Anti-Smoking Campaigns Work, So Don't Quit Now

As Funding for Anti-Tobacco Ads Dropped, So Did the Number of Smokers Kicking the Habit. Can a New Round of Ads Reverse Course?

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Get ready for a barrage of ads that will come at you with a singularly mind-blowing message: Smoking is bad for you. Not just bad for you. Really bad for you.

It's a fact that should be obvious to any sentient being, yet within the next year or so, not one but two federal agencies, the Centers for Disease Control and the Food and Drug Administration, will be newly pounding the nation's airwaves with anti-smoking ads -- as if it were a sure thing that you needed them. To be a smoker in 2012 is not only to ignore the biological reality that the habit will knock years off your life but also shrug off the cultural stigmas -- the dwindling number of smoke-friendly public places, the dirty looks -- and the fact that heavily-taxed smokes are priced at a point only a one-percenter could easily afford.

One of New York City's disturbing health-department ads.
One of New York City's disturbing health-department ads.

If we've seen a "denormalization of smoking," as the CDC describes it, do we need to drop hundreds of millions of dollars on a familiar message during cash-strapped times? If all those appeals to the brain, wallet and pride don't work, how will a bunch of ads?

As it turns out, anti-smoking ads actually do work. There's plenty of academic research proving it. And there's circumstantial, but no less compelling, evidence that in the absence of advertisements, smoking rates don't go down as quickly as they would without the nagging. And that entails its own costs.

Smoking's steady decline, which began in the 1960s after the Surgeon General's initial warning, has leveled off in recent years. Between 1998 and 2005, the adult smoking rate dropped 13%, but since 2005, any changes have been minimal. For the better part of six years, it has been at the 20% mark or just below. All-important youth-smoking rates declined 40% between 1997 and 2003, but between 2003 and 2009, that decline slowed to 21%. 

Meanwhile, during those years funding decreased dramatically for the main national anti-tobacco advertising player, Legacy, the foundation funded by the 1998 settlement between tobacco companies and the attorneys general of 46 states. According to Kantar, Legacy's media budget between 2007 and 2010 totaled about $100 million. That's the amount Legacy would spend in a single year in its early days. And, at the state level, average household exposure to anti-smoking ads peaked in 2006 and 2007 and has been coming down since, according to a study of Nielsen data by the University of Illinois-Chicago.

"There's no consistency at the state level," said Eric Asche, chief marketing officer at Legacy. "And the general trend has been to spend less, not more."

Connecting the slowing decline in smoking with the steeper drop in anti-tobacco ad spending is to draw a broad correlation. It's a mug's game to chart smoking-rate changes directly to the rise and fall of advertising budgets. Media spending is not the only factor in smoking prevention, and probably not even the most important. That distinction goes to taxes. There are other factors, especially smoke-free-air laws that effect bans in workplaces and other public places. With all the activity, it's difficult to isolate the effects of advertising.

But there's no doubt that the leveling off of the smoking rate has occurred at a time when many states, amid deep cuts to tobacco-prevention budgets, are spending next to nothing on ads and have been getting little air cover from the national level. This is bad news when you consider how effective those ads have been.

Research scientists have been studying the impact of anti-smoking ad campaigns for decades, even before the "Truth" campaign launched in 2000, when the job was mainly the province of individual states. 

Many have found what Sherry Emery, a health economist who has studied the impact of media campaigns at the state level, has. Ms. Emery said that analyses of youth and adult reaction "showed that higher levels of exposure to the state media campaigns were associated with less smoking and more anti-smoking attitudes and beliefs."

The Truth campaign, currently handled by Arnold , is the most important national anti-tobacco ad effort in recent years and has yielded positive results. A 2005 study in the American Journal of Public Health reported that about 22 % of the decline in youth smoking between 1999 and 2002 was attributable to the Legacy foundation ads -- not bad when you consider that the ads weren't even running through the entire period. Since 2003, Legacy's funding has been just a fraction of what it started with, a function of the master-settlement agreement.

That's because the agreement required the Big Four tobacco companies that signed it to fund Legacy only through 2003 if their collective market share fell below 99.05%. (By 2001, that share was already below the threshold, at 96%.) Settlement payments to states continue, but it's a sore spot with some that a small percentage of that revenue -- just under 2% of $25 billion in 2011 by the Campaign for Tobacco-Free Kids' count -- goes to fight tobacco use. As for the states, the dire economic conditions of recent years have led many to cut back their tobacco programs. The group estimates that total state spending has dropped 36 % over the past four years.

Kentucky, a tobacco-growing state tied for the highest smoking rate, and with a tiny budget to fight it, is as particular as it can be about what ads it will run. Rather than use off-the-shelf ads for its just-launched $370,000 secondhand-smoke campaign, the state developed creative via Doe Anderson, Louisville. It's a big investment, as average expenditure on media campaigns is in the neighborhood of $100,000 (but can be much less).

"I think it's very hard at the national level for a government agency to make ads that both can stand out and be acceptable to everyone," said Gwenda Bond, assistant communications director at Kentucky's Cabinet for Health and Family Services. "It's sort of a Catch-22 in some ways. I think the states have a little more freedom and flexibility to go a little bit further afield with their concept."

The good news is that there's evidence that various styles of advertising work, from the industry-as-manipulator ads of Truth to campaigns focusing on the nasty health effects of smoking. 

Ms. Emery is currently analyzing what kinds of ads work best. Preliminary results show that the answer is not what you might expect, and seem to have little to do with state-smoking laws or whether the state is a tobacco grower. Ms. Emery's hunch is that in "media markets that are dominated by one primary message, like a health-effects ad or secondhand-smoke ad, their overall campaign is a little less effective than media markets that have a diverse portfolio of messages."

OK, so you're not swayed by science. Then what about money? Do anti-smoking ads pay for themselves?

Return on investment is a knottier problem than whether the ads work with audiences on an emotional level, and it hasn't been studied as much. But there is one informative study.

Three years ago, the American Journal of Preventive Medicine published a cost-utility analysis of the Truth campaign between the years 2000 and 2002. The researchers found that campaign efforts costing $324 million averted about $1.9 billion in medical costs. That's a return of about 6 to 1 for one of the most intense -- in terms of reach and cost -- anti-smoking ad campaigns ever done. 

California has been another relatively big spender, and its program is a model for anti-smoking campaigns. Between 1989 and 2011, the state's tobacco-control program said, the smoking rate fell from 23.7% to 11.9%. That drop has averted more than $86 billion in smoking-related health-care costs, according to the state's public health department. Over that time, it spent more than $1.3 billion on its tobacco-control program, $450 million of which went to media campaigns.

That means that ad spending was a little more than a quarter of the overall budget. If we make the rather gross assumption that a similar proportion of the cost savings was attributable to advertising, we end up with about $30 billion in benefit on an ad outlay of $450 million. Again, that 's excellent, probably too-good-to-be-true ROI. Even if the campaign were responsible for just 1% of the economic benefit of all those California quitters, that would be $860 million, still a positive return. (Keep in mind that California has a relatively low excise tax -- 87 cents per pack, which ranks 32nd in the union.)

Take these back-of -the-envelope calculations for what they are. The overarching point borne out by plenty of evidence and controverted by nothing I could find should be that full-throated tobacco-cessation programs, in which advertising is considered a core feature, save taxpayers money in the long run. A study of Washington state's program found a return of almost $6 to every dollar invested. 

No one, including California health officials, is willing to hazard a guess on what portion of health-care-cost savings are attributable to ads. In an email, Colleen Stevens, the chief of California's tobacco-control program, acknowledged that higher taxes are the "most effective method" to decrease use and keep kids off smokes. And the cost of a pack since its anti-smoking program began has more than tripled, thanks in no small part to a rising excise tax.

Ms. Stevens said the campaign "reframed the perception of smoking from being a "smoker's rights issue' to educating Californians of the need to protect vulnerable populations from the impact of secondhand smoke."

California's media campaign is funded by a penny per pack of cigarettes sold in the state. Many other states are more subject to the whims of legislatures and see support for all types of tobacco-cessation programs ebb and flow with the economic tides. In 2010, only one state, North Dakota, spent at the level recommended by the CDC. (The CDC-recommended level varies from state to state).

With that sort of spotty support, it's hard to gauge whether the smoking rate has hit an "irreducible minimum," an idea addressed -- and dismissed -- by CDC Director Thomas Frieden. He believes the rate can go much lower, saving millions of lives and reducing national smoking-related health costs, now at $193 billion annually. Over the next few years, there'll be a lot of pressure on his organization and the FDA to make it happen. 

CDC, FDA to Push Fresh Anti-Smoking Efforts With $100M in Media

Over the next year or so, two federal agencies will break major ad campaigns designed to reduce the national smoking rate, which for years has hovered around the 20% mark.

A new education effort from the Centers for Disease Control is expected as early as the first quarter of this year, while a campaign from the Food and Drug Administration is expected further down the road. Together, the campaigns are likely to total at least $100 million in spending.

Here's a closer look:

FDA
The FDA, which assumed oversight of the tobacco industry in 2009, is seeking agencies for two campaigns totaling $600 million over five years. According to public documents, the larger campaign is expected to max out at $390 million over five years and will segment audiences by age group. The smaller campaign will be focused on "at-risk and underserved populations." The FDA, currently fielding proposals from agencies interested in the business, declined to comment, but it's clear from presentation documents posted online and interviews with people familiar with the plans that its strategy will be focused on "truthful science-based education efforts."

FDA officials have also been careful to articulate to agencies that tobacco companies are to be viewed as "stakeholders." One of its presentation slides said the contracts are not an opportunity to "frame the industry negatively." While the FDA is expected to focus on youth audiences, as the "Truth" campaign does, this signals a major departure from Truth, which has consistently criticized tobacco company practices in its ads.

Though that 's raised some eyebrows, it's worth pointing out that no one has said tobacco companies are involved in the creation. It's also worth noting that research shows many kinds of messaging have been effective, with a major exception being that of tobacco companies' own stop-smoking campaigns.

"Effective campaigns can come in a variety of styles," said Danny McGoldrick, VP-research at the Campaign for Tobacco-Free Kids. "We welcome the new national campaigns."

Agencies are being asked to create media plans based on $40 million and $80 million budgets. There's speculation that the campaign will launch later this year and might be tied to the new set of graphic warning labels on cigarette packs.

CDC
The CDC declined to comment, other than to confirm the campaign, but people familiar with it said that it has a broadcast TV element and is expected to focus on smoking's health effects, using scare tactics to encourage people to toss out the smokes.

This would make sense given that CDC Director Tom Frieden arrived at his post via New York City, where he was health commissioner from 2002 to 2009. There he oversaw a successful program that reduced the smoking rate by 20% in its first five years. A visible part of the program was a sometimes-controversial series of graphic ads starring sick and dying smokers.

Arnold , Boston, which has won armloads of awards for its work on Truth, is the creative agency.

Meanwhile, Truth will continue its approach, albeit with diminished funds. Legacy Foundation CMO Eric Asche said to expect a greater proportion of spending to be in cost-effective digital-media channels and other places where the broadcast-banned tobacco companies market.

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