts 

Achieving Equity to Reduce 

Tobacco-Related Disparities

Recognition of, and sensitivity to, diverse 

audiences is critically important in tobacco control 

mass-reach health communications campaigns, 

particularly to address disparities in tobacco use 

and corresponding inequities in tobacco-related 

health outcomes across population groups. The 

experiences of multiple states and CDC have 

shown that mass-reach health communication 

campaign funds can be efficiently and effectively 

used to reach and influence populations with the 

greatest tobacco-related burden through carefullyplanned formative research that determines which 

messages and approaches resonate powerfully 

across diverse audiences, as well as thoughtful 

media placement that reaches key audiences where 

and when they are most receptive to the messages. 

Television advertisements that are not tailored 

by audience segment are frequently used by state 

tobacco control programs in an effort to ensure 

the broad and consistent delivery of key messages. 

This approach is supported by evidence suggesting 

that there are some universally strong messages for 

tobacco prevention education advertisements, such 

as the serious negative effects of smoking on the 

body and the emotional impact on family members, 

and that these types of messages are effective across 

a broad spectrum of geographies and populations 

without requiring significant tailoring.19,23,47

However, it is still important to consider and 

address audience diversity when developing or 

selecting advertisements. For example, testimonial 

advertisements could feature individuals of varied 

sexes, ages, race/ethnicities, sexual orientations, 

gender identities, or other population characteristics. 

At the national level, CDC’s Tips campaign featured 

testimonials of former smokers from multiple 

population groups with high rates of tobacco use.27

Some state tobacco control programs also tailor 

media buys to reach specific audience segments 

within general-population campaigns. For example, 

certain population subgroups may be more likely to 

listen to radio, while others may be more likely to 

read language-specific print materials or to engage 

in social media. States can use these media channels 

to cost efficiently supplement television placements. 

For example, to reach low-SES male audiences, 

North Carolina placed an advertisement in a 

NASCAR publication and distributed earplugs with 

the state’s quitline number at the race. Similarly, 

New York purchased placement on a sports cable 

network and used baseball-themed advertisements 

from Florida and Massachusetts. To reach American 

Indians and Alaska Natives, CDC purchased 

placements on radio networks and regional 

print publications targeted to these audiences.
35

Section A: Mass-Reach Health Communication Interventions

When planning and developing a mass-reach 

health communication campaign, the most critical 

considerations are that the messages resonate 

effectively with each priority audience and that the 

tailored media placements help ensure that each key 

audience notices and internalizes those messages. 

Taking into account these considerations should 

ultimately help increase the likelihood that the 

messages lead to meaningful changes in tobaccorelated knowledge, attitudes, and behaviors.

Budget

Mass-reach health communication efforts 

must be adequately funded, sustained over time, 

and integrated with other program activities in 

order to counter tobacco industry marketing, 

reduce tobacco use initiation, increase cessation, 

and reduce exposure to secondhand smoke. 

Campaigns of longer duration and higher 

reach and frequency are associated with greater 

declines in smoking rates.2,22,23,48 Future funding for 

national campaigns sponsored by CDC, Legacy, 

and other organizations remains uncertain, and 

even if federal mass-media campaign efforts 

are conducted during some years, they are not 

sufficient alone and should not take the place 

of state-level media campaigns. Therefore, 

states may want to plan to provide the primary 

budget for mass-reach health communication 

interventions to ensure broad population-level 

exposure to messages that address the goals of a 

comprehensive tobacco control program. The three 

major content areas of these messages include:

 Motivating tobacco users to quit 

 Protecting people from the harms 

of secondhand smoke 

 Transforming social norms to 

prevent tobacco use initiation 

Budget recommendations should be sufficient 

to conduct mass-reach health communication 

campaigns in the state’s major media markets 

addressing these three key content areas. Evidence 

suggests that if proven message strategies are used, 

such as personal and graphic portrayals of the 

negative health consequences of tobacco use, the 

same advertisements can be effective among both 

youth and adults,2,19 thus maximizing the impact 

of limited funds. Funds can be competitively 

awarded to firms that understand a state’s media 

markets, have experience in reaching culturally 

diverse audiences, have the ability to conduct 

market research and surveillance of countermarketing efforts, and exhibit a willingness to 

review existing advertising before recommending 

that new advertising be developed. Additional 

guidance on selecting contractors for health 

communication interventions is available in 

Designing and Implementing an Effective 

Tobacco Countermarketing Campaign.22

Budget estimates for funding mass-reach health 

communication interventions are generally based 

on the Best Practices—2007 funding formula, 

but the estimates have been revised based upon 

more recent state and national experiences. These 

evidence-based levels of media presence were used 

to calculate the minimum and recommended levels 

of spending (see Appendix A for more details).

The minimum budget level assumes that three 

campaigns are conducted each year to address the 

following goals: 1) motivating smokers to quit; 2) 

protecting people from the harms of secondhand 

smoke exposure; and 3) transforming social 

norms to prevent tobacco use initiation, with a 

delivery of an average of 1,200 GRPs per quarter 

for either one of the cessation or secondhand 

smoke campaigns (assumes it is an introductory 

campaign and, thus, requires higher levels) and 

a delivery of an average of 800 GRPs for each of 

the other two campaigns. The minimum budget 

level also assumes a 20% reduction in costs to 

account for efficiencies in message communication 

and media negotiation (reduced rates or bonus 

placements) that would be expected when 

conducting three campaigns simultaneously. The 

recommended budget level assumes delivery of 

campaigns with the same overall goals, with an 

average of 1,600 GRPs per quarter for one of 

the cessation or secondhand smoke campaigns 

and 1,200 GRPs per quarter for the other two 

campaigns, and a 20% reduction in costs based 

on message and media negotiation efficiencies. 

This range of funding was applied to states 

according to the cost and complexity of their media 

markets, in part measured by the coverage provided 

by a state’s designated market areas (DMAs). Statelevel cost estimates for buying televised air time 

in all 210 U.S. DMAs in 2014 were acquired by 

CDC in May 2013. States with counties that fall 

outside their primary DMAs may need to consider 

purchasing media in a neighboring state or using 

other vehicles, such as digital, in order to reach 

75% to 85% of the target audience. Also, budgeting 

for cost-effective media campaigns is more 
36

Section A: Mass-Reach Health Communication Interventions

complicated for states having media markets that 

share major metropolitan areas with neighboring 

states, so such states may need to rely more on 

local vehicles (digital, out-of-home, newsprint, 

radio) and less on broadcast television to limit 

spending to reasonable levels. However, those 

placements may not easily translate to GRP levels.

It is important to note that the recommended 

level of media investment is for media placement 

only. Because they vary significantly across 

states, the following costs were not included 

in the budget estimates: advertising agency 

and media planning firm fees; audience insight 

research; pretesting of materials; advertising 

development and production; and talent fees. 

In addition, the more campaigns a state 

conducts, the more staffing will be required. 

Although the Infrastructure, Administrative, and 

Management chapter of this report provides 

general funding levels for staffing, additional 

funds will be needed to support three unique 

multimedia campaigns. Also, additional funds 

may be needed to tailor the campaign to specific 

population groups, especially to ensure language 

appropriateness, through the use of unique 

messages, materials, or media vehicles. However, 

states can lower advertising development costs by 

using existing television, radio, print, and outdoor 

advertisements from CDC’s MCRC.28 Also, alternative 

forms of communication—such as direct mail, 

Web sites, blogs, social media and text messaging, 

and working through health care providers, 

other government organizations, and the news 

media—can extend the reach and frequency of 

messages, as can recruiting audiences to produce 

or adapt, place, and promote messages themselves 

through social media and other digital technologies. 

In the event that available funding for massreach health communication interventions exceeds 

minimum levels and approaches recommended 

levels, state programs may want to consider 

allocating resources for elements related to the 

creation of their own advertisements, including 

audience insight research and advertisement 

development and production. It is important to 

note that these funding levels are general; thus, 

states may have to tailor certain factors—such 

as number of goals, campaigns conducted, and 

target audiences—to their unique situations.
37

Section A: Mass-Reach Health Communication Interventions

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