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Estimated Exposure of Adolescents to State-Funded Anti-Tobacco Television Advertisements --- 37 States and the District of Columbia, 1999--2003

The majority of persons who become regular smokers begin smoking during adolescence, making this period critical for preventing tobacco use (1). Evidence suggests that anti-tobacco mass media campaigns that include paid television advertising reduce youth smoking (1--3). With development of anti-tobacco programs in all 50 states during the 1990s, spurred by funding from the 1998 Master Settlement Agreement with major cigarette manufacturers, CDC, and other sources (4), an increasing number of states instituted anti-tobacco media campaigns. This report summarizes trends in median state estimates for the average number of state-funded anti-tobacco television advertisements to which adolescents aged 12--17 years were exposed per month in 37 states* and the District of Columbia (DC) during 1999--2003. The findings indicate that the median state estimate of the number of advertisement exposures per month increased from 0.04 in 1999 to 0.80 in 2002 but declined to 0.63 in 2003. The decline in estimated exposure from 2002 to 2003 is consistent with cutbacks in funding for state tobacco-prevention and -control programs during this period (4). Reduced exposure to state-funded anti-tobacco advertising might be contributing to the recent lack of substantial change in youth smoking prevalence from 2002 to 2004, which had been declining substantially since 1997 (5). The majority of states need to implement additional measures to ensure that adolescents are adequately exposed to effective paid anti-tobacco advertisements as part of tobacco-prevention activities.

The monthly advertisement-exposure data used in this analysis were based on target ratings points (TRPs) for adolescents aged 12--17 years obtained from Nielsen Media Research (6). TRPs are typically used as a mass-media exposure measure for a specific population during a defined period within a geographic media market, with 100 TRPs equaling an average of one exposure. Thus, if a television advertisement received 200 TRPs for adolescents for a given month, the average adolescent viewer in that market saw the advertisement two times. Data were available for state anti-tobacco advertisements appearing on network and cable television in the 75 largest media markets (i.e., designated market areas [DMAs]) in the United States during 1999--2003. These 75 DMAs were in 37 states and DC and accounted for 78% of television-viewing households in the United States.

DMAs are television broadcasting geographic regions with a predominantly, but not exclusively, metropolitan audience. For states with only one DMA, exposure estimates for that DMA were applied to the state as a whole. For states with multiple DMAs, estimates were averaged for all DMAs within a state to produce state-level estimates. Exposure estimates for DMAs that crossed state boundaries were assigned to the state in which the largest metropolitan area was located. Annual state estimates and 95% confidence intervals for the average number of advertisement exposures per month were calculated on the basis of means of TRPs for all 12 months. Median state estimates were calculated on the basis of average annual state estimates of monthly exposures.

The median average monthly exposure of adolescents to state-funded anti-tobacco television advertisements increased from 0.04 in 1999 to 0.80 in 2002 but decreased to 0.63 in 2003 (Figure). State advertisement exposure estimates in 2003 ranged from no exposure in Louisiana, Maryland, and South Carolina to more than two exposures per month in Indiana, Minnesota, Ohio, Utah, Virginia, and Washington (Table).

Research has demonstrated the effectiveness of several long-running programs in reducing youth smoking that used extensive state-funded media advertising and began before 1999 (1,2). From 1999 to 2003, estimated adolescent exposure to state-funded advertisements declined by 78%--88% in Florida, Massachusetts, and Arizona. The largest 1-year declines resulting from cutbacks in state program funding occurred in Florida from 2002 to 2003 (from 3.72 to 1.07) and in Massachusetts from 2001 to 2002 (from 1.83 to 0.40); however, the largest decline in exposure occurred in Arizona from 1999 to 2000 (from 10.25 to 4.36) after state program officials decided to adopt programs targeting a wider population in place of youth-oriented campaigns. In California, where the state anti-tobacco program had relatively stable funding during 1999--2003, the level of estimated youth exposure to state-funded anti-tobacco advertisements remained consistent during this period, with the annual estimated monthly exposures ranging from 1.15 to 1.79. Indiana was the only other state that maintained an estimated exposure level greater than 1.0 for all 5 years.

Reported by: G Szczypka, M Wakefield, PhD, S Emery, PhD, B Flay, PhD, F Chaloupka, PhD, S Slater, MS, Univ of Illinois at Chicago. Y Terry-McElrath, MSA, Univ of Michigan. H Saffer, PhD, National Bur of Economic Research, New York, New York. D Nelson, MD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

From 1999 to 2002, the overall estimated average monthly exposure of adolescents to state-funded anti-tobacco television advertising increased substantially. The Task Force on Community Preventive Services and CDC's Best Practices for Comprehensive Tobacco Control Programs both recommend that states use such paid advertising as part of their countermarketing activities (2,7), given that research has consistently demonstrated the role of such advertisements in preventing tobacco use (1--3). Moreover, sustained exposure of adolescents to such advertisements over time is important for prevention, as demonstrated in California and Indiana.

Despite these findings, the results of this report also indicate that exposure of adolescents to state-funded anti-tobacco advertisements decreased in 2003, coinciding with reduced funding for state tobacco-prevention and -control programs in response to state budget crises (4). From fiscal years 2002 to 2004, overall state spending on tobacco-prevention and -control programs declined by 28% in the United States. State program cuts have exceeded 75% in some states, such as Florida and Massachusetts (4,8). In Minnesota, program reductions were associated with reduced awareness of the state anti-tobacco campaign and a substantial increase in youth smoking susceptibility (8). Downward trends in adolescent exposure to state-funded anti-tobacco ads in Arizona, California, Florida, and Massachusetts were particularly noteworthy, given their long-term use of state-funded anti-tobacco advertising.

Comprehensive state tobacco-prevention and -control programs have a key role in preventing tobacco use (1--3). Components of effective state programs include paid anti-tobacco television advertisements as part of countermarketing activities, community-based programs, school programs, cessation-assistance efforts, and enforcement activities (7). An additional challenge to effective tobacco countermarketing is that adolescents were exposed to more "anti-tobacco" advertisements sponsored by the tobacco industry than to state-funded anti-tobacco advertisements (9). Research has indicated that tobacco industry-sponsored ads are not effective in preventing youth from smoking (10).

State-funded anti-tobacco advertisements, however, cannot be effective on a populationwide basis if they do not achieve adequate exposure among target audiences. At a minimum, states should make every effort to ensure that adolescents are exposed to, on average, at least one state-funded anti-tobacco television advertisement per month, given that even this low level of exposure has been shown to be associated with higher anti-tobacco sentiment and reduced smoking prevalence (9). Retaining sufficient levels of exposure consistently is especially important now that funding for the nationally aired and effective anti-tobacco advertisements produced by the American Legacy Foundation has been reduced (4).

The findings in this report are subject to at least five limitations. First, because Nielsen Media Research ratings measure the availability of audiences for advertising exposure, they do not guarantee actual viewing or recall of advertisements by adolescents. Nevertheless, Nielsen ratings are the standard approach used by corporations and others to estimate population exposure to television programs and advertising. Furthermore, research has demonstrated a dose-response relationship between estimated exposure of adolescents to anti-tobacco advertisements and their ability to recall seeing such advertisements (9). Second, this study did not examine the actual content of anti-tobacco advertisements. Third, the estimated exposure levels did not reflect adolescent exposure to nationally aired anti-tobacco advertisements. Fourth, these data are not nationally representative, given that no data were available from 13 states. Finally, DMAs, although they cover the majority of the population in the 37 states and DC, might not be fully representative of estimated adolescent exposure throughout each state.

Tobacco use remains the leading preventable cause of death in the United States (1). However, reductions in state-funded anti-tobacco television advertisements might be contributing to the recent absence of a substantial change in adolescent cigarette smoking prevalence from 2002 to 2004 (i.e., from 22.5% to 21.8% among high school students, and from 9.8% to 8.3% among middle school students; neither difference was statistically significant) (5). If these reductions continue, the Healthy People 2010 goal of reducing youth smoking prevalence to 16% by 2010 might not be achieved, and the short-term cost savings that states gain by reducing their support for televised anti-tobacco advertising campaigns might produce long-term increased costs from smoking-related health effects.


  1. US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000.
  2. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20(2S):16--66.
  3. Wakefield M, Chaloupka F. Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA. Tob Control 2000;9:177--86.
  4. Schroeder SA. Tobacco control in the wake of the 1998 Master Settlement Agreement. N Eng J Med 2004;350:293--301.
  5. CDC. Tobacco use, access, and exposure to tobacco in media among middle and high school students---United States, 2004. MMWR 2005;54:297--301.
  6. Szczypka G, Emery S, Wakefield M, Chaloupka F. The adaption and use of Nielsen Media Research commercial ratings data to measure potential exposure to televised smoking-related advertisements. Chicago, Illinois: University of Illinois at Chicago; 2003. Available at
  7. CDC. Best practices for comprehensive tobacco control programs. Atlanta, GA: US Department of Health and Human Services, CDC; 1999.
  8. Sly DF, Arheart K, Dietz N, et al. The outcome consequences of defunding the Minnesota youth tobacco-use prevention program. Prev Med 2005;41:503--10.
  9. Emery S, Wakefield MA, Terry-McElrath Y, et al. Televised state-sponsored anti-tobacco advertising and youth smoking beliefs and behaviour in the United States, 1999--2000. Arch Pediatr Adolesc Med 2005;159:639--45.
  10. Terry-McElrath Y, Wakefield M, Ruel E, et al. The effect of anti-smoking advertising executional characteristics on youth appraisal and engagement. J Health Comm 2005;10:127--43.

* Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin.


Table 1
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Figure 1
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