Media campaigns are widely recognized as useful public health tools [
1], particularly given that mass media campaigns can, by themselves, change health behavior without the need for multiple channels of communication [
2]. Psychological and political research on advertising and persuasion suggests that certain kinds of messages motivate change, particularly messages about trust [
3,
4]. Yet a review of mass media public health campaigns up to 1998 argued that such campaigns have not historically been theory based, and that when theory is considered, it is drawn primarily from social psychological theories not developed for media use [
1,
2].
Traditionally, many public health campaigns have focused on increasing individuals’ knowledge about disease risks, expecting that this increased knowledge will lead to changed behavior [
1,
2,
5]. However, individuals’
feelings about activities with health consequences predict behavior better than their
knowledge of the risks incurred. Specifically, people perceive that their health is more at risk when they feel reduced trust [
3].
Most public health campaigns have underemphasized the importance of trust messages in motivating behavior change [
3]. Instead, social marketing, a method of promoting healthy behaviors that relies on methods developed in product advertising, has become popular [
6,
7]. Recent research claims that less than one-third of public health campaigns develop messages based on research that identifies the social determinants of attitudes and behavior change [
1].
In recent years, public health researchers and advocates have called attention to structural and social causes of illness and premature death [
8,
9]. Public health advocacy frequently confronts existing corporate practices [
10] which are implicated in health problems such as obesity, tobacco, alcohol and other drug use, as well as in risks posed by automobiles, guns and pharmaceuticals [
9]. Corporate behavior is increasingly recognized as a fundamental cause of disease [
9,
11], and developing ways to challenge health-damaging corporate behavior is a key emerging issue in public health advocacy. Addressing diseases with social causes requires that public health advocates convince people, in the face of extensive product advertising by corporations, to reduce or eliminate use of products that increase disease risk. This may involve addressing risk perception through counter marketing; specifically, reducing trust can heighten popular awareness of risk [
3].
The marketing of products that increase health risks also creates a ‘share of voice’ problem for public health media campaigns. Health messages are viewed far less frequently than other media messages urging behavior that increases health risks, particularly consumption [
12]. Public health advertisements may be inadvertently packaged with product advertisements that undercut their message (see ). Public health campaigns cannot be successful without addressing these competing messages, but they must do so with far fewer resources than are available for corporate product advertising [
1,
12]. In addition to advertising disease-promoting products, businesses use positive advocacy advertising in an effort to improve their popular images [
7]. Thus, corporations have significant financial and structural advantages over public health advocates in conveying both consumption and public relations messages [
9]. Positive advertising, including product advertising and corporate image promotion, usually encourages people to rely on their comfort with the status quo [
13].
Research that has specifically addressed public health issues related to social and environmental risk factors suggests that media campaigns should be based on political advocacy tactics rather than social psychology [
7]. Political campaigns have developed a large repertoire of effective tactics, many based on what is commonly referred to as ‘negative advertising’ [
4]. Although the term negative advertising is not always clearly defined, it is generally regarded as consisting of messages intended to attack, criticize or discredit opponents and opponents’ messages, rather than messages designed to promote a preferred alternative [
4,
14]. Most research on negative advertising used in political campaigns has focused on its possible depressive effect on voter turnout, but studies also note that it is often more salient than other kinds of advocacy [
15]. It reaches people who were previously disinterested and not engaged with an issue [
16], is particularly useful for groups that have limited funding and popular exposure [
17] and is effective in reducing audience trust in the subject of attack [
18].
Negative political advertising, even when it relies on emotional appeals, cues rational decision making by increasing attentiveness to potential problems and encouraging people to reconsider their established opinions [
13]. These new attitudes, which are based on reasoning rather than reflexive comfort with the status quo, are far more resistant to change once they have been established than are status quo beliefs [
18]. This constellation of features—high salience, broad appeal, effectiveness despite limited exposure, trust reduction and the creation of attitudes that are resistant to change—suggests the immense potential value of negative advertising for public health campaigns that deal with social and environmental risk factors, particularly those involving corporate activity.
Tobacco control advocacy has been at the leading edge of public health efforts to change corporate practices that affect public health [
9], and its successes and failures offer insight for future public health campaigns. Counter marketing against tobacco was originally established as a public health strategy between 1968 and 1970, when the federal Fairness Doctrine required that the airing of cigarette advertisements in the mass media be balanced by advertisements promoting reduced tobacco consumption [
7]. The success of these early efforts was largely realized in hindsight. After the requirement for counter marketing was eliminated by the Federal Communications Commission ban on televised tobacco advertising, cigarette consumption increased once more [
19].
In this paper, we consider a case study of negative advertising, the “truth” campaign developed by the American Legacy Foundation, to show the effectiveness of this tactic in both reducing consumption of tobacco and forcing the tobacco industry to develop new strategies to combat the campaign, most of which were ineffective. However, the American Legacy Foundation faced unique constraints on its activities and funding. We conclude that advocacy by other public health groups could be far more aggressive and potentially more effective in the long term.