Selling Health: A Media Campaign Against Tobacco

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1 Selling Health: A Media Campaign Against Tobacco KENNETH E. WARNER GUEST EDITORIAL N late I985 and early I986, the American Medical Association, American Cancer Society, and American Heart Association added their voices to the call for a i: = 5 ban on the advertising and promotion of tobacco products, a call previously issued by many of the world's > s Za leadimg voluntary and professional health organizations. Widely publicized, the ban proposal has forced consideration of a number of issues, ranging from the constitutionality of prohibiting the advertising of a legal product to the behavioral consequences of advertis- ing (i). Examination of the historical evidence pertaining to the latter has renewed interest in tobacco counteradvertising, a strategy that relies on the techniques and imagery of conventional product advertising to sell a health message. Counteradvertising is seen today in posters parodying cigarette ad themes, produced by such organizations as DOC (Doctors Ought to Care), and the major voluntary health agencies-the American Cancer Society, American Heart Association, and American Lung Association. Using the cigarette ads' underlying themes of attractiveness, physical fitness, success, and confidence, the counterads often portray models as happy and healthy because they avoid tobacco. To drive home the absurdity of cigarette ads' imagery, some of the counterads refer to such cigarette brands as DOC's "Emphysema Slims." But the problem with counteradvertising at present is simply that it is not very visible, because the resources to produce, distribute, and- most importantlypurchase magazine space or television time are miniscule, when measured against the $2 billion per year the tobacco industry devotes to promoting smoking (2). It has been estimated that total expenditures on tobacco 434 Palgrave Macmillan is collaborating with JSTOR to digitize, preserve, and extend access to Journal of Public Health Policy

2 WARNER * SELLING HEALTH 43 5 counteradvertising, public and private, now equal only about $5 million per year (3). Drawing on voluntary resources, the potential magnitude of an antitobacco campaign pales in comparison with that achieved during the heyday of counteradvertising in the late I960S. From mid-i967 through 1970, television and radio broadcasters were required by the Federal Communication Commission's Fairness Doctrine to donate air time to the antismoking cause to balance the message conveyed by cigarette advertising. At their peak, the Fairness Doctrine antismoking messages received a minute of air time for every three minutes of pro-smoking advertising. In total, roughly $200 million in commercial air time (in 1970 dollars) was donated to combating the effort to sell cigarettes with the same kind of weapon the tobacco manufacturers had used for years to promote their products (4). While counteradvertising has a certain biblical appeal-it is, after all, based on an eye for an eye-its major attraction is its apparent effectiveness. Several empirical studies have concluded that the Fairness Doctrine messages were highly effective in discouraging smoking. In the four years they were aired, adult per capita cigarette consumption declined by more than I0 percent, representing the first time during the century that per capita consumption had fallen for more than two consecutive years (which decrease itself had been in response to media antismoking publicity) (4). An econometric study concluded that the counterads deterred substantially more smoking than pro-smoking ads encouraged (5). When cigarette ads were removed from the broadcast media in and the Fairness Doctrine messages disappeared with them -per capita consumption immediately resumed its upward trend. The apparent greater effectiveness of the antismoking messages led Hamilton to label the broadcast advertising ban a Pyrrhic victory for the antismoking forces (5). That this perception persists today, more than a decade later, is exemplified by the response of an attorney to the new ad ban proposal. Writing in the New York Times, Landsman called the proposal "not the best solution to the problem" and argued that, "[i]nstead, Congress should repeal its ban on radio and television advertising of cigarettes and require that broadcasters provide equal time for antismoking messages" (6). This alternative to the AMA ban proposal suffers from two flaws. First, the margin of the substantial short-run dominance of the effectiveness of the Fairness Doctrine messages over cigarette ads might not hold

3 436 JOURNAL OF PUBLIC HEALTH POLICY - WINTER I986 over the longer term. Certainly, the novelty of the antismoking messages may have contnrbuted to their effectiveness, just as the familiarity of the cigarette ads may have limited theirs. The effectiveness of the former might have diminished over time as the early years' counterads weeded out those smokers most susceptible to their message; the relatively smaller decrease in per capita consumption during the final year of the Faimess Doctrine period may reflect this possibility. Also, no study has attempted to assess the long-run implications for initiation of smoking habits by children of removing from TV the ever-present glamorization of smoking. Indeed, it is unlikely that such a phenomenon can be evaluated in a defaiitive scientific study (4). The second flaw in Landsman's alternative proposal lies in the implicit assumption that a media anti-tobacco campaign is inseparable from conventional advertising, the notion that in order to recapture the effectiveness of the counteradvertising of the late I960s, we must reinstate the nght of tobacco manufacturers to advertise their products on radio and television. There is nothing in law or logic that demands this linkage. From a public health perspective, the most desirable situation would be full implementation of a tobacco promotion ban and inauguration of a substantial, highly visible media anti-tobacco campaign. But there is a major barrier to attaining the latter in the absence of tobacco ads in the broadcast media and application of the Fairness Doctrine: money. Since the late I960s, prices have roughly trebled. Thus, to mount a paid broadcast media campaign comparable to that of the Fairness Doctrine era would require something on the order of $6oo million today. The resources available for this purpose from the nation's three leading voluntary health organizations, plus other interested private-sector organizations, could never approach more than a fraction of this amount. The issue, then, is how to finance a media campaign, assuming that such a campaign is deemed desirable. The latter has been an article of faith for years in the tobacco-and-health community; the issue of financing has been a source of despair, and the reason that no concerted effort has been made to mount such a campaign. The article of faith seems warranted by the evidence. Despite the qualification above that the substantial effectiveness of the Faimess Doctrine messages might have diminished over time, there is no question that the messages were highly effective in the short run, and little question that they would have continued to serve as a deterrent to smoking over

4 WARNER * SELLING HEALTH 437 the longer haul. Furthermore, a thorough new review of the intemational literature on the subject provides convincing evidence that a variety of types of media campaigns have been successful in encouraging smoking cessation (7). But where does the money come from to support a truly major campaign? One can imagine a number of possible sources that would be tied to present-day tobacco advertising. For example, if tobacco advertising were permitted to continue, the Federal Trade Commission could rule that it is inherently misleading, given its reliance on the imagery it currently employs. As a remedy, tobacco products advertisers could be ordered to pay for an equivalent amount of space (or a substantial fraction thereof) to be used by voluntary and professional health organizations to promote the antismoking message. At first blush, the notion of requiring manufacturers to pay for space to combat their products may seem patently absurd. That, however, is exactly what the cigarette companies are required to do today: every newspaper, magazine, billboard, and transit cigarette ad is required to devote space, of a prescribed dimension, to the Surgeon General's waming. The fact that the suggested possibility seems radically different speaks to the relative ineffectiveness of a small verbal messagejuxtaposed against a larger pictorial one. Altematively, if proposals now before Congress to end the tax deductibility of tobacco promotion expenditures are passed, some of the tax gains could be earmarked for an anti-tobacco media campaign. Each of these could create the resources needed for a media campaign, yet each remains coupled to the continued legality of tobacco promotion, contrary to the ban proposal and to the public health ideal. Each also suffers from the fact that the modus operandi of the funding mechanism might itself discourage promotion of tobacco products. While this might be desirable, the concurrent loss of resources for the counteradvertising campaign would not be. To completely uncouple the promotion ban and a media anti-tobacco campaign, an alternative solution is to earmark a portion of federal tobacco excise taxes to fund the media campaign. An earmarked tax of only one penny per pack of cigarettes (by far the dominant form of tobacco product) would generate close to $300 million in revenue per year. If the penny were taken from the current federal excise tax, it would impose no additional burden on smokers. If the penny represented an increase in the tax, it would cost the average pack-and-a-half-a-day

438 JOURNAL OF PUBLIC HEALTH POLICY WINTER I986 smoker only $5.50 a year. An additional three-cent earmarked tax would yield almost $900 million and cost the average smoker under $I 6. 50 each year.

5 438 JOURNAL OF PUBLIC HEALTH POLICY WINTER I986 smoker only $5.50 a year. An additional three-cent earmarked tax would yield almost $900 million and cost the average smoker under $I each year. An additional five-cent earmarked tax would produce close to $1.5 billion for the anti-tobacco effort-fully three-quarters of tobacco industry expenditures to promote cigarettes -and cost the average smoker less than $27.50 a year. The beauty of this proposal, in addition to its independence fronm tobacco advertising per se, is that the revenue to combat tobacco use would shrink automatically as the campaign worked and hence as the need for it diminished: as tobacco use fell, the tax yield would decrease proportionally. The campaign would self-destruct as Americans ceased their self-destructive tobacco habits. As the figures above suggest, the burden of the earmarked tax on the individual tobacco user would be nothing, if the current tax was used, or relatively small, if an additional tax was levied. The revenues would be ample, however, reflecting the large number of tobacco users in this country. If the earmarked tax were taken from the current federal cigarette tax, the government would lose some revenue otherwise available for general purposes, but the amounts contemplated here represent only a tiny fraction of a trillion-dollar budget, or even of a $I oo-plus billion deficit. If the government were reluctanto part even with these relatively minor sums, Congress could increase federal tobacco taxes by slightly more than the envisioned earmarking. This would preserve federal revenues, create media campaign resources, and, by raising tobacco product prices, have the added advantage of further discouraging tobacco consumption, particularly by children and teenagers (8). A further attraction of the earmarking strategy to mount a tobacco counteradvertising campaign is that it can be implemented at the state level. States are precluded by the preemption clause of the federal Public Health Cigarette Smoking Act of I969 from regulating cigarette advertising. But nothing legally prevents the states from raising their excise taxes and devoting proceeds to a media anti-tobacco campaign. The concept of raising state cigarette excise taxes and earmarking revenues is beginning to be put into practice, as is illustrated by the exanmple of Minnesota (9), but to date no state has earmarked revenues specifically for a media counteradvertising campaign. The proposal to ban tobacco advertising and promotion deserves the serious attention it has been receiving. But interest in that option should not deflect consideration from other strategies that might complement

6 WARNER * SELLING HEALTH 439 it and serve similar purposes. A counteradvertising campaign takes the best that Madison Avenue has had to offer the tobacco industry, and puts it to work for public health. REFERENCES i. Warner, K. E., Ernster, V. L., Holbrook, J. H., et al. "Promotion of Tobacco Products: Issues and Policy Options," J. Health Politics, Policy, and Law, in press. 2. Federal Trade Commission. Reporto Congress, Pursuanto the Federal Cigarette Labeling and Advertising Act,for the Years Washington, DC: Federal Trade Commission, June I 985; as revised December I Bonnie, R. J. "The Efficacy of Law as a Paternalistic Instrument," Nebraska Symposium on Motivation (I985): Warner, K. E. "Clearing the Airwaves: The Cigarette Ad Ban Revisited," Policy Analysis 5 (1979): Hamilton, J. L. "The Demand for Cigarettes: Advertising, the Health Scare, and the Cigarette Advertising Ban," Rev. Econ. Stat. 54 (1972): 40I-I I. 6. Landsman, R. M. "How to Counter Tobacco Ads, " New York Times, January 2, I986, p Flay, B. R. "Mass Media and Smoking Cessation: A Critical Review," Am. J. Pub. Health, in press. 8. Warner, K. E. "Smoking and Health Implications of a Change in the Federal Cigarette Excise Tax," JAMA 255 (I986): Schultz, J. M., Moen, M. E., Pechacek, T. F., et al. "The Minnesota Plan for Nonsmoking and Health: The Legislative Experience," J. Pub. Health Pol. 7 (I986):

Advertising, Promotion, Countermarketing, and Tobacco Use. Frank J. Chaloupka University of Illinois at Chicago

Advertising, Promotion, Countermarketing, and Tobacco Use Frank J. Chaloupka University of Illinois at Chicago www.uic.edu/~fjc US Cigarette Advertising and Promotional Expenditures, 1998 2% 5% 5% 23%