Program Profile: The truth® Campaign

A national smoking prevention campaign that uses advertisements with anti-tobacco messages targeted at youths ages 12 to 17 who are most at risk of smoking. The program is rated Promising. The evaluation found a reduction in smoking prevalence and a decreased risk of smoking initiation among youth.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals, Target Population, and Program Components

The truth® campaign is a national smoking prevention campaign that uses advertisements with anti-tobacco messages targeted at youths ages 12 to 17 who are most at risk of smoking. Young adults ages 18 to 24 are an important secondary audience. The truth® campaign is based on the tobacco-prevention program launched by the Florida Department of Health in 1998. The Florida program known as “truth” includes television advertisements that deglamorized smoking and portrayed youths confronting the tobacco industry. The marketing portion of the campaign was developed by a team of advertising and public relations firms but was driven by grassroots advocacy. The theory behind the campaign is that “truth” will change youths’ attitudes toward smoking, and that, in turn, will change their smoking behaviors, prevent them from initiating smoking, or both.

Program Theory

The truth® campaign was launched nationally in 2000. It is run by the American Legacy Foundation, which was founded under the terms of the Master Settlement Agreement between the U.S. tobacco companies and 46 U.S. states and 5 territories. The core strategy of the campaign is to market its message as a brand, like other youth brands (e.g., Nike®, Sprite®) to appeal to youths most at risk of smoking. The TV and print commercials feature “edgy” youths (i.e., those who are on the cutting edge of trends), promotional items (T-shirts, stickers), street marketing, and a Web site. Although “truth” is a national multiethnic campaign, special components were developed to reinforce its appeal to African Americans, Hispanics, and Asians.

The objective of the campaign is to allow youths to make informed choices about tobacco use by giving them facts about the tobacco industry and its products. The messages of the truth® campaign focus on smoking addiction, death and disease attributed to smoking, ingredients in cigarettes, and the social consequences of smoking. They feature historical statements from the tobacco industry’s dubious marketing tactics and its efforts to obscure the health effects of tobacco. Rather than use obvious and directive messages that tell teens not to smoke, campaign advertisements use graphic images that depict stark facts about the consequences caused by tobacco use. For example, a well-known commercial titled “Body Bags” showed youths piling 1,200 body bags outside the headquarters of a major tobacco company to illustrate the daily death toll from tobacco use.

Study 1

The Farrelly and colleagues 2005 study used a pre?post quasi-experimental design that relates changes in youth smoking prevalence to varied exposure to the truth? campaign over time and across media markets in the United States. The study used media delivery data as well as data from the Monitoring the Future (MTF) surveys during 1997?2002. The MTF survey is given annually in the spring to a nationally representative sample of roughly 50,000 8th, 10th, and 12th grade students and asks questions designed to monitor alcohol, tobacco, and illicit drug use among youths.

The study outcome was a dichotomous variable for reporting any quantity of smoking in the past 30 days, based on the following question from the MTF survey: how frequently have you smoked cigarettes in the past 30 days? The variable was coded as zero for students who answered ?none per day,? and was coded as 1 for students who answered ?less than 1 cigarette,? ?1 to 5 cigarettes,? ?about ? pack,? ?about 1 pack,? ?about 1? packs,? or ?2 packs or more per day.? The years 1997?99 represented a precampaign study period. The years 2000?02 represented the years the campaign was launched nationally, although the dose of campaign messages varied considerably across media markets and over time.

Student?s exposure to the truth? campaign was measured by cumulative gross rating points (GRPs) in each of the 210 television markets in the United States. GRPs measure the total volume of delivery of a media campaign to a target audience. They are equal to the percentage of the target audience that is reached by the campaign times the frequency of exposure. Student?s exposure was defined as the cumulative number of truth? campaign GRPs that were delivered in a school?s media market from the beginning of the campaign in February 2000 to the time of the MTF survey in the springs of 2000, 2001, and 2002. Students from 1997?99 served as a historical unexposed comparison group (GRP=0).

Potential confounding variables were controlled for, including individual-level variables (grade, race/ethnicity, gender, parental education), media market-level variables (median household income, percentage of the population who were college graduates, population size), and state-level variables (inflation-adjusted cigarette prices, investments in tobacco control programs). The study used population average logistic regression models to estimate current youth smoking prevalence as a function of individual-, media market?, and state-level influences. Regressions were estimated by combining the cross-sectional MTF surveys from 1997 through 2002 to relate the odds that an individual smoked to the media market dose of the campaign, measured at the time of the survey.

Study 2

A second study by Farrelly and colleagues (2009) used a similar quasi-experimental design to relate changes in smoking initiation to levels of exposure to the truth? campaign over time and across media markets in the United States using longitudinal data. The study analyzed data from the National Longitudinal Survey of Youth 1997 (NLSY97). The NLSY97 is designed to provide information about youths? transition from school to the labor market and into adulthood. Members of the longitudinal cohort were interviewed annually beginning in 1997 and were ages 15?20 when the truth? campaign began in 2000. Data from Rounds 1?8 (1997?2004) were used in the analyses. The baseline sample included a national representative sample of 8,904 adolescents between the ages of 12 and 17 years during the initial survey round in January 1997.

The outcome measure included the age of initiation of trying smoking based on three questions from the NLSY97. All youths were asked: have you ever smoked a cigarette? If youths answered ?yes,? they were asked a follow-up question to determine the age of initiation: how old were you when you smoked your first cigarette? For subsequent surveys, youths were asked: have you smoked a cigarette since the last interview? If youths answered ?yes? to this question, the age of initiation was based on their age at the time of the survey.

The authors again used gross rating points (GRPs) to quantify the reach and frequency of exposure to the campaign on television. The cumulative sum of exposure (the GRPs) was calculated for each study participant for each wave of the survey, based on the participant?s media market of residence each year. For example, if a market received 1,000 GRPs per year, cumulative exposure would be 5,000 GRPs by 2004 for a cohort member who lived in this market for all years since the campaign launch in 2000. The precampaign period before February 2000 (1997?99) was set to zero (GRP=0).

Several confounding variables were controlled for in the study, including individual/family confounders (race/ethnicity, gender, total individual income, living with both parents, ever being suspended from school, etc.), market-level characteristics (average disposable family income, average high school completion rates, and percentage of population living in rural areas), and time-varying confounders (such as cumulative GRPs, annual inflation-adjusted per capita state-level funding for tobacco control programs, and state cigarette prices). The study used discrete-time survival analysis to assess the influence of the truth campaign on smoking initiation. The process allowed for the calculation of the probability that an individual will initiate smoking for each age represented in the sample, given that he or she had not previously begun smoking.

Holtgrave and colleagues (2005) used standard methods of cost and cost–utility analysis in accordance with the U.S. Panel on Cost-Effectiveness in Health and Medicine. Consistent with this guidance, a societal perspective was employed. The costs and effects of the truth® campaign were compared with the absence of the campaign. Although it has been estimated that there were roughly 300,000 fewer youth smokers in 2002 as a result of the campaign, the study used a conservative estimate of 169,800 fewer youth smokers. The results showed that, between 2000 and 2002, total expenditures for the truth® campaign, including the costs to develop, deliver, evaluate, and litigate the campaign, came to just over $324 million. Estimates from the analysis showed that the campaign recouped its costs and that roughly $1.9 billion (and perhaps as much as $5.4 billion) in medical costs were averted for society, based on the number of youths who were prevented from initiating smoking.

Because of the nature of the intervention (a national tobacco awareness campaign), there are some limitations to the evaluations of the truth® campaign. The delivery of the program to youths nationwide through various national advertising media campaigns creates certain methodological difficulties for researchers trying to isolate the effect of the program from the effect of other factors that may have influenced adolescent tobacco use (such as school-based prevention programs or local laws passed to reduce selling of tobacco products to youth). Although there are methodological reservations in this regard, the studies included in the program’s evidence base made suitable efforts to minimize these limitations. The quasi-experimental design and sampling strategies were determined to meet the standards for inclusion on CrimeSolutions. However, users should still interpret the outcomes with some caution.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Farrelly, Matthew C., Cheryl G. Healton, Kevin C. Davis, Peter Messeri, James C. Hersey, and M. Lyndon Haviland. 2002. “Getting to the Truth: Evaluating National Tobacco Countermarketing Campaigns.” American Journal of Public Health 92(6):901–07.

Farrelly, Matthew C., Kevin C. Davis, Jennifer Duke, and Peter Messeri. 2009. “Sustaining ‘truth’: Changes in Youth Tobacco Attitudes and Smoking Intentions after 3 Years of a National Antismoking Campaign.” Health Education Research 24(1):42–48.

Holtgrave, David R., Katherine A. Wunderink, Donna M. Vallone, and Cheryl G. Healton. 2009. “Cost–Utility Analysis of the National truth® Campaign to Prevent Youth Smoking.” American Journal of Preventive Medicine 36(5):385–88.

Richardson, Amanda Kalaydjian, Molly Green, Haijun Xiao, Natasha Sokol, and Donna M. Vallone. 2010. “Evidence for truth®: The Young Adult Response to a Youth-Focused Anti-Smoking Media Campaign.” American Journal of Preventive Medicine 39(6): 500-506. (This study was reviewed but did not meet CrimeSolutions' criteria for inclusion in the overall program rating.)

Sly, David F., Richard S. Hopkins, Edward Trapido, and Sarah Ray. 2001. “Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida ‘truth’ Campaigns.” American Journal of Public Health 91(2):233–38.