The Role of the Media in Promoting and Reducing Tobacco Use doc

The Role of
the Media in
Promoting and
Reducing
Tobacco Use
NCI TOBACCO CONTROL MONOGRAPH SERIES
U.S. DEPARTMENT
OF HEALTH AND
HUMAN SERVICES
National Institutes
of Health
National Cancer Institute
Edited by
Ronald M. Davis, M.D.
Elizabeth A. Gilpin, M.S.
Barbara Loken, Ph.D.
K. Viswanath, Ph.D.
Melanie A. Wakefi eld, Ph.D.
19
Other NCI Tobacco Control Monographs
Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the
1990’s. Smoking and Tobacco Control Monograph No. 1. NIH Pub. No. 92-3316, December 1991.
Smokeless Tobacco or Health: An International Perspective. Smoking and Tobacco Control
Monograph No. 2. NIH Pub. No. 92-3461, September 1992.
Major Local Tobacco Control Ordinances in the United States. Smoking and Tobacco Control
Monograph No. 3. NIH Pub. No. 93-3532, May 1993.
Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Smoking and
Tobacco Control Monograph No. 4. NIH Pub. No. 93-3605, August 1993.
Tobacco and the Clinician: Interventions for Medical and Dental Practice. Smoking and Tobacco
Control Monograph No. 5. NIH Pub. No. 94-3693, January 1994.
Community-based Interventions for Smokers: The COMMIT Field Experience. Smoking and

Tobacco Control Monograph No. 6. NIH Pub. No. 95-4028, August 1995.
The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of
U.S. Cigarettes. Report of the NCI Expert Committee. Smoking and Tobacco Control Monograph
No. 7. NIH Pub. No. 96-4028, August 1996.
Changes in Cigarette-Related Disease Risks and Their Implications for Prevention and Control.
Smoking and Tobacco Control Monograph No. 8. NIH Pub. No. 97-4213, February 1997.
Cigars: Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9. NIH Pub. No.
98-4302, February 1998.
Health Effects of Exposure to Environmental Tobacco Smoke. Smoking and Tobacco Control
Monograph No. 10. NIH Pub. No. 99-4645, August 1999.
State and Local Legislative Action to Reduce Tobacco Use. Smoking and Tobacco Control
Monograph No. 11. NIH Pub. No. 00-4804, August 2000.
Population Based Smoking Cessation. Smoking and Tobacco Control Monograph No. 12. NIH Pub.
No. 00-4892, November 2000.
Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine.
Smoking and Tobacco Control Monograph No. 13. NIH Pub. No. 02-5047, October 2001.
Changing Adolescent Smoking Prevalence. Smoking and Tobacco Control Monograph No. 14.
NIH Pub. No. 02-5086, November 2001.
Those Who Continue to Smoke. Smoking and Tobacco Control Monograph No. 15. NIH Pub. No.
03-5370, September 2003.
ASSIST: Shaping the Future of Tobacco Prevention and Control. Tobacco Control Monograph
No. 16. NIH Pub. No. 05-5645, May 2005.
Evaluating ASSIST: A Blueprint for Understanding State-level Tobacco Control. Tobacco Control
Monograph No. 17. NIH Pub. No. 06-6058, October 2006.
Greater than the Sum: Systems Thinking in Tobacco Control. Tobacco Control Monograph No. 18.
NIH Pub. No. 06-6085, April 2007.
Note, when citing this monograph in other works, please use the following format:
National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco Use. Tobacco
Control Monograph No. 19. Bethesda, MD: U.S. Department of Health and Human Services, National
Institutes of Health, National Cancer Institute. NIH Pub. No. 07-6242, June 2008.

We dedicate this monograph
to our cherished colleague and friend,
Ronald M. Davis, M.D.
We have considered it a privilege to work with Ron Davis as the lead Senior Scientifi c Editor
of this monograph. Ron is known to many as a passionate advocate for tobacco control,
who has used his fi nely honed skills as a translator of complex scientifi c concepts to facilitate
progress in public health policy. Ron guided the development of this monograph from its
conception to completion with outstanding leadership qualities and an unfl inching pursuit
of excellence. The extraordinary breadth and depth of his knowledge and experience in this
fi eld, combined with his scientifi c rigor and precision, made his contributions invaluable.
Despite being diagnosed with pancreatic cancer in early 2008, Ron continued to work
tirelessly on this monograph, employing his characteristic patience, good humor, and focused
determination. His contributions will help ensure that this volume will serve as a defi nitive
resource to guide the tobacco control community for many years to come.
Both we and the tobacco control community are indebted to Ron for his work on this
monograph and for his remarkable and inspiring leadership in the cause of public health.
The Editorial Team of Monograph 19
M.W., E.G., B.L., K.V., S.M., and M.R.

v
Contents
Figures and Tables ix
Foreword xiii
Message from the Series Editor xv
Preface xvii
Acknowledgments xix
Acronyms and Abbreviations xxvii
Part 1—Introduction 1
Chapter 1—Overview and Conclusions 3
Introduction 4

Tobacco and the Media: A Multilevel Perspective 5
Studying the Media and Tobacco 8
Preparation of this Monograph 10
Monograph Organization 10
Major Conclusions 11
Chapter Summaries and Conclusions 12
References 23
Chapter 2—Theoretical Underpinnings of Media Research in Tobacco Control and
Tobacco Promotion 25
Introduction 26
History of Media-Effects Research 27
Levels of Theory and Analysis 28
Summary 44
References 45
Part 2—Tobacco Marketing 51
Chapter 3—Key Principles of Tobacco Promotion and Rationales for Regulation 53
Introduction
54
Key Principles of Tobacco Advertising and Promotion 54
A Rationale for Regulating Tobacco Promotion 74
Summary 86
Conclusions 86
References 88
Chapter 4—Types and Extent of Tobacco Advertising and Promotion 99
Introduction
100
Sources of Data 101
Types of Tobacco Advertising and Promotion 102
Extent of Tobacco Advertising and Promotion 118
vi

Summary 132
Conclusions 132
References 134
Chapter 5—Themes and Targets of Tobacco Advertising and Promotion 141
Introduction
142
Segmentation, Tailoring, and Targeting 143
Dominant Themes 145
Targeting of Population Subgroups 150
Summary 170
Conclusions 170
References 172
Chapter 6—Tobacco Companies’ Public Relations Efforts: Corporate Sponsorship
and Advertising 179
Introduction 180
Public-Image Problems of the Tobacco Companies 182
Corporate Sponsorship 184
Corporate Advertising 189
PM21: An Integrated Public Relations Campaign 198
Summary 202
Conclusions 204
References 205
Chapter 7—Infl uence of Tobacco Marketing on Smoking Behavior 211
Introduction 212
Adolescents’ Psychological Needs and the Infl uence of Cigarette Marketing 213
Role of Image Enhancement from Cigarette Marketing 227
Evidence of Effects of Exposure to Cigarette Marketing on Adolescent Smoking 238
Effects of Tobacco Advertising on Tobacco Consumption 268
Summary 278
Conclusions 280

References 282
Chapter 8—Legal and Constitutional Perspectives on Tobacco Marketing
Restr ictio ns 293
Introduction
294
Constitutional, Statutory, and Regulatory Perspectives 294
Summary 316
Conclusions 316
Notes 317
References 320
Part 3—Tobacco in News and Entertainment Media 327
Chapter 9—How the News Media Infl uence Tobacco Use 329
Introduction 330
Perspectives on News Story Selection and Content 331
Contents
vii
Monograph 19. The Role of the Media
Media Advocacy for Tobacco Control 335
Descriptive Studies of News Coverage of Tobacco Use 336
Relating News Coverage of Tobacco to Individual Attitudes, Behaviors, and
Policy Outcomes 341
Tobacco Industry Infl uence on News Reporting 345
Future Directions 348
Summary 350
Conclusions 350
References 352
Chapter 10—Role of Entertainment Media in Promoting or Discouraging Tobacco Use 357
Introduction
358
Historical Perspective: Movies 360

Movie Content 364
Effects on Attitudes, Beliefs, and Behavior: Movies 376
Tobacco Content in Other Media 392
Efforts to Reduce Exposure 399
Efforts to Modify Response to Exposure 409
Summary 411
Conclusions 412
Appendix 10A. Statement by Attorney General Curran of Maryland on Role of the
State Attorneys General 414
Appendix 10B. Letter from 28 State Attorneys General to Jack Valenti and Response 418
Appendix 10C. Letter from Lorillard to California Assistant Attorney General
Dennis Eckhart Regarding Brand Appearance of Newport in the Movie
City by the Sea 422
References 423
Part 4—Tobacco Control Media Interventions 429
Chapter 11—An Overview of Media Interventions in Tobacco Control: Strategies
and Themes 431
Introduction 432
Nontelevised Mass Media Antitobacco Interventions 434
Televised Antitobacco Advertisements 445
Relative Performance of Televised Antitobacco Advertising Approaches 449
New-Media Interactive Health Communications for Smoking Cessation 463
Summary 468
Conclusions 469
References 470
Chapter 12—Assessing the Effectiveness of the Mass Media in Discouraging
Smoking Behavior 479
Introduction 480
Controlled Field Experiments 482
Population-Based Studies 509

Summary 535
viii
Conclusions 536
References 538
Part 5—Media, Tobacco Control Interventions, and Tobacco Industry
Mitigation Efforts 547
Chapter 13—Tobacco Industry Efforts to Infl uence Tobacco Control Media
In t er v en tio ns 549
Introduction 550
Fairness Doctrine 550
Minnesota 551
California 556
Ar i zon a 562
Florida 565
American Legacy Foundation 567
Summary 571
Conclusions 571
References 572
Chapter 14—Tobacco Industry Media Efforts to Defeat State Tobacco Control
Ballot Initiatives and Referenda 577
Introduction 578
Criticisms of State Initiatives and Referenda 579
General Role of Media in State Initiatives and Referenda 583
Methods 584
State Tobacco Control Initiatives and Referenda 585
Tobacco Industry Opposition to State Tobacco Tax Initiatives and Referenda 585
Results 589
Summary 591
Conclusions 592
References 593

Part 6—Future Directions 595
Chapter 15—Future Directions 597
Introduction 598
Future Directions to Address Tobacco Promotion 598
Future Directions for Media Strategies in Tobacco Control 604
Conclusions 612
References 614
Appendix—Michigan’s Proposal A 619
Index 627
Contents
ix
Figures and Tables
Figures
Figure 1.1 The Nested Relationships among Advertising, Marketing
Communications, Consumer Marketing, and Stakeholder Marketing
in Tobacco Promotion 6
Figure 2.1 Institutional Conception of Media Organization 37
Figure 4.1 Cigarette Advertising and Promotional Expenditures in the
United States, 1970–2005 120
Figure 4.2 Share of Market for Light Cigarettes and Percentage of Marketing
Expenditures Devoted to Light Cigarettes, 1967–1998 128
Figure 6.1 Public Opinion of Tobacco Companies: Roper Poll of 2,078 Adults,
September 1999 183
Figure 6.2 Philip Morris’s Annual Advertising Expenditures for its Corporate and
Marlboro Brands 194
Figure 6.3 Overview of PM21 Advertising Campaign 199
Figure 7.1 Relationship between Levels of Advertising and Consumption
Aggregated at the National Level 270
Figure 7.2 Relationship between Levels of Advertising and Consumption
Aggregated at the Market Level 271

Figure 10.1 Smoking Initiation Rates Among U.S. Males and Females Ages 14–17
Years, by Year 361
Figure 10.2 Lowess Smoothed Curve Showing Cross-Sectional Relationship
between Exposure to Movie Smoking Depictions and Adolescent
Smoking Initiation in a Study of Northern New England Adolescents 382
Figure 10.3 Lowess Smoothed Curve Showing the Longitudinal Relationship
between Exposure to Movie Smoking Depictions and Adolescent
Smoking Initiation in a Study of Northern New England Adolescents 384
Figure 13.1 Adult Per Capita Cigarette Consumption and Major Smoking-and-
Health Events 551
Figure 13.2 Total Number and Type of Advertisements for the California Tobacco
Control Media Campaign, 1990 –2006 560
Figure 13.3 Budget Allocations for the California Tobacco Control Media Program,
1989– 2 003 562
Tables
Table 4.1 Chronology of Tobacco Industry Activities Related to Smoking in
Motion Pictures, 1972–2001 115
Table 4.2 Cigarette Advertising and Promotional Expenditures in the
United States, 1970–2005 119
x
Table 4.3 Cigarette Advertising and Promotional Expenditures in the
United States, 2005 121
Table 4.4 Cigarette Advertising and Promotional Expenditures in the
United States, 1995–2005 122
Table 4.5 Cigarette Advertising and Promotional Expenditures in the
United States, 1970–2005, with Relative Emphasis on Advertising
Versus Promotion 122
Table 4.6 Advertising-to-Sales Ratios for Selected Product Categories,
1975–200 6 123
Table 4.7 Cigarette Company Advertising Expenditures, 1945–1980 124

Table 4.8 Cigarette Company Advertising Expenditures for Selected Brands in
Selected Years between 1972 and 2000 125
Table 4.9 Global Brand Equity for Leading Brands, 2006 126
Table 4.10 Percentage of Total Advertising Expenditures in Selected Media
Devoted to Cigarette Advertising, United States, 1984–1988 127
Table 4.11 Cigar Advertising and Promotional Expenditures for Years 1996
and 1997 129
Table 4.12 Smokeless Tobacco Advertising and Promotional Expenditures by
Category for 2005 130
Table 7.1 Studies of the Relationships among Self-Image, Smoker Image, and
Adolescent Smoking 228
Table 7.2 Studies Involving Randomized Experimental Manipulation of
Exposure to Cigarette Marketing 235
Table 7.3 Cross-Sectional Studies of the Association of Tobacco Marketing
with Adolescent Smoking 242
Table 7.4 Longitudinal Studies Predicting Later Smoking Behavior from
Measures of Exposure to Tobacco Marketing at Baseline 259
Table 7.5 Econometric Studies of Tobacco Advertising and Consumption 273
Table 9.1 News Media Papers Presented at World Conferences on Tobacco OR
Health, 1983–2003 332
Table 10.1 Summary of Methods for Content Analysis Studies: Tobacco
in Movies 367
Table 10.2 Brand Cigarette Use Depicted in Contemporary Movies 375
Table 10.3 Summary of Results of Cross-Sectional and Longitudinal Studies:
Smoking and Movies 378
Table 10.4 Validity of Adolescents’ Recognition of Movie Titles 381
Table 10.5 Summary of the Methods and Results of Experimental Studies
Assessing Responses to On-Screen Tobacco Use 386
Table 10.6 Number of Smoking Acts per Hour of Television Drama for Different
Content Analysis Studies Conducted in the United States 393

Table 11.1 Mean Monthly Exposures per Year to Tobacco-Related Television
Advertising for Television Households and Adolescents Aged 12–17
Years, Based on the Top 75 Designated Market Areas in the
United States 435
Figures and Tables
xi
Monograph 19. The Role of the Media
Table 11.2 States Ranked for Mean Monthly Exposures to State Antitobacco
Television Advertising (Households, Gross Rating Points) 436
Table 11.3 States Ranked for Mean Monthly Exposures to State Antitobacco
Television Advertising (Adolescents Aged 12–17 Years, Target
Rating Points) 437
Table 11.4 Mass Media Antitobacco Campaigns in the United States, 1990–2004 438
Table 11.5 Characterizations of Antitobacco Advertisements’ Content and Style 450
Table 11.6 Studies Examining the Relative Performance of Different Advertising
Mess ages 4 51
Table 12.1 Summary of Reviewed Controlled Field Experiments: Youth 486
Table 12.2 Summary of Reviewed Controlled Field Experiments: Adults 494
Table 14.1 U.S. States in 2005 with Statewide Initiatives and Referenda 579
Table 14.2 U.S. States in 2005 by Type of Initiative Allowed 580
Table 14.3 Tobacco Control State Initiatives and Referenda from 1988 to 2006 581
Table 14.4 1988 Tobacco Industry Advertisements Opposing California’s
Proposition 99 586
Table 14.5 1992 Tobacco Industry Advertisements Opposing Massachusetts’s
Question 1 587
Table 14.6 2004 Tobacco Industry Advertisements Opposing Oklahoma’s State
Question 713 587
Table 14.7 2004 Tobacco Industry Advertisements Opposing Montana’s
Initiative 149 589
Table 14.8 2004 Tobacco Industry Advertisements Opposing Colorado’s

Amendment 35 589
Table 14.9 2006 Tobacco Industry Advertisements Opposing California’s
Proposition 86 590
Table 14.10 2006 Tobacco Industry Advertisements Opposing Missouri’s
Amendment 3 590
Table 14.11 Number of Times Tobacco Industry Advertising Themes Were Used
to Oppose California and Massachusetts Tobacco Tax Initiatives in
1988 and 1992 590
Table 14.12 Number of Times Tobacco Industry Advertising Themes Were Used
to Oppose 2004 Colorado, Montana, and Oklahoma Initiatives and
Referenda and 2006 California and Missouri Initiatives 591

xiii
Foreword
When I fi rst started TV work with the ABC affi liate in Boston in 1972, broadcast television
was king, with a realm dominated by only ABC, CBS, and NBC. Even though I got into the
business by accident and had no formal training in media, I quickly understood the power
of the airwaves to infl uence the minds and hearts of viewers. I also became very conscious of
the attendant responsibility to be accurate and understandable, remembering Mark Twain’s
admonition (loosely phrased) to beware of reading health books because mistakes can kill you.
Perusing the information in this enormously informative volume, I was once again reminded
of those elemental emotions: exhilaration about the opportunities offered by media and
anxiety about the potential for misuse. Any phrase or sound bite can affect millions of
people. In dealing with tobacco, I think the power of this potential must never be forgotten.
Tobacco captivates people when they cannot rationally resist its siren call and can unleash
a slow, deadly disease that can kill them even as they try to escape the tenacious trap of
addiction. So those of us given the privilege of access to media should be aware of our own
responsibilities in the fi ght against tobacco use—including the need to choose words and
images to counter misinformation and temptation aimed at the young entrusted to our care.
I have come to believe that unless we think and feel that we are fi ghting a lethal battle against

tobacco use, we will not succeed in stemming the forces that would promote it. This volume
contains a wealth of information about how tobacco companies use media to their benefi t.
I predict that, like me, even though you have seen them in action, you will be amazed by
the tactics used to promote tobacco. Tobacco use is a social phenomenon largely propelled
by mass media over the past century, led by tobacco industry professionals who constantly
change strategies to reach their goals. They combine the resourcefulness of a profi t-making
industry with a changing media and regulatory landscape to sell a product that remains our
greatest public health challenge. We will not remove tobacco from our society unless we are
willing to understand the industry’s constantly changing tactics.
But this volume provides encouragement—information about successful efforts to fi ght back.
Again I was surprised by what can work and stimulated to think about new ways to take a
stand and make a difference.
I invite you to consider this volume a valuable reference for understanding how media can
be used in the war against tobacco. Keep it handy for wise counsel, strategic encouragement,
and a partner in a noble cause.
Tim Johnson, M.D., M.P.H.
Medical Editor, ABC News
June 2008

xv
Message from the Series Editor
This volume is the 19th of the Tobacco Control Monograph series of the National Cancer
Institute (NCI). This series began in 1991 with a visionary blueprint for public health action
on tobacco prevention and control. In the years since, it has disseminated important cross-
cutting research in areas such as the effectiveness of community-based and population-level
interventions, the impact of tobacco control policies, the risks associated with smoking
cigars and low-tar cigarettes, and systems approaches to tobacco control.
The subject matter of this monograph stands at the confl uence of three major trends of the
past century: the growth of mass media, the concomitant rise in cigarette smoking as a social
phenomenon, and more recently, research to understand and to decrease the disease burden

caused by tobacco use. Cigarettes are a product of the mass media era; the art and science of
mass communications and mass marketing were critical to the growth of tobacco use in the
past century. At the same time, however, the media have contributed signifi cantly to the roughly
50% decline in smoking prevalence that took place over the past four decades, by increasing
public knowledge of the health hazards of cigarette smoking, helping to change social norms
about cigarette smoking, and increasing public acceptance of tobacco control policies.
This monograph summarizes what we have learned about the ability of the media to encourage
and discourage tobacco use. There has been much interest in and study of media, and several
government publications document the impact of advertising on tobacco use. This publication
provides the most comprehensive and critical review and synthesis of the current evidence base
in this area, drawing on work from many disciplines and research traditions. There is growing
interest in applying what we have learned in tobacco prevention and control to other public
health areas (such as dietary behavior). This monograph has important messages for public
health researchers, practitioners, and policymakers as well as those in the communication
science and media studies communities.
This monograph provides a comprehensive assessment of the literature on developing
effective pro-health media messages and on policies to control tobacco marketing, both in
the United States and abroad. This information is critical to support efforts to reduce the use
of tobacco and the morbidity and mortality associated with its use. The evidence presented
in this volume also underscores the need to continue to study and understand the ability of
protobacco forces to change media strategies to adapt to a changing tobacco control policy
environment.
We are pleased that Dr. Timothy Johnson, Medical Editor for ABC News, has provided the
Foreword to this volume. As a physician who began working in television in 1972, he has
a long-standing record of communicating the harmful effects of smoking to the public.
His background and commitment provide invaluable perspectives about the power of the
media and why this monograph is so important for tobacco prevention and control.
Stephen E. Marcus, Ph.D.
Monograph Series Editor
June 2008

xvii
Preface
The work presented in the National Cancer Institute’s Tobacco Control Monograph 19,
The Role of the Media in Promoting and Reducing Tobacco Use, is the most current and
comprehensive distillation of the scientifi c literature on media communications in tobacco
promotion and tobacco control. This ambitious effort to synthesize the science bridged
the disciplines of marketing, psychology, communications, statistics, epidemiology, and
public health and represents the combined efforts of fi ve scientifi c editors, 23 authors,
and 62 external peer reviewers.
The six main parts of this monograph deal with aspects of media communications relevant
to tobacco promotion and tobacco control. Part 1, an overview, frames the rationale for
the monograph’s organization and presents the key issues and conclusions of the research
as a whole and of the individual chapters. This section describes media research theories
that guided this assessment of the relationship between media and tobacco use, which can
be viewed as a multilevel issue ranging from consumer-level advertising and promotion to
stakeholder-level marketing aimed toward retailers, policymakers, and others.
Part 2 further explores tobacco marketing—the range of media interventions used by
the tobacco industry to promote its products, such as brand advertising and promotion,
as well as corporate sponsorship and advertising. This section also evaluates the evidence
for the infl uence of tobacco marketing on smoking behavior and discusses regulatory and
constitutional issues related to marketing restrictions.
Part 3 explores how both the tobacco control community and the tobacco industry have
used news and entertainment media to advocate their positions and how such coverage
relates to tobacco use and tobacco policy change. The section also appraises evidence of the
infl uence of tobacco use in movies on youth smoking initiation. Part 4 focuses on tobacco
control media interventions and the strategies, themes, and communication designs
intended to prevent tobacco use or encourage cessation, including opportunities for new
media interventions. This section also synthesizes evidence on the effectiveness of mass
media campaigns in reducing smoking. Part 5 discusses tobacco industry efforts to diminish

media interventions by the tobacco control community and to use the media to oppose state
tobacco control ballot initiatives and referenda. Finally, Part 6 examines possible future
directions in the use of media to promote or to control tobacco use and summarizes research
needs and opportunities.
Key lessons from this volume can inform policymakers as well as scientists and practitioners.
Most critical from a policy standpoint is the conclusion, supported by strong evidence, that
both exposure to tobacco marketing and depictions of tobacco in movies promote smoking
initiation. A fundamental theme throughout this monograph is the dynamic interplay
between tobacco promotion and tobacco control, whereby action in one area produces change
in the other. For example, when limits have been placed on tobacco promotion, the tobacco
industry typically has resisted, evolving alternative strategies to effectively reach current and
potential smokers with media messages that promote its products.
xviii
Preface
In the United States in 2005—the same year in which 2.7 million American adolescents
aged 12 to 17 used cigarettes in the past month
1
and 438,000 Americans died prematurely
from diseases caused by tobacco use or secondhand smoke exposure
2
—the tobacco industry
spent $13.5 billion (in 2006 dollars) on cigarette advertising and promotion,
3
an average
of $37 million per day. The tobacco industry continues to succeed in overcoming partial
restrictions on tobacco marketing in the United States, and tobacco marketing remains
pervasive and effective in promoting tobacco use. Efforts to curb the depiction of tobacco
use in movies have increased in recent years, and the evidence reviewed here indicates
that progress in this area could be expected to translate into lower rates of youth smoking
initiation in the future.

Strong evidence indicates that media campaigns can reduce tobacco use. This underscores
the importance of adequately funding mass media campaigns and of protecting them from the
tobacco industry’s efforts to impede them. The monograph provides guidance about the types
of media campaign messages that are most and least likely to perform well.
This volume highlights the complexities of assessing the media’s infl uence on tobacco-related
attitudes and behavior. The ubiquity of the media means that randomized controlled trial
designs are typically not feasible, so other study approaches must be used to assess causality
of associations between exposures and outcomes. Accordingly, a vast range of research—
from experimental forced-exposure studies in the laboratory to survey and cohort studies of
populations—is reviewed.
The monograph editors hope that the evidence gathered and synthesized in this volume
will facilitate progress in tobacco control in the United States and throughout the world.
This review should be a valuable resource for those seeking to understand the effects of
tobacco promotion and tobacco control media campaigns in their own jurisdictions as well as
those charged with implementing aspects of the Framework Convention on Tobacco Control.
Finally, this monograph contributes to a broader understanding of the media’s past and
potential roles to exacerbate or ameliorate other major public health problems of our time.
The Scientifi c Editors of Monograph 19
R.D., E.G., B.L., K.V., and M.W.
References
1. Substance Abuse and Mental Health Services Administration. 2005. Results from the 2005 National
Survey on Drug Use and Health. Offi ce of Applied Studies, NSDUH Series H-27, DHHS Publication
no. SMA 05–4061. Rockville, MD. />2. Centers for Disease Control and Prevention. 2006. Smoking and tobacco use fact sheet: Tobacco-
related mortality (updated September 2006). http//www.cdc.gov/tobacco/data_statistics/Factsheets/
tobacco_related_mortality.htm.
3. Federal Trade Commission. 2007. Federal Trade Commission cigarette report for 2004 and 2005.
/>xix
Monograph Series Editor
Stephen E. Marcus, Ph.D.
Epidemiologist

Tobacco Control Research Branch
Behavioral Research Program
Division of Cancer Control and Population
Sciences
National Cancer Institute
Bethesda, MD
Scientifi c Editors
Ronald M. Davis, M.D.
Senior Scientifi c Editor
Director
Center for Health Promotion & Disease
Prevention
Henry Ford Health System
Detroit, MI
Elizabeth A. Gilpin, M.S.
Clinical Professor of Biostatistics
Cancer Prevention & Control Program
University of California, San Diego
Moores Cancer Center
La Jolla, CA
Barbara Loken, Ph.D.
Professor
Department of Marketing
Carlson School of Management
University of Minnesota
Minneapolis, MN
K. Viswanath, Ph.D.
Associate Professor
Department of Society, Human Development
& Health

Harvard School of Public Health
Department of Medical Oncology
Dana Farber Cancer Institute
Boston, MA
Melanie A. Wakefi eld, Ph.D.
Senior Scientifi c Editor
Director and NHMRC Principal Research
Fellow
Centre for Behavioural Research in Cancer
Cancer Control Research Institute
The Cancer Council Victoria
Victoria, Australia
Contributing Authors
Lois Biener, Ph.D.
Senior Research Fellow
Center for Survey Research
University of Massachusetts, Boston
Boston, MA
Anthony Biglan, Ph.D.
Senior Scientist
Oregon Research Institute
Eugene, OR
Simon Chapman, Ph.D.
Professor
School of Public Health
University of Sydney
New South Wales, Australia
This monograph was developed by the National Cancer Institute under the general direction
of Stephen E. Marcus, Monograph Series Editor. The Scientifi c Editors Ronald M. Davis,
Elizabeth A. Gilpin, Barbara Loken, K. Viswanath, and Melanie A. Wakefi eld were responsible

for the editorial content of the monograph. The editors also drafted original chapters or
sections of chapters for this monograph. Contributing authors drafted chapters or sections of
chapters. Reviewers with relevant expertise provided critical reviews of the content by section,
chapter, and/or volume.
Acknowledgments
xx
Christine Cody
Oregon Research Institute
Eugene, OR
Erik C. Crankshaw, M.P.H.
Public Health Research Associate,
Community Health Promotion Research
Public Health and Environment Division
RTI International
Research Triangle Park, NC
Tess Boley Cruz, Ph.D., M.P.H.
Assistant Professor of Research
Institute for Prevention Research
Keck School of Medicine
University of Southern California
Alhambra, CA
Kevin C. Davis
Research Economist
RTI International
Research Triangle Park, NC
Timothy Dewhirst, Ph.D.
Assistant Professor
Department of Marketing and Consumer
Studies
College of Management and Economics

University of Guelph
Guelph, Ontario, Canada
Helen Dixon, Ph.D.
Senior Research Fellow
Centre for Behavioural Research in Cancer
Cancer Control Research Institute
The Cancer Council Victoria
Victoria, Australia
Matthew C. Farrelly, Ph.D.
Senior Program Director
Public Health Policy Research
Public Health & Environment Division
RTI International
Research Triangle Park, NC
John R. Finnegan Jr., Ph.D.
Professor & Dean
School of Public Health
University of Minnesota
Minneapolis, MN 55455
Michael Givel, Ph.D.
Associate Professor
Department of Political Science
University of Oklahoma
Norman, OK
Stanton A. Glantz, Ph.D.
Professor of Medicine
Department of Medicine
Division of Cardiology
University of California, San Francisco
San Francisco, CA

Marvin E. Goldberg, Ph.D.
Irving and Irene Bard Professor of Marketing
Smeal College of Business
Pennsylvania State University
University Park, PA
Lawrence Gostin, J.D.
Associate Dean
Research and Academic Programs
Georgetown University
Washington, DC
Gerard Hastings, Ph.D.
Director of the Institute for Social
Marketing and the Centre for Tobacco
Control Research
University of Stirling and the Open University
Stirling, Scotland
Lisa Henriksen, Ph.D.
Senior Research Scientist
Stanford Prevention Research Center
Stanford University School of Medicine
Stanford, CA
Jennifer K. Ibrahim, Ph.D., M.P.H., M.A.
Assistant Professor
Department of Public Health
Temple University
Philadelphia, PA
Gail H. Javitt, J.D., M.P.H.
Law and Policy Director
Genetics & Public Policy Center
Phoebe R. Berman Bioethics Institute

The Johns Hopkins University
Washington, DC
Acknowledgments
xxi
Monograph 19. The Role of the Media
Pamela Ling, M.D, M.P.H.
Assistant Professor in Residence
Department of Medicine, General Internal
Medicine
University of California San Francisco
San Francisco, CA
Henry Saffer, Ph.D.
Research Associate
National Bureau of Economic Research
New York, NY
James D. Sargent, M.D.
Professor of Pediatrics
Director, Cancer Control Research Program
Norris Cotton Cancer Center
Dartmouth Medical School
Lebanon, NH
Katherine Clegg Smith, Ph.D.
Assistant Professor
Bloomberg School of Public Health
Department of Health, Behavior, and Society
The Johns Hopkins University
Baltimore, MD
Victor J. Strecher, Ph.D., M.P.H.
Professor and Director
Health Media Research Laboratory

Department of Health Behavior &
Health Education
University of Michigan School of
Public Health
Associate Director, Cancer Prevention
and Control
University of Michigan Comprehensive
Cancer Center
Ann Arbor, MI
Reviewers
Edith Balbach, Ph.D.
Senior Lecturer
Community Health Program
Tufts University
Medford, MA
Ursula E. Bauer, Ph.D., M.P.H.
Director
Bureau of Tobacco Use Prevention and
Control
New York State Department of Health
Albany, NY
Michael E. Begay, Ph.D.
Department of Community Health Studies
School of Public Health & Health Science
University of Massachusetts, Amherst
Amherst, MA
Stella Aguinaga Bialous, RN, Dr.P.H., FAAN
President
Tobacco Policy International
San Francisco, CA

Paul N. Bloom, Ph.D.
Senior Research Scholar of Social
Entrepreneurship & Marketing
Center for the Advancement of Social
Entrepreneurship
The Fuqua School of Business
Duke University
Durham, NC
Alan Blum, M.D.
Center for the Study of Tobacco & Society
The University of Alabama
Tuscaloosa, AL
Ron Borland, Ph.D.
Nigel Gray Distinguished Research Fellow
in Cancer Prevention
The Cancer Council Victoria
Carlton South, Victoria, Australia
William J. Bukoski, Ph.D.
Senior Scientist
Division of Epidemiology, Services and
Prevention Research
National Institute on Drug Abuse
Rockville, MD
Joseph N. Cappella, Ph.D.
Annenberg School for Communication
University of Pennsylvania
Philadelphia, PA
xxii
Simon Chapman, Ph.D.
Professor

School of Public Health
University of Sydney
New South Wales, Australia
Joel B. Cohen, Ph.D.
Director
Center for Consumer Research
University of Florida
Gainesville, FL
K. Michael Cummings, Ph.D, M.P.H.
Chair, Department of Health Behavior
Division of Cancer Prevention &
Population Sciences
Roswell Park Cancer Institute
Buffalo, NY
Prabu David, Ph.D.
Associate Professor
School of Communication
The Ohio State University
Columbus, OH
Richard A. Daynard, J.D., Ph.D.
Professor of Law
Northeastern University School of Law
Boston, MA
Robert Donovan, Ph.D.
Professor of Behavioral Research
Division of Health Sciences
Curtin University
Bentley WA, Australia
Sherry L. Emery, Ph.D., M.B.A.
Senior Research Scientist

Institute for Health Research and Policy
University of Illinois at Chicago
Chicago, IL
Michael P. Eriksen, Sc.D.
Professor and Director
Institute of Public Health
Georgia State University
Atlanta, GA
James S. Ettema, Ph.D.
Department of Communications Studies
Northwestern University
Evanston, IL
Jean L. Forster, Ph.D., M.P.H.
Division of Epidemiology and Community
Health
University of Minnesota, Twin Cities
Minneapolis, MN
Brion Fox, S.M., J.D.
Associate Scientist
University of Wisconsin Paul P. Carborne
Comprehensive Cancer Center
Madison, WI
Stanton A. Glantz, Ph.D.
Professor of Medicine
Department of Medicine
Division of Cardiology
University of California, San Francisco
San Francisco, CA
Marvin E. Goldberg, Ph.D.
Professor of Marketing

Smeal College of Business
Pennsylvania State University
University Park, PA
Gerard Hastings, Ph.D.
Director of the Institute for Social
Marketing and the Centre for Tobacco
Control Research
University of Stirling and the Open University
Stirling, Scotland
Cheryl Healton, Ph.D.
President and CEO
American Legacy Foundation
Washington, DC
Anthony J. Hedley
Department of Community Medicine
University of Hong Kong
Hong Kong, China
Norbert Hirschhorn, M.D.
Retired
London, England
Acknowledgments
xxiii
Monograph 19. The Role of the Media
Thomas P. Houston, M.D.
Director
Ohio Health Nicotine Dependence Program
McConnell Heart Health Center
Clinical Professor
Family Medicine and Health
The Ohio State University

Columbus, OH
Corinne G. Husten, M.D., M.P.H.
Medical Offi cer
Offi ce of Smoking and Health
Centers for Disease Control and Prevention
Atlanta, GA
Gerald Kosicki, Ph.D.
Associate Professor
School of Journalism and Communication
Director of the Center for Survey Research
The Ohio State University
Columbus, OH
Matthew Kreuter, Ph.D., M.P.H.
Associate Professor and Director
Health Communication Research Laboratory
St. Louis University
St. Louis, MO
Anne Landman
Tobacco Document Research & Consulting
Glade Park, CO
Scott J. Leischow, Ph.D.
Professor, Family and Community Medicine
and Public Health
Deputy Director for Strategic Partnerships
and Policy
Arizona Cancer Center
The University of Arizona
Tucson, AZ
Ruth E. Malone, RN, Ph.D., FAAN
Professor and Vice Chair

Department of Social and Behavioral
Sciences
School of Nursing
University of California
San Francisco, CA
Alan B. Morrison, J.D.
Director, Public Citizen Litigation Group
Washington, DC
Monique E. Muggli, M.P.H.
Tobacco Document Consultancy
St. Paul, MN
Rebecca Murphy-Hoefer
Health Communications Specialist
National Center for Chronic Disease
Prevention & Health Promotion
Centers for Disease Control and Prevention
Atlanta, GA
David E. Nelson, M.D., M.P.H.
Senior Scientifi c Advisor, Alcohol Team
Centers for Disease Control and Prevention
Atlanta, GA
Cornelia Pechmann, Ph.D.
Graduate School of Management
Transdisciplinary Tobacco Use Research
Center
University of California, Irvine
Irvine, CA
Cheryl L. Perry, Ph.D.
Rockwell Chair in Society and Health
Professor and Regional Dean

Austin Regional Campus
University of Texas
Austin, Texas
John P. Pierce, Ph.D., M.Sc., M.A.
Sam M. Walton Professor for Cancer Research
Associate Director for Population Sciences
University of California, San Diego
Moores Cancer Center
La Jolla, CA
Richard W. Pollay, Ph.D.
Professor, Sauder School of Business
Vancouver, British Columbia, Canada
Ronald E. Rice, Ph.D.
Arthur N. Rupe Professor in Social Effects
University of California, Santa Barbara
Santa Barbara, CA
Charles T. Salmon, Ph.D.
Dean
College of Communication Arts and Sciences
Michigan State University
East Lansing, MI
xxiv
James E. Shanahan, Ph.D.
Associate Professor
Department of Communications
Cornell University
Ithaca, NY
Michael Siegel, M.D., M.P.H.
Professor
Social and Behavioral Sciences Department

Boston University School of Public Health
Boston, MA
David Simpson, OBE
International Agency on Tobacco & Health
London, England
Michael D. Slater, Ph.D.
Distinguished Professor
School of Communication
College of Social and Behavioral Sciences
The Ohio State University
Columbus, OH
Linda Squiers, Ph.D.
Project Offi cer for Research
National Cancer Institute, Cancer
Information Service
Rockville, MD
Colleen Stevens, M.S.W.
Tobacco Control Section
Department of Health Services
Sacramento, CA
Sharyn Sutton, Ph.D.
Managing Director
Communication & Social Marketing Group
Health Program
American Institutes for Research
Silver Spring, MD
Esther Thorson, Ph.D.
Acting Dean of Graduate Studies
Missouri School of Journalism
Columbia, MO

Thomas W. Valente, Ph.D.
Director, Master of Public Health Program
Institute for Prevention Research
University of Southern California
Alhambra, CA
Lawrence M. Wallack, Dr.P.H.
Dean
College of Urban and Public Affairs
Portland State University
Portland, OR
D. Charles Whitney, Ph.D.
Department of Creative Writing
University of California, Riverside
Riverside, CA
Phillip Wilbur
Director, Tobacco Control and Health
Programs
Danya International, Inc.
Silver Spring, MD
John K. Worden, Ph.D.
Research Professor Emeritus
University of Vermont
Offi ce of Health Promotion Research
University of Vermont
Burlington, VT
Other Contributors
Amanda Amos, Ph.D., M.Sc.
Professor of Health Promotion
Public Health Sciences
Medical School

University of Edinburgh
Edinburgh, Scotland
Thomas W. Valente, Ph.D.
Director, Master of Public Health Program
Department of Preventive Medicine
University of Southern California
Alhambra, CA
Gemma P. Vestal, J.D., M.P.H., M.B.A., R.N.
Legal Offi cer/Scientist
Tobacco Free Initiative
World Health Organization
Geneva, Switzerland
Acknowledgments
xxv
Monograph 19. The Role of the Media
The editors would like to acknowledge the
publication support services provided for
this monograph:
American Institutes for Research
Margot Raphael, Project Director and
Managing Editor
Elizabeth Bruce, Monograph Editor
Bethany Meissner, Project Assistant
Matthew Mowczko, Publication Production
Cygnus Corporation
Jennifer Bishop, Publications Manager
Ruth Christie and Patricia Spellman,
Copyeditors
Mary Bedford, Proofreader
R.S. Gallagher and Associates

Richard S. Gallagher, Technical Editor