HEALTH COMMUNICATION, 22(2), 91102

Copyright 2007, Lawrence Erlbaum Associates, Inc.

Anti-Smoking Media Campaign Messages:
Theory and Practice
Elisia L. Cohen
Department of Communication
University of Kentucky
Michelle D. Shumate
Department of Communication
University of Illinois Urbana-Champaign
Abby Gold
School of Nursing and Health
Minnesota State University
This study examined televised anti-smoking advertisements that were designed to discourage
adult and teen smoking. A content analysis of 399 television advertisements catalogued in
the Media Campaign Resource Center (MCRC) database were evaluated to determine (a)
whether the advertising content reflected core health communication theories used in the
design of health campaign messages to change behavior and (b) the affective presentation of
tobacco-control advertisements aimed to decrease smoking. The results revealed that anti-
smoking advertising relied overwhelmingly on appeals to attitudes. Although the benefits
of not smoking were mentioned in 61% of advertisements, barriers were mentioned in only
17% of advertisements. Advertisements emphasized the consequences of smoking more than
the viewers self-efficacy. Finally, advertisements were more likely to use informational
and humor appeals, rather than sadness, fear, or anger appeals. The research identifies the
types of advertisements that are most likely to be utilized and underutilized in national and
statewide anti-smoking advertising campaigns catalogued in the MCRC database.
Funded mass media campaigns are an important and
influential part of national tobacco control campaigns
designed to reduce and to prevent tobacco use among
adults and teens (U.S. Department of Health and Human
Services, 1994). Moreover, there has been growth in
well-funded tobacco control campaign efforts since the
states Attorney Generals Master Settlement Agree-
ment (MSA) with the tobacco industry (Wakefield,
Flay, Nichter, & Giovino, 2003). Evidence indicates
that the anti-smoking advertising campaigns initiated
after the MSA, such as those conducted in Arizona,
California, Florida, and Massachusetts, achieved measur-
able results in reducing tobacco use among adults and teens
Correspondence should be addressed to Elisia L. Cohen, Department
of Communication, 231 Grehan Bldg., University of Kentucky, Lexington,
KY 40506-0042. E-mail: Elisia.Cohen@uky.edu
(Bauer, Johnson, Hopkins, & Brooks, 2000; Institute
of Medicine & National Research Council, 2000;
Siegel & Biener, 2000; Sly, Heald, & Ray, 2000, Sly,
Heald, & Ray, 2001; Sly, Hopkins, Trapido, & Ray,
2001; Wakefield & Chaloupka, 2000). Yet there has
been little analytical research assessing the post-MSA
tobacco control media environment to identify the
common theoretically grounded content appearing in
such national, statewide, and private tobacco control
campaigns. Understanding the content appearing in
such campaigns is important to providing current and
future campaign designers insight into what types of
anti-smoking messages have been employed in post-MSA
efforts to prevent smoking.
Previous research by Beaudoin (2002) explored
anti-smoking advertisements for their common themes and
appeals. However, his study was limited to a sample of
92 COHEN, SHUMATE, GOLD
197 anti-tobacco advertisements distributed by the Centers
for Disease Control (CDC) that were produced between
1991 and 1999. This study seeks to extend Beaudoins
work by (a) examining the theoretical grounding of the
advertisements content, (b) evaluating the advertisements
affective appeals, and (c) extending content analysis to
the population of advertisements appearing in the Media
Campaign Resource Center (MCRC) archive, a more current
and exhaustive collection of anti-tobacco advertisements.
A clear understanding of the nature, design, theoretical
grounding, and availability of these tobacco control adver-
tisements has important benefits for practitioners, educators,
and tobacco control advocates alike. Future health campaign
efforts can benefit from an understanding of what message
strategies have been employed, not used, or have become
pervasive in current campaign efforts (Stephenson & Quick,
2005), particularly in the tobacco control context. In addi-
tion, systematic content analysis of federal, state, and
privately initiated tobacco control media efforts represents
a preliminary step toward a more theoretically grounded
understanding of these public health campaigns.
LITERATURE REVIEW
The development of theoretically grounded approaches to
understanding social influence (Maibach & Parrott, 1995;
Rice & Atkin, 2001) suggests that greater attention to
health communication theory and predictors of behavior
change may assist the design of comprehensive tobacco
control efforts. Common variables utilized to understand
and change a wide variety of human behaviors have
been identified in extant health communication research
(e.g., Cappella, Fishbein, Hornik, Ahern, & Sayeed, 2001;
Fishbein et al., 2001; Fishbein & Yzer, 2003). In fact,
Fishbein et al. maintain that five theoriesthree social
influence theories commonly utilized in the field of commu-
nication studies (health belief model, social cognitive
theory, and the theory of reasoned action) and two in the
field of social psychology (theory of subjective culture and
interpersonal relations, theory of self-regulation and self-
control)can be utilized to identify a set of variables
to account for most of the variance in any given delib-
erate behavior: intention, environmental constraints, skills,
anticipated outcomes (or attitude), norms, self-standards,
emotion, and self-efficacy (p. 5). Fishbein and Yzer (2003)
posit an integrated health communication theory based on
the health belief model, social cognitive theory, and the
theory of reasoned action, and argue that their combined
explanatory power is greater than that of any of these indi-
vidual theories. Cappella et al. (2001) argue that an inte-
grated theory of health behavior should be used to analyze
and to create persuasive anti-drug messages.
Stephenson (2002) was the first researcher to conduct
content analytic research to make the link between
utilization of these integrated theories by practitioners and
scholarly examination of what theoretical mechanisms were
utilized in anti-drug public service announcements (PSAs).
Stephenson (2002) evaluated the extent to which anti-drug
PSAs reflected health communication education and theory,
noting that less than half the PSAs in his sample reflected
any type of health communication theory. Stephenson
and Quick (2005) argue that content analysis of health
messages in the field is important, noting that it is one
key link between health communication theories, research,
and practice. Previous research evaluating the attributes of
tobacco control messages provides a framework for the
content analysis of anti-smoking advertisements (Beaudoin,
2002). Although Beaudoins (2002) categories clearly illus-
trate the different thematic frames present in anti-smoking
campaigns, the relationship of these themes to theoretical
models of health behavior is not evident. Research indicates
these themes fail to provide a guide for which message
strategies will result in behavior change (Wakefield et al.,
2003).
Through content analytic work, health communication
researchers can become aware of trends in health preven-
tion efforts, research unexamined assumptions behind some
health prevention tactics, and speak to the current best
practices. Knowing the extent and nature of appeals in
the MCRC database may aid researchers understanding of
whether a given appeal has been over- or underutilized, and
whether there is a gap between theoretical knowledge and
message design.
Health Behavior Theories
This study seeks to evaluate to what extent anti-
smoking advertisements include theoretically grounded
health communication message strategies. Three common
social influence theories relied on by researchers in the
field of communication to design messages and incorporated
into integrated health communication theories (Cappella
et al., 2001; Fishbein & Yzer, 2003) include the theory
of reasoned action (Fishbein & Ajzen, 1975), the health
belief model (Rosenstock, Strecher, & Becker, 1988), and
social cognitive theory (Bandura, 1977a, 1977b). These
models each present several mechanisms to increase the
likelihood of health-related action and provide an overlap-
ping set of theoretical constructs (Fishbein et al., 2001).
This study compares the use of these theories overlapping
constructs as persuasive health messages in anti-smoking
advertisements. Specifically, this study considers common
persuasive health messages derived from integrated health
communication theories and designed to meet persuasive
health objectives (Worden & Flynn, 2001) common to anti-
smoking campaigns. Following previous content-analytic
research (Stephenson, 2002), this study utilizes a framework
of health communication theories to identify the central
organizing construct of anti-smoking advertisements, or the
ANTI-SMOKING MEDIA CAMPAIGN MESSAGES 93
persuasive health message present in anti-smoking adver-
tisement content.
Theory of reasoned action. The theory of reasoned
action (Fishbein & Ajzen, 1975) has been very popular
in creating and evaluating health campaigns, from cancer
(Manfredi, Lacey, Warnecke, & Petraitis, 1998) to
HIV (Terry, Gallois, & McCarnish, 1993). The theory
posits that individuals intentions to perform preventive
health care behavior predicts preventive health behavior
(Fishbein & Ajzen, 1975).
1
Intentions are, in turn, predicted
by a persons attitudes about the behavior and his or her
perception of how significant others view the behavior (e.g.,
social norms). These two routes of persuasion (attitudes and
social norms) represent the best means to change behavior,
according to the theory of reasoned action (Fishbein &
Middlestadt, 1989).
Anti-smoking campaigns targeting adults and teens that
provide reasoned arguments for not smoking often utilize
these two routes of persuasion, focusing on what other
people think about smoking (social norms) or an indi-
viduals attitude toward smoking (personal attitude). These
two organizing constructs, whether an anti-smoking adver-
tisement tries to address social norms or whether an anti-
smoking advertisement addresses an individuals attitudes,
are important to consider. Anti-smoking advertisements
might address an individuals social norms by focusing
on what a spouse, friend, child or potential date thinks
about smoking (i.e., Im scared for them). In contrast, anti-
smoking advertisements might attempt to influence attitudes
by focusing on the unhealthy consequences of smoking or
focusing on its negative characteristics (i.e., here is what a
typical cigarette contains). Given the many different reasons
why people choose to smoke, the theory of reasoned action
provides the groundwork for health communication research
focusing on various attitudes and social norms (Cuerrier,
Deshaies, Mongeau, Luc, & Vallerand, 1992; Faucher &
Carter, 2001; McGahee, Kemp, & Tingen, 2000; Unger,
Rohrbach, Howard-Pitney, Ritt-Olson, & Mouttapa, 2001).
Social cognitive theory. Social cognitive theory
(Bandura, 1977a, 1977b; 1997) offers additional theoretical
mechanisms to discourage smoking that are more broadly
considered as part of social cognitive theory. Social cogni-
tive theory explains a wide range of influences on indi-
viduals performance of health behaviors (see Bandura,
2002, for a complete review of social learning and self-
efficacy mechanisms). One mechanism identified in effec-
tive messages is the inclusion of representational characters,
or models. When individuals recognize that the message
is directed toward their behavior, and not simply toward
1
The theory of reasoned action (Fishbein & Ajzen, 1975) is a general
theory of persuasion. For clarity, we describe the theory in the context of
preventive behavior, although it certainly is not the only context in which
it has been used.
someone else, the message takes on greater representational
meaning. Whether or not a message is framed with a repre-
sentation character or model, designed to spark the modeling
of learned behavior, is important to consider as a third
message frame.
Health belief model. The health belief model (HBM)
assumes rational actors weigh risk, benefits, and barriers
to action to determine if they will change their behavior
(Hochbaum, 1958; Strecher & Rosenstock, 1997). Some
perceived benefits of smoking include weight control and
tension management (Mikanowicz, Fitzgerald, Leslie, &
Altman, 1999). Other barriers might include addiction and
social barriers (i.e., my friends all smoke now and I wont).
Perceived benefits of not smoking might be health related,
financial, and social, or a combination of the foregoing. A
second message mechanism in the HBM is the inclusion
of a cue to action that motivates a person to take action.
Effective cues also assure individuals that they have the
ability to take action (enhancing self-efficacy and personal
motivation).
Moving From Theory to Practice
Taken together, these three health communication theories
support the idea that practitioners may create messages
designed to influence an individual in different ways.
However, each of these theories provides mechanisms to
increase individuals intentions not to smoke or to quit
smoking (Fishbein & Yzer, 2003). Fishbein and Yzer argue
that the theory of reasoned action, social cognitive theory,
and the HBM are best utilized in an integrated theoretical
model. In addition, they note that health messages should
target particular effective mechanisms to influence intention
and behavior. These mechanisms, in the integrated model,
originate from the three aforementioned theories.
The communication variables that influence the strength
and direction of intention (Fishbein et al., 2001, p. 5) are
social norms, attitudes, self-efficacy, and the balance of
benefits and barriers. In a 30-sec spot, message designers
must make a choice about the type of persuasive influence
they want to have, manifested in theory-driven persuasive
health message content. Although we recognize the multiple
mechanisms that influence changes in attitudes, beliefs, and
behaviors, first we consider the verbal component of the
persuasive health message. Then, we consider what behav-
iors are reinforced in the ads by identifying the type of
anti-smoking modeling images and explicit cues to actions
presented by the advertisements.
The first persuasive health message under consideration
in this study is social (normative) pressure, or messages
influencing what the person believes are the significant
others opinions about the behavior. Messages that present
social reasons to perform behaviors reinforce positive
94 COHEN, SHUMATE, GOLD
norms.
2
For example, in A Mothers Keeper, a mom is
preparing dinner when she sees her son walking toward
her bedroom. She sees her son dig through her purse, take
something from the purse and run toward the door. She
stops him and motions for him to hand the item back. He
hands her pack of cigarettes back and says, I dont want
you to die, Mom. The mother hugs her son, crushes the
pack of cigarettes and lets the crumpled pack drop to the
ground. In the next shot, the adult child tells the viewer
As a kid I did everything I could to get my mother to quit
smoking. And in the end she did. Thanks, Mom. Then his
mother appears on screen and gives him a hug. This ad
was coded as having a social (normative) pressure health
message because it was designed to show that the viewer
should quit because of childrens wants.
3
Other significant
others might include a spouse or friends who want a person
to quit smoking.
A second persuasive health message appears in adver-
tisements attempts to influence the individuals opinion
of the behavior, or the individuals attitude. This type of
persuasive health message emphasizes characteristics of the
undesirable behavior. We provide two types of messages
exemplary of the types of messages coded in this cate-
gory. The first type of ad focuses on smoking leading a
person to become undesirable or to do undesirable things.
For example, in Addicted Ashtray a twenty-something
girl sits in a dirty bus station. She pulls out an empty pack
of cigarettes and then desperately begins to scan the station.
She sees that the cigarette machine is out of order. Then the
announcer in the ad says, When you become addicted to
nicotine, your body craves it, needs it. And tobacco compa-
nies know youll do anything to get it. As the voiceover
plays, she glances over to the dirty ashtray and looks around
to see if anyone is watching. Then she reaches into the
ashtray and pulls out a half-smoked cigarette. The ad ends
as she puts the cigarette in her lips and lights it. In this type
of ad, the persuasive health message is that smoking leads
to disgusting behavior.
A second type of persuasive health message appealing to
attitudes includes those that focus on the characteristics of
the cigarette itself. For example, in Urinal, a man is using
the urinal in a public bathroom. A second man walks in and
uses another urinal. The first man leaves the bathroom and
the second man flushes the urinal. The second man then
bends over and reads Cigarettes contain urea. So does your
pee. In this example, the goal is to change the viewers
2
A second mechanism that a social norm may be reinforced in an
advertisement is through modeling. In our study, multiple mechanisms
are under consideration for evaluation, however, for purpose of analyzing
the persuasive verbal message, we treat the verbal appeal present in the
advertisement separately from the image (the models) that may reinforce
behavior.
3
A Mothers Keeper focuses on one source of normative influence, a
child. The theory of reasoned actions social norms refers to influences
from several sources important to an individual.
attitudes toward cigarettes themselves, indicating that they
contain chemicals one wouldnt want to inhale.
The third persuasive health message appeal is self-
efficacy, or messages designed to influence the individuals
belief that he or she can accomplish the desired behavior.
Messages that provide information reinforcing that an indi-
vidual has self-efficacy to execute the behavior in question,
or messages that encourage action, are critical to individ-
uals perceptions that they have the capacities to perform
the behavior under a number of different circumstances.
One way that health communication message designers
encourage action is by providing models of successful
behavior to promote vicarious learning (Bandura, 1997).
For example, in One Day at a Time an African American
woman encourages her friend to stick with her plan to quit
smoking. The new quitter tells her how marking the days
off on the calendar really helped. The friend tells her, Take
it from me. The first five days without cigarettes, thats the
hardest. You made it past that. Now the cravings will start
easing up. Just keep busy. The ad ends with a number to
call for tips on how to quit smoking.
Given these three persuasive appeals, coders were
provided an operational definition of an anti-smoking
persuasive health message to identify the core persuasive
message identified in the advertisement: An anti-smoking
persuasive health message is a message designed to prevent
smoking and to encourage quitting. We are interested in
determining whether or not the anti-smoking message in the
ad presents one of these three types of persuasive health
messages or, in some cases, directly mentions the core
persuasive message.
4
RQ1: What theory-based persuasive health messages are
most prevalent in anti-smoking advertisements?
This study seeks to take the theoretical analysis of public
health messages a step further by recognizing that messages
using attitudes, social norms, or self-efficacy persuasive
messages may include affective dimensions that influ-
ence risk perceptions. The extended parallel process model
(EPPM) hypothesizes that people who are threatened (by a
fear appeal) will take one of two courses of action: danger
control or fear control. When individuals seek to control
danger, they act to reduce the risk; in contrast, fear control
leads individuals to reduce the perception of risk (Witte,
4
Although all of these theoretically grounded persuasive health
messages may influence intention and behavior, it is important for
researchers and practitioners alike to know which mechanisms are being
utilized in current MSA anti-smoking advertisements. Smoking self-
efficacy based studies (Dino et al., 2004; Droomers et al., 2004; Siegel,
2002; Wakefield et al., 2003) and smoking studies based on the theory of
reasoned action (Cuerrier et al., 1992; Faucher & Carter, 2001; McGahee
et al., 2000; Unger et al., 2001) have shown both theories as having power
in predicting smoking behavior, but the extent to which their genera-
tive mechanisms are features in post-MSA anti-smoking advertisements is
unknown and worthy of exploration.
ANTI-SMOKING MEDIA CAMPAIGN MESSAGES 95
1992, 1994). Researchers testing the EPPM of communica-
tion show evidence that fear appeals risk triggering psycho-
logical reactance in both teenagers and adults. When fear
is used, it is important that individuals are shown both the
threat and a solution to the threat (Witte, 1992, 1994). By
coding for the affective dimension to anti-smoking adver-
tisements, researchers may better understand the context in
which fear appeals appear.
For purposes of replication and to explore multiple
affective dimensions, this study follows previous studies
typology of four affective appeals, including emotional
messages such as sadness, anger, humor, and fear (Freimuth,
Hammong, Edgar, & Monahan, 1990; Stephenson, 2002).
The first, fear, is a strategy designed with a message to
scare individuals about the possible consequences of risky
behavior (e.g., taking drugs, smoking). Studies suggest that
fear appeals may be more effective when the target audi-
ence is adults than when the target audience is teenagers
(Evans, 1976, 1979, 1983; Hale & Dillard, 1995). In the
context of anti-smoking appeals, Blums (1980) research
indicated that humor might be an effective tool. No research,
to the authors knowledge, has examined the effectiveness
of sadness in anti-smoking messages. Stephenson (2002)
utilized a fourth, informational/affectively neutral category,
to code for advertisements that offer verifiable informa-
tion, including statistics, without an attempt to convey
emotion. In this study, a fifth category was also added
to capture the affect of anger found in recent tobacco
control campaigns presenting industry manipulation tactics
and anti-smoking advocates talking back to the tobacco
industry.
RQ2: What affective appeals are most prevalent in anti-
smoking advertisements?
A final theoretical mechanism appearing in persuasive
health messages is exemplified when messages convey
greater benefits than barriers for behavior change. Fish-
bein et al. (2001) define the balancing of benefits and
barriers as whether or not an individual believes that the
advantages (benefits, anticipated positive outcomes) of
performing the behavior outweigh the disadvantages (costs,
anticipated negative outcomes) (p. 5). Evidence supporting
such a belief is thought to reinforce the positive attitude a
person holds toward performing the behavior.
This study examines the relative prevalence of persua-
sive messages, including the prevalence of arguments
concerning benefits of not smoking and barriers to quitting
smoking. The question of whether or not advertisements
discuss the benefits and barriers to not smoking is important
to consider distinctly in advertisements that present persua-
sive health messages (e.g., messages designed to change
individuals attitudes, adherence to social norms, or percep-
tions of self-efficacy). As a third level of analysis, we coded
all ads for their anti-smoking arguments.
RQ3a: Are there significant differences among advertise-
ments with different theory-based persuasive health
messages with respect to their indication of benefits
of not smoking or quitting smoking?
RQ3b: Are there significant differences among advertise-
ments with different theory-based persuasive health
messages with respect to their likelihood to indicate
the barriers to not smoking or quitting smoking?
RQ3c: Are there significant differences among advertise-
ments with different theory-based persuasive health
messages with respect to their likelihood to indi-
cate the benefits of and barriers to not smoking or
quitting smoking?
Message themes related to risk, including seriousness of
health risks and self-efficacy, are often considered important
media campaign components (Chew, Palmer, Slonska, &
Subbiah, 2003). According to the EPPM, four message
components increase the likelihood of a danger control
response over a fear control response. These include (a)
susceptibility or likelihood of the threat, (b) severity of
the threat, (c) effectiveness of the response, and (d) self-
efficacy of the individual to respond to reduce the threat
(Stephenson & Witte, 2001). This study examines these ads
for the cooccurrence of particular self-efficacy arguments
and severity of consequences arguments (see Method
section for operationalization) among advertisements with
different theoretical messages.
RQ4: Are there significant differences among anti-
smoking advertisements with different theory-based
persuasive health messages with respect to the
strength of self-efficacy and severity of harm argu-
ments present in the advertisements?
METHOD
Sample
The sample for this study was taken fromthe MCRCdatabase
funded by the CDCs Office on Smoking and Health, which
is an online archive of anti-tobacco advertisements developed
by a number of states, organizations, and federal agencies.
The database is intended for use by agencies in need of adver-
tising materials. The MCRC includes advertisements for the
purpose of tobacco prevention and cessation programs, and
catalogs data according to their target audiences and topic.
Advertisements included in this study sample were tele-
vision advertisements directed at youth, young adults, and
adults that utilized addiction, cessation, tobacco industry
manipulation, youth-prevention, youth-access, pregnancy,
and general health messages. Smokeless tobacco and
secondhand smoke advertisements were excluded unless
they also contained a general health message according to
the MCRC database search engine. Because the MCRC
96 COHEN, SHUMATE, GOLD
database is a changing entity (due to the addition of adver-
tisements and its regularly updated interface), researchers
created a list of advertisements in the population for anal-
ysis available before the last week in March 2004. Three
hundred and ninety-nine advertisements were included from
the MCRC television archive for final analysis. Only adver-
tisements with full video clips were selected for analysis. Of
these 399 advertisements, 28 (7%) were 15-sec, 27 (6.8%)
were 60-sec, and the vast majority, 342 (85.7%), were 30-
sec advertisements. Two (0.5%) had lengths over 60 sec.
Procedure
Content analysis was used to analyze the advertisements
(see Neuendorf, 2002 for an overview of the method).
Coders watched the advertisements three times using an
Internet-based digital media viewer. Advertisements were
coded for the persuasive health message that reflected the
aforementioned established theories.
5
Denition of Anti-Smoking Persuasive Health Message
and Unit of Analysis
In the tobacco control context, a persuasive health message
(see Maibach & Parrott, 1995) is defined as any verbal
message or performance depicting a credible health threat
to smoking, verbal messages depicting anti-smoking atti-
tudes, or performances depicting anti-smoking behaviors.
Persuasive health messages included certain depictions of
anti-smoking behaviors that depicted the harmful conse-
quences to smoking. Using this definition, the persuasive
health message was measured initially at the global unit
of analysis, in this case the appeal of the advertisement.
Secondary analysis, although not relevant to this study, was
conducted on the verbal and image-based components of
the advertisements.
Measures
The researchers relied on previous content analysis projects
to derive several of the content analysis categories. In
particular, Stephensons (2002), Freimuth et al.s (1990),
and Beaudoins (2002) categories were combined and
extended due to the nature of this dataset for the devel-
opment of persuasive health message and affective appeal
operationalization.
Persuasive health message. Each ad was coded for
the persuasive health message. Stephenson (2002) consid-
ered five possible theoretical messages in his study of anti-
drug messages. He operationalized these as overlapping
5
These theories were prominent in the health communication literature
(Rice & Atkin, 2001; Slater, 1999) and were employed in health message
development and texts on health education (Glanz, Lewis, & Rimer, 1990;
Maibach & Parrott, 1995) during the time period in which anti-smoking
advertisements were created.
frames derived from the theory of reasoned action (a focus
on attitudes, or what other people think; Fishbein & Ajzen,
1975), from the EPPM (a focus on eliciting fear through
graphic images, sounds, or descriptions; Witte, 1992), from
social learning theory (a focus on modeling appropriate
behavior; Bandura, 1977a, 1977b), and messages comparing
the benefits against consequences (from the HBM; Rosen-
stock et al., 1988). Stephenson (2002) did not achieve reli-
able coding for the last category, possibly under- or over-
coding this category due to its overlap with the focus on
attitudes, or what people think about smoking. By consid-
ering these mechanisms as overlapping frames, reliability
also may have been established with some necessary sacri-
fice of validity.
To properly identify the central persuasive health message
strategythat guidedtheadvertisements, coders weretrainedto
code the dominant or core persuasive health message.
6
We
asked coders to discriminate, based upon a complete viewing
of the ad, whichof the followingdescribedthe core persuasive
message strategy used in the ad:
1. The persuasive health message places an emphasis on
changing individual attitudes toward smoking. This
category described all ads that contain an expressed
message indicating individual disapproval of smoking,
including advertisements that describe knowledge,
awareness, and perceived risk of smoking, or the
perceived importance of not smoking to the individual.
These persuasive health messages argue that smoking
is harmful, describe an individuals characterization or
belief that smoking is dangerous. The message focuses
on an individuals attitudes, values, or beliefs about
smoking (e.g., that smoking is risky or gross)
2. The persuasive health message places an emphasis
on communicating positive social norms. This cate-
gory contains a verbally expressed social reason to
disapprove of smoking, a performance that illustrates
or demonstrates the reason(s) why smoking is not
socially acceptable, or verbally explains that most
adults and/or teenagers do not smoke. These messages
focus on what other people think about smoking.
Others may include significant others, such as a child,
friends, or a spouse, or generalized others (e.g., poten-
tial dates or persons on the street).
3. The persuasive health message focuses on cogni-
tive modeling or performances of recommended anti-
smoking behavior. Advertisements that provide an
image or a performance of an individual who had quit
smoking, or was trying to quit smoking are included
in this category. Following Banduras research, the
image or performance is broadly defined to include
instances when the communicator verbalizes thoughts
6
Consistent with Stephensons (2002) research, we found it was rare
for anti-smoking advertisers to use the HBM in their advertisement per se.
During preliminary analysis, when only 3 out of 399 television advertise-
ments were coded with dominant health belief frames, secondary analysis
questions were posed about the advertisements.
ANTI-SMOKING MEDIA CAMPAIGN MESSAGES 97
or describes actions about how he or she used cogni-
tive or other plans and strategies to diagnose and
solve problems, monitor the effects of their actions,
correct errors, used coping self instructions to over-
rule self doubts, or performs actions to stop or quit
smoking. These messages demonstrate someone quit-
ting smoking or refusing to smoke. They often also
include lessons learned or tips to imitate the persons
performance.
4. None of the above persuasive health messages are
prevalent.
Advertisements that were pro-smoking, or that portrayed
smoking as acceptable adult behavior were not coded as
a persuasive health message. Coders in this study identi-
fied the central theory-based persuasive health message in
each advertisement. Reliability for this variable was good
( = 0.60, PA =75%).
Dominant affective appeal. Coding of each adver-
tisement was also designed to evaluate affective message
strategy. Stephenson (2002) and Freimuth et al. (1990)
divided dominant affective message strategies into five cate-
gories. These included fear, humor, sadness, guilt, and infor-
mational. Guilt was not found to be a reliable variable in
Stephensons research, and was not considered in this study.
In addition, because Stephensons advertisements focused
on parents talking to their children, rather than the adults and
teens themselves, new strategies were considered that might
be present in this sample of anti-smoking advertisements.
Indeed, based on the strategy categories from the MCRC
database, anger was included as an additional strategy
used in anti-smoking advertising. Therefore, the following
message strategies were considered: (a) fear (advertisements
that aim to frighten), (b) humor (advertisements that feature
a humorous situation or dialog), (c) sadness (advertise-
ments that present an emotionally unhappy scene to elicit
heartache or anguish), (d) informational (advertisements
that present new information), and (e) anger (advertisements
that provoke harsh, negative feelings). Again, coders were
asked to discriminate for the affective appeal that framed
the entire advertisement. Reliability for this variable was
good ( = 0.71, PA = 78%).
Severity of consequences and self-efcacy. The
HBM (Rosenstock et al., 1988) indicates that an important
motivation for behavioral change is the severity of conse-
quences to smoking. Severity of consequences presented
was not examined in previous content-analytic studies of
alcohol or tobacco advertising. For purposes of this study,
severity of consequences was measured on a scale of one to
five. A code of one, not severe, was assigned if there was
no consequence to smoking described in the advertisement.
A code of two was assigned when the consequences were
mentioned, but were mild or lacking a reason (e.g., tobacco
is bad for your health). Moderate consequences such as
addiction or social implications (e.g., chronic bad breath)
were coded as three. A somewhat severe consequence (e.g.,
chronic illness or severe illness) or consequence short of
death was coded as equal to four. A very severe conse-
quence (e.g., death) was coded as equal to five. Utilizing
this scale, coder reliability was good (r = 0.69).
Self-efficacy is another important indicator of message
effectiveness (Bandura, 1997). Previous content analysis
studies of public service announcements did not measure the
degree to which ads encouraged action. Here, coders were
asked to measure on a scale from one to five, how much the
ad encourages self-efficacy beliefs. One, no self-efficacy,
was assigned when there was no indication in the ad of
how or what should be done. Five was equal to encourages
self-efficacy, assigned when the ad specifically indicated
that preventive action could be taken and the viewer had
the capability to take it. A two was assigned when self-
efficacy was modeled (where a script was given, or someone
demonstrated that they were able to take appropriate action).
A three was assigned when there was a suggestion of self-
efficacy (e.g., here is something that you should do, stop
smoking), and a four was assigned when there was a mild
cue to action (here is something that could be done). Coder
reliability was good (r = 0.69).
Due to the extreme skew in the self-efficacy argu-
ment variable, z (399) = 12.85, p - .05, these data were
trichotomized and compared as nominal variables. Cate-
gories that were computed for comparative analysis include
advertisement evidencing (a) no/weak severity (1 or 2 on
the 5-point scale) and no/weak self-efficacy (1 or 2 on the
5-point scale), (b) strong self-efficacy (4 or 5 on the 5-
point scale) and strong severity of harm (4 or 5 on the
5-point scale), (c) no/ weak severity of harm and strong
self-efficacy, and (d) strong severity of harm and strong
self-efficacy arguments. Ninety-two of the 399 advertise-
ments, where the ads indicated a moderate suggestion of
self-efficacy or moderate severity of harm, fell on the
scales midpoint (3 on the 5-point scale). These ads were
excluded from analysis for RQ4.
Benets and barriers. The HBM indicates that both
benefits and barriers are important criteria that individ-
uals use to make health decisions. Barriers were oper-
ationally defined as any individual, interpersonal, envi-
ronmental, social, or other factor that is perceived as
making it more difficult for an individual to quit smoking
or to stop smoking. Barriers to quitting smoking or not
smoking include weight control and tension management
(Mikanowicz et al., 1999). Other barriers to quitting include
nicotine addiction and social barriers (e.g., peer pressure).
The inclusion of barriers in the ad was coded as present
or absent and had good reliability ( = 0.66, PA = 89%).
Benefits were operationally defined as any personal, social,
or material benefits that result from performing a behavior
or holding or adopting a belief that is related to the persua-
sive health message. Benefits of not smoking include health
98 COHEN, SHUMATE, GOLD
benefits, social benefits, and financial benefits. The mention
of benefits in the ad was coded as present or absent and had
good reliability ( = 0.65, PA = 83%).
Training and Reliability
Coder training and pretesting. Coders were trained
and the coding instrument was tested using 20 adver-
tisements from the database not included in the target
sample. After initial coding, the two graduate student
coders discussed the coding method and came to agree-
ment on the operationalization of each variable. After the
3-week training period, codebook modifications were made
to clarify some categories to increase reliability during the
independent coding of the advertisements.
Coders then conducted a pretest by evaluating 10% of the
same advertisements from the MCRC target sample. Pilot
testing for reliability was conducted by having each coder
independently code these 40 spots. Following the recom-
mendations of Lombard, Snyder-Duch, and Bracken (2002),
the level of agreement between coders was calculated as
kappa for each subcategory under consideration. Variables
with low reliability were either dropped from the analysis
or codes were combined and operationalized to increase
agreement. Beyond unitizing reliability, following Lombard
et al.s (2002), recommendation, interpretive reliability was
enhanced by having the independent coders review adver-
tisements three times during coding, and by having the two
principle investigators review the coding to ensure that they
agreedwiththeprimarycoders initial analysis. Thecodebook
was again modified to include clarified constructs based on
coder discussion and agreement about variable meaning.
Final coding. The two coders then viewed and coded
the remaining advertisements in the sample, using the
revised codebook.
7
To evaluate unitizing reliability, 30%t of
the total sample advertisements were randomly selected for
both coders to analyze and to calculate reliability. Cohens
kappa was used to assess intercoder reliability for nominal
variables. Capozzoli, McSweeney, & Sinha (1999) argue
that due to the conservative nature of this statistic,
values greater than 0.75 or so may be taken to represent
excellent agreement beyond chance, values below 0.40 or so
may be taken to represent poor agreement beyond chance,
7
Two additional persuasive health messages were considered in our
initial coding scheme, but dropped from final analysis. The first was
a fear persuasive health message. There was poor discrimination both
conceptually and operationally between fear and attitude persuasive health
messages. These two categories were combined and the operational defi-
nition of attitude persuasive health message was modified (researchers
separately considered the affective, e.g., fear, dimension of any persuasive
health message). The second additional persuasive health message exam-
ined the benefits of not smoking against the consequences of smoking.
Due to the low number of advertisements (n = 3, 0.8%) casting the benefits
of not smoking to the consequences of smoking, no further analysis was
conducted with this persuasive health message.
and values between 0.40 and 0.75 may be taken to represent
fair to good agreement beyond chance. (p. 6; also see Landis
& Koch, 1977)
Pearsons correlation was used as the reliability measure-
ment for variables measured on a scale (Neuendorf, 2002).
A Pearsons correlation of .80 or above was considered
excellent, whereas a correlation greater than .60 was consid-
ered good. Finally, where the two coders disagreed, the two
principal investigators watched the advertisements together
to make a final decision. They discussed each case and
reached consensus on the final code.
RESULTS
First, this study examined the extent to which theory-based
persuasive health messages were present in anti-smoking
advertisements (RQ1). In the MCRC sample (N = 399),
the most prevalent persuasive health message was atti-
tudes (n = 188, 45.3%). A theory-based persuasive health
message could not be identified in many of the advertise-
ments (n = 109). Other theoretically grounded persuasive
health messages coded included reinforcing anti-smoking
social norms (n = 53, 13.3%) and anti-smoking behavioral
modeling (n = 46, 11.5%).
Second, this study evaluated which affective appeals
were most prevalent in anti-smoking advertisements (RQ2).
In 24.1% of the advertisements (n = 96), coders could not
identify an appeal. Of the remaining 303 advertisements,
15% (n = 60) of the advertisements used a fear affective
appeal, 8.8% (n = 35) used sadness, 25.6% (n = 102) used
an informational appeal, 23% (n = 93) used humor, and
3.3% (n = 13) of the advertisements used an anger appeal.
Third, this study examined the MCRC television adver-
tisements for their thematic arguments for tobacco control.
RQ3a inquired if there were significant differences among
advertisements with different theoretically grounded persua-
sive health messages in their acknowledgement of the
benefits of not smoking. Sixty-one percent of advertise-
ments indicated there were benefits of not smoking or
quitting smoking. Sixty-nine percent of advertisements that
acknowledged the benefits of not smoking had a persua-
sive health message targeting individual attitudes. Nineteen
percent of advertisements that acknowledged the benefits
of not smoking had a social norms persuasive health
message. Eleven percent of advertisements that acknowl-
edged the benefits of not smoking had an anti-smoking
behavioral modeling message. The relationship between the
presence of a persuasive health message and acknowledg-
ment of the benefits of not smoking was significant,
2
(3, n = 287) = 14.96, p - .01 (see Table 1).
RQ3b asked if there were significant differences among
advertisements with different persuasive health messages by
their propensity to mention barriers to quitting smoking or
ANTI-SMOKING MEDIA CAMPAIGN MESSAGES 99
TABLE 1
Theory-Based Message by Benets Acknowledged
Attitude (n = 188) Social Norms (n = 53) Behavioral Modeling (n = 46) Total (n = 287)
Acknowledged (n = 205)
Column 76.1% 75.5% 47.8% 71.4%
Row 69.8% 19.3% 10.7% 100%
Not acknowledged (n = 82)
Column 23.9% 24.5% 52.2% 28.6%
Row 54.9% 15.9% 29.3% 100%
Total 100% 100% 100% 100%
Note.
2
(3, N =287) =14.96, -.01. Displayed comparisons are only for advertisements for which a theory-based persua-
sive health message could be identified.
not smoking. Eighteen percent of advertisements acknowl-
edged barriers to not smoking or quitting smoking. Sixty-
four percent of advertisements that acknowledged barriers
to not smoking had persuasive health messages about
individual attitudes. Thirty percent of advertisements that
acknowledged barriers had a persuasive health message
indicating modeling. Six percent had a social norms
persuasive health message. The relationship between core
persuasive health message and acknowledging the barriers
to quitting smoking or not smoking was statistically signif-
icant,
2
(3, N& = 287) = 16.27, p - .01 (see Table 2).
RQ3c asked if there were significant differences among
advertisements with different persuasive health messages
by their propensity to acknowledge both the benefits of not
smoking and barriers to not smoking or quitting. Only 7%
of advertisements included both the benefits of not smoking
or quitting and the barriers to successfully doing so in a
combined message. The inclusion of a combined message
was not related to any persuasive health message,
2
(3,
N = 287) = 3.995, p = .138.
RQ4 asked if there were significant differences among
advertisements with different persuasive health messages in
their representation of the self-efficacy to quit smoking and
arguments pertaining to the severity of the smoking harm.
Most ads had no/weak self-efficacy and strong severity of
consequences (n = 159). Advertisements with no/weak self-
efficacy and no/weak severity of consequences were the
second most numerous category (n = 109). There was a
significant difference in the likelihood of advertisements
with different persuasive health messages to indicate self-
efficacy and severity of consequences,
2
(3, N = 200) =
130.50, p - .01 (see Table 3).
DISCUSSION
This research provides a detailed description of (a) which
persuasive health messages anti-smoking advertisements
used, (b) how anti-smoking advertisements considered both
the benefits and barriers of smoking, and (c) which affec-
tive appeals anti-smoking advertisements utilized. Knowing
the extent and nature of appeals in the MCRC database
may help researchers understand whether a given appeal
has been over- or underutilized, and whether there is a gap
between theoretical knowledge and message design.
Characteristics of Anti-Smoking Advertisements
Anti-smoking advertising, as represented by advertisements
in the MCRC database, has somewhat troubling charac-
teristics. Advertisements overwhelmingly focused on atti-
tudes, instead of social norms or modeling persuasive
TABLE 2
Theory-Based Message by Barriers Acknowledged
Attitude
(n = 188)
Social Norms
(n = 53)
Behavioral Modeling
(n = 46)
Total
(n = 287)
Acknowledged (n = 64)
Column 21.8% 7.5% 41.3% 22.3%
Row 64.1% 6.3% 29.7% 100%
Not acknowledged (n = 223)
Column 78.2% 92.5% 58.7% 77.7%
Row 65.9% 22.0% 12.1% 100%
Total 100% 100% 100% 100%
Note.
2
(3, N =287) =16.27, -.01. Displayed comparisons are only for advertisements for which a theory-based persua-
sive health message could be identified.
100 COHEN, SHUMATE, GOLD
TABLE 3
Theory-Based Message by Self-Efcacy/Severity of Consequences
Attitude
(n = 137)
Social Norms
(n = 30)
Behavioral Modeling
(n = 33)
Total
(n = 200)
No/weak severity and strong
self-efficacy (n = 19)
Column 1.5% 10.0% 42.4% 9.5%
Row 10.5% 15.8% 73.7% 100%
Strong severity and no/weak
self-efficacy (n = 120)
Column 75.9% 46.7% 6.1% 60.0%
Row 86.7% 11.7% 1.7% 100%
No/weak severity and no/weak
self-efficacy (n = 120)
Column 19.7% 43.3% 12.1% 22.0%
Row 61.4% 29.5% 9.1% 100%
Strong severity and strong
self-efficacy (n = 120)
Column 2.9% 0% 39.4% 8.5%
Row 23.5% 0% 76.5% 100%
Total 100% 100% 100% 100%

2
(3, N =200) =130.50, >.01.
health message strategies. These data also might indicate
that message designers have difficulty producing theoret-
ically grounded health communication messages. This is
troubling because Wakefield et al. (2003) contend that
advertisements that use a variety of messages in a market
may be more effective. In addition, health communication
campaign research has demonstrated the effectiveness of
messages that challenge individuals perception of social
norms toward risky behaviors (e.g., Basen-Engquist &
Parcel, 1992; Crone et al., 2003; Pechmann & Reibling,
2000; Viswesvaran & Schmidt, 1992) and bolster self-
efficacy (e.g., Dijkstra & De Vries, 2001; Dino, Kamal,
Horm, Kalsekar & Fernandes, 2004; Droomers, Schrijvers,
& Mackenbach, 2004; Siegel, 2002; Wakefield et al., 2003.)
Sixty-one percent of advertisements in the sample specif-
ically mentioned a benefit of not smoking or quitting
smoking. Very few advertisements mentioned barriers to not
smoking or quitting smoking (18%). Even fewer advertise-
ments mentioned both barriers and benefits (7%). From a
cognitive perspective, future research may examine whether
the viewer may easily discount advertisements that fail to
give a realistic view of the process of quitting smoking.
Alternatively, advertisements may result in reinforcing pro-
smoking attitudes if they fail to highlight the benefits of not
smoking.
In general, advertisements focused to a greater extent
on the severity of harm than on self-efficacy. Most adver-
tisements focused on death or very severe consequences
to smoking (33.3%) instead of less severe consequences
such as addiction or short-term health problems. In addi-
tion, most advertisements failed to give the viewer encour-
agement that they were capable of refusing to smoke
or quitting (76.6%). The extent of these messages is
significant, because research suggests that if anti-smoking
advertisements fail to provide messages of efficacy, conse-
quence information may provoke a self-defensive bias rather
than encourage behavior change (Wakefield et al., 2003).
Viewers whose attitudes are negative about smoking may
continue to smoke if they feel that they do not have the
ability to change their behavior (Stephenson & Witte, 2001).
Anti-smoking advertisements tend to use humor (25%)
and informational (23%) affective appeals. These results
mark a departure from the fear appeals that have dominated
health public service announcements in the past (see Witte,
1998, for a review of how fear appeals may impact persua-
siveness). Little to no research has tested the influence of
anger appeals on perceptions of anti-smoking messages.
Although prevalent in a significant minority of advertise-
ments, little to no research has examined the influence
of sadness appeals on the effectiveness of anti-smoking
advertisements.
Limitations and Areas for Future Research
Despite the large sample of advertisements in this research,
several limitations remain. First, this research examined
television advertisements included in the MCRC database.
This research did not examine print, radio, or billboard anti-
smoking advertisements, or the impressions of these televi-
sion advertisements. Future research should examine these
other media for the prevalence of theory-based messages
and affective appeals. Future researchers may also consider
the cooccurrence of persuasive health messages; in coding
mutually exclusive persuasive health messages these coders
sacrificed a degree of reliability for validity. In addition,
some anti-smoking media campaign advertisements are not
ANTI-SMOKING MEDIA CAMPAIGN MESSAGES 101
included in the MCRC database, although to date the MCRC
is the largest collection of anti-smoking advertisements that
has been studied using content analysis. Advertisements not
included in the MCRC database may differ systematically
from the advertisements examined. Future research should
pursue analysis of other advertising, including anti-smoking
advertising sponsored by tobacco companies and private
health insurance companies.
Message relevance and individual-level differences in
how people attend to information are often not addressed
in research (e.g., Ball-Rokeach, Rokeach, & Grube, 1984).
Future research is also needed to evaluate audience reac-
tions to messages using the various affective appeals
and persuasive health messages. Finally, theoretically
driven health communication research should examine
the sponsors assumptions about effective anti-smoking
advertisements.
CONCLUSION
Anti-smoking advertisements represent one of the most
intensely funded health communication campaigns. The
importance of formative research into the theoretical mech-
anisms of an effective advertising campaign targeting the
underlying motivations of the target population cannot be
overstated. Siegel (2002) maintains, If the campaign is
strategically planned based on carefully conducted market
research, the executions are creatively developed, and the
campaign messages are delivered repeatedly and consis-
tently over a long time period, then the chances of a
successful campaign are maximized (p. 159).
Current anti-smoking advertisements overemphasize atti-
tudes while underemphasizing social norms, barriers to
quitting smoking, and individuals self-efficacy. This
research furthers a program of research (Beaudoin, 2002;
Stephenson, 2002) that explores anti-drug and anti-smoking
advertisements. This research makes an effort to evaluate
real-world advertisements using theoretically based models
and research, which is essential if health communication
researchers hope to make the link between theoretical strate-
gies studied in the lab and campaign strategies conducted
in the field.
ACKNOWLEDGMENTS
The authors thank Kristen Anderson (M.A., Saint Louis
University), for her research assistance, and Teresa
Thompson, for her editorial support.
REFERENCES
Ball-Rokeach, S., Rokeach, M., & Grube, J. W. (1984). The great American
values test: Influencing behavior and belief through television. New
York: Free Press.
Bandura, A. (1977a). Self-efficacy: Toward a unifying theory of behavioral
change. Psychological Review, 84, 191215.
Bandura, A. (1977b). Social learning theory. Englewood Cliffs, NJ:
Prentice Hall.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York:
Freeman.
Bandura, A. (2002). Social cognitive theory in cultural context. Journal of
Applied Psychology: An International Review, 51, 269290.
Basen-Engquist, K., & Parcel, G. S. (1992). Attitudes, norms, and self-
efficacy: A model of adolescents HIV-related sexual risk behavior.
Health Education Quarterly, 19, 26377.
Bauer, U. E., Johnson, T. M., Hopkins, R. S., & Brooks, R. G. (2000).
Changes in youth cigarette use and intentions following implementation
of a tobacco control program: Findings from the Florida Youth Tobacco
Survey, 1998-200. Journal of the American Medical Association, 284,
723728.
Beaudoin, C. E. (2002). Exploring antismoking ads: Appeals, themes, and
consequences. Journal of Health Communication, 7, 123137.
Blum, A. (1980). Medicine vs. Madison Avenue: Fighting smoke with
smoke. Journal of the American Medical Association, 243, 739740.
Capozzoli, M., McSweeney, L., & Sinha, D. (1999). Beyond kappa: A
review of interrater agreement measures. The Canadian Journal of
Statistics, 27, 323
Cappella, J. N., Fishbein, M., Hornik, R., Ahern, R. K., & Sayeed, S.
(2001). Using theory to select messages in antidrug media campaigns:
Reasoned action and media priming. In R. E. Rice & C. K. Atkin (Eds.),
Public communication campaigns. (pp. 214230) Thousand Oaks, CA:
Sage.
Chew, F., Palmer, S., Slonska, Z., & Subbiah, K. (2003). Enhancing health
knowledge, health beliefs, and health behavior in Poland through a health
promoting television program series. Journal of Health Communication,
7, 179196.
Crone, M. R., Reijneveld, S. A., Willemsen, M. C., Van Leerdam., F. J.
M, Spruijt R. D., & Sing, R. A. H. (2003). Prevention of smoking in
adolescents with lower education: A school based intervention study.
Journal of Epidemiology & Community Health, 57, 675.
Cuerrier, J. P., Deshaies, P., Mongeau, C., Luc, P. G., & Vallerand, R. J.
(1992). Ajzen and Fishbeins theory of reasoned action as applied to
moral behavior: A confirmatory analysis. Journal of Psychology, 62,
98109.
Dijkstra, A., & De Vries, H. (2001). Do self-help interventions in
health education lead to cognitive changes, and do cognitive changes
lead to behavior change? British Journal of Health Psychology, 6,
121134.
Dino, G., Kamal, K., Horn, K., Kalsekar, I., & Fernandes, A. (2004).
Stage of change and smoking cessation outcomes among adolescents.
Addiction Behavior, 29, 935940.
Droomers, M., Schrijvers, C. T. M., & Mackenbach, J. P. (2004). Educa-
tional differences in the intention to stop smoking: Explanations based
on the theory of planned behaviour. European Journal of Public Health,
14, 194.
Evans, R. I. (1976). Smoking in children: Developing a social psycholog-
ical strategy of deterrence. Preventative Medicine, 5, 122127.
Evans, R. I. (1979). Fear is not enough: Modification of behaviour to
prevent disease. Postgraduate Medicine, 65, 195197.
Evans, R. I. (1983). Deterring smoking in adolescents: Evolution of a
research program in applied social psychology. International Journal of
Applied Psychology, 32, 7183.
Faucher, M. A., & Carter, S. (2001). Why girls smoke: A proposed
community-based prevention program. Journal of Obstetric, Gyneco-
logical and Neonatal Nursing, 30, 463471.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior:
An introduction to theory and research. Reading, MA: Addison-Wesley.
Fishbein, M., & Middlestadet, S. E. (1989). Using the theory of reasoned
action as a framework for understanding and changing AIDS-related
behaviors. In V. Mays, G. W. Albee, & S. Schneider (Eds.), Primary
102 COHEN, SHUMATE, GOLD
prevention of AIDS: Psychological approaches. (pp. 91110). Thousand
Oaks, CA: Sage.
Fishbein, M., Triandis, H. C., Kanfer, F. H., Becker, M., Middlestadt, S. E.,
& Eichler, A. (2001). Factors influencing behavior and behavior change.
In A. Baum, T. A. Revenson, & J. E. Singer, Handbook of health
psychology. (pp. 315). Mahwah, NJ: Lawrence Erlbaum Associates,
Inc.
Fishbein, M., & Yzer, M. C. (2003). Using theory to design effective
health behavior interventions. Communication Theory, 13, 164183.
Freimuth, V., Hammond, S. L., Edgar, T., & Monahan, J. L. (1990).
Reaching those at risk: A content-analytic study of AIDS PSAs. Commu-
nication Research, 17, 775791.
Glanz, K., Lewis, E. M., & Rimer, B. K. (1990). Health behavior and
health education: Theory, research and practice. San Francisco: Jossey-
Bass.
Hale, J. L., & Dillard, J. P. (1995). Fear appeals in health promotion
campaigns. In E. Maibach & R. L. Parrott (Eds.), Designing health
messages, (pp. 6580). Thousand Oaks, CA: Sage.
Hochbaum, G. M. (1958). Public participation in medical screening
programs: A sociopsychological study. PHS publication No. 572. Wash-
ington, DC: U.S. Government Printing Office.
Institute of Medicine & National Research Council. (2000). State programs
can reduce tobacco use. Washington, DC: National Academies of
Science Press. Available from http://books.nap.edu/html/state_tobacco
Landis, J. R., & Koch, G. G. (1977). The measurement of observer agree-
ment for categorical data. Biometrics, 33, 159174.
Lombard, M., Snyder-Duch, J., & Bracken, C. C. (2002). Content anal-
ysis in mass communication: Assessment and reporting of intercoder
reliability. Human Communication Research, 28(4), 587604.
Maibach, E., & Parrott, R. (1995). (Eds.). Designing health messages:
Approaches from communication theory and public health practice.
Thousand Oaks, CA: Sage.
Manfredi, C., Lacey, L. P., Warnecke, R., & Petraitis, J. (1998). Sociopsy-
chological correlates of motivation to quit smoking among low-SES
African American women. Health Education and Behavior, 25(3):
304318.
McGahee, W., Kemp, V., & Tingen, M. (2000). A theoretical model for
smoking prevention studies in preteen children. Pediatric Nursing, 26,
135143.
Mikanowicz, C. K., Fitzgerald, D. C., Leslie, M., & Altman, L. M. (1999).
Medium-sized business employees speak out about smoking. Journal of
Community Health, 24(6), 439450.
Neuendorf, K. A. (2002). The content analysis guidebook. Thousand Oaks,
CA: Sage.
Pechmann, C., & Reibling, E. (2000). Planning for an effective anti-
smoking mass media campaign targeting adolescents. Journal of Public
Health Management and Practice, 6, 8094.
Rice, R. E., & Atkin, C. K. (Eds.). (2001). Public communication
campaigns (3rd ed.). Thousand Oaks, CA: Sage.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning
theory and the health belief model. Health Education Quarterly, 15,
175183.
Siegel, M. (2002). Anti-smoking advertising: Figuring out what works.
Journal of Health Communication, 7, 157162.
Siegel, M., & Biener, L. (2000). The impact of anti-smoking media
campaigns on progression to established smoking: Results of a longitu-
dinal youth study in Massachusetts. American Journal of Public Health,
90, 380386.
Slater, M. (1999). Integrating application of media effects, persuasion, and
behavior change theories to communication campaigns: A stages-of-
change framework. Health Communication, 11, 335354.
Sly, D. F., Heald, G., & Ray, S. (2000). Preventing youth smoking
behaviors: How Floridas truth works. Tallahassee: Florida State
University.
Sly, D. F., Heald, G. R., & Ray, S. (2001). The Florida truth anti-
tobacco media evaluation: Design, first year results, and implications
for planning future state media evaluations. Tobacco Control, 10, 915.
Sly, D. F., Hopkins, R. S., Trapido, E., & Ray, S. (2001). Influence of
a counteradvertising media campaign on initiation of smoking: The
Florida truth campaign. American Journal of Public Health, 91,
233238.
Stephenson, M. T. (2002). Anti-drug public service announcements
targeting parents: An analysis and evaluation. Southern Communication
Journal, 67(4), 335350.
Stephenson, M. T., & Quick, B. L. (2005). Parent ads in the National
Youth Anti-Drug Media Campaign. Journal of Health Communication,
10, 701710.
Stephenson, M. T., & Witte, K. (2001). Creating fear in a risky world. In
R. Rice & C. K. Atkin (Eds.), Public communication campaigns. (pp.
88102) Thousand Oaks, CA: Sage.
Strecher, V. J., & Rosenstock, I. M. (1997). The health belief model. In
K. Glanz, F. Lewis, & B. Rimer, (Eds.), Health behavior and health
education (pp. 4159). San Francisco: Jossey-Bass.
Terry, D., Gallois, C., & McCarnish, M. (1993). The theory of reasoned
action and health care behavior. In D. Terry, C. Gallois, & M. McCar-
nish (Eds.), The theory of reasoned action: Its applications to AIDS
preventive behavior. (pp. 128). Tarrytown, NY: Pergamon Press.
Unger, J. B., Rohrbach, L. A., Howard-Pitney, B., Ritt-Olson, A., & Mout-
tapa, M. (2001). Peer influences and susceptibility to smoking among
California adolescents. Substance Use and Misuse, 36, 551571.
U.S. Department of Health and Human Services. (1994). Preventing
tobacco use among young people: A report of the Surgeon General.
Atlanta, GA: Author, Public Health Service, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health.
Viswesuaran, C., & Schmidt, F. L. (1992). A meta-analytic comparison
of the effectiveness of smoking cessation methods. Journal of Applied
Psychology, 77, 554562.
Wakefield, M., & Chaloupka, F. (2000). Effectiveness of comprehensive
tobacco control programs in reducing teenage smoking in the United
States. Tobacco Control, 9(2), 177186.
Wakefield, M., Flay, B., Nichter, M., & Giovino, G. (2003). Effects of
anti-smoking advertising on youth smoking: A review. Journal of Health
Communication, 8, 229247.
Witte, K. (1992). Putting the fear back into fear appeals: The extended
parallel process model. Communication Monographs, 59, 329348.
Witte, K. (1994). Fear control and danger control: A test of the
extended parallel process model. Communications Monographs, 61(2),
113134.
Witte, K. (1998). Fear as motivator, fear as inhibitor: Using the extended
parallel process model to explain fear appeal successes and failures (pp.
423450). In P. A. Andersen & L. K. Guerrero (Eds.), The handbook
of communication and emotion: Research, theory, applications, and
contexts. San Diego, CA: Academic.
Worden, J. K., & Flynn, B. S. (2001). The case for persuasive health
messages. Effective Clinical Practice, 4(2), 7375.