Gritty Antitobacco Ads and More From Legacy Foundation

WASHINGTON—Few were aware of the American Legacy Foundation until last February when it televised and then temporarily pulled two antitobacco advertisements, one of which showed body bags being stacked outside the headquarters of Philip Morris.

Legacy was created as an educational and research organization by the Master Settlement Agreement (MSA), which ended lawsuits against the tobacco industry by 46 states and 5 US territories. The foundation’s charges include “a nationwide sustained advertising and education program” to discourage the use of tobacco products by the young.

Legacy temporarily withdrew its gritty TV ads after complaints by tobacco companies that they violated an MSA clause that bars any “vilification” of the industry by the foundation. The TV spots were restored in April, and Legacy president Cheryl Healton, DrPH, vows the foundation will aggressively pursue its mission “to reach teens with empowering messages.”

Dr. Healton joined Legacy last December from Columbia University, where she served as head of the Division of Sociomedical sciences and associate dean for program development at the School of Public Health. In this interview, Dr. Healton discusses the foundation’s antitobacco efforts with ONI Washington Bureau Chief Patrick Young.

ONI: Can you effectively reach teens without having to repeatedly battle the tobacco industry over the vilification clause?

Dr. Healton: The evidence is mounting that one must empower young people as wary consumers in order to have an effective antitobacco campaign for youth. It is much less important with adults, where the goal is cessation. With kids, the goal is to ensure they never start the habit, and because they are a continuing target of the industry, you really do have to lay out the facts for them.

We try to do it in humorous ways and in ways that will capture their imagination, but our goal is not to vilify the industry. Our goal is to run an effective antitobacco campaign, which is what the MSA specifically says we must run. There have now been four studies, all of which conclude that one of the pillars of an effective campaign is awareness of the tobacco industry’s tactics.

ONI: You have said the foundation’s ads have an edge. Why is that necessary with teenagers?

Dr. Healton: Teenagers like to take control of their lives, and they have varying levels of responses to authority figures. But clearly, a campaign that puts them in the driver’s seat is more likely to get a buy-in with them than one that has a hierarchical, authoritarian, top–down message, such as “Don’t Smoke!”

The edge helps break through the noise and gets the message out to kids. I wouldn’t be honest if I didn’t say that currently funded antitobacco campaigns actually have many of the features of a campaign that is destined to fail. That is not what we want. We want to reduce youth tobacco use. We believe we can do it within a language in which they live.

ONI: Will this same edge be carried over into the foundation’s classroom education programs?

Dr. Healton: The classroom education programs are just now getting their first attention by the foundation. We are a relatively new organization, and we are talking to a range of organizations, many of them corporate entities that have an interest in educational materials for young people.

I doubt that these materials will have exactly the same edge, since many of those efforts are going to focus on younger kids. We are not particularly focusing our ad campaign on in-school students, but on kids at risk of smoking, many of whom actually are not all that engaged in school, including the 15- to 18-year-olds who have dropped out.

ONI: What role are teens playing in the foundation’s activities?

Dr. Healton: Teens have played a role in almost every aspect of the campaign, and in many ways, they are leading it. We brought about 100 teens together last September, two from every state, to kick things off, brainstorm ideas, and talk to advertising professionals.

The teenagers later met as a joint committee through conference calls and in person sometimes, as well as through email and faxing, to give feedback and ideas on story boards, on concepts for advertisements, on how to shape the website, etc.

In June, we had a National Youth Summit with 1,000 teens present to train, network, and brainstorm further in order to move the campaign forward.

ONI: Are states asking the foundation to help fund their antismoking efforts rather than using their own settlement money?

Dr. Healton: All of our grant programs for states require a match from the state. If a state is not willing to put any money in, then it won’t receive Legacy Foundation funding.

We have been very proactive in communicating to the states that the foundation is not a replacement for state-based tobacco activities. When the existence of the foundation is evoked as a reason not to do something on a state level, that is really just a subterfuge.

ONI: How does your charge to track and monitor youth smoking and substance abuse differ from the HHS Household Survey and other surveys?

Dr. Healton: Our survey goes from 6th to 12th grade, and every state that applies for our grant has to do the survey on a statewide level. So our survey will have data that will be reliable both as a national, overarching indicator for youth tobacco use and on the state level.

It will be the first time that we will be able to take the country as a model and say, “These 10 states had X policy and their youth smoking rates are X, and these 10 states had Y policies and their smoking rates are Y.”

ONI: Your charter includes an assignment to select an educational or medical institution as an affiliate. Have you chosen one?

Dr. Healton: My guess is that we will have formal linkages with multiple universities. Before I came here, a letter went out to approximately 30 to 40 academic medical centers and universities asking them to write about how they might be helpful to the foundation.

Since my arrival, I have revisited all of the responses, and we currently have discussions going on with four or five academic health sciences centers—in some cases, a medical school, in other cases, a school of public health.

ONI: What will be the medical affiliates’ role?

Dr. Healton: One of the requirements of the MSA is that the foundation develop a systematic program of evaluation and research. That mandate is very broad and presently funded at the level of about $25 million. We have a standing contract with an excellent research consortium, headquartered in Research Triangle Park, NC. We also will have periodic special evaluations of demonstration projects that the foundation undertakes, and we have many other ad hoc research needs.

For example, the foundation has made a major commitment to understand the needs of special populations with regard to tobacco. Only limited work has been done in particular populations—Native Americans, Hispanics, and African Americans. We will seek to form an affiliation with some institution that has a high concentration of minority faculty and a strong track record in conducting research in minority populations.

ONI: Do you have any plans to work with oncology groups?

Dr. Healton: Probably we will end up doing that. There is one goal that is not an official goal of the foundation, but about which there is much discussion, and that is the issue of differential access to cancer- and cardiovascular-related screening and intervention to interdict tobacco-related illness. The foundation might want to work aggressively with other groups to move this gap in access up the policy agenda.

ONI: What do you hope will be your legacy as Legacy president ?

Dr. Healton: I would like the foundation to have been effective with regard to its goals. I would certainly want to have created a range of programs that do not duplicate other antitobacco activities that are already taking place. For the first time, this country has a foundation solely dedicated to addressing the issue of tobacco use. It is my hope that we will find an appropriate place in the American landscape.