Robert Wood Johnson Foundation and Boston UniversitySchool of Medicine Working Group: Creating Statewide

Tobacco Control Programs after Passage of a Tobacco TaxSupplement to Cancer

Designing an Effective CounteradvertisingCampaign–California

Colleen Stevens, M.S.W.

Media Campaign Unit, Tobacco Control Section,Department of Health Services, Sacramento, Cali-fornia.

Presented at the Robert Wood Johnson Foundationand Boston University School of Medicine WorkingGroup: Creating Statewide Tobacco Control Pro-grams after Passage of a Tobacco Tax, Waltham,Massachusetts, October 3–4, 1997.

Address for reprints: Colleen Stevens, M.S.W., Me-dia Campaign Unit, Tobacco Control Section, De-partment of Health Services, P.O. Box 942732, MS#555, Sacramento, CA 94234-7320.

Received September 17, 1998; accepted Septem-ber 22, 1998.

OVERVIEW. In this report, the author shares some of the basic lessons learned in

conducting a tobacco education and prevention media campaign for the state of

California over the past 9 years. She highlights the three most fundamental lessons:

1) the qualities to look for in an advertising/public relations agency, 2) the impor-

tance of integrating a media campaign with other tobacco control activities, and 3)

the most successful advertising strategies. Cancer 1998;83:2736 – 41.

© 1998 American Cancer Society.

One basic lesson we have learned is, “Ensure that media activitiessupport and work in tandem with other tobacco education and

prevention programs for a synergistic outcome.” A brief review of thehistory and organization of California’s antitobacco effort demon-strates how we achieved this.

In November 1988, California voters overwhelmingly approved aballot initiative, Proposition 99 (also called the Tobacco Tax andHealth Protection Act of 1988), to increase the tax on each pack ofcigarettes by 25 cents. The fund established from this tax is allocatedto six accounts. One of these is the Health Education Account, whichis supposed to receive 20% of the tax revenues for community- andschool-based tobacco education and prevention programs. A portionof the Health Education Account is reserved for administration andevaluation. The remainder is equally divided among three programcomponents that work very closely with one another: competitivegrantees (grass roots nonprofit agencies funded through a competi-tive request for proposals [RFP] process); local lead agencies (61county and city health departments funded through an allocationformula); and the media campaign. The California media campaignincludes paid commercials and public service announcements fortelevision, radio, billboards, print, and public relations activities.

The responses to our advertising—including praise, criticism,challenges to the advertisements’ facts and figures, and a remarkablenumber of suggestions with ideas for a commercial or lyrics for anantitobacco song—are phenomenal. Of all the programs administeredby the Tobacco Control Section, the media campaign seems to be theone component that inspires an opinion in just about everyone. Themedia campaign also seems to activate creativity in many people,from legislators and other high officials to concerned citizens on bothsides of every tobacco issue. Part of the measure of our success is that

2736

© 1998 American Cancer Society

we are highly visible, and this invites commentaryfrom a multitude of sources.

Lessons LearnedLesson 1: Find the best advertising agencyThe very first step toward achieving an effective ad-vertising campaign is to get a good advertising agencyand build a partnership with them. The agency thatwill be most successful at supporting the comprehen-sive tobacco prevention movement will have all ormost of the following qualities:

An understanding of the strategic and political realitiesof the tobacco control universe. The agency shouldunderstand the history of tobacco control; who theplayers are and what they contribute; what is happen-ing at the local, state, and national levels; and whatsmokers and nonsmokers believe and think about to-bacco use and exposure to environmental tobaccosmoke. The agency also should have the ability to beresponsive to, and flexible within, the changing to-bacco environment.

An understanding of their partnership with the state.Advertising and public relations agency personnel willbecome an extension of the state’s staff. Their personnelwill have a close connection to media outlets, localevents, and local program staff. They must encouragestate staff to develop bold and daring advertisements,even when such advertisements seem certain to be re-jected by the more conservative powers controlling thecampaign. One must make every effort to educate thosein power about the need to stay focused on the strategicgoals of the campaign. The agency must have the exper-tise to counter strategically and outmaneuver the to-bacco industry tactics designed to influence and addictthe public. At the same time, agency personnel mustrealize that they are representatives of their client, thestate, which means that they must be cognizant of bu-reaucratic realities. They must appropriately representthe state’s position with regard to policies and strategies.

Superior creative expertise. The advertising/public re-lations team should have the capacity to producepowerful, effective advertisements and marketingtools that will help move the social norm in the rightdirection, while maintaining a positive partnershipwith state health education program staff and localprograms. Bidders for California’s tobacco educationmedia campaign have all submitted creative ideasthat, taken alone, make them appear to be outstand-ing. However, an ongoing campaign requires morethan just one shot of brilliance. The agency’s history,

breadth of experience, and subcontractors’ ability toextend the reach of messages to as wide an audienceas possible must all be considered.

Appropriate size and fiscal history. The size of theagency is important. The agency should be largeenough to staff the contract appropriately and handlethe fiscal responsibilities, yet the agency must be smallenough to consider the contract a high priority ac-count. The agency needs to have sufficient experience,personnel, and infrastructure to support the contract’ssize and complexity.

Leadership and “good chemistry.” It is essential to findout during the bidding and proposal process just whowill be assigned to the account and their level ofcommitment and experience. Before the contract isawarded, insist that the people with whom state staffwill be working on a day-to-day basis are the samepeople who are involved in the presentations. Do notaward a contract to a great group of advertising pitchprofessionals who will disappear mysteriously whenthe less glamorous work begins. In addition, the agen-cy’s senior account management staff must have pas-sion for, and dedication to, the goals of tobacco con-trol.

It also helps if state and agency personnel havethat intangible quality called “good chemistry,” whichmakes for clear communication, discussion, negotia-tions, and trust. “Good chemistry” is enhanced by thestate staff’s experience with media and public rela-tions principles and objectives as well as the agencystaff’s experience with government, public health, andsocial norm change campaigns. A state staff that dem-onstrates creativity and innovation and will supportand challenge the staff of the advertising agency is anadditional asset. Clues to the presence or lack of“chemistry” are first visible during the proposal reviewprocess. If the state’s proposal evaluators have diffi-culty understanding the written proposal, and the oralpresentation does not reveal direct links between theagency’s creativity and the state’s needs, it is unlikelythat “good chemistry” will be present in the day-to-day interactions of agency and state personnel. It isvery important to allow a question-and-answer dis-cussion period at the end of the oral presentation orduring the proposal process, to give the proposal eval-uators an opportunity to see how state and agencystaff will interact and relate.

No conflict of interest. The tobacco industry businessweb is enormous. Your advertising team cannot servetwo masters, so they must be required to disclose any

Effective Counteradvertising Campaign: California/Stevens 2737

potential conflicts of interest, including the agencystaff’s business ties and the agency’s client base. It canbe a sacrifice for an agency to take on a tobaccoeducation media contract because it means refusingbusiness with tobacco companies and all of their sub-sidiaries and affiliates; the same is true of subcontrac-tors and public relations firms.

The criteria for selecting the proposal review teamare as important as the criteria for contractor selec-tion. Reviewers who understand the advertising busi-ness and its jargon and who can separate substancefrom glitz are essential. Advertisers and public rela-tions agencies are experts at glitz and selling their ownbusinesses. Unfortunately, in too many proposals thegimmicks outweigh the substance. In the RFP, ask forthe format you want: simplicity and substance, with-out gimmicks and glitz. The emphasis should be onthe strength of the proposal and the probability thatthe agency can deliver on its plan. It is also importantto have reviewers who can decipher media cost pro-posals, which can be quite complex, especially forthose not versed in the language of media. The idealcombination of reviewers is one-third program staff,one-third constituency members, and one-third ad-vertising/public relations experts.

After the best agency is selected, their expertisemust be tapped. They were hired to give expert advicefrom their unique professional perspective. Their ad-vice must be combined with the public health andtobacco control knowledge on the part of programstaff. A marriage between the power of advertising andthe principles of public health can sometimes berocky. Copy writers and creative directors fall in lovewith their advertising. It is necessary at times to takethem back to the foundation strategies and goals ofthe program.

Placing and targeting the ads may become asource of conflict between advertising and publichealth experts. Public health groups may want a com-mercial for every target, but that would scatter anddilute the messages, not to mention the budget-break-ing cost. Instead, the program must rely on strategi-cally targeted placement of a few key messages basedon proven strategies. The California program, for in-stance, normally runs no more than three generalmarket television spots at any given time, with suffi-cient repetition to make the messages memorablewithout wearing out their freshness.

Another balancing act involves gaining maximuminput from the constituency and target groups withoutbecoming bogged down in “creative by committee.” Itis essential to consult with constituents and local pro-grams to make sure the message is on target and

follows an appropriate strategy, so that program ac-tivities and media will support, supplement, and mag-nify one another. The media is a tool to help theprograms get their job done. If media is developedwithout their participation, local program staff cannotplan effectively, nor can they integrate the media intotheir program plan. At the same time, the decision-making must rest with a core group of individuals whocan weigh all of the considerations involved in con-ducting an effective health advocacy campaign.

While “creative by committee” can be fragmentedand scattered, creative controlled by state bureaucracycan be even worse. Both the state tobacco controlprogram and its advertising agency must be empow-ered and challenged to produce bold, brazen, fresh,and extraordinary advertising. They need to competeeffectively with the flood of advertising messages of allkinds, including those from pro-tobacco forces, thatinundate the public.

Lesson 2: Integrate the media campaign and localprogram activitiesIn the war on tobacco, local programs are the army,and it is up to the advertising people to provide aircover while the public relations division provides am-munition and some of the weapons.

The advertising campaign’s commercials shouldproduce a grand-scale, in-your-face assault on thepublic’s complacency about tobacco use. This can beaccomplished by communicating general themes andframing issues that will increase the public’s receptiv-ity to a wide range of more specific messages fromlocal interventions. At the same time, the public rela-tions component should provide materials that will bememorable and worthy of news coverage, so that thelocal interventions will be heard and remembered.

While the advertising in California’s tobacco edu-cation media campaign has received a lot of positiverecognition, the public relations component has beenthe unsung hero of the campaign. The public relationswork is equal in importance to the advertising. At amoment’s notice, the public relations staff may becalled upon to assist the state and local program staffwith talking points and key messages on whateverissue may arise. This may involve an issue for which apromotion has been planned or something resultingfrom a breaking news story. In addition to developingnewsworthy sound bites, the public relations stafftrains state and local spokespersons to respond effec-tively to media inquiries and conduct news confer-ences and interviews.

Operation Storefront is an example of how effec-tive the results can be when local programs and public

2738 CANCER Supplement December 15, 1998 / Volume 83 / Number 12

relations work together. In the Spring of 1995, over 700trained youth and adult volunteers surveyed over 5700tobacco retailers throughout California, including gro-cery stores, supermarkets, drug stores, conveniencestores, small pharmacies, gas stations, and liquorstores. These volunteers documented the number ofindoor and outdoor storefront pro-tobacco advertise-ments at the retailers’ establishments, including win-dow signs, posters, banners, displays racks, decals,clocks, neon signs, doormats, ashtrays, counter mats,etc., showing tobacco brands or slogans. The results ofthe survey were released at 19 local press conferencesheld throughout the state. With coordination by stateand public relations staff, each local participatingagency was able to shine, while simultaneously con-tributing to the powerful statewide and national im-pact of the results.

The survey found a significantly higher averagenumber of tobacco advertisements and promotions instores near schools (within 1000 feet) than in storesnot near schools. Tobacco retailers near schools weremore likely to place tobacco advertisements close tocandy racks or less than 3 feet from the floor, wherethe best child’s-eye views are. The results of this sur-vey subsequently were incorporated into commercialsthat exposed tobacco industry advertising tactics di-rected towards children.

Lesson 3: Effective strategiesThe California legislature, which appropriates the to-bacco tax revenues, set an ambitious goal in 1989 forthe state tobacco control program: reduce tobacco useby 75% by the year 1999.

To accomplish a 75% reduction in tobacco use,social norms must be changed. In essence, tobacco usemust be denormalized. This means that the percep-tion of tobacco use as normal or even glamorous mustbe transformed into a realistic perception of tobaccoas dangerous, addictive, and unacceptable to society.Specific goals to help change social norms include thefollowing:

● Make the public (smokers and nonsmokers alike)aware of the health and economic consequences oftobacco use, secondhand smoke, and tobacco in-dustry marketing tactics used within communitiesto influence people, especially youth, to smoke.

● Prevent the initiation of tobacco use among youth.● Encourage tobacco users to quit, help them to quit,

and help them stay free from tobacco permanently.

California’s tobacco education program appliescutting-edge public health approaches and strategiesthat will help foster changes in social norms. A major

approach is to create environmental changes that sup-port behavioral changes. For example, the eliminationof secondhand smoke from the work environment isanother way that tobacco use is denormalized, andraises the level of discomfort in some people to thelevel that is needed to motivate them to stop usingtobacco altogether. Advocating change in tobacco-re-lated policies is a critical strategy in this approach.Public health research strongly supports policychanges as a key factor in promoting public healthgoals, because policies are immediate and also help toshape public perceptions over the long term. Changesin a community’s policies are dependent on publicawareness, support, and action.

A precursor to change is awareness and recogni-tion that a problem exists. Therefore, the program hadto heighten the general awareness of the magnitudeand consequences of tobacco use for Californians andtheir communities.

California’s media campaign was launched inApril 1990. Using state-of-the-art techniques, its ag-gressive tone and nontraditional appearance for apublic health campaign captivated both the publicand the news media. The campaign was able to fightthe tobacco industry using many of the same tech-niques the industry used. The comprehensive mediacampaign also directed specific advertising and publicrelations efforts to ethnic populations, using culturallyrelevant approaches in numerous languages. The me-dia campaign stormed the media marketplace, wherepreviously there had been little dialogue on the issueof tobacco use. It reframed the issue from “an individ-ual problem of the user” to a problem that is cultivatedand perpetuated by a huge industry, at the expense ofboth smokers and nonsmokers. The campaign focusedon raising awareness and building momentum forchanges among the general public and teens.

The two primary strategies of the media campaignhave been to increase the awareness of the dangers ofsecondhand smoke and to expose the manipulation ofthe tobacco industry in targeting and maintaining itscustomer base. These strategies have consistently pro-duced the prerequisite emotional reactions that makeadvertising memorable and more likely to move theaudience toward changing behavior. Throughout, fo-cus groups and other research have been used tofine-tune and adjust strategies and commercial exe-cutions to stay current with the changing social envi-ronment and to maximize the efficacy of the cam-paign.

Exposing the tobacco industry’s manipulationstrategy is a hallmark of California’s program. The firstspot created for the campaign, “Industry Spokesper-

Effective Counteradvertising Campaign: California/Stevens 2739

son,” set the tone for the entire program and an-nounced to the world that the program would beaggressive, hard-hitting, and effective. The televisionadvertisement depicted industry executives sittingaround a boardroom discussing their need for 3000new smokers to replace those who quit or die eachday, ending with the line, “We’re not in this businessfor our health.” When this advertisement was releasedin 1990, many people still believed that the tobaccoindustry was just another business, and some evenperceived it as a good example of corporate America inaction. In such an environment, for the first time, in avery public way, California suggested that the tobaccoindustry should be held responsible for the deaths anddisabilities caused by tobacco use.

Exposing tobacco industry manipulation andcountering pro-tobacco influences at the communitylevel have been essential to the success of California’sprogram. In California, the tobacco industry spendsapproximately $1.3 million on tobacco advertising andpromotions alone each day, predominately to attractnew users. Unfortunately, nearly all of these new usersare young people. To reduce the amount and influ-ence of tobacco advertising, promotions, and tobaccobrand sponsorships, we must educate youth, women,ethnic communities, and the general market. Ourstrategy to expose the tobacco industry tactics re-framed the issue from “smokers versus nonsmokers”to both “smokers and nonsmokers need protectionfrom tobacco industry manipulation.”

The secondhand smoke strategy has been equallystrong. Informing the public about the serious healthrisks from secondhand tobacco smoke set the stage forpublic and voluntary policies to increase the numberof smoke-free schools, homes, work sites, and publicplaces.

The secondhand smoke strategy mobilizes com-munities, gives nonsmokers a voice, and motivatescessation efforts. In 1990, when the state programbegan, only one local jurisdiction in California had asmoke-free indoor air policy. By the end of 1994, al-most 300 cities and counties had clean indoor airpolicies, and over 100 cities had smoke-free policies.In 1994, the California Smoke-Free Workplace Lawwas enacted, which prohibited smoking in most en-closed workplaces. As of January 1, 1998, a final pro-vision of the law made California the first state withsmoke-free bars and restaurants.

Nowhere is the synergy between the local pro-gram activities and the media campaign more evidentthan on the issue of secondhand smoke. The mediacampaign lays the foundation for change by raisingawareness of the dangers of secondhand smoke, and

the local programs guide and implement communityaction at the local level.

The concentration on these two media strategiesof secondhand smoke and tobacco industry manipu-lation, and their work in concert with local healthdepartments, competitive grantees, and the 1989 to-bacco tax increase, led to a decrease in California’sadult smoking prevalence from 26.7% in 1988 to 18.6%in 1996. Cigarette consumption during the same pe-riod declined almost 40%, from 121.7 to 73.6 packs percapita.

Great strides have been made on California’s pol-icy and program front to reduce adult tobacco use.Teens and children remain the biggest challenge foreveryone in tobacco control. Prior to our most recentwave of general market advertising, focus groups wereheld to test youth strategies: the strategies tested in-cluded short term and long term health effects, to-bacco industry youth manipulation, short term cos-metic effects, and social consequences.

The strategy that came to be known as “youthmanipulation” tested strongest. Teens generally havestrong emotional responses, often anger, to advertise-ments that depict youth as puppets and pawns of thetobacco industry. A radio spot based on this strategyshows the tobacco industry thanking youngsters forbeing stupid enough to stick up for them by usingtheir lethal products and making them rich, in spite ofthe disease and death their product causes. A televi-sion spot portrays the tobacco industry as cowboysherding children like cattle into a pen.

Another strategy that tested well with teens andadults alike was the secondhand smoke strategy.Although many teens deny the impact of smokingon their personal health, they are concerned aboutthe effect of their smoking on their friends and lovedones.

Recognizing that there is no “silver bullet” mediastrategy that will get all adults to quit smoking or keepall youth from starting to smoke, the secondhandsmoke and tobacco industry manipulation strategieshave been the foundation of the most memorable andeffective advertisements for California.

While other tobacco education programs have fo-cused nearly exclusively on youth, California’s cam-paign has focused, and continues to focus, on theenvironmental changes that will foster individualchange. Has the California approach been successful?In the 9 years that the program has been in operation,consumption and prevalence have declined approxi-mately 40% and 30%, respectively. California’s declinein smoking has outpaced the rest of the U.S. Accordingto a 1996 evaluation conducted by the University of

2740 CANCER Supplement December 15, 1998 / Volume 83 / Number 12

California at San Diego, 91% of indoor workers, 89% ofhouseholds with members younger than 18 years, andmore importantly 40% of households with childrenyounger than 6 years where all adults are smokers areprotected from secondhand smoke, by either publicpolicy or voluntary policies.1 Youth access to ciga-rettes via illegal sales plummeted from 52.1% in 1994to 21.7% in 1997.2

CONCLUSIONSGoing up against the tobacco industry with its deeppockets and endless resources means tobacco controladvocates must create a media campaign that is bold,attention-getting, and focuses attention back on the

tobacco industry. California’s media campaign is onepart of a comprehensive, multifaceted program withthe goal of reducing tobacco use by changing thesocial norms regarding tobacco’s use, appeal, avail-ability, and acceptability. In the war against tobacco,advertising can provide air cover and public relationscan provide ammunition, but the ground troops—local programs—are essential to winning every battle.

REFERENCES1. California Tobacco Survey (CTS). University of California,

San Diego, 1996.2. California Youth Purchase Survey, California Department of

Health Services, 1994 –1997.

Effective Counteradvertising Campaign: California/Stevens 2741