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Recall of Anti-Tobacco Advertisements and Effects on Quitting Behavior: Results From the California Smokers Cohort Eric C. Leas, MPH, Mark G. Myers, PhD, David R. Strong, PhD, C. Richard Hofstetter, PhD, and Wael K. Al-Delaimy, MD, PhD
Globally, one person dies from exposure to tobacco smoke every 6 seconds.1 Even in the United States, tobacco smoke exposure remains the leading cause of preventable death, with an estimated 480 000 adults dying from tobacco smoke exposure each year.2 Although the effects of tobacco smoke exposure are most severe among individuals who smoke on a daily basis, nondaily smoking and secondhand smoke exposure can lead to the same negative health consequences that result from daily smoking.3 Increasing smoking cessation, however, can significantly improve life expectancy; lower the risk of cancer, diabetes, heart disease, and lung disease; and, among women, lower the risk of infertility or low-birthweight children.2,4---7 Although the benefits of cessation are most prominent among the young, cessation at any age can immediately improve health outcomes.4 It is recommended that tobacco control programs develop mass-reach health communication interventions to increase cessation among current smokers and reduce smoking initiation among nonsmokers.8 There are multiple pathways through which mass media are intended to promote cessation, including directly marketing cessation assistance to smokers, changing public opinions about tobacco use to create a social norm against smoking, and increasing interpersonal discussions about tobacco use.9---11 The majority of evidence indicates that these mass media campaigns are effective in motivating individuals to think about quitting, make quit attempts, obtain help in quitting, and maintain abstinence.12---31 At the population level, advertisements are also associated with decreases in cigarette consumption and smoking prevalence.13,15,16,19,32---36 The magnitude of the effect of media campaigns on cessation is estimated to be relatively small; however, when
Objectives. We assessed whether an anti-tobacco television advertisement called “Stages,” which depicted a woman giving a brief emotional narrative of her experiences with tobacco use, would be recalled more often and have a greater effect on smoking cessation than 3 other advertisements with different intended themes. Methods. Our data were derived from a sample of 2596 California adult smokers. We used multivariable log-binomial and modified Poisson regression models to calculate respondents’ probability of quitting as a result of advertisement recall. Results. More respondents recalled the “Stages” ad (58.5%) than the 3 other ads (23.1%, 23.4%, and 25.6%; P < .001). Respondents who recalled “Stages” at baseline had a higher probability than those who did not recall the ad of making a quit attempt between baseline and follow-up (adjusted risk ratio [RR] = 1.18; 95% confidence interval [CI] = 1.03, 1.34) and a higher probability of being in a period of smoking abstinence for at least a month at follow-up (adjusted RR = 1.55; 95% CI = 1.02, 2.37). Conclusions. Anti-tobacco television advertisements that depict visceral and personal messages may be recalled by a larger percentage of smokers and may have a greater impact on smoking cessation than other types of advertisements. (Am J Public Health. 2015;105:e90–e97. doi:10.2105/AJPH.2014.302249)
this small effect is applied across an entire population, the reductions can be very meaningful. The United States Centers for Disease Control and Prevention (CDC), for example, recently estimated that its Tips From Former Smokers (TIPS) national ad campaign led to 1.64 million quit attempts and more than 100 000 Americans quitting smoking in just 1 year.19 Despite this current weight of evidence and the recommendations of Article 12 of the Framework Convention on Tobacco Control,8 there are several barriers that make it difficult for many countries to develop mass media campaigns.37 One of the main barriers is the expense of developing and airing advertisements. To provide a perspective, CDC reported receiving $54 million in US federal funding to carry out the TIPS campaign,19 and since the launch of the California Tobacco Control Program (CTCP) in 1990, approximately $464 million has been spent on mass media campaigns in California, with $13.4 million currently being spent annually.38 In funding
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climates that are restrictive, tobacco control programs may be able to reduce costs by focusing on high-impact advertisements.39 In the past decade, tobacco control advocates have begun promoting the use of mass media that rely on emotional messages, deal with the health consequences of smoking, or use personal narratives to convey their messages. These advertisements are intended to promote behavior change by evoking visceral reactions of sadness, fear, disgust, or anger in what has been referred to as a “fear appeal.”40,41 Although this concept of “scaring” smokers into quitting is anathema to many public health advocates,42,43 several researchers have demonstrated that advertisements that deal with the negative consequences of smoking in an emotionally evocative or personal way are effective. They are typically recalled more frequently even when they are aired at lower volumes,44---46 they reach socioeconomic groups equitably,34,47---50 and they are typically rated as more effective than advertisements with different themes.44,46,50---55 In addition, they promote more frequent use of quit
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lines12,14,26,29,47 and confer greater effects on quitting behavior.12,14,26,27,29,34,47---50 Thus far, evaluations of fear appeal advertisements have predominantly relied on grouplevel measures of exposure rather than individual-level measures of recognition. Exposure, in evaluations of advertisements, typically refers to whether a person has viewed an advertisement, but it does not necessarily imply that the person processed the message or remembered the ad. Exposure is usually estimated via group-level measures (e.g., Nielsen ratings or gross rating points) that assess the average number of people in a given population who are likely to have viewed an advertisement.56---58 These group-level measures can be very valuable to public health programs in their assessments of how well an advertisement is reaching a population; however, when behavior change resulting from advertisements is assessed at the individual level, these group-level instruments serve only as ecological measures. By contrast, advertisement recall, a measure of an individual’s recognition of an advertisement, may reduce the possibility of ecological bias and serves as an indicator of message processing, an expected direct effect of exposure to mass media campaigns.59 Although ad recall has long been used in mass media evaluations,12,60,61 to our knowledge it has not been employed in evaluations of behavior change resulting from fear appeal advertisements. We sought to provide further evidence for the use of advertisements that deal with the health consequences of smoking in a personal and emotional way by assessing recall of 4 anti-tobacco television advertisements developed by the CTCP and demonstrating the effects of recall of these ads on smoking cessation. We tested the following hypotheses: an ad called “Stages” that depicted a woman giving a personal narrative of her negative experiences with tobacco use would be recalled more often than 3 other ads with different intended themes among the current smokers in our cohort (hypothesis 1); recall of “Stages” would be distributed more equitably across individual characteristics in multivariable analyses than would recall of the 3 other ads (hypothesis 2); and recall of “Stages” would have a greater effect on cessation than recall of the 3 other ads (hypothesis 3).
METHODS Our analyses were based on a sample of adults (18---64 years old) from the 2011---2012 California Smokers Cohort (CSC) who entered the cohort as “current smokers” (i.e., they reported both smoking 100 cigarettes in their lifetime and currently smoking at least “some days” at baseline). The methodology for the CSC has been described elsewhere.62,63 Briefly, the CSC is a survey of a populationbased sample of adults in California who reported smoking 100 cigarettes in their lifetime. Interviews were conducted via landline and cell phone in both English and Spanish. At baseline, 4350 interviews were completed between July 26, 2011, and April 29, 2012. As a means of ascertaining changes in smoking behavior, follow-up interviews were conducted with 1745 baseline respondents. All follow-up interviews were completed between November 6, 2012, and January 16, 2013. Given that our analyses focused on current smokers, we excluded those who reported at baseline that they were former smokers by restricting the sample to include only individuals who reported smoking at least “some days” at baseline. The final sample consisted of 2596 respondents at baseline and 1000 respondents who completed follow-up interviews.
The Anti-Tobacco Commercials The CTCP has been producing television advertisements since its creation in 1990, with the following objectives: protecting people from exposure to secondhand smoke and environmental tobacco, reducing youth access to tobacco products, countering tobacco industry influence, and promoting free cessation services64 (several advertisements are available for viewing online at http://tobaccofreeca. com/ads/tv, and the advertisements used in this study are described briefly in Table 1). The advertisements assessed in this study were selected because they were aired contemporaneously with the dates of the baseline assessments. Not all advertisements we assessed had the same objectives. The ads titled “Trapped” and “Don’t Stop Fighting” aired during the daytime at lower volumes and were designed to market cessation assistance, whereas the other 2 ads, “Stages” and “The Emerging Man,” aired multiple times throughout the day at
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higher volumes, with messages aimed at changing opinions about the tobacco industry and fostering support for tobacco control.
Measures Advertisement recall. After listening to a onesentence description for each advertisement, all CSC respondents were asked whether or not they recalled having seen the ad in the past 60 days. In our analyses, we used the answers to each of these questions separately and also constructed a new variable focused on recall of at least one of the ads (yes or no). All of the advertisements we assessed had been airing for at least 65 days at the start of the baseline assessment and aired throughout the entire baseline assessment (Table 1). In our first analysis, we used advertisement recall as an outcome variable to assess characteristics associated with recall. In our second analysis, we assessed whether advertisement recall was predictive of quitting behavior at follow-up. We did not include a measure of advertisement exposure and instead made the assumption that those who recalled an ad had been exposed to it. Quitting behavior. Two types of quitting behavior were assessed in this study. We defined a quit attempt as intentional cessation for at least 1 day between baseline and followup, and we defined cessation as being abstinent from smoking for at least 1 month at the time of the follow-up. Covariates. The covariates we used were based on previous literature and included age (18---44 years, 45---64 years), education (less than college, some college, college or more), gender, ethnicity (Hispanic, non-Hispanic White, all other ethnic backgrounds), presence in the household of children younger than 18 years (yes or no), presence of other smokers in the household (yes or no), and addiction as measured by time to first cigarette in the morning (within 30 minutes, more than 30 minutes).
Statistical Analyses Descriptive statistics for all of the variables included are detailed in Table 2. We used frequencies and percentages to evaluate differences in average recall of each advertisement within the baseline sample of smokers. To test hypothesis 1, we used a multivariate analysis of variance to assess the statistical significance of differences in average recall across ads.
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TABLE 1—Characteristics of the 4 Anti-Tobacco Advertisements Assessed Title (Dates Aired; Rating Points)
Still Frame of Advertisement
Description of Advertisement This ad shows a young Debi Austin as the real Debi is heard speaking from the present. She
“Stages” (January 10, 2011–
explains how the tobacco industry targeted her early on, when she started smoking cigarettes
May 1, 2012; 800)
at just 13 years old. The ad transitions to modern Debi after a stoma appears in the mirrored reflection of young Debi—a health effect from cancer surgery caused by smoking—and she warns viewers not to be the tobacco industry’s next victim. See the advertisement at https:// www.youtube.com/watch?v=56OD-Qi3aAA. The internal struggle of a smoker is depicted by 2 men, identical in appearance, sitting on
“Don’t Stop Fighting” (May 23, 2011–
a sofa in a living room. The first man eyes a pack of cigarettes across the living room as the
August 5, 2012; 200)
second man watches. The first man lunges for the cigarette pack and is immediately tackled by the second man, who is trying to keep him from reaching the cigarettes. While the 2 men wrestle, a woman reading nearby is oblivious to the struggle. The viewer is told: “Quitting is a fight you can’t let yourself lose. It can take many tries, but keep trying and you will beat smoking.”
Only in Spanish: This is a representation of how people who are addicted to cigarettes are
“Trapped” (November 1, 2010–
literally trapped. No matter how hard they try to escape, they just simply cannot do it. The
June 27, 2012; 150)
screen is white. It is a Lycra limbo from which forms are seen emerging, first one hand and then another. Next can be seen the shape of a person’s head and torso, desperately trying to escape. The camera zooms back and shows that the person is trapped inside a gigantic cigarette, with an enormous smoke-filled black background. The camera continues pulling back, and it can be seen that more people are in the same situation. A landscape is shown made of cigarettes with people trapped inside. An announcer can be heard asking viewers whether they are trapped and unable to escape their addiction to cigarettes. The light at the end of the tunnel is the helpline. The ad’s spokesperson describes California’s successes in reducing the harm caused by
“The Emerging Man” (January 10, 2011–
tobacco as he travels through settings, such as a pizza kitchen and a hospital waiting room, that illustrate his points. He explains that “California should be proud. We were the first to
June 12, 2012; 975)
ban smoking on airplanes and the first to have smoke-free bars and restaurants, all while saving over $86 billion in health care costs and over 1 million lives.” The ad ends with the man cradling a baby in a hospital nursery while stating: “But even if you were born today, you’d still grow up in a world where tobacco kills more people than AIDS, drugs, alcohol, murder, and car crashes combined. We have a lot more work to do.”
To assess characteristics of the individuals recalling each advertisement, we calculated adjusted risk ratios (RRs) via 5 separate multivariable log-binomial regression models65 that simultaneously adjusted for all covariates. To test hypothesis 2, we evaluated the magnitude and significance of each individual characteristic across the 5 models to determine the characteristics associated with recall of specific ads. Similarly, we used 5 multivariable logbinomial and 5 modified Poisson regression models (one for each combination of ad recall and quitting behavior) to assess the effects of
advertisement recall on quitting behavior at follow-up. We used a modified Poisson model with robust variance error66 rather than a logbinomial model to calculate the adjusted risk ratio for prolonged smoking abstinence so that we could achieve model convergence and provide more conservative variance estimates given the rarity of our outcomes. All analyses assessing the effects of ad recall on quitting behavior were prospective, with ad recall measured at baseline (when the advertisements were aired) and quitting behavior assessed at follow-up.
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We used SAS version 9.3 for Windows 7 (SAS Institute Inc, Cary, NC) in conducting all of our analyses. The level of statistical significance was defined as a < .05.
RESULTS At baseline, CSC respondents were mostly older than 45 years (62.6%) and non-Hispanic White (69.4%), had some college education or had graduated from college (61.7%), did not live with children younger than 18 years (66.0%), and smoked within 30 minutes after
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TABLE 2—Characteristics of Respondents in the California Smokers Cohort: 2012–2013 Characteristic
Baseline (n = 2596), %
Follow-Up (n = 1000), %
Recall of Advertisements
Age, y 18–44
37.4
30.2
45–64
62.6
69.8
Education Less than college
38.3
34.8
Some college
41.6
44.9
College or above
20.1
20.3
Male
49.8
47.8
Female
50.2
52.2
Hispanic Non-Hispanic White
14.1 69.4
9.9 72.6
All other
16.5
17.5
Gender
Ethnicity
Children present in household Yes
33.9
28.7
No
66.0
71.3
Other smokers present in household Yes No Time to first cigarette in the morning
51.7
51.0
48.2
49.0
Within 30 minutes
56.7
59.5
More than 30 minutes
43.3
40.5
Saw “Trapped” advertisement Yes
23.1
...
No
76.4
...
25.6 73.8
... ...
Saw “Don’t Stop Fighting” advertisement Yes No Saw “The Emerging Man” advertisement Yes
23.4
...
No
75.9
...
Saw “Stages” advertisement Yes
58.5
...
No
40.5
...
Saw any of the 4 ads Yes
69.5
...
30.5
...
Yes
...
47.4
No
...
52.5
No
waking up in the morning (56.7%) (Table 2). About half (51.7%) of the respondents lived with other people who smoked cigarettes.
Quit attempt between baseline and follow-up
Prolonged smoking abstinence for 1 month at follow-up Yes
...
9.4
No
...
90.6
Note. For each advertisement, respondents were asked whether they had seen the ad in the 60 days preceding the interview. A multivariate analysis of variance indicated a significant difference (P < .001) in average recall across all advertisements.
The majority of respondents in the baseline sample mentioned that they recalled at least one of the ads assessed here in the 60 days before their interview (69.5%). Substantially more respondents recalled seeing the “Stages” advertisement (58.5%) than the other 3 advertisements being aired during the same period (23.1%, 23.4%, and 25.6%; P < .001). Respondents who had graduated from college were less likely than those with less than a college education to recall seeing any of the advertisements we assessed (adjusted RR range = 0.62---0.86), although there were some variations in the significance of this association (Table 3 ). Other than the association with education, none of the other variables we assessed were associated with recalling the “Stages” advertisement. This was not the case for the other advertisements, however. The probability of recalling the advertisement titled “The Emerging Man” was higher among those who were older than 45 years (vs 18---44 years; adjusted RR = 1.31; 95% confidence interval [CI] = 1.12, 1.54) and lower among women (vs men; adjusted RR = 0.77; 95% CI = 0.67, 0.89). The probability of recalling “Don’t Stop Fighting” was higher among those with ethnic minority backgrounds (vs non-Hispanic Whites), including Blacks, Asians, and all others (adjusted RR = 1.43; 95% CI = 1.22, 1.67), and lower among those who reported that children were living in their household (vs no children in the household; adjusted RR = 0.85; 95% CI = 0.73, 0.99). The probability of recalling “Trapped” was lower among those who had some college education (vs less than a college education; adjusted RR = 0.85; 95% CI = 0.73, 0.99) and higher among Hispanics (vs non- Hispanic Whites; adjusted RR = 1.33; 95% CI = 1.11, 1.61). In assessments of recall of any ads versus no ads, the response pattern closely reflected that of recall of “Stages” (Table 3).
Advertisement Recall as a Predictor of Cessation at Follow-Up Of the 5 advertisement recall measures we used, only one predicted quitting behavior at
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TABLE 3—Adjusted Risk Ratios for Advertisement Recall Among Respondents in the California Smokers Cohort: 2012–2013 Characteristic
“Trapped,” Adjusted RR (95% CI)
“Don’t Stop Fighting,” Adjusted RR (95% CI)
“The Emerging Man,” Adjusted RR (95% CI)
“Stages,” Adjusted RR (95% CI)
Any of the 4 Ads, Adjusted RR (95% CI)
Age, y 18–44 (Ref)
1.00
1.00
45–64
1.00 (0.86, 1.16)
1.15 (0.99, 1.33)
Education Less than college (Ref) Some college College or more
1.00
1.00 1.31** (1.12, 1.54)
1.00
1.00
0.97 (0.91, 1.04)
1.02 (0.96, 1.08)
1.00
1.00
1.00
1.00
0.85* (0.73, 0.99)
0.91 (0.79, 1.06)
0.93 (0.8, 1.09)
0.97 (0.91, 1.05)
0.97 (0.92, 1.02)
0.64*** (0.51, 0.80)
0.72*** (0.59, 0.88)
0.86*** (0.78, 0.95)
0.84*** (0.78, 0.91)
0.80* (0.65, 0.98)
Gender Male (Ref)
1.00
1.00
1.00
1.00
Female
1.13 (0.98, 1.31)
1.15 (1.00, 1.31)
0.77*** (0.67, 0.89)
1.00
1.04 (0.98, 1.11)
1.03 (0.98, 1.09)
1.33** (1.11, 1.61) 1.00
1.04 (0.85, 1.27) 1.00
0.96 (0.78, 1.19) 1.00
0.99 (0.90, 1.10) 1.00
0.99 (0.92, 1.07) 1.00
1.12 (0.92, 1.35)
1.43*** (1.22, 1.67)
1.05 (0.87, 1.26)
1.05 (0.96, 1.14)
1.05 (0.98, 1.12)
Yes
0.94 (0.81, 1.10)
0.85* (0.73, 0.99)
0.87 (0.74, 1.02)
0.96 (0.89, 1.03)
0.98 (0.93, 1.04)
No (Ref)
1.00
1.00
1.00
1.00
1.00
1.07 (0.93, 1.23)
1.04 (0.91, 1.19)
1.07 (0.93, 1.23)
1.04 (0.97, 1.11)
1.01 (0.95, 1.06)
1.00
1.00
1.00
1.00
1.00
Ethnicity Hispanic Non-Hispanic White (Ref) All other Children present in household
Other smokers present in household Yes No (Ref) Time to first cigarette in the morning Within 30 minutes (Ref)
1.00
1.00
1.00
1.00
1.00
More than 30 minutes
0.90 (0.78, 1.04)
0.99 (0.87, 1.04)
0.93 (0.81, 1.08)
0.98 (0.91, 1.04)
0.97 (0.92, 1.02)
Note. RR = risk ratio; CI = confidence interval. The sample size was n = 2596. Separate models were constructed for each advertisement, and all modeled risk ratios were simultaneously adjusted for all covariates. *P £ .05; **P £ .01; ***P £ .001.
follow-up (Figure 1 ). Those who recalled seeing “Stages” had a significantly higher probability of making a quit attempt between baseline and follow-up than those who did not recall seeing the ad (adjusted RR = 1.18; 95% CI = 1.03, 1.34) and a significantly higher probability of being in a period of prolonged smoking abstinence at follow-up (adjusted RR = 1.55; 95% CI = 1.02, 2.37). The advertisements designed to market cessation to smokers (“Trapped” and “Don’t Stop Fighting”) were not associated with either quit attempts or prolonged abstinence at follow-up, nor was recalling any as opposed to none of the ads (Figure 1). Although the difference did not quite reach significance at the .05 level, respondents who recalled seeing “The Emerging Man” were less likely than those who saw the other ads to be in a period of prolonged abstinence at follow-up (adjusted RR = 0.61; 95% CI = 0.37, 1.03).
Recalling this ad did not appear to have a significant effect on respondents’ probability of making a quit attempt (adjusted RR = 0.97; 95% CI = 0.83, 1.13).
DISCUSSION In line with our hypotheses, the “Stages” advertisement, which depicted a woman giving an emotional narrative of her experiences with tobacco use, was recalled more frequently than the other 3 advertisements we assessed. In addition, this ad involved a more equitable distribution of recall across individual characteristics and had a greater impact on subsequent quitting behavior than the other ads. The higher reported recall of this advertisement might be partially explained by its number of rating points. The advertisement was aired more frequently than 2 of the other ads
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and therefore might have had a higher chance of being seen.56---58 However, rating points probably do not explain all recall; “The Emerging Man,” which depicted a man popping out of a pizza oven and fish tank while talking about California laws, had the most rating points but was among the least likely to be recalled. Given the intended theme of “Stages,” our results are consistent with previous studies indicating that advertisements that rely on emotional and personal portrayals of the health consequences of smoking are more likely to be recalled.44---46 This finding serves to reinforce the notion that this type of advertisement may achieve high recall even at lower broadcasting volumes, whereas other advertisement themes might require higher broadcasting volumes to achieve the same levels of recall.44 As anticipated, fewer differences were observed across individual characteristics in recall
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a
b 1.10
1.28
"Trapped"
"Trapped" 0.95
1.03
"Don't Stop Fighting"
"Don't Stop Fighting" 0.61
0.97
"The Emerging Man"
"The Emerging Man" 1.18
1.55
"Stages"
"Stages" 1.42
1.10
Recalled any of the above
Recalled any of the above
0
1
2
3
0
ARR (95% CI)
1
2
3
ARR (95% CI)
Note. ARR = adjusted risk ratio; CI = confidence interval. The sample size was n = 1000. Advertisement titles are in quotation marks and refer to 4 anti-smoking ads being aired on television in California. For panel b, we fit a modified Poisson model with robust variance error for prolonged smoking abstinence given the rarity of the outcome; 10 separate models were used, one for each combination of advertisement and quitting behavior. All modeled adjusted risk ratios simultaneously adjusted for age, education, gender, ethnicity, addiction, presence of children in the household, and presence of other smokers in the household.
FIGURE 1—Estimates of the effects of advertisement recall on (a) quitting smoking intentionally for at least 1 day and (b) abstaining from smoking for at least 1 month at follow-up: California Smokers Cohort, 2012–2013.
of “Stages” than in recall of the other 3 advertisements. Although recall of all of the advertisements was less common among those who had graduated from college, “Stages” was recalled at about the same level across all other characteristics assessed. In contrast, recall differed across several individual characteristics for the other advertisements. These findings may indicate that, unlike other themes, emotional or personal narratives of the health consequences of smoking may yield similar levels of recall among smokers across individual characteristics, including socioeconomic categories. Others have also found that this type of advertisement tests well across socioeconomic categories, in developing countries, and among indigenous groups.34,47---50 These results are promising and consistent, but we believe that such associations will need to be reconfirmed over time given that receptivity to particular advertisements or even categories of advertisements is unlikely to remain constant in all areas. Although we used recall rather than exposure to measure contact with advertisement campaigns, our findings and effect sizes are consistent with research indicating that exposure to graphic or emotional advertisements is associated with successful cessation outcomes.12,14,26,27,29,34,47---50 For example, the
content depicted in “Stages” is analogous to advertisements in the TIPS campaign conducted by CDC, which had a similar effect on quit attempts.19 McAfee et al. reported a substantial impact of self-reported exposure to any TIPS advertisement on making a quit attempt in the preceding 3 months, with an adjusted odds ratio of 1.18 (95% CI = 1.05, 1.34); their result was very similar to our estimate for any quit attempt in the past year among those who recalled the “Stages” advertisement (adjusted RR = 1.18; 95% CI = 1.03, 1.34).19 We have added to and supported the current literature by providing estimates of the effects of recall of specific advertisements rather than possible exposure to advertisements. Although the difference did not reach significance, respondents who recalled seeing “The Emerging Man” were less likely than those who saw the other ads to be in a period of prolonged smoking abstinence at follow-up. It may be that this advertisement elicited an unfavorable response among smokers in our cohort. Others have found that ads such as Philip Morris’ “Think, Don’t Smoke,” which used humor to make fun of smokers, are also less effective and even counterproductive in discouraging smoking.67 We raise this point to emphasize that media campaigns should exercise caution when choosing which anti-tobacco
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advertisements to air. Further populationbased studies focused on reactions to advertisements could better elucidate this topic.
Limitations Several important limitations of our study should be noted. Although the method we used to assess ad recall had the advantage of ascribing contact with advertisements at the individual level, differences in recall could have been affected by the summary wording used to describe a specific ad and the degree to which any wording could adequately convey the audiovisual cues and message content of that ad. In addition, although we asked respondents about television advertisements running in the 60-day interval before the baseline assessment, it is possible that recall bias resulted in an overestimation of the number of respondents exposed to “Stages,” given that the ad’s spokesperson (“Debi”) was part of a CTCP television advertisement series beginning in the mid-1990s. Repeated exposures to the same spokesperson over a long period might promote recall and thereby cessation, and this approach may be useful to explore in future evaluations of anti-smoking advertisements. Finally, given that very few respondents were in a period of smoking abstinence at follow-up, we had low power to detect
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associations between advertisement recall and quitting. However, our effect estimate of advertisement recall on quitting behavior at follow-up remained despite these possible attenuating biases, it is consistent in magnitude with estimates from other studies, and it is theoretically supported by the literature, thus serving to strengthen the validity of our analyses and results.
Conclusions We have provided further evidence that tobacco control programs may be able to reduce costs by focusing on high-impact advertisements. Although California’s annual expenditure on anti-tobacco media campaigns of $13.4 million is well below the CDC’s recommended $76.0 million (or even the $52.8 million minimum funding level),68 the CTCP mass media program appeared to be successful in terms of its intended effects on cessation among smokers in our cohort. Although the fear appeals depicted in advertisements such as “Stages” are not always a particularly popular method of advertising among public health professionals, we hope that our findings encourage tobacco control programs to consider adopting media campaigns that use highquality and engaging health communications targeting mass audiences. Even one television advertisement consisting of emotional messages and personal testimonials about the health consequences of smoking may encourage cessation among smokers from all socioeconomic groups. j
About the Authors Eric C. Leas, David R. Strong, and Wael K. Al-Delaimy are with the Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA. Mark G. Myers is with the Psychology Service, Veterans Affairs San Diego Healthcare System, and the Department of Psychiatry, University of California, San Diego. C. Richard Hofstetter is with the Graduate School of Public Health and the Department of Political Science, San Diego State University, San Diego, CA. Correspondence should be sent to Wael K. Al-Delaimy, MD, PhD, Stein Clinical Research Building, Room 250, 9500 Gilman Dr 0628, La Jolla, CA 92093-0628 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted August 3, 2014.
contributed to the data analysis plan, development of measures, and the interpretation of the results. W. K. Al-Delaimy oversaw the data analysis plan, the interpretation of the results, and the drafting of the article. All of the authors contributed to revisions of the article.
Acknowledgments Data collection for the California Smokers Cohort was supported by the California Department of Public Health (contract 12-10046). We dedicate this article to Debi Austin (the spokeswoman in the “Stages” advertisement). Debi lost her battle with lung cancer on February 22, 2013. She will be greatly missed but continues to inspire many with her story. We thank Mary Modayil and Sandra Soria of the California Tobacco Control Program for their assistance in providing data on the advertisements and state media programs.
Human Participant Protection Ethical approval for the California Smokers Cohort was provided by the Human Subjects Protection Committee of the University of California, San Diego. Participants provided verbal informed consent to take part in the study.
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Contributors
8. World Health Organization. Guidelines for implementation of Article 12 of the WHO Framework Convention on Tobacco Control. Available at: http://www. who.int/fctc/guidelines/Decision.pdf?ua=1. Accessed October 20, 2014.
E. C. Leas conceptualized the analyses, conducted the literature review, analyzed the data, and drafted the article. M. G. Myers, D. R. Strong, and C. R. Hofstetter
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27. Nonnemaker JM, Farrelly MC, Kamyab K, MacMonegle AJ. Do different styles of antismoking ads influence the types of smokers who call quitlines? Health Educ Res. 2013;28(1):23---30. 28. Farrelly M, Mann N, Watson K, Pechacek T. The influence of television advertisements on promoting calls to telephone quitlines. Health Educ Res. 2013;28(1): 15---22. 29. Farrelly MC, Davis KC, Nonnemaker JM, Kamyab K, Jackson C. Promoting calls to a quitline: quantifying the influence of message theme, strong negative emotions and graphic images in television advertisements. Tob Control. 2011;20(4):279---284. 30. Langley T, Szatkowski L, Lewis S, et al. The freeze on mass media campaigns in England: a natural experiment of the impact of tobacco control campaigns on quitting behaviour. Addiction. 2014;109(6):995---1002. 31. Sims M, Salway R, Langley T, et al. Effectiveness of tobacco control television advertising in changing tobacco use in England: a population-based cross-sectional study. Addiction. 2014;109(6):986---994.
43. Hastings G, Stead M, Webb J. Fear appeals in social marketing: strategic and ethical reasons for concern. Psychol Marketing. 2004;21(11):961---986. 44. Biener L, Wakefield M, Shiner CM, Siegel M. How broadcast volume and emotional content affect youth recall of anti-tobacco advertising. Am J Prev Med. 2008;35(1):14---19. 45. Donovan RJ, Boulter J, Borland R, Jalleh G, Carter O. Continuous tracking of the Australian National Tobacco Campaign: advertising effects on recall, recognition, cognitions, and behaviour. Tob Control. 2003;12(suppl 2):ii30---ii39. 46. Terry-McElrath Y, Wakefield M, Ruel E, et al. The effect of antismoking advertisement executional characteristics on youth comprehension, appraisal, recall, and engagement. J Health Commun. 2005;10(2):127---143. 47. Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. Am J Public Health. 2009;99(12):2217---2223.
32. Davis KC, Farrelly MC, Duke J, Kelly L, Willett J. Antismoking media campaign and smoking cessation outcomes, New York State, 2003---2009. Prev Chronic Dis. 2012;9:E40.
48. Niederdeppe J, Farrelly MC, Nonnemaker J, Davis KC, Wagner L. Socioeconomic variation in recall and perceived effectiveness of campaign advertisements to promote smoking cessation. Soc Sci Med. 2011;72 (5):773---780.
33. Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health. 2008;98(8):1443---1450.
49. Stewart HS, Bowden JA, Bayly MC, et al. Potential effectiveness of specific anti-smoking mass media advertisements among Australian Indigenous smokers. Health Educ Res. 2011;26(6):961---975.
34. Farrelly MC, Duke JC, Davis KC, et al. Promotion of smoking cessation with emotional and/or graphic antismoking advertising. Am J Prev Med. 2012;43(5): 475---482.
50. Wakefield M, Bayly M, Durkin S, et al. Smokers’ responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries. Tob Control. 2013;22(1):24---31.
35. Hu TW, Sung HY, Keeler TE. Reducing cigarette consumption in California: tobacco taxes vs an antismoking media campaign. Am J Public Health. 1995;85 (9):1218---1222.
51. Biener L. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think. Tob Control. 2002;11(suppl 2):ii43---ii46.
36. White VM, Durkin SJ, Coomber K, Wakefield MA. What is the role of tobacco control advertising intensity and duration in reducing adolescent smoking prevalence? Findings from 16 years of tobacco control mass media advertising in Australia. Tob Control. 2013 [Epub ahead of print]. 37. World Health Organization. Global Health Observatory Data Repository: anti-tobacco mass media campaign data by country. Available at: http://apps.who.int/ gho/data/node.main.1289?lang=en. Accessed October 20, 2014. 38. Department of Finance Appropriations for Prop 99 Budgets. Sacramento, CA: California Department of Public Health; 2014. 39. Hammond D, Wakefield M, Durkin S, Brennan E. Tobacco packaging and mass media campaigns: research needs for Articles 11 and 12 of the WHO Framework Convention on Tobacco Control. Nicotine Tob Res. 2013;15(4):817---831. 40. Hill D, Chapman S, Donovan R. The return of scare tactics. Tob Control. 1998;7(1):5---8. 41. Nabi RL. A cognitive-functional model for the effects of discrete negative emotions on information processing, attitude change, and recall. Commun Theory. 1999;9 (3):292---320. 42. Hastings G, MacFadyen L. Controversies in tobacco control: the limitations of fear messages. Tob Control. 2002;11(1):73---75.
59. Hornik R, Yanovitzky I. Using theory to design evaluations of communication campaigns: the case of the National Youth Anti-Drug Media Campaign. Commun Theory. 2003;13(2):204---224. 60. Zielske HA. The remembering and forgetting of advertising. J Marketing. 1959;23(3):239---243. 61. Zielske HA, Henry WA. Remembering and forgetting television ads. J Advert Res. 1980;20(2):7---13. 62. Al-Delaimy WK, Norman G, Wivagg J. Technical Report on Analytic Methods and Approaches Used in the 2011 California Smokers Cohort Analysis: Data Collection Methodology. Vol 1. La Jolla, CA: University of California, San Diego; 2014. 63. Al-Delaimy WK, Norman G, Wivagg J. Technical Report on Analytic Methods and Approaches Used in the 2011 California Smokers Cohort Analysis: Statistical Methodology. Vol 2. La Jolla, CA: University of California, San Diego; 2014. 64. California Tobacco Control Program. Working to inspire social change. Available at: http://tobaccofreeca. com/ads/about. Accessed October 20, 2014. 65. Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162(3):199---200. 66. Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702---706. 67. Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting to the truth: evaluating national tobacco countermarketing campaigns. Am J Public Health. 2002;92(6):901---907. 68. US Department of Health and Human Services. Best practices for comprehensive tobacco control programs. Available at: http://www.cdc.gov/tobacco/ stateandcommunity/best_practices/pdfs/2014/ comprehensive.pdf. Accessed October 20, 2014.
52. Biener L, Ji M, Gilpin EA, Albers AB. The impact of emotional tone, message, and broadcast parameters in youth anti-smoking advertisements. J Health Commun. 2004;9(3):259---274. 53. Wakefield M, Durrant R, Terry-McElrath Y, et al. Appraisal of anti-smoking advertising by youth at risk for regular smoking: a comparative study in the United States, Australia, and Britain. Tob Control. 2003;12(suppl 2):ii82---ii86. 54. Biener L, McCallum-Keeler G, Nyman AL. Adults’ response to Massachusetts anti-tobacco television advertisements: impact of viewer and advertisement characteristics. Tob Control. 2000;9(4):401---407. 55. Davis KC, Nonnemaker JM, Farrelly MC, Niederdeppe J. Exploring differences in smokers’ perceptions of the effectiveness of cessation media messages. Tob Control. 2011;20(1):26---33. 56. Cowling DW, Modayil MV, Stevens C. Assessing the relationship between ad volume and awareness of a tobacco education media campaign. Tob Control. 2010;19 (suppl 1):i37---i42. 57. Niederdeppe J. Assessing the validity of confirmed ad recall measures for public health communication campaign evaluation. J Health Commun. 2005;10 (7):635---650. 58. Southwell BG, Barmada CH, Hornik RC, Maklan DM. Can we measure encoded exposure? Validation evidence from a national campaign. J Health Commun. 2002;7(5):445---453.
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Recall of Anti-Tobacco Advertisements and Effects on Quitting Behavior: Results From the California Smokers Cohort Eric C. Leas, MPH, Mark G. Myers, PhD, David R. Strong, PhD, C. Richard Hofstetter, PhD, and Wael K. Al-Delaimy, MD, PhD
Globally, one person dies from exposure to tobacco smoke every 6 seconds.1 Even in the United States, tobacco smoke exposure remains the leading cause of preventable death, with an estimated 480 000 adults dying from tobacco smoke exposure each year.2 Although the effects of tobacco smoke exposure are most severe among individuals who smoke on a daily basis, nondaily smoking and secondhand smoke exposure can lead to the same negative health consequences that result from daily smoking.3 Increasing smoking cessation, however, can significantly improve life expectancy; lower the risk of cancer, diabetes, heart disease, and lung disease; and, among women, lower the risk of infertility or low-birthweight children.2,4---7 Although the benefits of cessation are most prominent among the young, cessation at any age can immediately improve health outcomes.4 It is recommended that tobacco control programs develop mass-reach health communication interventions to increase cessation among current smokers and reduce smoking initiation among nonsmokers.8 There are multiple pathways through which mass media are intended to promote cessation, including directly marketing cessation assistance to smokers, changing public opinions about tobacco use to create a social norm against smoking, and increasing interpersonal discussions about tobacco use.9---11 The majority of evidence indicates that these mass media campaigns are effective in motivating individuals to think about quitting, make quit attempts, obtain help in quitting, and maintain abstinence.12---31 At the population level, advertisements are also associated with decreases in cigarette consumption and smoking prevalence.13,15,16,19,32---36 The magnitude of the effect of media campaigns on cessation is estimated to be relatively small; however, when
Objectives. We assessed whether an anti-tobacco television advertisement called “Stages,” which depicted a woman giving a brief emotional narrative of her experiences with tobacco use, would be recalled more often and have a greater effect on smoking cessation than 3 other advertisements with different intended themes. Methods. Our data were derived from a sample of 2596 California adult smokers. We used multivariable log-binomial and modified Poisson regression models to calculate respondents’ probability of quitting as a result of advertisement recall. Results. More respondents recalled the “Stages” ad (58.5%) than the 3 other ads (23.1%, 23.4%, and 25.6%; P < .001). Respondents who recalled “Stages” at baseline had a higher probability than those who did not recall the ad of making a quit attempt between baseline and follow-up (adjusted risk ratio [RR] = 1.18; 95% confidence interval [CI] = 1.03, 1.34) and a higher probability of being in a period of smoking abstinence for at least a month at follow-up (adjusted RR = 1.55; 95% CI = 1.02, 2.37). Conclusions. Anti-tobacco television advertisements that depict visceral and personal messages may be recalled by a larger percentage of smokers and may have a greater impact on smoking cessation than other types of advertisements. (Am J Public Health. 2015;105:e90–e97. doi:10.2105/AJPH.2014.302249)
this small effect is applied across an entire population, the reductions can be very meaningful. The United States Centers for Disease Control and Prevention (CDC), for example, recently estimated that its Tips From Former Smokers (TIPS) national ad campaign led to 1.64 million quit attempts and more than 100 000 Americans quitting smoking in just 1 year.19 Despite this current weight of evidence and the recommendations of Article 12 of the Framework Convention on Tobacco Control,8 there are several barriers that make it difficult for many countries to develop mass media campaigns.37 One of the main barriers is the expense of developing and airing advertisements. To provide a perspective, CDC reported receiving $54 million in US federal funding to carry out the TIPS campaign,19 and since the launch of the California Tobacco Control Program (CTCP) in 1990, approximately $464 million has been spent on mass media campaigns in California, with $13.4 million currently being spent annually.38 In funding
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climates that are restrictive, tobacco control programs may be able to reduce costs by focusing on high-impact advertisements.39 In the past decade, tobacco control advocates have begun promoting the use of mass media that rely on emotional messages, deal with the health consequences of smoking, or use personal narratives to convey their messages. These advertisements are intended to promote behavior change by evoking visceral reactions of sadness, fear, disgust, or anger in what has been referred to as a “fear appeal.”40,41 Although this concept of “scaring” smokers into quitting is anathema to many public health advocates,42,43 several researchers have demonstrated that advertisements that deal with the negative consequences of smoking in an emotionally evocative or personal way are effective. They are typically recalled more frequently even when they are aired at lower volumes,44---46 they reach socioeconomic groups equitably,34,47---50 and they are typically rated as more effective than advertisements with different themes.44,46,50---55 In addition, they promote more frequent use of quit
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lines12,14,26,29,47 and confer greater effects on quitting behavior.12,14,26,27,29,34,47---50 Thus far, evaluations of fear appeal advertisements have predominantly relied on grouplevel measures of exposure rather than individual-level measures of recognition. Exposure, in evaluations of advertisements, typically refers to whether a person has viewed an advertisement, but it does not necessarily imply that the person processed the message or remembered the ad. Exposure is usually estimated via group-level measures (e.g., Nielsen ratings or gross rating points) that assess the average number of people in a given population who are likely to have viewed an advertisement.56---58 These group-level measures can be very valuable to public health programs in their assessments of how well an advertisement is reaching a population; however, when behavior change resulting from advertisements is assessed at the individual level, these group-level instruments serve only as ecological measures. By contrast, advertisement recall, a measure of an individual’s recognition of an advertisement, may reduce the possibility of ecological bias and serves as an indicator of message processing, an expected direct effect of exposure to mass media campaigns.59 Although ad recall has long been used in mass media evaluations,12,60,61 to our knowledge it has not been employed in evaluations of behavior change resulting from fear appeal advertisements. We sought to provide further evidence for the use of advertisements that deal with the health consequences of smoking in a personal and emotional way by assessing recall of 4 anti-tobacco television advertisements developed by the CTCP and demonstrating the effects of recall of these ads on smoking cessation. We tested the following hypotheses: an ad called “Stages” that depicted a woman giving a personal narrative of her negative experiences with tobacco use would be recalled more often than 3 other ads with different intended themes among the current smokers in our cohort (hypothesis 1); recall of “Stages” would be distributed more equitably across individual characteristics in multivariable analyses than would recall of the 3 other ads (hypothesis 2); and recall of “Stages” would have a greater effect on cessation than recall of the 3 other ads (hypothesis 3).
METHODS Our analyses were based on a sample of adults (18---64 years old) from the 2011---2012 California Smokers Cohort (CSC) who entered the cohort as “current smokers” (i.e., they reported both smoking 100 cigarettes in their lifetime and currently smoking at least “some days” at baseline). The methodology for the CSC has been described elsewhere.62,63 Briefly, the CSC is a survey of a populationbased sample of adults in California who reported smoking 100 cigarettes in their lifetime. Interviews were conducted via landline and cell phone in both English and Spanish. At baseline, 4350 interviews were completed between July 26, 2011, and April 29, 2012. As a means of ascertaining changes in smoking behavior, follow-up interviews were conducted with 1745 baseline respondents. All follow-up interviews were completed between November 6, 2012, and January 16, 2013. Given that our analyses focused on current smokers, we excluded those who reported at baseline that they were former smokers by restricting the sample to include only individuals who reported smoking at least “some days” at baseline. The final sample consisted of 2596 respondents at baseline and 1000 respondents who completed follow-up interviews.
The Anti-Tobacco Commercials The CTCP has been producing television advertisements since its creation in 1990, with the following objectives: protecting people from exposure to secondhand smoke and environmental tobacco, reducing youth access to tobacco products, countering tobacco industry influence, and promoting free cessation services64 (several advertisements are available for viewing online at http://tobaccofreeca. com/ads/tv, and the advertisements used in this study are described briefly in Table 1). The advertisements assessed in this study were selected because they were aired contemporaneously with the dates of the baseline assessments. Not all advertisements we assessed had the same objectives. The ads titled “Trapped” and “Don’t Stop Fighting” aired during the daytime at lower volumes and were designed to market cessation assistance, whereas the other 2 ads, “Stages” and “The Emerging Man,” aired multiple times throughout the day at
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higher volumes, with messages aimed at changing opinions about the tobacco industry and fostering support for tobacco control.
Measures Advertisement recall. After listening to a onesentence description for each advertisement, all CSC respondents were asked whether or not they recalled having seen the ad in the past 60 days. In our analyses, we used the answers to each of these questions separately and also constructed a new variable focused on recall of at least one of the ads (yes or no). All of the advertisements we assessed had been airing for at least 65 days at the start of the baseline assessment and aired throughout the entire baseline assessment (Table 1). In our first analysis, we used advertisement recall as an outcome variable to assess characteristics associated with recall. In our second analysis, we assessed whether advertisement recall was predictive of quitting behavior at follow-up. We did not include a measure of advertisement exposure and instead made the assumption that those who recalled an ad had been exposed to it. Quitting behavior. Two types of quitting behavior were assessed in this study. We defined a quit attempt as intentional cessation for at least 1 day between baseline and followup, and we defined cessation as being abstinent from smoking for at least 1 month at the time of the follow-up. Covariates. The covariates we used were based on previous literature and included age (18---44 years, 45---64 years), education (less than college, some college, college or more), gender, ethnicity (Hispanic, non-Hispanic White, all other ethnic backgrounds), presence in the household of children younger than 18 years (yes or no), presence of other smokers in the household (yes or no), and addiction as measured by time to first cigarette in the morning (within 30 minutes, more than 30 minutes).
Statistical Analyses Descriptive statistics for all of the variables included are detailed in Table 2. We used frequencies and percentages to evaluate differences in average recall of each advertisement within the baseline sample of smokers. To test hypothesis 1, we used a multivariate analysis of variance to assess the statistical significance of differences in average recall across ads.
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TABLE 1—Characteristics of the 4 Anti-Tobacco Advertisements Assessed Title (Dates Aired; Rating Points)
Still Frame of Advertisement
Description of Advertisement This ad shows a young Debi Austin as the real Debi is heard speaking from the present. She
“Stages” (January 10, 2011–
explains how the tobacco industry targeted her early on, when she started smoking cigarettes
May 1, 2012; 800)
at just 13 years old. The ad transitions to modern Debi after a stoma appears in the mirrored reflection of young Debi—a health effect from cancer surgery caused by smoking—and she warns viewers not to be the tobacco industry’s next victim. See the advertisement at https:// www.youtube.com/watch?v=56OD-Qi3aAA. The internal struggle of a smoker is depicted by 2 men, identical in appearance, sitting on
“Don’t Stop Fighting” (May 23, 2011–
a sofa in a living room. The first man eyes a pack of cigarettes across the living room as the
August 5, 2012; 200)
second man watches. The first man lunges for the cigarette pack and is immediately tackled by the second man, who is trying to keep him from reaching the cigarettes. While the 2 men wrestle, a woman reading nearby is oblivious to the struggle. The viewer is told: “Quitting is a fight you can’t let yourself lose. It can take many tries, but keep trying and you will beat smoking.”
Only in Spanish: This is a representation of how people who are addicted to cigarettes are
“Trapped” (November 1, 2010–
literally trapped. No matter how hard they try to escape, they just simply cannot do it. The
June 27, 2012; 150)
screen is white. It is a Lycra limbo from which forms are seen emerging, first one hand and then another. Next can be seen the shape of a person’s head and torso, desperately trying to escape. The camera zooms back and shows that the person is trapped inside a gigantic cigarette, with an enormous smoke-filled black background. The camera continues pulling back, and it can be seen that more people are in the same situation. A landscape is shown made of cigarettes with people trapped inside. An announcer can be heard asking viewers whether they are trapped and unable to escape their addiction to cigarettes. The light at the end of the tunnel is the helpline. The ad’s spokesperson describes California’s successes in reducing the harm caused by
“The Emerging Man” (January 10, 2011–
tobacco as he travels through settings, such as a pizza kitchen and a hospital waiting room, that illustrate his points. He explains that “California should be proud. We were the first to
June 12, 2012; 975)
ban smoking on airplanes and the first to have smoke-free bars and restaurants, all while saving over $86 billion in health care costs and over 1 million lives.” The ad ends with the man cradling a baby in a hospital nursery while stating: “But even if you were born today, you’d still grow up in a world where tobacco kills more people than AIDS, drugs, alcohol, murder, and car crashes combined. We have a lot more work to do.”
To assess characteristics of the individuals recalling each advertisement, we calculated adjusted risk ratios (RRs) via 5 separate multivariable log-binomial regression models65 that simultaneously adjusted for all covariates. To test hypothesis 2, we evaluated the magnitude and significance of each individual characteristic across the 5 models to determine the characteristics associated with recall of specific ads. Similarly, we used 5 multivariable logbinomial and 5 modified Poisson regression models (one for each combination of ad recall and quitting behavior) to assess the effects of
advertisement recall on quitting behavior at follow-up. We used a modified Poisson model with robust variance error66 rather than a logbinomial model to calculate the adjusted risk ratio for prolonged smoking abstinence so that we could achieve model convergence and provide more conservative variance estimates given the rarity of our outcomes. All analyses assessing the effects of ad recall on quitting behavior were prospective, with ad recall measured at baseline (when the advertisements were aired) and quitting behavior assessed at follow-up.
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We used SAS version 9.3 for Windows 7 (SAS Institute Inc, Cary, NC) in conducting all of our analyses. The level of statistical significance was defined as a < .05.
RESULTS At baseline, CSC respondents were mostly older than 45 years (62.6%) and non-Hispanic White (69.4%), had some college education or had graduated from college (61.7%), did not live with children younger than 18 years (66.0%), and smoked within 30 minutes after
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TABLE 2—Characteristics of Respondents in the California Smokers Cohort: 2012–2013 Characteristic
Baseline (n = 2596), %
Follow-Up (n = 1000), %
Recall of Advertisements
Age, y 18–44
37.4
30.2
45–64
62.6
69.8
Education Less than college
38.3
34.8
Some college
41.6
44.9
College or above
20.1
20.3
Male
49.8
47.8
Female
50.2
52.2
Hispanic Non-Hispanic White
14.1 69.4
9.9 72.6
All other
16.5
17.5
Gender
Ethnicity
Children present in household Yes
33.9
28.7
No
66.0
71.3
Other smokers present in household Yes No Time to first cigarette in the morning
51.7
51.0
48.2
49.0
Within 30 minutes
56.7
59.5
More than 30 minutes
43.3
40.5
Saw “Trapped” advertisement Yes
23.1
...
No
76.4
...
25.6 73.8
... ...
Saw “Don’t Stop Fighting” advertisement Yes No Saw “The Emerging Man” advertisement Yes
23.4
...
No
75.9
...
Saw “Stages” advertisement Yes
58.5
...
No
40.5
...
Saw any of the 4 ads Yes
69.5
...
30.5
...
Yes
...
47.4
No
...
52.5
No
waking up in the morning (56.7%) (Table 2). About half (51.7%) of the respondents lived with other people who smoked cigarettes.
Quit attempt between baseline and follow-up
Prolonged smoking abstinence for 1 month at follow-up Yes
...
9.4
No
...
90.6
Note. For each advertisement, respondents were asked whether they had seen the ad in the 60 days preceding the interview. A multivariate analysis of variance indicated a significant difference (P < .001) in average recall across all advertisements.
The majority of respondents in the baseline sample mentioned that they recalled at least one of the ads assessed here in the 60 days before their interview (69.5%). Substantially more respondents recalled seeing the “Stages” advertisement (58.5%) than the other 3 advertisements being aired during the same period (23.1%, 23.4%, and 25.6%; P < .001). Respondents who had graduated from college were less likely than those with less than a college education to recall seeing any of the advertisements we assessed (adjusted RR range = 0.62---0.86), although there were some variations in the significance of this association (Table 3 ). Other than the association with education, none of the other variables we assessed were associated with recalling the “Stages” advertisement. This was not the case for the other advertisements, however. The probability of recalling the advertisement titled “The Emerging Man” was higher among those who were older than 45 years (vs 18---44 years; adjusted RR = 1.31; 95% confidence interval [CI] = 1.12, 1.54) and lower among women (vs men; adjusted RR = 0.77; 95% CI = 0.67, 0.89). The probability of recalling “Don’t Stop Fighting” was higher among those with ethnic minority backgrounds (vs non-Hispanic Whites), including Blacks, Asians, and all others (adjusted RR = 1.43; 95% CI = 1.22, 1.67), and lower among those who reported that children were living in their household (vs no children in the household; adjusted RR = 0.85; 95% CI = 0.73, 0.99). The probability of recalling “Trapped” was lower among those who had some college education (vs less than a college education; adjusted RR = 0.85; 95% CI = 0.73, 0.99) and higher among Hispanics (vs non- Hispanic Whites; adjusted RR = 1.33; 95% CI = 1.11, 1.61). In assessments of recall of any ads versus no ads, the response pattern closely reflected that of recall of “Stages” (Table 3).
Advertisement Recall as a Predictor of Cessation at Follow-Up Of the 5 advertisement recall measures we used, only one predicted quitting behavior at
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TABLE 3—Adjusted Risk Ratios for Advertisement Recall Among Respondents in the California Smokers Cohort: 2012–2013 Characteristic
“Trapped,” Adjusted RR (95% CI)
“Don’t Stop Fighting,” Adjusted RR (95% CI)
“The Emerging Man,” Adjusted RR (95% CI)
“Stages,” Adjusted RR (95% CI)
Any of the 4 Ads, Adjusted RR (95% CI)
Age, y 18–44 (Ref)
1.00
1.00
45–64
1.00 (0.86, 1.16)
1.15 (0.99, 1.33)
Education Less than college (Ref) Some college College or more
1.00
1.00 1.31** (1.12, 1.54)
1.00
1.00
0.97 (0.91, 1.04)
1.02 (0.96, 1.08)
1.00
1.00
1.00
1.00
0.85* (0.73, 0.99)
0.91 (0.79, 1.06)
0.93 (0.8, 1.09)
0.97 (0.91, 1.05)
0.97 (0.92, 1.02)
0.64*** (0.51, 0.80)
0.72*** (0.59, 0.88)
0.86*** (0.78, 0.95)
0.84*** (0.78, 0.91)
0.80* (0.65, 0.98)
Gender Male (Ref)
1.00
1.00
1.00
1.00
Female
1.13 (0.98, 1.31)
1.15 (1.00, 1.31)
0.77*** (0.67, 0.89)
1.00
1.04 (0.98, 1.11)
1.03 (0.98, 1.09)
1.33** (1.11, 1.61) 1.00
1.04 (0.85, 1.27) 1.00
0.96 (0.78, 1.19) 1.00
0.99 (0.90, 1.10) 1.00
0.99 (0.92, 1.07) 1.00
1.12 (0.92, 1.35)
1.43*** (1.22, 1.67)
1.05 (0.87, 1.26)
1.05 (0.96, 1.14)
1.05 (0.98, 1.12)
Yes
0.94 (0.81, 1.10)
0.85* (0.73, 0.99)
0.87 (0.74, 1.02)
0.96 (0.89, 1.03)
0.98 (0.93, 1.04)
No (Ref)
1.00
1.00
1.00
1.00
1.00
1.07 (0.93, 1.23)
1.04 (0.91, 1.19)
1.07 (0.93, 1.23)
1.04 (0.97, 1.11)
1.01 (0.95, 1.06)
1.00
1.00
1.00
1.00
1.00
Ethnicity Hispanic Non-Hispanic White (Ref) All other Children present in household
Other smokers present in household Yes No (Ref) Time to first cigarette in the morning Within 30 minutes (Ref)
1.00
1.00
1.00
1.00
1.00
More than 30 minutes
0.90 (0.78, 1.04)
0.99 (0.87, 1.04)
0.93 (0.81, 1.08)
0.98 (0.91, 1.04)
0.97 (0.92, 1.02)
Note. RR = risk ratio; CI = confidence interval. The sample size was n = 2596. Separate models were constructed for each advertisement, and all modeled risk ratios were simultaneously adjusted for all covariates. *P £ .05; **P £ .01; ***P £ .001.
follow-up (Figure 1 ). Those who recalled seeing “Stages” had a significantly higher probability of making a quit attempt between baseline and follow-up than those who did not recall seeing the ad (adjusted RR = 1.18; 95% CI = 1.03, 1.34) and a significantly higher probability of being in a period of prolonged smoking abstinence at follow-up (adjusted RR = 1.55; 95% CI = 1.02, 2.37). The advertisements designed to market cessation to smokers (“Trapped” and “Don’t Stop Fighting”) were not associated with either quit attempts or prolonged abstinence at follow-up, nor was recalling any as opposed to none of the ads (Figure 1). Although the difference did not quite reach significance at the .05 level, respondents who recalled seeing “The Emerging Man” were less likely than those who saw the other ads to be in a period of prolonged abstinence at follow-up (adjusted RR = 0.61; 95% CI = 0.37, 1.03).
Recalling this ad did not appear to have a significant effect on respondents’ probability of making a quit attempt (adjusted RR = 0.97; 95% CI = 0.83, 1.13).
DISCUSSION In line with our hypotheses, the “Stages” advertisement, which depicted a woman giving an emotional narrative of her experiences with tobacco use, was recalled more frequently than the other 3 advertisements we assessed. In addition, this ad involved a more equitable distribution of recall across individual characteristics and had a greater impact on subsequent quitting behavior than the other ads. The higher reported recall of this advertisement might be partially explained by its number of rating points. The advertisement was aired more frequently than 2 of the other ads
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and therefore might have had a higher chance of being seen.56---58 However, rating points probably do not explain all recall; “The Emerging Man,” which depicted a man popping out of a pizza oven and fish tank while talking about California laws, had the most rating points but was among the least likely to be recalled. Given the intended theme of “Stages,” our results are consistent with previous studies indicating that advertisements that rely on emotional and personal portrayals of the health consequences of smoking are more likely to be recalled.44---46 This finding serves to reinforce the notion that this type of advertisement may achieve high recall even at lower broadcasting volumes, whereas other advertisement themes might require higher broadcasting volumes to achieve the same levels of recall.44 As anticipated, fewer differences were observed across individual characteristics in recall
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a
b 1.10
1.28
"Trapped"
"Trapped" 0.95
1.03
"Don't Stop Fighting"
"Don't Stop Fighting" 0.61
0.97
"The Emerging Man"
"The Emerging Man" 1.18
1.55
"Stages"
"Stages" 1.42
1.10
Recalled any of the above
Recalled any of the above
0
1
2
3
0
ARR (95% CI)
1
2
3
ARR (95% CI)
Note. ARR = adjusted risk ratio; CI = confidence interval. The sample size was n = 1000. Advertisement titles are in quotation marks and refer to 4 anti-smoking ads being aired on television in California. For panel b, we fit a modified Poisson model with robust variance error for prolonged smoking abstinence given the rarity of the outcome; 10 separate models were used, one for each combination of advertisement and quitting behavior. All modeled adjusted risk ratios simultaneously adjusted for age, education, gender, ethnicity, addiction, presence of children in the household, and presence of other smokers in the household.
FIGURE 1—Estimates of the effects of advertisement recall on (a) quitting smoking intentionally for at least 1 day and (b) abstaining from smoking for at least 1 month at follow-up: California Smokers Cohort, 2012–2013.
of “Stages” than in recall of the other 3 advertisements. Although recall of all of the advertisements was less common among those who had graduated from college, “Stages” was recalled at about the same level across all other characteristics assessed. In contrast, recall differed across several individual characteristics for the other advertisements. These findings may indicate that, unlike other themes, emotional or personal narratives of the health consequences of smoking may yield similar levels of recall among smokers across individual characteristics, including socioeconomic categories. Others have also found that this type of advertisement tests well across socioeconomic categories, in developing countries, and among indigenous groups.34,47---50 These results are promising and consistent, but we believe that such associations will need to be reconfirmed over time given that receptivity to particular advertisements or even categories of advertisements is unlikely to remain constant in all areas. Although we used recall rather than exposure to measure contact with advertisement campaigns, our findings and effect sizes are consistent with research indicating that exposure to graphic or emotional advertisements is associated with successful cessation outcomes.12,14,26,27,29,34,47---50 For example, the
content depicted in “Stages” is analogous to advertisements in the TIPS campaign conducted by CDC, which had a similar effect on quit attempts.19 McAfee et al. reported a substantial impact of self-reported exposure to any TIPS advertisement on making a quit attempt in the preceding 3 months, with an adjusted odds ratio of 1.18 (95% CI = 1.05, 1.34); their result was very similar to our estimate for any quit attempt in the past year among those who recalled the “Stages” advertisement (adjusted RR = 1.18; 95% CI = 1.03, 1.34).19 We have added to and supported the current literature by providing estimates of the effects of recall of specific advertisements rather than possible exposure to advertisements. Although the difference did not reach significance, respondents who recalled seeing “The Emerging Man” were less likely than those who saw the other ads to be in a period of prolonged smoking abstinence at follow-up. It may be that this advertisement elicited an unfavorable response among smokers in our cohort. Others have found that ads such as Philip Morris’ “Think, Don’t Smoke,” which used humor to make fun of smokers, are also less effective and even counterproductive in discouraging smoking.67 We raise this point to emphasize that media campaigns should exercise caution when choosing which anti-tobacco
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advertisements to air. Further populationbased studies focused on reactions to advertisements could better elucidate this topic.
Limitations Several important limitations of our study should be noted. Although the method we used to assess ad recall had the advantage of ascribing contact with advertisements at the individual level, differences in recall could have been affected by the summary wording used to describe a specific ad and the degree to which any wording could adequately convey the audiovisual cues and message content of that ad. In addition, although we asked respondents about television advertisements running in the 60-day interval before the baseline assessment, it is possible that recall bias resulted in an overestimation of the number of respondents exposed to “Stages,” given that the ad’s spokesperson (“Debi”) was part of a CTCP television advertisement series beginning in the mid-1990s. Repeated exposures to the same spokesperson over a long period might promote recall and thereby cessation, and this approach may be useful to explore in future evaluations of anti-smoking advertisements. Finally, given that very few respondents were in a period of smoking abstinence at follow-up, we had low power to detect
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associations between advertisement recall and quitting. However, our effect estimate of advertisement recall on quitting behavior at follow-up remained despite these possible attenuating biases, it is consistent in magnitude with estimates from other studies, and it is theoretically supported by the literature, thus serving to strengthen the validity of our analyses and results.
Conclusions We have provided further evidence that tobacco control programs may be able to reduce costs by focusing on high-impact advertisements. Although California’s annual expenditure on anti-tobacco media campaigns of $13.4 million is well below the CDC’s recommended $76.0 million (or even the $52.8 million minimum funding level),68 the CTCP mass media program appeared to be successful in terms of its intended effects on cessation among smokers in our cohort. Although the fear appeals depicted in advertisements such as “Stages” are not always a particularly popular method of advertising among public health professionals, we hope that our findings encourage tobacco control programs to consider adopting media campaigns that use highquality and engaging health communications targeting mass audiences. Even one television advertisement consisting of emotional messages and personal testimonials about the health consequences of smoking may encourage cessation among smokers from all socioeconomic groups. j
About the Authors Eric C. Leas, David R. Strong, and Wael K. Al-Delaimy are with the Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA. Mark G. Myers is with the Psychology Service, Veterans Affairs San Diego Healthcare System, and the Department of Psychiatry, University of California, San Diego. C. Richard Hofstetter is with the Graduate School of Public Health and the Department of Political Science, San Diego State University, San Diego, CA. Correspondence should be sent to Wael K. Al-Delaimy, MD, PhD, Stein Clinical Research Building, Room 250, 9500 Gilman Dr 0628, La Jolla, CA 92093-0628 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link. This article was accepted August 3, 2014.
contributed to the data analysis plan, development of measures, and the interpretation of the results. W. K. Al-Delaimy oversaw the data analysis plan, the interpretation of the results, and the drafting of the article. All of the authors contributed to revisions of the article.
Acknowledgments Data collection for the California Smokers Cohort was supported by the California Department of Public Health (contract 12-10046). We dedicate this article to Debi Austin (the spokeswoman in the “Stages” advertisement). Debi lost her battle with lung cancer on February 22, 2013. She will be greatly missed but continues to inspire many with her story. We thank Mary Modayil and Sandra Soria of the California Tobacco Control Program for their assistance in providing data on the advertisements and state media programs.
Human Participant Protection Ethical approval for the California Smokers Cohort was provided by the Human Subjects Protection Committee of the University of California, San Diego. Participants provided verbal informed consent to take part in the study.
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