Efficacy of Anti-Tobacco Mass
Evidence-Based Media Campaigns on Adolescent
Practice Tobacco Use
Bernadette Mazurek Melnyk, PhD,
RN-CS, PNP
Michelle Zibisky Silver
Y
outh tobacco consumption is currently the most
Important public heaith issue because it is the iead-
ing cause of preventable death in the Gnited States
(Lamkin, Davis, & Kamen, 1998; Tuakli, Smith, &
Heaton, 1990). Eighty percent of tobacco users begin smok-
ing before they reach adulthood. More than 3,000 children
begin to smoke each day and, according to the CJ.S. Food and
Drug Administration (FDA), at least 1,000 of those children
will eventually die from a tobacco-related illness (Lamkin et
al., 1998; Peracchio, 1998). Smoking substantially increases
the risk of cardiovascular disease, cancer, and cJironic lung
diseases. If adolescents can be kept tobacco-free, most will
not start smoking as adults (Elders, Perry, & Erickson, 1994).
Public health experts agree that tobacco control efforts must
focus on preventing tobacco use and addiction among chil-
dren. After decades of public health education about the long-
term negative effects of tobacco use, children and adoles-
cents are the only age groups who continue to initiate smok-
ing in large numbers, resulting in the FDA classifying smok-
ing as a "pediatric disease" (Peracchio, 1998).
The Centers for Disease Control (CDC) conducted the
1999 National Youth Tobacco Survey, and results indicate
that about one in eight (12.8%) middle school students and
more than one third (34.8%) of high school students reported
using some form of tobacco in the previous month (Tobacco
Use, 1999). The CDC also analyzed data from the 1997 Youth
Risk Behavior Survey (YRBS) and found that, among U.S.
high school students in 1997, 70.2% had tried cigarette smok-
ing. Among those high school students who had tried ciga-
rette smoking, 35.8% went on to smoke daily (CDC, 1998).
Given the high rate of smoking initiation among the young
and the adverse health effects of smoking, it is increasingly
Michelle Zibisky Silver, BSN, RN, is a graduate nurse practitioner,
(Jniversity of North Florida, Jacksonvilie, FL.
Acknowledgment: The author would like to thank Doreen
Radjenovic, PhD, ARNP, for her encouragement, enthusiasm, and
editorial review. Without her valuable contribution, the completion
of this manuscript would not have been possible.
1 1
jThe Euidence-Based Practice section focuses on the search for andj
i critique of the "best evidence" to answer challenging clinical ques-|
itions so that the highest quality, up-to-date care can be provided to
; children and their families. To submit questions or obtain author
iguidelines, contact Bernadette Mazurek Melnyk, PhD, RN-CS, PNP;i
iSection Editor; University of Rochester School of Nursing; 6011
I Elmwood Avenue; Box SON; Rochester, NY 14642; (716) 275-
|8903; bernadette_melnyk@urmc.rochester.edu
PEDIATRIC NURSING/May-June 2001/Vol. 27/No. 3
important for health care professionals to take an active role
in preventing tobacco use. The importance of tobacco use
prevention and cessation programs for youth was addressed
in Healthy People 2000, and new goals have been established
for Healthy People 2010. Limited progress has been made in
reducing the proportion of people aged 20-24 who have
begun to smoke cigarettes, an approximate measure of youth
initiation. According to the CDC, the smoking rate in young
adults dropped from 30% in 1987 to 27% in 1993 (CDC,
1995). Non-profit organizations and government agencies
are increasingly turning to the media to devise advertise-
ments with messages aimed to prevent adolescents from
using tobacco.
Over the last 30 years, the American public has been
heavily influenced by the power of television and its ability to
dictate societal norms (DeJong & Winsten, 1990). Millions of
dollars from tobacco settlement lawsuits have been recently
earmarked for preventive interventions targeted at youth.
Specifically, large sums of money have facilitated the devel-
opment and use of mass media anti-tobacco messages.
Clinical Question
Are media-based anti-tobacco campaigns targeted for
teenagers effective as a community health intervention in pre-
venting youth tobacco use? Medline, FroQuest, and
Academic Index databases were searched using the key-
words adolescents, tobacco, smoking prevention, anti-smok-
ing campaigns, mass media, and health promotion. Members
of the Duval County Health Department in Jacksonville,
Florida, who were knowledgeable in accessing tobacco-relat-
ed research, assisted in locating articles. Reference lists of
data-based articles were used to locate other studies. Studies
were excluded from this review if they included adult subjects
or if they were not primary studies.
The Evidence
Study #1. Siegel and Biener (2000) examined the impact
of a statewide anti-smoking media campaign on smoking
incidence in adolescents who were not established smokers at
baseline. In 1992, Massachusetts voters increased the ciga-
rette excise tax and established a comprehensive anti-smok-
ing intervention that included a media campaign. Aspects of
the media campaign targeted at young people were almost
completely restricted to billboard, radio, and television adver-
tisements. Of the $735,000 expended on advertisements dur-
ing the first 6 months of the media campaign (when the base-
line survey took place), 80% was allocated for television
advertisements, 14 % for radio, 5% for billboards, and 1% for
newspaper advertisements.
In this 4-year longitudinal study of 592 Massachusetts
youth, with baseline data collected in 1993, effects of expo-
sure to television, radio, and outdoor anti-smoking advertis-
ing on the progression to established smoking habits was
assessed. The sample was based on a probability sample of
Massachusetts households drawn by random digit dialing.
Based on initial interviews with adult household informants, a
sample of youths was selected and interviewed over the
phone. Four years later, a portion of this sample of youths was
availahle for follow-up phone interview surveys. Exposure to
the three major channels of the media campaign (i.e., bill-
boards, television, or radio advertisements) was measured by
asking which one the respondent could recall.
The researchers used multiple logistic regression to test
separate and combined effects of each type of advertising on
progression to established smoking, controlling for: age, sex,
race, baseline smoking status, smoking by parents, friends
and siblings, television viewing, and exposure to anti-smok-
ing messages not related to the media campaign. Results
indicated that younger adolescents (aged 12-13 years)
reporting baseline exposure to television anti-smoking adver-
tisements were significantly less likely to progress to estab-
lished smoking than those who had not reported such expo-
sure. Exposure to television anti-smoking advertisements
was not significantly associated with progression to estab-
lished smoking among older adolescents (aged 14-15 years).
No significant effect of exposure to radio or outdoor anti-
smoking advertisements was found.
Study #2. Peracchio (1998) developed and tested an age-
appropriate print advertising campaign to discourage smok-
ing initiation among children and teens. The campaign was
based on young smokers' and nonsmokers' perceptions of
tobacco and the emergence of children's analogical reason-
ing ability. In this two-phase study, a focus group was initially
used to assess teenagers' attitudes and beliefs toward smok-
ing. The convenience sample consisted of 48 male and 58
female students, 15 to 18 years of age, in a large, public high
school in the Midwestern U.S. Respondents were invited to a
classroom furnished with sofas to participate in the focus
groups during a class period. Fifty-five students were smok-
ers and 51 were nonsmokers.
Students completed a screening questionnaire that asked
about smoking behavior. Subjects were divided into four
groups based on gender and smoking behavior. Twenty focus
groups, five of each type, were conducted. Differences in atti-
tudes and beliefs about smoking by gender and smoking sta-
tus were examined. Results suggested that by age 13, both
smokers and nonsmokers had already made long-term
smoking decisions and no longer listened to anti-tobacco
messages. Young smokers had difficulty conceptualizing the
negative effects of smoking on their bodies. Thus, it was con-
cluded that an advertising campaign to discourage smoking
initiation should target young children from 7 to 11 years of
age with the health risks communicated in a concrete man-
ner.
In the second phase of this study, Perrachio (1998)
described the development of an age-appropriate advertising
campaign designed to discourage smoking initiation among
children. Based on the understanding of youth tobacco per-
ceptions garnered in the first phase of this research, a print
advertising campaign was designed by the American Cancer
Society and BVK McDonald advertising agency. This cam-
paign used age-appropriate analogies between negative
smoking effects and health consequences of smoking. For
example, the simplest analogy made was between a dirty
sweat sock and an ashtray full of cigarette butts. In phase two
of this research, Peracchio tested the campaign with children
7 to 11 years of age in order to assess the age appropriate-
ness of tfie analogical messages developed. The ad campaign
was then implemented after testing. Peracchio's research did
not report an analysis of how the campaign impacted smok-
ing outcomes or how being in a smoking household affected
findings. The convenience sample included 50 male and 54
female grade school students who attended a large public
grammar school in the Midwestern U.S. Forty-five of the sub-
jects lived in smoking households, and 59 lived in nonsmok-
ing households. Respondents were divided into four groups
based on their gender and household smoking behavior. Four
focus groups of each type were conducted for a total of six-
teen focus groups. When the youngest students were asked to
interpret the sample ads, they had difficulty understanding
complex analogies representing the effects that smoking
might have on their bodies. This research suggests that if the
long-term health risks of smoking are to be conveyed effec-
tively to both future smokers and nonsmokers, the campaign
must be created in a developmentally appropriate form. It was
recommended that testing of anti-tobacco media advertising
campaigns is necessary to ensure that children can compre-
hend the advertising message.
Study #3. In order to test the ability of a targeted mass
media intervention to enhance the effectiveness of a school-
based smoking prevention program, Worden et al. (1996)
developed and tested a mass media smoking prevention
intervention targeted toward adolescent girls at increased risk
for smoking. The study design included two treatment groups
with two geographically different matched pairs. One pair was
located in the northeastern U.S., and one pair in Montana.
Within each matched pair, one group included students who
only received school smoking interventions and the other
group included students who received the school smoking
interventions and the targeted mass media intervention. This
cohort study included 5,458 students surveyed at baseline in
the fourth through sixth grades every year for 4 years.
The school smoking prevention program included grade
specific curricular material, annual teacher training, and mon-
itoring of program implementation. Educational objectives for
the mass media intervention program based on social learn-
ing and change theories encouraged adolescent girls to have
a negative view of smoking, a positive view of nonsmoking,
skills for refusing cigarettes, and the perception that most
people their age do not smoke. With these objectives in mind,
media producers created 36 television and 17 radio mes-
sages that especially appeal to teenagers.
Mass media interventions targeted at eighth, ninth, and
tenth grade girls resulted in a 40 % lower weekly smoking rate
for those who received the media and school intervention
compared to the school intervention alone. Lower weekly
smoking rates in girls who received the mass media interven-
tions persisted through the tenth, eleventh, and twelfth grades.
Results indicate that mass media interventions targeting spe-
cific audiences can reduce tobacco use for those populations.
Critique of the Evidence
Three studies involving mass media anti-tobacco cam-
paigns were reviewed that indicate the following major find-
ings: (a) anti-tobacco mass media advertising campaigns,
especially television targeted to younger children, are effec-
tive community health interventions in preventing youth
tobacco usage; (b) advertisements that target school-age
children and take into account the audiences' psychological
maturity (analogical reasoning ability) are effective; and (c)
anti-tobacco mass media advertising campaigns may be
most effective in reducing tobacco use in children when used
as part of a multifaceted approach, including community
health education in schools.
All of the studies reviewed were school-based intervention
studies. Studies #2 and #3 used inductive descriptive meth-
ods to develop interventions by gathering information from
surveys and focus groups with children. Sample sizes were
large enough to obtain significant results in all three studies.
Cross contamination was not discussed in any of these stud-
ies, but because the sample groups were in the same school
where the intervention and control programs were adminis-
PEDIATRIC NURSING/May-June 2001 Atol. 27/No. 3
tered, there is a chance that cross contamination occurred.
Despite the presence of any cross contamination, significant
differences between the groups were obtained.
Studies #2 and #3 are based on theoretical frameworks. In
Study # 2, children's analogical reasoning theories were used
to create advertising messages that communicated the health
risks of smoking. In Study #3, common educational objec-
tives for the school and mass media programs were based on
social learning theory and related behavior change theories.
In the 4-year longitudinal youth study by Siegel and Biener
(2000), the authors were the first to examine the relationship
between exposure to a state wide anti-tobacco media cam-
paign and changes in smoking status among youth by using
a cohort design. Using multiple logistic regression, the
authors controlled for multiple variables that could have con-
founded the results (e.g., age, sex, race, baseline smoking
status, smoking by parents, friends, and siblings). Another
strength of the study was random sampling methods from
11,4630 households, which strengthens external validity of
the study. One weakness of this study was that approximate-
ly half of the original baseline sample was lost to follow-up.
Although common, subject attrition is problematic in longitu-
dinal research and may threaten the internal validity of a
study.
According to Siegel and Biener (2000), there were sever-
al limitations to their study. First, the exposure measure that
was used assessed recall, not actual exposure to advertise-
ments. Because the methodology is retrospective, extraneous
variables may have had an effect on the dependent variables
and, therefore, threatened the internal validity of this study.
Second, the baseline survey was administered at the same
time as the opening of the media campaign. Thus, it is possi-
ble that some early respondents who said they were not
exposed did not have a chance to be exposed. The authors
speculate that less intense or less expensive campaigns may
not have the same effect.
Few studies have explored how to develop effective adver-
tising message content to discourage youth smoking initia-
tion. TTierefore, in Study #2, Peracchio (1998) and her asso-
ciates examined young smokers' and nonsmokers' attitudes
toward smoking and assessed children's ability to compre-
hend age-appropriate analogies, which allowed them to
develop an advertising campaign that would discourage chil-
dren from beginning to smoke. Peracchio's study makes sev-
eral contributions to knowledge about smoking initiation. One
contribution is the development of an anti-tobacco advertis-
ing campaign to discourage youth smoking initiation. The
advertisement campaign focuses on communicating the
long-term negative health effects of smoking in a concrete
way by creating analogies between the effects of smoking and
things with which children are familiar. Second, the research
clarifies some of the attitudinal differences between teenage
smokers and nonsmokers. Results also indicate that teen
smokers do not have concrete internal images of the negative
health effects of smoking, but nonsmokers do seem to have
such images.
A strength of Study #3 (Worden et al., 1996) is that it
included a 4-year long cohort study of adolescents from four
different communities. Two matched pairs of Standard
Metropolitan Statistical Areas (SMSAs) were selected using
U.S. Census data; one pair of communities was located in the
northeastern Gnited States and the other pair was in Montana.
Another strength included providing a clear definition of a
smoker and collecting saliva samples to increase accuracy of
self-reports.
Implications for Practice
Tobacco use is a significant health care issue. Because
PEDIATRIC NURSING/May-June 2001/Vol. 27/No. 3
Glossary of Terms
Cohort study
A study of a group of subjects who share common char-
acteristics or experiences over a specific time period.
Convenience sample
A nonprobability sample of individuals readily avail-
able for participation in a study.
Extraneous variable
The quantity of variance in the dependent variable
caused by forces other than the independent variable.
Focus group
A group of participants gathered to discuss, provide
expertise or information about, or work on a selected
topic.
Internal validity
The extent to which the independent variable, not
extraneous variables, accounts for the effects on the
dependent variable.
Longitudinal study
A study with data collection from the same sample at
repeated points in time.
Multiple logistic regression
A statistical method for computing the direction and
strength of the relationship between two or more inde-
pendent variables and one nominal dependent vari-
able.
Probability sample
A sample selected using random sampling procedures.
Note: Adapted from Doordan, A.M. (1998). Research survival
guide. Philadelphia: Lippincott-Raven Publishers.
many users begin before adulthood, it is important for health
care practitioners to be active in attempting to change this
dangerous course of action. The three studies reviewed pro-
vide data that suggest mass media anti-tobacco campaigns
targeted at children are effective in preventing tobacco use,
yet each study reveals something different about the effec-
tiveness of anti-tobacco mass media campaigns.
As the rate of tobacco use among children escalates, it is
increasingly important for health care professionals to take an
active role in preventing tobacco use. Preventing children
from using tobacco requires nurses to be active in many dif-
ferent ways. Tobacco related clinical interventions should be
routinely incorporated into all office visits with youth (LaSala
& Todd, 2000).
Despite evidence that it works, health care professionals
often do not use opportunities for tobacco use intervention
(Danis & Seaton, 1997; Merrill, 1995). Nurses have valuable
opportunities for face-to-face meetings with children and
teens. Every patient should be asked about smoking status at
each visit and this information should be documented.
Documentation of smoking status on the chart serves as a
reminder to members of the health care team to counsel the
child during each office visit (Larson, 1997). Nurses must
work in collaboration with other clinical professionals and
educators to counsel, educate, and motivate young children
to refrain from or stop smoking. Based on results from these
studies, addressing tobacco use prevention must begin with
school-age chiidren and continue with adolescents.
Nurses also must be actively involved in the community,
directing resources for public awareness and tobacco preven-
tion programs by assisting in formulating public policy to con-
trol youth tobacco use. Nurses are in a unique position to con-
tribute to a multifaceted approach to the anti-tobacco move-
ment that includes clinic-, community-, school-, and mass
media-based programs. Tobacco control programs need to
be systematically implemented and evaluated to determine
the most effective methods to reach children. Future research
should focus on sustaining the effects of anti-smoking mass
media messages in all age groups.
Nurses need to be active on state policy boards and task
forces, making decisions on how tobacco settlement dollars
granted to states will be spent. Funds need to be used for
tobacco prevention and control activities, cessation pro-
grams, and for health care issues related to tobacco use. In
order to make a powerful difference, nurses will need to be
intimately involved in the political process. It is not enough to
write and/or call legislators; nurses will have to work their way
into the political process as public health representatives
(LaSala & Todd, 2000).
In November of 1998, the attorneys general of 46 states
signed a settlement agreement with the tobacco industry that
would fund a national tobacco control foundation. Payments
to the states will total approximately $206 billion through the
first 25 years. Settlement agreements are a result of the initial
actions taken by the state of Florida in 1995. Florida sued the
tobacco industry to recoup costs for treating Florida's
Medicaid patients suffering from tobacco-induced illnesses,
fund smoking cessation, restrict tobacco marketing, and fund
an anti-tobacco education campaign. Rorida started an anti-
smoking campaign not only aimed at teenagers, but also
developed by them. According to the literature, it has been so
successful that in 1998, the year that the campaign received
the most funding in Florida, the teenage smoking prevalence
rate dropped 10%, and the number of 12-14-year-olds who
smoke dropped 19%. These figures made it the most effective
such campaign in the country {In Rorida, kicking butts,
1999; CDC, 1999). Unfortunately, some political leaders were
not convinced that the program was working and funding was
recently diminished (Givel & Qlantz, 2000).
Evidence shows that statewide, state-funded, anti-tobacco
mass media campaigns are effective as additions to commu-
nity efforts to decrease tobacco use among the target popula-
tion. The type of advertisements that appeal to children can be
expensive to produce, and researching effective messages is
costly. Therefore, it is important for nurses and health care pro-
fessionals to be aware of these types of interventions and their
effectiveness, and support their funding by state legislation.
Nurses and other heaith care professionals need to learn how
to support those health advocates who are active lobbyists and
become professional organization members and lobbyists for
health care issues that are important. At the very least, health
care professionals should be aware of the types of effective
interventions and messages that children are currently being
exposed to and continue to reinforce anti-tobacco messages.
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CaJtifor PoMuty Matters
Section Articles
The Family Matters section focuses on issues,
information, and strategies relevant to working
with families of pediatric patients. To suggest top-
ics, obtain author guidelines, or to submit queries
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CaJll for Pra^tice^ A ^ nsof
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The Practice Applications of Research section pre-
sents reports of research that are clinically
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