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Media advocacy: a case study of Philip Sokolof's cholesterol awareness campaigns.

According to statistics released by the National Institutes of Health (NIH), approximately 500,000 Americans die each year from coronary heart disease (NIH 1990b). Although coronary heart disease (CHD) is a complex, multifaceted health problem, attention has focused in recent years on dietary cholesterol and saturated fats as factors contributing to elevated blood cholesterol levels. Elevated blood cholesterol, specifically LDL (low density lipoprotein) cholesterol, can lead to arteriosclerosis (a narrowing of the arteries that slows or blocks the flow of blood) and greatly increases the risk of heart attack. In many instances blood cholesterol levels can be lowered through diet and exercise, and the risk of CHD can be reduced.

Cholesterol is only one causal factor underlying CHD. Other CHD risk factors include genetic predisposition, obesity, high blood pressure, diabetes, and smoking. Although only one factor, cholesterol is, however, an important factor. A person with a blood cholesterol level of 240 mg/dL (milligrams per deciliter) has a risk of CHD more than double that of an individual whose cholesterol is 200 mg/dL (NIH 1990a).

Public awareness of the health risks associated with high cholesterol levels has grown significantly. A recent study found the percentage of Americans who were informed that their blood cholesterol level was too high increased from 11 to 20 percent between 1987 and 1990, and the number of people tested during the same period increased by 25 percent ("Cholesterol Awareness Is Up" 1991). And, as awareness has increased, Americans have changed their diets. As recently as 1986, 23 percent of the adults surveyed in a national probability sample (N = 4,000) reported they had made dietary changes specifically to lower blood cholesterol levels (Schucker et al. 1987).

Three dietary habits commonly contribute to elevated blood cholesterol levels (NIH 1989a). First are diets with high levels of saturated fatty acids which can elevate LDL cholesterol levels. These are found in both animal fats (e.g., butterfat) and plant oils. Many tropical oils (e.g., palm, palm kernel, and coconut oils) contain particularly high concentrations of saturated fatty acids. Fortunately, tropical oils are a minor component of the U.S. food supply (Willett and Sacks 1991). Second are diets with relatively high levels of cholesterol. Dietary cholesterol is present only in foods and byproducts of animal origin. Third are high calorie diets that exceed normal body requirements and contribute to obesity. Accordingly, health experts have provided relatively consistent dietary guidelines for reducing blood cholesterol levels (NIH 1989b). Specific recommendations normally include lowering the intake of saturated fats and dietary cholesterol, increasing the relative proportion of foods high in complex carbohydrates, and reducing total caloric intake for overweight persons.

Although many Americans have responded to the threat posed by elevated blood cholesterol levels, problems remain. The average blood cholesterol level for adult Americans is approximately 210 mg/dL, and about 55 percent of the adult population have cholesterol levels of 255 mg/dL or higher (NIH 1990b). The National Center for Health Statistics (1986) estimated that 27.4 million adult Americans have cholesterol levels that put them at high risk of CHD, and another 19.6 million adults can be placed in the "moderate risk" category. Concern has also been expressed over elevated cholesterol levels in children. A study in New York determined that approximately 80 percent of the nine-year-old children surveyed were ingesting too much saturated fat and 60 percent were consuming excessive amounts of dietary cholesterol ("High Cholesterol in Children" 1989). Many researchers now feel that high cholesterol levels in childhood contribute to increased risk of heart disease and hypertension in adulthood.

Contemporary lifestyles often discourage sound dietary behavior. Increasing time pressures associated with work and decreasing time spent in the home forces many Americans to "eat on the run." And, despite increased public awareness, there is some indication today of an erosion in Americans' commitment to good nutrition. A recent article in American Demographics noted that "Americans claim to be concerned about nutrition, but demanding lifestyles and hunger pains are more likely to determine the foods they eat" ("Are Americans Eating Better?" 1989, 30).

The food industry has recognized the importance of reducing saturated fats and cholesterol in processed and restaurant-prepared foods. Although total fat content remains at unhealthy levels, in many instances restaurant chains have made progress in the direction of more healthful menu alternatives. McDonald's and Wendy's, two of the nation's largest fast food chains, now feature salads, yogurt, and fried foods prepared in vegetable oil. Other restaurant chains offer salad bars, seafood and poultry selections, and alternatives to fried foods ("Fast Food Gets Light and Lean" 1991). Food processors are also working to reduce fat content in popular foods. Tropical oils and animal by-products have been removed from many processed foods and significant progress has been made recently in reducing fat content in beef and hamburger, the mainstay of many American's midday meal ("Low-Fat Burger Being Tested by McDonald's" 1990). McDonald's 'McLean' hamburger is touted as containing only ten grams of fat, roughly one-half the amount contained in its 'Quarter Pounder' ("Low-Fat McDonald's Burger..." 1991).

Although progress has been made, in the opinion of Philip Sokolof, a heart attack victim, much remains to be done particularly by the food industry. Sokolof shocked America in 1989 and 1990 with his full-page "poisoning of America" advertisements which appeared simultaneously in many of the nation's most prestigious newspapers. McDonald's was targeted in the advertisements which alleged that the chain's hamburgers were "loaded with fat" and their french fries were cooked in beef tallow. The advertisements challenged McDonald's and all fast food restaurants to reduce fat content and to prepare foods with "heart healthy oils."

This article describes Sokolof's efforts to bring about change in the food industry and increase public awareness of potentially harmful effects of dietary cholesterol and saturated fats. It begins with a brief description of social marketing and media strategies, perspectives that are useful for assessing Sokolof's attempts to increase cholesterol conciousness. A detailed review of Sokolof's efforts is presented in the next section. The article concludes with a brief summary and evaluation.

SOCIAL MARKETING AND MEDIA STRATEGIES

A decade ago Fox and Kotler (1980-1981) suggested that "social marketing" offered great potential for reducing cigarette consumption. The authors argued that social marketing could succeed where other "piecemeal approaches" had failed. Certain parallels are evident between cigarettes and cholesterol: both pose major threats to public health, consumption rates are uneven across major segments of the population, and the public has been exposed to massive, conflicting amounts of information about effects of both tobacco and cholesterol. Social marketing offers promise for promoting heart healthy dietary behavior and provides a potentially useful framework for evaluating cholesterol awareness campaigns.

After two decades social marketing remains an elusive concept. In their seminal article on the subject, Kotler and Zaltman defined social marketing as "the design, implementation, and control of programs calculated to influence the acceptability of social ideas" (1971, 5). Implicit in this conceptualization is the premise that social marketing is distinguished by its focus on social versus commercial objectives. Fine reinforced this perspective, noting that social marketing "concerns the application of marketing methods to the dissemination of ideas--socially beneficial ideas like cancer research, energy conservation, and car-pooling" (1990, xiv). Public health problems like smoking, population control, mental health, and nutrition can be viewed as "social products" (Fine 1981), amenable to resolution through application of marketing concepts and techniques.

The common "link" between social and commercial marketing is the use of proven marketing methods. Marketing offers a "systematic, research-based process for problem solving" (Novelli 1990, 349). Fox and Kotler (1980) suggested that the classic marketing management framework popularized by McCarthy (1960) as the "4 Ps" (product, place, price, and promotion) can be readily applied to social marketing. Specifically, social marketing calls for systematic application of marketing research, development of desirable social products, and use of incentives and facilitators to encourage the process of social change. These elements can be integrated in the form of a comprehensive social marketing plan (Kotler and Roberto 1989), consisting of several interrelated components or phases including a specific statement of objectives and identification of target groups or segments, proposed strategies, budgets, and controls.

The social marketing approach to improving public health is well-exemplified by Project LEAN.(1) In 1987, the Henry J. Kaiser Family Foundation initiated a multifaceted, ten-year campaign to reduce the nation's risk levels for five major preventable causes of morbidity and mortality. Project LEAN, one component of the Foundation's campaign, was created to encourage the reduction of dietary fat consumption.(2) Three primary objectives were established:

(1) Reduce mean dietary fat intake levels to 30 percent of calories by 1998.

(2) Increase availability of low-fat foods from supermarkets, restaurants, and cafeterias in workplaces and schools.

(3) Increase cooperation and collaboration among national and community organizations committed to reducing dietary fat levels.

Two target audiences were initially identified: adults whose diets include high levels of dietary cholesterol and saturated fats and "food influentials" defined as "organizations and institutions who influence food choices" (Samuels 1990, 437). The latter group includes industry trade associations, food processors, and food outlets (e.g., supermarkets and restaurants). Project LEAN relies heavily on public service announcements and point of purchase "interventions" to relay information about diets and dietary behavior. A consumer hot line is also available, along with a variety of published materials, including the "LEAN Letter," current nutrition information, and recommended low-fat menus. Finally, Project LEAN is a collaborative, interdisciplinary undertaking. The project is advised by "Partners for Better Health," a 30-member coalition of the nation's leading health organizations. Member organizations include, among others, the American Dietetic Association, American Public Health Association, and the American Academy of Family Physicians. Program materials, concepts, and strategies are developed and exchanged with and through these member organizations.

Efficient and effective use of the mass media is often a key determinant of the success of social marketing programs. Indeed, Fox and Kotler (1980-1981) suggested that social marketing evolved from "social communication." While the two approaches are not antithetical, social communication differs from social marketing in that it focuses narrowly on the use of the media, representing an informational approach to social change.

In describing the role played by the media in health education, Wallack (1990) identified two fundamental approaches to using mass communication systems: an enhanced public communications model and "media advocacy." The public communications model is closely aligned with the underlying precepts of social marketing. Extensive reliance is placed upon the use of mass media to support and enhance program objectives and activities. Often, as with Project LEAN, maximum use is made of voluntary participation by the media and advertising industry. In the public health domain, the media focus or "copy thrust" tends to be on individuals and their control over risk factors relating to health.

Media advocacy was defined by former Federal Trade Commission Chairperson Michael Pertschuk as "the strategic use of mass media for advancing a social or public policy initiative" (Wallack 1990, 376). Two important differences between the public communications and media advocacy models are suggested by Mr. Pertschuk's definition. First, media advocacy generally involves redefining individual risks or responsibilities as environmental or public issues. As described by Wallack, "... media advocacy in the area of nutrition would carefully use media to reframe the problem of diet from one of poor individual eating habits ... to one of public policy..." (1990, 376-377). The ultimate goal may be to force a change in nutrition standards, food preparation, or labeling. Media advocacy often seeks to debase the industry in question by exposing practices which are exploitive and/or unethical (Wallack and Sciandra 1990-1991), tactics not unlike those associated with political campaigns calling for legislative or institutional responses to problems with law and order, the environment, and so forth.

Strategic use of the media is a second differentiating factor. Either through direct purchase of media time and space and/or by carefully reframing issues, the media advocate attempts to reduce dependency on voluntary coverage of important issues or programs. By targeting selected media, reporters, or issues, the media advocate attempts to leverage the media and increase total audience exposure. Sokolof's highly controversial advertisements placed in major newspapers like The New York Times and The Wall Street Journal received extensive secondary coverage by local media.

Both social marketing and media advocacy offer utility for analyzing Sokolof's efforts to increase cholesterol consciousness and induce change in the food industry. The early cholesterol screening campaigns focused on individual risk factors. Later, the mass media came to play an increasingly important role as Sokolof's campaigns became more focused on the industries that manufacture and market cholesterol- and fat-laden foods.

OVERVIEW OF SOKOLOF'S CHOLESTEROL CAMPAIGNS(3)

The National Heart Savers Association (NHS) was established in 1985 for the express purpose of increasing cholesterol consciousness. Its founder, Philip Sokolof, owns and operates Philips Manufacturing, a construction equipment company. Heart Savers is registered in Nebraska as a nonprofit organization. The organization does not solicit public funding. Since its creation, Sokolof has donated over $2.5 million to NHS, representing some 99 percent of the organization's funds. Sokolof's motivation to establish NHS stemmed from his near fatal heart attack in 1966 and a family history of coronary disease which has claimed the life of his father and brother-in-law.

Sokolof believes that his previous diet of "eggs, dairy products, chili, and all greasy foods" contributed to his elevated cholesterol and subsequent heart attack. He also believes that tying educational efforts to his individual experiences "... would be like baying at the moon." In all probability, Sokolof created NHS to serve as a credible vehicle for dissemination of information about cholesterol and related educational programs to the public. Today NHS distributes a variety of published materials to the public, including cholesterol guidelines ("Facts About Blood Cholesterol"), recommended books and free publications ("Increase Your Cholesterol Awareness"), and dietary alternatives to cholesterol and saturated fats (e.g., "Heart Savers Diet"). The name of the organization has also been prominently displayed on Sokolof's media attacks on the food industry.

Early Cholesterol Educational Campaigns

Sokolof first approached the task of increasing public cholesterol awareness through a series of city-wide screening programs conducted at several locations during 1985-1988. The initial screening programs faced obvious capacity limitations. Repeat testing was important for individuals with elevated cholesterol levels, and the scope of cholesterol screening had to be expanded beyond a few local areas. To encourage repeat testing, NHS donated cholesterol screening equipment to health departments in many of the cities where initial testing had taken place. To date, NHS has worked with local organizations in the screening of over 200,000 persons in 16 cities.

In order to focus national attention on the importance of cholesterol screening, Sokolof and NHS tested 9,600 senators, representatives, and staff personnel in Washington, DC in April 1987. A "National Know Your Cholesterol Week" was created and later expanded to "National Know Your Cholesterol Month" in April of 1988. The event was publicized by NHS in 315 newspapers across the United States. According to Sokolof, more people had their cholesterol tested during this period than at any other time in history. The establishment of NHS and the subsequent cholesterol screening programs were important steps in Sokolof's campaign to increase public cholesterol awareness.

Nevertheless, Sokolof was aware of important limitations. Only a small fraction of the public had been reached by the cholesterol screening programs, and he believed that most people still did not comprehend the complex relationships between diet and CHD.

Use of Advertising to Eliminate Tropical Oils

Sokolof believed that direct, highly targeted advertising could encourage the public to reduce their consumption of dairy products, red meats, and other foods high in cholesterol and saturated fats. He also believed that relatively few consumers were aware of harmful product ingredients, even when this information was provided on product labels. Demographic analysis has consistently indicated that labels have a differential effect across various segments of the population. Education, household size, and age have been found to be important correlates of consumer information use (Schucker et al. 1983). In general, undereducated, low income persons from large households tend to be the most infrequent users of label information. These same groups also commonly suffer from poor nutrition. Low income, undereducated ghetto residents suffer perhaps more than any other segment of society from high fat, salty, sugary diets ("Deadly Diet: Amid Ghetto Hunger, ..." 1990).

Sokolof decided to focus directly on manufacturers of products that contribute to unhealthy cholesterol levels. At this point a transition away from the traditional social marketing approach was initiated. Beginning with the campaign against tropical oils, Sokolof dramatically demonstrated how the mass media could be used to force changes in the food industry. As noted, tropical oils contain particularly high levels of saturated fats which can raise LDL cholesterol; specifically, coconut, palm kernel, and palm oils contain 92, 86, and 51 percent saturated fat, respectively (Toufexis 1989). Interestingly, some of these oils were found in products such as Procter and Gamble's "Crisco" vegetable shortening touted as having no cholesterol, and Kellogg's "Cracklin' Oat Bran" cereal positioned as a cholesterol lowering product.

Some 11,000 food processors were originally contacted through a direct mail campaign which urged them to use alternatives to tropical oils. Sokolof felt that this strategy was ineffective, i.e., "I did not get to first base." He observed:

We got a lot of nice letters from small companies, but the biggies of course basically double-talk you. They say, We're studying it. Yes we know this. We call up and say, We're National Heart Savers out of Omaha. What does that mean? It means, I'm Joe Blow from Podunk (Streitfeld 1989, B-5).

A subsequent tactic, employed in October 1988, featured the placement of full-page advertisements in The New York Times, Washington Times, The New York Post, USA Today, and The Wall Street Journal which deplored prominent consumer goods companies for using unhealthy tropical oils.(4) Specific products targeted in the advertisements included Carnation's "Coffee Mate," Kellogg's "Cracklin' Oat Bran," Pepperidge Farm's "Goldfish Crackers," Keebler's "Club Crackers," Procter and Gamble's "Crisco," Borden's "Cremora," and Sunshine's "Hydrox Cookies."

Sokolof knew that Sunshine had already removed coconut oil and was in the process of removing palm oil from its products, and he wanted to mention these efforts in his advertisements. Sunshine, however, wanted no related publicity. He, therefore, decided to include the Sunshine product in the advertisements in order to "move the company sooner." Approximately one week later, Sunshine announced they were removing all tropical oils from their products. The Associated Press reported the story, and for the first time, Sokolof and NHS were publicly tied into the tropical oil controversy in the national media.

Sokolof's advertising copy featured a skull and crossbones, signaling the first "poisoning of America" campaign. Readers were informed that their lives could be at stake and that they should not purchase products containing coconut or palm oil. Specific copypoints included

* A large number of food processors use tropical oils even though they know these ingredients have negative health ramifications.

* These companies have more pressing concerns than their consumers' health.

* Their actions are "poisoning" America ("poison" was defined at the bottom of the ad as "a substance that has an inherent tendency to destroy life or impair health").

At least two newspapers, The Washington Post and the New York Daily News, declined to run the ads because of the "poison" reference. Sokolof recognized that "poisoning" was negative, but he believed this terminology would be effective in gaining public and media attention. Predictably, many companies openly objected to Sokolof's tactics. He contended that their reactions may have actually advanced the campaign. Remarks made by a Kellogg vice president and Sokolof on USA Today placed Sokolof at the center of the tropical oil controversy:

My first TV exposure was on the USA Today television program shortly after our first ad appeared, and they had this man on saying that I was practicing quackery and was irresponsible. (The show) then got a bite from me, and I (replied): "If I'm irresponsible, (what about) Kellogg (which) has 3.7 grams of saturated fat in a product that is represented as a health food containing oat bran and sold in health stores?

The advertisements, now reinforced by the television show, proved to be effective. A week after the advertisements ran, Sunshine Biscuits agreed to eliminate tropical oils from its cookies and crackers, followed shortly thereafter by Kellogg's decision to eliminate these ingredients from "Cracklin' Oat Bran" cereal. Sokolof responded to these actions, "They're like dominoes.... Once one falls, they'll all fall" (Madden 1989, 118). Within a few months similar announcements were issued by Pepperidge Farms, Keebler, and Borden while General Mills, Ralston-Purina, Pillsbury, and Quaker Oats indicated that they were working on new recipes to eliminate tropical oils ("Five More Firms Will Stop..." 1989).

Sokolof regarded the advertising campaign "... a flat out victory," largely because he believed that the public had, for the first time, linked cholesterol to saturated fat and reassessed their purchasing decisions accordingly,

People don't realize how much power they do have when a company starts losing market share. Pepperidge Farms claimed the campaign cost them six to eight percent nationally, (equivalent to) the "Gold Fish" market share. ("A Man With a Mission..." 1989, 112)

His assessment was seconded in a Los Angeles Times editorial, "...here was indeed a case where one person made a difference, and where an idea had definite and beneficial consequences" ("...And Phil Sokolof" 1989, 4).

His role in bringing about change was not universally recognized. Critics noted that Sokolof focused undue attention on tropical oil as a major causal factor underlying CHD and that he failed to distinguish between products with large amounts of tropical oils and those with negligible amounts (Gaynor 1989). Organizations targeted in the advertisements also contended that plans to remove tropical oils were in place well before Sokolof's campaign began. Even within the industry, however, there was some recognition that Sokolof's efforts had an impact on corporate action. Joe Simrany, vice president of marketing for Sunshine Biscuits, indicated that his organization's announcement date signaling the removal of tropical oils was moved up because of the "negative press":

We couldn't ignore it |Sokolof's advertisements~. He forced the announcement, not the commitment to change.... |Sokolof~ is doing a good job.... It's his tactics that leave a lot to be desired. (Ogintz 1989, 1)

The initial advertisements were not universally effective. Nabisco's refusal to comply with the Heart Savers Association's advertisements prompted a second advertising campaign in Spring 1989. The advertisements, which appeared in some of the nation's most widely read newspapers, charged that 11 of the largest food processors had agreed to eliminate tropical oils, but Nabisco Brands continued to market 30 products containing tropical oils and 30 other products containing lard. Nabisco officials retorted that they had not ignored consumer demands for foods without fats. They further noted that the company had initiated a program to eliminate tropical oils from its products, but lard would continue to be used in some of its baked items, including Ritz Crackers, Premium Saltines, and Oreo Cookies (Williams 1989).

Fast Food/Fat Connection

The third, and perhaps most widely recognized, advertising campaign focused directly on the fast food chains. McDonald's, labeled a "fat factory" by Sokolof, was specifically targeted in "The Poisoning of America" advertisements which appeared in simultaneous editions of 20 major newspapers in April 1989.(5)

The copyline in the advertisements was simple, direct, and hard-hitting:

McDONALD'S, YOUR HAMBURGERS STILL HAVE TOO MUCH FAT AND YOUR FRENCH FRIES ARE COOKED WITH BEEF TALLOW!

The ads urged McDonald's to reduce the precooked fat content of its hamburgers (from 21.5 percent) by ten percent; cook french fries in heart healthy oils instead of beef tallow, and switch from two-percent milk to skim milk (Buchert 1990, 1-B). Sokolof knew that targeting McDonald's, one of America's most visible and respected fast food chains, would be controversial and would attract national attention to NHS efforts.

To accelerate the process, Sokolof scheduled a press conference at noon the first day of the campaign. Press releases and other materials from the conference were quickly disseminated by Federal Express to television networks around the nation. As a result, the story played on virtually every 6:00 p.m. newscast because the issues could be easily localized, and reporters could readily go to neighborhood McDonald's and interview employees and customers. Hence, these one-day advertisements, positioned in a few select newspapers, quickly generated a large secondary audience.

Sokolof predicted that his hard-hitting messages would change, but not destroy, McDonald's:

I can't say we're going to tear down the golden arches by the year 2000 ... but I am confident that by the year 2000 they are going to be serving more healthful food under those golden arches. (Robbins 1990, 16)

McDonald's president, Ed Rensi, retorted that the ads were sensationalistic and intended to scare people, misleading (he contended McDonald's fat content ranged from 17 percent to 19.5 percent), and overlooked the company's test cooking of french fries in vegetable oil in 500 stores and introduction of new health conscious products such as bran muffins, low-fat milkshakes, frozen yogurt, and fruit sorbet. Another McDonald's spokesperson contended

Just about everything in the ad except the spelling of McDonald's was inaccurate. The assertion of the ad, the poisoning of America, is an outrageous lie that we don't think any responsible publication should have published. (Nordgren 1990, C-11)

The corporation quickly extended its concern and implied the possibility of legal action against the newspapers which carried the advertisements. Joseph Califano, the corporation's lawyer and former U.S. Secretary of Health, Education and Welfare, wrote to several of the nation's largest newspapers and asserted that they had overlooked several errors and inaccuracies in the printed advertisements. Califano's letters suggested that further publications of the advertisements, without documented efforts to substantiate the accuracy of claims made in the advertising copy, would be considered a "malicious" act, a prerequisite condition for establishing libel.

Reactions to Califano's notification varied. A spokesperson for The Los Angeles Times supported Califano's position, noting that the paper had originally rejected the ads, believing them to be "unfair" (Sanchez 1990). However, spokespersons for The New York Times and USA Today were not particularly influenced by Califano's notice:

We had no reason to suspect the facts in this ad, so it's unlikely they were checked.... We neither agree nor disagree with the ad. We don't think it was irresponsible to run the ad and we have a long-standing tradition of running opinion advertising which allows an advertiser a forum for expression of its position. (Gibson 1990, B-3)

Others responded that if there were questions of accuracy (e.g., relating to fat content), then those questions were "between Sokolof and McDonald's" (Cox 1990, B-1). Sokolof refused to publicly reveal where his fat statistics originated, stating "I don't want to get involved in technicalities (such as) who did my testing" (Cox 1990, B-1). He also countered that McDonald's "could not have made a bigger mistake" than the one it made when it sent Califano's letter to the newspapers. "The Associated Press calls me up Friday afternoon, asks me to comment (on the letter).... This made another go around in Saturday's papers...." Sokolof further maintained that Califano failed to recognize that The New York Times has "as big an ego as McDonald's." Consequently, the Times gave far more comprehensive coverage to the controversy in the second round.

The advertisements and resultant publicity had a measurable impact on McDonald's and the fast food industry. An Advertising Age/Gallup poll conducted in May 1989 indicated that patronage of fast food chains declined following the advertisements. Thirty-one percent of the respondents in the national probability survey indicated awareness of the advertisements and 38 percent of these respondents indicated they had reduced their patronage of all fast food chains (Hume 1990). Note, however, that over half (58 percent) of those surveyed indicated no change in patronage or eating habits. Interestingly, McDonald's challenged the accuracy of the survey, noting that their customers "trust McDonald's a hell of a lot more than some guy from Omaha who makes parts that hold dry walls together" (Williams 1990, D-19).

Despite McDonald's refutation of the accuracy and impact of the campaign, change did occur. Three weeks after the survey results were published, Wendy's and McDonald's announced they would begin cooking french fries in 100 percent vegetable oil (Sperling 1990). McDonald's indicated this decision had nothing to do with the ads as the change "had been in the works for more than eight years." Sokolof, who had been in contact with McDonald's for more than three and one-half years before the advertisements ran, countered that the timing of the change to vegetable oils represented "some coincidence."

The Nutrition Labeling and Education Act of 1990

The Center for Science in the Public Interest concluded in a recent report, "Food Labeling Chaos: The Case for Reform," that consumers face three major problems under current nutrition labeling requirements (1990, i): (1) Lack of useful nutrition information; (2) Misleading nutrition and health claims; and (3) Incomplete, unclear nutrition information. Consistent with these conclusions, Nancy Chapman, vice chairperson for the American Heart Association's board of directors, likened the task of obtaining cholesterol-relevant information from food labels to "working The New York Times crossword puzzle" (Chapman 1990, 74).

The Nutrition Labeling and Education Act of 1990 (PL 101-535, 104 STAT. 2353, November 8, 1990) calls for sweeping changes in the nutrition labeling of food products. Although a detailed discussion of this legislation is beyond the scope of this article, it is significant to note that the law expands the scope of mandatory nutrition labeling to a wide range of food products, including both processed foods and many perishable items sold from bins and refrigerated cases.|6~ In the future, labels must reveal the amount of total fat, saturated fat, cholesterol, sodium, total carbohydrates, complex carbohydrates, sugar, total protein, and dietary fiber contained in an average serving. The Act also establishes much tighter guidelines and rules pertaining to the use of such terms as "lite," "natural," and "cholesterol-free."

Designated by Congress an unofficial co-sponsor, Sokolof actively promoted the bill's passage. Sokolof correctly perceived that the legislation was threatened by special interest groups and by key members of Congress who could stall the legislation in committee and ultimately prevent its passage. Convinced that the new, then threatened labeling bill could increase cholesterol consciousness, Sokolof resorted to familiar media tactics. Between July 24 and October 23, 1990, Sokolof and NHS financed a massive newspaper advertising campaign designed to focus national attention on the new bill. As he had done in earlier campaigns, Sokolof relied on direct, hard-hitting copy which targeted specific individuals and organizations. A full-page July 24th ad in The Washington Post and the Washington Times urged members of Congress to push the legislation to a floor vote. Senators Mitchell, Kennedy, Metzenbaum, and Hatch and Congresspersons Dingell and Waxman were identified in the advertisement. On September 12, another full-page ad appeared in The Washington Post and the Washington Times, plus all major Utah newspapers, urging Senator Orrin Hatch of Utah to stop his efforts to weaken the bill. In two other ads run during the same month, Senators George Mitchell and Edward Kennedy were targeted. On October 23, Sokolof attacked the National Milk Producers Federation with ads in The New York Times, USA Today, and The Washington Post. The bold headline read: "IT'S WRONG AMERICA! SPECIAL INTERESTS ARE TRYING TO DEPRIVE YOU...." The text emphasized that "one organization" (the National Milk Producers Federation) was pressuring senators to stall the legislation and prevent its passage.

Sokolof recognized that the manufacturers were generally opposed to the legislation, given its potential for attracting attention to the content of their products; e.g., "If you were making Armour's chili that had thirty-something grams of fat, I don't think you would want to put that on your label...." He also recognized that the majority of consumers do not make extensive use of nutrition label information; by his own estimate, "probably only 20 percent of the people read food labels." However, he believed the "20 percent" could be highly influential in changing "all the food products in the country."

Amended versions of the bill were passed by voice vote in the House on July 30, 1990 and in the Senate on October 24, 1990. President Bush, whose administration supported the legislation from the beginning, signed the bill into law November 8, 1990.

Sokolof invested approximately $650,000 in the labeling campaign. His efforts in promoting the bill were praised by Representative Henry Waxman of California: "What he was able to do on his own as an individual is an inspiration. This bill is a tribute to his tenacity" ("House OK Sends Bill on Nutrition Labeling to Bush" 1990, 8).

DISCUSSION

Health experts generally recognize a causal relationship between dietary practices and cardiovascular disease. Diets high in cholesterol and saturated fats are believed to elevate blood cholesterol levels which, in turn, can increase the risk of heart attack. Organizations such as the American Heart Association have consistently recommended that Americans reduce their consumption of both dietary cholesterol and saturated fats.

Philip Sokolof has campaigned to increase public awareness of the potential health risks associated with dietary cholesterol and saturated fats. Media reports indicate that Sokolof and the National Heart Savers Association have

(1) Initiated and supported cholesterol screening programs;

(2) Prompted the removal of tropical oils from many processed foods;

(3) Accelerated revisions in the products and menus of fast food chains; and

(4) Supported the passage of new nutrition labeling legislation.

The objective of increasing cholesterol awareness and forcing changes in the food industry places Sokolof's efforts in the social marketing domain. Further, his involvement with cholesterol screening and consumer education through NHS publications and programs can be interpreted from an individual risk perspective.

However, Sokolof's tropical oil, fast food, and labeling campaigns do not conform closely to the basic tenets of social marketing. For example, there is little indication that these campaigns were guided by a comprehensive strategic plan that identified target groups, calling for working relationships with community health organizations, or specified resource requirements. Nor is it apparent that well-defined, quantifiable public health goals (e.g., as in Project LEAN) were ever established. Sokolof candidly remarked during a recent interview with the author: "I started Heart Savers in January 1985 (and) I did not know the scope of it.... When you think of what's happened in the last five years, it's really mind-boggling."

The media advocacy model described offers considerable utility for evaluating Sokolof's campaigns against the food industry and opponents to labeling legislation. Two important media advocacy skills were evident: the effective framing of issues as to gain public attention and, second, the capability of gaining extended access to media. The "poisoning of America" campaigns symbolically characterized fast food chains like McDonald's and food processors such as Nabisco and Kellogg as exploitive, uncaring organizations. Public attention was riveted upon the industry's responsibility (or disregard) for public health. Similar tactics were again evident in the labeling campaign: "It's wrong America! Special interests are trying to deprive you...." The advertisements referred to "powerful organizations" and "special interests" which denied the individual the "right to make informed choices."

Sokolof also consistently demonstrated the ability to leverage the media and extend coverage. He used key, high-impact media as The New York Times and The Washington Post during periods when nutrition issues were likely to receive coverage. Sokolof knew other writers and media turn to these sources for news: "You have to get the press involved and ... The New York Times is the premier newspaper as far as people who write the articles are concerned." Media coverage was also extended through frequent contacts with the Associated Press: "When the AP puts something on the wire, other papers pick it up. The Kellogg's story was on the front page." And, regarding timing: "You want to be in the Saturday paper because they are lean and looking for something to write."

Coverage of issues was further extended by targeting highly visible organizations and public figures. McDonald's, for example, is one of the most familiar brands in the world. Sokolof knew that every local station and newspaper could relate national stories such as the "poisoning of America" to the neighborhood supermarket and corner fast food restaurant. The advertisements became news and cholesterol became an issue of direct public concern, as many could now directly relate health risks to behavior.

Although Sokolof's campaigns generated high levels of awareness, his contribution to public health, per se, remains a question. As noted by health professionals, the relationship between diet and heart disease is exceedingly complex. With the lone exception of the cholesterol screening programs he initiated and funded, doubts may be raised as to his specific contribution to public health education and dietary practices. A plausible case can be made that the media campaigns functioned to over simplify complex relationships among dietary cholesterol, saturated fats, serum cholesterol, and heart disease. Cholesterol, to cite but one example, is not a "poison" and the reduction or elimination of dietary cholesterol does not ensure that serum cholesterol will be at healthy levels. Also, there is tremendous potential variation in tolerances for cholesterol and saturated fats across individuals (and, perhaps, entire geographic regions and cultures). Failure to address these complexities may, indeed, lead to dietary and personal health monitoring practices that are inconsistent with the recommendations of trained health and nutrition professionals.

Although his specific contribution to public health remains a subject of controversy, Sokolof demonstrated the efficiency with which the mass media can be used to induce and accelerate change in the food and restaurant industry. His tactics, although blatant and simplistic, provide potentially valuable lessons for improving mass media performance in the public health domain.

1 Project LEAN is positioned by Kotler and Roberto (1989, 285-294) as a case study in social marketing. The case was reviewed by Drs. S. E. Samuels and L. W. Green of the Kaiser Foundation prior to the publication in the Kotler and Roberto text.

2 Much of the information in this section relating to Project LEAN was taken from materials provided by The Henry J. Kaiser Family Foundation, Menlo Park, CA 94025. See also, Samuels (1990).

3 The information in this section came from a variety of published sources and from a personal interview conducted with Mr. Sokolof in December 1990. Quotations not attributed to a specific source were obtained from the interview.

4 The advertisements placed by Sokolof can be regarded as "counter advertisements." Counter advertising has been positioned as a subset of "advocacy advertising." Formally defined, advocacy advertising is "a type of advertising in which organizations express their opinions on controversial issues in hopes of swaying public sentiment." Counter advertising is distinguished by its position in opposition to some practice or institution (Cutler and Muehling 1985, 40).

5 The advertisements were refused by The Los Angeles Times, New York Daily News, The Baltimore Sun, Houston Chronicle, and Chicago Sun Times.

6 Critics of the law suggest that the Act does not go far enough, contending that many meat and poultry products are still subject to "laissez-faire labeling" ("Labels on Meats Fail to Provide Nutrition Data" 1991).

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Ronald J. Adams is Associate Professor, Marketing, and Kenneth M. Jennings is Professor, Industrial Relations, University of North Florida, Jacksonville.
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Publication:Journal of Consumer Affairs
Date:Jun 22, 1993
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