Legislators and public health officials in the USA are currently debating the expenditure of millions of dollars flowing into their state coffers from the national tobacco settlement. In these debates, it should be recognised that anti-smoking advertising has the potential to be a viable and cost effective deterrent to youth smoking. When the Fairness Doctrine was applied to tobacco related broadcast speech from 1967 to 1970, broadcasters were required to donate an estimated $298 million per year (in 1996 dollars) in free airtime for anti-smoking advertising messages. Research indicates that per capita cigarette consumption, and both adult and adolescent smoking prevalences, fell significantly during this period.1-5
More recently, controlled experiments comparing “test” (intervention) and “control” (non-intervention) communities found that anti-smoking advertising can significantly reduce youth smoking prevalence, particularly when combined with synergistic school and community based activities.6-8 Additional supportive evidence comes from controlled laboratory experiments in which adolescents have been exposed either to anti-smoking or control (smoking unrelated) advertisements, and then asked to complete surveys that assessed their smoking related knowledge, perceptions, and behavioural intentions. Middle school students who viewed anti-smoking (versus control) advertising reported significantly less favourable perceptions of smokers.9 Likewise, showing an anti-smoking advertisement before a feature film significantly diluted the impact of the film's pro-smoking imagery on high school students.10
These prior studies indicate that anti-smoking advertising can work well under fairly controlled circumstances. However, like other advertising, it carries no guarantees. Indeed, several tobacco use prevention media campaigns have been documented failures because of inadequate length, funding or other factors.11-14Officials planning anti-smoking advertising are faced with an array of challenging planning and implementation tasks. The goal of this study is to provide guidance in planning effective anti-smoking advertising campaigns targeting youth, based on an analysis of past campaigns initiated by five US states (Arizona, California, Florida, Massachusetts, and Minnesota), a different country (Canada), and researchers from the University of Vermont who initiated a multicommunity trial.
Overview of study
The current study is an offshoot of work that we conducted in 1997-98 on adolescents' impressions of anti-smoking advertisements.15 At that time, we obtained copies of all English language television advertisements that had been used in major North American anti-smoking campaigns from 1985 to 1997. All campaigns had identified adolescents as either a primary or sole target audience. In total, we obtained 167 advertisements from six of the campaigns listed above. The Florida initiative had not yet started. We arranged for each advertisement to be viewed by approximately 50 adolescents, half seventh graders (age 12–13 years), half 10th graders (age 15–16 years). The adolescents then completed surveys that were designed to assess each advertisement's message content, the level of agreement (clarity) or disagreement (confusion) over the message content, and the consistency of messages within a campaign (that is, the proportions of advertisements containing the same message). In addition, adults content analysed each advertisement to determine whether the spokesperson appeared to be youthful (under 25 years old) and whether smoking behaviour was depicted. Prior research had indicated that these variables might potentially influence the effectiveness of anti-smoking advertisements targeting youths.16-18
We found that the campaigns differed rather substantially on the advertising message variables (content, clarity, and consistency) and on the executional variables (youthful spokespeople and depictions of smoking). We believed that, based on published reports or data, we could determine which campaigns had been relatively more effective than others at reducing adolescent smoking prevalence. Campaign costs could also be assessed. Hence, we decided to embark on a study to examine whether higher rankings on any of the advertising variables seemed to be associated with greater cost effectiveness. We were able to identify several factors that appeared to improve campaign cost effectiveness as measured by significant reductions in adolescent smoking prevalence. We present our study below, beginning with an explanation of the advertising variables and tentative research hypotheses, followed by our method and findings, and ending with a discussion of limitations and implications.
Advertising variables studied because possible associations with cost effectiveness
In our initial 1997-98 study,15 we reviewed the anti-smoking advertisements that had been provided by campaign sponsors and developed a checklist of messages used. As our adolescent subjects viewed each advertisement, they placed a checkmark next to each message they felt it contained. If 80% or more of the adolescents agreed that an advertisement contained a message, it was put into that message category. Categories with 12 or more advertisements were formally labelled. We identified seven such mutually exclusive categories. These categories are listed below.
Long term effects—advertisements that discuss the long term health effects of smoking, such as cancer and lung disease.
Short term effects—advertisements that highlight the short term cosmetic effects of smoking, such as smelly breath, and related outcomes such as romantic rejection.
Marketing practices—advertisements that describe relatively innocuous tobacco marketing practices, such as the use of glamorous models and the distribution of free promotional items.
Deceptive portrayal of lethal product—advertisements that highlight the deceptive tactics used to sell what is essentially a lethal and addictive product, such as illegally targeting minors and falsely claiming that cigarettes are nonaddictive.
Second hand smoke—advertisements that stress the negative impact of second hand smoke on family members and other people, particularly infants and children.
Smoker as negative role model—advertisements that depict smokers as people who have unwisely chosen a lifestyle that is both unappealing and unhealthy.
Refusal skills—advertisements that feature attractive, personable individuals and show these individuals refusing to smoke.
We relied on prior research to assess the potential efficacy of each message in terms of dissuading adolescents from smoking.15In our own research, hundreds of adolescents were randomly assigned to view advertisements of a particular type and the effects of this exposure (versus exposure to unrelated-to-smoking or control messages) on intentions to smoke were statistically assessed.15Another study examined the transcripts of innumerable focus groups that were convened to evaluate anti-smoking advertisements and looked for consensus as to which advertisements seemed to be the most convincing.19
Both studies concluded that second hand smoke messages work well with adolescents.1519 In addition, the focus group study found that youths responded well to advertisements disclosing the deception used to sell what is essentially a lethal and addictive product.19 Finally, our own experimental study indicated that adolescents were persuaded by social norm appeals, meaning advertisements that portrayed a smoker's lifestyle negatively (as unappealing and unhealthy) or advertisements that showed attractive people refusing to smoke. Other messages were found to be relatively ineffective with adolescents, including those stressing long term effects only,1519 short term effects only,1519 or relatively innocuous tobacco marketing practices.15 Thus, for the current study, we tentatively predicted that the more cost effective prevention campaigns would make greater use of the following messages: deceptive portrayal of lethal product, second hand smoke, smoker as negative role model, and/or refusal skills.
Advertising for most products and services is designed to communicate a single persuasive message for an extended period of time (for example, Crest fights cavities, Listerine kills germs).20-22 The goal is to remind consumers continually of the brand name and its unique selling proposition (positioning) such that, when making consumption or purchase decisions, consumers will immediately think of the brand and remember why to choose it. Also, consumers frequently do not attend to or process advertisements because they are busy or distracted.22 Hence, advertisers rely on repetition, the “oft referred to soul of persuasion” to increase the likelihood of changing behaviour.23 To avoid boring or irritating consumers with repetitive information, advertisers use multiple advertisement executions, that is, variations on the theme (such as different settings).22
Message repetition or consistency should be beneficial for anti-smoking advertising as well. If a campaign has a large budget, it perhaps has more flexibility in terms of conveying multiple messages. However, even cigarette advertisers with substantial budgets tend to utilise single themes. The Marlboro Man (male autonomy) and Virginia Slims (liberated female) campaigns are just two examples of this.24Therefore, we tentatively predicted that an anti-smoking campaign's cost effectiveness would be enhanced by a focus on a single efficacious theme.
In consumer advertising, it is widely recognised that messages can be either poorly comprehended or mistakenly comprehended.2526 Despite advertisers' best efforts, consumers frequently misunderstand the specific claims that are made, the general conclusions reached, and/or the sponsors of the advertisements.2728 Hence, it is commonplace for advertisers to test consumers' comprehension of advertisements in rough cut and/or final form, to rectify any problems that might arise.1829 Subtle changes in wording or dramatisation can make a substantial difference in whether a message is generally understood by target audience members.
There are some who believe that people can be subliminally persuaded by advertisements, independent of message awareness or comprehension.30 However, numerous studies by psychologists and consumer researchers have found no link between subliminal messages and consumer behaviour. It appears that subliminal advertising simply does not have the power attributed to it by its advocates.31 As one advertising agency executive put it, “We have enough trouble persuading consumers using a series of up front 30 second advertisements—how could we do it in 1/300th of a second?”.21 The rare instances of documented subliminal advertising effects have been produced in highly contrived and artificial settings that have little relevance to marketers.2232
Anti-smoking messages can be quite complex—for example, those that argue that tobacco marketers use deception to sell a deadly and addictive product. If youths fail to understand what an advertisement is saying, it is unlikely to have the intended effects. At least one study found that an anti-smoking advertisement that was carefully crafted by adult professionals, but subtle in its approach rather than hard hitting, was poorly understood by the adolescents for whom it was intended.33 Hence, we predicted that anti-smoking campaigns with a higher proportion of readily comprehended and strong messages would tend to be more cost effective.
AGE OF SPOKESPERSON
In general, people are more likely to be influenced by a persuasive appeal if they perceive it as coming from a spokesperson with whom they feel a sense of similarity.21 When audiences identify with a spokesperson, they are more likely to accept that person's opinions and recommendations as credible and relevant to their own lives.2234 Advertisers typically try to ensure that target audience members feel a sense of similarity or identification with the spokesperson by using a person that is similar to the audience in age, sex, race and/or lifestyle.161735-37
When advertisers court adolescents, they generally make a concerted effort to use youthful spokespeople who will be believed and respected by the youth subculture.3839 Some cigarette advertisers apparently feel that it is important to use youthful spokespeople as well.1738 According to studies, tobacco advertisers frequently violate their voluntary code to rely on models that look to be at least 25 years old.1740 One study examined magazines that accept cigarette advertisements and are popular with 12–15 year olds (for example, Sports Illustrated and People) and reported that four out of six cigarette models appeared to be under 25, with the median age being 19.40 Adolescents also reportedly prefer younger cigarette models.17 Often the implied message seems to be that, by smoking, they will become like the attractive young people in the advertisements.36 Experts have opined that the Marlboro Man appeals to youth, despite his age, by symbolising autonomy and freedom from authority, two dominant developmental goals for adolescents.35
The general rule of thumb is that, when targeting adolescents, spokespeople should be just slightly older than the target group and hence aspirational.38 Models can sometimes be too young, because teens are looking for images of “independence, adventure seeking, social approval, and sophistication.”35Since the advertising campaigns that we analysed targeted a diverse group of youths from roughly 9–19 years old, we could not address the issue of whether some of the spokespeople might have been too young for some audiences. Instead, we tentatively predicted that campaigns that made greater use of youthful spokespeople would be more effective at lowering adolescent smoking prevalence, holding other factors constant.41
DEPICTIONS OF SMOKING BEHAVIOUR
We also felt that it was important to consider the use of advertisements that depicted people smoking cigarettes. We were concerned that if a campaign depicted smoking too frequently, it might inadvertently imply that the behaviour is prevalent, normal, and accepted and thus convey a contradictory message.4142Adolescents already overestimate smoking rates among both peers and adults, and the more extreme the overestimate the higher the risk of smoking initiation.43 It may sometimes be appropriate to depict smokers to illustrate the negative aspects of tobacco use, model refusal skills, portray tobacco executives or the like. However, many experts feel that depictions of smoking in anti-smoking advertisements should be minimised because of the potential for unintended adverse effects.18
Turning to our research method, we first ranked each focal campaign on each advertising variable that we speculated might be related to cost effectiveness. Next, we obtained data on campaign costs and effects and developed cost effectiveness rankings. Then, we tested our tentative predictions regarding the relation between each advertising variable and cost effectiveness by comparing how the campaigns ranked on each dimension. For instance, we compared how the campaigns ranked in terms of message content versus cost effectiveness. If the rankings seemed to be associated and in the expected direction (for example, positively), we concluded that there was some support for our predictions.
ASSESSMENT OF ADVERTISING VARIABLES
To rank the campaigns on each advertising variable, we relied on the materials submitted by campaign officials. Officials assured us that they provided a complete or virtually complete set of advertisements from 1985 to 1997. Florida advertisements were not included because we completed this phase of the work in 1998 and their campaign started later. Adolescents provided the data used for ranking each campaign on the message variables: content, clarity, and consistency. We felt that adolescents would be the best judges—particularly regarding message clarity—of whether the messages would be comprehended by other youths. We believed that the executional variables (use of youthful spokespeople and depictions of smoking) could be readily assessed by adults trained in content analysis so we used that approach.
Data were collected from adolescents as follows. We recruited 1128 seventh and 10th graders in California from middle class, ethnically diverse school districts.15 The advertisements from the various sponsors were randomly divided into small pods of 8–9. Each adolescent was randomly assigned to evaluate one pod of advertisements. Immediately after viewing each advertisement twice, subjects answered a series of closed ended questions about the advertisement.
We used the data from adolescents in several ways. To assess the extent to which a campaign employed messages that research suggests may be especially efficacious for youth, we did the following. If at least 80% of subjects agreed that an advertisement contained a certain message, it was classified into that category (see earlier discussion). Then, for each campaign, we calculated the total percentage of advertisements that fell into the efficacious categories (deceptive portrayal of lethal product, second hand smoke, smoker as negative role model, and refusal skills). Vermont's score on efficacious message content, for instance, was 79% because 58% of its advertisements were classified as refusal skills, 13% as deceptive portrayal of lethal product, and 8% as smoker as negative role model.
To assess message consistency, we relied on the percentage of advertisements that fell into the most commonly used efficacious category. In the case of Vermont, since the most commonly used efficacious message was refusal skills and 58% of the advertisements used it, the consistency rating was 58%. To judge message clarity, we relied on the percentage of advertisements rated unclassifiable, meaning that fewer than 80% of the adolescents could agree on the message conveyed.
Additionally, three trained adults content analysed each advertisement to assess if the spokesperson (main character) appeared to be under 25 years of age and if any person was shown to be smoking cigarettes.3644 Inter-rater reliability was 81%. Researchers consider reliabilities over 80% to be acceptable.45 For each campaign, we then computed the percentages of advertisements that contained youthful spokespeople and depicted smoking behaviour.
ANALYSES OF CAMPAIGN COSTS
Information on anti-smoking advertising expenditures was obtained from officials in each US state (Arizona, California, Florida, Massachusetts, Minnesota), Canada (Health Canada), and Vermont. We also consulted published sources and the internet. For each campaign, an average expenditure across all available years was computed and then converted to per capita amounts by dividing by the 1996 USA census population estimate for the relevant geographic area. The per capita amount provides a control for differences in population sizes. For instance, since California is a more populated state, it needs a larger advertising budget to reach everyone who is to be targeted.
For California4647 (telephone conversation with Curt Fallor, California Tobacco Control Section, December 1999), Massachusetts4748 (email correspondence with Mark LaPlante, Massachusetts Department of Health Services, February 2000), Florida,4749 Canada,50 and Arizona (telephone conversation with Robert Suiter, Arizona Tobacco Education and Prevention, February 2000)4751 the per capita figure reflects the average annual budget from campaign inception to 1999. The per capita cost for Minnesota reflects the average annual budget for the complete campaign that occurred from 1986 to 1990. This figure was then adjusted to 1996 dollars using the consumer price index.4752-54 The Vermont campaign was conducted in communities across several states in the USA between 1985 and 1989. The researchers estimated that it would cost $84.5 million, in 1996 dollars, to replicate nationally. We divided this amount by the 1996 USA population to obtain a per capita estimate.4755
Figure 1 shows, for each campaign, the estimated per capita cost for all anti-smoking advertising, across all audiences. Information about the money spent strictly on youth was generally not available and thus not reported. We do not report how campaign expenditures changed over the years, because of incomplete data, but this issue is discussed in relevant places in the text. Figure 1 further illustrates the minimum and optimal per capita funding levels recommended by the Centers for Disease Control and Prevention (CDC) (in 1999 dollars),56and the estimated value of the anti-smoking advertisements run during the Fairness Doctrine Era ($1.12 in 1996 dollars).145As a basis for comparison, tobacco firms currently spend over $7 per capita per year in the USA on advertising, promotional items, and sponsorships.53
Comparison of adjusted per capita anti-smoking advertising expenses, 1985 to present. For California, Massachusetts, Florida, Canada, per capita expenditures were calculated from average annual budget allocated from campaign inception to 1999 and 1996 population estimates.46-51 Per capita cost for Minnesota reflects the average annual budget from the entire campaign (1986 to 1990) and 1996 population estimates, adjusted to 1996 dollars.475253 Costs for Vermont were calculated from published estimates for replicating the campaign at national level (in 1996 dollars) and 1996 national population estimate.4754Funding level during Fairness Doctrine was calculated from estimated expenditures of $298 million (in 1996 dollars) divided by 1996 US population estimates.414754
ANALYSES OF CAMPAIGN EFFECTIVENESS
Reports on the Minnesota and Vermont campaigns have appeared in academic journals, so we relied on those publications to assess the effects.7852 Both campaigns were evaluated by tracking weekly smoking prevalences over time in intervention and control communities using school based surveys. In Canada, current (last 30 day) adolescent smoking prevalences have been tracked since 1970 using personal and confidential home surveys. The data, and trends over time, have been reported in an academic article so we relied on that article.50
To evaluate the remaining campaigns, we used data from the sponsoring state and an appropriate comparison area (see below) to provide a baseline or control group.57 Since multiple data sources were available, we used the following selection criteria to minimise potential bias. First, we relied on academic journals or official government or university reports. Second, we used sources with two or more years of data so that we could assess changes in smoking prevalence. Third, the intervention and control (baseline) data pertained to youth in the same grade in school, collected in the same year, using the same measure: 30 day prevalence or current smoking (that is, any smoking within the past 30 days). Finally, we used surveys completed by random pools of subjects from randomly selected schools. We relied on school based surveys because, in phone surveys, youth generally report substantially less smoking behaviour.58 It seems that youths are hesitant to respond honestly about illicit tobacco use over the phone because they fear being overheard by family members.5859
Following these criteria, in virtually all cases, we relied on data collected by the states in cooperation with the CDC and its Youth Risk Behavior Survey (YRBS). The single exception was California where state specific data from Monitoring the Future were available and where the state's own surveys were phone based. Monitoring the Future also provided regional comparison data for Massachusetts and Florida, and US comparison data for California. California uses national (versus regional) data as its benchmark since the state represents roughly 69% of the western region, according to the US census.47 For Arizona, there was only one state specific data point available, stemming from a phone survey conducted more than two years after the campaign had commenced.51 Hence, we do not report on the effects of Arizona's campaign.
Tables 1 to 6 indicate the changes in adolescent smoking prevalence in the campaign and control (baseline) areas across relevant comparison years. Results for the Vermont study, Minnesota, and Canada are summarised as published.85052 Vermont researchers used a stepwise regression procedure to assess treatment effects between the intervention and control groups.78 Minnesota evaluators analysed that state's results using a hierarchical ANCOVA that compared the mean square effect for the state by year interaction against the mean square effect for school within state by year.52 This approach, while appropriate, was conservative and could possibly have underestimated the effects for Minnesota. The Canadian data were fit to stochastic models that estimated coefficients for trends, changes in trends, and random fluctuations in prevalences, by sex.50 If the Canadian advertising campaign had lowered adolescent smoking prevalence, a significant change in trend would have been observed.
For California, Massachusetts, Florida, and each selected comparison area, we calculated relative risk ratios using the PROC FREQ function in SAS. The ratios reflect between year comparisons of the proportions of adolescents who reported smoking within the past 30 days, with the uncertainty in each estimate being expressed by the 95% confidence interval (CI). The higher the ratio, the higher the smoking prevalence (risk). A confidence interval that does not contain 1.00 indicates a significant change (increase or decrease) in the risk of smoking over time.60
For example, the relative risk from 1997 to 1999 among Massachusetts 10th graders was 0.82. This value is significant because the 95% CI of 0.72 to 0.92 does not contain 1.00. The value also indicates that the overall risk for 30 day smoking prevalence was significantly lower in 1999 than in 1997. Absolute changes in prevalence are also reported in tables 1 to 6 and significant effects are flagged. Tests of absolute changes were conducted using the z statistic, but the results are identical to those using relative risk. All comparisons controlled for grade in school and geographic area—for example, Massachusetts 10th graders in 1997 were compared to that state's 10th graders in 1999, and so forth. Table 7 contains the estimated sample sizes used for the calculations in tables 1 to 6. For details on the sample sizes, see notes at the foot of table 7.
We concluded that an advertising campaign lowered adolescent smoking prevalence from time t to t+n (for example, 1997 to 1999) if (a) the focal area showed a significant decrease in prevalence and there was either no significant change or a significant increase in the comparison area, or (b) the prevalence was flat in the focal area and increased significantly in the comparison area. If there was no significant difference between the focal and comparison areas (that is, if both experienced increases in, decreases in, or constant prevalences), we concluded that the campaign had no effect during that period for that grade. In a few cases smoking prevalence significantly increased in the intervention (versus comparison) area. Factors extraneous to the campaign (for example, societal norms) or conceivably the campaign itself could have contributed to the increase. Since we could not distinguish between these competing explanations, we do not interpret these results.
Figure 2 provides data about each sponsor on each advertising message variable—namely, content, efficacious content, clarity, and consistency. For each sponsor, we used SPSS to compute crosstabs and χ2 tests comparing the frequency (prevalence) of use of different message content. The results of these within sponsor analyses are included in fig 2. The messages shown by black bars were used by the sponsor significantly more than the messages designated by white bars (p < 0.05). The messages depicted by grey bars were not used significantly more or less than any other messages.
Messages used in advertisements as identified by middle school and high school students (within campaign comparisons). Solid black and white bars within each figure differ significantly (p < 0.05). Grey bars do not differ significantly from each other or from black and white bars.
Figure 3 contains data about each sponsor on each advertising execution variable, namely, use of youthful spokespeople and depictions of smoking. We used SPSS crosstabs and χ2 tests to make the between sponsor comparisons shown. A black (versus white) bar indicates significantly greater use of the designated executional device by one sponsor versus another (p < 0.05). Grey bars indicate no significant differences.
Use of youthful spokespeople and depiction of people smoking (across campaign comparisons). Solid black and white bars within each figure differ significantly (p < 0.05). Grey bars do not differ significantly from each other or from black and white bars.
Trends in youth smoking prevalence: Vermont campaign, 1985 to 1989
Trends in youth smoking prevalence: California campaign, 1990 to present
Trends in youth smoking prevalence: Massachusetts campaign 1993 to present
Trends in youth smoking prevalence: Florida campaign 1998 to present
Trends in youth smoking prevalence: Minnesota campaign 1986 to 1990
Trends in youth smoking prevalence: Canada 1985 to present
Approximate sample sizes for youth smoking prevalence results
Detailed results for each advertising campaign
COST EFFECTIVENESS RANKINGS
Table 8 ranks the advertising campaigns from best to worst in terms of their cost effectiveness at dissuading youth from smoking. The findings indicate that one campaign was highly cost effective, three achieved modest effects at varying funding levels, two did not work, and the results for Arizona are unknown. Vermont's campaign worked very well by achieving significant effects inexpensively ($0.32 per capita).55 California is ranked after Vermont on cost effectiveness because its campaign resulted in modest effects at a low per capita cost ($0.4646; telephone conversation with Curt Fallor, California Tobacco Control Section, December 1999). Massachusetts and Florida rank next because they attained modest effects while spending substantially more per capita ($2.1648; email correspondence with Mark LaPlante, Massachusetts Department of Health Services, February 2000 and $1.2949 respectively). Minnesota's campaign was inexpensive ($0.51 per capita)53 but did not achieve any significant effects. Canada's campaign, with a per capita budget of $0.47,50 was not successful either. Arizona spent $2.35 per capita but a lack of behavioural outcome data prevents an analysis of cost effectiveness (telephone conversation with Robert Suiter, Arizona Department of Tobacco Education and Prevention, February 2000)51 (see both fig 1 and table 8).
PREDICTORS OF COST EFFECTIVENESS
Table 8 further ranks the campaigns on each advertising variable that was measured due to its potential association with cost effectiveness (in terms of lowering adolescent smoking prevalence). All but one of the variables does seem to be associated with cost effectiveness. The more cost effective campaigns generally utilised a larger percentage of messages that, based on prior research, seem to be especially efficacious at dissuading youth from smoking. Typically, the more cost effective campaigns showed greater consistency in terms of emphasising a single efficacious message. Campaigns that ranked higher on cost effectiveness generally avoided unclear messages and employed youthful spokespeople more often. The frequency of depictions of smoking behaviour did not seem to be associated with cost effectiveness, however (table 8).
Summary of case study findings: advertising cost effectiveness and possible predictors
The campaign that was undertaken by Vermont researchers sought to stress the positive consequences of non-smoking, model refusal skills, convey the immediate social and physical problems associated with smoking, and teach adolescents about cigarette marketing.761 It ranks as the most cost effective because it achieved significant reductions in smoking prevalence with a low per capita budget.61 The campaign ran from 1985 to 1989 as a part of a multi-community experimental trial.55
The two intervention communities received mass media advertisements and a school program; the two control communities received only the school program. At the onset, the students were in grades 6 and their weekly smoking prevalence was less than 2%. By the time they had reached grade 8, the intervention group was smoking significantly less than the control group (intervention 5.0%, control 9.3%; p < 0.05). Two years later, smoking prevalence in the intervention group remained significantly lower (intervention 12.8%, control 19.8%; p < 0.05).861 The effects were sustained for at least two years after the campaign ceased (intervention 16%, control 24%; p < 0.05).8
PREDICTORS OF COST EFFECTIVENESS
It appears that the success of the Vermont campaign can be attributed to a variety of factors. Based on our results, 79% of the advertisements communicated message content that prior research found to be efficacious with youth. Advertisements with the refusal skills theme comprised 58% of the campaign which indicates a very high degree of consistency over time. Two other efficacious themes were used: deceptive portrayal of lethal product (13%) and smoker as negative role model (8%). Only 4% of Vermont's messages were deemed unclassifiable (meaning low agreement on message).
Executional factors may have also contributed to Vermont's success. In particular, 70% of Vermont's advertisements featured youthful spokespeople which may have enhanced the campaign's relevance to its target audience. While 46% of the advertisements depicted smoking, apparently the depictions were unflattering and reinforced the anti-smoking messages. Overall, the Vermont researchers mounted a homogeneous and effective campaign that can serve as a model for states considering anti-smoking advertising.
California chose to emphasise the health effects of second hand smoke and to attack the tobacco industry for selling a lethal and addictive product and targeting kids.6263 The campaign, started in 1990 after voters approved a tobacco excise tax hike, has had moderate success.1964 Since the campaign was relatively inexpensive, it ranks second in terms of cost effectiveness.
Our findings indicate that from 1993 to 1995 the California campaign realised some positive results. Although smoking prevalences among California eighth and 10th graders remained flat during this time, nationally there were significant increases in smoking prevalences in both grades (for eighth graders: California relative risk 1.00, 95% CI 0.74 to 1.35; US relative risk 1.14, 95% CI 1.05 to 1.25; for 10th graders: California relative risk 1.00, 95% CI 0.78 to 1.29; US relative risk 1.13, 95% CI 1.05 to 1.21). From 1995 to 1997, there is little indication that California's campaign was impacting youth. For grades 8 and 10, while smoking prevalences continued to be flat in California, nationally the prevalences were flat as well.6566 One reason may be that the California advertising budget was cut; it has also been speculated that the California advertisements became less hard hitting.4667
PREDICTORS OF COST EFFECTIVENESS
There are several reasons why California seems to have had some success. First, 58% of its advertisements used message themes that prior research identified as being efficacious with adolescents. One such theme—deceptive portrayal of lethal product—was used in 32% of the advertisements. This indicates a relatively high degree of consistency over time. California used additional efficacious themes: second hand smoke (14%), smoker as negative role model (7%), and refusal skills (5%). Only 17% of California's advertisements were rated as unclassifiable, meaning that the majority were readily comprehended. Executionally, 50% of the California advertisements featured youthful spokespeople which was about average across the sponsors. Smoking behaviour was modelled in 42% of the California advertisements which was also about average.
Convincing 9 to 17 year olds not to smoke is one of three major objectives of the Massachusetts campaign.68 A primary message is to communicate the “harsh medical realities of the effects of smoking”.6269 Additional messages include second hand smoke, cosmetic effects, and testimonials from ex-employees and former supporters of the tobacco industry.6270 The surtax funded campaign started in 1993 and has had modest success.71 Similar to California, there is evidence that adolescent smoking prevalence decreased in some instances, but the per capita spending to achieve this result was higher. As such, we rank Massachusetts third (tied with Florida) on cost effectiveness.
Imagine for a moment that a sick bigot published an ad insulting blacks, Jews or homosexuals. We might debate the scope and limits of the first amendment and the freedom of individuals to say what they please, so long as they please the lynch mobs.
But what if the government ran it?
Nazi Germany in the thirties? No, America in the nineties. The only difference is that the group out of favor today is smokers. Anyone who dismisses the comparison has not been reading the news. Smokers are banned from universities, libraries, most places of business and the halls of government. They have been denied employment and fired from their jobs for smoking at home. They have been fined and thrown in jail. And the anti-smoking campaign is just getting warmed up: what lies ten years ahead?
There are two fundamental problems here. First, there seems to be a general acceptance that a majority can do anything it likes to a minority. If you are unconcerned or even happy about the present plight of puffers, you should remember that in one respect or another everyone belongs to some minority and that one day, your turn will come.
Second, and more seriously, our government, which was elected to serve (not rule!) us, is now in the business of bashing the politically incorrect. That phrase, once used humorously, is now starting to acquire the sinister tone that it carries in China. Once we allow the state the power to coerce "correct" behavior, it is only a matter of time, given present trends, before we are all clad neck to toe in severe black garments and addressing each other as "thee".
But some states (notably California and Massachussets, with others sure to follow) have a special indignity reserved for smokers: They must pay for their own persecution. In California, an additional 25 cents per pack tax on cigarettes was passed in 1988 to be used for cancer research, 5%; wetlands(!), 5%; indigent medical care, 40%; and "education" - read anti-smoker campaign - 50%. If you have no problem with that, try switching minority groups and see how well it sits. What about 5% for sickle-cell anemia research and 50% for an anti-black campaign, to be funded entirely by taxing blacks?
The argument that this is being done "for smokers' own good" is demeaning: our bodies are not government property. The argument that smokers cost society money is specious: about one third of us considerately die before cashing in on social security. The argument that smoke is harmful to others is nothing but a subterfuge: the risk of second-hand smoke exposure has been so outrageously distorted that it amounts to an outright lie.
For over twenty years I have watched the growing persecution of a minority with discrimination, harrassment, demeaning propaganda, unfair taxes and laws that fly in the face of our country's constitution. This has been made possible by smokers who are, by and large, apathetic and apolitical. The time is long overdue for smokers to stand up for their rights: to become aware of the issues, armed with facts and willing to work to restore their freedom, their dignity and their rightful place in society.
Secondhand Smoke: The Big Lie
The principal ammunition used in the war on smokers consists of these claims:
All of these falsehoods depend for their general acceptance on the credibility of those disseminating them and upon the inability of the typical listener to perform simple sanity checks using common sense and arithmetic. The simplest is this. It takes 20 years or more for damage to manifest itself in a smoker. ETS is hundreds of times more dilute than mainstream smoke. Non smokers would have to live with ETS for upwards of 2,000 years to incur the same damage. Here's another. Smoke from charcoal contains many of the same components as those most feared in tobacco smoke (carbon monoxide, formaldehyde, carcinogens and so forth). A ten pound bag of charcoal produces as much smoke (and harmful chemicals) as 160 packs of cigarettes. Are you going to quit barbecuing? Probably not. Yet the slightest whiff of tobacco smoke gives many anti-smokers apoplectic fits. Are they being hysterical? Read on and decide for yourself.
CancerThe reason science enjoys such weight and credibility is that it has generally been structured so as to encourage a wide scrutiny of methods, data and findings, peer review and a healthy debate from all viewpoints. In the end, faulty data and fanciful theories are laid to rest, and truth emerges the winner. Usually.
Scientists, like everyone else, are subject to personal bias. They can set out to prove a pet theory, they can ignore data which contradicts a favored hypothesis, and they can read into data facts which simply aren't there. In addition, and perhaps more importantly, their employers can be biased. Employers can put pressure on researchers or even research firms to validate a preordained position or to produce a desired result. Not that they really have to, since it is much easier to hire or retain investigators who agree with them to begin with. And even that is not necessary, since the employer gets to write conclusions and recommendations. Scientists who dissent can effectively be buried simply by not publishing what they have to say.
In an open and honest world, all of this would amount to little, since all sides would have their say and we could count on disinterested observers to wade through the fancy and glean the facts. In the case of secondhand smoke, however, it is near impossible to find anyone who is both disinterested and of sufficient standing to be heard. What we have instead is a war of credibility over conflicting interpretations of biased reports. What we have is politics.
On one side are anti-smokers and the EPA. On the other, smokers and the tobacco companies. At this moment, the antis and the EPA clearly have the upper hand, enjoying as they do a credibility which is just as clearly undeserved. No one is surprised that the tobacco companies have a financial agenda. The same people, on the other hand, express astonishment at the suggestion that the government might actually have a political agenda. Or at the fact that the government, too, is an employer, with more power than most to select and pressure the scientists it employs and to bury the ones that dissent. Nowhere is this power more abused than on the subject of ETS. Last year's EPA report on ETS, the cornerstone of the anti-smokers' arguments, is worse than just bad science.
It is corrupt.
Corrupt science has two salient characteristics. First, instead of starting with a hypothesis and data and deriving from that a conclusion, it does just the opposite: starting with a desired conclusion, it then selects data in order to support the hypothesis. Second, it stifles dissent by excluding dissenters from the process of review and by using ad hominem arguments to question their character and motives. The EPA is guilty on both counts.
Of the 30 studies on spousal smoking referred to in the EPA report, only 6 found any statistically significant association between ETS and cancer in nonsmokers married to smokers, and none found a strong relative risk. The studies actually used by the EPA were limited to 11 studies done in the United States. Using the EPA's own Guidelines for Carcenogenic Risk Assessment, none of these showed a statistically significant risk. These guidelines call for a 95% Confidence Interval. By lowering it to 90%, only one of the 11 studies showed a statistically significant risk. More importantly, the two largest and most recent studies, one of which was partially funded by the National Cancer Institute, were omitted from consideration altogether. Had these two been included, no statistically significant risk would have been found even after lowering the Confidence Interval to 90%. Even after violating its own guidelines, in other words, the EPA could still show no statistically significant risk without selecting data to fit its hypothesis. This cooked data is the EPA's only basis for declaring ETS to be a "Group A" carcinogen. ("Group A", incidentally, does not mean "extra deadly". It simply means "human".)
The EPA's studies on ETS operate under a "zero threshold" hypothesis, or the assumption that if huge quantities of something are dangerous, then microscopic quantities are dangerous also. The data they used, however, fails to bear this out: virtually all of the studies used either found no risk at all or a risk so weak that it would not be considered significant if applied to other subjects.
A "strong" risk is one with an "odds ratio" of 5 to 20 - reflecting an incidence of the problem five to twenty times higher in a group that was exposed to something than in a control group that wasn't. 5 in a population of 100,000, say, compared to 1. (Or 500 vs 100, or 5 in a million vs 1; since it is a ratio, it indicates nothing about the size of the risk itself. Only the relative risk.) A ratio of 1 indicates no risk at all. Odds ratios under 3 are usually considered so low as to be the possible result of random variation or margin of error. The odds ratio of contracting cancer from chlorinated tap water, for example, has been calculated by the EPA to be 1.5 - not enough to worry about, in other words. Yet the EPA used an odds ratio of 1.19 - considerably smaller than that of chlorinated tap water - to classify ETS as a human carcinogen.
One of the largest and most recent studies of ETS is the Brownson study, partially funded by the National Cancer Institute. This study found odds ratios varying from .7 in non-smoking spouses of smokers exposed for fewer than 40 years, to 1.3 in those exposed for over 40 years. .7 is a negative correlation, meaning that those exposed to ETS for less than 40 years experienced fewer cancers than the control group. Since the implication that ETS actually protected those subjects from cancer is biologically implausible, the only other conclusion that can be drawn is that the study's margin of error, caused by random variation, is .3 or higher. This means that the 1.3 figure is equally suspect. The total risk for all groups averages out to exactly 1, or no risk at all.
The Brownson study was available to the EPA, but was not used in its report. Had it been included, the conclusions would have had to have been revised downwards to show no risk.
Though the EPA claims a "19% increase in risk", the actual order of magnitude is less than intimidating. Even if the odds ratio of 1.19 is eventually found to be accurate and not the result of random variation, what this would mean is that instead of the 6 lung cancers per year normally expected in a population of 100,000, we might find 7. Put another way, the average lifetime risk of dying from exposure to ETS (as opposed to eventually dying of something else) would be about 1 in 700. Furthermore, the risk (if real) is concentrated among the non-smoking spouses of smokers exposed to ETS (a heavier exposure than that found elsewhere) for upwards of 40 years, and cannot be extrapolated to include the general population. By way of comparison, the December, 1989 study by the Department of Transportation estimated the probability of contracting cancer from the cosmic radiation at cruising altitude as being some 2,000 times greater than the risk posed by ETS while on the aircraft. The question is, is this sufficient grounds to justify the subjugation of 50 million people? Before you answer, consider this: driving across town to your favorite restaurant entails a risk many times higher - 17 to be exact - than inhaling any secondhand smoke once you get there. If you include the risks associated with the food and drink you are likely to consume there, that multiple rises to over 450. And if you choose one of the many non-smoking restaurants provided by a free market, you get no exposure at all.
A look at the people who worked on this study explains this twisted methodology. Leading anti-smokers pervade both the EPA and the Science Advisory Board responsible for reviewing its analysis, and some of the work was contracted to the founder of a prominent anti-smoking group. It should come as no surprise that the EPA's Workplace Policy Guide was written well before the ETS risk study was completed.
The underlying philosophy at work here is that the end justifies the means; that since a smoke-free society is deemed to be a worthy goal, manipulation of data and even lies are permissible in achieving it. The EPA official responsible for the report admitted in "Science" magazine (7/31/92) that "she and her colleagues had engaged in some fancy statistical footwork" in order to arrive at the indictment of ETS. The opinions of dissenting EPA scientists were ignored, and references to works not in accordance with the EPA position were omitted from the bibliography of the report. Finally, those gainsayers who actually manage to make themselves heard are refuted not with data and reason but with character assassination.
Corrupt scientists have always been eager to ride the bandwagon of popular opinion. Early in this century, Russian scientists drew diagrams purporting to show that the skulls of Jews were smaller than average, reflecting a smaller brain and therefore a lowered intelligence and moral sense. This "justified" the pogroms. In our own country, studies claiming a lower IQ among African Americans (referred to in the studies as "Negroes") "justified" segregation. The damage done by these studies took decades to undo, while millions suffered. Both conclusions share an insidious and horrifying circularity: if the subject of the slur has the temerity to question the evidence, the response is "You can't believe him, he's stupid. Look: my charts prove it!" And that is exactly what is being repeated today. Using corrupt science, the EPA has manufactured a conclusion which states, in effect, that smokers and the tobacco companies are killing 3,000 Americans each year and are by implication morally corrupt. When anyone disagrees, the anti-smokers have the perfect counter argument: "You can't believe them, they're morally corrupt. Look: the EPA report proves it!"
"Political science" has taken on a whole new meaning.
Heart DiseaseWith the appellation of "Doctor" and his little black bag of anti-smoking calculations, Dr. Stanton Glantz is generally assumed to be a medical doctor. Nor is he eager to dispel that notion among his listeners. Actually, he has a PhD in Mechanical Engineering, and no medical training at all. His field of expertise notwithstanding, he gets paid handsomely for doing what he loves most: slandering smokers.
In the not too distant past, researchers (using smokers' tax dollars, naturally) claimed that non-smokers exposed to secondhand smoke over a long period of time exhibited a tiny but measurable increase in fatty deposits on their arterial walls. Given the bias of such researchers, their tendency to make leaps of faith when interpreting inconclusive data and the difficulty of eliminating confounding factors, one cannot accept with any degree of certainty that what they claim is true. However, let us assume for the sake of argument that the phenomenon is real, and proceed.
The arterial deposits in question are caused by diets rich in fats and cholesterol, and by lack of exercise. When coronary arteries become so clogged up that sufficient blood can no longer pass, a fatal heart attack can result. Clearly, this does not happen until a critical degree of obstruction, or "threshold", has been reached. A microscopic buildup in an otherwise healthy person is simply a curiosity, nothing more.
Enter Stanton Glantz, PhD. Each year some 1,000,000 Americans die from heart disease. Ignoring the concept of a threshold, Glantz "reasoned" that if the fatty buildup claimed by the researchers to be attributable to ETS was only one-twentieth as thick as that required to produce a heart attack, then surely it must be producing a twentieth of the heart attacks, or 50,000 of them. He then wrote a thick paper saying so. This is like saying that if a million people cross a body of water ten feet deep and 100,000 drown, then 1,000 would drown if the water were an inch deep. This claim is not just absurd. It is pure fantasy.
Stanton Glantz knows this.
No matter. His paper was his ticket to the lucrative anti-smoker lecture circuit, where his adoring audiences hear what they most want to hear, namely that smokers are killing people. He also found a receptive audience in the American Heart Association, which acts as a sort of wholesale distributor for his misinformation. AHA representatives are to be seen and heard at every City Council hearing on proposed anti-smoking ordinances, where they parrot this pernicious poppycock ad nauseum.
Doubtless the more educated members of the AHA realize what is going down. Perhaps they justify this to themselves by rationalizing that the claim is not really theirs, but rather the "work of a credible expert". Warranties, in other words, are the responsibility of the manufacturer, not the distributor. And since smoking itself is associated with heart disease, and since the goal of the AHA is to get smokers to quit, by outlawing tobacco if necessary, the end justifies the means. Doesn't it?
Respiratory IllnessesThe phrase "respiratory illnesses", when used in connection with ETS, is usually found appended to a list of other claims, as in "cancer, heart disease and ...". It seems to round off the list nicely and is purposely left vague. If pressed, anti-smokers will, as if by rote, recite "... such as asthma, colds, influenza and pneumonia". But none of these ailments is caused by smoking, much less by ETS. Pressed further, the antis will backpedal to the claim that ETS "aggravates" these conditions. The degree of this "aggravation" I shall examine in a moment. First, however, some interesting numbers bear looking at.
Since 1979, the number of smokers has declined significantly, from about 33% of adults, or higher, to a proportion varyingly reported as being from 20% to 25%. During the same period, a host of anti-smoking laws have dramatically curtailed smoking in public places. Today, exposure to ETS is not one tenth of what it was in 1979. Yet, according to an article in the San Jose Mercury News (October 12, 1993), fatal asthma attacks have nearly doubled in that time. More than 5,100 Americans suffered fatal asthma attacks in 1991, up from about 2,600 in 1979. Clearly, some scapegoat other than ETS will have to be found.
So where are the mystery deaths caused by "respiratory illnesses" that can be blamed on ETS? There aren't any. The diabolical innuendo of the phrase "... cancer, heart disease and respiratory illnesses" causes many to believe people die this way and to repeat the rumor. But it is akin to saying "nuclear bombs, biological warfare and firecrackers."
So far, in this country anti-smokers have enjoyed free rein to make wild claims about ETS without having to back them up with rigorous evidence in an objective, impartial setting such as a court of law. With the pending challenge to the EPA's report, that is about to change. For a preview of the truth likely to emerge, we have only to look at a recent Australian court case in which the Australian Department of Occupational Health, Safety and Welfare was pressing a complaint against a casino in an attempt to enforce a no-smoking law.
The question of "respiratory illnesses" quickly became a question of whether the effect of ETS should more properly be characterized as an "irritation" [the defense] or an "inflammation" [the prosecution]. After considering the evidence and witnesses from both sides, the judge likened it to "the experience of ordinary people who sneeze, or whose eyes water when peeling onions." The infamous "respiratory illnesses", in other words, were boiled down in the crucible of truth to simple runny noses.
In addition, the prosecution introduced as part of their evidence the January '93 EPA report on lung cancer and ETS. About this report the judge had these words: "I would have thought that these reports would be those which supported the prosecution case most strongly, but they appear not to. One of these reports is the American EPA report... Chapter 7.9 of the report covers passive smoking and respiratory symptoms and lung function in adults. Table 7.11 tabulates 6 studies and their results, which really show the contrary to what the prosecution witnesses say." The decision, handed down in Perth on September 17, 1993, concluded: "Whilst ETS is annoying and of discomfort to non smokers it has not been proved at the required standard, or at all, that it is a risk to the health of the employees at the Casino."