Literature Review: Tobacco Control; Youth

Using Mass Media Campaigns to Reduce Youth Tobacco Use: A Review

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Jane Appleyard Allen, MA; Jennifer C. Duke, PhD; Kevin C. Davis, MA; Annice E. Kim, PhD; James M. Nonnemaker, PhD; Matthew C. Farrelly, PhD Abstract

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Objective. This review synthesizes the published literature on using mass media campaigns to reduce youth tobacco use, with particular focus on effects within population subgroups and the relative effectiveness of campaign characteristics. Data Source. A search of PubMed and PsycINFO conducted in March of 2014 yielded 397 studies with 34 suitable for inclusion. Study Inclusion and Exclusion Criteria. Included were quantitative studies that evaluate an antitobacco media campaign intended to influence youth cognitions or behavior or explore the relative effectiveness of campaign characteristics among youth. Data Extraction. An automated search and assessment of suitability for inclusion was done. Data Synthesis. Study outcomes were compared and synthesized. Results. Antitobacco media campaigns can be effective across racial/ethnic populations, although the size of the campaign effect may differ by race/ethnicity. Evidence is insufficient to determine whether campaign outcomes differ by socioeconomic status and population density. Youth are more likely to recall and think about advertising that includes personal testimonials; a surprising narrative; and intense images, sound, and editing. Evidence in support of using a health consequences message theme is mixed; an industry manipulation theme may be effective in combination with a health consequences message. Research is insufficient to determine whether advertising with a secondhand smoke or social norms theme influences youth tobacco use. Conclusion. Our recommendation is to develop antitobacco campaigns designed to reach all at-risk youth, which can be effective across racial/ethnic populations. Research priorities include assessing campaign influence among lower socioeconomic status (SES) and rural youth, disentangling the effects of message characteristics, and assessing the degree to which this body of evidence may have changed as a result of changes in youth culture and communication technology. (Am J Health Promot 0000;00[0]:000–000.) Key Words: Youth, Smoking, Tobacco, Prevention, Media, Campaign, Message. Manuscript format: literature review; Setting: state/national; Health focus: smoking control; Strategy: education, skill building/behavior change, policy, culture change; Target population age: youth; Target population circumstances: education/income level, geographic location, and race/ethnicity

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All authors are with the Public Health Policy Research Program at RTI International, Research Triangle Park, North Carolina. Send reprint requests to Jane Allen, MA, Public Health Policy Research Program, RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709; [email protected]. This manuscript was submitted May 10, 2013; revisions were requested April 27, 2014; the manuscript was accepted for publication June 4, 2014. Copyright Ó 0000 by American Journal of Health Promotion, Inc. 0890-1171/00/$5.00 þ 0 DOI: 10.4278/ajhp.130510-LIT-237

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INTRODUCTION

Strong evidence supports the use of mass media campaigns to reduce youth smoking prevalence,1–6 risk of initiation,7–13 and likelihood of progression to established smoking.7,14 Although comprehensive tobacco control efforts—including mass media campaigns, tax increases, smoke-free laws, and community programs—are perhaps the most effective way to reduce tobacco prevalence,15–18 a 2008 review conducted by the National Cancer Institute (NCI) concludes that media campaigns used alone are effective for reducing youth smoking.15 Furthermore, studies indicate that a national, youth-focused tobacco prevention media campaign can be costeffective or cost-saving for society.19–21 Media campaigns are therefore a potentially powerful tool for tobacco control and are endorsed by the Centers for Disease Control and Prevention (CDC),17,18 the Institute of Medicine (IOM),22 and NCI.15 This systematic literature review builds and expands on earlier reviews of the literature in this area.15,16,23–25 Earlier reviews do not explore campaign effectiveness by race/ethnicity or other population subgroups with the exception of age, leaving campaign planners uncertain as to whether a tailored campaign is necessary to produce behavioral effects within specific populations. Earlier reviews also note substantial limitations of the available evidence. For example, a 2003 review by Farrelly et al.,16 which sought to identify effective message characteristics, concludes that ‘‘the current literature provides little guidance toward designing successful campaigns.’’16

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Schar et al.23 lament that ‘‘[i]t is difficult, if not impossible, to disentangle the unique contribution of each message element (content, format, tone) to ad effectiveness.’’ This review synthesizes the current evidence about using mass media campaigns to reduce youth tobacco use, with particular focus on campaign effects within population subgroups and relative effectiveness of message characteristics. Based on this review, high-priority areas for future research are proposed.

METHODS Data Sources and Extraction Studies were selected through a systematic, automated search of the indexed literature in PubMed and PsycINFO, followed by assessment of relevance based on predefined criteria. The automated search, conducted in March 2014, was designed to capture studies related to media campaigns and youth smoking (terms available upon request). This process yielded 397 discrete studies. Criteria for inclusion were as follows: (1) The study examines the effectiveness of an antitobacco mass media campaign intended to influence youth cognitions or behavior, or one component of such a campaign, or (2) the study examines the efficacy of antitobacco messages as measured in the context of experimental research. Studies were excluded if they were not quantitative in nature and if they did not include results for youth aged 18 or younger. Evidence for this review is based on 34 studies, shown in the Table.

characteristics. Nevertheless, the authors sought to draw general conclusions based on the available evidence.

EVIDENCE FOR THE EFFECTIVENESS OF MASS MEDIA CAMPAIGNS WITHIN SPECIFIC POPULATIONS

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Data Synthesis The methodology of each study was documented. Studies were classified by sample type (convenience or random); study design (experimental, cross-sectional survey, longitudinal survey); and measure of media exposure (self-report or exogenous). Study outcomes were categorized as cognitions, behaviors, or both. Studies were grouped by topic areas (race/ethnicity, socioeconomic status), and findings were compared and synthesized. Quantitative comparison of findings across studies was not necessarily possible given differences in methodologies, populations of interest, and other study

Numerous studies show that smoking is associated with specific demographic and psychographic characteristics.53 For campaign planners, a critical question is whether campaigns designed to reach a general population of at-risk youth will be effective within population subgroups or whether a tailored campaign is needed to influence the smoking behavior of, for example, AfricanAmerican youth or rural youth. This tension arises from the cost-efficiencies associated with a general audience campaign relative to a tailored campaign. In this section, we examine the evidence on antitobacco mass media campaign effects by race/ethnicity, gender, socioeconomic status (SES), and population density.

been more effective among AfricanAmerican youth than among Hispanic and white youth. A 2009 study shows that, among youth who had never smoked, campaign exposure was associated with intention not to smoke in the future; results were robust among African-American youth (OR ¼ 5.39, p , .01) and marginally statistically significant among Hispanic (OR ¼ 2.00, p , .1) and white youth (OR ¼ 1.76, p , .1).28 Among youth who had smoked in the past, the association was strong and statistically significant among youth overall and within every racial/ethnic group (Asian: OR ¼ 8.51, p , .01; white: OR ¼ 6.53, p , .001; African-American: OR ¼ 6.11, p , .01; Hispanic: OR ¼ 5.83, p , .001).28 A longitudinal study from the state of California found that, among more than 2000 middle school students, exposure to antitobacco media messages was associated with lower rates of smoking susceptibility 2 years later (p , .01) and that race/ethnicity did not moderate this association.13 Studies of other state campaigns are less rigorous because outcomes are not directly linked with exposure to a media campaign2,9 or because measures of race/ethnicity were dichotomous (white versus non-white) and intended only as control variables.14,35 A controlled field experiment designed to evaluate the effect of a 9-month media campaign in four designated market areas in Florida, South Carolina, Texas, and Wisconsin showed that, although there was no overall campaign effect, there was a marginally statistically significant association between living in an intervention media market and current smoking among Hispanic youth (p ¼ .09).33

Effectiveness by Race/Ethnicity Studies suggest that antitobacco mass media campaigns can be effective across racial/ethnic populations, although the size of the campaign effect may differ by race/ethnicity. For example, Terry-McElrath et al.1 used aggregated target rating point (TRP) data to assess the influence of state tobacco control advertisements on more than 120,000 youth in grades 8 through 12 living in the 74 largest media markets in the United States.1 A TRP is a measure of the reach and frequency of an advertisement (otherwise known as a gross rating point, or GRP) within a given population.17 This study indicates that from 1999 to 2003, exposure to state tobacco control advertising was associated with lower odds of current smoking among African-American (odds ratio [OR] ¼ .76, p , .001), Hispanic (OR ¼ .85, p , .05), and white (OR ¼ .93, p , .05) youth.1 The effect among Asian youth was not statistically significant (OR ¼ 0.76, p , .1).1 Evaluations of the national truth campaign found that it was effective overall6,32 and suggest that it may have

Effectiveness by Gender Campaigns designed specifically for female youth are effective, and campaigns designed to reach all at-risk youth are similar in effectiveness among females and males. A quasiexperimental study in two intervention and two control communities in the United States showed that smoking rates among females in grades 8 through 10 were 40% lower in communities that received a 4-year mass media campaign designed specifically for girls, compared with no cam-

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Table Studies Related to Campaign Effects Within Population Subgroups and Effectiveness of Message Themes Study Description Author, Year, Title

Overview of Study (Media Studied; Audience; Data Source; Year)

Bauer et al.,2 2000. Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998–2000. Biener et al.,26 2004. The impact of emotional tone, message, and broadcast parameters in youth anti-smoking advertisements. Biener L.,27 2002. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think.

Study occurs within the context of, but does not measure exposure to, Florida truth campaign; youth in MS and HS; Florida Youth Tobacco Survey data; 1998 to 2000.

Cowell et al.,28 2009. Assessing the impact of the national ‘truth’ antismoking campaign on beliefs, attitudes, and intent to smoke by race/ethnicity. Davis et al.,29 2009. The impact of national smoking prevention campaigns on tobacco-related beliefs, intentions to smoke and smoking initiation: results from a longitudinal survey of youth in the United States. Duke et al.,30 2009. Increasing youths’ exposure to a tobacco prevention media campaign in rural and low-populationdensity communities. Farrelly et al.,31 2002. Getting to the truth: evaluating national tobacco countermarketing campaigns. Farrelly et al.,6 2005. Evidence of a dose-response relationship between ‘‘truth’’ antismoking ads and youth smoking prevalence. Farrelly et al.,32 2009. Sustaining ‘‘truth’’: changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign. Flynn et al.,33 2010. Mass media interventions to reduce youth smoking prevalence. Gilpin et al.,9 2001. The California Tobacco Control Program: a decade of progress, results from the California Tobacco Surveys, 1990–1998. Hafstad et al.,34 1997. Provocative appeals in anti-smoking mass media campaigns targeting adolescents—the accumulated effect of multiple exposures. Kandra et al.,35 2013. The evaluation of North Carolina’s state-sponsored youth tobacco prevention media campaign. Kelly et al.,36 2006. Tobacco counteradvertisements aimed at bicultural Mexican American youth: the impact of language and theme. Niederdeppe J.,37 2005. Syntactic indeterminacy, perceived message sensation value-enhancing features, and message processing in the context of anti-tobacco advertisements. Niederdeppe et al.,38 2007. Stylistic features, need for sensation, and confirmed recall of national smoking prevention advertisements.

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Pechmann and Reibling,39 2006. Antismoking advertisements for youths: an independent evaluation of health, counterindustry, and industry approaches. Pechmann et al.,40 2003. What to convey in antismoking advertisements for adolescents: the use of protection motivation theory to identify effective message themes.

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Analysis of ad and campaign characteristics on recall and perceived effectiveness; Massachusetts Anti-Smoking Media Campaign; Massachusetts youth aged 12 to 15; 1993 Massachusetts Tobacco Survey of Youth, 1993 and 1997. Assess receptivity to antitobacco advertisements created by tobacco control agencies and tobacco companies; Massachusetts youth aged 14 to 17; a random-digit-dial telephone survey; 1999. Analysis of exposure to truth campaign media; youth aged 12 to 17; seven waves of nationally representative, cross-sectional media tracking data collected by phone; 1999 to 2003. Analysis of exposure to truth and Philip Morris ‘‘Think. Don’t Smoke.’’ ads; students in grades 6 to 12; longitudinal survey in seven communities in five states; 2000 to 2002. Other subgroup analysis is risk for smoking.

Supplemental truth campaign media delivered to 8 of 16 media markets; youth aged 12 to 17; longitudinal data collected by phone; 2007. Other subgroup analysis is rural and low-population-density communities. Evaluation of the national truth campaign; two waves of Legacy Media Tracking Survey (LMTS) data; youth aged 12 to 17; 2000. Assessment of the influence of the national truth campaign on national youth smoking rates; youth in grades 8, 10, and 12; Monitoring the Future data; 1997 to 2002. Assessment of the influence of the national truth campaign on beliefs, attitudes, and intentions to smoke; youth aged 12 to 17; eight waves of Legacy Media Tracking Survey (LMTS) data; 2000 to 2003. Media campaign delivered within four of eight metropolitan areas over 4 years; public school students in grades 4 through 12; cross-sectional, in-school survey; 2005. Evaluation of the California Tobacco Control Program; California youth aged 12 to 17; California Tobacco Surveys (CTS); 1993, 1996, 1999. Three mass media campaigns tailored for girls, delivered to one of two counties in Norway; youth aged 14 and 15; longitudinal data collected over 3 years; 1992 to 1995. Media campaign Tobacco. Reality; unfiltered; youth aged 11 to 17; cross-sectional survey; 2009. Other subgroup analysis is sensation seeking. Nine print antismoking advertisements; Mexican American youth in grades 7 and 8 in a California/Mexico border community; experimental data; date of data collection not reported. Examined the relationship between advertising features and youth processing; Florida truth campaign advertising; Florida youth aged 12 to 18; Florida Antitobacco Media Evaluation (FAME) Surveys; 1998 through 2001. Examined the relationship between stylistic features of advertising and youth recall; truth campaign advertising; youth aged 12 to 17; eight waves of Legacy Media Tracking Survey (LMTS) data; 1999 through 2003. Other subgroup analysis is sensation seeking. Examined whether health ads about tobacco victims lower intention to smoke when ads elicit disgust and anti-industry feelings rather than fear; ads from a number of U.S. media campaigns; youth aged 14 to 15; experimental data; 2002. Other subgroup analysis is youth with a conduct disorder. Examined the relationship between message themes and youth intention to smoke; 195 antismoking ads that aired between 1986 and 1997; youth in grades 7 and 10; experimental data; study year not reported.

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Table, Extended Sample

Study Design

Measure of Exposure

Conve- Random Experi- Cross- Longitunience mental sectional dinal Survey Survey X X

X

NA

NA

Reported Outcomes

Subgroup Outcomes

Cognitions Behavior

Race/ Gender SES Population Other Ethnicity Density

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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X

X

X

o X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

NA

X

NA

X

X

X

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X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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X

X

X

Exogenous

X

X

X

SelfReport

X X

X

X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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Table, Continued Study Description

Siegel and Biener,14 2000. The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. Sly et al.,7 2001. Influence of a counteradvertising media campaign on initiation of smoking: The Florida ‘‘truth’’ campaign. Sly et al.,41 2001. The Florida ‘‘truth’’ anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Sutfin et al.,42 2008. Adolescents’ responses to anti-tobacco advertising: exploring the role of adolescents’ smoking status and advertisement theme. Terry-McElrath et al.,43 2005. The effect of antismoking advertisement executional characteristics on youth comprehension, appraisal, recall, and engagement. Terry-McElrath et al.,1 2007. State anti-tobacco advertising and smoking outcomes by gender and race/ethnicity.

Vardavas et al.,46 2010. What defines an effective antitobacco TV advertisement? A pilot study among Greek adolescents. Vogeltanz-Holm et al.,47 2009. Confirmed recall and perceived effectiveness of tobacco countermarketing media in rural youth.

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Wakefield et al.,48 2003. Appraisal of anti-smoking advertising by youth at risk for regular smoking: a comparative study in the United States, Australia, and Britain.

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Assessment of youth response to three key themes found in 33 antismoking ads; youth from two rural high schools in Virginia; experimental data; study year not reported. Other subgroup analysis is youth smoking status. Assessment of executional characteristics of 50 antismoking ads created by tobacco control agencies, tobacco companies, and pharmaceutical companies; youth in grades 8 through 12; experimental data; March to May 2001. Analysis of exposure to state antitobacco ads; students in grades 8, 10, and 12; merged Monitoring the Future and aggregated GRP data for the largest 74 media markets; 1999 to 2003. Explored effects of message theme on youth intention to smoke; print advertisements; experimental data; Finnish youth aged 13 to 16; 2004. Analysis of exposure to truth campaign media; youth ages 12 to17; seven waves of nationally representative, cross-sectional media tracking data collected by phone; 2000 to 2004. Assessment of message characteristics associated with perceived effectiveness; seven antitobacco ads from media campaigns around the world; Greek youth aged 12 to 19; experimental data; April to June, 2008. Assessing youth responses to an antismoking media campaign conducted in a U.S. Northern Plains state; 10 television and radio ads that aired as part of the U.S. ‘‘The Plain Truth’’ Campaign; youth aged 12 to 17; random-digit-dial telephone survey; 2004. Assessment of executional characteristics of 50 antismoking ads among youth in the United States, Britain and Australia; youth in grades 8 through 12; experimental data; March to May 2001. Other subgroup analysis is country of residence. Assessment of executional characteristics of 50 antismoking ads created by tobacco control agencies, tobacco companies and pharmaceutical companies; youth in grades 8 through 12; experimental data; March to May 2001. Analysis of exposure to anti-tobacco ads aired in Southern California; MS students; In-school survey; 2004. Other subgroup analysis is acculturation.

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44 ¨ Uusitalo and Niemela-Nyrhinen, 2008. Exploring message themes in antismoking advertising targeted at teenagers. Vallone et al.,45 2009. Is socioeconomic status associated with awareness of and receptivity to the truth campaign?

Wakefield et al.,49 2005. Youth responses to anti-smoking advertisements from tobacco-control agencies, tobacco companies, and pharmaceutical companies. Weiss et al.,13 2006. Longitudinal effects of pro-tobacco and anti-tobacco messages on adolescent smoking susceptibility. White et al.,50 2003. Do adult focused anti-smoking campaigns have an impact on adolescents? The case of the Australian National Tobacco Campaign. Worden et al.,51 1996. Using mass media to prevent cigarette smoking among adolescent girls. Zollinger et al.,52 2006. Antitobacco media awareness of rural youth compared to suburban and urban youth in Indiana.

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Examined the impact of a statewide antismoking media campaign on progression to established smoking; Massachusetts Antismoking Media Campaign; youth aged 12 to 15 at baseline; longitudinal survey of youth; 1993 to 1998. Assessment of the short-term effects of television advertisements from the Florida ‘‘truth’’ campaign on rates of smoking initiation; the Florida anti-tobacco media evaluation (FAME); Florida youth aged 12 to 17; 1998 to 1999. Evaluation of the Florida anti-tobacco media campaign; the Florida anti-tobacco media evaluation (FAME); Florida youth aged 12 to 17; 1998 to 1999.

Assessment of youth awareness of Australia’s National Tobacco Campaign (NTC); youth aged 12 to 17; two cross-sectional surveys; 1998 and 1999. Media campaign plus school intervention tailored for girls delivered within two of four communities over 4 years; students in grades 5 through 7 at baseline; longitudinal survey, 1985 to 1988. A media campaign that aired in Indianapolis, Indiana; MS students; in-school, crosssectional survey; date of study not reported. Other subgroup analysis is rural/ suburban/urban.

*SES indicates socioeconomic status; NA, not applicable; MS, middle school; HS, high school; and GRP, gross rating point. Measure of exposure is listed as NA for two studies that did not directly link smoking with a media campaign.

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Table, Continued Extended Sample

Study Design

Measure of Exposure

Conve- Random Experi- Cross- Longitunience mental sectional dinal Survey Survey X X

X

X

SelfReport

X

X

Exogenous

Reported Outcomes

Subgroup Outcomes

Cognitions Behavior

Race/ Gender SES Population Other Ethnicity Density

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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o X

X

X

X

X

X

paign.51 Effects were maintained in grades 10 through 12.51 A Norwegian campaign that also focused on girls consisted of two ads that would appeal exclusively to females and one that

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X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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X

X

X

X

X

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X

X

X

would appeal to both females and males. The campaign was associated with lower odds of initiation among females (OR ¼ .77, 95% CI ¼ .63–.95) and males (OR ¼ .67, 95% CI ¼ .53–

X

X

X

X

.85) and with quitting among female smokers (OR ¼ .52, 95% CI ¼ .40– .96).34 Other studies suggest it is not necessary to tailor campaigns by gen-

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der. A longitudinal study of California middle school students found that gender did not moderate the association between exposure to antitobacco media messages and smoking susceptibility.13 Likewise, a national study of U.S. youth showed that campaign exposure was associated with similar odds of current smoking among females (OR ¼ .92, p , .05) and males (OR ¼ .90, p , .01).1 Effectiveness by Socioeconomic Status (SES) Evidence is insufficient to determine whether campaign outcomes differ by SES, but evidence suggests that research in this area is warranted. From 2000 to 2004, youth who lived in lower education zip codes were less likely to have confirmed awareness of the national truth campaign than those in higher education zip codes, although there were no differences in receptivity to advertising.45 A controlled field experiment by Flynn et al.33 conducted within markets serving lower-income and lower-education populations in Florida, South Carolina, Texas, and Wisconsin yielded no statistically significant association between a 9-month media campaign and smoking outcomes.

EVIDENCE FOR THE EFFECTIVENESS OF SPECIFIC MESSAGE CHARACTERISTICS

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Effectiveness by Population Density Evidence is insufficient to determine whether campaign outcomes differ by population density, but further research is warranted. A quasi-experimental study comparing 16 treatment and control media markets showed that the national truth campaign— which originally aired predominantly on broadcast television but subsequently shifted to cable—delivered less than the mean national level of advertising in rural areas and that rural youth were less likely to be aware of the campaign.30 Receptivity to campaign advertising, however, was not associated with population density.30 A survey of nearly 4000 youth in Indiana likewise showed that rural youth were less likely than suburban and urban youth to recall antitobacco messages, but also showed that they were less likely to report that antitobacco ads made them think about the dangers of tobacco use and to consider antitobacco ads effective.52

Earlier reviews find it difficult to draw conclusions about the relative effectiveness of specific message characteristics because variables of interest are strongly correlated.16,23 For example, two studies note the very strong correlation among advertisements with a health effects theme, a negative tone, and a personal testimonial ad execution.43,48 Further complicating this issue, definitions of the terms ‘‘theme,’’ ‘‘tone,’’ and ‘‘execution’’ differ across studies; within the category of message theme, definitions of ‘‘industry manipulation’’ and ‘‘health effects’’ differ. Although this review adds 13 studies— published since the 2006 Schar et al. review23—to the evidence base on message characteristics, it remains difficult to draw firm conclusions about the effectiveness of specific message characteristics.

testimonial.’’43,48 Other studies suggest that youth may consider tobacco industry ads less interesting than tobacco control ads in part because they have less negative emotional content (p , .05).49 In contrast with this body of evidence, one study unequivocally supports the use of a positive tone for advertisements designed to reduce youth smoking; among youth in rural Virginia, ads that generated positive emotion were associated with lower intention to smoke than negative ads (p , .01).42 Many effective youth antitobacco campaigns—including the state campaigns of Florida, California, and Massachusetts; the national truth campaign; and the Australia National Tobacco Campaign—have employed advertising with a negative tone. Nevertheless, most evaluations of those campaigns do not shed light on the effectiveness of a negative tone per se. This is because they assess the effectiveness of the campaigns as a whole, without seeking to isolate the role played by the negative tone.

Message Tone Evidence suggests that advertising with a negative emotional tone will have a greater influence on youth than advertising with a positive or neutral tone. ‘‘Message tone’’ is defined here as the degree to which an advertisement is generally negative versus positive. Research is warranted to clarify the relationship between tone and other message characteristics and whether tone itself influences youth behavior. Two studies of youth perceptions by Biener et al.26,27 show that advertisements that generate negative emotion, such as sadness and fright, are perceived by youth to be more effective than advertisements that generate positive emotion such as humor and happiness or that are neutral in tone. Two studies43,48 suggest that, in a multivariate model including a variety of common antitobacco themes and execution types, advertisements that elicit sadness, empathy, or fear are associated 1 week later with recall of the ads, discussion about the ads, and youth assessments of the ads as ‘‘good’’ and ‘‘thought provoking’’ (all p , .01 or better). The authors note a very strong correlation between such ads and the ad execution type ‘‘personal

Message Execution Youth are more likely to recall and think about advertising when executions include personal testimonials; a surprising narrative; and intense images, sound, and editing. Message execution is defined here as the format (testimonial, graphic imagery) and production aspects (sound, camera cuts) of an advertisement. Studies that focus on format produce less clear results than those that focus on production aspects of ads. For example, there are known correlations among the personal testimonial format, negative tone, and a health effects theme. Other studies indicate that graphic imagery is similarly correlated with tone and theme.50 Research is warranted to clarify the relationship between message execution and other message characteristics, and whether advertisements based on facts are more effective than those based on opinion. A study of U.S. youth at risk for smoking indicates that ‘‘personal testimonial’’ ads were considered ‘‘good’’ and ‘‘thought provoking’’ and were associated with subsequent self-reported recall and discussion, whereas ‘‘visceral negative’’ ads (ads using graphic

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imagery to provoke fear or disgust) were not.43 In contrast, a related study conducted with at-risk youth in the United States and Australia found that both ‘‘personal testimonial’’ and ‘‘visceral negative’’ ads were associated with positive ad assessments.48 A study that linked content analysis of antitobacco advertisements with survey responses from 32,000 youth showed that youth were substantially more likely to recall tobacco control advertisements that had sound saturation (OR ¼ 1.87); intense images (OR ¼ 1.76); loud, fast music (OR ¼ 1.73); a second-half ‘‘punch’’ or surprise twist (OR ¼ 1.44); a number of discrete camera shots (OR ¼ 1.05); and a number of unrelated camera cuts (OR ¼ 1.05) (all p , .001).38An advertisement with none of these features could be expected to generate recall rates of 15%; one with all of them would generate an estimated recall rate of 30% to 38%, regardless of level of sensation seeking.38 A related study showed that use of ‘‘suspenseful features,’’ such as intense imagery and a second-half punch, increased message processing among youth aged 16 to 18, but not among youth aged 12 to 15.37

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when used alone and whether changes in youth culture have reduced the effectiveness of the theme, as some have suggested.16 Evidence supports the combined use of the industry manipulation and health consequences message themes. A longitudinal survey of more than 35,000 students in five states found that self-reported recall of truth campaign advertising was associated with lower intention to smoke, lower odds of initiation, and lower odds of progression to established smoking, while recall of Philip Morris’ ‘‘Think. Don’t Smoke’’ (TDS) advertising—featuring nonsmoking youth refusing cigarettes and the message that smoking is not cool—was associated with greater intention to smoke in the future.29 Similar findings were reported in an earlier cross-sectional study.54 Related studies show that youth were more receptive to truth than to TDS advertising31 and gave higher ratings to Massachusetts’ ‘‘Outrage’’ advertising than to TDS advertising.27 Other studies indicate that a combination industry manipulation/health consequences theme contributes to youth’s perception that tobacco control advertising is more interesting,49 and effective,26,27 than advertising sponsored by the tobacco industry. Evidence is less supportive of the industry manipulation theme when used alone. Several experimental studies show that advertisements with an industry manipulation theme had no influence on intention to smoke.39,40,42 Moreover, advertisements characterized by other themes—disease and suffering,39 smokers’ negative life circumstances,42 and social disapproval of smoking40—were more effective in influencing intentions. A study of youth perceptions showed that an industry manipulation advertisement that did not also convey serious health consequences of smoking was rated lower in perceived effectiveness than one that graphically depicted the harm of smoking.47 Other studies indicate that the theme produces less positive ad assessments than a health effects theme, but that neither was associated with ad assessments in a multivariate model that included ad tone and ad execution.43,48 Studies suggest youth respond differently to industry manip-

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Message Theme Health Consequences. Evidence in support of using a health consequences message theme is mixed. Advertising with a health consequences theme focuses on the short- or long-term effects of smoking. This analysis included studies on health effects,43,44 disease and suffering,39 disease and death,40 and graphic health harms.47 Research is warranted to determine whether certain types of health consequences messages are more effective than others and to disentangle the relationship between this theme and other ad characteristics. An experimental study with approximately 1700 students showed that exposure to advertisements about tobacco-related disease and suffering— but not ads about industry manipulation or secondhand smoke (SHS)—was associated with lower mean intention to smoke among youth without a conduct disorder (p , .01), although not among youth overall.39 Another study showed that although exposure to advertising with a disease and death

theme was associated with perceptions about health risks, it was not associated with intention to not smoke, although other types of ads (endangering others, refusal skills role model) were.40 Studies of youth perceptions show that advertisements focusing on the health consequences of smoking are perceived to be more effective than social norms and SHS ads.46 In contrast, other studies find the health consequences ad theme is not associated with youth attitudes toward smoking44 and that positive youth perceptions about health effects ads are insignificant in multivariate models that include the variables ad tone and ad execution.43,48 ‘‘Health consequences’’ was the dominant theme of the effective Massachusetts, North Carolina, and Australia campaigns.5,14,27,35,50 Evaluations of those campaigns are not included in this analysis because they do not advance our understanding of the effectiveness of this message theme over and above other campaign and ad characteristics. This is because they assess the effectiveness of the campaigns as a whole, without seeking to isolate the role played by the message theme. While these evaluations suggest that a health consequences theme can be effective, they don’t rule out the possibility that the campaigns were effective despite the health consequences theme as a result of other campaign characteristics.

Industry Manipulation. An industry manipulation theme is effective for reducing youth smoking when combined with a health consequences theme, but it may not be effective when used alone. The industry manipulation theme highlights the predatory business practices of the tobacco industry. However, some of the most well-known examples of industry manipulation campaigns—the Florida truth campaign, the national truth campaign, and the Massachusetts campaign6,7,28,32,41,54—have combined the industry manipulation and health consequences themes, making it difficult to determine whether the industry manipulation theme is effective when used alone. Research is warranted to determine whether the theme influences youth cognitions or behavior

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ulation advertising depending on their prior exposure to the theme48 and that this theme may not resonate with youth today.16 Secondhand Smoke. Evidence is insufficient to recommend an SHS message theme for reducing youth smoking. Advertising with an SHS theme focuses on the harm smokers do to those around them. Studies included in this section also refer to this theme as ‘‘endangering others’’40 and ‘‘environmental tobacco smoke.’’39 Research is warranted to determine whether the SHS message theme is associated with youth smoking behavior. A survey of 1700 middle and high school students who were shown antitobacco advertisements in a school setting suggests that advertising with an SHS theme was associated with intention not to smoke in the future (p , .01) and was more effective than industry manipulation and health consequences ads.40 In contrast, similar studies found that an SHS theme was not associated with intention to smoke39,42 and was less effective than ads with a disease and suffering theme.39 Studies of youth perceptions of ad characteristics indicate that SHS ads are considered less good, less thought provoking, and less memorable than ads that show the health effects of smoking,43 but that the ad theme was not statistically significant in a multivariate model including ad tone and execution.43,48

further research in this area is warranted. Studies of youth perceptions show that the social norms theme is not associated with youth attitudes toward smoking44 and that it is associated with lower perceived effectiveness than ads focused on illness (p , .0001).26 Other studies show that youth are less likely to discuss or positively appraise ads with a ‘‘smoking is uncool’’ message relative to those with a health effects message, although neither theme was statistically significant in a multivariate model that included ad tone and execution.43,48 A study of Mexican American youth suggests that advertising with a social norms theme is likable, but unbelievable.36

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Social Norms. Evidence is insufficient to recommend a social norms theme for reducing youth smoking. Advertising with a social norms theme is designed to change perceptions of the prevalence of peer smoking or suggest that smoking is not a ‘‘cool’’ or socially normative behavior. Use of this message theme is rooted in studies showing that perceived smoking prevalence is predictive of smoking initiation among youth.55,56 Although the California campaign is often referred to as a ‘‘social norms’’ campaign, in fact, California advertisements focus on dangers of tobacco use, SHS, industry manipulation, and promotion of services.10,57 Given the research showing that youth are influenced by their perceptions of peer smoking behavior,

populations. This review also finds similar campaign effects by gender. More research is needed to determine whether campaign effects differ by SES and population density. Given the high smoking rates, low cessation rates, and increased risk of tobacco-related disease within low SES and rural populations, this question is especially relevant to the tobacco control community. Earlier reviews found it difficult to draw conclusions about the relative effectiveness of specific message characteristics, in large part because of strong correlations among variables of interest. Although 38% of the studies cited in this review were published after the Farrelly et al.16 and Schar et al.23 reviews, it remains difficult to draw firm conclusions about message characteristics. This review finds that advertising with a negative tone has a greater influence on youth than advertising with a positive or neutral tone, although studies do not examine behavioral outcomes. Youth were more likely to recall and think about advertising that included personal testimonials; a surprising narrative; and intense images, sound, and editing. Bearing in mind that ad themes are poorly defined and not mutually exclusive, this review finds that evidence in support of using a health consequences message theme is mixed and that an industry manipulation theme may be effective only when combined with a health consequences message. More research is needed to determine whether advertising with an SHS or a social norms theme can influence youth tobacco use behavior. Experimental research could be used to isolate individual variables of interest to advance knowledge in this area and provide practical guidance for campaign planners. Also, because changes in youth culture can influence the types of messages and message executions that resonate with youth, it would be helpful to assess the degree to which this body of evidence represents youth today. This review is subject to several limitations. First, it is not possible to quantify differences in effectiveness across media campaigns because of variation in audience, messaging, media delivery, environmental context,

This review expands and updates earlier reviews of the evidence regarding use of mass media campaigns to reduce youth tobacco use. While earlier reviews do not explore campaign effectiveness by race/ethnicity, this review finds that antitobacco mass media campaigns can be effective across racial/ethnic populations, although the size of the campaign effect may differ by race/ethnicity. Evidence is based on antitobacco advertisements that aired in the United States from 1999 through 2003, from the national truth campaign, and from a longitudinal study conducted in California. It is worth noting that the national truth campaign included racial/ethnic minority youth in formative research and as spokespersons in advertisements. Taken together, these data suggest that an antitobacco media campaign that is designed to reach all at-risk youth— including racial/ethnic minority youth—can be effective across racial/ ethnic populations. It is plausible that a campaign tailored specifically to youth of a single race or ethnicity would be more effective than a general market campaign within that population, but existing data do not permit analysis on this point. Research in this area has been hampered by the cost of media campaign implementation and evaluation. It is particularly expensive to design evaluations with sufficient power to detect effects within minority

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measurement, analysis, and reported outcomes. Second, it is not possible to quantify differences in effectiveness across message characteristics because studies use different terminology and definitions and are typically unable to isolate the variables of interest. Third, much of the evidence related to effectiveness of mass media campaigns is from a single campaign: the national truth campaign. Fourth, evidence from adult mass media antitobacco campaigns, youth antidrug campaigns, and other public health campaigns has been excluded from this review for the sake of focus, although those studies represent a relevant body of evidence that provides context for these findings. Fifth, given that the investigators synthesizing this body of research bring their own perspectives to the work, it is possible that conclusions are inadvertently biased. This review has implications for the development and implementation of mass media campaigns. It suggests that an antitobacco media campaign designed to reach all at-risk youth— including racial/ethnic minority youth—can be effective across racial/ ethnic populations. It is not necessary to tailor campaigns by race/ethnicity; youth culture likely unites teens more than race/ethnicity divides them. Therefore, our recommendation is to develop comprehensive antitobacco campaigns for all at-risk youth. Focus groups for brand, campaign, and message development should include a substantial proportion of at-risk minority participants. Ads should feature racial/ethnic minority spokespersons or characters. The media purchase should ensure exposure among racial/ ethnic minority populations. In the case of a national campaign, it will be helpful to supplement national media in markets and through channels that reach a large proportion of at-risk minority individuals. Finally, the evaluation design should be robust enough to detect effects in racial/ethnic minority populations. These steps should result in a general appeal campaign that is effective overall, as well as within minority populations. This review points to several areas in which further research would markedly advance our understanding of how to use antitobacco mass media campaigns

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findings based on television campaigns are transferable to the Internet, including social media. A large proportion of state tobacco control programs have already begun to reach out to youth via Internet and social media, without fully understanding what their expectations should be in terms of outcomes. Critical questions in this area include whether engagement with a campaign via social media results in cognitive and behavioral change over and above simple message exposure as well as how we can begin to answer this question with the tools that are currently available for evaluating online campaigns. Efforts to strategically advance the research on using mass media campaigns to reduce youth tobacco use will yield practical guidance for campaign development and evaluation in the years ahead and ultimately will contribute to reductions in youth tobacco use.

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to reduce youth smoking. Research is needed to determine why awareness of antitobacco media campaigns is lower among low SES and rural youth relative to their peers and whether alternative media delivery strategies could enhance campaign effects within these populations. Research is also needed to disentangle the effects of message characteristics. Experimental research could be used to isolate the independent effects of message tone, execution, and theme in order to determine whether certain message characteristics are more effective than others. Other questions of importance revolve around changes in youth culture and communication technologies. Studies must begin to address the degree to which message research conducted 10 and 20 years ago relates to—and resonates with—youth today. It is possible that the messages or message executions that influence youth have changed with youth culture. It is also critical to assess the degree to which

SO WHAT? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic? Strong evidence supports the use of mass media campaigns to reduce youth smoking prevalence, risk of initiation, and likelihood of progression to established smoking. What does this article add? This review expands and updates earlier reviews of the evidence regarding use of mass media campaigns to reduce youth tobacco use. This review finds that antitobacco mass media campaigns can be effective across racial/ethnic populations, although the size of the campaign effect may differ by race/ethnicity. What are the implications for health promotion practice or research? Comprehensive antitobacco campaigns designed to reach all at-risk youth can be effective across racial/ ethnic populations. Research priorities include assessing campaign influence among lower socioeconomic status (SES) and rural youth, disentangling the effects of message characteristics, and assessing the degree to which this body of evidence may have changed as a result of changes in youth culture and communication technology.

Acknowledgments

This work was funded under a RTI International contract with the Florida Department of Health’s Bureau of Tobacco Free Florida. The authors are grateful to Kelsey Campbell of RTI, who assisted in the development of this review, and to Susan Murchie of RTI, who edited the manuscript.

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