Zack and Brian, 10- and 13-year-old brothers, look up at the camera and describe what it was like to lose their father to lung cancer. It's been only a few months since the death of their father, a cigarette smoker in his early 40s. The boys speak about comforting their grieving mother.

The adults in the room, all smokers, fall quiet as they watch the video. One man gets up abruptly and starts making coffee, his back to the others. When he sits down, his eyes are brimming with tears. "That could be my son," he says. "My son sees me as his hero. What would happen to him if something happened to me?"

The focus group was convened in 1999 to respond to new advertisements created by California's landmark anti-tobacco media campaign, the longest-running, most comprehensive, and best-funded anti-smoking effort in the nation.

The television spot featuring Brian and Zack hit its mark exactly as intended. It forced people to confront their smoking habit and the devastating effect it could have on those they love most. The ad is one example among hundreds of powerful anti-smoking messages that the California Department of Health Services, which oversees the media campaign, has carefully crafted and released since April 1990.

The risks the media campaign takes and the uncompromising quality of the work have earned the program a national reputation as a trailblazer and model for other states. Several states, notably Massachusetts, Florida, and Arizona, are now following California's lead.

"We proved in California that you could take on the tobacco industry and the world didn't end. We made it safe for other states to be aggressive," says Colleen Stevens, who, as chief of the Tobacco Education Media Campaign, leads the charge.

In California that aggression has paid off. Since the campaign began, per capita cigarette consumption has plummeted more than 60 percent -- nearly twice the level of smoking reduction accomplished in any other state. The number of adult smokers has fallen from 22.7 percent of the population in 1988 to 14 percent in 2005, the lowest in the country after Utah. (The state has a large population of Mormons, whose religion prohibits smoking.)

Even more significant, the campaign actually saved lives. In its first nine years, the program prevented an estimated 33,000 heart-disease deaths, according to a study published in the December 2000 issue of the New England Journal of Medicine.

Interestingly, between 1989 and 1997, the Centers for Disease Control and Prevention reported that lung cancer rates dropped 14 percent in California, far exceeding the 2.7 percent decline in the rest of the country. And while lung cancer rates for women are rising by 13 percent elsewhere, in California there's been a 4.8 percent decrease in the last decade.

How they did it

Fighting big tobacco's influence isn't easy -- the industry still spends $15.2 billion a year ($41 million a day) to market its products nationwide. The toll is enormous: Smoking kills more than 400,000 people each year, more than the number who die from alcohol, AIDS, car accidents, illegal drugs, murders, and suicides combined, reports the CDC. Smoking is the number one cause of preventable death in the United States.

Faced with these numbers, California's ad campaign has never taken the safe route. It declined to promote the run-of-the-mill "Please quit, and if you don't smoke, don't start" message embraced by other anti-smoking efforts. One of the campaign's very first ads, released in early 1990, ignited controversy because of its characterization of the tobacco industry. "We need 3,000 kids to start smoking every day to replace the people who die every year from cigarettes," says an actor playing a tobacco executive to his colleagues gathered in a boardroom.

Building on this theme a decade later, a series of new ads lampoons tobacco advertising executives as they discuss their behind-the-scenes strategy to get young people to smoke. In one of them, ad executive "Ken Lane" squats down next to a child in a convenience store and gleefully says, "This is what we're talking about," pointing to a tobacco ad placed at the child's eye level.

One tough ad in particular inflamed the wrath of a top tobacco executive, says Stevens. The 1994 television spot, "Nicotine Sound Bites," showed actual footage of U.S. Rep. Henry Waxman's famous hearings in which tobacco company CEOs testified one after another that they did not believe nicotine was addictive. The tag line read, "Do they think we're stupid?" Attorneys for R.J. Reynolds' former CEO James W. Johnston, one of the executives who testified, fired off an irate letter and threatened to sue if the ad was not withdrawn. It was not, and Johnston backed down.

All this hard-hitting ad copy came about because of Proposition 99, passed by California voters in 1988, despite a $22 million campaign by the tobacco industry to defeat it. The measure increased the tax on cigarettes by 25 cents per pack, raising $134 million annually, about $25 million of which currently goes toward the media campaign (The state also nets $22 million a year from the tobacco master settlement to combat youth smoking.)

Since Prop 99 was passed, California's anti-smoking sentiments are even stronger, garnering the state a reputation for having the toughest anti-smoking laws in the country. State law bans smoking in most indoor workplaces, bars, and restaurants. Local governments have passed ordinances that restrict smoking in public buildings, public transit, and parks as well as near playgrounds. To further discourage smoking, voters bumped up cigarette prices by 50 cents per pack in 1999.

"You need a comprehensive program that hits people everywhere they go, just like the tobacco industry does," says Danny McGoldrick, research director for the Campaign for Tobacco-Free Kids, an independent, nonprofit advocacy group. "We have to be as sophisticated in our thinking as the people we're up against."

"I miss my lung, Bob"

That tobacco companies deceived the public became common knowledge after evidence surfaced that their executives had known for decades that tobacco was addictive. This culminated in the historic 1998 legal settlement between 46 states and the tobacco companies for $206 billion. The four remaining states settled separately for an additional $40 billion, to be used to recover tobacco-related health care costs and for anti-tobacco campaigns.

"California has done brilliantly at exposing the truth about the tobacco industry's marketing tactics," says Michael Siegel, MD, MPH, associate professor at Boston University School of Public Health and a specialist in tobacco control policy.

The Marlboro man series of billboard ads drives this point home. One of the best-known of California's ads, it takes on a tobacco-advertising icon and humanizes its victims. Tobacco, it tells us, hurts even the most macho among us. "Bob, I've got emphysema" the cowboy says in one ad. "I miss my lung, Bob," he says in another.

"People loved those ads," says Stevens. "Everybody knows the Marlboro Man. He's strong and virile, and if you smoke for 20 years you're going to end up like him."

One of the most disturbing ads produced by the media campaign is called "Debi." In it, a laryngectomy patient smokes through a tracheotomy opening in her throat. An astonishing 95 percent of those who see the ad remember it, giving it the highest recall of any ad produced, Stevens says. Many people say they can't watch it. In a more recent spot, Debi explains her decision to quit smoking for the sake of her niece. In another, she discusses her addiction and the fact that the tobacco industry lied in claiming tobacco wasn't addictive.

To reach California's highly diverse population, the media campaign also targets African American, Asian/Pacific Islander and Hispanic/Latino communities with culturally relevant ads. In "Taps," for example, which is targeted to African-Americans, a son reminisces about his heroic father -- who began smoking in the armed services, where cigarettes were given out for free -- and the cost paid when his father died from a smoking-related illness. In "Bedroom," aimed at Asian/Pacific Islanders, a couple's intimacy is compromised by impotence from cigarette smoking.

One television spot shows smokers offering up their usual excuses about why they don't quit. The ad juxtaposes the smokers' reasons for not stopping with the health consequences of their decision. After viewing the storyboard version, a focus group of longtime smokers went silent. "Several people said, 'Oh my God, that's exactly what I say,'" recalls Stevens. "The ad jumped over their denial. They saw themselves."

Says Stevens, "It's hard to hit home runs time after time, but we've had a few grand slams."

"Don't talk to us like we're kids"

Reducing smoking among young adults, however, hasn't been as successful, Stevens says. The number of smokers in the 18-to-24 age group -- the prime target of the Joe Camel cartoon character -- has shown smaller decreases than among older adults. R.J. Reynolds Tobacco Company did away with Joe Camel in 1997 following lawsuits that claimed the colorful, slick camel was designed to make cigarettes appealing to children. Reynolds' ad campaign has been so successful that research shows more than 90 percent of 6-year-olds can match the Joe Camel image with a picture of a cigarette. Even more startling, it indicates that the average 14-year-old has been exposed to more than $20 billion worth of tobacco advertising.

Making sure that California's anti-tobacco media campaign grabs the attention of young people is especially vital, Stevens says. Over the years their research has shown that the most effective way to reach youth is to create messages that target adults and youth at the same time. Unlike states that have media campaigns focused exclusively on young people, California's strategy is to make sure adults are the role models for the next generation. "For kids to be successful nonsmokers, we believe they have to grow up in environment where it is not normal to smoke," says Stevens. "Kids now see adults huddled outside of buildings smoking. It's not glamorous or hip to smoke like when I was growing up."

For example, both young people and adults loved the recent "Mind if I smoke?" "Care if I die?" billboard series, which featured a '50s retro look, says Stevens. "The ad really strikes a chord with kids," she says. "It's sassy, it's how kids talk."

Harnessing young people's natural rebelliousness is key. Kids don't like to be manipulated or controlled, says Boston University's Siegel. "Tobacco industry ads convey smoking as representing freedom and independence," he says. "To get kids not to smoke, you have to turn the tables, so that only by rejecting that manipulation can kids demonstrate their true independence."

In 1997 Stevens and her staff revisited their strategy with youth focus groups and discovered they were on the right course. "Kids feeling manipulated by the tobacco industry resonated way stronger than anything else," recalls Stevens. "'Don't talk to us like we're kids,' they told us."

Another new ad series that has surveyed well with youth and adults alike features a smug cartoon crocodile that represents the tobacco industry. In one, a crocodile with Big Tobacco emblazoned across its chest responds to the fact that tobacco kills 400,000 people each year with, "Darn, my best customers too."

A similar ad states that "Tobacco is legal, profitable, and it kills people." The crocodile has an answer for that, too: "Well," he says, "two out of three's not bad." The best antismoking messages, Stevens says simply, are universal. "A great ad -- the strongest and most effective -- transcend age, ethnicity, and culture."

-- Loren Stein is a medical and legal writer based in Palo Alto, California.

References

First published December 13, 2001
Last updated January 4, 2007
Copyright © 2001 Consumer Health Interactive