Intended for healthcare professionals

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Shock to stop?

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:66
  1. John Worden, research professors,
  2. Brian Flynn, research professors
  1. Office of Health Promotion Research, University of Vermont, Burlington, USA

    Massachusetts' antismoking campaign

    Pam Laffin, a 29year old mother of two, is the latest weapon in the US health sector's war on the tobacco industry. Mrs Laffin's struggle to survive emphysema is being shown on prime time television in Massachusetts in a series of 30second antismoking advertisements.

    Paid for by the state's Department of Public Health, the media campaign reveals that she is waiting for a second lung transplant, her body having rejected the first. It also features a comparison of a healthy lung and a tobacco ravaged lung, and displays the woman's transplant scar. Costing $1.5m ($0.9m), these advertisements are intended to grab the attention of smokers who need more urging to quit and young people who are just starting to smoke.

    The Massachusetts adverts reflect a trend started by an Australian campaign in 1997that used scare tactics to target smokers aged 18-39.The adverts in this campaign began with smokers lighting up, followed by smoke coursing through bronchial tubes, and ended with a particularly gory scene of an aorta spewing fatty deposits. The message was: “Every cigarette is doing you damage.”

    But what are these adverts doing? Are they having any effect on reducing smoking, or are they simply gaining attention for the organisations that are sponsoring them? In Austlia it has been reported that the “jury is still out” but that there are “early signs” from telephone interviews that more people were talking about the campaign and that there was “increased activity toward quitting.” In Massachusetts it has been reported that calls to the state's antismoking counselling service have increased sixfold. But people talking about adverts or making telephone inquiries are a far cry from reducing smoking prevalence. This is hardly compelling evidence that this approach will have any greater effect on smoking behaviour than others have in the past.

    The term “mass media” carries the promise of reaching all with a single message, but the situation is considerably more complex, as any good marketing expert can testify. There are many different audience segments, and the variety of widely available, special interest programming has expanded dramatically. As audience segments become increasingly split into smaller units, new opportunities emerge for specialised health messages addressing these segments.

    Smokers comprise several audience segments. They include both old and young, with vastly different communication styles and perspectives on smoking. Perhaps the new adverts based on fear are just right to jar into immediate action an older smoker who has been considering quitting and might have stopped smoking in the near future even without seeing this message. What effect do these messages have on the much larger group of smokers who are not even thinking about quitting, and what help do they offer those who are currently trying to quit or stay quit?

    Youths who do not yet smoke comprise other segments. The period of highest risk for starting smoking falls between preadolescence and the mid-teens. The social and cultural differences between ages 10and 15can be as impressive as the physical differences; different developmental trajectories by sex enliven this picture further. The relevance of messages featuring an elderly looking hospital patient or an oozing aorta could easily be missed by a 10year old boy mainly interested in motorcycle racing and professional wrestling.

    Although message styles need to differ substantially, educational strategies for smoking prevention that have been tested in controlled studies clearly point to guidelines that apply across these differences. These guidelines emphasise the importance of social influences, both positive and negative, on a young person's decisions about becoming a smoker. Since we have educational models that can be used to design and evaluate effective campaigns, why aren't they being applied in the war against tobacco? The Australian campaign has made a serious attempt at using some of these models in designing their campaign, but the designers report no rigorous evaluation.


    Pam Laffin, on TV and the web (

    With the advent of settlements from tobacco companies, many governments are on the verge of making huge investments in antismoking media campaigns. It is time to stop improvising with messages that appeal primarily to antismoking advocates and executives of advertising agencies. Until we do, we will continue to waste a potentially powerful weapon in the war against tobacco.

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