continued Within the next few weeks, representatives of the Women vs. Smoking Network appeared on NBC Nightly News, CBS This Morning, CBS Evening News, the MacNeil-Lehrer NewsHour, Nightwatch, and Nightline. Representatives were also interviewed by major national newspapers, including USA Today; by numerous local papers; by CBS Radio Network, the Black Radio Network, and National Public Radio; and by local talk shows. Last, repre- sentatives were asked to testify on the topic at con- gressional hearings. The network followed up on the publicity by spotlighting several different projects, including a petition to the tobacco compa- nies to adhere to their own voluntary code of cor- porate ethics. Even the cigarette’s proposed name drew criti- cism. Groups in North Dakota and South Dakota objected to the name, as did Sioux tribal organiza- tions, because “Dakota” means “friend” or “ally” in the Sioux language. These groups formed a coa- lition of more than 40 organizations and collected 25,000 signatures on a petition objecting to the use of the word and demanding that RJ. Reynolds cease chairman Joe Garagiola by lawmakers and Secretary of Health and Human Services Donna Shalala. More than $70 million in electronic media coverage has been generated directly from NSTEP efforts. In addition, NSTEP activities appear to have substantially in- creased the coverage of smokeless tobacco issues in the print media. Before NSTEP there were approxi- mately 500 print articles annually devoted to smoke- less tobacco; since NSTEP that number has climbed to Components of Community Programs Reducing Tobacco Use selling the cigarette, which had been test-marketed, as planned, beginning in April 1990. The Women vs. Smoking Network provided strategic counsel- ing and technical support to the grassroots coali- tion and was instrumental in helping arrange a press conference in Washington, DC, in June 1990, which featured then Surgeon General Antonia Novello, Senator Larry Pressler (R-SD), and others objecting to the marketing plan. Although advocacy groups were able to gen- erate considerable community and media mobili- zation, R.J. Reynolds continued test-marketing. Advocates felt they had raised national concern about the targeting of cigarette advertising, al- though this impression was not directly verified through survey research. Dakota cigarettes were withdrawn two vears later, however, because the brand did not sell as well as officials had hoped (Amterican Medical News 1992). In this instance, al- though advocates might attribute the end result to the effective use of the media to promote the agenda for reducing tobacco use, the demise of the Dakota brand was probably more attributable to market forces. more than 5,000. One article alone appeared in more than 800 newspapers on a given weekend, and NSTEP estimated the value of this media coverage at $15 mil- lion. A recent survey of major league baseball players and coaches found that more than 44 percent of smoke- less tobacco users want to quit in the next six months, perhaps attributable to NSTEP’s active participation in educating ballplayers during spring training. Community Advocacy and Mobilization Electronic Networking Interactive communication technologies, such as computer networks, have been used extensively by advocacy groups for reducing tobacco use. For ex- ample, daily communications played an important part in the response to Philip Morris’ Bill of Rights Tour (see the text box later in this chapter). Many active, functioning networks now provide communication services to assist in efforts to reduce tobacco use. The Institute for Global Communications, based in San Francisco, was an early provider of issue- specific networks to the general public. PeaceNet and Comprehensive Programs — 403 Surgeon General's Report EcoNet, which were developed in 1986, are among the most widely used and well known of the institute's networks. As of October 1994, the institute reported a combined membership of 12,000 people from 130 coun- tries (Moore 1994), Within these networks, and others like them, are smaller groups focused on a specific as- pect of an issue or a particular policy. For instance, among, HandsNet’s 2,500 member organizations, which span the nonprofit sector, is a forum linking 200 community coalitions on substance abuse. This forum, managed by the Boston-based group Join Together and supported by the Robert Wood Johnson Foundation, provides on-line technical assistance to these coalitions. The forum also provides news summaries and infor- mation available on funding opportunities and proposed legislation. Several networks link people who work in health- related areas. In 1993, the Public Health Network pro- vided forums, e-mail service, and databases for its membership, which was composed of nearly 600 users from state and local health agencies and of program directors who were members of the CDC’s Public Health Leadership Institute. In 1998, this network was replaced by the Information Network for Public Health Officials. Established by the CDC's Pub- lic Health Practice Program Office, the network links the public health community to the Internet and pro- vides access to on-line information. Planned Parent- hood Federation of America hosts PPXNet, a network for its affiliates in regional and national offices, pri- marily for communication within the organization itself. During the 1990s, the CDC offered the electronic resource WONDER to public health officials, acade- micians, and others so that they were able to commu- nicate via e-mail with and have access to the CDC's databases of health data. The advent of the Internet, including Web-based e-mail and list serv technology, has facilitated the exchange of public health informa- tion for health professionals and the public. CDC now offers its health data, materials, databases, electronic journals, and other resources on its Web site at www.cdc.gov. In 1990, the Advocacy Institute founded SCARCNet, a multiuser interactive bulletin board that served the tobacco control community. (The history of the bulletin board’s sponsoring organization—the resource center known by the acronym SCARC—is discussed in “Impact of Direct Advocacy,” later in this chapter.) When SCARCNet ceased in January 2000, it had more than 1,000 subscribers and was circulated to thousands of readers throughout the world on vari- ous networks. SCARCNet’s most popular feature was the “Daily Bulletin,” which each day summarized 404. Chapter 7 major newspaper and journal stories on reducing to- bacco use (Advocacy Institute 1994). The “Daily Bul- letin” was accompanied by a “Morning Briefing,” which put these news stories in perspective for the tobacco control community. The contents of the “Daily Bulletin” stories were retained and stored in a data- base that is currently available for searching at www.tobacco.org. Another notable feature of SCARCNet was the publication of “Action Alerts.” These two-page summaries of current issues requir- ing immediate action included objectives for action, suggested actions, media bites, quotes, and talking points and were sent to SCARCNet as needed (on av- erage, twice per month). The conferencing section on SCARCNet, called the “Strategy Exchanges,” provided a forum for planning, counseling, and experience sharing. The technology allowed for concurrent but separate discussions on discrete issues, such as clean indoor air, tobacco advertising and promotion, tobacco pricing policies, and minors’ access to tobacco prod- ucts. Since its inception in 1990 to its final edition on January 31, 2000, SCARCNet, along with its global counterpart GLOBALink, became an important re- source for the tobacco control community. In Febru- ary 2000, the American Legacy Foundation began its support of a newly designed and enhanced news ser- vice system that harnesses advances in Web technol- ogy to build on SCARCNet’s valued features. This system provides users with the leading national news stories and also includes a news service that allows users to receive a customized selection of other stories based on their geographic location and specialty areas of greatest personal interest (e.g., advertising, en- forcement, etc.). SCARCNet has served as a model for other pub- lic health advocacy networks. Examples include Safety Net (an advocacy network for violence prevention) and the Marin Institute’s ALCNet (a network for alcoho] control advocates), which is modeled closely after SCARCNet. ALCNet has been used for media advo- cacy as well, particularly to facilitate strategy devel- opment to counteract certain alcohol products and promotions. As with other modalities used for social change. the precise role of on-line networks—one element ina multifaceted approach—is difficult to define. Al- though process measures are available (e.g., frequency of interactions and message traffic), they do not assess the basic value of computer links in furthering the agenda for reducing tobacco use, nor is it likely (as is noted at the beginning of this chapter for social inter- ventions overall) that their efficacy can be precisely estimated. Current enthusiasm for the mechanism, however, will probably ensure its continuation, and accrued anecdotal experience—to date, quite positive— will provide the ultimate judgment. Direct Advocacy History and Activities National-level activities, including the work of the Coalition on Smoking OR Health (see “Further Regulatory Steps” in Chapter 5; see also “Community Mobilization,” earlier in this chapter) and others (see Chapter 2 and USDHHS 1989b), have played a promi- nent role in the evolving policy changes concerning the reduction of tobacco use. Of equal interest, from the point of view of the potential impact of advocacy, are decentralized grassroots organizations. The nonsmokers’ rights movement originated in the early 1970s (see “From Antismoking to Nonsmok- ers’ Rights” in Chapter 2). It consisted of individuals acting on their own and of small grassroots organiza- tions of people irritated by ETS or convinced that their health suffered from it. During this period, the docu- mented adverse health effects of ETS were first being brought to the public’s attention (Steinteld 1972; U.S. Department of Health, Education, and Welfare 1972). As research documenting these health hazards accu- mulated, nonsmokers’ rights organizations grew in number and strength. Many of the early grassroots organizations used the acronym GASP to represent similar titles, includ- ing the Group Against Smokers’ Pollution, the Group Against Smoking Pollution, the Group to Alleviate Smoking in Public Places, and Georgians Against Smoking Pollution. Other acronyms were also used, including FANS (Fresh Air for Nonsmokers), TAPS (Texans Against Public Smoking), and ANSR— pronounced “answer”—(Association for Nonsmokers Rights). Organizations were small, poorly funded, and often run from home by volunteers. Initially, many nonsmokers’ rights organizations simply provided a forum for nonsmokers to express their concerns about smoking and ETS. These groups helped legitimize their members’ complaints and em- power them to take protective actions. Such actions required courage, assertiveness, and no small measure of tact, since smoking in public areas was normative at the time. Group members might thus learn how to politely ask people to refrain from smoking; or to ob- viate direct confrontation with smokers, groups might provide members with signs, cards, or buttons asking people not to smoke in their presence. Early in the movement, nonsmokers’ rights associations adopted public policy change as an Reducing Tobacco Use important goal. Groups began to work for passage of measures to restrict public smoking. Such regulations are often referred to as clean indoor air laws (see “Clean Indoor Air Regulation” in Chapter 5). To encourage these measures, an early GASP organization produced a “Bill of Rights” that stated, in part, that Non-Smokers have the right to breathe clean air, free from harmful and irritating tobacco smoke. This right supersedes the right to smoke when the two conflict. Non-Smokers have the right to express—firmly but politely—their discomfort and adverse reactions to tobacco smoke. . . . Non- Smokers have the right to take action through legislative channels, social pressures or any other legitimate means—as individuals or in groups— to prevent or discourage smokers from polluting the atmosphere and to seek the restriction of smoking in public places (Group Against Smokers’ Pollution, n.d.). Over time, many organizations moved to encom- pass broader policy goals for reducing tobacco use— in particular, they sought ways to decrease tobacco use by minors. Largely as a consequence of those efforts, direct advocacy and public policy change became im- portant parts of these organizational strategies. In some communities, nonsmokers’ rights orga- nizations worked in isolation. In others, they formed associations with medical societies, voluntary health associations, and other organizations; the result was a more intense effort to ensure passage of desired legis- lation. Despite initial obstacles, in many communities nonsmokers’ rights associations were a driving force in moving their allies toward a legislative approach to reducing tobacco use. For example, one of the earliest and most influential nonsmokers’ rights organizations was California GASP, founded in 1976, which eventu- ally became Americans for Nonsmokers’ Rights (ANR). ANR is now the principal national-level tobacco control group devoted primarily to promot- ing legislation for clean indoor air. In California, ANR helped support the passage of such ordinances in many localities. Partly as a result of ANR’s work, California has more local ordinances for clean indoor air than any other state. ANR has served as a national consultant to other groups pursuing such legislation. Impact of Direct Advocacy In retrospect, the grassroots organizations can be seen as having worked to diminish the legitimacy of tobacco use in the eves of the public and the credibil- ity of the tobacco industry. The passage of ordinances Comprehensive Programs — 405 Surgeon General’s Report against public smoking (see “Clean Indoor Air Regu- lation” in Chapter 5) occurred over several years, dur- ing which a shift in public opinion about smoking became evident. During the 1960s and 1970s, the right to smoke was largely unquestioned. In more recent years, declining smoking prevalence and public opin- ion polls have indicated an increasing intolerance for public smoking (USDHHS 1989b). The work of non- smokers’ rights organizations is coeval with these legal, epidemiologic, and social changes. Sorting out cause and effect is difficult, but the nonsmokers’ rights movement seems to have contributed to the changing social norm (Glantz 1987). There were, however, some important exceptions to the emerging nonsmoking norms. By the mid-1980s, it was apparent that both the traditional educational efforts and the passage of ordinances to protect non- smokers from ETS had a limited effect on young people’s smoking-related attitudes and behaviors (USDHHS 1994). Efforts to reduce smoking appeared unable to reduce the prevalence of smoking among teenagers (Lynch and Bonnie 1994), and smoking prevalence among white females began increasing sharply during the 1970s, as did the prevalence of smokeless tobacco use among males. The failure to decrease smoking among young people is as difficult to assess as is the success observed among adults (particularly among adult men). Ana- lyzing the effect of prevention activities on voung people must include weighing the hampering effects of advertising and promotional efforts backed by the tobacco industry’s enormous marketing budget (see “Advertising and Promotion” in Chapter 5; DiFranza et al. 1991; Pierce et al. 1991; Lynch and Bonnie 1994; USDHHS 1994). Whatever the interplay of the forces involved, the result is that protobacco activity directed at those entering the market has been generally suc- cessful. An exception is the continued decline in preva- lence among young African Americans, particularly among young women (USDHHS 1998). Perhaps some of the shortfall in grassroots efforts to reduce tobacco use is associated with the early iso- lation of these groups from the established national advocacy organization. Anecdotally, there is evidence of aculture clash. When the nonsmokers’ rights move- ment emerged in the 1970s, many medical and volun- tary health organizations decried what they perceived as the unprofessional, indecorous, confrontational ap- proach that these activists took to an issue that had previously fallen in the domain of the traditional pub- lic health structure. Some traditional organizations in the public health arena may also have felt that 406 9 Chapter 7 grassroots organizations were infringing on their “turf” and their fund-raising base. For their part, nonsmokers’ rights associations objected to what they saw as the overly cautious, mea- sured approach of researchers, medical associations, and volunteer health associations, whose efforts seemed to have done little to solve the problems of day-to-day exposure to ETS. The grassroots organi- zations urged voluntary health organizations to exam- ine their mission statements and dedicate appropriate resources to cost-effective solutions to reducing to- bacco use. In time, both approaches acknowledged that the lack of coordination and cohesion was a significant barrier to their efforts. The groups noted that, in con- trast, the tobacco industry operated as a monolith through the coordinated efforts of the Tobacco Insti- tute, a lobbying and public relations organization representing the industry. This insight led to the emer- gence of several groups—somewhat disparate in their approaches—that attempted to bridge some of the dis- tance between the grassroots and national approaches to reducing tobacco use. Among the oldest of these groups is DOC (Doc- tors Ought to Care), which was founded in 1977 as a national coalition of health professionals, students, and concerned individuals. DOC groups take an activist approach to public health problems and sponsor com- munity projects and events on reducing tobacco use and other issues. From the outset, members chose con- frontational programs, such as counteradvertising and picketing industry-sponsored sports events, to delegitimize the tobacco industry and focus attention on its activities by involving both physicians and voung people in advocacy activities. DOC groups use satire, ridicule, and parody in their work to appeal to children and teenagers (Blum 1982); for example, they have sponsored “Emphysema Slims” tennis matches featuring appearances by “Martina Nosmokanova.” DOC also maintains a large archive of activities related to the tobacco industry, including past advertising campaigns and marketing strategies (Mintz 1995). The activities of DOC are similar in style, if not content, to those of the Australian organization Billboard Utilising Graffitists Against Unhealthy Promotions (BUGA-UP), which was founded in 1979. BUGA-UP members, some of whom are physicians, have used unconven- tional tactics, such as spray-painting billboards that advertise tobacco products (Jacobson 1983). Another group is Stop Teenage Addiction to To- bacco (STAT), which was founded in 1985 with the aim of reducing tobacco use among minors. From its inception, STAT aimed to unite the medical and scientific arm and the grassroots arm of the movement to reduce tobacco use. Although STAT frequently ap- proaches tobacco issues from the activist perspective, the organization has long included key members of the medical and public health establishment in its leadership. DOC, STAT, and other groups have attempted to make the activist, confrontational ap- proach to reducing tobacco use acceptable to the more conservative medical and voluntary health organiza- tions. Partly because of these efforts, an activist approach is now an important component of the move- ment (see the text box “Bill of Rights Tour’). Another impetus for a more unified movement was the establishment of the Smoking Control Advo- cacy Resource Center (SCARC) at the Advocacy Insti- tute in 1987. The Advocacy Institute’s mission—to study, analyze, and teach public interest advocacy— included a focus on smoking reduction as a model public interest movement. The institute received fund- ing from the Henry J. Kaiser Family Foundation to establish SCARC. Rather than be a frontline organi- zation, SCARC proposed to help build the movement's infrastructure. As such, SCARC would be viewed as a neutral player and would not vie with the movement's other organizations in seeking media, voluntary, or funding sources. Since its formation, SCARC has served three important roles as convener, tobacco industry monitor, and center for strategic development, training, and counseling (Butler 1990). Media Advocacy Media advocacy for reducing tobacco use was developed during the 1980s by a small number of ac- tivists working primarily in the United States, Canada, Australia, and the United Kingdom. The attendees at the September 1985 International Summit of Smoking Control] Leaders resolved to produce a handbook that would provide guidance on using the media to sup- port tobacco control. The resulting document, Smoke Signals: The Smoking Control Media Handbook (Pertschuk 1987), describes many of the important themes and skills needed for using what would later be dubbed “media advocacy.” In January 1988, the Advocacy In- stitute convened a two-day consensus workshop, sponsored by the NCI, that produced a second hand- book on media advocacy, Media Strategies for Smoking Control: Guidelines (USDHHS 1989a), which formally recognized the importance of media advocacy in re- ducing tobacco use (and in which the term “media advocacy” was first employed). Media advocacy has been defined as the strate- gic use of mass media to advance a social or public Reducing Tobacco Use policy initiative (NCI 1991). In contrast to the goal of traditional health communications efforts, the goal of media advocacy is to change public policy and thereby generate a broader impact on tobacco use by creating an environment in which smoking is not normative. Smoke Signals articulates six critical tasks the media must perform to help accomplish this goal: (1) edu- cate the public about the severity of the risks of smok- ing, the susceptibility of every smoker, and the health benefits of quitting; (2) educate the public about the health risks of ETS; (3) alert citizens and policymakers to injurious public policies that promote smoking, in- cluding insufficiently regulated advertising and pro- motion of cigarettes, as well as unrestricted smoking in public areas and the workplace; (4) respond to and counteract the propaganda and disinformation cam- paigns of the tobacco industry; (5) counter the eco- nomic and political influence of the tobacco industry, which thwarts the adoption of remedial policies; and (6) reinforce evolving social nonsmoking norms (Pertschuk 1987). Media advocacy campaigns have been likened to political campaigns “in which competing forces con- tinuously react to unexpected events, breaking news, and opportunities” (Pertschuk et al. 1991, p. 3). Such campaigns require both presenting the public health side of an issue and negating the opposing side. Like political campaigns, media advocacy campaigns re- quire quick reactions that contrast with the carefully planned, fixed agendas of traditional media programs. Media advocacy recognizes the potential of the press to place on the public agenda issues concerning the reduction of tobacco use and to either advance or retard progress toward policy goals. Successful me- dia influence requires gaining access to the news and framing or shaping coverage of the resulting story. These strategies are interrelated, since the framing of a story helps determine whether a journalist will agree to cover it. The use of media advocacy has two daunting limi- tations: it is a new technique that requires complex skills and an understanding of the news media, and it demands a large investment in time (Wallack 1990). But another apparent barrier—the reliance on an outside party (the media) to achieve program goals—is also a source of considerable strength: media advocacy is a means by which public health practitioners can indi- rectly confront and compete with forces that are tradi- tionally beyond their policy and financial reach. These forces represent powerful vested interests—the tobacco industry, advertising industry, retail establishments that sell tobacco, and others. The financial and political influence of these entities can limit the ability of public Comprehensive Programs 407 408 surgeon Geieral’s Report Bill of Rights Tour I fall 1989, Philip Morris, the largest U.S. manu- facturer of cigarettes, contracted with the U.S. National Archives and Records Administration to sponsor a commemoration of the 200th anniversary of the Bill of Rights. The commemoration involved a national advertising campaign, including com- mercials on prime-time television and full-page advertisements in major newspapers, asking Ameri- cans to “Join Philip Morris and the National Archives in celebrating the 200th anniversary of the Bill of Rights” (cited in Advocacy Institute 1989, p. 1). Philip Morris soon announced plans to transport Virginia’s copy of the Bill of Rights to ali 50 states in coopera- tion with the Virginia State Library and Archives. Advocates for reducing tobacco use inter- preted Philip Morris’ effort as an attempt to link smoking with the national freedoms guaranteed by the Bill of Rights. These groups believed that Philip Morris would use its association with the Bill of Rights Tour, which highlighted themes of liberty and freedom of expression, to gain public support for the company’s claim of a First Amendment right to advertise. Philip Morris’ project with the National Archives raised concern in the U.S. House of Rep- resentatives, which held hearings on the issue but did not intervene. Advocates for reducing tobacco use began using the 16-month tour schedule to coordinate local efforts to counter what they con- sidered to be a tobacco-marketing pian. The Washington state chapter of Doctors Ought to Care (DOC) built a countersymbol, the “Statue of Nicotina,” to travel with the tour. Ata press conference, comments from the president of the chapter, Dr. Robert Jaffe, captured the flavor of the symbol’s proposed use: Nicotina is modeled [on] the Statue of Liberty. She’s holding a cigarette in her upheld hand, instead of a torch, and her eyes are closed, the symbol of shame that she’s been . . . made a symbol of tobacco. The chains from her ciga- rettes in the pack help to illustrate to all of the children who are going to see the Bill of Rights Tour that this is a dangerous, addictive drug. At her feet are the words, “Give me your poor, your tired, your women, your children yearn- ing to breathe free...” (quoted in Wallack et al. 1993, p. 185). Chapter 7 The Advocacy Institute published an advance schedule of the national tour, including dates and specific locations for each of the tour’s stops. The institute also tracked activities in various states and disseminated strategic information through Action Alerts posted on SCARCNet, the institute’s com- puter network dedicated to sharing information on reducing tobacco use. SCARCNet (see “Electronic Networking,” earlier in this chapter) was a key mechanism for advocates to share information and develop strategies. In addition, the American Lung Association and the American Medical Association provided materials and strategic support to its in- terested affiliates. Initially, Philip Morris responded to protests at tour sites by establishing a “speaker’s corner” that restricted protesters to a site away from the exhibit hall. At first, this strategy successfully muted attacks and deflected positive attention from protesters. Indeed, by appearing to encourage protesters, Philip Morris was portrayed by some me- dia reports as being faithful to the spirit of the Bill of Rights. As the tour continued, however, groups opposed to the sponsorship learned from experience in other states. The groups refined their message, learned how best to respond to Philip Morris’ spokespersons, discussed public reaction to their protests, and modified their tactics appropriately. They developed a simple slogan, “Bill of Rights Yes / Philip Morris No” (cited in Wallack et al. 1993, p. 186), to clarify the theme of their protests. With the changed approach, advocates re- ported improved media coverage of the protests. At almost every tour stop, advocates staged press conferences before the opening of the exhibit and displayed the Statue of Nicotina, which was trans- ported from state to state. By February 1991, five months into the tour, Philip Morris scaled down the number of scheduled stops. The tour, accom- panied by advocates for reducing tobacco use, continued through its conclusion in Richmond, Virginia, in December 1991. The ultimate effectiveness of this advocacy effort is difficult to judge, but the effort played an obvious role in muting the public relations benefits to the tobacco industry. At the very least, the re- sources invested by the industry did not appear to bring the expected return. (as well as private) agencies to use confrontational tac- tics. In addition, many communities prefer consensus building to confrontation with powerful opposition parties. However, because the visible products of me- dia advocacy—-the media reports themselves—emerge from a disinterested party (the media) rather than from parties for or against reducing tobacco use, this new- est form of social intervention can be successful in pre- viously problematic areas. As with other social interventions, the precise contribution of media advocacy to the effort to reduce tobacco use is difficult to judge. Events like those sur- rounding the marketing of the cigarette brands Up- town, X, and Dakota and the Philip Morris-sponsored Bill of Rights Tour demonstrate the role that media advocacy can play in the overall effort. Countermarketing Mass Media in Tobacco Control In contemporary society, the mass media are the most important means of educating and informing the public and, through public response to media, policy- makers. By design or not, the media plays an enor- mous role in influencing the smoking behavior of individuals and the actions of policymakers in both the public and the private sector (Pertschuk 1987). Public health programs have used various health communi- cation programs to inform and influence the behavior of the general public. Traditionally, communication programs intended to reduce tobacco use have tried to influence the behavior of individuals. Most such media campaigns have focused on influencing the behavior of adult smokers—and hence have focused more on smoking cessation than on prevention. Flay (1987) describes three prominent types of mass media programs and campaigns designed to influence smoking-related knowledge, attitudes, and behavior: (1) those that inform the public of the negative health consequences of cigarette smoking and try to motivate smokers to quit, (2) those that promote specific smok- ing cessation actions to those smokers motivated to quit (e.g., smokers are encouraged to call a help line or to request specific materials, such as a tip sheet ora self-help manual), and (3) those that promote smok- ing cessation self-help clinics for those smokers who desire to quit. A smaller number of campaigns have focused on youth, either encouraging young people to avoid using tobacco products or convincing young people who smoke to try to quit (USDHHS 1994). A factor that has limited the success of traditional mass media campaigns is the small size of the cam- paign budgets compared with the advertising and Reducing Tobacco Use marketing budgets of the tobacco industry (Flay 1987; USDHHS 1994). In addition, these campaigns to re- duce tobacco use have experienced drawbacks because of their traditional reliance on public service announce- ments (PSAs). Although PSAs have been an integral part of such efforts for many years, the number of PSAs on any subject provided to broadcasters has increased, whereas the amount of donated air time available for PSAs has decreased. Also, the advent of cable tech- nology, which has increased the number of channels through which people can be reached and therefore has diffused the audience, has further hampered efforts to reach targeted groups efficiently. By the mid- 1980s, it had become apparent that the role of the media in the effort to reduce tobacco use required re- evaluation. In the following sections, the uses of mass media approaches for tobacco control are summarized. Effects of Protobacco Advertising and Promotion The effect of tobacco advertising and promotion activities on both adult consumption and youth ini- tiation has been the subject of considerable research over the past decade (see “Advertising and Promo- tion” in Chapter 5). While noting that existing evi- dence suggests that tobacco marketing increases the level of tobacco consumption, the 1989 Surgeon General’s report Reducing the Health Consequences of Smoking: 25 Years of Progress concluded that the issue is so complex that a sufficiently rigorous study capable of providing definitive scientific evidence is not available and that “none is likely to be forthcom- ing in the foreseeable future” (USDHHS 1989b, pp. 516-7). The 1994 Surgeon General's report Preventing Tobacco Use Among Young People similarly noted the absence of a definitive longitudinal study of the direct relationship of tobacco advertising to adolescent smok- ing. However, acknowledging the value of recent nonlongitudinal studies focused on young people, the report offered this major conclusion: “Cigarette advertising appears to increase young people’s risk of smoking by affecting their perceptions of the perva- siveness, image, and function of smoking” (USDHHS 1994, p. 6). Also in 1994, the Institute of Medicine con- cluded that the preponderance of evidence suggests that tobacco marketing encourages young people to smoke (Lynch and Bonnie 1994). In its rule to restrict the access and appeal of to- bacco products to young people, the Food and Drug Administration (FDA) reviewed the quantitative and qualitative evidence and concluded that cigarette ad- vertising is causally related to the prevalence of smok- ing among young people (Federal Register 1996). The Comprehensive Programs 409 Surgeon General's Report agency also cited statements from internal documents of the tobacco industrv to show the importance of the youth market segment to the industry’s continued success. More recently, a 1998 Report to the United Kingdom's Chief Medical Officer by the Scientific Committee on Tobacco and Health concluded unani- mously that tobacco advertising and promotion influ- ence young people to begin smoking (Scientific Committee on Tobacco and Health 1998). Survey data show that among children who smoke, most use the most heavily advertised brands of cigarettes, whereas many adult smokers buy generic or value category brands, which have little or no im- age advertising (CDC 1994). A major econometric marketing study found that young people are three times more affected by advertising than are adults (Pollay et al. 1996). Research has also pointed to the impact of other tobacco promotional activities, such as sponsorship of public entertainment events and dis- tribution of specialty or premium items. These activi- ties constitute the largest (and an increasing) share of tobacco marketing expenditures. The CDC has esti- mated that today’s U.S. teens already have been ex- posed to more than $20 billion in imagery advertising and promotions since age 6, creating a “friendly fa- miliarity” for tobacco products and an environment in which smoking is seen as glamorous, social, and normal (Eriksen 1997). Although the effect of this ex- posure is difficult to quantify, especially nationwide, one study has estimated that 34 percent of all vouth experimentation with smoking in California between 1993 and 1996 can be attributed to tobacco promotional activities (Pierce et al. 1998). A recent study found that teenagers who can readily name a cigarette brand and who own a tobacco-company-sponsored promotional item are more than twice as likely to become estab- lished smokers than adolescents who do neither (Biener and Siegel 2000). Effects of Tobacco Countermarketing In light of ubiquitous and sustained protobacco messages, countermarketing efforts of comparable in- tensity and duration are needed to alter the social and environmental context of tobacco use. Evidence of effectiveness comes from three main sources: (1) the natural experiment of the counteradvertising cam- paign that occurred during the late 1960s as the result of a Fairness Doctrine ruling (also discussed in “Broad- cast Advertising Ban” in Chapter 5), (2) school and community intervention studies incorporating mass media approaches (see “Supplemental Programs” in Chapter 3), and (3) recent experience with large paid 410 9 Chapter 7 media campaigns in several U.S. states and with a na- tionwide campaign funded by the FDA. Because of the special sensitivity of young people to tobacco mar- keting and the high rates of tobacco use among teen- agers, the subsequent review in this chapter will focus on countermarketing media campaigns that include prominent youth-targeted components. The literature provides strong evidence of the value of mass media campaigns to inform the public at large—including young people—about the hazards of smoking, to pro- mote specific cessation actions and services (such as telephone help lines), and to provide cessation clinics to adult smokers (Flay 1987; Pierce 1995). The Fairness Doctrine campaign. In 1967, the Federal Communications Commission (FCC) applied the Fairness Doctrine (discussed in “Broadcast Adver- tising Ban” in Chapter 5) to cigarette advertising and required broadcasters to provide a significant amount of airtime to antismoking messages—a requirement interpreted by the FCC at that time to be about one antismoking message per three tobacco advertising messages). This requirement resulted in the onlv sus- tained nationwide tobacco control media campaign to date. From mid-1967 through 1970, roughly $200 million in commercial airtime (in 1970 dollars) or $75 million per year was donated for antismoking mes- sages on television and radio (Warner 1986; USDHHS 1989b). The campaign produced significant reductions in both adult and youth smoking behaviors (Hamilton 1972). For the first time in the 20th century, adult per capita cigarette consumption fell for more than three consecutive years. Teenage smoking prevalence was 3 percentage points smaller during the Fairness Dac- trine period than it was in the 16 months before the campaign, and the campaign was associated overall with a 3.4-percentage point reduction in teen smoking prevalence. Perhaps the ultimate indicator of the campaign’s impact was a change that followed the campaign’s end: with the 1971 enactment of congres- sional legislation banning tobacco commercials from television—and with them, the Fairness Doctrine- mandated counteradvertisements—per capita cigarette consumption immediately resumed its upward trend (see “Broadcast Advertising Ban” in Chapter 5). Hamilton (1972) suggested that during the Fair- ness Doctrine period, the antismoking campaign mes- sages had an effect that was nearly six times that of cigarette advertisements. Warner (1979) noted that the government's broadcast ban—and the consequent end of the countermarketing campaign—was especially detrimental to the ongoing effort to prevent young people from smoking. Cigarette promotion remained highly visible in the print media and in tobacco com- panies’ sponsorship of sporting events at the same time the broadcast ban “virtually eliminated mass promo- tion of the antismoking cause” (p. 445), Community intervention studies. As described in “Research on Multifaceted Programs” in Chapter 3, multicomponent youth-directed programs that include a prominent mass media component have shown long- term success in postponing or preventing smoking onset in adolescents. In the University of Vermont School and Mass Media Project, the study featuring the most intensive paid counteradvertising campaign, the preventive effect actually increased during the two- year intervention period among the adolescents at higher risk for smoking (Flynn et al. 1997)—a rare outcome for most campaigns trying to change health behaviors. The authors noted that counterad vertising can effectively reach higher-risk youth because of their greater exposure to the mass media, particularly ra- dio and television. It is also likely that higher-risk youth make their decisions about tobacco use earlier in life than lower-risk youth; mass media influences can be especially powerful in shaping attitudes and normative perceptions at early ages. State-based media campaigns. Mass media cam- paigns are standard components of the well-funded, ongoing tobacco contral programs in California, Mas- sachusetts, Arizona, Florida, and other states receiv- ing money for counteradvertising programs from state excise tax increases or tobacco settlement allotments (as was discussed in “Example of Major State Pro- grams,” earlier in this chapter). Although it is diffi- cult to sort out the effectiveness of media campaigns from other program components, evaluations of these statewide public education programs, particularly in California and Massachusetts (see “Supplemental Pro- grams” in Chapter 3), have shown their success in re- ducing tobacco use among adults, slowing the uptake of tobacco among youth, and protecting children from exposure to ETS (CDC 1996). A recent study of the Massachusetts media campaign in 1993 and 1997 found that among younger adolescents (those aged 12-13 years in 1993), those who had been exposed to the counteradvertising campaign on television were about half as likely to have become smokers as those who had not been able to recall campaign advertisements (Siegel and Biener 2000). Food and Drug Administration campaign. In 1998, the FDA launched a national advertising campaign to help retailers comply with the age and photo identification provisions of the FDA's rules to prevent tobacco sales to children and adolescents. The Reducing Tobacco Use campaign began with a test in Arkansas and by year’s end was active in 42 states. Funded annually at about $9 million, the campaign featured radio spots, bill- boards, newspaper advertisements, posters, and store signage. The overall approach was to use humor to relieve the discomfort clerks may feel when checking young people’s identification / proof-of-age cards and to increase awareness of the rule provisions among re- tailers, underage youth, and the general population. One counter card, for example, reads, “Our cashier really stinks at guessing ages. So if you want ciga- rettes, can we see some J.D.?” A campaign tracking survey (Market Facts 1998) in nine states with test and control sites found that during the first year of the campaign, knowledge of age 27 as the cutoff age for checking identification increased from 34 to 54 percent in test sites and from 31 to 40 percent in control sites. Most important was a small but significant decline in the average number of times minors tried to buy tobacco. According to re- tailer self-reports, this number declined from 3.4 times each day before the campaign to 2.8 times daily after the media effort. In control sites, the frequency of un- derage purchase attempts did not decrease from be- fore (2.4 times daily) to after (2.7 times daily) the time of the campaign. For customers from whom identifi- cation was requested in the test sites, retailers reported that the proportion of those who were “often” or “al- ways” irritated declined from 34 percent to 28 percent. Counteradvertising and entertainment media. The increase in movie depictions of tobacco use is a powerful media influence promoting use among teens (Stockwell and Glantz 1997). In focus groups, young people are not able to recall antismoking messages on television or in the movies, but they recall specific movies that portray smoking and can identify actors and actresses who smoke in their entertainment roles (Crawford et al. 1998). Counteradvertising holds promise for helping denormalize and deglamorize these portrayals in the entertainment media. In an experimental study, Pechmann and Shih (1999) found that placement of a 30-second California Department of Health Services tobacco counteradvertisement before the popular movie Reality Bites served to inocu- late teenagers against the movie's pervasive prosmoking cues without detracting from their enjoy- ment of the film. Because paid advertising in movie theaters is a highly efficient method of reaching adolescents, the authors recommend this tactic as a nationwide cost-effective prevention strategy. Research on best practices. Although produc- ers of counteradvertising campaigns use formative re- search techniques to develop products, inconsistent Comprehensive Programs 4171 Surgeon General's Report testing methods hinder comparison of the etfective- ness of different messages. This situation has helped create the impression that there is little agreement over “what works” in tobacco counteradvertising, as typified by this Washington Post headline: “The Anti- Smoking Campaign’s a Many Splendored Thing, and That’s the Problem” (Teinowitz 1998). Goldman and Glantz (1998), using available fo- cus group data and research reports obtained froma number of states, concluded that two message strate- gies, industry manipulation and the hazards of ETS, are the most effective for denormalizing smoking among young people and reducing consumption among adults. The researchers reported that addic- tion and cessation messages can also be effective, but that four strategies are not effective: youth access, short-term health effects, long-term health effects, and romantic rejection. They also characterized California’s counteradvertising campaign as more “confrontational with the industry” (p. 772) than Mas- sachusetts’ “more youth-oriented approach” (p. 772), citing this difference as a major reason for their find- ing that the California media campaign was relatively more cost-effective. This paper elicited some strong responses. The University of Vermont School and Mass Media Project investigators (Worden et al. 1998) em- phasized the limitations of focus group results and the importance of audience age in reactions to messages. They argued that for young people aged 10 to 12 years (the age group in which they recommended starting prevention efforts), presenting messages that foster positive social influence and social norms have proved most effective in reducing tobacco use among youth. Balch and Rudman (1998) responded that young people participating in 110 focus groups in five differ- ent states considered numerous concepts and judged five to be more credible, relevant, and persuasive: addiction, short-term health effects, athletic perfor- mance, role model for younger siblings, and effects on family. From Massachusetts, Connolly and Harris (1998) noted that industry manipulation and ETS themes constituted 32 percent of all youth-targeted messages and 37 percent of all messages in the Massa- chusetts tobacco control media campaign and that on a per capita basis, the state actually outspent Calitor- nia on these messages. Moreover, the researchers re- ported that Massachusetts experienced a larger decline in per capita cigarette consumption than did Califor- nia for the period 1990-1996. To obtain data in a more quantitative way, Pechmann and Shih (1999) created a tvpology based on 196 youth-oriented antismoking television adver- tisements. They identified three main types—fear 412) Chapter 7 appeals, peer norms, and tobacco marketing—and further subdivided these into seven main messages: (1) smokers may face serious health problems, (2) to- bacco company deception results in disease and death, (3) smokers endanger their family members, (4) smok- ing is unattractive, (5) smokers are perceived by peers as misguided, (6) most young people choose not to smoke, and (7) advertisement shows how tobacco com- panies market their products. The investigators tested a sample of 56 of their advertisements in a group of ethnically diverse 7th, 9th, and 10th graders. After viewing a selection of test and placebo advertisements, study participants completed an evaluation survey to assess the effect of each category on their intent to smoke and on other pertinent measures, such as atti- tudes toward smoking and knowledge of tobacco marketing tactics. Results showed that only three of the seven messages were highly effective in reducing teenagers’ intent to smoke: those that conveyed that smokers endanger their family members, that smok- ers are perceived by peers as misguided, and that most young people choose not to smoke. In the Massachusetts campaign study (Siegel and Biener 2000), the authors tested eight smoking-related knowledge and attitude variables corresponding to campaign themes. Only one variable, perceived youth smoking prevalence, changed significantly with expo- sure to the media campaign at baseline and was asso- ciated with the reported reduction in tobacco uptake. Exposed youths were more than twice as likely than their unexposed peers to have an accurate perception at follow-up that fewer than half of the students at their high school were smokers. Variables that did not change were knowledge and attitudes related to low- tar cigarettes, environmental tobacco smoke, chemi- cals, wrinkles, tobacco company tactics, dating, and sports. This finding points to the power of the mass media, especially television, to set social norms and supports the effectiveness of counteradvertising mes- sages that denormalize tobacco use. As part of a three-year study exploring racial/ ethnic and gender differences in teen tobacco use, a group of 11 CDC-funded university-based Prevention Research Centers conducted a series of focus groups during 1996-1997 to explore potentially effective counteradvertising strategies and messages. Six of the 11 centers used television spots from CDC's Media Campaign Resource Center for Tobacco Control to elicit reactions and stimulate discussion. For the most part, different centers used different advertisements, and they did not attempt to “test” the advertisements in any standardized way to determine relative effective- ness. Nevertheless, the conclusions that emerged from Reducing Tobacco Use Teen Focus Group Response to Counteradvertising Messages (Findings from 11 Prevention Research Centers) ¢ Without an overall context provided by ongo- ing advertising and other program elements, the message that tobacco companies are manipu- lating young people to smoke (“they’re lying to you”) has relatively low interest and salience among teens and may be miscomprehended. * Attempts to explain the concept of nicotine ad- diction and make it personally relevant for young nonsmokers is difficult because most have not experienced the physical cravings of addiction and tend to take messages literally. ¢ The television spot shown to the most focus groups (about physical performance and fea- turing the U.S. Women’s National Soccer Team) was easily understood, attention getting, and credible and may be generalizable (with some effort) to nonathletic endeavors. * Young people did not like advertisements that feature text. ¢ Young people, particularly whites, were sharply critical of any advertisement they perceived as corny, “cute,” staged, or unhip. this research (Tobacco Network, unpublished data) give some indication of the complexity of people’s response and the considerable challenges to crafting effective messages (see the text box “Teen Focus Group Response to Counteradvertising Messages”). Audience targeting. The use of counteradver- tising aimed only at young people rather than the use of a general marketing approach has been controver- sial. Glantz (1996) criticized the public health community’s “preoccupation with youth” (p. 157), particularly youth access campaigns, as an ineffective strategy and one that diverts energy from reducing adult smoking and creating a smoke-free society. Cummings and Clarke (1998) warned that campaigns focused exclusively on young people may be counter- productive if the messages make smoking more ap- pealing to youth by promoting it as something that is e Asadvertising professionals have reported in the research literature, humor was found to be a double-edged sword: it can be very effec- tive, but if used inappropriately can be seen as trivializing the issue. In some focus groups, humorous advertisements obtained both the highest and the iowest scores. « Young people reacted emotionally and favor- ably to true, nonpreachy stories about the im- pact of smoking on a person’s or family member’s life (such as a television spot from California featuring a man whose wife had died from exposure to his smoking). ¢ Cartoons tend to have low “stopping power” because teens have seen so many, whereas the use of surprising characters like animals (such as the “Animals” and “Butts” spots from Min- nesota) can rivet attention. These attention- getting spots do not necessarily communicate an effective countermessage, however. * Messages that portray the negative social effects of tobacco use perform well among teens; mes- sages that focus on health effects can be effec- tive if they are presented dramatically but realistically (such as a California spot featuring a laryngectomy patient smoking a cigarette). not for them. Indeed, a chief criticism of the tobacco industry-funded booklet Tobacco: Helping Youth Say No was that it portrayed tobacco use as a forbidden fruit and a badge of maturity, thereby increasing its attrac- tion to youth (DiFranza and McAfee 1992). The Insti- tute of Medicine noted that “as adolescents venture more and more into the community, their perceptions that certain norms seem to apply only to them and not to adults may promote health-compromising behaviors” (Lynch and Bonnie 1994, p. 87). Young people participating in focus groups conducted dur- ing the third year (1997-1998) of the CDC-funded Tobacco Network project reported that they respect and regard policies targeted to the public at large, such as clean indoor air laws, but resent policies specific to them, such as vouth access restrictions. They also resented the inconsistent enforcement of general Comprehensive Programs — 413 Surgeon General's Report Tips for Success in Health Promotion Campaigns * Target young people in grades six and nine (ages 11 and 15). These years define critical periods in most children’s social development, times when many young people change schools and peer groups. * Target adults with complementary, noncontra- dictory messages. Ina comprehensive strategy, media messages that inevitably spill over from one audience to another can be mutually rein- forcing and synergistic. Clean indoor air mes- sages can provide added motivation for adults to quit smoking. Cessation messages for adults can affect young people’s perception of norms and highlight the problem of addiction. Pre- vention messages for young people can increase the salience of the tobacco issue among parents and community leaders. © Highlight nonsmoking as the majority behavior. Most young people overestimate the number of their peers who use tobacco. Campaigns should not seek to correct this misperception and highlight an increasing “problem” of kids who smoke. ¢ Present realistic tobacco-free lifestyles as prac- ticed by diverse, appealing, and interesting per- sons. Youth behaviors are driven by how young people perceive the behaviors of people like them. Having a repertoire of social choices is a fundamental need for teens, who are going through a period of profound social and envi- ronmental transition. policies, such as allowing teachers but not students to smoke on school property. Worden (in Cummings and Clarke 1998), referring to the research literature on multifaceted education cam- paigns, noted that reducing the demand for tobacco among young people requires a combination of direct (to youth) and indirect (to adults) messages and careful attention to audience segmentation. He stressed that young people and adults need separate media cam- paigns that do not contradict each other. For example, a youth-directed television spot that communicates the 414 0 Chapter 7 * Provide constructive alternatives to tobacco use and discourage destructive alternatives. Sports and other youth-oriented activities as- sociated with the tobacco-free lifestyle can pro- vide some of that positive social repertoire. * Communicate the relevant dangers of tobacco. Certain dangers of tobacco, if explained in a creative and memorable manner, resonate with young people—for example, addiction por- trayed as a loss of control, the carcinogenicity of environmental tobacco smoke, the toxic chemicals in tobacco products and smoke, and the tangible suffering and visible disfigurement from tobacco-related diseases. Communicate health messages through personal testimonies (tell a story) and creative executions that break through young people’s sense of immortality and their (and adults’) resistance to traditional health messages. ¢ Encourage youth empowerment and control. Teens need to be offered information and anec- dotal experience from which they can begin to understand the world and take control of their own lives. ¢ Abandon the search for the “magic-bullet” message. There is no single best motivator for preventing or reducing tobacco use. Campaign messages for both voung people and adults should feature a variety of themes, appeals (fear, humor, satire, testimonials, etc.), and execu- tional styles. Maximize the number, variety, and novelty of messages rather than communi- cating a few messages repeatedly. continued on next page message “most kids don’t smoke” can be neutralized by an adult-aimed but youth-viewed spot that says “more and more kids are smoking every day.” Characteristics of Successful Campaigns Though debate continues over the relative effec- tiveness of strategies employing specific messages, the experience reviewed in preceding sections suggests consensus that counteradvertising campaigns must have sufficient reach, frequency, and duration to be continued © Use multiple nonpreachy voices. Not only do different teens require different appeals and creative executions, but diversity of messages is itself a sophisticated message. Teens strongly reject attempts by anvone to domi- nate or direct them. Messages about indus- try manipulation, if they are to be relevant and acceptable to youth, should be delivered by nonauthoritarian sources (such as Florida’s “Truth” campaign teenagers), not with melo- dramatic appeals. Avoid highlighting a single theme, tagline, identifier, or sponsor. ¢ Use acomplementary, reinforcing mix of tele- vision, radio, print, and outdoor advertising. The campaign should also explore the vari- ous alternative media options available (e.g., movie trailers, the Internet, other computer resources, video games, materials for schools and community groups). The media mix is especially important in view of today’s pro- liferating fragmented media market. * Involve parents and families in activities that will reduce risk factors and promote protec- tive factors for young people at risk for to- bacco use. Parents and other family members have substantial influence on the perceptions and behaviors of young people. successful. The 1967-1970 media campaign, enabled by the Fairness Doctrine, achieved high frequency (one antismoking advertisement per three cigarette adver- tisements), extended reach (virtually complete audi- ence penetration through three [pre-cable television] national networks), and long duration (three and a half years). The youth-aimed media campaign of the Uni- versity of Vermont School and Mass Media Project exposed 50 percent of the target population to each television and radio spot about 6 times each year over a four-year period (about the midpoint in the recom- mended exposure range of 3 to 10 times per year). This level of exposure is possible only through paid media placement. Another lesson from health promotion campaigns is the need for research at every phase of campaign planning and implementation. Campaigns should be grounded in the extensive literature on psychosocial risk factors for initiating, continuing, and stopping tobacco use and should be guided by expertise in Reducing Tobacco Use * Maximize use of existing high-quality media materials produced by the government, volun- tary agencies, and a number of individual states. (A new, high-quality television spot commonly costs more than $100,000 to produce.) A large collection of advertisements is currently avail- able through the CDC’s Media Campaign Re- source Center for Tobacco Control. The cost of placing an advertisement will vary significantly by state and media market. * Include grassroots promotions, local media ad- vocacy, event sponsorships, and other com- munity tie-ins to support and reinforce the counteradvertising campaign (see “Media Ad- vocacy,” earlier in this chapter). Work in con- cert with other interventions to promote policies that aim to change social norms regarding to- bacco. A local “look” for local media messages (e.g., featuring people of ethnic or geographic representation similar to the viewing audience) appears to be more important for adults than for youth, because young people tend to share and be shaped by a more universal, multiethnic youth “media world.” communications theory and practice. Media materials should undergo rigorous audience pretesting to ensure they achieve predetermined communication objectives with their target audiences. Ongoing measurement of the communications’ impact is needed to evaluate the effectiveness of the campaign and to guide midcourse corrections. Through the Columbia University Preventior Research Center in New York City, the CDC convened a panel of youth marketing and research experts in 1996 to advise the agency on effective countermarketing approaches to prevent tobacco use among young people. Over two years, the expert panel reviewed the literature, interviewed experts in tobacco control and health promotion, and drew on their private-sector experience and resources to develop a set of strategic guidelines for such a campaign (McKenna et al. 2000). This work, supplemented by other reviews of counteradvertising campaigns (USDHHS 1994; Pechmann 1997; Siegel 1998; Teenage Research Comprehensive Programs — 415 Surgeoit General's Report Unlimited 1999; Pechmann and Reibling 2000), vielded recommendations for effective media cam- paigns to prevent tobacco use (see the text box “Tips for Success in Health Promotion Campaigns”). These recommendations serve as general guidance for tobacco counteradvertising efforts, but further research is needed to refine our understanding of the role and effects of mass media. Relevant areas for fur- ther investigation include determining the impact of Summary counteradvertising on tobacco use behaviors, on readi- ness to quit, on attitudes toward tobacco advertising and tobacco use, and on other predictors of initiation and cessation; identifying the most effective themes, techniques, and messages; tailoring messages to high- risk groups; exploring the role of new communication tools, such as the Internet; attributing impact; and ex- amining the interaction of media campaigns with pri- vate and public tobacco control policies. The conceptual framework described at the start of this chapter defines the basic components of the health promotion intervention model. The statewide tobacco control programs being funded either by increases in cigarette excise taxes or settlements with the tobacco in- dustry are creating a new laboratory to test many of these conceptual models for comprehensive tobacco control. Recently, both the Institute of Medicine (OM) and re- searchers have released reviews of the emerging data from these statewide tobacco control efforts. In their report, the JOM (2000) noted that it is difficult to at- tribute a reduction in tobacco use to any single factor; nevertheless, they conclude that “multifaceted state tobacco control programs are effective in reducing to- bacco use” (p. 4). Ina review focusing more specifically on the effectiveness of these new statewide tobacco con- trol programs on teenage smoking, Wakefield and Chaloupka (1999) conclude that “There is consistent evidence the programs are associated with a decline in adult smoking prevalence” (p. 6), but they are somewhat more cautious about the impact of these programs on youth smoking. Nevertheless, they do conclude that “Notwithstanding these cautions, we find that the weight of evidence falls in favor of comprehensive tobacco control programs being able to reduce teenage tobacco use” (p. 6). In the consideration of the emerging data from these statewide tobacco control programs, it is impor- tant to note that many programmatic elements of the comprehensive tobacco control program framework are still being refined and evaluated. Thus, no current statewide program serves an ideal or model program. Wakefield and Chaloupka (1999) conducted a careful review of the various elements of the statewide 4160 Chapter 7 programs in Arizona, California, Florida, Massachu- setts, and Oregon. They placed special attention on the strengths of the “inputs”—“namely, what was actually implemented as part of the programs.” Addi- tionally, they assessed how “actual implementation of program strategies may differ substantially from in- tended implementation” and noted that “the extent of disparity may vary over time and between programs.” Much more evaluation research is needed in order to sort out the efficacy of individual components of these evolving comprehensive programs and to refine the comprehensive program structure. Finally, although the data from these statewide tobacco control programs are encouraging, these results need to be considered in the perspective of the less fa- vorable results from the community trials. The concep- tual framework for the comprehensive tobacco control programs shares many elements with the theoretical models used to develop the community trial interven- tions. However, as Wakefield and Chaloupka (1999) noted, the programs actually implemented may differ substantially trom the intended implementation. There has been some effort to analyze how the program components within the emerging statewide tobacco control programs may differ from interventions tested within the community trials (Green and Richard 1993; Schmid et al. 1995), but much more work is needed in this area. As the LOM (2000) and Wakefield and Chaloupka (1999) concluded, the results from the state- wide tobacco control programs are favorable. However, both reviews emphasize the importance of continued surveillance and evaluation efforts to monitor program performance, to provide accountability for the use of public funds, and to improve program efforts. Conclusions Reducing Tobacco Use N The large-scale interventions conducted in com- munity trials have not demonstrated a conclusive impact on preventing and reducing tobacco use. 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