Social Marketing Campaigns and Children’s Media Use

Social Marketing Campaigns and
Children’s Media Use
W. Douglas Evans
Summary
Media-related commercial marketing aimed at promoting the purchase of products and services by children, and by adults for children, is ubiquitous and has been associated with negative health consequences such as poor nutrition and physical inactivity. But, as Douglas Evans points out, not all marketing in the electronic media is confined to the sale of products. Increasingly savvy social marketers have begun to make extensive use of the same techniques and strategies used by commercial marketers to promote healthful behaviors and to counter some of the negative effects of conventional media marketing to children and adolescents.
Evans points out that social marketing campaigns have been effective in helping to prevent and control tobacco use, increase physical activity, improve nutrition, and promote condom use, as well as other positive health behaviors. He reviews the evidence from a number of major recent campaigns and programming in the United States and overseas and describes the evaluation and research methods used to determine their effectiveness.
He begins his review of the field of social marketing by describing how it uses many of the strategies practiced so successfully in commercial marketing. He notes the recent development of public health brands and the use of branding as a health promotion strategy. He then goes on to show how social marketing can promote healthful behavior, how it can counter media messages about unhealthful behavior, and how it can encourage discussions between parents and children. Evans concludes by noting some potential future applications to promote healthful media use by children and adolescents and to mitigate the effects of exposure to commercial marketing.
These include adapting lessons learned from previous successful campaigns, such as delivering branded messages that promote healthful alternative behaviors. Evans also outlines a message strategy to promote “smart media use” to parents, children, and adolescents and suggests a brand based on personal interaction as a desirable alternative to “virtual interaction.”

www.futureofchildren.org
W. Douglas Evans is vice president for public health and environment at RTI International.
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ommercial marketing is central to the American, indeed the global, economy. Since the early twentieth century, marketing strategies have grown in reach and influence as media channels have proliferated and people’s exposure to media has increased. At its core, marketing is about an exchange of value between the marketer and consumer. If the marketer can promote a product or service to make the consumer perceive sufficient value, the consumer is more likely to purchase it. In the past thirtyfive years, marketers have begun to use the same powerful idea in a new way—not to sell products and services but to promote socially beneficial causes and behaviors. A growing body of evidence shows that marketing is highly effective in this arena as well.
Marketing is perhaps best exemplified by the strategy of “branding” products, services, organizations, and ideas. Brands, recognition of brands, and the relationship between brand and consumer largely explain the tremendous success of product advertising and the growth of the American and global consumer economy over the past century. Marketers use brands to build relationships that enhance the value of products and services for consumers.
By providing additional value for consumers, brands can instill a sense of loyalty and identification that causes consumers to continue purchasing the branded products and services over competitors. Brands project a personality with which consumers identify and seek to associate themselves through owning and using the branded products and services.1 Very much like reputations, brands precede the individual or organization and shape how the world responds.
In this article, I examine social marketing and its use of commercial marketing principles to
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promote health behavior change. I argue that, like commercial marketers, social marketers create value for target audiences through their own form of branding—by creating positive associations with health behaviors and encouraging their adoption and maintenance. Social marketers also use market research to identify attitudes and beliefs among their target audiences that may support or inhibit the intended behavior change—increasing exercise or using a condom, for example. They apply audience segmentation techniques to develop targeted
(to a group) and tailored (to an individual) messages and promotional activities.
Substantial evidence, especially from subject areas such as tobacco control, nutrition and physical activity, and HIV/AIDS, suggests that social marketing can change health behavior and is a broadly effective social-change strategy that can be applied in other subject areas as well. Well-funded social marketing campaigns, such as the American Legacy
Foundation’s truth campaign, have demonstrated robust effect sizes and have had major population-level effects on health behavior, morbidity, and mortality.2 The challenge for social marketers is to compete successfully in a media-saturated environment against better-funded commercial marketers and their often unhealthful commercial messages for products such as junk and fast food, tobacco, and alcohol.
After discussing the evidence that social marketing works, I turn to the question of how it works. As noted, social marketing applies the central marketing strategy of building positive relationships with the audience to increase the value of promoted behaviors and to encourage exchange in the form of behavior adoption. Many social marketing campaigns have used branding to meet the

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competition head-on. The anti-tobacco use truth campaign, for example, developed behavioral alternatives and creative branded messaging to counter its competition, tobacco industry advertising. The approach used in truth and other anti-tobacco use campaigns is often called “countermarketing.” Countermarketing campaign advertisements provide behavioral alternatives to smoking, such as rebelling against industry manipulation and expressing independent thinking, thereby outdoing the industry’s own marketing of cigarettes as hip and cool products. Similar approaches have been developed in nutrition, physical activity, and HIV/AIDS social marketing. Social marketing has also been used to promote better parent-child communication and improved family health.
Social marketing in fields such as these can target not only individual behavior, but also public policy. Social marketing in tobacco control, for example, has been used to promote policy change and new legislation, leading to changes in social norms and the acceptability of smoking.3 Public health organizations use branding strategies to promote social mobilization and to influence public debate and opinion.4 Whether to focus on individual behavior or larger policy issues involves a strategic decision by the social marketing campaign based on available resources and competition for public attention.
Social marketing has also been used to promote behaviors such as better parentchild communication and improved family health. Many social marketing messages, such

as nutrition and physical activity messages promoted by the 1% Or Less milk campaign and the 5-4-3-2-1 Go! campaign in Chicago, have targeted parents to encourage them to change the home health environment and talk to their children about health behaviors.5
These efforts also use relationship-building strategies, and many have used community outreach as well as mass media components for a multi-channel message strategy.
These strategies have clear applications to children’s media use and the effects of advertising on children’s health behavior. Marketers have the ability to reach parents of young children and adolescents with targeted social marketing campaigns aimed at changing social norms about media use. They can promote “smart”—limited in time and self-aware in terms of influences—media use and a culture of parental involvement with messages that vary by children’s stage of development.
At the same time, marketers are able to target adolescents with messages to promote “smart” media use and brand it as socially desirable behavior. The evidence suggests that social marketers would be most likely to succeed not by demonizing media use but by competing with media influences by providing appealing behavioral alternatives. Using positive messages and imagery, they could promote alternatives to media use—for example,
“branding” direct social interaction as cool and hip. Such a strategy could lead to a culture of more healthful engagement with, and understanding of, media and its influences.

Social Marketing
Social marketing uses the principles and processes of commercial marketing, but not with the aim of selling products and services.
Rather, the goal is to design and implement programs to promote socially beneficial
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behavior change.6 In public health, social marketing attempts to increase healthful behaviors in a population by using such proven marketing techniques as market research to understand audience attitudes and beliefs that may affect behavior in response to a health message. Social marketers analyze their competition and use persuasive techniques such as creating social models to engage in the promoted behavior. In some cases, marketers can even create messages tailored for individuals using information about personal preferences and behavior just as online and direct mail commercial marketers do. In recent years, social marketers have successfully branded such health behaviors as being

a nonsmoker, being physically active, or using a condom in an effort to encourage those behaviors.7 In this article, I review research on social marketing to highlight its potential application to counter the flood of often unhealthful commercial media marketing to which
American children and adolescents are exposed, explore what is now being done on these topics, and outline a future agenda for research to enhance the impact of social marketing as a protective factor in the lives of children and adolescents. In the following section, I explain how social marketing works.
Then I turn to address three main topics:

Table 1. Major Recent Social Marketing Campaigns
Campaign

Topic area

Research design

Location

Target audience

1% Or Less

1% milk consumption

Observational

California

Adults, parents, and families 5-4-3-2-1 Go!

Nutrition and physical activity Experimental promotion Chicago

Parents and families

5-A-Day for Better Health

Fruit and vegetable consump- Observational tion United States

Adults, parents, and families Florida TRUTH

Tobacco countermarketing

Quasi-experimental

Florida

Adolescents and young adults Jalan Sesama

Educational entertainment

None

Indonesia

Youth

KNOW HIV/AIDS

HIV/AIDS awareness and prevention Observational

United States

Young adults

loveLife

HIV/AIDS awareness and prevention Observational

South Africa

Adolescents and young adults Massachusetts antitobacco campaign

Tobacco countermarketing

Quasi-experimental

Massachusetts

Adolescents (prevention) and adults (cessation)

Parents Speak Up

Reproductive health

Experimental

United States

Parents and families

Salama

HIV/AIDS awareness and prevention Observational

Tanzania

Adolescents and young adults Sisimpur

Educational entertainment

None

Bangladesh

Three- to six-year-olds

stand

Tobacco countermarketing

Quasi-experimental

Ohio

Adolescents and young adults The TV Boss

Children’s media use

Observational

United States

Parents

Trust

HIV/AIDS awareness and prevention Observational

Kenya

Adolescents and young adults truth

Tobacco countermarketing

Quasi-experimental

U.S.

Adolescents and young adults VERB: It’s What You Do

Physical activity promotion

Quasi-experimental

U.S.

Pre-adolescent children

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how social marketing can promote healthful behavior, how it can counter media messages about unhealthful behavior, and how it can encourage discussions between parents and children. How Social Marketing Works
Social marketing has been widely and successfully used to affect health and other social behaviors related to children and adolescents.
Table 1 summarizes many of the major social marketing campaigns conducted over the past fifteen years.
Social marketing efforts aimed directly at pre-adolescents or adolescents—exhorting them not to start smoking, for example, or to exercise regularly—have evolved in recent years. During the 1980s and earlier, most efforts focused on providing young people with facts and information about health risks.
In tobacco control, school-based programs aimed to equip adolescents with protective intrapersonal and interpersonal skills to stay tobacco-free in a social environment rich in positive imagery encouraging tobacco use.8
Since the early 1990s, social marketing to children and adolescents has begun directly taking on the commercial marketing competition, countering unhealthful product marketing and social messages and providing young people with positive behavioral alternatives.9 Social Modeling, Imagery, and
Environment
The concept of social modeling has long been understood by psychologists and by commercial marketers. In the work of Albert
Bandura, for example, social modeling plays a central role in social learning and social cognition; that is, the formation of knowledge, attitudes, and beliefs.10 In marketing, social models embody the ideals promised

by an advertisement or a larger campaign.
For example, the Marlboro Man, so familiar in commercials since the 1950s, provided an appealing social model for the Marlboro cigarette’s target audience. Of late, social marketers have also made use of models, such as the independent, rebellious youth featured in the American Legacy Foundation’s truth campaign.11 Imagery can be a powerful marketing tool to help create an idealized social model and thus promote product purchases and certain kinds of behavior. The Marlboro Man riding out on the range, the BMW driver cornering nimbly on a windy road, the truth campaign young adult confronting the tobacco industry—all embody socially desirable, idealized characteristics. Research has shown that such images feed the targeted audience’s aspirations to realize such an ideal—to be like the Marlboro Man, to own a BMW, to stand boldly against the tobacco industry.12 Social images exemplify socially desirable behavior and the attributes of those who engage in a behavior—for example, the affluent, sporty, sexy BMW driver.13
Because social imagery formation plays an important role in determining adolescent health behaviors, such as smoking, it can be used both to encourage and to discourage those behaviors. For example, tobacco brand marketing portrays smokers as cool, popular, and blessed with many friends.14 Because adolescents typically value these traits, they may be likely to at least experiment with smoking.15 But, as with the truth campaign, social marketers can make their own use of social imagery.
The social environment, especially the influence of parents among pre-adolescent children and of peers among adolescents, is
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another powerful influence on health behavior that can be used in social marketing. The associations teens form among their immediate social environment, social images, and exposure to marketing can explain adoption of health behaviors.

Competition
By creating and promoting positive social images of healthful behaviors aimed at countering unhealthful imagery, social marketers can compete for children’s and adolescents’ time, attention, and behavioral choices. In marketing terminology, social marketing can compete with commercial messages by identifying the “frame of reference”—the competing behavioral options in a given social context, such as whether to play outdoors or watch TV—and the “point of difference”— how to portray one behavior as superior to another—and developing messages based on that analysis.16
Social marketers have developed messages to compete both with commercial marketing and with the social norms that promote behaviors such as smoking, excessive media use and other sedentary behavior, or consumption of junk and fast foods. For example, the
Centers for Disease Control and Prevention’s
VERB: It’s What You Do campaign branded children’s play as fun, cool, and socially desirable behavior.17 The health campaign portrayed the competition—excessive sedentary behavior, such as watching television—as socially undesirable, dull, and boring for the target audience of tweens (nine- to thirteen– year-olds). The VERB brand’s vision was to
“free children to play out their dreams.”18
Social marketing messages like VERB and
Legacy’s truth campaign compete with commercial marketing—TV as a pastime rather than active play, or the tobacco industry as
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an industry and source of unhealthful behavioral choices—in an overarching sense, but not necessarily with specific commercial brands. Douglas Evans, Simani Price, and
Steven Blahut argue that the truth brand sought to take “market share” away from the tobacco industry.19 In traditional product marketing and branding, taking market share would involve one product, such as CocaCola, increasing its share of a population, such as soda drinkers or total sales of soda among a specific population, at the expense of a competitor, such as Pepsi, in that same population. But social marketing efforts in a health domain, such as physical activity, compete with commercial marketing in that domain as a whole by pitting one lifestyle against another.
For example, the active lifestyle promoted by
VERB represents a range of possible active behavioral choices, from running, to jumping, to climbing trees, to playing soccer. It is the general behavior of physical activity that is at stake. In this context, “market share” means the proportion of individuals who choose one behavioral alternative or another. The competition is between engaging in an unhealthful behavior, such as being a couch potato or becoming a smoker, and choosing to engage in a physically active lifestyle and maintaining that choice.
Social marketing can provide children and adolescents with reasons and opportunities to engage in healthful alternatives by demonstrating behavioral alternatives that tap into their wants and needs, just as commercial marketers tap into their wants and needs through product promotion. For example, the truth campaign tapped into adolescents’ need for independence, rebellion, and personal control through appealing social images of nonsmoking lifestyle—cool kids

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living without tobacco.20 The social marketing objective is to get the target audience, in the case of truth adolescents and young adults aged twelve to twenty-four, to do other things besides smoking. By doing other things— taking action against the tobacco industry, joining a social movement against tobacco use—adolescents aspire to the nonsmoking lifestyle promised by the campaign.

Social marketing can provide children and adolescents with reasons and opportunities to engage in healthful alternatives by demonstrating behavioral alternatives that tap into their wants and needs.
Public Health Branding
By marketing a coherent set of behavioral alternatives, public health marketing campaigns also can “brand” a healthful lifestyle by creating and maintaining social models of that lifestyle through advertising and promotional activities similar to those used by commercial marketing.21 In the commercial world, brands represent products and services.22 Commercial marketers seek to build strong relations
(positive associations, brand identification, and loyalty) between customers and product and service brands such as BMW, Nike, and
Crest toothpaste. Public health brands represent health behaviors or lifestyles that embody multiple health behaviors.23 The hypothesis underlying public health branding as a social marketing strategy is that adopting branded “healthful lifestyles” increases the probability that individuals will engage in health-promoting and disease-preventing

behaviors and that the associations individuals form with these brands, such as truth or
VERB campaign brands, mediate the relationship between social marketing messages and health behaviors such as remaining a nonsmoker or exercising.24
Factors such as brand loyalty, identification with brand characteristics, and the perception of positive brand personality traits, among others, operate as cognitive and emotional mechanisms in the minds of the audience that brand marketers use to promote consumer behavior.25 These factors can be measured as both immediate effects of brand exposure on consumers, and, consequently, influences on consumer behavior, that form the basis for individual-level brand research and evaluation. For example, if I am exposed to BMW marketing, I may form positive perceptions of the BMW personality (affluent, sporty, sexy). Forming these personality associations makes me more likely to buy a
BMW in order to attain the social benefits it promises (idealized imagery in the brand promotion). Individual-level factors such as loyalty, identification, and personality are among the constructs underlying brand equity, the higher-order construct (that is, composed of individual-level factors) that captures the effects of commercial brands on consumers and public health brands on individual health behaviors.26 Like commercial brands, public health brands present a call to action—and give the targeted audience a voice in making informed decisions about their health and society’s well-being. For example, tobacco countermarketing calls on adolescents to join a social movement against tobacco use, to live a nonsmoking lifestyle, and to take action to promote a nonsmoking society.27 All brands make a “promise”—that the individual will
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realize value by associating with the brand and that the exchange for that value will benefit the individual.28 The state of Ohio’s tobacco countermarketing brand, called stand, promises, “Make a difference in the lives of important people around you by
Standing Up against tobacco use.”29

The final element of public health brands, and one that helps to distinguish them from commercial brands, is the notion that they “vaccinate” or “inoculate” adolescents against unhealthful lifestyles.
The final element of public health brands, and one that helps to distinguish them from commercial brands, is the notion that they
“vaccinate” or “inoculate” adolescents against unhealthful lifestyles. The truth campaign provided arguments, both rational and emotional, for choosing a nonsmoking lifestyle.30
Adolescents and young adults who accept those arguments—who associate with the brand—thereby have rational and emotional tools to resist being influenced by tobacco industry arguments. This view reflects the well-known Elaboration Likelihood Model and the view that individuals who engage in a process of elaboration of persuasive messages are more likely to accept and act on them as intended.31

How Social Marketing Can
Influence Health Behavior
The best evidence of social marketing effectiveness comes from studies of mass, population-level communication campaigns,
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which afford opportunities for rigorous evaluation and intervention research. Smaller-scale social marketing, such as tailored communication for individuals or small groups, is growing in popularity and has substantial applications using the Internet and handheld devices.32 However, tailored health communications is a new field and has not yet been widely applied to prevention and health promotion, and there is limited evidence of its effectiveness in these applications.

Evaluations of Social Marketing Campaigns
Unlike commercial marketing, where unpublished proprietary research is the norm, social marketing is generating a large and growing research and evaluation literature. Much of the research on outcomes of social marketing campaigns, especially mass media campaigns, are effectiveness studies conducted in real time, in the media markets or communities in which messages are delivered. For example, a national evaluation of the truth campaign was based on a quasi-experimental design—that is, it included a treatment group and a control group, but the groups were not randomly assigned, as they are in a true experimental design— in which campaign exposure was measured both from environmental measures and self-reported “confirmed awareness” of campaign ads.33
In many instances, however, such evaluations are impractical or impossible, thus limiting opportunities to advance the state of health communication research and the knowledge base on effective campaign strategies, messages, and channels. In the case of paid media campaigns, funds may be too limited for the campaign to reach a wide enough audience to detect campaign effects using population survey methodologies. Logistical constraints such as campaign implementation timelines may also preclude collection of pre-campaign

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survey data. In the case of unpaid media, or public service announcements (PSAs), the campaign reach in any given designated market area is typically low. For example, television PSAs typically run late at night or on midweek afternoons, when audiences are small. Thus it is difficult to detect campaign effects because of low statistical power.
As a result of practical limits facing many social marketing campaign evaluations, much of the research in this field is either quasiexperimental, like the truth campaign evaluation, or observational—that is, with no control group. With the help of several colleagues,
I reviewed evaluations of social marketing campaigns that used branding strategies and found that only three out of thirty-three studies used a randomized experimental design, the gold standard for evaluations. Five reported outcomes from quasi-experimental designs. Twenty-five of the studies were based on observational designs.

Evidence of the Effectiveness of
Social Marketing
Other recent reviews of social marketing evidence, including campaigns that were not explicitly “branded,” indicate that mass media social marketing through television, radio, outdoor and print advertising, and the Internet is effective in changing health behaviors on a population level. In general, these studies show that social marketing has successfully changed health behavior such as smoking, physical activity, and condom use, as well as behavioral mediators such as knowledge, attitudes, and beliefs related to these behaviors.
Most of these studies, however, have shown effect sizes of less than 10 percent.34
In their widely cited study of forty-eight U.S. social marketing campaigns based on mass media, Leslie Snyder and Mark Hamilton

found that the average campaign accounted for about 9 percent of the variation in health risk behavior outcomes, but with varying results.35 The subset of “non-coercive” campaigns—that is, those that simply deliver health information instead of attempting to persuade and advocate for a behavior— accounted for about 5 percent of observed variation, as compared with 9 percent for all forty-eight campaigns reviewed.
A study of seventeen recent European media campaigns on a range of topics including promotion of HIV testing, myocardial infarction hospital admissions, immunizations, and cancer screenings found similar effects in the range of 5–10 percent.36 Like previous research, this study shows that single or few-time behaviors can be easier to promote than behavior requiring repetition and maintenance over time.37 Some behaviors that do not require long-term maintenance, such as breastfeeding and Vitamin A promotion, and switching to 1 percent milk, have shown greater effect sizes and generally appear to have higher rates of success.38
One example of social marketing to promote a broad range of healthful behaviors that has not, as yet, been widely evaluated is “edutainment” programming, such as adaptations of the Sesame Street series sponsored by the
Sesame Workshop.

Edutainment: The Sesame Workshop
Edutainment (sometimes called “educational entertainment” or “entertainment-education”) is another form of social marketing that has been widely used to reach children and adolescents for the purpose of informing and changing health and social behaviors.
Edutainment seeks to instruct or socialize its audience by embedding lessons in some familiar form of entertainment: television
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programs, computer and video games, films, music, websites, multimedia, and so on.
Sesame Workshop, a nonprofit educational media producer, has created a series of adaptations of the long-running children’s educational program, Sesame Street. Sisimpur, for example, the Bangladeshi adaptation of
Sesame Street, is designed to meet the learning needs of three- to six-year-olds across social classes and different regions of the country. The series features unique Banglaspeaking Muppets such as Ikri Mikri, an imaginative three-year-old who encourages young girls to have a limitless sense of possibility. Original music and locally produced live-action and animated segments reflect the rich artistic heritage of Bangladeshi culture.
With a curriculum defined by Bangladeshi educators, the series emphasizes literacy, math, and science and also helps foster values such as self-respect, empathy, and cooperation. Other key objectives include improving educational opportunities for young girls; promoting good nutrition, hygiene, and safety; and encouraging appreciation of the shared cultural heritage of diverse segments of
Bangladeshi society.
Another recent adaptation by Sesame
Workshop is Jalan Sesama, a television series created by local producers and educators to meet the needs of Indonesian children aged three to six. Jalan Sesama promotes ageappropriate and culturally relevant academic and life skills. Like its counterpart in the
United States, the television program has a
“magazine” format comprising short animations, live action (documentary film) pieces, and studio segments featuring puppets, affording opportunities to present an array of educational experiences that enhance and expand children’s knowledge and skills. Each segment of Jalan Sesama addresses a specific
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educational objective from one of the following developmental domains: physical (including physical development, health, and safety); cognitive (including such areas as cognitive development, language arts, mathematics, and science); emotional (identifying, expressing, and managing emotions); social skills to get along with peers and adults; aesthetic (appreciating art forms, creativity, and culture); and moral (moral principles and integrity, honesty, fairness, and manners).

The Sesame Workshop adaptations and others like them have successfully integrated multiple health, educational, and social topics into a single program, or series of programs, thus addressing multiple risk factors.
Edutainment, many examples of which span the spectrum of health, education, and social issues, has several major advantages as a form of social marketing. First, as commercial programs, edutainment can reach a wider audience than many other social marketing campaigns.39 Second, edutainment combines the benefits of branding, through characters and story lines, with knowledge- and skillsbuilding through health information delivery.
Finally, in a program format, the Sesame
Workshop adaptations and others like them have successfully integrated multiple health, educational, and social topics into a single program, or series of programs, thus addressing multiple risk factors. This approach has significant potential for social marketing

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aimed at protecting children from the effects of commercial media and marketing.

How Social Marketing Can Counter
Media Messages about Unhealthful
Behavior
As noted, social marketing campaigns have been notably successful in three areas: preventing tobacco use, promoting diet and physical activity, and preventing HIV/AIDS. In each area, messages promote healthful behavior and counter the effects of media messages that glamorize or otherwise encourage risky behaviors. These three areas have seen the largest number of effective branded campaigns.40

Tobacco Countermarketing Campaigns
One of the most successful social marketing efforts has been tobacco countermarketing campaigns aimed at preventing youth from starting to smoke. For example, campaigns such as the American Legacy Foundation’s truth campaign have successfully reduced smoking initiation and progression to established smoking. Matthew Farrelly and several colleagues showed that from 1999 to 2002,
U.S. youth smoking prevalence declined from
25.3 percent to 18.0 percent and that truth accounted for approximately 22 percent of that decline.41
Although the effect size of the truth campaign is small by clinical standards, the campaign shows that social marketing can have a big impact on population-level health. In the case of truth, the campaign-attributable decline in youth smoking equates to some 300,000 fewer youth smokers and thus millions of added life years as well as tremendous reductions in health care and other social costs.
State-funded countermarketing campaigns have also been effective in preventing and controlling tobacco use. Edward Siegel and

Lois Biener analyzed longitudinal data from the Massachusetts countermarketing campaign and found that adolescents who were aged twelve to thirteen years at the study’s outset and who reported exposure to television antismoking advertisements were significantly less likely to progress to established smoking than their peers who did not report exposure.42 The study, however, found no effect on progression to established smoking among adolescents aged fourteen to fifteen as the study began and no effects of exposure to radio or outdoor advertisements.
Countermarketing campaigns have been found effective in influencing specific, targeted attitudes and beliefs to affect smoking behavior. A longitudinal study of the Florida
TRUTH campaign (the state campaign that preceded, and was the model for, the national truth campaign) found that teenagers with high levels of anti-tobacco industry attitudes were four times less likely to initiate smoking and more than thirteen times less likely to become established smokers than their peers with low levels of such attitudes.43 James
Hersey and several colleagues found that state countermarketing campaigns using an antitobacco industry message prime, or make more salient, negative perceptions about tobacco industry practices.44 Jeffrey Niederdeppe, Matthew Farrelly, and M. Lyndon
Haviland confirmed that TRUTH reduced smoking among Florida teens and found specifically that adoption of two counterindustry beliefs central to the campaign were associated with lower teen smoking rates.45

Diet and Physical Activity Countermarketing Campaigns
Social marketing’s success in the arena of nutrition and physical activity promotion and obesity prevention has provided insights to help inform future nutrition campaigns.46
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Several effective branded nutrition campaigns, such as the National Cancer Institute’s (NCI)
5-A-Day for Better Health, are widely known to the public. In a workshop on diet and communication sponsored by NCI in July 2005, researchers examined the potential for diet and communication fields to work collaboratively and develop more effective social marketing strategies.47 The workshop confirmed previous research on poor nutrition as a serious and growing risk factor for children’s health and highlighted social marketing’s promise in protecting children and promoting better nutritional health.48
One of the most successful diet and nutrition efforts has been the 1% Or Less campaign, which encouraged adults and children older than age two to drink milk with a fat content of 1 percent or less, instead of whole or 2 percent milk.49 Designed by the Center for
Science in the Public Interest, a nonprofit group dedicated to improving the nation’s health through better nutrition, this campaign has been carried out at many sites since 1995.
The campaign includes news stories and advertisements on television, radio, billboards, and in newspapers; milk taste-tests at a variety of community sites; supermarket shelf labeling to draw attention to low-fat milk; and school activities. The California
Adolescent Nutrition and Fitness (CANFit) program found that after its 1% Or Less campaign in East Los Angeles, whole milk purchases had dropped from 66 percent to 24 percent of overall sales and that the share of all low-fat milk sold had more than doubled.50
Although it was not a goal of the campaign, overall milk purchases had increased by
30 percent.51

HIV/AIDS Countermarketing Campaigns
HIV/AIDS prevention in the United States, other developed nations, and the developing
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world, especially Africa, presents a different kind of social marketing challenge. Sexual imagery, sexualization of children, and normalization of early sexual debut among adolescents are pervasive in both contemporary media and commercial marketing and represent a major risk factor.52 Having sex is often seen as a rite of passage of youth, and the peer pressure and social desirability of being sexually active may be stronger than they are in the case of smoking or other risk behaviors. Social marketing campaigns must consider these factors when developing messages and setting behavior change objectives. The Henry J. Kaiser Family Foundation partnered with media giant Viacom to launch
KNOW HIV/AIDS, a comprehensive public education campaign in the United States in
2003.53 The effort built on the existing partnership between the Kaiser Family Foundation and Black Entertainment Television
(BET, whose parent company is Viacom), which promoted HIV/AIDS prevention and awareness through the targeted Rap It Up campaign beginning in 1998.54 The campaign reports that it has produced 131 rights-free
(that is, non-copyrighted) messages, totaling a media value commitment of more than $600 million.55 KNOW HIV/AIDS has five aims: to increase awareness about HIV/AIDS and how to prevent it, to encourage dialogue between partners and with health care providers about sexual health issues, to encourage and promote testing, to address the role that stigma and discrimination play in spreading the disease, and to promote safer sex behaviors.56
The campaign uses partnerships with media, commercial businesses, government, and community-based groups and contributions of air time, community outreach, and similar

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methods to increase campaign exposure. It promotes messages through paid and unpaid targeted television, radio, and outdoor PSAs;
HIV-themed television and radio programming (primarily through partners Viacom and
BET); print media; online and other electronic media; and public outreach.57
The 2004 survey of African Americans reported by Victoria Rideout revealed that 82 percent of all respondents and 94 percent of young adults aged eighteen to twenty-four recalled at least one campaign advertisement or program component, and 70 percent recalled seeing two specific advertisements. Brand awareness for the Rap It Up campaign was also high, with 58 percent of all respondents and 92 percent of young adults reporting awareness. Approximately 30 percent of all respondents and young adults demonstrated recall of the KNOW HIV/AIDS brand.58
Respondents who reported exposure to one or more campaign component said that the campaign had influenced their plans for the future, including visiting a doctor or getting tested for HIV, and were more likely than respondents who were not aware of campaign components to indicate they planned to engage in these behaviors. However, one major study did not show a link between exposure and intentions or sexual behavior.59
Three branded HIV/AIDS prevention social marketing campaigns that illustrate strategies for reaching adolescents and young adults have recently been conducted in Africa: Trust in Kenya, Salama in Tanzania, and loveLife in South Africa.60 Trust, conducted by the
U.S.-based Population Services International
(PSI), promoted the social desirability of condom use to make using a condom seem cool.
Special events such as concerts were part of the campaign. Salama, also led by PSI, tar-

geted high-risk groups including young people aged fifteen to twenty-four, commercial sex workers, and rural populations, but it also operated on the principle that young people are susceptible to messages about behavior change. Salama relied heavily on community outreach such as concerts, cultural shows, mobile video units, and sport tournaments.
The loveLife campaign was the most comprehensive of the three. It aimed to reduce by half the rate of HIV infection among fifteento twenty-year-olds, as well as to reduce other sexually transmitted diseases and the incidence of teenage pregnancy. It promoted a lifestyle choice valuing abstinence, delayed initiation of sexual activity, fewer sexual partners among already sexually active teenagers, and condom use. It was supported by nationwide adolescent-centered reproductive health services in government clinics and a network of youth outreach and support.
Studies show that each of the campaigns increased adolescent and young adult awareness of these HIV/AIDS prevention brands and also increased awareness of HIV/AIDS health risks and intentions to use condoms.61
Effects of the campaigns included delayed onset of sexual activity and increased condom use among those with repeated exposure to these brands. No comparable interventions, however, have been conducted in the United
States.

How Social Marketing Can
Encourage Discussions among
Parents and Children
Social marketing campaigns can also help parents influence their children’s behaviors.
Three examples stand out. The first is a traditional public service announcement, an unpaid (that is, air time was provided free by media outlets) mass media campaign called
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the TV Boss campaign sponsored by the
Ad Council. The second is a multi-channel, mixed community- and media-based campaign aimed at reducing childhood obesity, in part through reduced screen time and increased exercise, called 5-4-3-2-1 Go! sponsored by the Consortium to Lower
Obesity in Chicago Children. The third is the
Parents Speak Up national campaign, a U.S.
Department of Health and Human Services campaign to promote parent-child communication about delaying sexual activity.
Each of these examples highlights different ways that social marketing can possibly protect children from effects of exposure to commercial media and marketing, either directly through messages to them or indirectly through messages to parents and family. Lessons learned from these examples may be instructive to future social marketing efforts in this arena.

The TV Boss Campaign
The Ad Council has created a TV Boss website and a public service announcement campaign in collaboration with major sponsors such as the Motion Picture Association of America, the National Cable and Telecommunication Association, the National Association of Broadcasters, and others.62 The stated purpose of the campaign is to “give parents the tools and information they need to guide their child’s television consumption.”
The campaign is a “direct influence” effort to raise parents’ knowledge and build their skills to control children’s TV and media use.
Recognizing that motivation will be important to encourage parental action, the campaign uses themes such as parental control over negative media influences, depicting knowledgeable parents “blocking” potentially risqué or violent characters in PSA spots.
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The TV Boss is a good example of the use of branding to reduce media use and limit children’s exposure to specific content. The campaign has virtually all the major elements of public health branding.63 First, it seeks to develop a relationship with the target audience by depicting parents in the same situation that audience members likely would be (need to protect kids, lots of negative TV characters out there), modeling their concerns, and showing them being strong and taking control by blocking negative content. The campaign adds value for audience members by providing tools and information and builds on positive norms of parental involvement and control that tap into parents’ needs with respect to their children, especially adolescents.
To date, no evaluation data on The TV Boss have been published. But this and other campaigns that are directly aimed at behaviors to protect children and adolescents from inappropriate TV content are a promising social marketing strategy and should be evaluated. In particular, it will be important to compare the effectiveness of parentally oriented campaigns and those targeting children directly using risk factor and behavior change messages.

The 5-4-3-2-1 Go! Campaign
The Consortium to Lower Obesity in Chicago
Children (CLOCC) developed a public health education initiative to bolster ongoing local efforts addressing Chicago’s childhood obesity epidemic through healthful eating and physical activity. A citywide coalition of groups representing virtually all social sectors developed the 5-4-3-2-1 Go! social marketing initiative, which involves community youth and partners across Chicago in developing and disseminating the core messages. After completing a training process, youth ambassadors (known as Go! Teams) deliver these messages through community outreach activities. The campaign

Social Marketing Campaigns and Children’s Media Use

Table 2. 5-4-3-2-1 Go! Delivery Channels
Channels

Aim

Strategy

Tactics

Effects

Go! Teams

Create 5-4-3-2-1 Go! Teams to provide a “for us, by us” element to the program so that the targeted Chicago children, adolescents, and families will relate to it.

Engage Chicagoans who are social models and embody the values of living a healthful lifestyle, such as high school sports stars, political leaders, sports, TV and movie personalities.

Create a team of high school student leaders
(the Go! Team) from diverse ethnic backgrounds who can serve as positive role models for younger kids and, at the same time, serve as living mascots who build awareness for the
5-4-3-2-1 Go! brand.

Brand the look of the Go!
Team to guarantee recognition and visual appeal.

Earned media coverage through community media and events

Raise public awareness and promote support for 5-4-3-2-1
Go! and involvement in 5-43-2-1 Go! activities through advocating for and drawing attention to the campaign, leading to news media coverage. CLOCC has more than 500 community partners, many in the six target communities.
Working with partners, 5-43-2-1 Go! will promote news media attention to its activities using media advocacy techniques such as staging events. Go! Teams work through community partners to reach community-level newspapers published in English and Spanish.

Awareness of the existence of 5-4-3-2-1 Go! will increase, as measured by response to 5-4-3-2-1 Go! awareness and specific questions about exposure to news media coverage of
5-4-3-2-1 Go!

Website www. clocc.net/ Create a 5-4-3-2-1 Go! website (www.clocc.net/) featuring information in English and
Spanish as an effective way to disseminate information about the campaign 24 hours a day/7 days a week.

The site contains detailed and practical information based on key messages and is updated weekly. It features upcoming events and how to participate, prizes and how to win them, photos, and games to test kids’ nutrition and fitness knowledge.
CLOCC works with Chicago schools to direct traffic to the site and make it a “favorite” on all elementary school computers. Drive traffic to the site by coordinating with
Chicago Park District,
Chicago Public Schools,
Mayor’s Office of Special Events, and other partners to establish a hyperlink back to the site. Promote the site through Go! Teams.

The website becomes a trusted health information source for community members. They receive more detailed information on the 5-4-3-2-1 Go! message and specific information about how to access community resources, how to make more healthful food choices, and where to get nutritious foods (for example, local farmers’ markets and the producemobile).

is based on a simple 5-4-3-2-1 healthful eating and active living message for children: consume five or more fruits and vegetables, four servings of water, and three servings of low-fat dairy a day; spend no more than two hours watching television or engaging in a similar sedentary behavior; and get at least one hour of physical activity a day.
The 5-4-3-2-1 Go! campaign uses a healthfullifestyles branding strategy aimed at improving family food choices and increasing use of community physical activity resources.64 It targets six vanguard community areas that are linked to census boundaries in Chicago and is in part a response to the “obesigenic” environment, both social and physical, in those

communities that inhibits healthful lifestyles.65
The campaign also responds to the complex and potentially reciprocal relation among characteristics of the physical environment, social capital, and physical activity. For example, highly walkable, mixed-use neighborhoods have been associated with increased physical activity in the form of more walking for transportation.66
The social marketing strategy behind the campaign is culturally relevant and true to community norms and values. Its healthfullifestyles brand uses a name and logo-treatment that embodies the brand essence:
“Eating right and being healthy is as easy as
5-4-3-2-1 Go!” It communicates positive
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messages that resonate across different ethnic communities and builds on local community pride in being Chicago residents. Table 2 summarizes the delivery channels used to market key messages and their hypothesized effects. Parents Speak Up National Campaign
In 2005, Congress authorized up to $10 million for the Administration on Children and
Families to carry out the Parents Speak Up national campaign, a national public education campaign to promote delayed sexual debut by teenagers. The national multimedia campaign encourages parents to talk “early and often” to their pre-adolescent and adolescent children aged ten to fourteen about delaying the onset of sexual activity. The purpose is to increase parent-child communication as a proximal behavioral outcome leading to delayed onset of sexual activity.
The strategy of aiming messages promoting parent-child communication at this target audience has been used on a smaller scale in school- and community-based interventions, but never on a national scale in a mass communication campaign. The campaign was publicly released in June 2007.
The campaign applies many of the principles of marketing. In particular, it uses a theorybased behavior-change model that hypothesizes increased parent-child communication will result from positive reactions to the public service advertising. It also develops a credible and likeable “argument” for delaying initiation of sexual activity by communicating personal (social, educational, career-related) advantages of abstinence. The campaign uses strategies such as promoting self-efficacy and appealing to fear to communicate the health risks of early sexual debut, the individual’s ability to delay sexual debut, and the benefits of waiting.67
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The campaign’s primary means of communication is paid and unpaid public service announcements designed for a general audience. The campaign also supports three outreach centers—African American, Hispanic, and American Indian—to get help with research, message development, creative development, support building, and message penetration in these communities. Finally, the campaign uses outdoor advertising
(billboards), bus media, posters, Web banners, and media kits.
Parents Speak Up also includes a 4Parents.gov website and associated parent and adolescent guides. The website provides information
(as opposed to motivational messages) for parents about how to talk with their preteen or teen about waiting to have sex, about the accuracy of social norms among teens, and about related topics such as parent-child relationship quality and setting goals for the future.68
There is also an ongoing impact evaluation to measure reactions and changes associated with exposure to Parents Speak Up messages and ad executions. The evaluation will be the first of its kind of a national campaign to increase parent-child communication about sexual activity. The primary evaluation study is a randomized controlled trial of mothers and fathers of children aged ten to fourteen, the campaign’s target audience. Parents are randomly assigned to control, treatment (exposure to a core set of campaign messages), and treatment plus booster (core plus additional and more frequent campaign messages) conditions. The different groups will be surveyed at baseline (before message exposure) and at four follow-up time points, four weeks, six months, twelve months, and eighteen months later.

Social Marketing Campaigns and Children’s Media Use

Conclusions and Recommendations
Social marketing has been successful at changing a wide range of health behaviors, especially in the domains of tobacco use, nutrition and physical activity, and HIV/AIDS.
Social marketers have become increasingly adept at using commercial marketing strategies to craft competing messages and reduce the percentage of children and adolescents responding to commercial messages. In some cases, despite their relatively small budgets and slender resources, social marketers have been successful at taking market share away from the commercial sector.69

The competition between industry and social marketing brands is far from even. How can social marketing succeed in the long run given this comparative disadvantage?
Unlike more heavily funded commercial marketers, however, social marketers can rarely maintain public exposure to health messages at high levels. Given the importance of exposure, social marketers thus often operate at a significant disadvantage to the commercial sector. The competition between industry and social marketing brands is far from even.
How can social marketing succeed in the long run given this comparative disadvantage?
The answer to date has been threefold: develop more socially powerful and persuasive competing messages; use multiple channels including media, community outreach, and mobilization and develop social movements; and focus on social and health policies that affect individual behavior and

behavioral determinants. Tobacco countermarketing campaigns like truth, for example, have developed innovative public health brands and created messages based on an adolescent “consumer” orientation.70 At the same time, truth engaged communities and advocated for state and national tobacco policy changes, such as clean indoor air laws and cigarette tax increases.71
Future efforts to limit children’s media use should draw on lessons learned from past efforts: know the audience and target messages appropriately; use creative marketing and promotional strategies such as branding healthful lifestyle choices; use multiple channels to increase exposure; and address public policy in addition to individual behavior.
There are several potentially fruitful avenues for future messages and campaigns. For pre-adolescent children, parents are a powerful social influence and have substantial opportunities to limit media use and marketing exposure. Social marketers should conduct formative research with parents to understand the home and family media environment and parents’ role in regulating children’s media use. Amy Jordan and several colleagues conducted research along these lines, though not aimed at designing a social marketing campaign, that could serve as a starting point.72
Based on findings of this and related research, a campaign targeting possibly two distinct groups—parents of preschool (aged two to five) and elementary school (aged six to eleven) children—could be developed.
Messages would be crafted specifically for each group with the aim of informing each about what constitutes appropriate media use
(for example, two or fewer hours of screen time a day) and raising awareness of the
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health risks of excessive media use and the potential risks of marketing exposure. Another aim would be to modify parent attitudes and practices about children’s media use, following other successful campaigns by portraying an active healthful lifestyle as socially desirable. The overarching goal would be to change the social norm about media use from one of permissiveness to one of parental involvement and management of the home and family media environment.
For adolescents (aged twelve to seventeen), and potentially also a secondary audience of young adults (aged eighteen to twentyfour), separate formative research should be conducted on their knowledge, attitudes, beliefs, and practices related to media use and how they use their time with media, including television, music, and new media, as compared with other pursuits. The goal of this campaign would be to brand limited media use as socially desirable, as the new, hip, and cool way to live. Media use would not be demonized, but placed in the context of a larger, socially desirable lifestyle in which television, the Internet, and other media devices are part of a wide array of pursuits— living a physically active, outgoing, socially engaged lifestyle—in which hip young people want to engage. Messages would be aimed at changing social norms about media use, raising consciousness of the limitations of mediamultitasking, and increasing awareness of the value of interpersonal interaction in balance with human-media interaction. Advertising to promote the brand would use social modeling by portraying hip, edgy, cool kids using media in moderation or balancing media use and multitasking with popularity among peers and direct (not online) social interaction as

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desired goals. Media use—“it’s cool but don’t let it rule (your life).”
Five new strategies now being developed and used within social marketing campaigns may help in future messages and campaigns. The first such strategy is improved audience segmentation. For example, social marketers can use market research data, such as that used by commercial marketers, to identify more refined behavioral predictors and related message strategies. The second strategy is to develop tailored messages for very specific groups, such as adolescents who visit certain websites. The third strategy is co-branding.
Like the commercial marketers, social marketers can link their branded messages to other trusted brands, such as by co-branding a nutrition social marketing message with the
Sesame Workshop. The fourth strategy is to make full use of technology. The Internet, handheld devices, and other media offer social marketers opportunities to compete with industry using low-cost word-of-mouth marketing (so-called viral marketing). The fifth and final strategy is social networking.
Social marketers can place messages in media used by children and adolescents to network and take advantage of potential social diffusion effects (for example, through MySpace,
Facebook, and iPods).
Innovations such as these are no panacea.
The task facing social marketing is daunting in the face of the rising tide of children’s media use and large and growing commercial marketing efforts and budgets. These approaches, however, would continue the so-far successful trends in social marketing demonstrated in tobacco control, diet and physical activity, and HIV/AIDS prevention.

Social Marketing Campaigns and Children’s Media Use

Endnotes
1. D. Aaker, Building Strong Brands (New York: Simon & Schuster Inc., 1996).
2. M. C. Farrelly and others, “Evidence of a Dose-Response Relationship between ‘truth’ Antismoking Ads and Youth Smoking,” American Journal of Public Health 95, no. 3 (2005): 425–31.
3. W. D. Evans and others, “The ASSIST Newspaper Tracking System,” in Evaluation of Project ASSIST:
A Blueprint for State-Level Tobacco Control, edited by F. Stillman and W. Trochim (Bethesda, Md.:
National Cancer Institute, 2006).
4. M. Haider, “Branding of International Public Health Organizations: Applying Commercial Marketing to
Global Public Health,” in Public Health Branding: Applying Marketing for Social Change, edited by
W. D. Evans and G. Hastings (Oxford University Press, 2008.)
5. W. D. Evans and others, “The 5-4-3-2-1 Go! Intervention: Social Marketing for Nutrition,” Journal of
Nutrition Education and Behavior 39, no. 2, S.1 (2007): S55–S59; B. Reger, M. Wootan, and S. BoothButterfield, “Using Mass Media to Promote Healthful Eating: A Community-Based Demonstration
Project,” Preventive Medicine 29 (1999): 414–21; B. Reger and others, “1% or Less: A Community-Based
Nutrition Campaign,” Public Health Reports 113, no. 5 (1998): 410–19.
6. W. D. Evans, “How Social Marketing Works in Health Care,” British Medical Journal 322 (2006):1207–10.
7. W. D. Evans and others, “Systematic Review of Public Health Branding,” Journal of Health Communication (forthcoming).
8. G. J. Botvin and others, “Effectiveness of Culturally-Focused and Generic Skills Training Approaches to Alcohol and Drug Abuse Prevention among Minority Youths,” Psychology of Addictive Behaviors 8
(1994): 116–27.
9. W. D. Evans, S. Price, and S. Blahut, “Evaluating the truth® Brand,” Journal of Health Communication 10, no. 2 (2005): 181–92.
10. A. Bandura, Social Foundations of Thought and Action: A Social Cognitive Theory (Englewood Cliffs,
N.J.: Prentice Hall, 1986).
11. W. D. Evans and others, “Branding Behavior: The Strategy behind the truth® Campaign,” Social Marketing Quarterly 8, no. 3 (2002): 17–29.
12. W. D. Evans and others, “Social Imagery, Tobacco Independence, and the truth® Campaign,” Journal of
Health Communication 9, no. 5 (2004): 425–41.
13. L. Chassin and others, “Self-Images and Cigarette Smoking in Adolescence,” Personality and Social
Psychology Bulletin 7 (1981): 670–76.
14. P. A. Aloise-Young and K. M. Hennigan, “Self-Image, the Smoker Stereotype, and Cigarette Smoking:
Developmental Patterns from Fifth through Eighth Grade,” Journal of Adolescence 19 (1996): 163–77.
15. D. Burton and others, “Image Attributions and Smoking Intentions among Seventh Grade Students,”
Journal of Applied Social Psychology 19 (1989): 656–64.
16. A. Tybout and B. Sternthal, “Brand Positioning,” in Kellogg on Branding, edited by A. Tybout and
T. Calkins (New York: John Wiley and Sons, Inc., 2005).
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17. M. Huhman and others, “Effects of a Mass Media Campaign to Increase Physical Activity among Children:
Year-1 Results of the VERB Campaign,” Pediatrics 116 (2005): e247–54.
18. M. Huhman, S. Price, and L. Potter, “Branding Play for Children: VERB™ It’s What You Do,” in Public
Health Branding: Applying Marketing for Social Change, edited by W. D. Evans and G. Hastings (London:
Oxford University Press, 2008).
19. Evans, Price, and Blahut, “Evaluating the truth® Brand” (see note 9).
20. Ibid.
21. W. D. Evans and G. Hastings, “Public Health Branding: Recognition, Promise, and Delivery of Healthy
Lifestyles,” in Public Health Branding: Applying Marketing for Social Change, edited by Evans and Hastings
(London: Oxford University Press, 2008).
22. Aaker, Building Strong Brands (see note 1).
23. Evans, Price, and Blahut, “Evaluating the truth® Brand” (see note 9); W. D. Evans and others, “Systematic Review of Public Health Branding” (see note 7).
24. Evans, Price, and Blahut, “Evaluating the truth® Brand” (see note 9); Huhman and others, “Effects of a
Mass Media Campaign” (see note 17); Farrelly and others, “Evidence of a Dose-Response Relationship”
(see note 2).
25. K. L. Keller, “Branding Perspectives on Social Marketing,” Advances in Consumer Research 25 (1998): 299–302.
26. Evans and Hastings, “Public Health Branding” (see note 21); Evans, Price, and Blahut, “Evaluating the truth® Brand” (see note 9).
27. Farrelly and others, “Evidence of a Dose-Response Relationship” (see note 2).
28. T. Calkins, “The Challenge of Branding,” in Kellogg on Branding, edited by Tybout and Calkins (New
York: John Wiley and Sons, Inc., 2005).
29. W. D. Evans and others, “Prevention Effects of an Anti-tobacco Brand on Adolescent Smoking Initiation,”
Social Marketing Quarterly 13, no. 2 (2007): 19–38.
30. J. C. Hersey and others, “The Theory of truth®: How Counterindustry Campaigns Affect Smoking
Behavior among Teens,” Health Psychology 24, no. 1 (2005): 22–31.
31. R. E. Petty and J. T. Cacioppo, Communication and Persuasion: Central and Peripheral Routes to Attitude
Change (New York: Springer-Verlag, 1986).
32. M. Kreuter and others, Tailored Health Messages: Customizing Communication with Computer Technology
(Mahwah, N.J.: Lawrence Erlbaum Associates, 2000).
33. Farrelly and others, “Evidence of a Dose-Response Relationship” (see note 2). The environmental measures were gross rating points, or GRPs, derived from designated market areas, or DMAs.
34. R. C. Hornik, ed., Public Health Communication: Evidence for Behavior Change (Mahwah, N.J.: Lawrence
Erlbaum, 2002).
35. L. B. Snyder and M. A. Hamilton, “Meta-analysis of U.S. Health Campaign Effects on Behavior:
Emphasize Enforcement, Exposure, and New Information, and Beware the Secular Trend,” in Public
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Health Communication: Evidence for Behavior Change, edited by Robert C. Hornik (Hillsdale, N.J.:
Lawrence Erlbaum Associates, 2002), pp. 357–83.
36. R. Grilli, C. R. Ramsay, and S. Minozzi, Mass Media Interventions: Effects on Health Services
Utilisation, Cochrane Database of Systematic Reviews, Issue 1 (2002): Art. Number: CD000389,
DOI:10.1002.14651858.CD000389.
37. Evans, “How Social Marketing Works in Health Care” (see note 6).
38. R. C. Hornik, “Public Health Education and Communication as Policy Instruments for Bringing about
Changes in Behavior,” in Social Marketing, edited by M. Goldberg, M. Fishbein, and S. Middlestadt
(Mahwah, N.J.: Lawrence Erlbaum, 1997).
39. R. C. Hornik, ed., Public Health Communication: Evidence for Behavior Change (Mahwah, N.J.: Lawrence
Erlbaum, 2002).
40. Evans and others, “Systematic Review of Public Health Branding” (see note 7).
41. Farrelly and others, “Evidence of a Dose-Response Relationship” (see note 2).
42. M. Siegel and L. Biener, “The Impact of an Antismoking Media Campaign on Progression to Established
Smoking: Results of a Longitudinal Youth Study,” American Journal of Public Health 90 (2004): 380–86.
43. D. F. Sly, E. Trapido, and S. Ray, “Evidence of the Dose Effects of an Antitobacco Counteradvertising
Campaign,” Preventive Medicine 35 (2002): 511–18.
44. J. C. Hersey and others, “How State Counter-Industry Campaigns Help Prime Perceptions of Tobacco
Industry Practices to Promote Reductions in Youth Smoking,” Tobacco Control 14 (2005): 377–83.
45. J. Niederdeppe, M. C. Farrelly, and M. L. Haviland, “Confirming ‘truth’: More Evidence of a Successful
Tobacco Countermarketing Campaign in Florida,” American Journal of Public Health 94, no. 2 (2004):
255–57.
46. L. Snyder, “Health Communication Campaigns and Their Impact on Behavior,” Journal of Nutrition
Education and Behavior 39, no. 2, S. 1 (2007): S32–40.
47. W. L. Johnson-Taylor and others, “What Can Communication Science Tell Us about Promoting Optimal
Dietary Behavior?” Journal of Nutrition Education and Behavior 39, no. 2, S. 1 (2007): S1–S4.
48. A. F. Subar and others, “Dietary Sources of Nutrients among U.S. Children, 1989–1991,” Pediatrics 102
(1998): 913–23.
49. Reger, Wootan, and Booth-Butterfield, “Using Mass Media to Promote Healthy Eating” (see note 5);
Reger and others, “1% or Less: A Community-Based Nutrition Campaign” (see note 5).
50. CANFit, “CANFit’s Latino 1% Milk Social Marketing Campaign,” CANFit Connection (www.canfit.org/ assets/images/Newsletter_-_Fall_2000.PDF [August 10, 2007]).
51. Reger, Wootan, and Booth-Butterfield, “Using Mass Media to Promote Healthy Eating” (see note 5).
52. S. Villani, “Impact of Media on Children and Adolescents: A 10-Year Review of the Research,” Journal of the American Academy of Child and Adolescent Psychiatry 10, no. 4 (2001): 392–401.
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53. The Henry J. Kaiser Family Foundation, “About Viacom: KNOW HIV/AIDS” (www.kff.org/entpartnerships/ viacom/index.cfm [August 10, 2007]).
54. V. Rideout, “Assessing Public Education Programming on HIV/AIDS: A National Survey of African
Americans” (Washington, D.C.: Kaiser Family Foundation, 2004).
55. The Henry J. Kaiser Family Foundation, “KNOW HIV/AIDS: Learn about the Campaign” (www.know hivaids.org/learn_about.html [August 10, 2007]).
56. Rideout, “Assessing Public Education Programs on HIV/AIDS” (see note 54).
57. Kaiser Family Foundation, “About Viacom: KNOW HIV/AIDS” (see note 53).
58. Rideout, “Assessing Public Education Programs on HIV/AIDS” (see note 54).
59. Ibid.
60. W. D. Evans and M. Haider, “Public Health Brands in the Developing World,” in Public Health Branding:
Applying Marketing for Social Change, edited by W. D. Evans and G. Hastings (London: Oxford University
Press, 2008).
61. S. Agha, “The Impact of a Mass Media Campaign on Personal Risk Perception, Perceived Self-Efficacy, and Other Behavioral Predictors,” Aids Care 15, no. 6 (2003): 749–62; P. M. Eloundou-Enyegue,
D. Meekers, and A. E. Calves, “From Awareness to Adoption: The Effect of AIDS Education and Condom Social Marketing on Condom Use in Tanzania (1993–1996),” Journal of Biosocial Science 37 (2005):
257–68; J. Stadler and L. Hlongwa, “Monitoring and Evaluation of loveLife’s AIDS Prevention and
Advocacy Activities in South Africa, 1999–2001,” Evaluation and Program Planning 25 (2002): 365–76.
62. The Ad Council, “Parents: The TV Boss” (www.thetvboss.org/ [July 9, 2007]).
63. Evans and others, “Systematic Review of Public Health Branding” (see note 7).
64. W. D. Evans and others, “The 5-4-3-2-1 Go! Intervention: Social Marketing Strategies for Nutrition” (see note 5).
65. J. O. Hill and J. C. Peters, “Environmental Contributions to the Obesity Epidemic,” Science 280 (1998):
1371–74; J. O. Hill and others, “Obesity and the Environment: Where Do We Go from Here?” Science
299 (2003): 853–55.
66. L. D. Frank and others, “Linking Objectively Measured Physical Activity with Objectively Measured
Urban Form: Finding from SMARTRAQ,” American Journal of Preventive Medicine 28 (2005): 117–25.
67. P. Slovic and others, “Risk as Analysis and Risk as Feelings: Some Thoughts about Affect, Reason, Risk, and Rationality,” Risk Analysis 24, no. 2 (2004): 311–22; K. Witte, “Putting the Fear Back into Fear
Appeals: The Extended Parallel Process Model,” Communication Monographs 59 (1992): 329–49.
68. U.S. Department of Health and Human Services (http://4parents.gov/ [October 29, 2007]).
69. Evans and Hastings, “Public Health Branding” (see note 21).
70. Evans, Price, and Blahut, “Evaluating the truth® Brand” (see note 9); Evans and others, “Systematic
Review of Public Health Branding” (see note 7).
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71. D. Holden and others, “Modeling Psychological Empowerment among Youth Involved in Local Tobacco
Control Efforts,” Health Education and Behavior 32, no. 2 (2005): 264–78.
72. A. Jordan and others, “Reducing Children’s Television-Viewing Time: A Qualitative Study of Parents and
Their Children,” Pediatrics 118, no. 5 (2006): 1303–10.

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