In 2003, the state of North Carolina (NC) implemented a multi-component initiative focused on teenage tobacco use prevention and cessation. One component of this initiative is Tobacco.Reality.Unfiltered. (TRU), a tobacco prevention media campaign, aimed at NC youth aged 11–17 years. This research evaluates the first 5 years of the TRU media campaign, from 2004 to 2009, using telephone surveys of NC youth. Overall, TRU campaign awareness was moderate among youth in its first year, with awareness significantly increasing over time. The majority of youth who saw the advertisements reported that they were convincing, attention grabbing and gave good reasons not to smoke. In 2009, logistic regression models revealed awareness of the TRU advertisements was associated with decreased odds of current smoking and experimenting with cigarettes for at-risk NC youth. Results from this research may help other states to define, evaluate and modify their own media campaigns, especially within financially or politically constraining environments.