A Closer Look

This article is part of a series of stories related to cancer communications. You can read more articles in the series here.

Personal Stories, Evidence Drive Successful Antismoking Ad Campaign

Button from Tips from Former Smokers campaign

The campaign was "among the year's most memorable advertising, and perhaps among the best-ever work in its category," according to AdWeek.
AdWeek wasn't referring to the television commercial featuring a boy in a Darth Vader costume who starts the family's new car with "The Force." Nor were they talking about the latest hi-tech gadget being rolled out with a Super Bowl ad blitz.
The object of their professional acclaim was Tips from Former Smokers, the antismoking campaign developed by the Centers for Disease Control and Prevention (CDC). Tips was the first paid, national mass media campaign funded by the federal government urging adult smokers to quit. And, according to the data available thus far, the campaign was a rousing success.
When the ads ran last year, from March 19 to June 10, calls to NCI's smoking quitline, 1-800-QUIT-NOW, more than doubled, and visits to www.smokefree.gov were five times the levels measured during the same 12-week period in 2011. Both resources were featured in the campaign, which placed ads on television, radio, the Internet, and billboards, as well as in print publications and movie theaters.
"The [campaign's] primary emphasis was on giving a voice to the 8 million people in the U.S. who are suffering from diseases caused by smoking, giving them an opportunity to tell their story," said Dr. Timothy McAfee, director of the CDC's Office on Smoking and Health (OSH), which spearheaded Tips.
The featured people, the provocative style, and the prominent placement of where to get help to quit did not happen by accident. They were supported by a foundation of research on how best to reach and make an impression on smokers.
"The view from within the tobacco control community is that this was a very well done and very evidence-based campaign," said Dr. Nancy Rigotti, who directs the Tobacco Research and Treatment Unit at Massachusetts General Hospital.
And, although researchers are still analyzing the Tips campaign's impact, based on the early indications of success, another round of ads is already being developed.
Real People, Real Consequences
Button from Tips from Former Smokers campaign

Successful public health campaigns have employed various approaches and strategies, and the optimal approaches for an antismoking campaign have become pretty clear, explained Diane Beistle, who heads the OSH Health Communications Branch. Reviewing the published research "provides a pretty solid base for the efficacy of hard-hitting, emotionally resonant campaigns," she said.
For example, controlled studies of smokers have consistently shown that antitobacco ads that emphasize the harms of smoking in a way intended to generate an emotional response are most memorable and most likely to make smokers contemplate changing their behavior.
Those research findings are consistent with campaign effects in the real world. In New York, an antismoking mass media campaign that ran throughout much of the 2000s featured several gripping television ads—such as one of a woman lying in bed

, struggling to breathe because of a smoking-related illness, as her young son gives her a glass of water. The campaign was credited with contributing to sharp declines in smoking in the state.

Everything You Always Wanted to Know about Media Campaigns Against Tobacco Perhaps the most comprehensive resource on media campaigns against tobacco is The Role of the Media in Promoting and Reducing Tobacco Use.
Chapter 11 and Chapter 12 of this NCI monograph provide thorough overviews of campaigns conducted in the United States and abroad. They also include detailed summaries of the studies conducted to assess their impact.

Both Tips and the New York campaigns used the results of the highly successful Australian campaign called Every Cigarette Is Doing You Damage, which began in 1997, to inform their ad development. Although the U.S. and Australian campaigns featured some disturbing images (one of the Australian television ads

, for example, showed smoking-induced plaque being squeezed out of the aorta of a deceased 32-year-old-smoker), just invoking fear isn't necessarily enough to ensure success, said Dr. Barbara Loken, a psychologist and professor of marketing at the University of Minnesota, whose research focuses on public health campaigns.
"Having a story line, a real narrative, is what really engages people," Dr. Loken said. To that end, Tips featured the stories of real people, such as Brandon

, whose legs were amputated from the knees down because of a smoking-related condition called Buerger disease.
Although other elements, such as mortality statistics and advice from health care professionals, have a place in antitobacco campaigns, she continued, "having a real person whose life has been forever changed by smoking can be extremely effective."
Fringe Benefits
Studies have shown that the Australian and similar campaigns have also had important ancillary benefits. Although the campaigns were "almost entirely focused on making sure they resonated with adults, they also resonated with youth," noted Dr. McAfee.
Button from Tips from Former Smokers campaign

When Australian researchers surveyed adolescents about their response to the Damage campaign, for instance, about one-quarter of teens who smoked regularly said the campaign convinced them to reduce the number of cigarettes they smoked.
The ancillary effects can be quite broad, stressed Dr. Melanie Wakefield of the Cancer Council Victoria, who has studied the impact of Damage and other antitobacco campaigns.
"To the extent that [the campaigns] reduce adult smoking, smoking becomes less normative in society as a whole, and that's good for youth," she said. "Second, these types of campaigns reduce smoking among adults who are parents, and we know that quitting in parents reduces the likelihood of their children taking up smoking."
The ability of these campaigns to "denormalize" smoking at the population level is very important, explained Dr. Kelly Blake, a program director in NCI's Health Communication and Informatics Research Branch. "Those effects are difficult, but not impossible, to isolate with well-designed studies," Dr. Blake said.
Taking Action and Measuring Success
Studies have shown that offering a way to act on the emotions aroused by an ad is critical to achieving the desired results, Dr. Rigotti explained.

Having a story line, a real narrative, is what really engages people.

—Dr. Barbara Loken

"Pairing a personal testimonial with actionable information … can really drive a response," she said.
In one study, for example, antismoking ads were run on TV and radio stations with predominantly African American audiences and directed viewers and listeners to their regional smoking quitline. As a result, the average number of weekly calls from African Americans to the quitline rose from fewer than 2 before the campaign to 86 during the campaign.
The challenge for all public health communication campaigns "is to show an effect on behavioral outcomes, in this case, smoking cessation," said Dr. Blake. "That requires an analysis over a longer period of time, but the interim and proxy measures [of the Tips campaign] are very promising markers of success."
Such an analysis is under way. CDC researchers are conducting a cohort study that includes thousands of smokers and nonsmokers, using pre- and post-campaign interviews to measure their awareness of the campaign and, for smokers, whether they have quit smoking or attempted to quit. They expect to report the preliminary results early next year.
A second round of the Tips campaign is also expected to roll out in 2013. According to Dr. McAfee, round two will be similar to the original campaign, featuring a new group of individuals who developed serious smoking-related illnesses.
With this next round, he added, the CDC hopes to build on the campaign's momentum and extend its impact, including more outreach to physicians.
"We think about 80 percent of smokers saw these ads during the 3 month campaign," Dr. McAfee said. "They can really provide a golden opportunity for physicians … to ask their patients who smoke about the ads and start a meaningful dialogue about quitting."
In the fall of 2013, meanwhile, the Food and Drug Administration (FDA) will roll out a national antitobacco campaign targeted at teens and young adults. According to Jennifer Haliski of the FDA's Center for Tobacco Products, the campaign, slated to run for 2 years, is a direct result of the expanded authority granted to the agency under the 2009 Family Smoking Prevention and Tobacco Control Act.
—Carmen Phillips
Further reading: "Federal Campaign Seeks to Shrink Smoking Rates Further"

A Brief History of Antismoking Campaigns
Although Tips is the first federally financed national tobacco education ad campaign, some of the earliest mass media campaigns included public service announcements that ran in the late 1960s, when, under the Fairness Doctrine, a court ruling required stations to run the announcements for free to counter the frequent cigarette ads running on television and radio. Some announcements featured television and movie stars, such as the 1985 ad

from the American Cancer Society that featured actor Yul Brynner and aired nationally shortly after Brynner died from lung cancer.
In the United States, successful state-wide campaigns have been conducted in a number of states, including California, Florida, Minnesota, and New York. California's long-running campaign, which began in 1989, highlighted the dangers of secondhand smoke and how to quit. It also featured messages against the tobacco industry. The ad campaign was one part of a larger state-wide tobacco control program that included a substantial increase in cigarette taxes. The California program has been credited with cutting smoking in California to record low rates; in 2010, only 11.9 percent of California adults smoked cigarettes, making California one of only two states to reach the federal Healthy People 2020 target of reducing adult smoking prevalence to 12 percent.
In 2000, the American Legacy Foundation launched the Truth campaign, a paid, national antitobacco campaign targeting youth. Ads from the campaign used multiple messages and approaches, and many of the ads employed an anti-establishment, anti-industry tone. Over the time it ran, the Truth campaign was found to substantially reduce smoking among high school students.
Around the same time that the Truth campaign was launched, several large tobacco companies created their own ad campaigns encouraging youth not to smoke. Phillip Morris, for example, developed two national ad campaigns, one geared toward teens called Think. Don't Smoke., and one for parents called Talk. They'll Listen. Independent studies, however, found that the campaigns were at best ineffective and possibly counterproductive.