Chapter 6

Activities To Involve the Smoking Public in Tobacco Control in COMMIT

Russell C. Sciandra, Lawrence Wallack, Carolyn L. Johnson, Janine Sadlik, and Juliet Thompson

INTRODUCTION

Public education is a necessary tool to facilitate smoking control efforts. For many years, the tobacco industry has used public education in the form of advertising to promote the use of its products in such a way that exposure to tobacco cues is virtually impossible to ignore (Johnston et al., 1987; Centers for Disease Control, 1990). The information presented by the tobacco industry regarding the consequences of tobacco use is often fallacious. For example, cigarette advertisements link smoking with images of fitness, health, beauty, and social acceptance (Warner, 1986). There is increasing evidence linking such false advertising to an increase in consumption (Seldon and Doroodian, 1989; Tye et al., 1987). Furthermore, the clout exerted by the advertisers often results in limited coverage in the media of the ill effects associated with tobacco use (Weis and Burke, 1986; Minkler et al., 1987). An excellent example of this occurred when lung cancer became the primary cancer killer of women, exceeding breast cancer, and the issue was largely ignored by women’s magazines, which are also primary recipients of tobacco advertising revenues (Kessler, 1989).

Although public education in the interest of reducing public health problems has few resources at its disposal relative to the tobacco industry, some important efforts have been made to use this channel to reduce tobacco use. Flay (1987), in a review of 56 evaluated media tobacco control programs, came to the following conclusions:

• Such programs inform people.

• People are motivated to attempt to quit.

• Potential quitters can be encouraged to take some kind of action (e.g., calling a hotline).

• Smokers can quit for extended periods.

Smoking reductions in mediated quit programs also have been reported by Cummings and colleagues (1987 and 1989), Pierce and coworkers (1990), and Thompson and Curry (1994). Although the cessation rates associated with such programs are low, their public health effect is significant because they reach many people. However, the majority of the tobacco control interventions have been directed at individual smokers in an attempt to encourage them to quit.

In the past few years, new efforts have been added to the general use of public education and the media for tobacco control. Rather than relying only on activities designed to assist smokers in quitting or preventing youth from beginning smoking, tobacco control advocates are taking an aggressive approach to the use of mass media. This approach has been called “media advocacy,” and its central approach is to reframe public debate so that more support is generated for effective policy change around a public health issue (U.S. Department of Health and Human Services, 1989). Media advocacy is not targeted to the individual and does not focus on changing individual risk behavior; rather, it focuses on the larger, structural factors that might make a problem a public health issue (Advocacy Institute, 1987). For example, in the tobacco control arena the emphasis is placed on the ethical and legal liability of the tobacco companies, which make a product responsible for much premature morbidity and mortality. An example of effective media advocacy was apparent in the negative framing of the attempt to introduce a new brand of cigarettes, “Uptown,” to urban minorities. Antitobacco advocates were successful in convincing the public and opinion leaders that this targeting was a deliberate effort to exploit the minority group. Demonstrations and protests ultimately led R.J.Reynolds to withdraw the product (Freedman, 1990).

RATIONALE AND PROCESS OBJECTIVES

Communitywide public education efforts were central to the Community Intervention Trial for Smoking Cessation (COMMIT). The public education channel was seen as a way to coordinate and promote the activities of the other channels by providing media campaigns to promote smoking as a public health problem, to promote smoking cessation, and to encourage the prevention of smoking.

The overall strategy for the public education channel was to increase community activities that would stimulate public debate about smoking. Of key concern was that such a debate help create a social environment where support for nonsmoking was increased and support for continued smoking decreased.

Three overall goals were developed for the public education channel:

• promote social norms and actions toward a smoke-free community;

• promote the importance of smoking as a public health issue; and

• enhance the effectiveness of smoking control in other program areas.

The process objectives shown in Table 1 were developed to meet these goals. The activities can be categorized into three major types: (1) activities designed to change the community climate for smoking through media campaigns, (2) activities designed to change the community climate through media advocacy, and (3) activities to enlist smokers in quit attempts. Changing the To introduce the project to the community, activities in this area Community began with a kickoff event, the major element of which was a Climate Through news conference involving as many media outlets as possible. Media Campaigns Annually, another major news conference was held to describe the achievements of the past year and plans for the next intervention year. A few months after the announcement of the project, the communities.

released their own locally developed smoking control plans. This plan summarized the framework for the entire 4-year intervention period. It used local data and local individuals to present the smoking problem. Another key charge in this area was to publicize smoking control activities in other task force areas. Community campaigns were to be developed to fit with other activities. Each community was required to conduct a campaign to publicize the availability of a Cessation Resources Guide (CRG) (see Chapter 8), a campaign to publicize the Smokers’ Network (see Chapter 10), and a campaign to encourage heavy smokers to ask their health care providers for advice about smoking cessation (see Chapter 9). At least two other campaigns, of the community’s choosing, also were required.

Media Advocacy Media advocacy also was an important part of changing the community climate. Within each community, a staff person was trained in media advocacy. The training, conducted during a half-day session by qualified trainers, sought to convey the skills needed to put smoking control on media agendas. The trained staff person was then responsible for organizing media advocacy training sessions in the community. As part of an ongoing effort to find appropriate information for media advocacy, each field office was connected to a communication network that provided regular information on national or regional events that could contribute to public awareness if a local “spin” was put on the story.

Enlisting The public education channel also had the goal of enlisting smokers Smokers in in quit attempts. Each community was responsible for designing Quit Attempts and implementing two “magnet events” annually. A magnet event is a well-publicized, communitywide activity that stimulates smokers to quit. Examples of magnet events include the American Cancer Society’s The Great American Smokeout (GASO), in which a week’s worth of activities precede a day when smokers quit for the day, and communitywide “Quit and Win” contests, in which incentives are used to get smokers to quit for a certain period (usually 30 days). Quit and Win contests provide a communitywide outreach that involves not only smokers but also nonsmokers in assisting smokers in quitting. They have been used successfully in several communities (Elder et al., 1991; Lando et al., 1990; Cummings et al., 1990).

CAMPAIGNS

The resources available to COMMIT communities exceeded what is usually available for smoking interventions; however, they were not adequate to mount fully developed media campaigns, especially compared with the media assets commanded by the tobacco industry for promoting cigarettes. Therefore, it was necessary to leverage what was available from the funding agency to maximize its impact. This was done in a variety of ways that are more fully discussed below but can be briefly summarized as drawing on community resources not previously involved in tobacco control. There was significant variability in how communities implemented media activities. Although most sites were able to initiate the minimum number of activities required by the protocol, there was considerable variety in the quality of the interventions. Moreover, some sites substantially exceeded protocol requirements, whereas others devoted more effort to other intervention channels. This disparity arose from differences among communities (some had limited free-standing media; some had media that overlapped with the comparison community) and from variations in the interests and skills of community staff and volunteers.

Medford/Ashland, OR The experience of the Medford/Ashland, OR, site was typical of many in the trial. The Medford/Ashland intervention community, one of the smallest in the trial, had a relatively large number of media outlets at its disposal. These included 2 well-read daily newspapers; 3 local, commercial television stations; 1 public broadcast system; 1 public access television channel; and 11 radio stations. Based on previous experience in the community, COMMIT staff members had contacts with several media personalities and spent considerable time and effort maintaining these relationships throughout the trial.

Early in the intervention phase, “COMMIT To Quit,” as the program was named in Medford/Ashland, used media advocacy techniques to seize the news media’s attention. For example, it held news conferences complete with visual aids comparing cyanide levels in cigarettes to cyanide levels in tainted Chilean grapes declared unfit for consumption. Following this event, COMMIT To Quit became recognized as the “local expert” when reporters were working on tobacco-related stories.

During the first intervention year, the Public Education Task Force relied almost solely on voluntary press coverage of COMMIT events. A few paid print advertisements were run to promote a Worksite Smoking Policy Workshop and a Win a (Cold) Turkey contest as part of the GASO. The task force was disappointed at the numbers of participants generated and decided that the poor reponse was the result of a heavy reliance on public service advertising. Despite cautions from the representatives of voluntary agencies, which use no paid advertising, the task force decided to set funds aside to buy air time. COMMIT To Quit was viewed by media outlets as a voluntary organization and given the nonprofit, column-inch rate in the newspapers and the two-for-one rate in radio and television commercials.

In the second intervention year (1990), the task force contacted a marketing instructor at a local 4-year college and asked whether he would make the design of a 3-month campaign to reach heavy smokers a class project. When he agreed, the class was divided into three groups. Each group had to research the target audience; select a slogan; generate artwork, scripts, and storyboards for television and radio commercials; and propose the media placements. The winning group developed the concept of maximizing the small budget by partnering with a local minor league baseball team. The campaign included a billboard for the ballpark, a full-page advertisement in the program, busboards for the Rapid Transit District buses, and radio commercials. The campaign culminated in participants signing up for a stop-smoking contest, with free admission to the ballpark and a barbeque celebration for those that did so. The winning theme was “Time To Quit!” A request for proposal was sent to all advertising agencies in the county, and an agency contracted to produce a jingle, a 60-second radio commercial, and a 30-second television commercial. (Seven other COMMIT sites later bought copies of the television commercial.) The task force decided to use the agency to create print advertisements and to negotiate advertising purchases throughout the remainder of the project.

The advertising agency proved a wonderful asset in leveraging advertising dollars. Despite the fact that COMMIT tripled its paid advertising, it continued to receive public service advertising. During the last year of the intervention (1992), the Public Health Task Force produced a four-page newspaper insert titled “A Resolution You Can Live With.” A student poster replaced the Time To Quit artwork on the busboards, and COMMIT donated billboards at the ballparks to a local drug prevention group in exchange for its pledge to address tobacco and nicotine in its programs. The highlight of this year of the project was the production of a 30-minute documentary about COMMIT’s 4 years in the community. The documentary was premiered at COMMIT’s gala farewell celebration before an audience of dignitaries and volunteers and was later aired in prime time to promote participation in that year’s GASO.

In summary, the Medford/Ashland experience demonstrates how the creative use of community resources (college classes, student art, songwriter and composer, filmmaker) and the use of leveraged media buying (partnerships, piggybacking, multiple cosponsors, professional agency) can maximize the reach and frequency of health promotion messages on a shoestring budget.

Utica, NY

The Utica, NY, program devoted more resources to media-related activities than any other site. At the beginning of the project, the volunteer Board suggested that an advertising agency be retained to produce a consistent theme for the project’s antismoking messages. The agency that was selected developed a slogan, “Yes, You Can,” which was integrated into all the project’s messages over the next 4 years. The advertising campaign consisted of radio and television advertisements, bus cards, billboards, and point-of-purchase displays. Some advertising was developed locally, but for the most part, advertisements produced elsewhere were borrowed and tagged with the project’s slogan. As in Medford/ Ashland, the program received two- or three-for-one advertising rates in broadcasting. There were several campaigns over the 4 years, all tied together by the “Yes, You Can” theme. The repetition of this theme helped build public awareness of the program.

As in other communities, the COMMIT office soon became the recognized source of information and comment for media stories on tobacco. The computerized communication network provided by the trial gave advance notice that news was breaking nationally; this allowed staff members and volunteers to contact local media to alert them and provide local comment and statistics. Being in the news so frequently built credibility and awareness of the program. Sometimes this had unforeseen benefits.

The Utica field director stopped in a pharmacy to pick up a prescription, and the pharmacist recognized her from television as the COMMIT spokesperson. As a professional pharmacist, he was interested in doing something about smoking. This chance encounter led to activities involving a major pharmacy chain in a series of smoking cessation activities. Bellingham, WA The Bellingham, WA, site had to cope with several media problems. None of the major television outlets viewed by residents had local offices. One cable station existed, and it provided some local access but little else. The local newspaper was read widely but was part of a chain, which placed constraints on local practices. Nevertheless, COMMIT staff members and the Public Education Task Force took on the challenge of providing the information to the community.

The task force did not elect to use one theme for the entire intervention period of the project. It tied campaigns to specific community activities and events that would capitalize on local values and characteristics. The first media campaign developed by volunteers and staff took place during the 1989 holiday season (November 1989 through January 1990). This holiday gift campaign was based on the theme that “The best gift you can give yourself and your loved ones is the gift of your own good health.” Several radio commercials were developed with the collaboration of a local disc jockey who donated his time. The commercials urged listeners who were interested in giving themselves good health by stopping smoking to call the COMMIT office number to receive a free “holiday quit kit.” The commercials began playing on four local radio stations just after Thanskgiving and continued until the first part of January. The radio stations were selected to reach diverse audiences and included a local popular news station, a country-western music station, a rock music station, and another station that had a variety of programming. Good coverage was obtained by varying the time of day when the commercials were aired. Costs were kept reasonable by obtaining two or three advertisements for every one that was purchased.

Individuals who responded to the radio commercials were given a gift package that included a quit kit (containing quit tips, items to keep their hands busy while quitting smoking, cartoons, sugarless mints and gum, and various other aids intended to make cessation easier), a gift card to present to a friend or family member stating the respondent was giving the person the gift of his or her health, and self-help materials on smoking cessation. The response was overwhelming. From the first day the messages aired, telephone calls and visits were received from people who heard the messages and wanted to quit. In 6 weeks more than 400 gift packages were distributed.

The Bellingham group also developed the “Be a Winner” campaign that commenced in fall 1990. The COMMIT staff members and volunteers worked with a local television production company to develop a message that winners were people who tried, often many times, to achieve a goal. Football players provided the basic image, and they were shown running down the field many times and finally scoring a touchdown. This theme was used in the hope of reaching blue-collar smokers and convincing them that repeated attempts to win (i.e., quit) were normal in many aspects of life. In this way, perhaps they could be motivated to try to quit more than once. The football and winner theme was chosen to coincide with the National Football League season, and especially the playoffs, so that interest in a Quit and Win contest that was scheduled to begin in January would be high

The response to the campaign was good. Although no quantitative data were collected on the campaign, anecdotal data indicated that people saw the commercials (they were mentioned when people signed up for the contest) and liked them. The connection with the football theme was seen as positive, and no negative comments were received.

Raleigh, NC

The project in Raleigh, NC, began with a large kickoff event that was well received; however, staff members soon discovered that it was difficult to convince the daily newspaper to cover issues considered by COMMIT volunteers to be important. Their strategy became one of presenting unique analyses of tobacco issues and staging visually interesting events by members of the community.

The kickoff event coincided with Raleigh’s Downtown Beautification Project. After learning of the attention that would be paid to the project, the COMMIT project donated 100 oak tree saplings to the city, a symbol of Raleigh’s “turning over a new leaf.” During the presentation, COMMIT volunteers tied to the saplings construction-paper leaves with the names of recent quitters on them. This activity received much media attention.

The Raleigh group had great success in publicizing the 1990 Surgeon General’s report as well as several local youth-buying operations. The media response to the first part of their COMMIT To Quit program, a Quit and Win contest, was outstanding. However, as the project continued, it was apparent that gaining media attention was not always easy. For example, the 1991 COMMIT To Quit occurred at the same time as the Persian Gulf War, and it was difficult to keep the media’s interest. Furthermore, staff members discovered that it was hard to sustain enthusiasm in a yearly event; the media prefer new angles. The Raleigh group, being in the heart of tobacco country, faced particular hardships. The newspapers often overlooked them. Any competing events seemed to draw the media away from COMMIT activities. Even the introduction of “big name” speakers did not generate media coverage. The biggest, consistent media success for this community was the coverage generated by underage teen-buying operations.

MAGNET EVENTS

All COMMIT communities had numerous magnet events. Every community had at least one Quit and Win contest, with a total of 26 such contests held throughout the trial. The contests varied in length and awards but had some commonalities. First, efforts were made to extensively promote the contest in the community. In addition to the usual media outlets, small media also were used to advertise the event. For example, contest organizers convinced grocery stores to print information on grocery bags; leaflets were distributed in specific neighborhoods; posters with attached entry forms were distributed to retail stores, doctors’ offices, public buildings, and worksites; and brochures were distributed. Second, some biochemical verification of smoking status (usually expired carbon monoxide) at the end of the contest was required. Third, there was a period for registration before the big “quit day,” which was usually tied to a date that is noteworthy for smoking cessation (e.g., New Year’s Day, the GASO). Fourth, many prizes were distributed, with a major grand prize of $1,000 in almost every contest. Fifth, the event ended with a celebration for all participants and their families. The examples that follow give a flavor of the activities involved in conducting Quit and Win contests.

Fitchburg/

Fitchburg/Leominster, MA, initiated the first of their three Quit Leominster, MA and Win contests in 1990. Planning for the activity, called Time To Quit, began 2 1/2 months before the contest. Most preparation work was done by field staff. COMMIT paid for advertising, which included radio commercials, newspaper advertisements, discussions on local talk radio, and a videotape that was aired on the local cable television channel. Posters and registration cards were sent to community worksites and health care providers. Entry forms also were included in the COMMIT newsletter.

One hundred and five smokers registered for the contest; of those, approximately 40 quit for a month. Most registrations came from the COMMIT newsletter. Every week during the contest, COMMIT staff members sent postcards containing support messages and quit tips to the participants. These were reported to be helpful in reinforcing quit attempts. The end of the contest, which coincided with the American Lung Association’s (ALA) Non-Dependence Day, was celebrated in the parking lot of the local mall. A local radio station donated 3 hours to broadcast the events, including the drawing of winners, and to interview contest participants and volunteers. The contest was considered a success; however, volunteers also learned from this first activity. COMMIT staff members and volunteers believed a longer planning period was necessary. There also was a feeling that promotion of the event was too narrowly focused and began too close to the start date; thus, fewer people enrolled than might have. For example, the grocery bags appeared only 1 week before the start date. The following year (1991), planning began much earlier, and promotion was more extensive. In addition, entrants received a “scratch” lottery ticket just for entering. Other venues were targeted for recruitment, including bingo halls, bowling alleys, and Lamaze classes. Worksites were enrolled, and a between-worksites competition of four platoons of firefighters brought more entrants. Approximately 200 smokers participated in this second effort.

Paterson, NJ

Paterson, NJ, has a high proportion of ethnic minorities; thus, involvement in a Quit and Win contest had to appeal to several different groups. The COMMIT Board and task forces planned a long-term, comprehensive contest that focused on recruiting the heavy smokers in the community. The contest began on January 24, 1991, and ended June 30, 1991. The basic format of the contest involved an ongoing recruitment effort, with drawings made monthly for a prize ($250) to be given to a quitter at the end of the contest (provided he or she remained in the quit category), followed by a final cash award of $1,000 given to a quitter whose name was drawn from all quitters at the end of the contest. The recruitment effort dominated the activity. The group began with the usual methods of information dissemination: media promotion, use of a graphic artist to design a contest theme, distribution of promotional items, and mailings of entry forms. The contest also was promoted in Spanish-language media. As time went on, volunteers became more active in getting registrants; they went to barbershops, beauty shops, day-care centers, family centers, supermarkets, shopping malls, and other areas to sign up smokers to participate. Additional promotion efforts included giving economic incentives to youth to sign up smokers, and even police departments were contacted to invite area convicts to participate. The Worksites and Organizations Task Force contacted all local workplaces to sign up smokers; 7,000 flyers were sent home with children in the Paterson school system, and 9,000 payroll stuffers were distributed to all area hospital and city employees. By the end of June, 501 smokers had participated in the contest. A grand finale was held during a local festival, with the overall winner’s name drawn by the mayor of Paterson.

This ambitious effort required significant time and resources, and the COMMIT staff members and volunteers learned from the event. First, they learned that recruiting smokers was more difficult and tedious than anticipated. Ultimately, door-to-door recruitment was seen as the most effective method of getting smokers involved in the contest. This group also experienced problems with late promotion of the event, largely as a result of initial difficulties with the graphics firm that was to design and conduct the publicity. Although these problems eventually were resolved, time was lost in promoting the event. Logistics problems also emerged in this community; there were some incomplete entries that led to the inability to find entrants. Overall, however, this contest was considered successful. It reached the targeted smokers as evidenced by the demographic characteristics of the participants (which closely matched the community demographics); it increased the number of smokers who signed up for the Smokers’ Network; and it greatly increased the visibility of COMMIT.

Santa Fe, NM

Santa Fe, NM, held a 3-month Quit and Win contest in 1991 that culminated on the ALA’s Non-Dependence Day. Participants were eligible for interim awards. Relapsers in the first month of the contest were encouraged to sign up again for the remainder of the contest. A total of 377 people initially joined the contest, with an additional 46 April relapsers joining in May or June. Contest participants were encouraged to find people to support them in their quit efforts. At the grand finale, quitters (verified by expired carbon monoxide) were eligible for first-, second-, or third-prize drawings, based on the amount of time they had been tobacco-free. Followup telephone calls were made to entrants every week to ascertain whether they needed materials or support in quitting or remaining abstinent. A grand finale was held on the Santa Fe Plaza on July 5, 1991. Music was provided by a local group; a puppet show was held for children that included content on smoking; a city council member read a proclamation declaring July 5 Non-Dependence Day; and the awards were given.

This event ran smoothly, and recruitment of participants exceeded expectations. All task forces were involved in the recruitment process and in promotion of the event. The Public Education Task Force worked with a public relations firm to plan the promotion of the activity and helped to plan all aspects of the promotion. Schools were involved in spreading the word about the contest. Puppet shows presented to children were designed to get the message to parents. Peer educators helped with mailings and other logistics. Cessation Resources Task Force members assembled materials and delivered them to health care facilities and provider offices. They also convinced local cessation resources to provide discounts during the contest. The Health Care Provider Task Force ensured that materials were available in all provider offices. They also set up five “minicontests” between individual offices and clinics. The Worksites and Organizations Task Force contacted local businesses and organizations to inform them of the contest and to recruit from the employees or membership. Few problems were encountered in this community. One disappointment was the inability to find a celebrity to hand out the awards. This was attributed to the event occurring on the holiday weekend. Another problem was that the ALA changed Non-Dependence Day from July 5 to July 3; nevertheless, the Smoke-Free Santa Fe group continued with July 5 as the date of the finale.

Yonkers, NY

Yonkers, NY, ran its second contest, called “A Thousand Good Reasons To Quit Smoking,” from January to February 1992. The activity focused on the effects of smoking on children; thus, each entrant in the contest was required to designate a youth supporter between the ages of 5 and 18. The grand prize for the contest was a $1,000 U.S. savings bond for the child’s education and a $250 gift certificate for the quitter. Only residents of Yonkers were eligible. All quitters had to undergo cotinine testing to verify their smoking status. Many community sectors participated. The school system sent home 12,000 newsletters advertising the contest with elementary school students. Several worksites permitted staff members to personally register smokers. Media promotion was used, and many articles about the contest appeared in the local newspaper. Prizes were donated by several local businesses; these included monetary donations, a weekend for two at a local inn, dinner for two at a theater club, movie tickets, and gift certificates. A total of 164 smokers entered the contest.

Staff members and volunteers felt the contest was successful but had hoped for a larger enrollment. Staff members felt that there were several constraints on the enrollment. First, the prize that went to the winner was not large because the youth supporter received most of the benefits. Second, a number of smokers did not enroll with youth and had to be contacted to provide the name of a youth supporter. This suggested that many smokers may have declined to enroll because of that stipulation. Third, the cotinine testing presented a problem because it required 2 weeks to obtain laboratory results. Participants found it annoying to come in to provide a saliva sample. Fourth, a staff suggestion to initiate a contest between schools and worksites to sign up smokers was vetoed by the Board. Fifth, the grand finale was not well attended, probably because it was held in a relatively obscure location in a local mall.

Cedar Rapids/

Cedar Rapids/Marion, IA, took advantage of the newly imposed ban Marion, IA on smoking on commercial air flights to institute a magnet event. Working with a representative of the ALA Iowa affiliate, COMMIT staff members and volunteers planned an event at which materials would be distributed at the Cedar Rapids airport on the day the ban started. Permission was readily given by the airport administration, and “panic packs” were assembled. These were packages that contained tips for surviving the flight, a CRG, balloons, hard candy, buttons, wrist snappers, and headless matches. The event was held in late afternoon on the day of the ban and was well covered by the media. The event served the additional purpose of providing an energy boost for COMMIT staff members and volunteers who saw that, with a little extra effort, it was possible to “seize the moment” and get substantial media attention.

Medford/

The third intervention year (1991) in this community began with Ashland, OR a locally produced and televised “Freedom From Smoking” cessation program cosponsored by a television station, the local power company, and the county library system. A small group of smokers was recruited to meet daily for a week and share experiences in following each activity in the cessation guide. Five thousand guides were distributed throughout southern Oregon. Each night during the news, the anchor showed a segment of the discussion among the smokers and directed viewers to the next day’s assignment in the guide. Print advertisements and other promotional features directed smokers to pick up guides at several prominent locations. The program continued to use a combination of press releases and print, radio, and television commercials to promote activities, and participation rates increased each year.

Medford/Ashland, OR, These two areas conducted a “friendly” competitive and Bellingham, WA magnet event. Because each community has a minor league baseball team, COMMIT staff members collaborated on a joint activity. The impetus came from Medford (the ballpark is located in Medford, not both communities), where a promotional campaign was designed to link with the local baseball team, the Southern Oregon Athletics (minor league team for the Oakland Athletics). Conditions of the competition were that both communities would have a smoke-free family night at the baseball game and sign up smokers for the Smokers’ Network. Dates were set for when the teams would be playing against each other. The Southern Oregon Athletics challenged the Bellingham Mariners (minor league team for the Seattle Mariners) to go smoke-free for the night, and the challenge was reversed when the Medford team came to Bellingham. In both communities, COMMIT purchased (or received donated) tickets to the game. Also, smokers or chewers received a free ticket in exchange for a packet of cigarettes or a can of snuff. Arrangements were made for the announcer to mention frequently the COMMIT To Quit message.

In Medford, the teams backed out of their commitment to go tobacco-free for the night for fear that playing would be affected. Fifty smokers signed up to participate and received free tickets to the game. The smoke-free family section censured an individual who tried to light up a cigarette in that section of the ballpark, and many smokers in the smoking section were cajoled by family and friends into going to the COMMIT booth for testing. Although participation was less than expected, the clown hired by COMMIT, the favors passed out, and a bright, sunny day made it an enjoyable event. One of the COMMIT volunteers noted that the event was charming because it recruited smokers and rewarded nonsmokers.

Bellingham

COMMIT needed to beat the number of participants recruited by Medford/Ashland COMMIT. The group was successful in convincing the Bellingham Mariners players to go tobacco-free for the night. Media coverage of the event included interviews with players who stated that youth should not start chewing because it is a difficult habit to break. Thirty participants gave a package of cigarettes or chew in exchange for a free ticket; however, the game was repeatedly delayed by bad weather. By the time the game began, there were virtually no spectators. Determining that Medford/Ashland had won, the Bellingham field director had a plaque made for the Oregon site and presented it to the COMMIT Board representatives at an annual meeting in February 1991.

The between-community competition generated a great deal of interest and fun. Media coverage was excellent in both communities. Interestingly, the between-community competition portion of the event was not much added effort because the events were already scheduled in each community. It is surprising that more events like this did not occur throughout the various intervention communities. There was much sharing of material and promotional campaigns, but it may have been threatening to various staff members to feel that they had to compete with each other.

Other Magnet Quit and Win contests were not the only magnet events devised Events to draw smokers into quit attempts. Every community conducted numerous activities around the GASO or, in the case of the Canadian communities, “Weedless Wednesday.” Activities focused on this annual event included providing cold turkey sandwiches, setting up a “survival camp” for smokers who pledged to quit for the day, providing smokers’ quit kits to interested smokers, having someone dress as a 7-foot turkey to symbolize “quitting cold turkey,” organizing competitions to see which worksites could have the most quitters and supporters during the GASO, and providing the community with messages about tobacco control. Numerous other magnet events were held in the intervention communities. In Medford/Ashland, staff members and volunteers designed, constructed, and staffed a float for an Independence Day parade. Brantford, Ontario, Canada, held a community forum to gain community input on tobacco control. Brantford also held a “Butt Out” party to encourage quitters to keep their New Year’s resolutions. Bellingham COMMIT sponsored a team for an annual fitness race from Mount Baker to Puget Sound. Paterson organized a rally against cigarette advertisements on billboards. Other events also were held.

MEDIA ADVOCACY

Media advocacy is the strategic use of mass media to advance a public policy initiative. Media advocacy involves capitalizing on news events (or creating news events) to stimulate broad-based coverage and reframe public debate, in contrast to the tendency of the news media to present health problems as a function of personal choice or circumstances. Media advocates focus on factors shaping the environment in which individuals’ decisions about health behavior are made. By exploiting the news media’s appetite for conflict, controversy, irony, innovation, and the “local angle,” advocates can redefine the issue as a social problem and promote a public policy solution.

The ability of COMMIT to openly advocate for legislative and regulatory change was limited by restrictions on the use of Federal funds. Therefore, communities used the media to advocate for the view that tobacco is a communitywide problem and for certain general principles, such as the right to a smoke-free environment. A consistent theme was to shift attention (and blame for the problem) from tobacco users to tobacco-product manufacturers and marketers. This enabled smokers and nonsmokers to identify a common enemy—the tobacco industry.

Utica, NY

The Utica site conducted a series of media advocacy events throughout the intervention. Many of these events were intended to focus public attention on the predatory nature of the tobacco industry and to portray it as an intruder from outside the community (as opposed to the community-based COMMIT program). Among the media advocacy events staged by Utica COMMIT were:

• picketing and leaflet distribution at a dance performance sponsored by Philip Morris;

• an appearance by members of the national boomerang team, which had refused tobacco industry sponsorship;

• a news conference with alcohol and other substance abuse agencies calling on the proposed director of national drug policy to break his nicotine addiction;

• a news conference announcing the results of a survey checking merchant compliance with the law against selling tobacco to minors; and

• a youth antitobacco rally in the hotel room next to an RJR Nabisco, Inc., “smokers’ rights” meeting.

Media advocacy, which is based on opposition and conflict, makes many community health professionals and volunteers uncomfortable. Advocacy challenges traditional notions of public health based on education and consensus building, and COMMIT sites encountered some resistance from community members unwilling to engage in confrontation. However, as the program continued to repeat advocacy events, members of the coalition became more comfortable with the concept. By the 3rd year, it was community members who, learning of the smokers’ rights meeting described below, organized the counterdemonstration and contacted the media. The event was a watershed in Utica, marking the advent of a new level of activism by grassroots tobacco control advocates.

Several volunteers in Utica had signed up to receive regular information from smokers’ rights groups, and in early March 1991, they were notified of a smokers’ rights meeting to be held in Utica. A coalition member contacted the field director, who also had received a notice, and both agreed to talk to as many coalition members as possible about the upcoming meeting. Fortuitously, all the task forces were meeting at about that time, and they all were informed of the upcoming event. Volunteers were outraged that the tobacco industry was bringing its extensive lobbying into their community, and they agreed that something had to be done, although there was no immediate agreement on what that would be.

After much discussion, the group decided there should be some physical presence at the meeting but that it was important not to be too confrontational and not to do anything illegal. COMMIT staff members noted that it was important to frame the smokers’ rights meeting as part of an industry lobbying campaign, in this case, directed at proposed State legislation to further restrict youth access to cigarettes. The group decided this meant that youth and children should be involved. The field director and COMMIT volunteers mobilized a local advocacy agent for low-income, at-risk youth to participate. A local physician, who was also a COMMIT volunteer, was recruited to attend, along with her daughter. Another volunteer, whose father had died of lung cancer earlier that year, agreed to come. While participants were being recruited, the media were alerted about the event. News releases were prepared, and spokespersons were briefed on the areas they should cover.

The COMMIT group had rented a room in the same hotel as the smokers’ rights group. Forty-two COMMIT volunteers, staff members, and young people arrived 30 minutes before the smokers’ rights meeting and were briefed on the counterdemonstration agenda. They were told they could observe the smokers’ rights meeting as long as they did not disturb the proceedings. Teens handed out antitobacco flyers to people who came to the smokers’ rights meeting. The tobacco company employee was surprised by the countermeeting. He asked a radio reporter who had contacted the media. Without asking their ages, he also gave written materials about cigarettes and lighters to the teens who entered the smokers’ rights meeting.

Broadcast and print news coverage of the dual event surpassed all expectations. The field director, the physician, and a local teen were interviewed by media at the event. Four radio stations covered the activity, and two asked the field director to appear on half-hour talk shows. The television station gave the event coverage on the nightly news. The newspaper ran a story and a photograph, which generated an editorial and seven letters to the editor, only two of which were for smokers’ rights.

Board members were enthusiastic about the event and the publicity it generated. A few who had initially expressed reservations about possible negative publicity were especially pleased and expressed hope that other, similar opportunities would appear. The Utica physician used an excellent reframing strategy in her letter to the editor. She said, “Utica smokers don’t need political consultants from R.J. Reynolds telling them what to do. They need the support and concern of their families, friends, and neighbors. We will be here next week, next month, next year. R.J. Reynolds’ political consultant left town the same night” (McCall, 1991).

Brantford, Ontario

The Brantford community had a difficult time involving Canada volunteers in media advocacy; indeed, the Public Education Task Force was initially reluctant to become involved in this area at all. Volunteers were not comfortable with the type of confrontation and conflict displayed in Utica and were inclined to move more slowly. It was not until an individual was hired to deal specifically with the media that things began to happen with the community media. The media staff member designated a spokesperson for each news conference, and she fully briefed that spokesperson ahead of time. Other staff members and community volunteers were recruited to assist with the conference as required. She also ensured that press kits were available ahead of time, and she was willing to reorganize her time to be responsive to the changing needs of the media. The majority of the staff person’s time was spent in building relationships with the media. Because of the patience and prompting she provided, the media now turn to COMMIT for information. However, the form of media advocacy taken in Brantford is largely confined to writing letters to the editor and writing op-ed pieces.

Bellingham, WA

From the beginning, media advocacy was a problem in Bellingham. In the first year of intervention, a large media advocacy workshop was held. It was well attended by COMMIT volunteers and other community members. The workshop was thorough and covered issues besides the confrontation methods. At a subsequent COMMIT Board meeting, there was significant discomfort about the workshop and the methods of media advocacy that had been portrayed. Board members had no problem with trying to increase media coverage and shifting blame for the tobacco problem from smokers to the tobacco industry but found it difficult to advocate by using conflict and confrontation. From the outset, Board members wanted the project to be encouraging and reinforcing and, indeed, would not even allow the universal nonsmoking emblem to be used on the COMMIT letterhead.

Over time, the Board members relaxed their stance somewhat. They, like their Brantford counterparts, began writing letters to the editor of the local newspaper. Some volunteers were especially good at writing pieces about the effects of smoking relative to other risks. They wrote effective pieces about the cyanide in Chilean grapes compared with the cyanide in cigarettes and about the benzene in Perrier compared with the benzene in cigarettes. They began leaving stickers in restaurants complimenting owners for a smoke-free environment or stating that their dining experience would have been enhanced by a smoke-free environment. They encouraged youth-buying operations and urged media coverage of the results. However, the kind of media advocacy that occurred in Utica never really got a foothold in this community.

WHAT COULD HAVE BEEN DONE DIFFERENTLY?

This public education channel was a source of both frustration and pride for most of the communities. Initial reaction to changing the community environment through media campaigns was positive. The media seemed pleased to hear about COMMIT, wrote stories about COMMIT, and provided cut rates for advertising. However, it soon became clear that the media would tire of writing and covering the same themes over and over. Their focus is on items that are new and newsworthy. Few COMMIT staff members had the skills and resources to constantly attract the media.

In retrospect, more attention should have been paid to training field staff members to deal with the media. Training sessions where staff members produced news bites and news releases would have been good practice for the implementation of the activities in this channel. Training also should have been given in adding gimmicks to the press conferences about the annual action plans so that media representatives had a reason to continually attend. It might have been wise to build in an activity and resources for establishing a relationship with a public relations or advertising firm from the beginning of the project. Such groups are experts in gaining access to media and in designing campaigns to meet the needs and desires of specified target groups. Communities that used such groups seemed to do better than those that relied on volunteers or field staff members to conduct those activities. For example, the “Yes, You Can” campaign designed for Utica lasted the length of the project and provided a foundation for many media promotions. The “Kiss Your Butts Good-bye” campaign in Paterson also provided a visible identification with the COMMIT project. The “Hooked” campaign in Cedar Rapids/Marion was an eye-catching symbol of the addictive nature of tobacco. All these campaigns could be shaped by the advertising firms into the more specifically required campaigns such as “Ask a Doc” or promotion of the CRG or Quit and Win contests.

COMMIT staff members and volunteers were comfortable with the idea of using paid media. Many had previously worked with other volunteer groups and were accustomed to relying on public service announcements to promote projects. The COMMIT projects saw real advantages in having control of the content of messages and the times those messages were aired. This advantage, when combined with the ability to leverage more air time than was paid for, was seen as beneficial for the trial. In addition, staff members and volunteers liked the ability to target media outlets that were most likely to reach the target population. However, the amount of money allowed for media campaigns was still relatively modest, and many staff members thought that more resources should have been allocated for media campaigns.

Most communities were frustrated by media advocacy expectations. As previously noted, media advocacy is not an easy thing to do, and many staff members and volunteers elt uncomfortable with it. Even more indepth training did not seem to provide many people with the skills needed to do good media advocacy. The reluctance to get involved in this cannot be attributed to the lack of information. A computerized system regularly provided each community with relevant national news items, along with sound bites and brief statements that could be used in news conferences, op-ed pieces, and so forth. The constant competition for getting on the media’s agenda was frustrating to many COMMIT staff and volunteers. Careful preparation of news releases and planned press conferences that were ignored because of some other breaking story wore down many people involved in the project.

Probably the main reasons media advocacy was not used more were the fear of confrontation and the reluctance to engage in open, conflict-filled debate. To be comfortable in this process requires more training than COMMIT staff members or volunteers received. In addition, most Boards did not want to alienate other community members by publicly proclaiming their stance on specific issues. The one exception was in the area of youth. Without exception, Boards, staff members, and other volunteers were willing to take a stand when youth were involved. Thus, communities were willing to openly advocate for restrictions on youth access, even if it meant conducting undercover merchant compliance checks and presenting the results to the media. Similarly, Boards were willing to support the banning of billboards that advertised products considered harmful to youth or exploitive of youth, women, and minorities (i.e., alcohol and tobacco products).

It may not be possible to expect everyone to be a media advocate and confront a tobacco company employee as was done in Utica. It may not be possible for community members to boycott stores that sell tobacco products. Communities that have received support from the tobacco industry for cultural sports events may be reluctant to give up that support in the absence of other sponsors. As Wallack and Sciandra (1990-91) noted, much more work and research are needed on this issue.

This channel also provided some of the best experiences in the various communities. The magnet events were universally well received. For the staff, it was gratifying to see some real progress in terms of people who actually quit smoking. Staff members were working “blind” when it came to knowing whether their activities had any effect on smokers. This was because of the design of the trial that blinded investigators and the staff to trial outcomes throughout the intervention period. The appeal of the Quit and Win contest is understandable in that context. Staff members and volunteers alike could document how many smokers joined and how many quit smoking at least for a certain period. In addition, these events were usually fun and interesting. Many artifacts could be distributed, many volunteers could become involved, and a celebration at the end gave the event some closure.

One thing that is clear about the contests is that many resources— human and otherwise—go into them. A recent study of the COMMIT Quit and Win contests noted that for the 26 trial contests, the mean cost per participant, including staff and contributed community resources, was $78.57 (Shipley et al., submitted for publication). Estimating a 16 percent, 8-month continuous abstinence rate, the authors determined that the mean cost per quitter was $428. Interestingly, a high correlation (> .70) was seen between resources expended and participation. Finally, the most highly correlated measure (.82 on a per smoker basis) was between participation and the total value of nonprize resources. These findings suggest that such contests are a good way to draw smokers into quit attempts.

In summary, the public education channel, as most of the others, had good and bad points. Whether the communities achieved the channel goals of promoting social norms and actions toward a smoke-free community, increasing the perception of smoking as an important public health issue, and enhancing the effectiveness of smoking control in other program areas remain to be determined as the data are analyzed. The major positive point of this channel was the gratification of working with smokers and seeing them quit. The main downside was trying to understand how to deal with media, keep them interested, and deal with the new strategy of media advocacy.

REFERENCES

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2. Cummings, K.M., Kelly, J., Sciandra, R., DeLoughry, T., Francois, F. Impact of a community-wide stop smoking contest. American Journal of Health Promotion 4(6): 429-434, 1990.
3. Cummings, K.M., Sciandra, R., Davis, S., Rimer, B. Response to an anti-smoking campaign aimed at mothers with young children. Health Education Research 4: 429-437, 1989.
4. Cummings, K.M., Sciandra, R., Markello, S. Impact of a newspaper-mediated quit smoking program. American Journal of Public Health 77: 1452-1453, 1987.
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10. McCall, M. Letter to the Editor. Utica, NY: Observer-Dispatch, April 10, 1991.
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AUTHORS

• Russell C. Sciandra Director Tobacco Control Program New York State Department of Health Empire State Plaza Corning Tower, Room 515 Albany, NY 12237

• Lawrence Wallack,Ê Dr.P.H. Principal Investigator University of California, Berkeley School of Public Health 516 Warren Hall Berkeley, CA 94720

• Carolyn L. Johnson,Ê R.N. Program Manager Healthy Start Program Jackson County Department of Health and Human Services Building A 1005 East Main Street Medford, OR 97504

• Janine Sadlik Executive Director Court Street Diagnostic and Treatment Center 430 Court Street Utica, NY 13502

• Juliet Thompson Field Director Bellingham COMMIT Site 4407 Wilkin Street Bellingham, WA 98226