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—Massachusetts

Anne Miller

Arnold Communications, Boston, Massachusetts.

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.

Ms. Miller is an employee of Arnold Communica-tions, which has a client relationship with theMassachusetts Department of Public Health.

Address for reprints: Anne Miller, Arnold Commu-nications, 101 Huntington Avenue, Boston, MA02119.

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

OVERVIEW. In this report, the author reviews the major lessons from the Massa-

chusetts tobacco counteradvertising efforts. Ms. Miller ties in the Massachusetts

three-pronged campaign of youth prevention, adult cessation, and public support

with focus group-tested counteradvertising strategies. Cancer 1998;83:2742–5.

© 1998 American Cancer Society.

The Massachusetts Tobacco Control Program (MTCP) was created bya voter’s ballot initiative (Question 1) in 1992. A 25-cent-per-pack

cigarette tax funded this comprehensive tobacco control program aimedat reducing tobacco use in Massachusetts. Massachusetts’ campaign, thesecond in the country, was launched in 1993. Arnold Communicationslooked to California’s experience to help guide a successful effort forMassachusetts. The lessons learned were invaluable.

Campaign OverviewThe Massachusetts campaign is comprised of three communicationsobjectives, each intended to play an integral role in the overall reduc-tion of tobacco use. These are: 1) convince youth not to start smoking;2) prompt smokers to quit; and 3) create a supportive environment fora smoke free future.

To achieve each of these three objectives, the media targets adifferent, distinct audience (Table 1).

The Role of the Media CampaignEach campaign differs not only by objective and target but in otherways as well. The youth campaign itself is an intervention. It engageschildren in a dialogue and advances the psychologic and social rea-sons to be smoke free. It directly counters the methods used by thetobacco industry to deliver prosmoking messages. The campaigncomplements the efforts of local youth programs that engage young-sters individually with messages regarding the benefits of beingsmoke free.

By contrast, the media-driven cessation campaign serves a spe-cific function within the general cessation program by reaching outand beginning a dialogue with smokers. The campaign targets smok-ers who have long and short range plans to quit. The media’s role isto accelerate smokers through these stages to create demand forcessation and thus cessation services. These services then are pro-vided by educational programs, the statewide Quitline, and healthcare providers.

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© 1998 American Cancer Society

Finally, in the public opinion campaign, mediaplays yet another role by providing “cover” for policyand local level initiatives. The campaign is a tool toframe the debate. It can introduce an issue and create“noise.” This not only sparks dialogue but can itselfbecome the environment. Through planning, theMTCP can orchestrate media coverage to support in-dividual community actions for maximum success.

The ProcessThe Massachusetts process for developing media mes-sages is rooted in research.

Formative researchThe process begins with a review of existing researchand interviews with experts in related fields to serve asan “information dump.” The media team analyzes thisinformation and arrives at a variety of different mar-keting hypotheses.

A “voice of the consumer” plan is implemented toelicit “consumer” responses and input on general to-bacco issues as well as on specific hypotheses.Whether the plan calls for a quantitative study, a seriesof focus groups, or both, this process is dynamic. As itunfolds, it becomes a guide to refining what is asked ofthe “consumer.” In this way, hypotheses are con-firmed, denied, or evolved into the most promisingcommunications strategies.

Message developmentAs a result of the formative process, the campaigncommits to key directions. Important questions mustbe answered before we develop concepts: 1) to whomis the message aimed; 2) what helpful informationregarding these messages is available; 3) what is thesingle message to communicate; 4) what tone andmanner should be used; and 5) what justifies theclaims that are made? Once identified, specific ideasfor advertisements are checked with the “voice of theconsumer.” Putting the ideas in front of the targetaudience tests whether the message is communicated,relevant, understandable, and interesting. It also de-

termines whether there are any unintended negativeconsequences.

ExecutionIf the concepts check out on paper, they move intoproduction. Television spots are filmed and edited.Media buys are made. The spots air.

EvaluationFinally, once the campaign has aired, quantitativeevaluative research is conducted to assess the cam-paign on key measures. It is standard to appraise thecampaign on measures of awareness and attitudinalchange. The results of this research are diagnostic andcontribute to the formative process of new initiativeswithin the campaign.

Lessons LearnedLesson 1: youth–there is no one silver bulletYouth are a very diverse target. It is not surprising that9-year-olds are very different from 17-year-olds, butthere are even profound differences between ages 11and 13 years. Age is only one of many factors thataffect the way children view and approach the use oftobacco, and their responses to different motivationalstimuli regarding tobacco. Hence, it is necessary toemploy a variety of messages. The campaign mustidentify those “motivators” that have the broadest im-pact on the population. The following types proved tobe most motivational.

Universal truths. Although youth are different, thereare a number of aspirations that are universal amongadolescents. The majority of teenagers aspire to hav-ing money to do what they want, looking good, beingattractive to the opposite sex, being a good athlete,and being a good role model for younger brothers andsisters.

Smoking can be a barrier to achieving these goals,and messages demonstrating how smoking hindersthese universal aspirations resonate with broad seg-ments of young people. Specific message platformsare: most teens don’t want to date smokers; smokingcauses shortness of breath; smoking causes wrinkles;smoking costs $1000 a year; and smoking leadsyounger siblings to smoke.

Industry manipulation. Having grown up in a world inwhich the media constantly exposes individuals’ andcompanies’ immoral acts, children are extremely cyn-ical. This generation’s reaction has been to live and letlive. They are quick to excuse the tobacco executivesas simply doing their jobs. When we can expose thetobacco industry as different from other industries

TABLE 1Media Targets for MTCP

Objective: Convince youth not to smokeTarget: Youths ages 9–17 yearsObjective: Prompt smokers to quitTarget: Smokers ages 18–49 yearsObjective: Create a supportive environment for a smoke free futureTarget: General public ages 25–54 years

MTCP: Massachusetts Tobacco Control Program.

Effective Counteradvertising Campaign: Massachusetts/Miller 2743

because they manipulate the public, this crosses a linefor youngsters, putting the tobacco industry in a cat-egory apart from all other big business. Specifically,the tobacco industry is positioned as dishonest, ma-nipulative, and trading lives for profits.

Young people will reject any implication that theypersonally have been manipulated by advertising orimagery. This outright rejection of being manipulatedbreaks down the credibility of any positioning thatsupports this personal manipulation. By generalizingthe manipulation, youngsters can accept the argu-ment. They are more apt to agree that younger chil-dren or their friends are manipulated than they are toagree that they are to agree that they are personallymanipulated.

Addiction. The universal aspirations noted earlier andindustry manipulation are the basis for broad strokemessages that resonate across many youth segments.It also is important to discern which messages effec-tively reach the most at-risk sector of this population.

In identifying those groups with both the greatestintentions to smoke and the highest uptake, the cam-paign found (consistent with other studies) that thekey age of cigarette uptake is between 11 and 14 years.In addition, an examination of psychographic and at-titudinal characteristics of the high propensity groupsshowed them to have the following profile: more likelyto get in fights; do not like school; enjoy risky behav-iors; come from families that smoke; and have friendswho smoke.

Universal aspiration messages resonated with“high risk” youngsters and the general youth popula-tion. We also found that high risk youngsters oftenwere surrounded by cigarettes and cigarette smokers.Even as nonsmokers, they believed they had an inti-mate knowledge of cigarettes and purported to under-stand addiction. In their opinion, addiction was realand was a commonly heard reason not to smoke.However, nonsmokers in the high risk group tended tominimize the strength of the addiction claim. Theyequated addiction to what they could relate to “It’slike wanting a piece of chocolate really bad. . .” Onlyaddicted smokers demonstrated a realistic knowledgeof the properties of addiction.

The campaign identified this gap between theirperception versus the reality of addiction as an oppor-tunity. Given that high risk youth believed addictionexisted and was a reason not to smoke, demonstratingthe power and control of a nicotine addiction gavemeaning to their belief that such addiction was areason not to smoke. Addicted youngsters perceivethree different characteristics of addiction that thecampaign has addressed: the physical nature (pres-

sure); the lack of control; and the indiscriminate na-ture of addiction (it can happen to anyone whosmokes a cigarette, anytime).

Emotional benefits. All of the above motivators arerational reasons not to smoke. Successful advertise-ments persuade consumers with a rational argumentand seduce consumers with an emotional benefit.

Adolescent smoking has its roots in the emotionalgratification that smoking behavior offers. Young peo-ple want to be “cool” and this is the image that theyassociate with cigarettes. To counter this strong emo-tional “promise,” antismoking media campaigns mustcreate an alternative emotional promise for a smokefree life-style.

Rewards. The final message category is a direct re-sponse to the tobacco industry’s promotional tactics.The campaign turns their proposition around and of-fers children prizes for choosing a smoke free life-style.

Lesson 2: adult smokers–acknowledge readiness to quitIn exploring the role of advertising in encouragingadults to quit smoking, the campaign learned thatsmokers vary by mindset and can be categorized alonga quit continuum. Smokers are located somewherealong a continuum based on their readiness to quit.“Pre-Contemplators” are smokers with no intention orplans to quit smoking. At the other end of the contin-uum are “Active Quitters.” In the middle are “Contem-plators,” those who have long term plans to quit, and“Ready-to-Quits,” those who have short term plans toquit.

Rather than targeting all smokers with the goalof convincing them to quit, the campaign ad-dressed specific smokers with the goal of movingthem one step closer to cessation. Behavioral the-ory suggested that those who are closer to quit-ting (“Contemplators and Ready-to-Quits”) weremost receptive to “helping relations.” The cam-paign attempted to establish such relations by cre-ating a personal trust, a message of encouragement,and an empathic tone. Messages regarding the ben-efits of quitting were most motivating to “Contem-plators.”

Conversely, “Pre-Contemplators” were most mo-tivated by negative environmental and social pressure.To inspire movement among this group, the campaignfocused on the negative consequences of smoking. Toachieve maximum impact from these messages, themedia effort orchestrated their exposure in a way thatalternated the positive benefits of quitting with the

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negative consequences of smoking, “pushing” and“pulling” the smoker along the continuum.

Lesson 3: public opinion–activate the middleTo create an environment for a smoke free future, it isimportant to have the backing of the majority. In thisway, advertising tobacco is like issue marketing ratherthan product marketing. There are staunch supporterson both sides of the tobacco issue. To win, tobaccocontrol programs must capture the large group thatcurrently is in the uncommitted middle. To capturethe middle, we need to succeed on two fronts: num-bers of supporters and conviction of supporters.

Number of supportersIn convincing this uncommitted middle that tobaccois an important issue, the most compelling messagemay be secondhand smoke. Secondhand smoke repo-sitions the tobacco issue from its current standing as apersons’ right to smoke, to a new place, a persons’right to breathe.

A corollary to the secondhand smoke message isacknowledging that the middle group are not zealotsand will defend their smoking friends. Messages mustbe absolutely clear that the smoker is not the enemyand the issue does not pit smokers against nonsmok-ers. Rather, it is an issue of society against the tobaccoindustry.

ConvictionAlthough changing the attitudes of the middle is im-portant, it is not enough. Victory cannot be claimeduntil there is conviction. Attitude changes must giveway to beliefs. To accomplish this transition, theremust be an emotional reason to care. The researchconducted during the ballot initiative identified theemotional platform for this issue as protecting chil-dren. Even smokers agreed that protecting youth wasa good reason to tax cigarettes.

The campaign returns to the theme of protectingyouth periodically to serve as a reminder of this un-derlying goal and rallying cry. Protecting youth fromaccess, marketing, and exposure to secondhandsmoke all strike an emotional chord and serve to in-spire conviction. The combination of conviction andnumbers will produce the support necessary for actionat the community level.

CONCLUSIONSMassachusetts was one of the first states to embrace amultifaceted approach toward the overall goal of re-ducing tobacco use. These three initiatives (youth pre-vention, adult cessation, and public support) have allcontributed toward the overall success of the programto date.

Effective Counteradvertising Campaign: Massachusetts/Miller 2745