The Strategy Behind Florida’s “Truth” Campaign: An Infirm Public Health Intervention—Meng-Yun Lin

Introduction
Smoking has been a public health concern afflicting national and international communities. In 2000, worldwide there were about 5 million deaths related to smoking, in particular between 1997-2001 there were over 435000 deaths attributable to cigarette use ([1]). Centers for Disease Control and Prevention (CDC) conducted a survey in 2006 and reported that 20.8% adults and 23.9% young adults, younger than 18 years old, are current smokers. This survey surprisingly showed that younger kids reported to be current smokers. In the same report, adults reported that they were daily smokers (71%) and smoked their first cigarette before the age of 18 years old (90%) ([2]); 60% started before age 14([3]). Researchers studying senior high school students reported that in 2001, 19% of them reported daily smoking. Studies indicate that people who start to smoke at a younger age are at higher risk for cancer, heart disease, stroke and chronic obstructive lung disease ([4]). No doubt, tobacco use is a serious public health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Public health interventions should target young kids who are at risk to start smoking, to prevent and reduce the long term consequences of tobacco exposure.


"Truth" campaign: a counter-marketing, anti-tobacco media program
In 1997, the Tobacco Industry and the state of Florida reached a settlement of 11.3 billion dollars and 200 million dollars per year to reduce smoking among kids. ([5],[6]). The program made it possible to markedly expand tobacco control programs in the states and provided for the creation of a new foundation, American Legacy Foundation, whose primary purpose is to combat tobacco use in the United States. Florida hired Crispin Porter & Bogusky as their advertising agency to take the lead on the Florida’s youth anti-tobacco project. The agency was charged with creating a series of social marketing interventions incorporating mass media advertisement and web based education sites. This campaign was eventually called the “Truth campaign.” In 1998, a study indicated the percentage of youth tobacco users declined by 7.4 percentage points in middle school and 4.8 percentage points in high school. The "truth" campaign has been well received by public and reduced smoker among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry ([7]).


It seems that the “Truth campaign” is much successful in youth smoker control, however, considering the context of behavior theories it is an inform public health intervention. In this paper, first, I will look at the modified social marketing theory that the “Truth” campaign uses and focus on the flaws of the anti-tobacco campaign. In my view, the unconventional youth marketing theory is flawed because it neglects to consider the individual factors and environmental effect, rather than just looking at the group level factors. Second, behavior is part of a continuous interactive cycle that includes individuals and their physical and culture environment. I will contemplate the program based on social cognitive theory (SCT) (9-15). Final, I will also argue that the Florida’s “Truth Campaign” should be a model across the nation to decrease smoking among kids ([8]) and discuss how media tobacco control programs use Social Marketing Theory ([9],[10]).


"Truth" campaign lacks tools to promote self- efficacy
Florida’s “truth” campaign is not valid because it does not take into account individual factors for example self-efficacy, self-control and behavioral capability. According to the SCT ([11],[12],[13],[14]), changing behavior includes the following: individual characteristics, environmental factors and reciprocal determinism. Especially, individual factors similar to an internal engine switch and further activate the behavior of quitting smoking or keeping from smoking. For example, self-efficacy as the representative of confidence decides whether kids can shift their behavior to healthier one. And behavior capability meaning the knowledge or skill related to change behavior determines if one can accomplish changing process. Here, I generalize the above-mentioned elements as self-efficacy, teenagers’ ability of devoting themselves to changing behavior. Only when teenagers possess internal impetus can they possibly achieve the action of changing behavior. However, youths at the stage of developing personality usually have lower willpower and lack of self-efficacy. Therefore, it is more difficult for teenagers to make up their mind of changing behavior and to maintain changed behavior.


SCT is based on self-efficacy, and assumes that people have the belief that they could perform a behavior. In the anti-tobacco campaign, even though the ads are very impressive and successfully attract teenagers’ attention, self-efficacy can not be given to students through the ad campaign, therefore reducing their ability to make behavioral changes. In other words advertising succeeds in awaking kids to the “truth”, the death toll of smoking, it does not result in devoting to quit smoking or keeping from cigarette. After all, knowing is one thing and doing is another thing. Elisia L. Cohen ., 2007, conducted a study looking at televised anti-smoking ads to discourage adult and teenagers from smoking, and this study reported that the ads focused on people’s attitudes on smoking([15]). The study also reported that the ads mentioned the benefits of not smoking 61% of the time, while barriers to smoking were mentions 17% of the time. This advertisement campaign demonstrates how anti-smoking campaigns emphasize on the consequences of smoking more that the concept of self-efficacy.


The SCT also states that people need three things to maintain self-efficacy: expectations and expectancies, self-control and emotional coping ability. The people’s expectation about what will happen after changed behavior and if the expect outcome is rewarded. The level of strong will in terms of making the change. Their ability to deal with the emotions involved in the behavior change. To completely change behavior, maintaining self-efficacy plays a crucial role in sustaining changed behavior (11, 12). Campaigns like the “Truth” campaign may get teenagers attention; however teenagers with lower self-esteem may have a more difficult time to change smoking behaviors. And teenagers with low self esteem may have inadequate behavioral and emotional skills to quiet smoking and give up the wayside while suffering from emotional strikes involved in changing step. Finally youth’s behaviors often shift between positive and negative behaviors, making television ads anti-smoking campaigns ineffective.


"Truth" campaign does not emphasize environment factors
This program is ineffective because it regards the young tobacco users as a relatively independent group and ignores the external content in that teenagers live in. Social Cognitive Theory also tells us that individuals social and physical environmental factors play an important role to change behavior. For example, the behavior of other people and the consequences of that behavior cause vicarious learning. Different circumstances in which the anti-smoking communicate may make viewers product distinct perceptions concerning tobacco. In addition, negative or positive reinforcements among live environment give teens various responses to cigarette (9-15). In the program targeted on young people, gender, geography and family’s tobacco use are all critical factors implicating in the intervention outcome. On the other hand, I think temperate education or persuasion is insufficient to reduce youth tobacco prevalence and hence a rigid legislation may be a more active and dominated kind of intervention.
Teenagers that have parents and other family members that smoke are more likely to have access to cigarettes and are at high risk to start smoking at a young age. In a study that compared teenagers with parents that smoked with teenagers that didn’t have parents that smoked reported that the Truth campaign was more effective in preventing smoking among youths that didn’t have parents who smoked ([16]). In other words, in a tobacco-using environment, kids are more likely to access cigarette and it is harder to keep them from smoking. It is clear that access to cigarettes in a home environment and parents that smoke are role models that offset the goal of the Truth campaign. Anti-smoking campaigns should not only target teenagers’ peers, but also include family, because they can also have a strong influence on their smoking behaviors.


Policy changes are an effective way to effect the way that Anti-tobacco campaigns are focused on education or persuasion interventions ([17],[18],[19],[20]). At first, with high public visibility and strong public support, “truth” campaign is somehow significantly successful. Many short-term surveys indicated the teen smoking prevalence rate dropped from 23.3% to 20.9%. Nevertheless, in 1999, the state legislature cut the program’s funding from $70.5 million to $38.7 million, and the Bush administration dismantled the program’s administrative structure ([21]). These changes effected the implementation of the “Truth” campaign, as not only limited the funding support but also weakened the political support for this campaign. Public Health interventions would be more stable if intervention programs were pushed through legislation and became enacted bills. This would allow interventions to become established to be more effective to change behavior. Because smoking prevalence is preventable through precluding potential smoker, legislating will be a powerful intervention. Lack of legislation to control tobacco use resulted in dramatic rise in tobacco consumption in India, the third largest grower of tobacco in the world ([22]). It is more economical to prevent a problem in advance rather then to deal with the puzzle while it developed.


"Truth" campaign risks overestimated the efficacy of marketing
The Truth campaign is too optimistic in having a social marketing media campaign address teenagers issues to effectively change their smoking behavior. In this campaign, social marketing theory sees behavior change a selling product to teenagers. Every year, new public health mass media campaigns are launched attempting to change health behavior and improve health outcomes. Recent years, these campaigns enter a crowded media environment filled with messages from competing limited sources ([23]). With limited government funding, state funded agencies and organizations also have limited resources and political support from legislators to help with funding resources.


Due to the widespread communication, “truth campaign” produced a substantial impact reducing cigarette consumption and stimulating the development of policies to eliminate environmental tobacco exposure. Research looking at teenagers smoking attitudes report that they perceive the serious consequences of smoking from anti-tobacco ads regardless of their sex and ethnicity ([24]). However, such achievements do not therefore lead to the reduction of smoking initiation and smoker population among adolescents in a long term frame. As I mentioned before, if there were state legislation supporting anti-tobacco campaigns it would give them the stability to have long term impacts on the reduction of teenagers smoking rates ([25],[26]) .


The past studies designed to estimate the outcome of “truth” campaign revealed controversial results: some reports showed ads had created a great decrease in teen smoking ([27]) as other studies claimed there were no apparent effect ([28]). The differences in measurement of public health media program might contribute to the effect of differences observed. However, even existing positive outcome the conclusions regarding effectiveness is limited and exclusive. For instance, adolescents who live in tobacco producing regions appear to be less responsive to anti-industry ads than their counterparts in non-tobacco producing regions ([29]). Also, although the anti-smoking campaign had an effect on both sexes, less of an effect was required to influence young women than young men and the effect of ads on young men continued to be weakened ([30]). In addition, study found industry sponsored anti-smoking ads do more to promote corporate image than to prevent youth smoking ([31]). Between traditional marketing-brand cigarette ads, the counter- conventional anti-smoking campaign marketing public health issue seems not as helpful for youth as we expecting.


Conclusion
The Florida’s “truth” campaign uses a variety of scenarios to address the death toll caused by cigarette using, during 1998. The campaign ads use fear and humors tactics to attract teenagers’ attention ([32]), however anti-smoking TV media campaigns are unlikely to be effective, and could have negative unintended consequences. It is crucial to prevention of risk behavior before it becomes embedded in an individual's life ([33]), therefore recent anti-smoking programs principally targeted on young adults. A public health intervention such as the true campaign simple through advertising its idea of anti-smoking, however, is not sufficient. First, anti-Smoking ad campaigns should further focus on the complexity of the behavior the intervention is trying to change. These include individual and social factors. Intervention should not only targets on teenagers but consider them with their parents, families, and communities as a whole. Second, we should reduce the chance of letting kids expose to a smoking-use environment. Forbid smoking around children in daily life as ban against smoking in public places such as schools and hospitals. Increase cigarette taxes according to the growing tobacco consumption and strictly forbid young adults purchasing cigarette through legislating. Third, give adolescents the ability of choosing healthier behavior by establishing their self-efficacy. Set physician counseling to introduce smoking cessation and help children quit smoking. As many teenagers regard smoking as an emblem of independence like adults , through public education teach them anti-smoking is even a mature and cool behavior and giving up smoking is as easy as engaging in. The more extensively a behavior is embedded, the more difficult it is to alter such behavior. Relative levels of embeddedness of the risk behavior and its entanglement with other nonrisky behavior evolve and change throughout one's life course. Without controlling the trend of young smoking population, it would reverse the decline in whole smoking prevalence seen in the past several decades.


REFERENCES
[1] Centers for Disease Control and Prevention. Annual Deaths Attributable to Cigarette Smoking—United States, 1997–2001. http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdths.htm
[2] US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center to Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994
[3] Epps RP, Manley MW. A physician’s guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991; 88:140–144.
[4] Davis JW, Shelton L, Watanabe IS, Arnold J. Passive smoking affects endothelium and platelets. Arch Intern Med 1989; 149:386–389.
[5] Jeffrey Hicks. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
[6] Bauer UE, Johoson TM, Hopkins RS, et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program. JAMA 2000; 284:723-728.
[7] C Healton. Who's afraid of the truth? American Journal of Public Health 2001; 91:554-558.
[8] Zucker D, Hopkins RS, Sly DF, Urich J, Kershaw JM, Solari S. Florida's "truth" campaign: a counter-marketing, anti-tobacco media campaign. J Public Health Manag Pract. 2000;6(3):1-6.
[9] Philip Kotler, Gerald Zaltman. Social Marketing: An Approach to Planned Social Change. Journal of Marketing 1971; 35(3): 3-12.
[10] Lefebvre, R. Craig; Flora, June A. Social Marketing and Public Health Intervention. Health Education Quarterly 1988;15(3): 299-315.
[11] Mark Edberg. Social, Culture, and Environmental Theories (PartI) (pp 51-64). In: Mark Edberg, ed. Essentials of Health Behavior. Sudbury, MA: Junes and Bartlett, 2007.
[12] Bandura, A. Social cognitive theory. Annals of child development 1989; 6:1-60.
[13] Bandura, A. Social cognitive theory of self-regulation. Organizational behavior and human decision processes 1991; 50:248-287.
[14] Bandura, A. Human agency in social cognitive theory. American Psychologist 1981; 44:1175-1184.
[15] Elisia L. Cohen . Original: Anti-Smoking Media Campaign Messages: Theory and Practice. Health Communication 2007; 22(2), 91-102.
[16] David F. Sly, Richard S. Hopkins, Edward Trapido, ScD, Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[17] Chin R. Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976
[18] Rosenblatt M. should our judicial system and legislatures protect infants and children from second-hand tobacco smoke? Children’s Legal Right Journal 2005; 25:37-50
[19] Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.
[20] Siegel M. Making it unlawful to smoke around children could have detrimental effect on children’s health, especially among disadvantaged populations. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 22, 2006.
[21] Michael S. Givel, Stanton A. Glantz. Failure to Defend a Successful State Tobacco Control Program: Policy Lessons From Florida American. Journal of Public Health 2000; 90(5): 762-767.
[22] Riti Shimkhada, John W. Peabody. Tobacco control in India. Bull World Health Organ 2003; 81(1): 48-52.
[23] Whitney Randolph, K. Viswanath. Lessons Learned from Public Health Mass Media Campaigns: Marketing Health in a Crowded Media World. Annual Review of Public Health 2004; 25: 419-437.
[24] L Biener. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think. Tobacco Control 2002; 11:43-46.
[25] Michael Siegel & Lois Biener. Evaluating the Impact of Statewide Anti-Tobacco Campaigns: The Massachusetts and California Tobacco Control Programs. Journal of Social Issues 1997; 53(1):147-168.
[26] Michael Siegel. THE EFFECTIVENESS OF STATE-LEVEL TOBACCO CONTROL INTERVENTIONS: A Review of Program Implementation and Behavioral Outcomes. Annual Review of Public Health 2002; 23: 45-71.
[27] Matthew C. Farrelly, Kevin C. Davis, M. Lyndon Haviland, Peter Messeri, and Cheryl G. Healton. Evidence of a Dose–Response Relationship Between “truth”Anti-smoking Ads and Youth Smoking Prevalence. American Journal of Public Health 2005; 95(3): 425-431.
[28] Matthew C. Farrelly, Cheryl G. Healton, Kevin C. Davis, Peter Messeri, James C. Hersey, and M. Lyndon Haviland. Getting to the Truth: Evaluating National Tobacco Countermarketing Campaigns. American Journal of Public Health 2002; 92(6):901-907.
[29] J F Thrasher, J Niederdeppe, M C Farrelly, K C Davis, K M Ribisl and M L Haviland. The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth® campaign. Tobacco Control 2004;13:283-288
[30] David F. Sly, Richard S. Hopkins, Edward Trapido and Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[31] L Henriksen, A L Dauphinee, Y Wang and S P Fortmann. Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tobacco Control 2006; 15:13-18.
[32] Cheryl Healton. Who’s Afraid of the Truth? American Journal of Public Health 2001; 91(4): 554-558.
[33] Melanie Booth-Butterfield . Embedded Health Behaviors From Adolescence to Adulthood: The Impact of Tobacco. Health Communication 2003; 15(2):171-184.