Public Health Nursing Vol. 32 No. 6, pp. 613–624 0737-1209/© 2015 Wiley Periodicals, Inc. doi: 10.1111/phn.12188
POPULATIONS
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LIFESPAN: POPULATION STUDIES
Creating Effective Media Messaging for Rural Smoke-free Policy Carol A. Riker, MSN, RN,1 Karen M. Butler, DNP, RN,1 JaNelle M. Ricks, MPA,1 Rachael A. Record, MA,1 Kathy Begley, BA,1 Debra Gay Anderson, PhD, RN,1 and Ellen J. Hahn, PhD, RN, FAAN2 1 College of Nursing, University of Kentucky, Lexington, Kentucky; and 2Colleges of Nursing and Public Health, University of Kentucky, Lexington, Kentucky
Correspondence to: Karen M. Butler, Tobacco Policy Research Program, 423 College of Nursing, University of Kentucky, Lexington, KY 40536, USA. E-mail: karen. [email protected]
ABSTRACT Objectives: Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents. Design and Sample: Qualitative methods design. Thirty-nine rural adults recruited by community partners. Measures: Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy. Results: Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials. Conclusions: Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS. Key words: Rural residents, media messaging, smoke-free policy.
Secondhand smoke (SHS) exposure is the leading cause of preventable disease and death in nonsmoking adults and children, especially in rural areas (Centers for Disease Control and Prevention, 2010; U.S. Department of Health and Human Services, 2006). Rural populations are disproportionately affected by tobacco use, SHS exposure, and smoking-attributable disease and death (Rahilly & Farwell, 2007). Potential contributing factors include low socioeconomic status (SES), lack of cessation services, lower levels of education, inadequate insurance coverage, and distance to health care facilities (Hutcheson et al., 2008).
Unique historical, cultural, familial, and social factors exist in rural communities which also may affect tobacco use. Some communities have social norms supportive of tobacco culture (e.g., tobaccogrowing communities). Residents are often exposed to tobacco industry marketing campaigns such as sponsorships of rural sporting events or targeting through marketing designed for blue-collar and rural men with “rugged, manly images” (American Lung Association, 2012). Proximity to tobacco growing in rural areas is another potential issue (American Legacy Foundation, 2009; Denham, Meyer, & Toborg, 2004). Tobacco use is often considered acceptable, and even supportive of family
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and community in these areas where residents tend to have strong family ties and close-knit social networks (Bauer, College, & Growick, 2003; Schoenberg, Hatcher, & Dignan, 2008). All of these factors may make it challenging for public health nurses who work with this vulnerable population to effect change in smoking rates and exposure to SHS in their communities. Smoke-free policies increase cessation and decrease tobacco use, youth initiation, and exposure to SHS (The Guide to Community Preventive Services, 2012, November). For example, in one community after a comprehensive smoke-free public places ordinance was enacted, there was 31.9% decline in adult smoking (25.7% prelaw to 17.5% postlaw) (Hahn et al., 2008). However, a survey conducted in six Appalachian states found that rural communities have fewer smoke-free laws and voluntary restrictions compared to urban areas (Ferketich et al., 2010). Rural residents may perceive smoke-free policies as incompatible with their values of self-reliance and personal freedoms (American Lung Association, 2012). Some rural communities have a history of economic dependence on tobacco growing, making tobacco use socially acceptable. Rural community leaders and residents may resist tobacco control efforts as a perceived threat to the local economy (Denham & Rathbun, 2005; Ferketich et al., 2010). Understanding tobacco’s historical role in society is essential as researchers develop and test interventions to promote smoke-free policy in rural communities. Culturally sensitive media messages and credible media channels that resonate with rural residents are needed to build demand for smoke-free policies in rural areas (Gilbert, Karahalios, & Sandvig, 2010; Kostygina, Hahn, & Rayens, 2014). Targeted and relatable messages have been found to be effective in motivating rural smokers to consider cessation and increase cessation attempts, particularly among lower socioeconomic groups (Butler et al., 2014; Durkin, Biener, & Wakefield, 2009). Studies have investigated what smokers perceive as effective media messaging for cessation. For example, media ads using a “why to quit” strategy, including graphic images or personal testimonials, were perceived by smokers to be more effective than other ad categories (Davis, Nonnemaker, Farrelly, & Niederdeppe, 2011; Durkin et al., 2009). Other researchers found that ads that evoke emotion and
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contain personalized stories about effects of smoking and smoking cessation are more effective in the promotion of cessation and reduction of socioeconomic disparities in smoking (Durkin et al., 2009). However, few studies have examined messaging to promote smoke-free policy (Kostygina et al., 2014; Quick, Bates, & Romina, 2009). Consistent with the overall goal of disease prevention and health promotion, clear and effective health communication is essential to public health nursing practice. Public health nurses can use established communication strategies to positively influence individuals, families, and communities to promote better personal and environmental health outcomes through education, intervention, and promotion of public health policy. Understanding the targeted population and tailoring messages are strategies that can be used effectively by public health nurses to reach individuals and communities, as well as to design public health campaigns which may inform and influence policy change (Lv et al., 2014). It is important to recognize that communication inequalities may exist, such as differences in access to and ability to take advantage of health information, particularly in disadvantaged populations such as rural residents. Some of this may be associated with use of media. Media use related to health differs by socioeconomic factors such as race, ethnicity, language, and social class, and providing greater access to high quality health-related media by considering factors associated with social determinants may contribute to addressing social disparities in health (Viswanath & Ackerson, 2011). Asking rural residents to share their perceptions about effective messages will promote messages that may prompt smoke-free policy change in rural communities, and can be an important tool for public health nurses to use in reaching those improved outcomes. The aims of this study were to explore the perceived effectiveness of existing smoke-free print advertisements in rural communities and to generate additional message content, characteristics, and media delivery channels that resonate with rural residents.
Methods Design and sample A qualitative methods design was used similar to other studies (Butler et al., 2012; Devlin, Eadie,
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy Stead, & Evans, 2007). Four focus groups (N = 39) were held in two rural counties, purposively selected from 22 rural intervention counties participating in a larger controlled trial to test the impact of a policy advocacy intervention (Hahn, Rayens, Adkins, Begley, & York, 2014). Each county had one smoke-free city, but no county or statewide smoke-free law. Community partners recruited participants via word of mouth and selected convenient locations to conduct the focus groups, two of which were smoke-free. Sample sizes by focus group were 5, 7, 15, and 12, respectively. Participant incentives included a light meal, child care, and $20. The university’s Medical Institutional Review Board approved the conduct of the study.
Measures Two group facilitators with expertise and experience in tobacco-related issues and qualitative methods each conducted two focus groups each in the counties involved in the study. After providing informed consent, participants completed an anonymous survey assessing demographics, smoking status, and ties to tobacco growing. Group discussion followed, using a written interview guide and prompts (Table 1). The guide was adapted from a study by Kostygina et al. (2014) to determine relevant cultural themes and key message features affecting receptivity to ads used during the Smoke-free Rural Communities project (Hahn et al., 2014). Kostygina suggested additional focus group topics for the current study and coalition members who had conducted a successful smokefree rural policy campaign refined them for generating input for possible new messages (G. Kostygina personal communication, January 10, 2011). No pilot testing of the adapted interview guide was conducted. The first three questions prompted a discussion on the facts of SHS and participants’ exposure to and attitudes toward smoke-free policy. Facilitators supplemented participants’ knowledge as needed. For example, if participants shared that smoke-free policy hurts local business, information from economic studies in rural areas was shared (Pyles & Hahn, 2011b). The fourth question elicited suggestions for content and culturally sensitive ways to deliver information on SHS and smoke-free policy. The facilitator then asked participants to review a packet of eight existing print ads and discuss
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perceived effectiveness. For example, one ad concept on indoor air pollution presented the information in two different ways: text versus graph. We also tested a version of the “It’s not about the smoker; it’s about the smoke” ad concept found to be effective by (Kostygina et al., 2014). Seven interviewer questions related to the ads, ranging from “Of all the ads you have seen, which ones stand out?” to “Is there anything else you’d like to tell us about the ads?” The ads were selected based on Kostygina’s suggestions that we evaluate ads about indoor air quality; ads that attack tobacco industry tactics in opposing smoke-free laws; and other community ads not tested in her study (G. Kostygina personal communication, September 16, 2011; Kostygina et al., 2014). We chose five ads used by county smoke-free coalitions in Kentucky and three from TobaccoScam (Glantz, 2002–2015) (Table 2).
Analytic Strategy Focus groups were recorded and transcribed. Opencoding was used to define and develop theme categories (Kostygina et al., 2014). Sixty-four themes emerged in three dominant categories: message content, characteristics, and delivery channels (Table 3). Two independent researchers coded the transcripts and developed a codebook containing the themes and descriptions. Interrater reliability was strong, with 84% agreement on the comparison of every 10th data bit. Atlas.ti, a qualitative software program, was used to organize and summarize the transcripts (Scientific Software Development, 2003–2005).
Results Sample characteristics The sample comprised 39 rural adults, the majority of whom were female (59%), between 55 and 74 years of age (61.5%), Caucasian (65.8%), and had greater than a high school education (74.4%). The sample differed slightly from the state population that is 50.8% female, 88.5% Caucasian, and 83% with greater than a high-school education. The lower educational level of the sample may be explained by the rural location. In addition, the state percentage of adults over age 65 was 13% in 2013, so the study sample represented an older population than the state average (U.S. Census Bureau, 2014). As one of the focus group locations
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TABLE 1. Focus Group Questions and Prompts Questions 1. What do you know or what have you heard about secondhand smoke (SHS)?
Prompts
in it? • What’s • How does it affect people’s health?
○ Immediately ○ Long-term ○ Other diseases not yet mentioned
big of a problem is it? • How • What have you heard about thirdhand smoke? Now we will pause for some information on secondhand smoke and smoke-free policy.a 2. How much SHS are you exposed to at What is SHS exposure like for you? Has anyone’s workplace recently gone smoke-free? work or in public places?
• •
○ What was that like for you?
3. What do you think of efforts by government or businesses to go smoke-free? 4. What suggestions would you have for us as we develop educational materials on SHS and smoke- free policy for rural areas?
Is it OK for servers and blue-collar workers to be exposed to SHS at work? Messages: What are some of the most important things you have heard tonight about smoke-free policy? What would you like to know more about? How could we best communicate the risks of SHS? Materials: How would we get the word out best? For example, pamphlets, posters, flyers, newspaper or “advertiser” ads, radio, cable TV, weather crawler? What would be the best locations to place materials? For example: grocery stores, fast food places, churches? How would we best incorporate the language and style of rural communities into our messages?
• • • • • •
Now please take a few minutes to look at the ads in your packet 5. Of all the ads you have seen, which ones Why? stand out? 6. Did anything about the content of the Why? ads make you feel uncomfortable? 7. Were any of the ads particularly Why do you think you like them? appealing to you? 8. Were any of the ads particularly What do you think made you dislike them? unappealing? 9. Do you think any information is missing Is there anything you would add? from the ads? 10. Were any of the ads effective in What makes them effective? promoting smoke-free policy? What makes others ineffective? 11. Is there anything else you want to tell us about the ads? Thank you for taking the time to participate in the study a
5–10 min of education depending on misconceptions and existing knowledge.
was a predominantly African-American church, the percentage of non-Caucasians in the study sample was higher than the state average. Three participants (7.7%) were current smokers and six (16.2%) either grew tobacco or owned property where
tobacco was grown. The smoking prevalence in the sample was much lower than the state adult smoking prevalence (26.5%) but may be partially explained by the small sample size and the fact that few smokers were comfortable participating in
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TABLE 2. Print Ads and Sources Ad topic/Message
Source
Air pollution from secondhand smoke nearly 49 higher than outdoor pollution standard (smoke graphic) Indoor air pollution level 39 higher than the federal standard for outdoor air (data graph)
Breathe Easy Rowan County
“We all support health codes for restaurants. Why make an exception for the tobacco industry?” (restaurant picture) “Opening up a smoke-free restaurant in the middle of tobacco country wasn’t outrageous. Just smart.” (restaurant picture) “Big Tobacco has been conning the restaurant business for years. Don’t be a sucker. Go smoke-free.” (restaurant picture) Think secondhand smoke won’t hurt you? Think again. (heart & EKG graphic): 5 min of exposure makes it harder for your heart to pump blood 20–30 min of exposure causes blood clots and fat to build up in the arteries, increasing the risk of heart attack and stroke 2 hr of exposure can speed up the heart rate and lead to abnormal heart rhythms which may cause death
Breckinridge County Smoke-free Coalition; Breckinridge County Coalition for Change; Breckinridge County Health Department TobaccoScam (Glantz, 2002–2015) TobaccoScam (Glantz, 2002–2015) TobaccoScam (Glantz, 2002–2015) Ohio County Smoke Free
• • •
It is not about the smoker. It is about the smoke! (smoke graphic) Heart Disease Lung Cancer Breast Cancer Asthma Pneumonia Tobacco smoke contains a deadly mix of more than 7,000 chemicals. Hundreds are toxic. About 70 can cause cancer Support Smoke-free NKY Are you breathing poisons at work? (bowling alley graphic)
Smoke-Free Boyle County
focus groups related to this topic (Centers for Disease Control and Prevention, 2013).
simply going to work and then being around someone who smokes and you can keep showing consistently that kind of a pattern.” Also discussed were inappropriate ways to address worker health, noting that it would be “Ineffective to say all you customers have to quit smoking because I work here now.” Third, they suggested analogies, identifying situations similar to smoking inside workplaces. One suggested, “Slavery was also part of our heritage. Women did not have the right to vote was part of our heritage. When we learned it wasn’t a good thing, we stopped. So, if we know that tobacco . . . that’s killing people secondhand, what pride is there in contributing to that?” Fourth, economic impact was suggested as a media message to reassure community members that local businesses will not suffer (Pyles & Hahn,
Theme category 1: Content themes Six major themes emerged: dangers of smoking and SHS, worker health, analogies, economic impact, rights, and nostalgia. First, participants felt that the dangers of smoking and secondhand smoke were important messages. One participant said, “If you can, establish the medical harm from the smoking.” Others said, “The issue of freedom has to be addressed in some fashion to clearly demonstrate that smoke is harming other people,” and “The smoke might be out of sight, but the particles are still there . . . and somebody is still inhaling particles.” Second, worker health was a major concern. One participant shared, “You know [if a person is saying] I’ve contracted . . . lung cancer from just
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TABLE 3. Themes and Coding Frequency Theme and description Category 1: Content themes and descriptions Tobacco use and/or cessation 01 What about cigarettes makes them so deadly; what are the effects of the chemicals (including discussions about carcinogens) 02 Taxes on cigarettes 03 All potential smoking related illnesses and physical limitations caused by smoking 04 Smoking addiction 05 Most people do not smoke 06 Youth smoking behaviors 07 Quitting (reasons for and against) 08 Personal costs of smoking cigarettes (including personal financial burden) 09 How to help smoker (including suggestions for how to do that and local resources available) 10 Not about the smoker 11 Smoke-free laws’ effect on quit behaviors 12 Use of other tobacco products (discussions of smokeless, e-cigarettes, pipes, cigars, and all other tobacco products other than cigarettes) Secondhand smoke 13 Dangers of secondhand smoke (including dangers of particles) 14 No level of secondhand smoke exposure is safe 15 Secondhand smoke’s effect on children (including protecting children from secondhand smoke) 16 Ventilation systems 17 SHS smell (including particles in the smell and smell of other tobacco products, in general) 18 Odor fatigue (one no longer senses a smell even though it is still present) 19 One should not have to go elsewhere to breathe clean air 20 There is no societal benefit to having secondhand smoke in the air Economics 21 Effects of smoke-free policies on restaurants and bars 22 Not about the farmer 23 Times have changed and crops other than tobacco could be grown 24 Tobacco-related health care costs to society Freedoms 25 Worker health (arguments for and against) 26 Business & farmer rights (including comments regarding business owners having the right to allow smoking) 27 Freedom to live, freedom of nonsmokers, and not harming others via smoking 28 Smokers’ rights Other 29 Comparisons to similar situations which are not as controversial (including alcohol, death rate comparisons, etc.) 30 Community specific data (messages should give rates/statistics about their own community) 31 Death (from smoking and/or secondhand smoke) 32 Religious references 33 Nostalgia for Kentucky’s history as a tobacco state
Frequency
9 1 5 9 2 5 4 4 4 10 0 4
8 4 7 2 8 1 2 1 10 2 3 2 12 6 8 8 12 1 2 1 7 (continued)
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TABLE 3. (Continued) Theme and description Category 2: Message characteristics Message format 34 Be short and to the point 35 Be tailored to the community (include pictures, quotes, and stories from respected community members) 36 Large enough to read 37 Be simple and easy to understand 38 Be understandable by low literate individuals Message tone 39 Do not place blame (including not attacking smokers) 40 (Use or not use) graphic visuals 41 (Use or not use) personal stories 42 (Use or not use) statistics/charts/graphs Messenger 43 Local authority figure (including medical expert, public figure, etc.) 44 Child or youth 45 Backed by powerful national agencies 46 Someone relatable Message target 47 Policymakers 48 Youth 49 General Community Category 3: Media delivery channels 50 Newspapers 51 Radio 52 Technology and Internet based (including social media, personal websites, etc.) 53 Television (including cable, satellite, etc.) 54 Print materials (including posters, flyers, brochures, bumper stickers, pamphlets, yard signs, bookmarks, mail stuffers, etc.) 55 Billboards 56 Magazines Channel locations 57 Waiting rooms 58 Religious outlets 59 Local businesses 60 In an easy place to read (e.g., not in places where one needs to read while driving but where one can read when stopped) 61 In popular locations (including most driven roads, busiest restaurants, etc.) Other themes 62 Social Barriers 63 Smoking in spite of dangers 64 Media Campaigns
Frequency
11 0 2 5 3 3 14 8 13 8 5 3 2 1 5 3 12 3 11 5 5 10 4 2 0 0 2 2
3 4 2
A phrase or section may have been coded using up to three codes.
2011a,b; Pyles, Mullineaux, Okoli, & Hahn, 2007). Participants observed that smoke-free policies do not harm business. One stated, “Well, they’ve just proved already that they’ve increased [business]— every restaurant in [our town] . . . And, that’s because people that don’t smoke are finally going out to eat. . .” Another shared, “I know that’s been a
real sticking point that bar owners and restaurant owners are really concerned that their clientele is going to go elsewhere if they can’t smoke.” Fifth, nonsmokers’ rights were identified as important. One said, “This [smoking] is not a violent crime, but just as deadly . . . As I watched my mom die from Dad’s smoking, I think the
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government has a right to protect its citizens from that, just as they protect me from someone shooting me.” Participants also described how messages can be misinterpreted by smokers, stating “People feel personally attacked” and “Stay focused on the effects more than personalizing.” Some participants liked the ad, “It’s about the smoke, not the smoker (Kostygina et al., 2014).” One said, “My rights [to smoke] stop where your rights start; you have the right to not smell the smoke.” The rights of local farmers were also discussed. Participants said, “I don’t think the Chinese [U.S. exports tobacco] should have to breathe it either, but if the concern is . . . putting farmers out of business, I don’t think that’s a legitimate concern . . . the product is already exported;” and “What affects [the Chinese] affects us, because we are one.” Finally, nostalgia for family ties to tobacco as well as for Kentucky as a tobacco-growing state was expressed. One shared, “I remember [being] out there with everyone else stripping tobacco; it was good memories of high school days. If you come out against it, it might be like I’m against my own family.”
Theme category 2: Message characteristics Seven over-arching most effective message characteristics emerged. First, they suggested short and to the point messages that are understandable to those with low literacy. One participant shared, “It’s easier to read a couple of lines and take [the message] in.” Another, referring to one of the ads, said, “I wouldn’t read down through there.” Others recommended choosing “Words used in everyday speaking,” and “Maybe a picture and a big word.” Second, messages large enough to read so that they will catch the eye and not require a lot of time were suggested. One participant stated, “You know it [right] off the bat by that big headline. . ..” Third, participants recommended graphic images that can be powerful and emotional. Examples were: “Child playing on Daddy’s grave” or an image so negative that people look away. The risk of unintended consequences was pointed out by others, who stated, “People miss the smoke-free message because of harsh pictures [like an autopsy].” Fourth, they suggested poignant stories that move people on an individual level. One stated, “If more people heard a story like [a parent dying],
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they might jump in [to support smoke-free policies].” Fifth, statistics, charts, and graphs were mentioned as effective. One participant liked an existing ad presenting an air quality graph showing the difference between smoke-free and smoky venues. An important qualifier was that statistics “Need to tell a [local] story.” Sixth, the message sender or delivery by a local authority figure was important. One participant shared, “Instead of the Surgeon General, use a local medical person” or someone relatable. Another stated, “If I [saw] somebody in there I know, I’d read the whole page.” Finally, messages targeting varied local groups were important. Participants said, “You have to get up into those rural areas . . . up in those hollows;” “Some messages will target young, some more mature; it’s a scattergun approach in order to get all groups and all access points;” and “Throw in all approaches, all kinds of levels . . . different campaigns with different sets of values/goals. . .”
Theme category 3: Media delivery channels Four effective delivery channels were identified: local television, newspaper, and radio; technology/ Internet; billboards; and print materials. Local TV, newspapers, and AM radio were recommended over national or statewide media. One participant emphasized the importance of local television stations: “The major issue is not so much the message [issues are the same] but make sure [our] county hears its name.” Two participants described the use of the local newspaper: “. . .the very front page . . . where they put on this little sticker.” Others discussed the importance of using local AM versus FM radio stations because some people only listen to the local AM station and watch the local cable station. Technology and Internet such as Facebook and other social media sites were described as very useful: “Everyone’s on it, chatting;” “Someone just got diagnosed with breast cancer . . . and people were Facebooking [the news got around fast];” “Set up Facebook, Twitter, and a YouTube account and link them together;” and “Keep it fresh.” Billboard messages and proper placement were important: “In an easy place to read, near stoplight or leaving campus.” Print materials for smoke-free messaging yielded several suggestions for expanding
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy reach: “send it in a [utility] bill, so when they open it they get a smoke-free message;” “a little poster wherever smoking is not allowed;” “bumper stickers;” and “any place where people have to sit and wait.”
Discussion This study examined perceived effectiveness of existing smoke-free print advertisements in rural communities to generate additional message content, characteristics, and media delivery channels that resonate with rural residents. Recommendations included established strategies, such as presenting the dangers of smoking and SHS, keeping messages short and to the point, and using everyday language understandable by those with low health literacy (Davis, Williams, Marin, Parker, & Glass, 2002; U.S. Department of Health and Human Services, 2010). Unique, specific suggestions were made for reaching diverse segments of rural populations including new ideas for how to tailor messages for specific cultures or age groups with high health risks, smokers and nonsmokers, and those with specific religious values or sociocultural norms (Kostygina et al., 2014; Lv et al., 2014). One of the most interesting content themes was the use of analogies as a messaging strategy for articulating the reasons for smoke-free policies. The use of analogies touched important values such as family and community. Figurative language is a powerful tool for behavior change, but communicating logic through an analogy is a fairly innovative approach (McGuire, 2000). Pairing a logical argument that was not controversial (“You wouldn’t drink with children in the car”) with a more provocative one (“So why would you smoke with kids in the car?”) was perceived as effective. Use of analogies is consistent with recommendations that tobacco messages be tailored to the intended population (Jamrozik, 2004). If a population identifies with the message, it is more likely to result in attitude change (Dal Cin, Zanna, & Fong, 2004). Using narratives from easily recognized local people to whom the audience can relate was another important suggestion. Similarly, Durkin et al. reported a strong relationship between exposure to highly emotional personal narratives and calls to the tobacco quit-line (Durkin, Wakefield, &
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Spittal, 2011). One study in rural Kentucky noted that rural residents related to their neighbors’ stories that were featured as part of a community media campaign (Butler et al., 2012). Culturally sensitive messaging takes on special meaning as one considers the nostalgia expressed for Kentucky’s tobacco-growing heritage. Although the number of small farms in Kentucky decreased by 87.4% from 1997 to 2007, acceptance of smokefree policies remains a particular challenge in rural areas (U.S. Department of Agriculture, 2007). Participants described their proud tobacco heritage, telling stories from childhood about families and neighbors working in the tobacco fields. Some shared that it is difficult to say anything about tobacco without it being perceived as a personal attack on smokers or disrespectful to farmers, bearing out Denham’s caution to present information in a nonjudgmental and polite manner with Appalachians (Denham & Rathbun, 2005). Participants agreed that culturally sensitive messages were critical because tobacco has been an important part of Kentucky’s economy and culture. Suggestions included focusing on the health of nonsmokers and workers. There was a desire to protect the health of nonsmokers without stigmatizing smokers, seeking a solution that preserves respect for the perceived nostalgia surrounding tobacco. Personal rights may not feel as personal when they are detrimental to others (Satterlund, Cassady, Treiber, & Lemp, 2011). A recent study conducted in the same geographic area was designed to identify pro-health messages that may counter the local pro-tobacco culture. Results showed that shifting focus away from smokers is an effective strategy with rural residents (Kostygina et al., 2014). For example, a community included in the study reported here placed a brightly colored lift-off sticker on the front page of the newspaper, reading, “It’s the smoke, not the smoker.” The findings of this study are consistent with previous research findings showing that rural communities use media channels in slightly different ways than national trends indicate (Gilbert et al., 2010). Local radio and TV stations as well as newspapers were considered more effective than statewide channels, because each community has its own idiosyncrasies and residents and local officials often relate better to local rather than state or national stories (Klein, Liber, Kauffman, Berman, &
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Ferketich, 2014). Indeed, Helme and colleagues concluded that rural print media may be receptive to pro-health messages, even in tobacco-growing communities, and recommended submission of tobacco control articles to local newspapers Helme et al., 2012). Billboards placed in high-traffic areas were recommended, avoiding locations where they could be overlooked (i.e., next to other billboards). Caution was recommended in selecting the message characteristics for billboards. Harsh, graphic images were discouraged, as they could be distracting and detract from the message. Similarly, fear appeal messages often cross the line from emotional to too graphic (Hale & Dillard, 1995). In addition to traditional media, findings of this study supported the use of the Internet as an effective media channel, consistent with an online advertising study effective in reaching low SES populations (Graham, Milner, Saul, & Pfaff, 2008). However, rural communities often lack the resources needed to support media advocacy to promote tobacco control efforts (York et al., 2010). The recommendations of community leaders and members in the study reported here cannot be realized without adequate resources, capacity, and efforts (York et al., 2010). A limitation of the study is its lack of generalizability due to the convenience sample in two rural communities in a tobacco-growing state. Some participants in one county knew the focus group facilitator, increasing the potential for socially desirable responses. However, knowing the facilitator could also have promoted group sharing. There may have been a potential for bias toward smoke-free policy and related messaging because the focus group participants resided in one of the intervention counties in the larger research study (Hahn et al., 2014). Further, some responses may have been socially desirable given the culturally sensitive nature of the questions. The researchers’ supplementation of participants’ knowledge during the focus groups may have increased the potential for socially desirable responses, because they may have felt “corrected”. In addition, the sample included only three smokers. As the majority of the sample was comprised of nonsmokers, there may have been more support for smoke-free policies in general, creating potential for bias. Carefully designed message content and media delivery channels based on input from members of the target population are important for building
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demand for smoke-free policies in rural communities (Jamrozik, 2004; Kostygina et al., 2014). Insight from community members is critical because health messages are most effective and most likely to result in changes in attitudes or beliefs when audiences relate to the message characteristics (Butler et al., 2014; Durkin et al., 2009). Rural focus group participants in a tobaccogrowing state reaffirmed that basic SHS information remains a key component in smoke-free campaigns, as is an emphasis on worker health and reassurance that smoke-free policy will not damage the local economy (Hahn, 2010). The use of analogies in the development of media messaging adds to the literature on effective smoke-free campaigns. In addition, the findings of this study support previous studies related to message characteristics such as the use of personal narratives with local pictures (Butler et al., 2014; Kostygina et al., 2014). Further research is needed to identify messages that may resonate with rural residents, particularly smokers, to promote support for comprehensive smoke-free policies. More research is also needed to test the effects of these identified message content themes and media channels on policy outcomes. Public health practitioners can use key informants in small towns to identify culturally sensitive modifications of existing messages and specific low-cost delivery channels used by local residents. Integrating effective smoke-free messages into a multicomponent intervention can help move the community toward tobacco-free lifestyles (Lv et al., 2014).
Acknowledgments The authors thank the Franklin County Smoke-free Coalition and the Nelson County Smoke-free Coalition for their assistance in recruiting focus group participants, securing venues for the groups, and providing child care. Special thanks go to Patrick Whelan, who completed Human Subjects Protection training and facilitated two of the focus groups.
References American Legacy Foundation. (2009). Tobacco Control in Rural America. Washington, DC: American Legacy Foundation. American Lung Association. (2012). Cutting tobacco’s rural roots: Tobacco use in rural communities. Retrieved from http:// www.lung.org/assets/documents/publications/lung-diseasedata/cutting-tobaccos-rural-roots.pdf Bauer, W. M., College, M., & Growick, B. (2003). Rehabilitation counseling in Appalachian America. Journal of Rehabilitation, 69(3), 18.
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy Butler, K., Hedgecock, S., Record, R., Derifield, S., McGinn, C., Murray, D., et al. (2012). An evidence-based cessation strategy using rural smokers’ experiences with tobacco. The Nursing Clinics of North America, 47(1), 31–43. Butler, K. M., Rayens, M. K., Adkins, S., Record, R., Langley, R., Derifield, S., et al. (2014). Culturally-specific smoking cessation outreach in a rural community. Public Health Nursing, 31(1), 44–54. doi:10.1111/phn.12066. Centers for Disease Control and Prevention. (2010). Tobacco Control State Highlights, 2010. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Centers for Disease Control and Prevention. (2013). State tobacco activities tracking and evaluation (STATE) system. Retrieved from http://www.cdc.gov/tobacco/data_statistics/state_data/state_system/index.htm Dal Cin, S., Zanna, M. P., & Fong, G. T. (2004). Narrative persuasion and overcoming resistance. In E. S. Knowles, & J. A. Linn (Eds.), Resistance and persuasion (pp. 175–191). Mawah, NJ: Erlbaum. Davis, K. C., Nonnemaker, J. M., Farrelly, M. C., & Niederdeppe, J. (2011). Exploring differences in smokers’ perceptions of the effectiveness of cessation media messages. Tobacco Control, 20(1), 26–33. doi:10.1136/tc.2009.035568. Davis, T. C., Williams, M. V., Marin, E., Parker, R. M., & Glass, J. (2002). Health literacy and cancer communication. C: A Cancer Journal for Clinicians, 52(3), 134–149. Denham, S. A., Meyer, M. G., & Toborg, M. A. (2004). Tobacco cessation in adolescent females in Appalachian communities. Family and Community Health, 27(2), 170–181. Denham, S. A., & Rathbun, A. (2005). Community health assessment Appalachia: An overview of health concerns and health literacy. Athens, OH: Appalachian Rural Health Institute. Devlin, E., Eadie, D., Stead, M., & Evans, K. (2007). Comparative study of young people’s response to anti-smoking messages. International Journal of Advertising, 26(1), 99–128. Durkin, S. J., Biener, L., & Wakefield, M. A. (2009). Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. American Journal of Public Health, 99(12), 2217–2223. doi:10.2105/ajph.2009.161638. Durkin, S. J., Wakefield, M. A., & Spittal, M. J. (2011). Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups? Health Education Research, 26(6), 998–1009. doi:10.1093/her/cyr048. Ferketich, A. K., Liber, A., Pennell, M., Nealy, D., Hammer, J., & Berman, M. (2010). Clean indoor air ordinance coverage in the Appalachian region of the United States. American Journal of Public Health, 100(7), 1313–1318. doi:10.2105/ ajph.2009.179242. Gilbert, E., Karahalios, K., & Sandvig, C. (2010). The network in the garden: Designing social media for rural life. American Behavioral Scientist, 53(9), 1367–1388. doi:10.1177/ 0002764210361690. Glantz, S. (2002–2015). Tobaccoscam. Retrieved from http:// www.tobaccoscam.ucsf.edu/our-ads Graham, A. L., Milner, P., Saul, J. E., & Pfaff, L. (2008). Online advertising as a public health and recruitment tool: Comparison of different media campaigns to increase demand for smoking cessation interventions. Journal of Medical Internet Research, 10(5), Available at http:// www.ncbi.nlm.gov/articles/PMC2630839/ Hahn, E. J. (2010). Smokefree legislation: A review of health and economic outcomes research. American Journal of Preventive Medicine, 39(6 Suppl 1), S66–S76. doi:10.1016/j.amepre.2010.08.013. Hahn, E. J., Rayens, M. K., Adkins, S., Begley, K., & York, N. (2014). A controlled community-based trial to promote
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smoke-free policy in rural communities. Journal of Rural Health, 31, 76–88. doi:10.1111/jrh.12087. Hahn, E. J., Rayens, M. K., Butler, K. M., Zhang, M., Durbin, E., & Steinke, D. (2008). Smoke-free laws and adult smoking prevalence. Preventive Medicine, 47(2), 206–209. doi:10.1016/j.ypmed.2008.04.009. Hale, J. L., & Dillard, J. P. (1995). Fear appeals in health promotion campaigns: Too much, too little or just right? In E. Maibach, & R. L. Parrott (Eds.), Designing health messages: Approaches from communication theory and public health practice (pp. 65–80). Thousand Oaks, CA: Sage. Helme, D. W., Rayens, M. K., Kercsmar, S. E., Adkins, S. M., Amundsen, S. J., Lee, E., et al. (2012). Rural print media portrayal of secondhand smoke and smoke-free policy. Health Promotion Practice, 13(6), 848–856. doi:10.1177/ 1524839911399429. Hutcheson, T. D., Greiner, K. A., Ellerbeck, E. F., Jeffries, S. K., Mussulman, L. M., & Casey, G. N. (2008). Understanding smoking cessation in rural communities. Journal of Rural Health, 24(2), 116–124. doi:10.1111/j.17480361.2008.00147.x. Jamrozik, K. (2004). ABC of smoking cessation: Population strategies to prevent smoking. British Medical Journal, 328 (7442), 759–762. Klein, E. G., Liber, A. C., Kauffman, R. M., Berman, M., & Ferketich, A. K. (2014). Local smoke-free policy experiences in Appalachian communities. Journal of Community Health, 39(1), 11–16. doi:10.1007/s10900-013-9733-6. Kostygina, G., Hahn, E. J., & Rayens, M. K. (2014). ‘It’s about the smoke, not the smoker’: Messages that motivate rural communities to support smoke-free policies. Health Education Research, 29(1), 58–71. doi:10.1093/her/cyt087. Lv, J., Liu, Q. M., Ren, Y. J., He, P. P., Wang, S. F., Gao, F., et al. (2014). A community-based multilevel intervention for smoking, physical activity and diet: Short-term findings from the Community Interventions for Health programme in Hangzhou, China. Journal of Epidemiology and Community Health, 68(4), 333–339. doi:10.1136/jech-2013203356. McGuire, W. J. (2000). Standing on the shoulders of ancients: Consumer research, persuasion, and figurative language. Journal of Consumer Research, 27(1), 109–114. doi:10.1086/ 314312. Pyles, M. K., & Hahn, E. J. (2011a). Economic effects of Ohio’s smoke-free law on Kentucky and Ohio border counties. Tobacco Control, 20(1), 73–76. doi:10.1136/ tc.2009.035493. Pyles, M. K., & Hahn, E. J. (2011b). Economic effects of smoke-free laws on rural and urban counties in Kentucky and Ohio. Nicotine and Tobacco Research, 16, 66–68. doi:10.1093/ ntr/ntr123. Pyles, M. K., Mullineaux, D. J., Okoli, C. T. C., & Hahn, E. J. (2007). Economic impact of a smoke-free law in a tobaccogrowing community. Tobacco Control, 16, 66–68. Quick, B. L., Bates, B. R., & Romina, S. (2009). Examining antecedents of clean indoor air policy support: Implications for campaigns promoting clean indoor air. Health Communications, 24(1), 50–59. doi:10.1080/10410230802606992. Rahilly, C., & Farwell, W. (2007). Prevalence of smoking in the United States: A focus on age, sex, ethnicity, and geographic patterns. Cardiovascular Risk Reports, 1(5), 379–383. Satterlund, T. D., Cassady, D., Treiber, J., & Lemp, C. (2011). Barriers to adopting and implementing local-level tobacco control policies. Journal of Community Health, 36(4), 616– 623. doi:10.1007/s10900-010-9350-6. Schoenberg, N. E., Hatcher, J., & Dignan, M. B. (2008). Appalachian women’s perceptions of their community’s health threats. The Journal of Rural Health, 24(1), 75–83. doi:10.1111/j.1748-0361.2008.00140.x.
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Scientific Software Development. (2003–2005). Atlas.ti (Version WIN 5.0). Berlin, Germany: Scientific Software Development. The Guide to Community Preventive Services. (2012). Reducing tobacco use and secondhand smoke exposure: Smoke-free policies. ATLANTA, GA: Centers for Disease Control and Prevention. U.S. Census Bureau. (2014). State and county quick facts. Retrieved from http://quickfacts.census.gov/qfd/states/21000.html U.S. Department of Agriculture. (2007). Census of agriculture. Retrieved from http://www.agcensus.usda.gov/Publications/2007/ U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Cen-
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ter for Chronic Disease and Prevention and Promotion, Office of Smoking and Health. U.S. Department of Health and Human Services. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Viswanath, K., & Ackerson, L. K. (2011). Race, ethnicity, language, social class, and health communication inequalities: A nationally-representative cross-sectional study. PLoS ONE, 6(1), e14550. doi:10.1371/journal.pone.0014550. York, N. L., Rayens, M. K., Zhang, M., Jones, L. G., Casey, B. R., & Hahn, E. J. (2010). Strength of tobacco control in rural communities. Journal of Rural Health, 26(2), 120–128. doi:10.1111/j.1748-0361.2010.00273.x.
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: POPULATION STUDIES
Creating Effective Media Messaging for Rural Smoke-free Policy Carol A. Riker, MSN, RN,1 Karen M. Butler, DNP, RN,1 JaNelle M. Ricks, MPA,1 Rachael A. Record, MA,1 Kathy Begley, BA,1 Debra Gay Anderson, PhD, RN,1 and Ellen J. Hahn, PhD, RN, FAAN2 1 College of Nursing, University of Kentucky, Lexington, Kentucky; and 2Colleges of Nursing and Public Health, University of Kentucky, Lexington, Kentucky
Correspondence to: Karen M. Butler, Tobacco Policy Research Program, 423 College of Nursing, University of Kentucky, Lexington, KY 40536, USA. E-mail: karen. [email protected]
ABSTRACT Objectives: Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents. Design and Sample: Qualitative methods design. Thirty-nine rural adults recruited by community partners. Measures: Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy. Results: Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials. Conclusions: Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS. Key words: Rural residents, media messaging, smoke-free policy.
Secondhand smoke (SHS) exposure is the leading cause of preventable disease and death in nonsmoking adults and children, especially in rural areas (Centers for Disease Control and Prevention, 2010; U.S. Department of Health and Human Services, 2006). Rural populations are disproportionately affected by tobacco use, SHS exposure, and smoking-attributable disease and death (Rahilly & Farwell, 2007). Potential contributing factors include low socioeconomic status (SES), lack of cessation services, lower levels of education, inadequate insurance coverage, and distance to health care facilities (Hutcheson et al., 2008).
Unique historical, cultural, familial, and social factors exist in rural communities which also may affect tobacco use. Some communities have social norms supportive of tobacco culture (e.g., tobaccogrowing communities). Residents are often exposed to tobacco industry marketing campaigns such as sponsorships of rural sporting events or targeting through marketing designed for blue-collar and rural men with “rugged, manly images” (American Lung Association, 2012). Proximity to tobacco growing in rural areas is another potential issue (American Legacy Foundation, 2009; Denham, Meyer, & Toborg, 2004). Tobacco use is often considered acceptable, and even supportive of family
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and community in these areas where residents tend to have strong family ties and close-knit social networks (Bauer, College, & Growick, 2003; Schoenberg, Hatcher, & Dignan, 2008). All of these factors may make it challenging for public health nurses who work with this vulnerable population to effect change in smoking rates and exposure to SHS in their communities. Smoke-free policies increase cessation and decrease tobacco use, youth initiation, and exposure to SHS (The Guide to Community Preventive Services, 2012, November). For example, in one community after a comprehensive smoke-free public places ordinance was enacted, there was 31.9% decline in adult smoking (25.7% prelaw to 17.5% postlaw) (Hahn et al., 2008). However, a survey conducted in six Appalachian states found that rural communities have fewer smoke-free laws and voluntary restrictions compared to urban areas (Ferketich et al., 2010). Rural residents may perceive smoke-free policies as incompatible with their values of self-reliance and personal freedoms (American Lung Association, 2012). Some rural communities have a history of economic dependence on tobacco growing, making tobacco use socially acceptable. Rural community leaders and residents may resist tobacco control efforts as a perceived threat to the local economy (Denham & Rathbun, 2005; Ferketich et al., 2010). Understanding tobacco’s historical role in society is essential as researchers develop and test interventions to promote smoke-free policy in rural communities. Culturally sensitive media messages and credible media channels that resonate with rural residents are needed to build demand for smoke-free policies in rural areas (Gilbert, Karahalios, & Sandvig, 2010; Kostygina, Hahn, & Rayens, 2014). Targeted and relatable messages have been found to be effective in motivating rural smokers to consider cessation and increase cessation attempts, particularly among lower socioeconomic groups (Butler et al., 2014; Durkin, Biener, & Wakefield, 2009). Studies have investigated what smokers perceive as effective media messaging for cessation. For example, media ads using a “why to quit” strategy, including graphic images or personal testimonials, were perceived by smokers to be more effective than other ad categories (Davis, Nonnemaker, Farrelly, & Niederdeppe, 2011; Durkin et al., 2009). Other researchers found that ads that evoke emotion and
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contain personalized stories about effects of smoking and smoking cessation are more effective in the promotion of cessation and reduction of socioeconomic disparities in smoking (Durkin et al., 2009). However, few studies have examined messaging to promote smoke-free policy (Kostygina et al., 2014; Quick, Bates, & Romina, 2009). Consistent with the overall goal of disease prevention and health promotion, clear and effective health communication is essential to public health nursing practice. Public health nurses can use established communication strategies to positively influence individuals, families, and communities to promote better personal and environmental health outcomes through education, intervention, and promotion of public health policy. Understanding the targeted population and tailoring messages are strategies that can be used effectively by public health nurses to reach individuals and communities, as well as to design public health campaigns which may inform and influence policy change (Lv et al., 2014). It is important to recognize that communication inequalities may exist, such as differences in access to and ability to take advantage of health information, particularly in disadvantaged populations such as rural residents. Some of this may be associated with use of media. Media use related to health differs by socioeconomic factors such as race, ethnicity, language, and social class, and providing greater access to high quality health-related media by considering factors associated with social determinants may contribute to addressing social disparities in health (Viswanath & Ackerson, 2011). Asking rural residents to share their perceptions about effective messages will promote messages that may prompt smoke-free policy change in rural communities, and can be an important tool for public health nurses to use in reaching those improved outcomes. The aims of this study were to explore the perceived effectiveness of existing smoke-free print advertisements in rural communities and to generate additional message content, characteristics, and media delivery channels that resonate with rural residents.
Methods Design and sample A qualitative methods design was used similar to other studies (Butler et al., 2012; Devlin, Eadie,
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy Stead, & Evans, 2007). Four focus groups (N = 39) were held in two rural counties, purposively selected from 22 rural intervention counties participating in a larger controlled trial to test the impact of a policy advocacy intervention (Hahn, Rayens, Adkins, Begley, & York, 2014). Each county had one smoke-free city, but no county or statewide smoke-free law. Community partners recruited participants via word of mouth and selected convenient locations to conduct the focus groups, two of which were smoke-free. Sample sizes by focus group were 5, 7, 15, and 12, respectively. Participant incentives included a light meal, child care, and $20. The university’s Medical Institutional Review Board approved the conduct of the study.
Measures Two group facilitators with expertise and experience in tobacco-related issues and qualitative methods each conducted two focus groups each in the counties involved in the study. After providing informed consent, participants completed an anonymous survey assessing demographics, smoking status, and ties to tobacco growing. Group discussion followed, using a written interview guide and prompts (Table 1). The guide was adapted from a study by Kostygina et al. (2014) to determine relevant cultural themes and key message features affecting receptivity to ads used during the Smoke-free Rural Communities project (Hahn et al., 2014). Kostygina suggested additional focus group topics for the current study and coalition members who had conducted a successful smokefree rural policy campaign refined them for generating input for possible new messages (G. Kostygina personal communication, January 10, 2011). No pilot testing of the adapted interview guide was conducted. The first three questions prompted a discussion on the facts of SHS and participants’ exposure to and attitudes toward smoke-free policy. Facilitators supplemented participants’ knowledge as needed. For example, if participants shared that smoke-free policy hurts local business, information from economic studies in rural areas was shared (Pyles & Hahn, 2011b). The fourth question elicited suggestions for content and culturally sensitive ways to deliver information on SHS and smoke-free policy. The facilitator then asked participants to review a packet of eight existing print ads and discuss
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perceived effectiveness. For example, one ad concept on indoor air pollution presented the information in two different ways: text versus graph. We also tested a version of the “It’s not about the smoker; it’s about the smoke” ad concept found to be effective by (Kostygina et al., 2014). Seven interviewer questions related to the ads, ranging from “Of all the ads you have seen, which ones stand out?” to “Is there anything else you’d like to tell us about the ads?” The ads were selected based on Kostygina’s suggestions that we evaluate ads about indoor air quality; ads that attack tobacco industry tactics in opposing smoke-free laws; and other community ads not tested in her study (G. Kostygina personal communication, September 16, 2011; Kostygina et al., 2014). We chose five ads used by county smoke-free coalitions in Kentucky and three from TobaccoScam (Glantz, 2002–2015) (Table 2).
Analytic Strategy Focus groups were recorded and transcribed. Opencoding was used to define and develop theme categories (Kostygina et al., 2014). Sixty-four themes emerged in three dominant categories: message content, characteristics, and delivery channels (Table 3). Two independent researchers coded the transcripts and developed a codebook containing the themes and descriptions. Interrater reliability was strong, with 84% agreement on the comparison of every 10th data bit. Atlas.ti, a qualitative software program, was used to organize and summarize the transcripts (Scientific Software Development, 2003–2005).
Results Sample characteristics The sample comprised 39 rural adults, the majority of whom were female (59%), between 55 and 74 years of age (61.5%), Caucasian (65.8%), and had greater than a high school education (74.4%). The sample differed slightly from the state population that is 50.8% female, 88.5% Caucasian, and 83% with greater than a high-school education. The lower educational level of the sample may be explained by the rural location. In addition, the state percentage of adults over age 65 was 13% in 2013, so the study sample represented an older population than the state average (U.S. Census Bureau, 2014). As one of the focus group locations
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TABLE 1. Focus Group Questions and Prompts Questions 1. What do you know or what have you heard about secondhand smoke (SHS)?
Prompts
in it? • What’s • How does it affect people’s health?
○ Immediately ○ Long-term ○ Other diseases not yet mentioned
big of a problem is it? • How • What have you heard about thirdhand smoke? Now we will pause for some information on secondhand smoke and smoke-free policy.a 2. How much SHS are you exposed to at What is SHS exposure like for you? Has anyone’s workplace recently gone smoke-free? work or in public places?
• •
○ What was that like for you?
3. What do you think of efforts by government or businesses to go smoke-free? 4. What suggestions would you have for us as we develop educational materials on SHS and smoke- free policy for rural areas?
Is it OK for servers and blue-collar workers to be exposed to SHS at work? Messages: What are some of the most important things you have heard tonight about smoke-free policy? What would you like to know more about? How could we best communicate the risks of SHS? Materials: How would we get the word out best? For example, pamphlets, posters, flyers, newspaper or “advertiser” ads, radio, cable TV, weather crawler? What would be the best locations to place materials? For example: grocery stores, fast food places, churches? How would we best incorporate the language and style of rural communities into our messages?
• • • • • •
Now please take a few minutes to look at the ads in your packet 5. Of all the ads you have seen, which ones Why? stand out? 6. Did anything about the content of the Why? ads make you feel uncomfortable? 7. Were any of the ads particularly Why do you think you like them? appealing to you? 8. Were any of the ads particularly What do you think made you dislike them? unappealing? 9. Do you think any information is missing Is there anything you would add? from the ads? 10. Were any of the ads effective in What makes them effective? promoting smoke-free policy? What makes others ineffective? 11. Is there anything else you want to tell us about the ads? Thank you for taking the time to participate in the study a
5–10 min of education depending on misconceptions and existing knowledge.
was a predominantly African-American church, the percentage of non-Caucasians in the study sample was higher than the state average. Three participants (7.7%) were current smokers and six (16.2%) either grew tobacco or owned property where
tobacco was grown. The smoking prevalence in the sample was much lower than the state adult smoking prevalence (26.5%) but may be partially explained by the small sample size and the fact that few smokers were comfortable participating in
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TABLE 2. Print Ads and Sources Ad topic/Message
Source
Air pollution from secondhand smoke nearly 49 higher than outdoor pollution standard (smoke graphic) Indoor air pollution level 39 higher than the federal standard for outdoor air (data graph)
Breathe Easy Rowan County
“We all support health codes for restaurants. Why make an exception for the tobacco industry?” (restaurant picture) “Opening up a smoke-free restaurant in the middle of tobacco country wasn’t outrageous. Just smart.” (restaurant picture) “Big Tobacco has been conning the restaurant business for years. Don’t be a sucker. Go smoke-free.” (restaurant picture) Think secondhand smoke won’t hurt you? Think again. (heart & EKG graphic): 5 min of exposure makes it harder for your heart to pump blood 20–30 min of exposure causes blood clots and fat to build up in the arteries, increasing the risk of heart attack and stroke 2 hr of exposure can speed up the heart rate and lead to abnormal heart rhythms which may cause death
Breckinridge County Smoke-free Coalition; Breckinridge County Coalition for Change; Breckinridge County Health Department TobaccoScam (Glantz, 2002–2015) TobaccoScam (Glantz, 2002–2015) TobaccoScam (Glantz, 2002–2015) Ohio County Smoke Free
• • •
It is not about the smoker. It is about the smoke! (smoke graphic) Heart Disease Lung Cancer Breast Cancer Asthma Pneumonia Tobacco smoke contains a deadly mix of more than 7,000 chemicals. Hundreds are toxic. About 70 can cause cancer Support Smoke-free NKY Are you breathing poisons at work? (bowling alley graphic)
Smoke-Free Boyle County
focus groups related to this topic (Centers for Disease Control and Prevention, 2013).
simply going to work and then being around someone who smokes and you can keep showing consistently that kind of a pattern.” Also discussed were inappropriate ways to address worker health, noting that it would be “Ineffective to say all you customers have to quit smoking because I work here now.” Third, they suggested analogies, identifying situations similar to smoking inside workplaces. One suggested, “Slavery was also part of our heritage. Women did not have the right to vote was part of our heritage. When we learned it wasn’t a good thing, we stopped. So, if we know that tobacco . . . that’s killing people secondhand, what pride is there in contributing to that?” Fourth, economic impact was suggested as a media message to reassure community members that local businesses will not suffer (Pyles & Hahn,
Theme category 1: Content themes Six major themes emerged: dangers of smoking and SHS, worker health, analogies, economic impact, rights, and nostalgia. First, participants felt that the dangers of smoking and secondhand smoke were important messages. One participant said, “If you can, establish the medical harm from the smoking.” Others said, “The issue of freedom has to be addressed in some fashion to clearly demonstrate that smoke is harming other people,” and “The smoke might be out of sight, but the particles are still there . . . and somebody is still inhaling particles.” Second, worker health was a major concern. One participant shared, “You know [if a person is saying] I’ve contracted . . . lung cancer from just
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TABLE 3. Themes and Coding Frequency Theme and description Category 1: Content themes and descriptions Tobacco use and/or cessation 01 What about cigarettes makes them so deadly; what are the effects of the chemicals (including discussions about carcinogens) 02 Taxes on cigarettes 03 All potential smoking related illnesses and physical limitations caused by smoking 04 Smoking addiction 05 Most people do not smoke 06 Youth smoking behaviors 07 Quitting (reasons for and against) 08 Personal costs of smoking cigarettes (including personal financial burden) 09 How to help smoker (including suggestions for how to do that and local resources available) 10 Not about the smoker 11 Smoke-free laws’ effect on quit behaviors 12 Use of other tobacco products (discussions of smokeless, e-cigarettes, pipes, cigars, and all other tobacco products other than cigarettes) Secondhand smoke 13 Dangers of secondhand smoke (including dangers of particles) 14 No level of secondhand smoke exposure is safe 15 Secondhand smoke’s effect on children (including protecting children from secondhand smoke) 16 Ventilation systems 17 SHS smell (including particles in the smell and smell of other tobacco products, in general) 18 Odor fatigue (one no longer senses a smell even though it is still present) 19 One should not have to go elsewhere to breathe clean air 20 There is no societal benefit to having secondhand smoke in the air Economics 21 Effects of smoke-free policies on restaurants and bars 22 Not about the farmer 23 Times have changed and crops other than tobacco could be grown 24 Tobacco-related health care costs to society Freedoms 25 Worker health (arguments for and against) 26 Business & farmer rights (including comments regarding business owners having the right to allow smoking) 27 Freedom to live, freedom of nonsmokers, and not harming others via smoking 28 Smokers’ rights Other 29 Comparisons to similar situations which are not as controversial (including alcohol, death rate comparisons, etc.) 30 Community specific data (messages should give rates/statistics about their own community) 31 Death (from smoking and/or secondhand smoke) 32 Religious references 33 Nostalgia for Kentucky’s history as a tobacco state
Frequency
9 1 5 9 2 5 4 4 4 10 0 4
8 4 7 2 8 1 2 1 10 2 3 2 12 6 8 8 12 1 2 1 7 (continued)
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TABLE 3. (Continued) Theme and description Category 2: Message characteristics Message format 34 Be short and to the point 35 Be tailored to the community (include pictures, quotes, and stories from respected community members) 36 Large enough to read 37 Be simple and easy to understand 38 Be understandable by low literate individuals Message tone 39 Do not place blame (including not attacking smokers) 40 (Use or not use) graphic visuals 41 (Use or not use) personal stories 42 (Use or not use) statistics/charts/graphs Messenger 43 Local authority figure (including medical expert, public figure, etc.) 44 Child or youth 45 Backed by powerful national agencies 46 Someone relatable Message target 47 Policymakers 48 Youth 49 General Community Category 3: Media delivery channels 50 Newspapers 51 Radio 52 Technology and Internet based (including social media, personal websites, etc.) 53 Television (including cable, satellite, etc.) 54 Print materials (including posters, flyers, brochures, bumper stickers, pamphlets, yard signs, bookmarks, mail stuffers, etc.) 55 Billboards 56 Magazines Channel locations 57 Waiting rooms 58 Religious outlets 59 Local businesses 60 In an easy place to read (e.g., not in places where one needs to read while driving but where one can read when stopped) 61 In popular locations (including most driven roads, busiest restaurants, etc.) Other themes 62 Social Barriers 63 Smoking in spite of dangers 64 Media Campaigns
Frequency
11 0 2 5 3 3 14 8 13 8 5 3 2 1 5 3 12 3 11 5 5 10 4 2 0 0 2 2
3 4 2
A phrase or section may have been coded using up to three codes.
2011a,b; Pyles, Mullineaux, Okoli, & Hahn, 2007). Participants observed that smoke-free policies do not harm business. One stated, “Well, they’ve just proved already that they’ve increased [business]— every restaurant in [our town] . . . And, that’s because people that don’t smoke are finally going out to eat. . .” Another shared, “I know that’s been a
real sticking point that bar owners and restaurant owners are really concerned that their clientele is going to go elsewhere if they can’t smoke.” Fifth, nonsmokers’ rights were identified as important. One said, “This [smoking] is not a violent crime, but just as deadly . . . As I watched my mom die from Dad’s smoking, I think the
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government has a right to protect its citizens from that, just as they protect me from someone shooting me.” Participants also described how messages can be misinterpreted by smokers, stating “People feel personally attacked” and “Stay focused on the effects more than personalizing.” Some participants liked the ad, “It’s about the smoke, not the smoker (Kostygina et al., 2014).” One said, “My rights [to smoke] stop where your rights start; you have the right to not smell the smoke.” The rights of local farmers were also discussed. Participants said, “I don’t think the Chinese [U.S. exports tobacco] should have to breathe it either, but if the concern is . . . putting farmers out of business, I don’t think that’s a legitimate concern . . . the product is already exported;” and “What affects [the Chinese] affects us, because we are one.” Finally, nostalgia for family ties to tobacco as well as for Kentucky as a tobacco-growing state was expressed. One shared, “I remember [being] out there with everyone else stripping tobacco; it was good memories of high school days. If you come out against it, it might be like I’m against my own family.”
Theme category 2: Message characteristics Seven over-arching most effective message characteristics emerged. First, they suggested short and to the point messages that are understandable to those with low literacy. One participant shared, “It’s easier to read a couple of lines and take [the message] in.” Another, referring to one of the ads, said, “I wouldn’t read down through there.” Others recommended choosing “Words used in everyday speaking,” and “Maybe a picture and a big word.” Second, messages large enough to read so that they will catch the eye and not require a lot of time were suggested. One participant stated, “You know it [right] off the bat by that big headline. . ..” Third, participants recommended graphic images that can be powerful and emotional. Examples were: “Child playing on Daddy’s grave” or an image so negative that people look away. The risk of unintended consequences was pointed out by others, who stated, “People miss the smoke-free message because of harsh pictures [like an autopsy].” Fourth, they suggested poignant stories that move people on an individual level. One stated, “If more people heard a story like [a parent dying],
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they might jump in [to support smoke-free policies].” Fifth, statistics, charts, and graphs were mentioned as effective. One participant liked an existing ad presenting an air quality graph showing the difference between smoke-free and smoky venues. An important qualifier was that statistics “Need to tell a [local] story.” Sixth, the message sender or delivery by a local authority figure was important. One participant shared, “Instead of the Surgeon General, use a local medical person” or someone relatable. Another stated, “If I [saw] somebody in there I know, I’d read the whole page.” Finally, messages targeting varied local groups were important. Participants said, “You have to get up into those rural areas . . . up in those hollows;” “Some messages will target young, some more mature; it’s a scattergun approach in order to get all groups and all access points;” and “Throw in all approaches, all kinds of levels . . . different campaigns with different sets of values/goals. . .”
Theme category 3: Media delivery channels Four effective delivery channels were identified: local television, newspaper, and radio; technology/ Internet; billboards; and print materials. Local TV, newspapers, and AM radio were recommended over national or statewide media. One participant emphasized the importance of local television stations: “The major issue is not so much the message [issues are the same] but make sure [our] county hears its name.” Two participants described the use of the local newspaper: “. . .the very front page . . . where they put on this little sticker.” Others discussed the importance of using local AM versus FM radio stations because some people only listen to the local AM station and watch the local cable station. Technology and Internet such as Facebook and other social media sites were described as very useful: “Everyone’s on it, chatting;” “Someone just got diagnosed with breast cancer . . . and people were Facebooking [the news got around fast];” “Set up Facebook, Twitter, and a YouTube account and link them together;” and “Keep it fresh.” Billboard messages and proper placement were important: “In an easy place to read, near stoplight or leaving campus.” Print materials for smoke-free messaging yielded several suggestions for expanding
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy reach: “send it in a [utility] bill, so when they open it they get a smoke-free message;” “a little poster wherever smoking is not allowed;” “bumper stickers;” and “any place where people have to sit and wait.”
Discussion This study examined perceived effectiveness of existing smoke-free print advertisements in rural communities to generate additional message content, characteristics, and media delivery channels that resonate with rural residents. Recommendations included established strategies, such as presenting the dangers of smoking and SHS, keeping messages short and to the point, and using everyday language understandable by those with low health literacy (Davis, Williams, Marin, Parker, & Glass, 2002; U.S. Department of Health and Human Services, 2010). Unique, specific suggestions were made for reaching diverse segments of rural populations including new ideas for how to tailor messages for specific cultures or age groups with high health risks, smokers and nonsmokers, and those with specific religious values or sociocultural norms (Kostygina et al., 2014; Lv et al., 2014). One of the most interesting content themes was the use of analogies as a messaging strategy for articulating the reasons for smoke-free policies. The use of analogies touched important values such as family and community. Figurative language is a powerful tool for behavior change, but communicating logic through an analogy is a fairly innovative approach (McGuire, 2000). Pairing a logical argument that was not controversial (“You wouldn’t drink with children in the car”) with a more provocative one (“So why would you smoke with kids in the car?”) was perceived as effective. Use of analogies is consistent with recommendations that tobacco messages be tailored to the intended population (Jamrozik, 2004). If a population identifies with the message, it is more likely to result in attitude change (Dal Cin, Zanna, & Fong, 2004). Using narratives from easily recognized local people to whom the audience can relate was another important suggestion. Similarly, Durkin et al. reported a strong relationship between exposure to highly emotional personal narratives and calls to the tobacco quit-line (Durkin, Wakefield, &
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Spittal, 2011). One study in rural Kentucky noted that rural residents related to their neighbors’ stories that were featured as part of a community media campaign (Butler et al., 2012). Culturally sensitive messaging takes on special meaning as one considers the nostalgia expressed for Kentucky’s tobacco-growing heritage. Although the number of small farms in Kentucky decreased by 87.4% from 1997 to 2007, acceptance of smokefree policies remains a particular challenge in rural areas (U.S. Department of Agriculture, 2007). Participants described their proud tobacco heritage, telling stories from childhood about families and neighbors working in the tobacco fields. Some shared that it is difficult to say anything about tobacco without it being perceived as a personal attack on smokers or disrespectful to farmers, bearing out Denham’s caution to present information in a nonjudgmental and polite manner with Appalachians (Denham & Rathbun, 2005). Participants agreed that culturally sensitive messages were critical because tobacco has been an important part of Kentucky’s economy and culture. Suggestions included focusing on the health of nonsmokers and workers. There was a desire to protect the health of nonsmokers without stigmatizing smokers, seeking a solution that preserves respect for the perceived nostalgia surrounding tobacco. Personal rights may not feel as personal when they are detrimental to others (Satterlund, Cassady, Treiber, & Lemp, 2011). A recent study conducted in the same geographic area was designed to identify pro-health messages that may counter the local pro-tobacco culture. Results showed that shifting focus away from smokers is an effective strategy with rural residents (Kostygina et al., 2014). For example, a community included in the study reported here placed a brightly colored lift-off sticker on the front page of the newspaper, reading, “It’s the smoke, not the smoker.” The findings of this study are consistent with previous research findings showing that rural communities use media channels in slightly different ways than national trends indicate (Gilbert et al., 2010). Local radio and TV stations as well as newspapers were considered more effective than statewide channels, because each community has its own idiosyncrasies and residents and local officials often relate better to local rather than state or national stories (Klein, Liber, Kauffman, Berman, &
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Ferketich, 2014). Indeed, Helme and colleagues concluded that rural print media may be receptive to pro-health messages, even in tobacco-growing communities, and recommended submission of tobacco control articles to local newspapers Helme et al., 2012). Billboards placed in high-traffic areas were recommended, avoiding locations where they could be overlooked (i.e., next to other billboards). Caution was recommended in selecting the message characteristics for billboards. Harsh, graphic images were discouraged, as they could be distracting and detract from the message. Similarly, fear appeal messages often cross the line from emotional to too graphic (Hale & Dillard, 1995). In addition to traditional media, findings of this study supported the use of the Internet as an effective media channel, consistent with an online advertising study effective in reaching low SES populations (Graham, Milner, Saul, & Pfaff, 2008). However, rural communities often lack the resources needed to support media advocacy to promote tobacco control efforts (York et al., 2010). The recommendations of community leaders and members in the study reported here cannot be realized without adequate resources, capacity, and efforts (York et al., 2010). A limitation of the study is its lack of generalizability due to the convenience sample in two rural communities in a tobacco-growing state. Some participants in one county knew the focus group facilitator, increasing the potential for socially desirable responses. However, knowing the facilitator could also have promoted group sharing. There may have been a potential for bias toward smoke-free policy and related messaging because the focus group participants resided in one of the intervention counties in the larger research study (Hahn et al., 2014). Further, some responses may have been socially desirable given the culturally sensitive nature of the questions. The researchers’ supplementation of participants’ knowledge during the focus groups may have increased the potential for socially desirable responses, because they may have felt “corrected”. In addition, the sample included only three smokers. As the majority of the sample was comprised of nonsmokers, there may have been more support for smoke-free policies in general, creating potential for bias. Carefully designed message content and media delivery channels based on input from members of the target population are important for building
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demand for smoke-free policies in rural communities (Jamrozik, 2004; Kostygina et al., 2014). Insight from community members is critical because health messages are most effective and most likely to result in changes in attitudes or beliefs when audiences relate to the message characteristics (Butler et al., 2014; Durkin et al., 2009). Rural focus group participants in a tobaccogrowing state reaffirmed that basic SHS information remains a key component in smoke-free campaigns, as is an emphasis on worker health and reassurance that smoke-free policy will not damage the local economy (Hahn, 2010). The use of analogies in the development of media messaging adds to the literature on effective smoke-free campaigns. In addition, the findings of this study support previous studies related to message characteristics such as the use of personal narratives with local pictures (Butler et al., 2014; Kostygina et al., 2014). Further research is needed to identify messages that may resonate with rural residents, particularly smokers, to promote support for comprehensive smoke-free policies. More research is also needed to test the effects of these identified message content themes and media channels on policy outcomes. Public health practitioners can use key informants in small towns to identify culturally sensitive modifications of existing messages and specific low-cost delivery channels used by local residents. Integrating effective smoke-free messages into a multicomponent intervention can help move the community toward tobacco-free lifestyles (Lv et al., 2014).
Acknowledgments The authors thank the Franklin County Smoke-free Coalition and the Nelson County Smoke-free Coalition for their assistance in recruiting focus group participants, securing venues for the groups, and providing child care. Special thanks go to Patrick Whelan, who completed Human Subjects Protection training and facilitated two of the focus groups.
References American Legacy Foundation. (2009). Tobacco Control in Rural America. Washington, DC: American Legacy Foundation. American Lung Association. (2012). Cutting tobacco’s rural roots: Tobacco use in rural communities. Retrieved from http:// www.lung.org/assets/documents/publications/lung-diseasedata/cutting-tobaccos-rural-roots.pdf Bauer, W. M., College, M., & Growick, B. (2003). Rehabilitation counseling in Appalachian America. Journal of Rehabilitation, 69(3), 18.
Riker et al.: Creating Effective Media Messaging for Rural Smoke-free Policy Butler, K., Hedgecock, S., Record, R., Derifield, S., McGinn, C., Murray, D., et al. (2012). An evidence-based cessation strategy using rural smokers’ experiences with tobacco. The Nursing Clinics of North America, 47(1), 31–43. Butler, K. M., Rayens, M. K., Adkins, S., Record, R., Langley, R., Derifield, S., et al. (2014). Culturally-specific smoking cessation outreach in a rural community. Public Health Nursing, 31(1), 44–54. doi:10.1111/phn.12066. Centers for Disease Control and Prevention. (2010). Tobacco Control State Highlights, 2010. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Centers for Disease Control and Prevention. (2013). State tobacco activities tracking and evaluation (STATE) system. Retrieved from http://www.cdc.gov/tobacco/data_statistics/state_data/state_system/index.htm Dal Cin, S., Zanna, M. P., & Fong, G. T. (2004). Narrative persuasion and overcoming resistance. In E. S. Knowles, & J. A. Linn (Eds.), Resistance and persuasion (pp. 175–191). Mawah, NJ: Erlbaum. Davis, K. C., Nonnemaker, J. M., Farrelly, M. C., & Niederdeppe, J. (2011). Exploring differences in smokers’ perceptions of the effectiveness of cessation media messages. Tobacco Control, 20(1), 26–33. doi:10.1136/tc.2009.035568. Davis, T. C., Williams, M. V., Marin, E., Parker, R. M., & Glass, J. (2002). Health literacy and cancer communication. C: A Cancer Journal for Clinicians, 52(3), 134–149. Denham, S. A., Meyer, M. G., & Toborg, M. A. (2004). Tobacco cessation in adolescent females in Appalachian communities. Family and Community Health, 27(2), 170–181. Denham, S. A., & Rathbun, A. (2005). Community health assessment Appalachia: An overview of health concerns and health literacy. Athens, OH: Appalachian Rural Health Institute. Devlin, E., Eadie, D., Stead, M., & Evans, K. (2007). Comparative study of young people’s response to anti-smoking messages. International Journal of Advertising, 26(1), 99–128. Durkin, S. J., Biener, L., & Wakefield, M. A. (2009). Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. American Journal of Public Health, 99(12), 2217–2223. doi:10.2105/ajph.2009.161638. Durkin, S. J., Wakefield, M. A., & Spittal, M. J. (2011). Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups? Health Education Research, 26(6), 998–1009. doi:10.1093/her/cyr048. Ferketich, A. K., Liber, A., Pennell, M., Nealy, D., Hammer, J., & Berman, M. (2010). Clean indoor air ordinance coverage in the Appalachian region of the United States. American Journal of Public Health, 100(7), 1313–1318. doi:10.2105/ ajph.2009.179242. Gilbert, E., Karahalios, K., & Sandvig, C. (2010). The network in the garden: Designing social media for rural life. American Behavioral Scientist, 53(9), 1367–1388. doi:10.1177/ 0002764210361690. Glantz, S. (2002–2015). Tobaccoscam. Retrieved from http:// www.tobaccoscam.ucsf.edu/our-ads Graham, A. L., Milner, P., Saul, J. E., & Pfaff, L. (2008). Online advertising as a public health and recruitment tool: Comparison of different media campaigns to increase demand for smoking cessation interventions. Journal of Medical Internet Research, 10(5), Available at http:// www.ncbi.nlm.gov/articles/PMC2630839/ Hahn, E. J. (2010). Smokefree legislation: A review of health and economic outcomes research. American Journal of Preventive Medicine, 39(6 Suppl 1), S66–S76. doi:10.1016/j.amepre.2010.08.013. Hahn, E. J., Rayens, M. K., Adkins, S., Begley, K., & York, N. (2014). A controlled community-based trial to promote
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smoke-free policy in rural communities. Journal of Rural Health, 31, 76–88. doi:10.1111/jrh.12087. Hahn, E. J., Rayens, M. K., Butler, K. M., Zhang, M., Durbin, E., & Steinke, D. (2008). Smoke-free laws and adult smoking prevalence. Preventive Medicine, 47(2), 206–209. doi:10.1016/j.ypmed.2008.04.009. Hale, J. L., & Dillard, J. P. (1995). Fear appeals in health promotion campaigns: Too much, too little or just right? In E. Maibach, & R. L. Parrott (Eds.), Designing health messages: Approaches from communication theory and public health practice (pp. 65–80). Thousand Oaks, CA: Sage. Helme, D. W., Rayens, M. K., Kercsmar, S. E., Adkins, S. M., Amundsen, S. J., Lee, E., et al. (2012). Rural print media portrayal of secondhand smoke and smoke-free policy. Health Promotion Practice, 13(6), 848–856. doi:10.1177/ 1524839911399429. Hutcheson, T. D., Greiner, K. A., Ellerbeck, E. F., Jeffries, S. K., Mussulman, L. M., & Casey, G. N. (2008). Understanding smoking cessation in rural communities. Journal of Rural Health, 24(2), 116–124. doi:10.1111/j.17480361.2008.00147.x. Jamrozik, K. (2004). ABC of smoking cessation: Population strategies to prevent smoking. British Medical Journal, 328 (7442), 759–762. Klein, E. G., Liber, A. C., Kauffman, R. M., Berman, M., & Ferketich, A. K. (2014). Local smoke-free policy experiences in Appalachian communities. Journal of Community Health, 39(1), 11–16. doi:10.1007/s10900-013-9733-6. Kostygina, G., Hahn, E. J., & Rayens, M. K. (2014). ‘It’s about the smoke, not the smoker’: Messages that motivate rural communities to support smoke-free policies. Health Education Research, 29(1), 58–71. doi:10.1093/her/cyt087. Lv, J., Liu, Q. M., Ren, Y. J., He, P. P., Wang, S. F., Gao, F., et al. (2014). A community-based multilevel intervention for smoking, physical activity and diet: Short-term findings from the Community Interventions for Health programme in Hangzhou, China. Journal of Epidemiology and Community Health, 68(4), 333–339. doi:10.1136/jech-2013203356. McGuire, W. J. (2000). Standing on the shoulders of ancients: Consumer research, persuasion, and figurative language. Journal of Consumer Research, 27(1), 109–114. doi:10.1086/ 314312. Pyles, M. K., & Hahn, E. J. (2011a). Economic effects of Ohio’s smoke-free law on Kentucky and Ohio border counties. Tobacco Control, 20(1), 73–76. doi:10.1136/ tc.2009.035493. Pyles, M. K., & Hahn, E. J. (2011b). Economic effects of smoke-free laws on rural and urban counties in Kentucky and Ohio. Nicotine and Tobacco Research, 16, 66–68. doi:10.1093/ ntr/ntr123. Pyles, M. K., Mullineaux, D. J., Okoli, C. T. C., & Hahn, E. J. (2007). Economic impact of a smoke-free law in a tobaccogrowing community. Tobacco Control, 16, 66–68. Quick, B. L., Bates, B. R., & Romina, S. (2009). Examining antecedents of clean indoor air policy support: Implications for campaigns promoting clean indoor air. Health Communications, 24(1), 50–59. doi:10.1080/10410230802606992. Rahilly, C., & Farwell, W. (2007). Prevalence of smoking in the United States: A focus on age, sex, ethnicity, and geographic patterns. Cardiovascular Risk Reports, 1(5), 379–383. Satterlund, T. D., Cassady, D., Treiber, J., & Lemp, C. (2011). Barriers to adopting and implementing local-level tobacco control policies. Journal of Community Health, 36(4), 616– 623. doi:10.1007/s10900-010-9350-6. Schoenberg, N. E., Hatcher, J., & Dignan, M. B. (2008). Appalachian women’s perceptions of their community’s health threats. The Journal of Rural Health, 24(1), 75–83. doi:10.1111/j.1748-0361.2008.00140.x.
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Scientific Software Development. (2003–2005). Atlas.ti (Version WIN 5.0). Berlin, Germany: Scientific Software Development. The Guide to Community Preventive Services. (2012). Reducing tobacco use and secondhand smoke exposure: Smoke-free policies. ATLANTA, GA: Centers for Disease Control and Prevention. U.S. Census Bureau. (2014). State and county quick facts. Retrieved from http://quickfacts.census.gov/qfd/states/21000.html U.S. Department of Agriculture. (2007). Census of agriculture. Retrieved from http://www.agcensus.usda.gov/Publications/2007/ U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Cen-
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ter for Chronic Disease and Prevention and Promotion, Office of Smoking and Health. U.S. Department of Health and Human Services. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Viswanath, K., & Ackerson, L. K. (2011). Race, ethnicity, language, social class, and health communication inequalities: A nationally-representative cross-sectional study. PLoS ONE, 6(1), e14550. doi:10.1371/journal.pone.0014550. York, N. L., Rayens, M. K., Zhang, M., Jones, L. G., Casey, B. R., & Hahn, E. J. (2010). Strength of tobacco control in rural communities. Journal of Rural Health, 26(2), 120–128. doi:10.1111/j.1748-0361.2010.00273.x.
