2742 Robert Wood Johnson Foundation and Boston University School of Medicine Working Group: Creating Statewide Tobacco Control Programs after Passage of a Tobacco Tax Supplement to Cancer Designing an Effective Counteradvertising Campaign—Massachusetts Anne Miller Arnold Communications, Boston, Massachusetts. OVERVIEW. In this report, the author reviews the major lessons from the Massachusetts 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. T he Massachusetts Tobacco Control Program (MTCP) was created by a voter’s ballot initiative (Question 1) in 1992. A 25-cent-per-pack cigarette tax funded this comprehensive tobacco control program aimed at reducing tobacco use in Massachusetts. Massachusetts’ campaign, the second in the country, was launched in 1993. Arnold Communications looked to California’s experience to help guide a successful effort for Massachusetts. The lessons learned were invaluable. Campaign Overview The Massachusetts campaign is comprised of three communications objectives, each intended to play an integral role in the overall reduction of tobacco use. These are: 1) convince youth not to start smoking; 2) prompt smokers to quit; and 3) create a supportive environment for a smoke free future. To achieve each of these three objectives, the media targets a different, distinct audience (Table 1). The Role of the Media Campaign Presented at the Robert Wood Johnson Foundation and Boston University School of Medicine Working Group: Creating Statewide Tobacco Control Programs after Passage of a Tobacco Tax, Waltham, Massachusetts, October 3– 4, 1997. Ms. Miller is an employee of Arnold Communications, which has a client relationship with the Massachusetts Department of Public Health. Address for reprints: Anne Miller, Arnold Communications, 101 Huntington Avenue, Boston, MA 02119. Received September 17, 1998; accepted September 22, 1998. © 1998 American Cancer Society Each campaign differs not only by objective and target but in other ways as well. The youth campaign itself is an intervention. It engages children in a dialogue and advances the psychologic and social reasons to be smoke free. It directly counters the methods used by the tobacco industry to deliver prosmoking messages. The campaign complements the efforts of local youth programs that engage youngsters individually with messages regarding the benefits of being smoke free. By contrast, the media-driven cessation campaign serves a specific function within the general cessation program by reaching out and beginning a dialogue with smokers. The campaign targets smokers who have long and short range plans to quit. The media’s role is to accelerate smokers through these stages to create demand for cessation and thus cessation services. These services then are provided by educational programs, the statewide Quitline, and health care providers. Effective Counteradvertising Campaign: Massachusetts/Miller TABLE 1 Media Targets for MTCP Objective: Target: Objective: Target: Objective: Target: Convince youth not to smoke Youths ages 9–17 years Prompt smokers to quit Smokers ages 18–49 years Create a supportive environment for a smoke free future General public ages 25–54 years MTCP: Massachusetts Tobacco Control Program. Finally, in the public opinion campaign, media plays yet another role by providing “cover” for policy and local level initiatives. The campaign is a tool to frame the debate. It can introduce an issue and create “noise.” This not only sparks dialogue but can itself become the environment. Through planning, the MTCP can orchestrate media coverage to support individual community actions for maximum success. The Process The Massachusetts process for developing media messages is rooted in research. Formative research The process begins with a review of existing research and interviews with experts in related fields to serve as an “information dump.” The media team analyzes this information and arrives at a variety of different marketing hypotheses. A “voice of the consumer” plan is implemented to elicit “consumer” responses and input on general tobacco issues as well as on specific hypotheses. Whether the plan calls for a quantitative study, a series of focus groups, or both, this process is dynamic. As it unfolds, it becomes a guide to refining what is asked of the “consumer.” In this way, hypotheses are confirmed, denied, or evolved into the most promising communications strategies. Message development As a result of the formative process, the campaign commits to key directions. Important questions must be answered before we develop concepts: 1) to whom is the message aimed; 2) what helpful information regarding these messages is available; 3) what is the single message to communicate; 4) what tone and manner should be used; and 5) what justifies the claims that are made? Once identified, specific ideas for advertisements are checked with the “voice of the consumer.” Putting the ideas in front of the target audience tests whether the message is communicated, relevant, understandable, and interesting. It also de- 2743 termines whether there are any unintended negative consequences. Execution If the concepts check out on paper, they move into production. Television spots are filmed and edited. Media buys are made. The spots air. Evaluation Finally, once the campaign has aired, quantitative evaluative research is conducted to assess the campaign on key measures. It is standard to appraise the campaign on measures of awareness and attitudinal change. The results of this research are diagnostic and contribute to the formative process of new initiatives within the campaign. Lessons Learned Lesson 1: youth–there is no one silver bullet Youth are a very diverse target. It is not surprising that 9-year-olds are very different from 17-year-olds, but there are even profound differences between ages 11 and 13 years. Age is only one of many factors that affect the way children view and approach the use of tobacco, and their responses to different motivational stimuli regarding tobacco. Hence, it is necessary to employ a variety of messages. The campaign must identify those “motivators” that have the broadest impact on the population. The following types proved to be most motivational. Universal truths. Although youth are different, there are a number of aspirations that are universal among adolescents. The majority of teenagers aspire to having money to do what they want, looking good, being attractive to the opposite sex, being a good athlete, and being a good role model for younger brothers and sisters. Smoking can be a barrier to achieving these goals, and messages demonstrating how smoking hinders these universal aspirations resonate with broad segments of young people. Specific message platforms are: most teens don’t want to date smokers; smoking causes shortness of breath; smoking causes wrinkles; smoking costs $1000 a year; and smoking leads younger siblings to smoke. Industry manipulation. Having grown up in a world in which the media constantly exposes individuals’ and companies’ immoral acts, children are extremely cynical. This generation’s reaction has been to live and let live. They are quick to excuse the tobacco executives as simply doing their jobs. When we can expose the tobacco industry as different from other industries 2744 CANCER Supplement December 15, 1998 / Volume 83 / Number 12 because they manipulate the public, this crosses a line for youngsters, putting the tobacco industry in a category apart from all other big business. Specifically, the tobacco industry is positioned as dishonest, manipulative, and trading lives for profits. Young people will reject any implication that they personally have been manipulated by advertising or imagery. This outright rejection of being manipulated breaks down the credibility of any positioning that supports this personal manipulation. By generalizing the manipulation, youngsters can accept the argument. They are more apt to agree that younger children or their friends are manipulated than they are to agree that they are to agree that they are personally manipulated. sure); the lack of control; and the indiscriminate nature of addiction (it can happen to anyone who smokes a cigarette, anytime). Addiction. The universal aspirations noted earlier and industry manipulation are the basis for broad stroke messages that resonate across many youth segments. It also is important to discern which messages effectively reach the most at-risk sector of this population. In identifying those groups with both the greatest intentions to smoke and the highest uptake, the campaign found (consistent with other studies) that the key age of cigarette uptake is between 11 and 14 years. In addition, an examination of psychographic and attitudinal characteristics of the high propensity groups showed them to have the following profile: more likely to get in fights; do not like school; enjoy risky behaviors; come from families that smoke; and have friends who smoke. Universal aspiration messages resonated with “high risk” youngsters and the general youth population. We also found that high risk youngsters often were surrounded by cigarettes and cigarette smokers. Even as nonsmokers, they believed they had an intimate knowledge of cigarettes and purported to understand addiction. In their opinion, addiction was real and was a commonly heard reason not to smoke. However, nonsmokers in the high risk group tended to minimize the strength of the addiction claim. They equated addiction to what they could relate to “It’s like wanting a piece of chocolate really bad. . .” Only addicted smokers demonstrated a realistic knowledge of the properties of addiction. The campaign identified this gap between their perception versus the reality of addiction as an opportunity. Given that high risk youth believed addiction existed and was a reason not to smoke, demonstrating the power and control of a nicotine addiction gave meaning to their belief that such addiction was a reason not to smoke. Addicted youngsters perceive three different characteristics of addiction that the campaign has addressed: the physical nature (pres- Rewards. The final message category is a direct response to the tobacco industry’s promotional tactics. The campaign turns their proposition around and offers children prizes for choosing a smoke free lifestyle. Emotional benefits. All of the above motivators are rational reasons not to smoke. Successful advertisements persuade consumers with a rational argument and seduce consumers with an emotional benefit. Adolescent smoking has its roots in the emotional gratification that smoking behavior offers. Young people want to be “cool” and this is the image that they associate with cigarettes. To counter this strong emotional “promise,” antismoking media campaigns must create an alternative emotional promise for a smoke free life-style. Lesson 2: adult smokers–acknowledge readiness to quit In exploring the role of advertising in encouraging adults to quit smoking, the campaign learned that smokers vary by mindset and can be categorized along a quit continuum. Smokers are located somewhere along a continuum based on their readiness to quit. “Pre-Contemplators” are smokers with no intention or plans to quit smoking. At the other end of the continuum are “Active Quitters.” In the middle are “Contemplators,” those who have long term plans to quit, and “Ready-to-Quits,” those who have short term plans to quit. Rather than targeting all smokers with the goal of convincing them to quit, the campaign addressed specific smokers with the goal of moving them one step closer to cessation. Behavioral theory suggested that those who are closer to quitting (“Contemplators and Ready-to-Quits”) were most receptive to “helping relations.” The campaign attempted to establish such relations by creating a personal trust, a message of encouragement, and an empathic tone. Messages regarding the benefits of quitting were most motivating to “Contemplators.” Conversely, “Pre-Contemplators” were most motivated by negative environmental and social pressure. To inspire movement among this group, the campaign focused on the negative consequences of smoking. To achieve maximum impact from these messages, the media effort orchestrated their exposure in a way that alternated the positive benefits of quitting with the Effective Counteradvertising Campaign: Massachusetts/Miller negative consequences of smoking, “pushing” and “pulling” the smoker along the continuum. Lesson 3: public opinion–activate the middle To create an environment for a smoke free future, it is important to have the backing of the majority. In this way, advertising tobacco is like issue marketing rather than product marketing. There are staunch supporters on both sides of the tobacco issue. To win, tobacco control programs must capture the large group that currently is in the uncommitted middle. To capture the middle, we need to succeed on two fronts: numbers of supporters and conviction of supporters. Number of supporters In convincing this uncommitted middle that tobacco is an important issue, the most compelling message may be secondhand smoke. Secondhand smoke repositions the tobacco issue from its current standing as a persons’ right to smoke, to a new place, a persons’ right to breathe. A corollary to the secondhand smoke message is acknowledging that the middle group are not zealots and will defend their smoking friends. Messages must be absolutely clear that the smoker is not the enemy and the issue does not pit smokers against nonsmokers. Rather, it is an issue of society against the tobacco industry. 2745 Conviction Although changing the attitudes of the middle is important, it is not enough. Victory cannot be claimed until there is conviction. Attitude changes must give way to beliefs. To accomplish this transition, there must be an emotional reason to care. The research conducted during the ballot initiative identified the emotional platform for this issue as protecting children. Even smokers agreed that protecting youth was a good reason to tax cigarettes. The campaign returns to the theme of protecting youth periodically to serve as a reminder of this underlying goal and rallying cry. Protecting youth from access, marketing, and exposure to secondhand smoke all strike an emotional chord and serve to inspire conviction. The combination of conviction and numbers will produce the support necessary for action at the community level. CONCLUSIONS Massachusetts was one of the first states to embrace a multifaceted approach toward the overall goal of reducing tobacco use. These three initiatives (youth prevention, adult cessation, and public support) have all contributed toward the overall success of the program to date.