Florida's "truth" campaign: a counter-marketing, anti-tobacco media campaign

Developing a text-message library for tobacco prevention among adolescents: A qualitative study

INTRODUCTION

Communicating the risks associated with nicotine and tobacco use to adolescents can be challenging, especially with the current tobacco market's attempt to capture the attention of youths. Text message interventions have emerged to address the need to improve tobacco risk communication. This article informs the design of a message library for tobacco risk communication that is based on the transtheoretical model and addresses the risk of multiple tobacco products.

METHODS

We draw findings from this study from two phases. Phase 1 involved six remote focus group discussions (n = 25) and an in-depth interview, and Phase 2 involved online ideation sessions (n = 11) that led to the current version of the messages. We conducted the study within a larger project for the design and testing of a tobacco prevention program. With thematic analysis and the affinity mapping technique, two research team members identified repeated topics and relevant quotes to organize them into themes and subthemes.

RESULTS

In Phase 1, thematic analysis revealed four major themes: 1) Adolescents' gap in tobacco knowledge, 2) Social influence and popularity, 3) Attitude toward marketing, and 4) Text message framing preferences. During Phase 2, participants generated 1-to-7 iterations of the original messages. Votings and discussions resulted in a library of 306 messages under 7 sections, categorized based on the processes of change from the transtheoretical model.

CONCLUSION

The current study presents key insights crucial for developing and evaluating a library of tobacco prevention text messages that is scientifically valid and successfully resonates with today's adolescents. Our future plan is to go beyond this initial message development and vet the message library by adolescents and expert reviewers in tobacco risk communication. Future research may consider developing messages that are tailored based on gender, ethnicity, and other factors that are predictive of tobacco use.

Disparities in Infant Nutrition: WIC Participation and Rates of Breastfeeding in Florida

Being cognizant of the pronounced health advantages of breastfeeding for both the nursing mother and her infant, the breastfeeding dyad, we examined breastfeeding rates among Floridian women who gave birth from 2012 to 2014 (N = 639,052). We investigated the associations between breastfeeding initiation and WIC-based breastfeeding support (the Special Supplemental Nutrition Program for Women, Infants, and Children), education level, and race and ethnicity. We compared the percentage of breastfeeding mothers between those in the WIC program and those who were not, and we compared breastfeeding rates across racial and ethnic groups. Consistent with previous reports, black newborns in this study were breastfed at lower rates than other racial groups, and WIC program participants were less likely to breastfeed than non-WIC program participants. However, by breaking down the data by education level and race, and ethnicity, we see a significantly increased rate of breastfeeding due to WIC participation for both Hispanic and black women with less than a high school education. Further, we assessed differences by insurance type, race, and WIC participation. In multivariable logistic regression, we showed that the WIC program has a significant positive impact on breastfeeding rates for all but white non-Hispanic mothers, independent of sociodemographic and geographic variables. We also note a trend of increasing breastfeeding rates over the study period (p-value < 0.0001), which has positive public health implications.

Examining Truth and State-Sponsored Media Campaigns as a Means of Decreasing Youth Smoking and Related Disparities in the U.S

INTRODUCTION

To analyze the impact of Truth and state-sponsored anti-tobacco media campaigns on youth smoking in the U.S., and their potential to reduce tobacco-related health disparities.

METHODS

Our study included data from the 2000-2015 Monitoring the Future study, an annual nationally representative survey of youth in 8 th (n=201,913), 10 th (n=194,468), and 12 th grades (n=178,379). Our primary exposure was Gross Ratings Points (GRPS) of Truth or state-sponsored anti-tobacco advertisements, from Nielsen Media Research. Modified Poisson regression was used to assess the impact of a respondent's GRPs on smoking intentions, past 30-day smoking participation, and first and daily smoking initiation. Additive interactions with sex, parental education, college plans, and race/ethnicity were used to test for differential effects of campaign exposure on each outcome.

RESULTS

Greater campaign exposure (80 th vs. 20 th GRP percentile) was associated with lower probabilities of smoking intentions among 8 th graders, smoking participation among 8 th and 12 th graders, and initiation among 8 th graders. Greater exposure was associated with a greater reduction in the likelihood of smoking participation among 10 th and 12 th grade males than females; 10 th and 12 th graders with parents of lower education versus those with a college degree; and 12 th graders who did not definitely plan to go to college relative to those who did.

CONCLUSIONS

Media campaign exposure was associated with a lower likelihood of youth smoking behaviors. Associations were more pronounced for groups disproportionately affected by smoking, including youth of lower socioeconomic status. Media campaigns may be useful in reducing smoking disparities and improving health equity.

IMPLICATIONS

Few recent studies have investigated the impact of anti-tobacco media campaigns on youth smoking and their potential to reduce tobacco-related health disparities in the U.S. We found media campaigns - specifically state-sponsored media campaigns - reduced the likelihood of several smoking outcomes among youth, with some evidence that they mitigate disparities for disproportionately affected groups.

Exploring How Exposure to Truth and State-Sponsored Anti-Tobacco Media Campaigns Affect Smoking Disparities among Young Adults Using a National Longitudinal Dataset, 2002-2017

BACKGROUND

Little is known regarding long-term impacts of anti-tobacco media campaigns on youth smoking and related disparities in the United States.

METHODS

We examined longitudinal cohort data from Monitoring the Future (MTF) between 2000 and 2017 in modified Poisson regression models to understand the long-term impacts of televised Truth and state-sponsored ad campaign exposure at baseline (age 18) on first cigarette and daily smoking initiation 1 to 2 years later (at modal ages 19/20). We also used additive interactions to test for potential effect modification between campaign exposure and smoking outcomes by sex, race/ethnicity, and parental educational attainment.

RESULTS

We found no evidence for baseline media campaign exposure to be associated with first cigarette or daily smoking initiation at modal age 19/20. Further, results showed no evidence for effect modification between campaign exposure and first cigarette or daily smoking initiation.

CONCLUSIONS

We found no evidence that baseline Truth and state-sponsored ad exposure was associated with first cigarette or daily smoking initiation at follow up, nor did we find any evidence for effect modification by sex, race/ethnicity, or parental education. We hypothesize that anti-tobacco media campaigns might have had a short-term impact on smoking behaviors, though these effects were not sustained long term.

Differential Associations Between Anti-Tobacco Industry Attitudes and Intention to Quit Smoking Across Young Adult Peer Crowds

PURPOSE

To compare the relationship between anti-tobacco industry attitudes and intention and attempts to quit smoking across 6 young adult peer crowds.

DESIGN

A cross-sectional bar survey in 2015.

SETTING

Seven US cities (Albuquerque, Los Angeles, Nashville, Oklahoma City, San Diego, San Francisco, and Tucson).

PARTICIPANTS

Two thousand eight hundred seventeen young adult bar patrons who were currently smoking.

MEASURES

Intention to quit in the next 6 months and having made a quit attempt in the last 12 months were binary outcomes. Anti-industry attitudes were measured by 3 items indicating support for action against the tobacco industry. Peer crowd affiliation was measured using the I-Base Survey.

ANALYSIS

Adjusted multivariable logistic regression models examined the association between anti-industry attitudes and the outcomes for the total sample and for each peer crowd.

RESULTS

Overall, anti-industry attitudes were positively associated with both intention to quit (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.24-1.52) and attempt to quit (OR = 1.14, 95% CI = 1.03-1.27). Intriguingly, the relationship between anti-industry attitudes and intention to quit differed by peer crowd affiliation, with significant associations for Homebody, Partier, Hipster, and Hip Hop, but not for Young Professional and Country.

CONCLUSIONS

Developing health communication messages that resonate with unique peer crowd values can enhance the relevance of public health campaigns. Tobacco control practitioners should tailor anti-industry messages to promote intention to quit smoking among the highest risk young adults.

Smokers' unprompted comments on cigarette additives during conversations about the genetic basis for nicotine addiction: a focus group study

BACKGROUND

Research designed to elicit smokers' cognitive and affective reactions to information about chemicals that tobacco companies add to cigarettes ("additives") found that knowledge is limited. However, little is known about smokers' unprompted thoughts and feelings about additives. Such information could be used to shape future communication efforts. We explored the content and possible functions of spontaneous statements about cigarette additives made by smokers during a study examining reactions to learning about the genetic link to nicotine addiction.

METHODS

Adult smokers (N = 84) were recruited from a medium-sized Midwestern city. Focus groups (N = 13) were conducted between April-September 2012. Data were analyzed by 2 coders using thematic analysis.

RESULTS

Comments about cigarette additives arose without prompting by the focus group moderator. Three main themes were identified: (1) discussing additives helped participants navigate the conceptual link between smoking and genetics, (2) additives were discussed as an alternative mechanism for addiction to cigarettes, and (3) additives provided an alternative mechanism by which cigarette smoking exacerbates physical harm. Notably, discussion of additives contained a pervasive tone of mistrust illustrated by words like "they" and "them," by statements of uncertainty such as "you don't know what they're putting into cigarettes," and by negative affective verbalizations such as "nasty" and "disgusting".

CONCLUSIONS

Participants had distinct beliefs about cigarette additives, each of which seemed to serve a purpose. Although mistrust may complicate communication about the health risks of tobacco use, health communication experts could use smokers' existing beliefs and feelings to better design more effective anti-smoking messages.

Adolescent Smoking Prevention: Feasibility and Effect of Participatory Video Production

PURPOSE

This study tested whether a youth participatory video production program for smoking prevention is feasible and effective.

DESIGN AND METHODS

A participatory video production program was implemented in eight twice-weekly sessions at a youth summer camp in a community center in a low-income neighborhood. Twenty-three youths participated. Descriptive statistics and a qualitative analysis were conducted to test the feasibility of the program by assessing attendance rates, the time and resources required, reasons for participation, and program satisfaction using checklists and interviews. Smoking intention was measured via pre- and post-intervention surveys and a quantitative analysis utilizing a Wilcoxon Signed Rank test to detect differences in intention for non-smoking.

RESULTS

Participants worked in groups to produce four video clips containing anti-smoking messages. Three main themes (active engagement, participation for community health, and personal growth and healthy development) emerged from the qualitative interview data. >75% of the participants considered the program excellent and stated that it met their expectations. Significant positive changes were also found from baseline to post-intervention in intention not to smoke.

CONCLUSIONS

This study demonstrated the effect of a participatory digital media production approach and confirmed its feasibility for youth health promotion and health education. Participants' active involvement in producing anti-smoking videos for a community health-promotion campaign decreased their intention to smoke and empowered them as advocates for a non-smoking community.

PRACTICE IMPLICATIONS

These findings confirm the feasibility and utility of digital media use and interactive technology for actively engaging young people in health promotion.

Mass media interventions for preventing smoking in young people

BACKGROUND

Mass media interventions can be used as a way of delivering preventive health messages. They have the potential to reach and modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To assess the effects of mass media interventions on preventing smoking in young people, and whether it can reduce smoking uptake among youth (under 25 years), improve smoking attitudes, intentions and knowledge, improve self-efficacy/self-esteem, and improve perceptions about smoking, including the choice to follow positive role models.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE and Embase in June 2016. This is an update of a review first published in 1998.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and interrupted time-series studies that assessed the effect of mass media campaigns (defined as channels of communication such as television, radio, newspapers, social media, billboards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person-to-person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years. We define smoking behaviour as the presence or absence of tobacco smoking or other tobacco use, or both, and the frequency of tobacco use. Eligible comparators included education or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risks of bias. We combined studies using qualitative narrative synthesis. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool, alongside additional domains to account for the nature of the intervention. We assessed the quality of evidence contributing to outcomes using GRADE.

MAIN RESULTS

We identified eight eligible studies reporting information about mass media smoking campaigns, one of which is new for this update. Seven of the studies used a controlled trial design and one an interrupted time-series analysis. Risks of bias were high across all included studies and there was considerable heterogeneity in study design, intervention and population being assessed.Three studies (n = 17,385), one of which compared a mass media intervention to no intervention and two of which evaluated mass media interventions as adjuncts to school-based interventions, found that the mass media interventions reduced the smoking behaviour of young people. The remaining five studies (n = 72,740) did not detect a significant effect on smoking behaviour. These included three studies comparing a mass media intervention to no intervention, one study evaluating a mass media intervention as an adjunct to a school-based intervention, and one interrupted time-series study of a social media intervention. The three campaigns which found a significant effect described their theoretical basis, used formative research in designing the campaign messages, and used message broadcast of reasonable intensity over extensive periods of time. However, some of the campaigns which did not detect an effect also exhibited these characteristics. Effective campaigns tended to last longer (minimum 3 years) and were more intense (more contact time) for both school-based lessons (minimum eight lessons per grade) and media spots (minimum four weeks' duration across multiple media channels with between 167 and 350 TV and radio spots). Implementation of combined school-based components (e.g. school posters) and the use of repetitive media messages delivered by multiple channels (e.g. newspapers, radio, television) appeared to contribute to successful campaigns.

AUTHORS' CONCLUSIONS

Certainty about the effects of mass media campaigns on smoking behaviour in youth is very low, due to inconsistency between studies in both design and results, and due to methodological issues amongst the included studies. It would therefore be unwise to offer firm conclusions based on the evidence in this review. Methodologically rigorous studies investigating the effect of social media and novel forms of technology as part of tobacco prevention campaigns for youth are needed.

Evaluating Point of Sale Tobacco Marketing Using Behavioral Laboratory Methods

With passage of the 2009 Family Smoking Prevention and Tobacco Control Act, the FDA has authority to regulate tobacco advertising. As bans on traditional advertising venues and promotion of tobacco products have grown, a greater emphasis has been placed on brand exposure and price promotion in displays of products at the point-of-sale (POS). POS marketing seeks to influence attitudes and behavior towards tobacco products using a variety of explicit and implicit messaging approaches. Behavioral laboratory methods have the potential to provide the FDA with a strong scientific base for regulatory actions and a model for testing future manipulations of POS advertisements. We review aspects of POS marketing that potentially influence smoking behavior, including branding, price promotions, health claims, the marketing of emerging tobacco products, and tobacco counter-advertising. We conceptualize how POS marketing potentially influence individual attention, memory, implicit attitudes, and smoking behavior. Finally, we describe specific behavioral laboratory methods that can be adapted to measure the impact of POS marketing on these domains.

Salience and Health Campaigns

Motivated by current topics in health economics, we apply the theory of salience to consumer policy. If a government intends to encourage healthier diets without harming consumers by raising taxes, it could initiate information campaigns which focus consumers' attention either on the healthiness of one item or the unhealthiness of the other item. According to our approach, both campaigns work, but it is more efficient to proclaim the unhealthiness of one product in order to present it as a " bad." Our findings imply that comparative advertisement is particularly efficient for entrant firms into established markets.

Adolescents' Perceptions of Risks and Benefits of Conventional Cigarettes, E-cigarettes, and Marijuana: A Qualitative Analysis

PURPOSE

Although rates of adolescent cigarette use have remained constant or decreased, rates of marijuana and e-cigarette use are rising. Knowledge and perceptions of risks and benefits of tobacco products impact adolescents' decisions to use these products. However, little is known regarding adolescents' knowledge and perceptions of risks of e-cigarettes and marijuana nor how these perceptions are formed. This study uses qualitative techniques to assess and compare adolescents' perceptions of the risks and benefits of cigarettes, e-cigarettes, and marijuana.

METHODS

Twenty-four adolescents (nine females and 15 males) from Northern California participated in six small-group discussions. Adolescents were asked what good or bad things might happen from using these products. To assess how perceptions and knowledge of risks and benefits were formed, participants were asked where and from whom they had learned about these products.

RESULTS

Adolescents described negative consequences of cigarette use but were much less sure regarding risks of marijuana and e-cigarette use. Conversely, they described few benefits of cigarettes but described a number of benefits of e-cigarette and marijuana use. Adolescents described learning about these products from the media, from family and friends, and from the school environment.

CONCLUSIONS

Adolescents have learned from multiple sources about risks of using cigarettes, but they receive much less and often incorrect information regarding marijuana and e-cigarettes, likely resulting in their positive and often ambivalent perceptions of marijuana and e-cigarettes.

Identifying misclassification in youth self-reported smoking status: testing different consent processes of biological sample collection to capture misclassification

INTRODUCTION

In Florida, since 1998, identical survey items have been used to measure youth smoking status for the CDC sponsored state school-based survey and the tobacco control program evaluation telephone survey. The two surveys should parallel one another to track tobacco use. Tobacco items collected in the two surveys closely paralleled one another until recently. Since 2008, data show dramatically divergent youth smoking estimates (e.g., relative differences as high as 50%), which cannot be explained by differences in survey and sampling design. As a first step in detecting misclassification of smoking status, we examined the feasibility of asking youth to self-report their smoking behavior and collect a biological sample, with the expectation that some youth will misreport their smoking status.

METHODS

Using a cross-sectional population level telephone survey, youth were randomly assigned to one of three groups to test mode effects of collecting biological data with self-reported survey data (n = 303).

RESULTS

It showed two groups of youth (those who are not asked for a biological and those asked for a biological with an indirect explanation of its use) had similar response rates and self-reported smoking status, while the third group (biological request with a direct explanation of its use) had a substantially lower response rate and self-reported smoking status.

CONCLUSIONS

The data show youth who are given an indirect explanation of how biological data are to be used were as likely to self-report their smoking status as youth who were not asked to provide a biological sample.

Systematic review of health branding: growth of a promising practice

Brands are marketing tools that create mental representations in the minds of consumers about products, services, and organizations. Brands create schema that help consumers decide whether to initiate or continue use of a product or service. Health branding determines behavioral choice by building consumer relationships and identification with health behaviors and their benefits. Health branding can be measured by the associations individuals form with health behaviors. In 2008, Evans and colleagues systematically reviewed the literature on health brands, reported on branded health messages and campaigns worldwide, and examined specific branding strategies in multiple subject areas. This paper extends that review. We replicated the comprehensive online literature search strategy from 2008. We screened a total of 311 articles and included 130 for full-text review. This included both articles from the 2008 review and new articles. After excluding those new articles that did not meet full-text inclusion criteria, we reviewed 69 in total. Of these, 32 were new articles since the 2008 review. Branded health campaigns cover most major domains of public health and appear worldwide. Since 2008, we observed improvement in evaluation, application of theory, and description of campaign strategies in published work. We recommend enhanced education of public health practitioners and researchers on the use and evaluation of branding.

Peeling lead paint turns into poisonous dust. Guess where it ends up? A media campaign to prevent childhood lead poisoning in New York City

Successful public health media campaigns promote messages, increase awareness, engage the public, and encourage behavior change. Between 2004 and 2006, the Lead Poisoning Prevention Program of the New York City Department of Health and Mental Hygiene conducted a media campaign grounded in social learning theory and the social marketing model to increase parents' awareness of childhood lead poisoning, ways to protect their children, and property owners' legal responsibility to fix peeling lead paint safely, and increase awareness of regulatory changes and encourage enforcement of New York City's Local Law 1 of 2004. Campaign materials were focus group tested and the campaign was refined annually. The campaign ran city-wide and in targeted high-risk neighborhoods. Neighborhoods and media venue (bus, train, kiosk, and store) changed annually, based on population risk factors and venue availability. Exposure to the campaign, campaign-related knowledge, and behavior were assessed using pre- and postcampaign street intercept surveys. Results showed that campaign reached the targeted population, and had an impact on knowledge of lead poisoning prevention measures as evidenced by increased knowledge of lead paint exposures sources in one year and increased knowledge of preventive behaviors in another year; these improvements were observed for both genders and most ethnic, primary language, educational attainment, and age groups in each year. Lessons learned indicate that well-targeted media campaigns, designed with audience participation, can reach parents through various venues, and improve key knowledge areas. Evaluation challenges faced include high levels of knowledge at baseline, competing media messages, and balancing between program needs and evaluation design.

Receipt and redemption of cigarette coupons, perceptions of cigarette companies and smoking cessation

BACKGROUND

Although it is known that cigarette companies use cigarette coupons to market their products, little is known about the characteristics of those who receive these coupons. The influence of receipt and redemption of these coupons is also unknown.

METHODS

Participants of the Minnesota Adult Tobacco Survey Cohort Study who were smokers in 2008, completed surveys in 2008 and 2009, and had smoked for at least 6 months between those surveys, were included. In 2009, participants reported whether they had received cigarette coupons in the past 12 months, and whether they had used the coupons. They also reported their perceptions of cigarette companies and their smoking status. Multivariate logistic regressions were used to assess associations between receiving and redeeming coupons, perceptions of cigarette companies, and smoking status.

RESULTS

Overall, 49.4% of the sample reported receiving cigarette coupons, and 39.9% redeemed them (80.1% of those who received these coupons). Female, younger and heavier smokers were more likely to report receiving these coupons (p<0.05). Smokers who received these coupons were more likely to agree that cigarette companies care about their health and do the best they can to make cigarettes safe, and less likely to agree that cigarette companies lie (p<0.05). Smokers who used these coupons were less likely to quit smoking (p<0.05).

CONCLUSIONS

Our findings suggest a negative association between cigarette coupons and smoking cessation. Longitudinal studies are needed to establish whether cigarette coupons influence smoking behaviour to inform the necessity for policies to prohibit the use of these coupons to assist smokers to quit smoking.

Tobacco industry denormalisation as a tobacco control intervention: a review

OBJECTIVE

To conduct a review of research examining the effects of tobacco industry denormalisation (TID) on smoking-related and attitude-related outcomes.

METHODS

The authors searched Pubmed and Scopus databases for articles published through December 2010 (see figure 1). We included all peer-reviewed TID studies we could locate that measured smoking-related outcomes and attitudes toward the tobacco industry. Exclusion criteria included: non-English language, focus on tobacco use rather than TID, perceived ad efficacy as sole outcome, complex program interventions without a separately analysable TID component and non peer-reviewed literature. We analysed the literature qualitatively and summarised findings by outcome measured.

RESULTS

After excluding articles not meeting the search criteria, the authors reviewed 60 studies examining TID and 9 smoking-related outcomes, including smoking prevalence, smoking initiation, intention to smoke and intention to quit. The authors also reviewed studies of attitudes towards the tobacco industry and its regulation. The majority of studies suggest that TID is effective in reducing smoking prevalence and initiation and increasing intentions to quit. Evidence is mixed for some other outcomes, but some of the divergent findings may be explained by study designs.

CONCLUSIONS

A robust body of evidence suggests that TID is an effective tobacco control intervention at the population level that has a clear exposure-response effect. TID may also contribute to other tobacco control outcomes not explored in this review (including efforts to 'directly erode industry power'), and thus may enhance public support and political will for structural reforms to end the tobacco epidemic.

Strong tobacco control program requirements and secure funding are not enough: lessons from Florida

Florida's Tobacco Pilot Program (TPP; 1998-2003), with its edgy Truth media campaign, achieved unprecedented youth smoking reductions and became a model for tobacco control programming. In 2006, 3 years after the TPP was defunded, public health groups restored funding for tobacco control programming by convincing Florida voters to amend their constitution. Despite the new program's strong legal structure, Governor Charlie Crist's Department of Health implemented a low-impact program. Although they secured the program's strong structure and funding, Florida's nongovernmental public health organizations did not mobilize to demand a high-impact program. Implementation of Florida's Amendment 4 demonstrates that a strong programmatic structure and secure funding are insufficient to ensure a successful public health program, without external pressure from nongovernmental groups.

Evidence for truth®: the young adult response to a youth-focused anti-smoking media campaign

BACKGROUND

Previous studies have shown that exposure to truth® and similar countermarketing campaigns is associated with an increase in anti-smoking attitudes and beliefs in those aged 12-17 years and a decrease in youth smoking. However, it is unclear how such campaigns influence young adults aged 18-24 years.

PURPOSE

To examine levels of awareness and the effect of the national truth campaign on smoking-related attitudes, beliefs, and intentions in young adults.

METHODS

Data on respondents, aged 18-24 years, from the Legacy Media Tracking Surveys-eight cross-sectional nationally representative telephone surveys administered from 2000 to 2004-were combined and analyzed in 2009. Logistic regression analyses were used to examine the associations between confirmed awareness of the truth campaign and smoking-related attitudes, beliefs, and intentions. A second set of models was used to examine the association of attitudes and beliefs targeted by the campaign with smoking intentions.

RESULTS

A majority of young adults showed confirmed awareness of the truth campaign. Awareness was associated with roughly half of the anti-smoking attitudes and beliefs, and it was associated marginally with the intention to quit among smokers (p=0.06). Several of the attitudes and beliefs targeted by the campaign were associated with the intention to not smoke (among nonsmokers) and to quit (among smokers).

CONCLUSIONS

Messages contained in youth-focused anti-smoking campaigns may promote attitudinal and behavioral change in young adults. Young adults are at risk for both initiation and establishment of smoking, while also being targeted specifically by the tobacco industry, so it is critical to consider this audience when developing and implementing anti-smoking interventions.

Mass media interventions for preventing smoking in young people

BACKGROUND

The mass media have been used as a way of delivering preventive health messages. They have the potential to reach and to modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To evaluate the effectiveness of mass media interventions to prevent smoking in young people in terms of reduced smoking uptake, in addition to secondary outcomes including improved smoking outcomes, attitudes, behaviours, knowledge, self-efficacy and perception.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of MEDLINE and EMBASE in July 2010.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and time series studies that assessed the effectiveness of mass media campaigns (defined as channels of communication such as television, radio, newspapers, bill boards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person to person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risk of bias was abstracted by two independent reviewers. Studies were combined using qualitative narrative synthesis.

MAIN RESULTS

Seven out of a total of 84 studies reporting information about mass media smoking campaigns met all of the inclusion criteria. All seven studies used a controlled trial design. Three studies concluded that mass media reduced the smoking behaviour of young people. All of the effective campaigns had a solid theoretical basis, used formative research in designing the campaign messages, and message broadcast was of reasonable intensity over extensive periods of time.

AUTHORS' CONCLUSIONS

There is some evidence that mass media can prevent the uptake of smoking in young people, however the evidence is not strong and contains a number of methodological flaws.

'Acceptable rebellion': marketing hipster aesthetics to sell Camel cigarettes in the US

OBJECTIVE

The aim of the present work was to understand why and how RJ Reynolds and other tobacco companies have marketed tobacco products to young adult social trendsetting consumers (termed 'hipsters') to recruit trendsetters and average consumers to smoke.

METHODS

Analysis of tobacco industry documents and industry marketing materials.

RESULTS

Since 1995, RJ Reynolds developed its marketing campaigns to better suit the lifestyle, image identity and attitudes of hip trendsetters (so-called 'hipsters'), and Camel's brand identity actively shifted to more closely convey the hipster persona. Camel emphasised in-venue events such as promotional music tours to link the brand and smoking to activities and symbols appealing to hipsters and their emulating masses.

CONCLUSIONS

To reach this targeted and socially valuable trend-setting population, public health advocates must tap into hipster psychology and expose to the targeted community the tobacco company's efforts to infiltrate the hipster community to turn hipsters into tobacco-using role models.

Awareness effects of a youth suicide prevention media campaign in Louisiana

Research on the efficacy of mediated suicide awareness campaigns is limited. The impacts of a state-wide media campaign on call volumes to a national hotline were analyzed to determine if the advertisements have raised awareness of the hotline. We use a quasi-experimental design to compare call volumes from ZIP codes where and when the campaign is active with those where and when the campaign is not active. Multilevel model estimates suggest that the campaign appears to have significantly and substantially increased calls to the hotline. Results from this study add evidence to the growing public health literature that suggests that mediated campaigns can be an effective tool for raising audience awareness.

Young adult smoking behavior: a national survey

BACKGROUND

Young adults have the highest smoking rate of any age group in the U.S., and new strategies to decrease young adult smoking are needed. The objective of the current study was to identify psychographic and demographic factors associated with current smoking and quitting behaviors among young adults.

METHODS

Attitudes, social groups, and self-descriptors, including supporting action against the tobacco industry, advertising receptivity, depression, alcohol use, and other factors associated with smoking were tested for associations with smoking behaviors in a 2005 cross-sectional survey of 1528 young adults (aged 18-25 years) from a web-enabled panel. Analyses were conducted in 2007.

RESULTS

Being older was associated with current smoking, whereas having some higher education and being African American or Hispanic were negatively associated with smoking. Supporting action against the tobacco industry was negatively associated with smoking (AOR=0.34 [95% CI=0.22, 0.52]). Perceived usefulness of smoking, exposure to smokers, increased perceived smoking prevalence, receptivity to tobacco advertising, binge drinking, and exposure to tobacco advertising in bars and clubs were associated with smoking. Supporting action against the tobacco industry was associated with intentions to quit smoking (AOR=4.43 [95% CI=2.18, 8.60]).

CONCLUSIONS

Young adults are vulnerable to tobacco-industry advertising. Media campaigns that denormalize the tobacco industry and appeal to young adults appear to be a powerful intervention to decrease young adult smoking.

Encouraging the installation of rollover protective structures in New York State: the design of a social marketing intervention

Aims: Increasing the percentage of rollover protective structure (ROPS) equipped tractors has been the focus of many agricultural safety campaigns. Traditionally efforts have attempted to persuade farmers through education or community awareness interventions. These efforts have lead to marginal change. In response, a social marketing approach was tested as a means for increasing interest in ROPS retrofitting in New York. Methods: An initial phone survey was conducted with a random sample of New York farmers to identify a potential target population. Following target selection, in-depth interviews were conducted to isolate barriers and motivators to retrofitting. This information was used to develop message prototypes which were tested in small focus group discussions. Selected and revised messages, as well as various other incentives developed in response to feedback from interviews, were then tested in a prospective, quasi-randomized controlled trial. Results: Small crop and livestock farms were selected as the intervention target since they represent 86% of New York farms with none or only one ROPS protected tractor. Barriers to retrofitting which were identified in interviews were: 1) constant exposures normalize risk, 2) risk is modeled by significant others and 3) safety in general and retrofitting in particular requires too much time and money. The piloting of ROPS incentives led to a marked increase in ROPS sales in New York. Conclusions: Social Marketing provides a promising framework for the design of agricultural injury prevention programs. The potential implications for other health initiatives seeking to promote behaviour change are also discussed.

Designing a tobacco counter-marketing campaign for African American youth

The objectives of this qualitative study were to: a) identify common marketing themes and tactics used by the tobacco industry to entice African Americans (AA's) and youth to initiate and maintain smoking behavior, especially smoking mentholated brands of cigarettes, and b) determine AA youths' knowledge, attitudes, intentions, and beliefs about smoking and the tobacco industry. Together, these activities could aid in the development of effective tobacco counter-marketing campaigns for AA youth. Using publicly available tobacco industry documents, computerized searches using standardized keywords were run and results were cataloged and analyzed thematically. Subsequently, 5 focus groups were conducted with n = 28 AA middle school-aged youth. Results suggest that the tobacco industry consistently recruited new AA smokers through a variety of means, including social and behavioral marketing studies and targeted media and promotional campaigns in predominantly AA, urban, and low income areas. AA youth interviewed in this study were largely unaware of these tactics, and reacted negatively against the industry upon learning of them. Youth tended to externalize control over tobacco, especially within the AA community. In designing a counter-marketing campaign for this population, partnering knowledge of tobacco industry practices with youth needs and community resources will likely increase their effectiveness.

The effects of television advertisements for junk food versus nutritious food on children's food attitudes and preferences

Television (TV) food advertising has attracted criticism for its potential role in promoting unhealthy dietary practices among children. Content analyses indicate junk food advertising is prevalent on Australian children's TV; healthy eating is rarely promoted. This paper presents (a) a cross-sectional survey examining associations between children's regular TV viewing habits and their food-related attitudes and behaviour; and (b) an experiment assessing the impact of varying combinations of TV advertisements (ads) for unhealthy and healthy foods on children's dietary knowledge, attitudes and intentions. The experimental conditions simulated possible models for regulating food ads on children's TV. Participants were 919 grade five and six students from schools in Melbourne, Australia. The survey showed that heavier TV use and more frequent commercial TV viewing were independently associated with more positive attitudes toward junk food; heavier TV use was also independently associated with higher reported junk food consumption. The experiment found that ads for nutritious foods promote selected positive attitudes and beliefs concerning these foods. Findings are discussed in light of methodological issues in media effects research and their implications for policy and practice. It is concluded that changing the food advertising environment on children's TV to one where nutritious foods are promoted and junk foods are relatively unrepresented would help to normalize and reinforce healthy eating.

The effect of support for action against the tobacco industry on smoking among young adults

OBJECTIVES

We investigated associations between tobacco industry denormalization attitudes and the smoking behavior of young adults (aged 18 to 29 years).

METHODS

We analyzed data from 9455 young adults in the 2002 California Tobacco Survey.

RESULTS

The data showed that 27.4% of young adults were "ever smokers" (smoked > or = 100 cigarettes in their lifetime), of whom 66.9% were current smokers (18.3% of young adults). Denormalization attitudes formed 2 major factors: support for anti-tobacco industry action and mistrust of tobacco companies. In multivariate logistic regression, support for action against the tobacco industry was negatively associated with current smoking (odds ratio [OR] = 0.16; 95% confidence interval [CI]=0.13, 0.19) and susceptibility to smoking, after we controlled for demographics, exposure to smokers, and advertising receptivity. Mistrust of tobacco companies was associated with smoking behavior, with anti-industry support acting as a mediating variable. Among current smokers, support for anti-tobacco industry action was strongly associated with intentions to quit (OR=4.64; 95% CI=3.15, 6.84) after we controlled for demographics, exposure to smokers, and advertising receptivity.

CONCLUSIONS

Support for anti-tobacco industry action protects against smoking and is associated with intentions to quit among young adults. Encouraging involvement in tobacco control and against the tobacco industry may decrease smoking among young adults.

Philip Morris's Project Sunrise: weakening tobacco control by working with it

OBJECTIVE

To analyse the implications of Philip Morris USA's (PM's) overtures toward tobacco control and other public health organisations, 1995-2006.

DATA SOURCES

Internal PM documents made available through multi-state US attorneys general lawsuits and other cases, and newspaper sources.

METHODS

Documents were retrieved from several industry documents websites and analysed using a case study approach.

RESULTS

PM's Project Sunrise, initiated in 1995 and proposed to continue through 2006, was a long-term plan to address tobacco industry delegitimisation and ensure the social acceptability of smoking and of the company itself. Project Sunrise laid out an explicit divide-and-conquer strategy against the tobacco control movement, proposing the establishment of relationships with PM-identified "moderate" tobacco control individuals and organisations and the marginalisation of others. PM planned to use "carefully orchestrated efforts" to exploit existing differences of opinion within tobacco control, weakening its opponents by working with them. PM also planned to thwart tobacco industry delegitimisation by repositioning itself as "responsible". We present evidence that these plans were implemented.

CONCLUSION

Sunrise exposes differences within the tobacco control movement that should be further discussed. The goal should not be consensus, but a better understanding of tensions within the movement. As the successes of the last 25 years embolden advocates to think beyond passage of the next clean indoor air policy or funding of the next cessation programme, movement philosophical differences may become more important. If tobacco control advocates are not ready to address them, Project Sunrise suggests that Philip Morris is ready to exploit them.

Antismoking initiatives: effects of analysis versus production media literacy interventions on smoking-related attitude, norm, and behavioral intention

This study developed inoculation-driven antismoking interventions aimed at changing attitudes, norms and intentions about smoking to influence smoking behavior in adolescents. This study explored the efficacy of 2 intervention approaches designed to help adolescents to refrain from smoking initiation. Participants were junior high students (6th, 7th, and 8th grade) from schools in the Northeast. Two kinds of experimental workshops and a control group were designed as stimulus material in a repeated measure nonequivalent group experimental design. The 2 intervention workshops developed included: analysis + analysis (where participants discussed and analyzed cigarette and antismoking ads) and analysis + production (where participants discussed, analyzed, and then created their own antismoking ads). The analysis + production workshop was generally more successful than the analysis + analysis workshop and control group in changing participants' behavioral intention to smoke and attitude toward smoking but not subjective norms over time. Implications and directions for future research are discussed.

Social marketing: an overview of approach and effects

This paper reviews the applicability of commercial and social marketing to teen driving safety. It draws on a wide range of information, including evaluation studies of specific programs as well as standards of practice within these two professions. Social marketing has been widely applied for more than three decades in the fields of public health, environmental protection, and political marketing with significant success. The paper attempts to distinguish between the practice of commercial marketing, whose goal is profit, and the practice of social marketing, whose goal is societal benefit. Issues of sustainability, segmentation, differences in behavioral characteristics, and cultural competence are discussed with specific examples drawn from the transportation safety literature. The paper suggests that social marketing represents a viable companion to control and education approaches to behavior change to promote teen driving safety.

Empowering youth for tobacco control

PURPOSE

To investigate common youth group activities and how they relate to young people's attitudes of empowerment around tobacco control.

DESIGN

A mailed survey was administered to 940 Minnesota youth involved in locally organized tobacco prevention groups. By multivariate linear regression, participation in eight tobacco-related activities and selected personal characteristics were examined in relation to youths'perceived influence on youth smoking.

RESULTS

Two activities--developing materials with antismoking messages and taking action to change school smoking policies--were associated with significantly higher perceived influence scores for the youth involved (p < .05). Youth in groups who had worked to raise awareness of how the tobacco industry targets teens also had significantly higher influence scores (p < .001). Associated personal factors included high involvement in extracurricular activities (p < .001), having never experimented with smoking (p < .01), leadership experience (p < .001), and being white (p < .01).

DISCUSSION

Some youth group activities and strategies may be particularly effective at instilling attitudes of empowerment for tobacco control among youth.

A systematic review of school-based smoking prevention trials with long-term follow-up

BACKGROUND

Several systematic reviews of school-based smoking prevention trials have shown short-term decreases in smoking prevalence but have not examined long-term follow-up evaluation. The purpose of this study was to conduct a systematic review of rigorously evaluated interventions for school-based smoking prevention with long-term follow-up data.

METHODS

We searched online bibliographic databases and reference lists from review articles and selected studies. We included all school-based, randomized, controlled trials of smoking prevention with follow-up evaluation to age 18 or 12th grade and at least 1 year after intervention ended, and that had smoking prevalence as a primary outcome. The primary outcome was current smoking prevalence (defined as at least 1 cigarette in the past month).

RESULTS

The abstracts or full-text articles of 177 relevant studies were examined, of which 8 met the selection criteria. The 8 articles included studies differing in intervention intensity, presence of booster sessions, follow-up periods, and attrition rates. Only one study showed decreased smoking prevalence in the intervention group.

CONCLUSIONS

Few studies have evaluated the long-term impact of school-based smoking prevention programs rigorously. Among the 8 programs that have follow-up data to age 18 or 12th grade, we found little to no evidence of long-term effectiveness.

Selling off or selling out? Medical schools and ethical leadership in tobacco stock divestment

Medical and health science schools occupy a prestigious place in U.S. society. When they express a position on tobacco use--either by action or silence--that expression is consequential. Recognizing this, the tobacco industry has worked to sustain and exploit relationships with academic health sciences institutions. Corporate contributions to medical research are more visible, but institutional investments in tobacco stocks are also crucial to these relationships. The American Medical Association divested (sold) its tobacco holdings in 1986, urging others to do the same. Yet, as late as 2004, at least five of the leading dozen medical schools have not divested, and those that have seem reluctant to publicize their actions. The authors use internal tobacco industry documents and secondary source material to describe and analyze Philip Morris's response to two cases of threatened academic divestment. In each case, the world's largest tobacco company succeeded in minimizing the impact of divestment activities--in the first, by muting the consequences of a divestment, and in the second, by convincing university decisionmakers to recommend against tobacco stock divestment. In addition to arguing that tobacco divestment would lead to other pressures or be ineffective, the company exploited university concerns about losing corporate research funding as a key element of its antidivestment strategy. If academic medical centers regard protection of the public's health as a primary mission, divestment from tobacco holdings is essential; profiting from tobacco either through investments or research funding undermines this mission. Silent divestment squanders opportunities for ethical leadership and public dialogue.

Outcomes of a statewide anti-tobacco industry youth organizing movement

PURPOSE

To outline the design and present select findings from an evaluation of a statewide anti-tobacco industry youth organizing movement.

DESIGN

A telephone survey was administered to teenagers to assess associations between exposure to anti-industry youth organizing activities and tobacco-related attitudes and behaviors. A group-level comparison between areas high and low in youth organizing activities was planned. Methodological obstacles necessitated a subject-level analytic approach, with comparisons being made between youth at higher and lower levels of exposure.

SETTING

Six rural areas (comprising 13 counties) and two urban regions of Minnesota were selected for survey.

SUBJECTS

The study comprised 852 youth, aged 15 to 17 years old, randomly selected from county-specific sampling frames constructed from a marketing research database.

MEASURES

Exposure index scores were developed for two types of activities designed to involve youth in the anti-industry program: branding (creating awareness of the movement in general) and messaging (informing about the movement's main messages). Attitudinal outcomes measured attitudes about the tobacco industry and the effectiveness of youth action. Behavioral outcomes included taking action to get involved in the organization, spreading an anti-industry message, and smoking susceptibility.

RESULTS

Branding index scores were significantly correlated with taking action to get involved (p < or = .001) and spreading an anti-industry message (p < or = .001). Messaging index scores were significantly correlated with all five attitudinal constructs (all associations, p < or = .001), taking action to get involved (p < or = .001), and spreading an anti-industry message (p < or = . 01). The hypothesized association between messaging scores and susceptibility was not significant.

CONCLUSION

A youth organizing effort, in combination with an intensive countermarketing media campaign, can be an effective strategy for involving youth in tobacco prevention and generating negative attitudes about the industry.

Lessons learned from public health mass media campaigns: marketing health in a crowded media world

Every year, new public health mass media campaigns are launched attempting to change health behavior and improve health outcomes. These campaigns enter a crowded media environment filled with messages from competing sources. Public health practitioners have to capture not only the attention of the public amid such competition, but also motivate them to change health behaviors that are often entrenched or to initiate habits that may be new or difficult. In what ways are public health mass media campaigns now attempting to succeed in a world crowded with media messages from a myriad of sources? What are the conditions that are necessary for a media campaign to successfully alter health behaviors and alter outcomes in the long term? To what extent can the successes and failures of previous campaigns be useful in teaching important lessons to those planning campaigns in the future? In this chapter we attempt to answer these questions, drawing from recent literature on public health mass media campaigns.

Going below the line: creating transportable brands for Australia's dark market

OBJECTIVE

To investigate non-point-of-sale cigarette marketing in Australia, one of the "darkest" markets in the world.

DESIGN

Analysis of 172 tobacco industry documents.

RESULTS

The tobacco industry has continued to market their products despite severe restrictions on legal marketing activity. They made careful plans to circumvent regulation well in advance. In preparation for bans, they chose and strengthened existing brands to enable their continued success in a dark market and prepared the consumer for bans by increasing their spending on below the line activities. Bans reduced the industry's effectiveness and efficiency. After bans new brand launches stopped: instead key existing brands were strengthened via alterations to the product, line extensions, and stretching loopholes in the legislation as far as possible. In line with the general trend towards integrated marketing, a range of activities have been used in combination, including guerrilla marketing, advertising in imported international magazines, altering the pack, sponsorships, brand stretching, event promotions, lifestyle premiums, and the development of corporate websites.

CONCLUSIONS

The tobacco industry acknowledges that marketing restrictions have an impact, validating their continued use in tobacco control. The industry is extremely creative in circumventing these marketing restrictions, requiring tobacco marketing regulations to be informed by marketing expertise, regularly updated, and to adopt the broadest possible scope. Tobacco control advocates, particularly those communicating with young people, could learn from the creativity of the tobacco industry.

From legitimate consumers to public relations pawns: the tobacco industry and young Australians

OBJECTIVE

To document the Australian tobacco industry's activities regarding youth smoking to support tobacco control.

METHOD

492 industry documents from primary and secondary websites were abstracted and analysed.

RESULTS

Australian legislation and rhetoric on youth and tobacco has changed dramatically over the last 50 years, from an unproblematic association of teenagers and smoking in the 1960s, through the industry's aggressive attacks and denials in the 1980s, to the 1990s, when industry became newly compliant with "societal expectations" and youth became a dominant bargaining issue in the industry's public relations strategy. The industry's current policy is to simultaneously blame others for underage smoking, frame the industry as socially responsible via voluntary marketing codes, youth access programmes, and school education, and market actively to young adults.

CONCLUSIONS

The arbitrary distinction between 17 and 18 year olds is, particularly in Australia's dark market, a liability for tobacco control and an opportunity for the industry, which is attempting to claim the high moral ground traditionally occupied by tobacco control on the youth issue. The current review of Australia's Tobacco Advertising Prohibition Act of 1992 should prohibit all forms of industry communication targeting young people, including retail access and schools programmes and below-the-line marketing. Tobacco control advocacy should highlight the industry's attempts to use the youth issue in its own favour while laying the blame elsewhere.

A social marketing approach to changing mental health practices directed at youth and adolescents

The mental health problems of children are of increasing social concern. Many best practices have been developed but often not implemented. Social marketing has been suggested as an innovative, useful approach to this challenge-along with others in the health care field. However, much confusion exists over what the approach entails, where it has been applied and how it can be adapted to significant social challenges such as changing mental health practices directed at youth and adolescents. This article defines key terms, offers historical perspective and provides a specific approach and set of models to implement an effective social marketing strategy in a range of contexts.

A Randomized Trial Comparing the Effects of Self-Help Materials and Proactive Telephone Counseling on Teen Smoking Cessation

We conducted a 2-arm randomized trial to test the efficacy of self-help materials with or without proactive telephone counseling to increase cessation among teen smokers. Teen smokers (N = 402) recruited from 11 shopping malls and 1 amusement park in the southeastern United States were randomized to 1 of 2 groups: written self-help material plus video; or written self-help material, video, and telephone counseling. Cessation rates based on 7-day point-prevalent abstinence for the self-help and counseling arms were 11% and 16%, respectively (p = .25), at 4 months postbaseline and 19% and 21%, respectively (p = .80), at 8 months postbaseline. Sustained abstinence, reflecting 7-day abstinence at both time points, in the self-help and counseling arms was 7% and 9% (p = .59). Results suggest that minimal self-help cessation approaches that target youth have comparable success to that shown among adult smokers. However, refinements in telephone-counseling approaches may be needed to achieve the success observed in adult populations.

Media campaign influences parents' opinions about their children and tobacco

The study assessed the effectiveness of a media campaign in convincing parents that children are targeted by the tobacco industry and that children should be banned from tobacco use. An 800-parent sample survey was conducted prior to a statewide anti-tobacco campaign, and another survey sample of 790 parents was conducted afterward.

THE RESULTS

Though parents who smoked in high school and those who did not agreed that children are targeted and should be banned from tobacco use, parents who did not smoke in high school believed it more strongly. Parents who had a history of smoking changed more on the issue of banning, perhaps because they had more room to change. The study concluded that media campaigns can change parents' attitudes.

The effectiveness of state-level tobacco control interventions: a review of program implementation and behavioral outcomes

In 2001, nearly one billion dollars will be spent on statewide tobacco control programs, including those in California, Massachusetts, Arizona, and Oregon, funded by cigarette tax revenues, and the program in Florida, funded by the state's settlement with the tobacco industry. With such large expenditures, it is imperative to find out whether these programs are working. This paper reviews the effectiveness of the statewide tobacco control programs in California, Massachusetts, Arizona, Oregon, and Florida. It focuses on two aspects of process evaluation--the funding and implementation of the programs and the tobacco industry's response, and four elements of outcome evaluation--the programs' effects on cigarette consumption, adult and youth smoking prevalence, and protection of the public from secondhand smoke. The paper formulates general lessons learned from these existing programs and generates recommendations to improve and inform the development and implementation of these and future programs.

Evidence of the dose effects of an antitobacco counteradvertising campaign

OBJECTIVE

The objectives were to assess the cumulative effects of exposure to multiple antitobacco advertisements shown over a 22-month period on smoking uptake, and determine if there is evidence of a dose effect and how this effect operates through response to the campaign's major message theme and antitobacco attitudes.

METHODS

A follow-up telephone survey of persons ages 12-20 years was conducted after 22 months of the Florida "truth" antitobacco media campaign. Logistic regression analyses were used to estimate adjusted odds ratios for the likelihood that time-one nonsmokers would remain nonsmokers at time two by levels of confirmed advertisement awareness, self-reported influence of the campaign's message theme, and anti-tobacco industry manipulation attitudes. Separate cohorts are analyzed and controls include gender and time-one susceptibility.

RESULTS

The likelihood of nonsmokers remaining nonsmokers increases as the number of ads confirmed, the self-reported influence of the campaign's major message theme, and the level of antitobacco attitudes increases. The pattern to these relationships holds within cohorts of young and older youth and for a cohort that has aged into the early young adult years. Considering all variables simultaneously suggests that ad confirmation operates through its effects on the influence of the message theme and antitobacco industry manipulation attitudes.

CONCLUSIONS

There is evidence of a dose effect; however, considering only ad confirmation underestimates this. Antitobacco campaigns that target youth can have effects at least through the early young adult ages. The uniqueness of the Florida campaign may limit the generalization of reported results.

The approach of comprehensive tobacco control in cancer prevention: elements and evidence

The aim of this overview is to present measures of comprehensive tobacco control (CTC) and recent evidence according to their efficacy. CTC includes eight measures: raising taxes, consumer regulations, information about tobacco products, advertisement and sponsoring, economic alternatives to the production of tobacco, programmes for the support of the motivation to stop smoking and maintain tobacco abstinence, including the change of attitudes and norms in the population to support non-smoking, financial and human resources of CTC, and quality assurance of CTC. These measures include single elements such as activities against smuggling, to be considered in conjunction with tax increases. Evidence, particularly from single US states, reveals the efficacy of CTC. As discussed, the literature shows that programmes have not yet included all single elements. This is due to individual, programme-related and external limiting factors. It is concluded that in spite of these, CTC programmes are effective in adults as well as minors. A dose-response relationship between CTC and reduction of smoker rates, the amount of tobacco consumption and tobacco-attributable mortality is probable.

Tobacco industry surveillance of public health groups: the case of STAT (Stop Teenage Addiction to Tobacco) and INFACT (Infant Formula Action Coalition)

OBJECTIVES

The goal of this study was to describe how the tobacco industry collects information about public health groups.

METHODS

Publicly available internal tobacco industry documents were reviewed and analyzed using a chronological case study approach.

RESULTS

The industry engaged in aggressive intelligence gathering, used intermediaries to obtain materials under false pretenses, sent public relations spies to the organizations' meetings, and covertly taped strategy sessions. Other industry strategies included publicly minimizing the effects of boycotts, painting health advocates as "extreme," identifying and exploiting disagreements, and planning to "redirect the funding" of tobacco control organizations to other purposes.

CONCLUSIONS

Public health advocates often make light of tobacco industry observers, but industry surveillance may be real, intense, and covert and may obstruct public health initiatives.

Susceptibility of youth to tobacco: a social ecological framework for prevention

For most smokers, tobacco dependence begins in childhood or adolescence. This review summarizes the state of social science with respect to the prevention of tobacco use. Social ecology is introduced as a theoretical framework useful for organizing prevention approaches. In recent years, the field has shifted from approaches directed at individuals, towards appreciation of additional, more comprehensive social and environmental influences on initiation. These range from intra-individual factors (including physiological responses to nicotine and the psychology of use) to individual, interpersonal, organizational, community, and population factors affecting access and demand. This review highlights prevention approaches that address social and societal influences, from school programs that attempt to change susceptibility of individual youth to tobacco, to community projects, media campaigns, restrictive policies, and tobacco pricing. The most promising approaches are those designed with input based on extensive formative research including studies with youth, directed at multiple levels of the social ecology, and sustained over time with significant resources and ongoing, multi-sector inputs.