There is widespread appreciation that the media has an influence on health behaviors. In most instances, the perception among public health advocates is that this impact is primarily negative (such as tobacco use, obesity, violence). In a few other cases, the media framing of a health problem is less contentious; what is debated is how to harness the media for improving public health. In the past year, I have heard repeatedly from international HIV prevention experts that what we need to do is launch the same type of media campaigns to change social norms that the tobacco control community has done. Unfortunately, this call is then followed by a riff on the need for ‘hard-hitting, fear-arousal’-types of efforts. What is unfortunate is that these experts do not appreciate the multiplicity of media efforts that have gone into developing tobacco control media activities – they have not simply been emotional television ads.
The National Cancer Institute has published the monograph The role of the media in preventing and reducing tobacco use (media release). It should be required reading for anyone using, or considering using, the mass media in any of its forms to address public health issues from obesity to mental illness to climate change. The monograph is a collection of chapters reviewing the empirical evidence on the role of mass media on tobacco use including industry marketing and promotion practices (often the playbook for other industries), tobacco portrayal in news and entertainment media, tobacco control media interventions, and the use of the media by the industry to weaken tobacco control efforts (pay attention to this one too). Here’s a sampling of some of the conclusions, pulled from the Executive Summary (pdf file), to start your thinking (my emphasis is added). The key in reading this list, and the monograph, is to make the inference to your own issue and the players and practice that you face. I write this remembering a nutrition professional who after listening to me talk about tobacco advertising and promotion practices and their influence on tobacco use raised her hand and innocently asked: could the food industry do the same thing to encourage excessive consumption, and therefore obesity? Yes they (and others) DO.
- The total weight of evidence - from multiple types of studies, conducted by investigators from different disciplines, and using data from many countries - demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use.
- Tobacco advertising has been dominated by three themes: providing satisfaction (taste, freshness, mildness, etc.), assuaging anxieties about the dangers of smoking, and creating associations between smoking and desirable outcomes (independence, social success, sexual attraction, thinness, etc.).
- Targeting various population groups - including men, women, youth and young adults, specific racial and ethnic populations, religious groups, the working class, and gay and lesbian populations - has been strategically important to the tobacco industry.
- Substantial evidence exists from the United States and several other countries that tobacco companies typically respond to partial advertising bans in ways that undermine the ban’s effectiveness. These responses include shifting promotional expenditures from “banned” media to “permitted” media (which may include emerging technologies and “new” media), changing the types and targets of advertising in permitted media, using tobacco-product brand names for nontobacco products and services,
- Corporate sponsorship of events and social causes represents a key public relations strategy for major tobacco companies, which spent more than $360 million on these efforts in 2003. Key targets included sporting events, antihunger organizations, and arts and minority organizations. These efforts have been used, in certain cases, to influence opinion leaders who benefit from such sponsorship.
- Corporate image campaigns by tobacco companies have highlighted their charitable work in the community and have promoted their youth smoking prevention programs; at times, corporate spending on these campaigns has vastly exceeded the amount actually given to the charities. These campaigns have reduced perceptions among adolescents and adults that tobacco companies are dishonest and culpable for adolescent smoking, and among adults, have increased perceptions of responsible marketing practices and favorable ratings for the individual companies.
- Strong and consistent evidence from longitudinal studies indicates that exposure to cigarette advertising influences nonsmoking adolescents to initiate smoking and to move toward regular smoking.
- The studies of tobacco advertising bans in various countries show that comprehensive bans reduce tobacco consumption. Noncomprehensive restrictions generally induce an increase in expenditures for advertising in “nonbanned” media and for other marketing activities, which offset the effect of the partial ban so that any net change in consumption is minimal or undetectable.
- News coverage that supports tobacco control has been shown to set the agenda for further change at the community, state, and national levels. Despite this, organized media advocacy efforts on behalf of tobacco control issues remain an underutilized area of activity within public health.
- Experimental studies show that images of cigarette smoking in film can influence adolescent and adult viewers’ beliefs about social norms for smoking, beliefs about the function and consequences of smoking, and their personal intentions to smoke. Protobacco movie content (e.g., stars smoking, absence of health consequences portrayed) appears to promote prosmoking beliefs and intentions. The effects observed for experimental studies of smoking in movies on viewers’ smoking-related beliefs are of a similar magnitude as those observed in experimental media research on other health topics (e.g., effects of media violence on viewers’ aggression).
- The total weight of evidence from cross-sectional, longitudinal, and experimental studies, combined with the high theoretical plausibility from the perspective of social influences, indicates a causal relationship between exposure to movie smoking depictions and youth smoking initiation.
- Numerous studies have shown consistently that advertising carrying strong negative messages about health consequences performs better in affecting target audience appraisals and indicators of message processing (such as recall of the advertisement, thinking more about it, discussing it) compared with other forms of advertising, such as humorous or emotionally neutral advertisements. Some of these negative advertisements also portray deception on the part of the tobacco industry. Advertisements for smoking cessation products and tobacco-industry sponsored smoking prevention advertising have been shown to elicit significantly poorer target audience appraisals than do advertisements based on negative health consequences.
- Population-based studies of antitobacco mass media campaigns that were only one component of multicomponent tobacco control programs provide considerable evidence for reduced use of tobacco by youth and adults. The antitobacco mass media campaign and the other program components together may have reduced smoking more than did any single component alone. The relative contributions of various components to program effectiveness are difficult to determine, but some of the controlled field experiments showed a dose-response relationship between reduced smoking and an increased number of program components.
- Increasing consumer awareness of tobacco industry activities to counteract public-health-sponsored campaigns designed to reduce tobacco use can be an important component of effective media interventions.
- The tobacco industry consistently has used several primary themes to defeat state tobacco tax increase initiatives. These include suggestions that the measures would impose unfair taxes and that tax revenues would not be spent on health care or tobacco control programs as intended. Secondary themes used consistently over an 18-year time span include that the measures would increase “big government” and wasteful spending, discriminate against smokers, and increase crime and smuggling. Other, less frequent themes were that the measures would be a tax cut for the rich, impede economic growth, fail to solve state budget problems, restrict personal choice, and violate antitrust laws.
The point here is with a research base that is probably the most extensive with respect to the role of the media and a health behavior (well, with the exception of the portrayal of aggression on television and violent behaviors which we have known about since the early 1960s), you have to think about media in the broadest possible way – including new media, movies, news coverage, editorial pages and the public policies that govern them. It is not just advertisements, entertainment-education or mass media campaigns. I am particularly pleased to see that research in this area is also finding that it is the exposures to multiple channels, rather than the magic bullet, that is most likely to lead to behavior change. If researchers would stop asking the wrong question of “which one is it” among a multi-component program and focus instead on how to maximize the impact of media multiplexity, we will move further along the path of developing better interventions across channels that are relevant to our priority audience.
The review also highlights another point I subscribe to: media need to be approached as an agenda-setting tool for policy shifts that encourage healthier behaviors. Changing social norms is an admirable goal, but unless behaviors change and policies are in place to encourage, reinforce and sustain the changes and normative shifts, we are undertaking a Sisyphean task: the norms will always roll back on us after short-lived gains.