Karen Gutierrez: global reviews of mass media campaigns for smoking cessation and youth tobacco use prevention: "comprehensiveness is the key".

What are the goals of the Centers for Disease Control and Prevention in the area of tobacco control?

The Office on Smoking and Health in the Centers for Disease Control and Prevention (CDC) has three key tobacco control focuses: reducing exposure to secondhand smoke, preventing youth from starting to smoke and helping current smokers quit.

The Health Communications Branch of the CDC's Office on Smoking and Health gives advice to states, national organizations and other countries on how to craft optimal mass media campaigns--media campaigns being one key component of a comprehensive overall program. To give them good advice, we thought an important first step would be to look at what works and what does not work in mass media campaigns. That is how the global reviews came about. We first conducted one on learnings from cessation campaigns; the second focused on learnings from youth tobacco use prevention campaigns; and a third will cover learnings from campaigns focused on reducing exposure to secondhand smoke.

Does the CDC focus on the U.S. alone, or is the issue seen as a global concern as well?

While the mission or the scope of the CDC is primarily U.S.-focused because it is part of the U.S. Government, we do see tobacco control as a global issue. Often, we will talk about the almost 5 million deaths per year across the globe caused by tobacco, not just the 430,000 per year in the United States. We recognize that you cannot talk about tobacco control within one country alone. It's also important to realize that at the current rates, deaths from tobacco are expected to rise to 10 million per year gLobally by 2050; and by the year 2020, 70% of deaths from tobacco are expected to be in developing countries where rates of tobacco use are increasing quickly, particularly among women and children. At the same time, we understand the role that multinational tobacco companies play in increased rates of tobacco use, as they expand to new markets.

Both because of its expertise and resources and because the issue is so global, CDC feels enormous responsibility to go beyond U.S. boundaries. For example, several people in the Office on Smoking and Health work on this issue at a global level, and we do what we can in the area of best practices and sharing the science related to tobacco use and secondhand smoke because we have recognized that a limited number of countries outside of the U.S. have extensive tobacco control experience, such as England and Australia.

One of the reviews was co-sponsored by the World Health Organization (WHO) and the Centers for Disease Control, so that would be an instance in which the CDC partners with international organizations. Basically, the two organizations pull from one another's strengths. For example, the WHO has a much better global network, so we took advantage of this to be able to pull data together for the review from a wide range of sources.

What sorts of initiatives have you found work best?

We always emphasize a comprehensive package of efforts. A mass media campaign is one proven way to make an impact, but it has to work synergistically with other elements, such as increasing the price of cigarettes, in-school prevention programs for youth, and policies related to clean indoor air. I work with departments of health on development of their media campaigns, and it is my responsibility to build and then share expertise and best practices related to mass media campaigns and the part that they play in comprehensive tobacco control programs.

I am going to talk primarily about paid campaigns which are like advertising run by manufacturers of consumer products. But when we talk comprehensively about communications, we always mean a combination of paid and 'earned' media, the latter basically means press coverage. States, organizations and countries work hard to get press coverage that is accurate and credible in addition to the paid messages that are aired because the combination of those two is the most effective. Paid advertising does not always have as much credibility because people know that someone is paying for it. However, paid ads can be placed exactly where you want them, when you want them, and you get to control the message. Earned media is much less expensive and much more personal; it is human resource-heavy but not dollar-resource heavy. In addition, people generally believe the press and believe it to be a relatively unbiased source. The disadvantage is that you cannot control your message. That is why we work very hard on training people to get the right message across, to at least increase the likelihood that the reporter will cover your top points and write about the issue accurately.

As I mentioned before, comprehensiveness is the key: there are no examples of a mass media campaign successfully changing tobacco-related behaviors on its own, no matter how strong it is, if there are no other program elements involved. So we strongly encourage the use of comprehensive programs with 15% to 25% of the budget going to mass media campaigns and the rest to policy initiatives (where tobacco control programs are allowed to influence policy), in-school curriculum programs, and/or cessation services like telephone quit lines, counseling services or getting nicotine replacement therapy and pharmacological products made available to people.

The programs that have been most successful have typically sought to de-normalize tobacco and to encourage an attitude change so that people don't think that tobacco is such a great thing for anybody. This new perspective requires a certain knowledge base about the health effects of secondhand smoke and tobacco use, about the tobacco industry's practices, and about the role they play in influencing people. Basically, you get people to such a level of understanding about the issues that they conclude: who would want to smoke?

California is probably the best example. Their smoking rates have decreased by about 50% since their comprehensive tobacco control program began in 1989, and their rates are now lower than any other state except Utah (which has a high population of Mormons who do not smoke for religious reasons). While the tobacco industry tries to communicate that smoking is the thing to do, it is so cool, so hip, it will give you confidence, it will make you attractive to the opposite sex, the California program shows people the negative aspects of tobacco use in many different ways--the important truths to recognize while making the decision to begin or continue smoking.

How do you go about de-normalizing tobacco?

Within a media campaign there are different types of messages, each which may appeal to different people. One message is to talk about the health effects of smoking. For some people, especially youth, living with the negative consequences of tobacco use may seem worse than dying from them. For others, such as adult smokers, dying from tobacco use and leaving one's family to suffer from the loss is a message that motivates them to quit.

Another message is that secondhand smoke kills. Secondhand smoke also causes high rates of asthma in kids, and it is one of the leading causes of sudden infant death syndrome. There are a variety of points you could make about secondhand smoke. What we find is that most smokers live, socialize, or work with people they care about so the secondhand smoke message can be a very effective one. Most people care about what those around them think, feel or experience as far as health.

Then there is the "tobacco industry deceptive practices" theme: exposing the truth about the tobacco industry's deception and greed. These messages help people realize that they are playing into the hands of the industry every time they make a choice to buy a pack of cigarettes or smoke one. The tobacco companies know that their products are addictive. They know that "lights" are no safer than regular cigarettes. They know that there are numerous carcinogens in a cigarette. They know all these things, and yet they have tried to hide them for years and years. Why? Because each person they addict is worth a lot of money, and those new smokers replace the ones who die every year.

These are just some of the examples of message strategies used successfully in campaigns. All of these messages are unique and appeal to different people at different times and in different ways. So that is why we recommend using a combination of them.

What other strategies are used by successful media campaigns for smoking cessation?

We found that the advertising from effective cessation campaigns could be separated into two categories that work very closely together. We call them "why to quit" ads and to "how to quit" ads.

The "why to quit" ads are very shocking, graphically or emotionally or both. And they basically make smokers wake up and realize how bad it could get if they don't quit. Lighter messages like, "Wouldn't life be great if you weren't smoking?" and "Everyone is happy once they quit," don't typically register. We found that hard-hitting ads are necessary to make smokers "put quitting on today's agenda," rather than putting off quit attempts until some future date. Smokers know how hard it is. Most of them have tried many times. Quite frankly, [smokers] want to avoid it. They know it is going to be difficult. They know that they might fail. They don't want to try again because it is so disillusioning each time they go through it. And yet they know they should. It is easy for them to walk away from a message. So you have to really grab them and shake them and say, "Remember, these are the very important reasons why you should be quitting."

The second set of messages are very hopeful, very empathetic and encouraging. We call those the "how to quit" messages. Once you have shaken someone up, these messages say, "We are here to help. Here are some tips for you. We care about you. There are people who know how to help you quit." These messages are very positive and helpful. This one-two punch ("why to quit" and "how to quit" ads) seems to be the combination that works best.

We also found that the most effective campaigns were ones that targeted broadly to include all kinds of smokers either through a combination of messages--one for every stage of readiness to make changes in your life--or they were able to reach everybody with the message and not allow people to deny or avoid it. One of the best examples is from Australia's "Every Cigarette is Doing You Damage" campaign which included a series of television, radio and print ads. In one of the TV ads, graphic images of cancerous cells and tumors were accompanied by the following voice-over:

   Every cigarette is doing you
   damage. New research shows how
   tobacco smoke attacks a vital
   gene, which protects lung cells
   from cancer. One damaged cell is
   all it takes to start lung cancer
   growing. Every cigarette is doing
   you damage, so the sooner you
   quit, the better off you will be.

(Ed. note: Readers can see this and other ads from Australia's Quit Now! campaign on-line at http://www.quitnow.info.au)

This is probably the most effective campaign overall for cessation that we have seen in the world to date. It has been reapplied in at least six different countries, and all of the countries that measured the outcome showed positive results.

Smokers find that it's very difficult to turn away from the message. It says that every single cigarette that you smoke is harming you. It is not only for the three-pack-a-day smoker or the fifty-year-old. The series includes men and women, all young to middle-aged adults. The other thing is that it provides news. Every smoker will tell you, "I know smoking is bad for you." But do they really understand the changes that occur? We found that news was a really important aspect of the messages. You cannot just repeat the same old thing. You have to give a new perspective or new information or both to influence their knowledge, their attitudes and hopefully their behaviors.

What are some examples of successful "why to quit" ads?

The TV ad called "Tiny Carey" is from the U.S. state of Oregon is a great example. It focuses on the pain family members experience when a smoker dies.

Woman: We were married eleven years on July 27th and he passed away on August 4th. And we spent that time in the hospital, on our anniversary. He got really upset with me. I was kind of flirting with him as I always did. He grabbed hold of his face and started to cry. And he said, "I don't know how you can love me the way I look." I cannot believe that he is gone.

These kinds of testimonial or real life story ads have worked well in several countries because they make smokers realize that the same could happen to them, and how it would affect their families. This realization motivates them to want to quit, if not for themselves then for those they love.

Another example is a TV ad from California called "Echo." Although it is too new to have hard results, its concept is a good one: confronting smokers with the typical excuses and rationalization they give about why they can't quit, coupled with the more severe consequences that are possible if they don't quit.

Man #1 : I cannot go more than a few hours without a cigarette.

Man #2: I cannot go more than a few feet without the oxygen tank. [Weak-looking man, with tubes and tank]

Woman #1 : I tried stopping and I put on five pounds.

Woman #2: I have lost 25 pounds. [Chemotherapy patient]

Man #3: I have trouble getting out of bed without a smoke, man.

Man #4: I have trouble getting out of bed. [Visibly-ill man]

Man #5: No, I don't think l could quit.

Man #6. I don't think I can operate. [Physician looking at X-rays of lung-cancer patient]

Announcer: Quitting is hard. Not quitting is harder.

The other "why to quit" messages that we have found really effective are those about secondhand smoke. Sometimes these messages motivate smokers not to smoke around people they care about. But doing so is an important step toward quitting, and it is one of the reasons that people will tell you they quit, especially parents of small children.

This ad from California has been very effective in a number of locations:

Man: She said it's bad for you. It makes the drapes smell. She even said she would stop kissing me if I did not quit. I said, "It is my lungs and my life." But I was wrong. I didn't quit. I had no idea that the life I would lose was not my own. It was hers. She was my life. My wife was my life.

This is another example of a testimonial ad. They are emotional. They talk about not just the harm you do to yourself but also the harm you do to other people. A few different research studies show that ads that elicit emotion, particularly negative emotions like anger, disgust, fear and loss, seem to be the most persuasive and may get people to change their attitudes about smoking. Ads that might have the same general message but lack emotion don't seem to work as well.

(Ed. note: Another moving testimonial from Health Canada's Tobacco Control Program can be seen on-line at http://www.hc-sc.gc.ca/hecs-sesc/tobacco/)

We also learned, interestingly enough, that some of the most effective cessation ads were also the most polarizing ones. It is okay to be controversial at times, as long as you are able to manage the controversy. "Every Cigarette is Doing You Damage" is a great example. In two areas, these ads were aired during dinner time and people called the TV stations complaining that they found the ads offensive. However, the Health Department provided data on the ads' effectiveness, and they were kept on the air. It is okay to cause discomfort in some people as long as it has a good purpose: it shakes them up and motivates them to change their behavior.

Are the "how to quit" ads very different?

In England there was a whole series of very funny "how to quit" ads using John Cleese. Humor does not always work, but in this case smokers really felt like he was with them, not that he was making fun of them. It is a very delicate balance. Cleese was able to communicate persuasively, and I think it was because he was an ex-smoker.

Many of the "how to quit" ads try to make people more comfortable about calling the quit lines. They may show someone making a call, and they show that the person at the other end of the line is not scary or judgmental. In Australia they produced an ad where they showed someone calling the quit line and walked the viewer through the process. In California they did a three-minute ad to make Asian men feel more comfortable calling because Asian men saw calling a quit line as an admission of having a problem, appearing weak, asking for help.

Have the findings from the youth prevention campaign review been very different from the cessation campaign review findings?

On youth tobacco-use prevention, the number one point is the exact same one as for cessation: comprehensive programs work. A combination of multiple messages is most effective because different messages reach different people at different times. Number two: Comprehensiveness is synergistic with other program elements, so you don't just conduct an ad campaign in isolation. It is also important that media campaigns take advantage of multiple vehicles: Internet, television, radio, print, both paid and earned media, so you have a very comprehensive media mix as well.

Unlike our findings from the adult cessation campaigns, there were no significant findings on targeting among youth except that 12-to 17-year-olds are the typical target audience. However, some of the best tobacco control programs were so effective among the whole population that they did not even need to target youth specifically. So there are two ways to promote tobacco-use prevention among youth: either through a comprehensive program for 12-to 17-year-olds of through an excellent comprehensive tobacco control program for the general public. California and Massachusetts are great examples of the latter. They don't have separate efforts for youth, and yet they have significantly reduced youth smoking. Through efforts focused solely on youth, you may be able to change young peoples' attitudes, but what happens if they go home and their parents are both smoking? If all the role models around them are smoking, then it is going to be really hard for them to change those attitudes into behavior.

As a result, we are leaning more towards this comprehensive, general population approach rather than youth-focused prevention efforts alone. But even within a general population program, a lot of states have separate efforts for youth in addition to secondhand smoke campaigns and cessation campaigns primarily targeted toward adults.

What are the most effective messages for young people?

The messages that we found most persuasive for young people were health effects: either living with the consequences of smoking or the loss to both you and your family if you die. The idea of dying by itself is not that important to them because they view dying as something that inevitably happens to everyone and not as a short-term risk.

There is a series of ads featuring a young mother suffering from emphysema caused by smoking, the Pam Laffin Documentary Campaign, which portrays the reality of living with the consequences of tobacco use. One of the ads in the series first shows Pam as a teenager: she was just beautiful. Then just ten years later, it shows her looking completely different and awful. She can barely breathe on a respirator. These sorts of ads produce fear and sadness, which are very powerful emotions, and they make young people respond, "I would never want that to happen to me." The testimonials have to be real stories; and they have to be credible, otherwise kids will just laugh at them.

Another message that works with young people is industry deception and greed. In this case a very dark, cynical humor can work. A lot of the ads that have been used to expose the truth have really gotten young people angry at the industry These ads take advantage of teenagers' natural rebellion, and instead of them rebelling by smoking, they rebel by telling the tobacco industry: "You can't control my life. I see what you want. You only want profit. You don't care about me, and I am not going to buy into it." It does not work with all youth, but it has played a part in significant reductions in smoking in Florida, Minnesota, Mississippi, Massachusetts and California.

We are beginning to think that possibly the most effective messages are those that combine the two message themes. The "Body Bags" ad is a good example of the combination of industry deceptive practices and health effects messages. This ad was a sort of guerilla theater in which kids working with the American Legacy Foundation piled up a huge number of body bags around a tobacco company's New York headquarters to simulate the 1,200 people a day who are being killed by tobacco-related diseases and illnesses.

The American Legacy Foundation was started from the 46-State Master Settlement Agreement (MSA) with the tobacco industry. Money from the MSA was set aside for the creation of this foundation to educate young people about the dangers of tobacco because the tobacco companies agreed that youth should not smoke.

The Foundation created the "Truth Campaign," and "Body Bags" was one of the ads in the multi-year campaign. One of the most effective elements of the Truth campaign is the grassroots involvement that it has gotten from youth. The campaign encouraged youth to stand up to the tobacco industry and resist its marketing efforts, and thousands of young people all over the country became active in the campaign. It is that combination of a mass-media campaign and youth involvement at the grassroots level that I think makes it very effective.

(Ed. note: Readers can visit the Truth Campaign's multimedia campaign for youth, "Welcome to Crazyworld," at http://www.thetruth.com/truth.cfm)

As for other messages, some studies show that social disapproval from peers can be very effective in causing youth to reject smoking, but we are looking for more broadcast campaign experiences with this theme. When these kinds of messages have been used in isolation, they have made some impact, but when they have been evaluated versus the health effects and industry deceptive practices messages, the former often are not judged as effective by youth at influencing young people to avoid tobacco.

Are there message themes for teenagers that have not been successful?

Ads focusing on addiction, cosmetic affects (your hair will smell, your teeth will get stained) and athletic performance haven't typically produced positive results, especially in comparison to the other successful themes mentioned earlier. We think addiction has a lot of potential, but no one has figured out how to do it in a way that really gets kids to believe it. It is extremely hard to get kids to understand what addiction is like. When you ask them if nicotine and cigarettes are addictive, they will respond, "Yes, they are." But if you ask them what that is like, they will say it is like being addicted to chocolate.

Cosmetic affects are not that compelling in the big scheme of things. There are too many examples of popular kids who smoke and have dates. And the same goes for athletic performance. There are too many example of kids who do well on the track team who also smoke. And at the same time, the kids who really care about athletic performance are not the ones smoking anyway, so you are not appealing to the most vulnerable group of young people.

The one theme about which we do have enough data to say that it is not effective is the "choice" theme, the messages of "You don't have to smoke to be cool. You can make your own decision. If smoking is not for you, you don't have to do it." We think that these messages don't work because they have not been coupled with compelling reasons for youth to choose not to smoke. These are the sorts of ads that are generated by the tobacco companies in their "youth prevention" media campaigns, and when they have been evaluated, youth have judged the messages as weak in terms of influencing youth to reject tobacco.

Ironic because one would think that the theme of choice would be empowering.

But it is the industry deceptive practices and health consequences ads that are very empowering because they lay out the truth, and then they let youth decide what they want to do. The successful ads never say not to smoke. They never tell youth what to do. But they do provide the audience with new perspectives and new information, to help them make the most informed decision possible. It is the same with the testimonials ads. They never say, "Look what happened to my dad. You shouldn't smoke either," but they share one person's experience and allow the viewer to reflect on it and think about its relevance to his/her life.

What sort of anti-tobacco advertising might be effective in Latin America?

I think the theme of loss to your family has the potential to be very successful. Most Latin Americans are very family oriented and don't want to hurt people they are close to. What I think could work would be a combination of testimonials showing people about the loss to family coupled with hard-hitting facts, perhaps with graphic visuals, like the ones we have seen in the Australia campaign.

In Latin America the concept that smoking is bad for you is well understood, but everything else is bad for you too: fatty foods are bad for you, alcohol is bad for you. Tobacco is seen as just another small thing that is bad for you. People have no idea how much worse it is than many other things, and how many more deaths it is causing. I think that trying to share with them facts and information in a persuasive format could be coupled very well with an emotional approach, talking about real stories of people in Santiago, in Lima, in Bogota and Quito who have died because of their tobacco use or whose lives have become a living hell from tobacco use and the impact it has had on their family.

Earlier, you explained the difference between paid and earned advertising campaigns. What kinds of possible partners exist in our region for paid advertising?

One really important source for advertising is the CDC's Media Campaign Resource Center (MCRC). We have compiled virtually all the ads created in the United States and a few ads created in other countries: more than 600 television ads, more than one hundred print and outdoor ads and some 200 radio ads. All of these materials are available for others to use. Within the collection are as many as 75 Spanish-language television, print, outdoor and radio ads.

If regional health ministries or any non-profit organization wanted to use these ads, they only have to pay the talent fees and sign a licensing agreement with the state/country that produced the ads. While a good-quality TV commercial typically costs US$50,000-250,000 to make, the talent fees on an already-produced ad would only be around US$1,000-$5,000, and in some cases, ads are even available without talent lees. For a small amount more, you could record a voice-over on an ad if the original voice-over was in English or in an accent that you didn't feel was appropriate for your population. This has worked very well in Poland, the Czech Republic, Singapore and elsewhere.

The MCRC's website is www.cdc.gov/tobacco/mcrc. While the MCRC cannot directly help organizations outside the U.S. or government agencies in other countries with their leasing agreements, they can provide contact information for the producers of the ads.

Placement is another financial challenge. It costs money to place ads exactly where you want them. But I have noticed in Latin America that there is not as much competition for public service announcement spots. Perhaps there is an opportunity to approach those media outlets either at the corporate level or the country level and say, "Here is a very high-quality ad. These are the reasons why we think it would be effective. Could you put this in the rotation of public service announcements?" In this case, you don't get to completely control the placement, but it is free. We also encourage people to negotiate two-for-one or three-for-one media buys. If you have a small amount of money for ad placement, try to leverage that to get one or two free placements for each placement that you purchase.

Yet another option is taking advantage of earned media. For example, the testimonial approach is an excellent option for earned media. You can talk to a knowledgeable doctor, nurse or some other health care professional and ask them to help you identify individuals who might be willing to share their stories about the negative impact of tobacco on their lives and their families and you link them with a reporter. Testimonials make fascinating human interest stories, and you can very effectively get across some of your key points through articles in newspapers or through magazines, television or radio.

One last suggestion is radio ads. They are very inexpensive to produce because they include a voice but no visuals. There is an inventory of radio ads at the CDC that could be translated or could be the inspiration for locally written ads.

However, one caveat is that we feel pretty strongly that people who don't have experience doing advertising should not be making up ads. We sea people wanting to do this all the time because they have a great sense of ownership over it, and they want to do something that is very local. The unfortunate tradeoff is that when you don't have professionals involved, it is hard to get it exactly right. There are many ways advertising executions can go wrong and can even backfire. You could cause people to just tuna out the message or to want to smoke more, not less.

WORLD NO TOBACCO DAY 2003 Tobacco Free Film, Tobacco Free Fashion--Action!

World No Tobacco Day 2003 focused on the role of the fashion and film industries in fostering the worldwide tobacco epidemic and urged them to stop being used as vehicles of death and disease. The world of film and fashion cannot be accused of causing cancer, but they often promote a product that does.

The World Health Organization called on the entertainment and fashion industries to stop promoting a product that kills every second regular user. In November 2002, WHO and the Smoke Free Films Project of the University of California in San Francisco (USA) in calling on these industries to ensure that their social responsibility is commensurate with their global influence.

Hollywood and Bollywood--the Indian film industry in the city of Mumbai--were invited to join the worldwide movement to stop promoting tobacco in their films.

* For more information visit the WHO website at http://www.who.int/tobacco/wntd/2003/en/

RELATED ARTICLE: Five million tobacco-related deaths in 2000.

According to a study recently published in the British medical journal, The Lancet, 4.83 million people died in 2000 due to tobacco-related illnesses. For the first time, smoking-related deaths in developing nations--borne to 930 million of the world's 1.1 billion smokers--almost matched those in industrialized countries. More than 75 percent of these worldwide deaths were among men. The leading causes of death were cardiovascular illness (1.69 million deaths), chronic obstructive pulmonary disease (970,000 deaths) and lung cancer (850,000 deaths).

Patterns of tobacco consumption make it likely that tobacco-related deaths will increase in the future as will smoking-related mortality among women, due to increased tobacco consumption by women and adolescent girls.

In May 2003 the World Health Organization adopted the Framework Convention on Tobacco Control. One of the objectives of this convention is to restrict tobacco advertising and to promote greater awareness about the health risks of tobacco consumption, including harm to passive smokers.

* For more information about the Framework Convention on Tobacco Control, visit the website http://www.who.int/tobacco/fctc

Useful, Moving and Amazing Websites

Campaign for Tobacco-Free Kids http://www.tobaccofreekids.org/

ASH--Action on Smoking and Health http://www.ash.org.uk

CDC's Tobacco Information and Prevention Source http://www.cdc.gov/tobacco

CDC's Media Campaign Resource Center http://www.cdc.gov/tobacco/mcrc/index.htm

Health Canada Tobacco Control Program (includes testimonial videos that can be viewed on-line) http://www.hc-sc.gc.ca/hecs-sesc/tobacco/

The Truth Campaign (Welcome to Crazywodd, a multimedia campaign for youth) http://www.thetruth.com/truth.cfm

GLOBAlink, the Tobacco Control Community http://new.globalink.org/

Quit Now! (features several videos from Australia's campaigns) http://www.quitnow.info.au

Karen Gutierrez is a Fellow with the U.S. Centers for Disease Control and Prevention (CDC). She is currently based in Santiago, Chile. Interview by WHJ editor Deborah Meacham.