Increasing the dose of television advertising in a national antismoking media campaign: results from a randomised field trial

Examining the influence of tobacco control mass media campaign expenditure on the association between motivation to stop smoking and quit attempts: A prospective study in England

OBJECTIVE

To explore whether expenditure on national tobacco control mass media campaigns moderates the association between motivation to stop smoking and future quit attempts.

METHOD

Data were from 2601 people who smoke participating in a population survey with 12-month follow-up between April 2015 and February 2021. We used logistic regression to test associations of (i) baseline level of motivation to stop smoking, (ii) mean monthly tobacco control mass media campaign expenditure in England between baseline and follow-up, and (iii) their interaction, on past-year quit attempts assessed at 12-month follow-up. Covariates included age, sex, occupational social grade, and region.

RESULTS

Between baseline and follow-up, 38.6% of participants made a quit attempt. Each one-point increase in baseline motivation to stop smoking was associated with 1.37 times greater odds (95%CI = 1.31-1.43) of making a quit attempt over 12-month follow-up. Each one standard deviation increase in tobacco control mass media expenditure between baseline and 12-month follow-up was associated with 13% greater odds of making a quit attempt (95%CI = 1.05-1.23). There was no significant interaction between mass media expenditure and motivation to stop on quit attempts (OR = 1.01, 95%CI = 0.97-1.05); the data provided strong evidence for the null (Bayes factors = 0.07 and 0.04 based on expected effect sizes of OR = 1.5 and OR = 0.67, respectively).

CONCLUSIONS

Among people who smoke, self-reported level of motivation to stop strongly predicted whether they made a quit attempt in the subsequent year. Increased expenditure on tobacco control mass media campaigns was associated with increased quit attempts. The association between motivation and quit attempts did not differ according to tobacco control mass media expenditure over this period.

Persuasive Messages, Social Norms, and Reactance: A Study of Masking Behavior during a COVID-19 Campus Health Campaign

Efforts by universities to reduce the spread of COVID-19 include health campaigns intended to encourage students to wear masks. While well-intended, these efforts may produce counter-persuasion (e.g., decrease masking) if they are seen as threatening individuals' freedom to choose. In a rolling cross-sectional study of one university campaign (n = 681), we found that the presence of the campaign did instigate a form of resistance known as reactance and that reactance was negatively associated with masking behavior. Masking was also diminished by the frequency with which respondents observed others not wearing a mask (anti-masking descriptive norm) and the frequency with which respondents observed others expressing disdain for masking (anti-masking injunctive norm). Most of these findings were magnified among students who identified as politically conservative. There was no evidence that the frequency of seeing others speak in favor of masks (pro-masking injunctive norm) produced an increase in masking. The results provide valuable theoretical insights into the causes of reactance and empirical evidence of the risks associated with student-oriented COVID safety campaigns.

Impact of the Tips From Former Smokers Anti-Smoking Media Campaign on Youth Smoking Behaviors and Anti-Tobacco Attitudes

INTRODUCTION

Anti-tobacco media campaigns can prevent youth smoking, but there is little research on how adult-targeted campaigns affect youth. We investigated the association between the Tips From Former Smokers (Tips) campaign and youth smoking behaviors and anti-tobacco attitudes, and variation by sex, race and/or ethnicity, or socioeconomic status.

AIMS AND METHODS

We used data from the monitoring of the future study, a nationally representative survey on 8th, 10th, and 12th graders, from 2013-2015. Quartiles of Tips gross rating points (GRPs) were used to estimate exposure. Youth smoking behavior outcomes included smoking prevalence, initiation, and susceptibility. The anti-tobacco attitude outcomes included the extent that anti-tobacco ads made participants (1) less favorable towards smoking or (2) less likely to smoke cigarettes. Modified Poisson regression models estimated average marginal effects; separate additive interactions between Tips GRP exposure and sex, race and/or ethnicity, parents' highest education, and college plans (12th graders only) were used to test for effect modification.

RESULTS

Tips GRPs were not associated with smoking behaviors within any grade. However, 12th graders in the highest quartile of Tips had a 7.0 percentage point higher probability (95% CI = 0.023-0.116) of responding that anti-tobacco ads made them less likely to smoke. Tips GRPs were associated with a lower probability of past 30-day smoking prevalence among 10th grade females, but not males (joint P-value = .002). No additional statistically significant interactions were found for any other outcomes for any grade.

CONCLUSIONS

This study revealed the potential for adult-targeted campaigns to increase youth's anti-smoking attitudes, but campaign exposure was not associated with smoking behaviors.

IMPLICATIONS

Few studies have examined the potential for anti-smoking media campaigns to influence audiences outside their targeted audience. In this study, we show the potential for adult-targeted campaigns to impact youth and suggest that Tips exposure may promote anti-smoking attitudes among youth.

The Effect of Tobacco Control Mass Media Campaigns on Smoking-Related Behavior Among People With Mental Illness: A Systematic Literature Review

INTRODUCTION

Tobacco control mass media campaigns (MMCs) can be effective generally, but little is known about their effects among people with mental illness. The objectives of this study were to systematically review: (1) Whether tobacco control MMCs affect smoking-related outcomes among people with mental illness. (2) Cost-effectiveness.

AIMS AND METHODS

Data sources: MEDLINE, Embase, PsycInfo, Web of Science, CINAHL, the Cochrane Library (searched March 2021), reference lists of included articles and relevant systematic reviews. Study eligibility criteria: Population: Adults with mental illness and experience of smoking tobacco and/or using other nicotine-containing products. Intervention/exposure: Tobacco control MMC messages. Comparator: No exposure, other tobacco control intervention(s), no comparator. Primary outcome: Changes in quitting behaviors. Study design: All primary research. Quantitative data were appraised using the EPHPP tool, qualitative data using CASP's Studies Checklist. Data were synthesized narratively.

RESULTS

Eight studies were included, seven were at high risk of bias. There was inconclusive evidence of the effect of MMCs on quit attempts and intentions to quit among people with mental illness. Increasing advertisement exposure did not increase quit attempts or intentions to quit among those with mental illness, however, increased exposure to an advertisement that addressed smoking and mental health did. None of the studies assessed cost-effectiveness.

CONCLUSIONS

Findings should be interpreted with caution as data are limited and of low or moderate quality. There is evidence to suggest that tobacco control MMCs have limited impact on those with mental illness, although campaigns that are specific to smoking and mental health may be effective.

IMPLICATIONS

There is a paucity of good-quality evidence of the effect of tobacco control MMC messages among people with mental illness. Careful consideration should be given to the design of future studies that evaluate MMCs in order to minimize the risk of bias, establish causality, and ensure the findings reflect real-world implementation. Further research should examine the need for MMC messages that address mental health.

Development and evaluation of a social marketing campaign to address methamphetamine use in Los Angeles County

Background

This study describes the development and impact of a social marketing campaign in early 2020 intended to prevent and reduce methamphetamine use in Los Angeles County (LAC). We used social marketing principles and the transtheoretical model to design the campaign, which was intended to avoid stigmatization of methamphetamine users and communicate compassion, empathy, and support.

Methods

To evaluate its impact, we collected cross-sectional online survey data post-campaign (n = 1,873) from LAC residents in population segments considered higher risk for methamphetamine use. We examine associations between campaign exposure and outcomes using bivariate analyses and binary logistic regression models, which control for the impact of the COVID-19 pandemic on methamphetamine use or likelihood of use.

Results

The analyses revealed that campaign exposure was associated with having more negative attitudes toward methamphetamine, calling LAC’s substance abuse service helpline, using methamphetamine fewer days, and considering abstaining. Frequency of exposure to campaign advertisements was positively associated with calling the helpline, suggesting a campaign dose effect. COVID-19-related factors were associated with using methamphetamine in the past 30 days.

Conclusions

Social marketing campaigns hold promise for impacting methamphetamine prevention and cessation behaviors. This study adds to the limited literature on mass marketing interventions to address this major health issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14180-y.

Exposure to e-cigarette health claims and association with e-cigarette use and risk perceptions: A cohort study of young adults

INTRODUCTION

E-cigarettes have been marketed illicitly as smoking cessation aids and reduced risk tobacco products in the United States. Our study assessed consumers' exposure to such claims and evaluated their impact on relative risk perceptions and e-cigarette use.

METHODS

Data are from the Assessment of the post-College Experience study, which followed a cohort of young adults since 2010 when they were college freshmen. We used data from survey waves 10 (fall 2017) through 14 (fall 2019) to assess past 6 month exposure to e-cigarette marketing that made smoking cessation or modified risk tobacco product (MRTP) claims. Logistic regression models examined if exposure to claims at waves 11 through 14 were predictors of e-cigarette use and relative risk perceptions at wave 14.

RESULTS

Exposure to MRTP (28.4% to 40.1%) and cessation claims (29.1% to 46.6%) increased, with participants reporting more exposure to cessation than MRTP claims at each wave. Multiple exposures were associated with perceptions that e-cigarettes are less harmful compared to cigarettes (Cessation: AOR = 1.12, CI: 1.01-1.23; p = 0.025; MRTP: AOR = 1.16; CI: 1.05-1.29; p = 0.003). Neither claim type was associated with past 30-day e-cigarette use. Claim exposure did not increase e-cigarette initiation among never e-cigarette users. However, current cigarette smokers who had never used e-cigarettes at wave 10 had 2.5 higher odds of initiating e-cigarette use by wave 14 for each exposure to a cessation claim (AOR = 2.53; CI: 1.43-4.45; p = 0.001).

CONCLUSIONS

Young adults reported increasing exposure to unauthorized e-cigarette health claims. Exposure was associated with reduced relative risk perceptions, but was not associated with past 30-day e-cigarette use. Cessation claims may motivate current cigarette smokers to try e-cigarettes.

Integrated Multicultural Media Campaign to Increase COVID-19 Education and Vaccination Among Californians, 2021

Despite the availability of safe, effective COVID-19 vaccines, many remain unvaccinated or partially vaccinated. In 2021, the California Department of Public Health launched a California-wide integrated multicultural vaccine media campaign. The campaign was evaluated in two waves through online surveys with adults (n = 1594; n = 1575). Campaign exposure was associated with looking for vaccine information, visiting a state vaccine Web site, and becoming fully vaccinated during the campaign. Higher campaign exposure was associated with greater odds of vaccine engagement. (Am J Public Health. Published online ahead of print August 11, 2022:e1-e5. https://doi.org/10.2105/AJPH.2022.306974).

Optimising tobacco control campaigns within a changing media landscape and among priority populations

Reviews published over the past decade confirm tobacco control campaigns can be effective for influencing adult and youth tobacco use behaviours, with strengthening evidence for high cost-effectiveness. Evidence is also accumulating for positive campaign effects on interpersonal discussions, social norms and policy support that can help motivate and sustain quitting and reduce uptake. Research needs over the next decade centre on the rapidly changing media environment and the equity of campaign effects among high smoking prevalence communities. The field needs specific evidence on: how to measure total campaign reach and frequency across the diverse range of media platforms and channels; the optimum mix of traditional, digital and social media to achieve behaviour change, especially among high smoking prevalence communities; the relative reach and impact of the wide variety of integrated, digital and social media message delivery methods; the relative effectiveness of messages that aim to build capacity to quit and optimum methods for combining motivational and capacity-building messages, especially for high prevalence groups who face additional barriers to staying quit; the ongoing effectiveness of traditional versus new versions of messages highlighting tobacco industry practices; the influence of e-cigarette use on tobacco control campaign effects; and the effectiveness of different types of campaigns aiming to prevent e-cigarette uptake and motivate e-cigarette cessation. Research is also needed to investigate the potential for campaigns to influence the public's understanding and support for endgame tobacco control policies and for campaign elements that may influence the social and environmental contexts surrounding smokers that support and maintain behaviour change.

A comparison of self-reported exposure to fast food and sugary drinks marketing among parents of children across five countries

Exposure to unhealthy food and beverage marketing is an important environmental determinant of dietary intake. The current study examined self-reported exposure to marketing of unhealthy foods and beverages across various media channels and settings among parents of children younger than 18 years in five high and upper-middle income countries. Data from 4827 parents living with their children were analyzed from the International Food Policy Study (2017), a web-based survey of adults aged 18-64 years from Canada, the United States (US), the United Kingdom (UK), Australia, and Mexico. Respondents reported their exposure to marketing of fast food and of sugary drinks across media channels/settings overall and how often they see fast food and sugary drink marketing while viewing media with their children. Regression models examined differences across countries and correlates of marketing exposure. Parents in Mexico and the US reported greater exposure to marketing for fast food and sugary drinks compared to parents in Australia, Canada, and the UK. Patterns of exposure among parents were generally consistent across countries, with TV, digital media, and radio being the most commonly reported media channels for both fast food and sugary drinks. Exposure to marketing of fast food and sugary drinks was associated with a variety of sociodemographic factors, most strongly with ethnicity and education, and sociodemographic trends differed somewhat between countries. The findings demonstrate differences in self-reported parental exposure to marketing of fast food and sugary drinks between countries, and may help to evaluate the impact of marketing restrictions implemented over time.

Effect of Cigarette Constituent Messages With Engagement Text on Intention to Quit Smoking Among Adults Who Smoke Cigarettes: A Randomized Clinical Trial

IMPORTANCE

The US Food and Drug Administration (FDA) is required to communicate the risks of tobacco constituents to the public. Few studies have addressed how FDA media campaigns can effectively communicate about cigarette smoke constituents.

OBJECTIVE

To examine whether messages about cigarette smoke constituents are effective in reducing smoking intentions and behaviors among adults who smoke.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled participants who were aged between 18 and 65 years, were English speakers, were living in the United States, and who smoked at least 100 cigarettes during their lifetime and now smoked every day or some days. Participants received daily messages via email for 15 days. Participants were randomized to 1 of 2 message conditions or a control group and reported their previous-day smoking behaviors daily. Follow-up surveys were conducted on days 16 and 32. Data were collected from June 2017 to April 2018 and analyzed from April to September 2018.

INTERVENTIONS

The 3 groups were (1) constituent plus engagement messages (eg, "Cigarette smoke contains arsenic. This causes heart damage.") that included the FDA as the source and engagement text (eg, "Within 3 months of quitting, your heart and lungs work better. Ready to be tobacco free? You can quit. For free nicotine replacement, call 1-800-QUIT-NOW"); (2) constituent-only messages that did not list the FDA as the source or include engagement text; and (3) a control condition with messages about littering cigarette butts.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in quit intentions (range, 1-4, with higher scores indicating stronger intentions) from pretest to day 16. Secondary outcome measures included daily smoking behaviors and quit attempts.

RESULTS

A total of 789 participants (mean [SD] age, 43.4 [12.9] years; 483 [61.2%] women; 578 [73.3%] White; 717 [90.9%] non-Hispanic) were included in the study. The mean (SD) quit intention score was 2.5 (0.9) at pretest. Mean (SE) change in quit intention score from pretest to day 16 was 0.19 (0.07) points higher in the constituent plus engagement condition than in the control condition (P = .005) and 0.23 (0.07) points higher in the constituent-only condition compared with the control condition (P = .001). Participant reports of cigarettes smoked, forgone, and butted out were similar across study conditions at baseline and did not differ significantly at days 16 and 32 across study conditions. Viewing more messages was associated with an estimated decrease of 0.15 (SE, 0.01) cigarettes smoked per day per message viewed overall across conditions.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first longitudinal test of cigarette constituent campaign messages in a national sample of adults who currently smoke. Messages about cigarette smoke constituents, with or without engagement text and source information, increased participants' intentions to quit, lending support to FDA efforts to educate consumers about such constituents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03339206.

Impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions

BACKGROUND

While price increases and targeted cessation support have been found to reduce inequalities in smoking by socioeconomic status (SES), evidence on other measures is mixed. We aimed to update the most recent (2014) previous review by identifying and appraising evidence published since 2013 on the equity impact of population tobacco control measures.

METHODS

Systematic searching of 10 electronic databases and hand-searching of four key journals identified 68 primary research articles published since 2013 that sought to examine the equity impact of population tobacco control measures in high-income countries with a negative socioeconomic gradient in smoking. Reported equity impacts were categorised as positive (greater impact among lower SES), neutral (no difference by SES), negative (greater impact among higher SES) or mixed/unclear.

RESULTS

There was substantial growth in research seeking to evaluate the equity impact of tobacco control interventions, but the majority of new studies showed mixed/unclear results. Findings for price increases and targeted cessation support continue to suggest an equity-positive impact, but limitations in the available evidence make further assessment difficult. Substantial differences in the context, scale and implementation of tobacco control policies make straightforward comparison of findings from the previous 2014 and current reviews problematic.

CONCLUSION

Researchers need to adopt more sophisticated, multidisciplinary approaches in evaluating the equity impact of tobacco control measures-developing robust measures of equity effect and using frameworks that take account of context, existing systems/processes and the likely mechanisms of action. Socioeconomic differences in intervention impact within low-income and middle-income countries require evaluation.

Review of Evaluation Metrics Used in Digital and Traditional Tobacco Control Campaigns

BACKGROUND

Mass media campaigns for public health are increasingly using digital media platforms, such as web-based advertising and social media; however, there is a lack of evidence on how to best use these digital platforms for public health campaigns. To generate this evidence, appropriate campaign evaluations are needed, but with the proliferation of digital media-related metrics, there is no clear consensus on which evaluation metrics should be used. Public health campaigns are diverse in nature, so to facilitate analysis, this review has selected tobacco control campaigns as the scope of the study.

OBJECTIVE

This literature review aimed to examine how tobacco control campaigns that use traditional and digital media platforms have been evaluated.

METHODS

Medicine and science databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and Scopus), and a marketing case study database (World Advertising Research Center) were searched for articles published between 2013 and 2018. Two authors established the eligibility criteria and reviewed articles for inclusion. Individual campaigns were identified from the articles, and information on campaigns and their evaluations were supplemented with searches on Google, Google Scholar, and social media platforms. Data about campaign evaluations were tabulated and mapped to a conceptual framework.

RESULTS

In total, 17 campaigns were included in this review, with evaluations reported on by 51 articles, 17 marketing reports, and 4 grey literature reports. Most campaigns were from English-speaking countries, with behavioral change as the primary objective. In the process evaluations, a wide range of metrics were used to assess the reach of digital campaign activities, making comparison between campaigns difficult. Every campaign in the review, except one, reported some type of engagement impact measure, with website visits being the most commonly reported metric (11 of the 17 campaigns). Other commonly reported evaluation measures identified in this review include engagement on social media, changes in attitudes, and number of people contacting smoking cessation services. Of note, only 7 of the 17 campaigns attempted to measure media platform attribution, for example, by asking participants where they recalled seeing the campaign or using unique website tracking codes for ads on different media platforms.

CONCLUSIONS

One of the key findings of this review is the numerous and diverse range of measures and metrics used in tobacco control campaign evaluations. To address this issue, we propose principles to guide the selection of digital media-related metrics for campaign evaluations, and also outline a conceptual framework to provide a coherent organization to the diverse range of metrics. Future research is needed to specifically investigate whether engagement metrics are associated with desired campaign outcomes, to determine whether reporting of engagement metrics is meaningful in campaign evaluations.

Association of Exposure to Court-Ordered Tobacco Industry Antismoking Advertisements With Intentions and Attempts to Quit Smoking Among US Adults

IMPORTANCE

In 2006, a US district court judge ordered tobacco companies to sponsor nationwide antismoking advertising campaigns. This landmark ruling and its subsequent execution represent an unprecedented tobacco control event; however, the association of this campaign with intentions and/or attempts to quit smoking is unknown.

OBJECTIVES

To assess the reach of the expanded court-ordered tobacco industry antismoking advertisements (via television, newspapers, tobacco company websites, and/or cigarette packages), to examine associations between exposure to industry antismoking advertisements and intentions and/or attempts to quit smoking among cigarette smokers, and to calculate the numbers of US smokers who would have quit intentions associated with exposure to multiple advertisements.

DESIGN, SETTING, AND PARTICIPANTS

Data for this study were obtained from 5309 US adults, including 610 smokers, who responded to the Health Information National Trends Survey, a nationally representative cross-sectional survey conducted from January 22 to April 30, 2019. Respondents were representatives of households selected by equal-probability sampling of a database of US residential addresses.

EXPOSURE

Reported exposure to antismoking messages.

MAIN OUTCOMES AND MEASURES

Cigarette smoking cessation attempt in the past 12 months and intentions to quit cigarette smoking in the next 6 months. Covariates were age, sex, household annual income, race/ethnicity, educational level, and geographical residence. Data were weighted to be nationally representative after applying survey weights specified for the survey cycle.

RESULTS

The overall sample of 5309 respondents were a mean (SD) age of 55.6 (19.1) years and included 3073 women (51.2%), 3037 non-Hispanic white respondents (59.1%), 4645 respondents who lived in urban US areas (84.7%), and 610 current smokers (12.5%). Findings indicate that 2464 US adults (45.8%; 95% CI, 43.2%-48.5%) and 410 current smokers (66.8%; 95% CI, 61.1%-72.4%) were exposed to antismoking advertisements. Exposure to multiple antismoking messages was associated with 2.19 (95% CI, 1.10-4.34) greater odds of having intentions to quit cigarette smoking but was not associated with attempts to quit (adjusted odds ratio, 1.31; 95% CI, 0.69-2.52). Furthermore, an examination of the association of cumulative exposure to antismoking messages with cessation intentions revealed that, with each additional exposure to an antismoking message, the odds of smoking cessation intentions increased by 1.21 (95% CI, 1.02-1.44). If all smokers were to be exposed to multiple antitobacco messages, there could be an estimated 3.98 million (95% CI, 492 480-7 223 040) current smokers in the United States with intentions to quit.

CONCLUSIONS AND RELEVANCE

Although the reach of court-ordered industry advertisements increased among smokers, the reach of these advertisements within the general population remains suboptimal. The finding that industry advertisements helped smokers consider quitting highlights their potential to aid smoking cessation. However, the lack of association with actual attempts to quit suggests that the industry antismoking advertisement campaigns were inadequate. The design and content of industry antismoking advertisement campaigns should be enhanced to help smokers quit.

E-cigarette Marketing Regulations and Youth Vaping: Cross-Sectional Surveys, 2017-2019

BACKGROUND

Increased electronic cigarette (e-cigarette) use among young people is often attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing.

METHODS

Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions.

RESULTS

The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97-2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23-1.62), past week (AOR = 1.44, 95% CI = 1.22-1.70), and ≥20 days in the past month (AOR = 1.42, 95% CI = 1.11-1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25-1.80, P < .001), and in the past week (AOR = 1.65, 95% CI = 1.33-2.05, P < .001).

CONCLUSIONS

Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use.

An Eye Tracking Study of Anti-Smoking Messages on Toxic Chemicals in Cigarettes

The US Food and Drug Administration is tasked with communicating information to the public about the harmful chemicals in cigarette smoke. Our study used eye tracking method to test the effectiveness of messages about the harmful chemicals in cigarettes smoke among adult smokers. A sample size of 211 current cigarette smokers viewed four communication messages that included: Health effects of a chemical in cigarette smoke and an image depicting the health effect. The messages focused on arsenic, formaldehyde, uranium, and general health. Eye tracking recorded the length of time participants viewed the text and the image. After each message, the participants were asked about the messages' effectiveness in changing attitudes towards smoking. We analyzed the data using multilevel modeling, and of the 211 smokers, 59.7% were female, 36.5% were Black, and 21.3% had a high school degree or less. Compared to the general message, the messages about formaldehyde and uranium were more discouraging to smoking (p < 0.05). Messages about formaldehyde were more believable and made participants want to quit more than the general messages. Increasing message dose was significantly associated with discouraging participants from smoking and made participants want to quit (p < 0.05). Our findings suggest that anti-smoking messages, containing chemical information, can successfully increase negative attitudes toward smoking cigarettes and potentially encourage quitting.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

Evidence of the Impact of the Tips From Former Smokers Campaign: Results From the Behavioral Risk Factor Surveillance System

The Tips From Former Smokers campaign (Tips) has demonstrated significant impact as a population-based intervention for smoking cessation in the United States. Since 2012, evaluations of Tips have relied on web-panel data to attribute the campaign to smoking cessation outcomes. We re-examined the relationship between market-level doses of the campaign and quit attempts by using Behavioral Risk Factor Surveillance System (BRFSS) data to triangulate prior findings. We found that Tips was associated with increased quit attempts among smokers, which validates prior evaluation research on the impact of Tips. These results suggest that continued investments in Tips may help sustain its impact on cessation-related outcomes.

Exposure to Court-Ordered Tobacco Industry Antismoking Advertisements Among US Adults

IMPORTANCE

In 2006, US District Judge Gladys Kessler ordered tobacco companies to make corrective statements through paid advertisements informing the public of their deceptive practices. This landmark ruling and its subsequent execution represent the first time the tobacco industry sponsored a nationwide corrective advertising campaign against its own products.

OBJECTIVE

To assess the reach of the court-ordered antismoking advertisements within the US adult population, stratified by demographic characteristics and tobacco use.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative, population-based cross-sectional survey of US adults included respondents to the 2018 Health Information National Trends Survey 5, Cycle 2. Respondents were representatives of households selected by equal-probability sampling of the Marketing Systems Group database of addresses that included all nonvacant US residential addresses. Data collection was conducted from January to May 2018, and analysis took place from December 2018 to April 2019.

MAIN OUTCOMES AND MEASURES

Self-reported exposure to court-ordered antismoking advertisements.

RESULTS

The overall sample of 3484 respondents included 2054 women (weighted percentage, 50.8%), 1976 non-Hispanic white respondents (weighted percentage, 59.9%), 2952 respondents who lived in urban US areas (weighted percentage, 84.9%), and 450 current smokers (weighted percentage, 15.6%). Estimated exposure to court-ordered antismoking advertisements was 40.6% (95% CI, 37.5%-43.7%) among the full sample and 50.5% (95% CI, 41.4%-59.6%) among current smokers. Exposure was lowest among those aged 18 to 34 years (37.4%; 95% CI, 28.0%-46.8%), those with a high school education or less (34.5%; 95% CI, 29.3%-39.8%), and those with household annual income less than $35 000 (37.5%; 95% CI, 32.0%-42.9%). Among current smokers, Hispanic respondents had lower exposure rates (42.2%; 95% CI, 18.5%-65.9%) than non-Hispanic white respondents (51.7%; 95% CI, 40.4%-63.1%). As the advertising campaign's duration increased, exposure rates increased. Individuals with a high school education or less had lower odds of antismoking advertisement exposure than those with college or postgraduate degrees (adjusted odds ratio, 0.67; 95% CI, 0.48-0.94). Current smokers had higher odds of exposure than never smokers (adjusted odds ratio, 1.81; 95% CI, 1.17-2.80). Among those exposed to antismoking advertisements, 70.5% saw multiple antismoking messages.

CONCLUSIONS AND RELEVANCE

Approximately 1 of 2 smokers reported exposure to the federal court-ordered antismoking advertisements. However, exposure was relatively lower among several subgroups, including individuals aged 18 to 34 years, only one-third of whom reported exposure. Increasing the duration of antismoking advertisements as well as expanding their coverage to youth-oriented media may increase their potential public health impact.

Impact of U.S. Antismoking TV Ads on Spanish-Language Quitline Calls

INTRODUCTION

Cigarette smoking is a major preventable cause of disease and death among U.S. Hispanics. Tobacco-cessation quitlines have been shown to increase quitting among Hispanics. However, the use of quitlines by this population remains low, especially among Spanish-speaking Hispanics. This study evaluates the promotion of 1-855-DÉJELO-YA (a quitline portal that routes callers to state-specific Spanish-language services) implemented as part of the Centers for Disease Control and Prevention's national Tips From Former Smokers^® (Tips^®) campaign. Additionally, this study examines how media content impacted calls to 1-855-DÉJELO-YA.

METHODS

Using National Cancer Institute data on calls to 1-855-DÉJELO-YA from February 2013 to December 2014, multivariate linear regressions were conducted of weekly area code-level call volume as a function of media market-level Gross Rating Points for Tips Spanish-language TV ads tagged with 1-855-DÉJELO-YA. The models were adjusted for covariates, including market-level population characteristics and state fixed effects. The data were analyzed from October 2017 through April 2018.

RESULTS

Greater exposure to Tips Spanish-language ads was associated with increased calls to 1-855-DÉJELO-YA (p<0.001). On average, each additional 100 Tips Gross Rating Points per media market increased calls by 0.56 (95% CI=0.45, 0.67) calls/week/area code, representing ≅ 974 additional calls beyond the baseline. Media messages highlighting health consequences of smoking had a greater effect size than messages highlighting health effects of secondhand smoke.

CONCLUSIONS

A national Spanish-language quitline number could be a useful cessation resource for Spanish-speaking cigarette smokers. Opportunities exist to increase use of this number through a national Spanish-language media campaign, particularly by focusing campaign messages on the health consequences of smoking.

Cost of Tobacco-related Cancer Hospitalizations in the U.S., 2014

INTRODUCTION

Smoking has been causally linked to 12 tobacco-related cancers: oral cavity and pharynx, esophagus, stomach, colon and rectum, liver, pancreas, larynx, lung, cervix, bladder, kidney, and acute myeloid leukemia. Tobacco-related cancers-related morbidity and mortality have been well described, but little is known about the prevalence of tobacco-related cancer hospitalizations and associated costs. This study estimates the annual number of tobacco-related cancer hospitalizations and their associated direct medical costs in the U.S.

METHODS

This study examined data from the 2014 National Inpatient Sample, the largest publicly available all-payer inpatient care database in the U.S. The authors calculated number of hospitalizations, total costs, length of stay, and cost per stay for tobacco-related cancer hospitalizations and cancer hospitalizations not related to tobacco.

RESULTS

In 2014, there were an estimated 461,295 annual tobacco-related cancer hospitalizations at a cost of $8.2 billion in the U.S. Tobacco-related cancers accounted for 45% of total cancer hospitalizations and cancer hospitalization costs. Compared with cancer hospitalizations not related to tobacco, tobacco-related cancer hospitalizations had a longer mean length of stay (6.8 vs 5.7 days).

CONCLUSIONS

The burden of tobacco-related cancer hospitalizations is substantial in the U.S. These findings highlight the importance of tobacco prevention and cessation efforts to decrease the burden of tobacco-related cancers in the U.S.

Media Flight Schedules and Seasonality in Relation to Quitline Call Volume

CONTEXT

Given the high profile, cost, and vulnerability to budget cuts of mass-reach health education campaigns, researchers have cited the need for media buying strategies.

OBJECTIVE

The objective of the current study is to fill a gap in the literature by comparing the impact of media flight schedule types in relation to tobacco quitline call volume.

DESIGN

The retrospective study was designed to determine whether type of media flight schedule (eg, flighting, continuous, pulsing) impacted number of calls to the Maine Tobacco Helpline, while accounting for number of gross rating points (GRPs), seasonality, holidays, and other factors.

SETTING

Maine has 3 designated market areas (DMAs): Portland/Auburn, Bangor, and Presque Isle.

MAIN OUTCOME MEASURES

Daily call volume was matched with weekly GRPs.

METHODS

A negative binomial regression model was created to examine the relationship among media flight schedules, number of GRPs, and call volume. Gross rating points reflect national networks and local cable TV media buys. A second model examined the association between GRP dose levels and call volume.

RESULTS

The number of GRPs was a significant predictor of call volume (P < .001). Weekly number of GRPs within a media flight schedule was the most important indicator for potential effectiveness. Weekly low-dose GRPs were not effective in increasing calls, indicating a minimum threshold. For every 250 GRPs, 29% (or 73) more calls per week were attributed to the media campaigns (P < .001). Weekly quitline call volume was 21% (or 53 calls) lower during the weeks of Christmas, US Thanksgiving, and US Independence Day.

CONCLUSION

Type of media flight schedule should be considered in the context of purchasing sufficient weekly, as well as quarterly, rating points to increase tobacco quitline call volume. In addition, our study is the first to quantify and report on lower tobacco quitline call volume during several US holidays.

Potential Effectiveness of Pictorial Warning Labels That Feature the Images and Personal Details of Real People

Introduction

Pictorial warning labels (PWL) that use photographs and the personal details of real people whose health has been affected by smoking (testimonial PWL) provide factual information about the consequences of tobacco use.

Methods

Nine hundred and twenty-four adult current smokers participated in an online experiment that tested responses to four types of warning labels: (1) non-testimonial text warning labels (currently on packs in the United States); (2) non-testimonial PWL (previously proposed by the United States Food and Drug Administration); (3) image only testimonial PWL (created for study); (4) image + personal details testimonial PWL (created for study). Participants were randomly assigned to condition and then exposed to up to five warning labels addressing different health effects. Differences between conditions were assessed using emotional responses and a set of intention measures immediately following exposure, and self-reported behavior change at 5-week follow-up.

Results

Compared to the non-testimonial text warning labels, all PWL elicited stronger emotional responses and intentions to forgo cigarettes and avoid the warning labels. Non-testimonial PWL and image + personal details testimonial PWL elicited stronger intentions to quit, whereas image only testimonial PWL generated a greater amount of quitting activity in the weeks following exposure. There were no significant differences in responses when comparing the non-testimonial PWL with both types of testimonial PWL.

Conclusions

PWL that use images of real people convey factual information about the health effects of tobacco use. These testimonial PWL may be a promising alternative to the images previously proposed for use on PWL in the United States.

Implications

In the United States, the PWL developed by the Food and Drug Administration (FDA) in 2011 were found by the courts to be unconstitutional, in part because they were deemed to present an opinion rather than fact. Findings from this experimental study indicate that PWL that use the images and personal details of real people to convey factual information about the health effects of tobacco use may satisfy the FDA's requirement for a set of PWL that (1) have the potential to positively impact the determinants of smoking cessation behavior, (2) meet legislative requirements under the Family Smoking Prevention and Tobacco Control Act and (3) may be more acceptable to the courts than the previously proposed and now dismissed PWL that carried non-factual images.

Evaluation of a federally funded mass media campaign and smoking cessation in pregnant women: a population-based study in three states

OBJECTIVES

In 2012, theCenters for Disease Control and Prevention initiated a national anti-smoking campaign, Tips from Former Smokers (Tips). As a result of the campaign, quit attempts among smokers increased in the general population by 3.7 percentage points. In the current study, we assessed the effects of Tips on smoking cessation in pregnant women.

METHODS

We used 2009-2013 certificates of live births in three US states: Indiana, Kentucky and Ohio. Smoking cessation by the third trimester of pregnancy was examined among women who smoked in the 3 months prepregnancy. Campaign exposure was defined as overlap between the airing of Tips 2012 (March 19-June 10) and the prepregnancy and pregnancy periods. Women who delivered before Tips 2012 were not exposed. Adjusted logistic regression was used to determine whether exposure to Tips was independently associated with smoking cessation.

RESULTS

Cessation rates were stable during 2009-2011 but increased at the time Tips 2012 aired and remained elevated. Overall, 32.9% of unexposed and 34.7% of exposed smokers quit by the third trimester (p<0.001). Exposure to Tips 2012 was associated with increased cessation (adjusted OR: 1.07, 95% CI 1.05 to 1.10).

CONCLUSIONS

Exposure to a national anti-smoking campaign for a general audience was associated with smoking cessation in pregnant women.

Disparagement of health warning labels on cigarette packages and cessation attempts: results from four countries

Health warning labels (HWLs) on cigarette packs that use strong fear appeals may evoke defensive responses including acts of disparaging the warnings. Whether warning disparagement undermines HWL effectiveness remains unclear. We assessed correlates of one type of HWL disparagement and its association with subsequent cessation attempts. Longitudinal data (2012-14) on adult smokers from Australia, Canada, Mexico and the United States (US) were analyzed. HWL disparagement was assessed as the frequency of making fun of HWLs in the past month. Using Generalized Estimating Equation models we estimated correlates of HWL disparagement and whether HWL disparagement predicted subsequent cessation attempts. In each country, across all waves, 24-31% of smokers reported making fun of the warnings at least once in the past month. More frequent disparagement was found among males, younger participants, those with higher education and greater addiction, and those who recently attempted to quit. Attention to, avoidance of and talking to others about HWLs were all positively associated with HWL disparagement. In all countries, except the US, this type of HWL disparagement was an independent predictor of subsequent cessation attempts. HWL disparagement among smokers may indicate greater warning relevance and processing and does not result in counterproductive effects on cessation efforts.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in November 2016.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included.Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, or odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality (MB, LS, RTM). One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among seven campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the eight studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Perceived Effectiveness of Antismoking Ads and Association with Quit Attempts Among Smokers: Evidence from the Tips From Former Smokers Campaign

BACKGROUND

Measures of perceived effectiveness (PE) of ads have been validated to predict changes in cognitive precursors of quit attempts, but a relationship between PE and actual quit attempts has not been shown in population-based studies. We analyzed smokers' PE ratings of ads from the national Tips From Former Smokers (Tips) campaign to (1) establish the validity of PE in predicting quit attempts in a large, nationally representative sample of smokers; (2) identify behavioral and demographic correlates of PE among respondents; and (3) examine whether PE is influenced by matching the race/ethnicity of ad participants with that of the ad viewer.

METHODS

We used survey data from two waves (baseline and follow-up) of a longitudinal online cohort of adult U.S. cigarette smokers. Respondents were shown one or more of 14 Tips campaign ads and were asked to assess each ad in terms of PE. We used multivariate models to estimate the association between baseline PE and prospective quit attempts; cross-sectional associations between PE and various respondent characteristics, including race/ethnicity, desire to quit, and health conditions; and the association between race/ethnicity of respondents and Tips ad participants.

RESULTS

Higher PE at baseline was associated with increased odds of a quit attempt at follow-up. Higher PE scores were associated with non-Hispanic black race, Hispanic ethnicity, higher desire to quit, presence of a chronic health condition, and presence of a mental health condition. There was no relationship between PE scores and matched race/ethnicity of the respondent and Tips ad participants.

CONCLUSIONS

This is the first study to demonstrate an association between PE scores for antismoking ads and prospective quit attempts in a large, nationally representative sample of smokers. Our findings also provide strong evidence that racial/ethnic minority subpopulations, including non-Hispanic blacks and Hispanics, react more favorably to Tips campaign ads irrespective of race/ethnicity of the ad participant. This suggests that message characteristics (e.g., graphic visuals and emotional content) may play a more important role in PE than race/ethnicity of ad participants.

Association Between Media Doses of the Tips From Former Smokers Campaign and Cessation Behaviors and Intentions to Quit Among Cigarette Smokers, 2012-2015

BACKGROUND

Since 2012, the Centers for Disease Control and Prevention (CDC) has implemented Tips From Former Smokers ( Tips), the first federally funded tobacco education campaign in the United States. To date, there are no evaluations of its long-term impact.

AIMS

To assess the impact of varied doses of the Tips campaign from 2012 through 2015 on cessation-related behaviors and intentions among U.S. smokers.

METHOD

We used a national probability-based online survey of cigarette smokers ( n = 22,189) and recent quitters ( n = 776) to examine associations between doses of Tips advertising, measured by gross rating points (GRPs), and intentions to quit smoking in the next 30 days and quit attempts within the past 3 months. A curvilinear (i.e., square root) functional form of GRPs was used to capture patterns of diminishing effects at higher GRP levels.

RESULTS

An increase of 1,000 quarterly Tips GRPs at the media market level was associated with increased odds of making a quit attempt in the past 3 months (adjusted odds ratio = 1.23, p < .001) and increased odds of intending to quit in the next 30 days (adjusted odds ratio = 1.17, p = .030).

DISCUSSION

Results suggest that CDC-recommended media buys of 800 to 1,000 GRPs per quarter are sufficient to generate statistically significant increases in the likelihood of quit attempts in the past quarter.

CONCLUSIONS

The Tips campaign has had a substantial impact on cessation behaviors among U.S. adult smokers over time. These data support the continued use of graphic and/or emotional media campaigns that encourage smokers to quit to further reduce tobacco use in the United States.

Trends in serious quit attempts in the United States, 2009-14

BACKGROUND AND AIMS

Quitting smoking is the most potent way to reduce the health risks associated with smoking cigarettes, and public health objectives in the United States include dramatic increases in the proportion of smokers making a serious quit attempt each year. The US Centers for Disease Control and Prevention (CDC) has, since 2000, set as its Healthy People 2020 objective to encourage 80% of smokers to make a serious quit attempt per year. This study assessed the trend in quit attempts from 2009 to 2014.

DESIGN

We examined the percentage of US smokers making a serious quit attempt each year from 2009 to 2014 from the repeating cross-sectional National Health Interview Survey (NHIS).

SETTING

United States.

PARTICIPANTS

The number of qualifying respondents per year ranged from 5748 in 2010 to 7219 in 2012, with a total of 40 362 respondents included in the analysis.

MEASUREMENTS

Respondents were deemed to have made a serious quit attempt if they were either current smokers who reported that they stopped smoking for more than 1 day in the past 12 months because they were trying to quit smoking, or reported being former smokers (smoked 100+ cigarettes life-time, but now not smoking) who quit in the past year.

FINDINGS

Analyses of trends from 2009 to 2014 showed an overall linear increase in quit attempts [odds ratio (OR) = 1.02, 95% confidence interval (CI) = 1.01-1.04, P = 0.0075], but also a quadratic trend (OR = 1.01, 95% CI = 1.00-1.02, P = 0.0189).

CONCLUSIONS

The proportion of US smokers making a serious quit attempt has increased since 2009, due to an upward trend since 2011. The 2014 serious quit attempt rate was 55.0%. These rates are still below the Healthy People 2020 objective of 80% of smokers making a serious quit attempt per year.

Does Digital Video Advertising Increase Population-Level Reach of Multimedia Campaigns? Evidence From the 2013 Tips From Former Smokers Campaign

Background

Federal and state public health agencies in the United States are increasingly using digital advertising and social media to promote messages from broader multimedia campaigns. However, little evidence exists on population-level campaign awareness and relative cost efficiencies of digital advertising in the context of a comprehensive public health education campaign.

Objective

Our objective was to compare the impact of increased doses of digital video and television advertising from the 2013 Tips From Former Smokers (Tips) campaign on overall campaign awareness at the population level. We also compared the relative cost efficiencies across these media platforms.

Methods

We used data from a large national online survey of approximately 15,000 US smokers conducted in 2013 immediately after the conclusion of the 2013 Tips campaign. These data were used to compare the effects of variation in media dose of digital video and television advertising on population-level awareness of the Tips campaign. We implemented higher doses of digital video among selected media markets and randomly selected other markets to receive similar higher doses of television ads. Multivariate logistic regressions estimated the odds of overall campaign awareness via digital or television format as a function of higher-dose media in each market area. All statistical tests used the .05 threshold for statistical significance and the .10 level for marginal nonsignificance. We used adjusted advertising costs for the additional doses of digital and television advertising to compare the cost efficiencies of digital and television advertising on the basis of costs per percentage point of population awareness generated.

Results

Higher-dose digital video advertising was associated with 94% increased odds of awareness of any ad online relative to standard-dose markets (P<.001). Higher-dose digital advertising was associated with a marginally nonsignificant increase (46%) in overall campaign awareness regardless of media format (P=.09). Higher-dose television advertising was associated with 81% increased odds of overall ad awareness regardless of media format (P<.001). Increased doses of television advertising were also associated with significantly higher odds of awareness of any ad on television (P<.001) and online (P=.04). The adjusted cost of each additional percentage point of population-level reach generated by higher doses of advertising was approximately US $440,000 for digital advertising and US $1 million for television advertising.

Conclusions

Television advertising generated relatively higher levels of overall campaign awareness. However, digital video was relatively more cost efficient for generating awareness. These results suggest that digital video may be used as a cost-efficient complement to traditional advertising modes (eg, television), but digital video should not replace television given the relatively smaller audience size of digital video viewers.

Evaluation of the National Tips From Former Smokers Campaign: the 2014 Longitudinal Cohort

Introduction

Since 2012, the Centers for Disease Control and Prevention has aired a national tobacco education campaign to encourage quitting, Tips From Former Smokers (Tips), which consists of graphic antismoking advertisements that feature former cigarette smokers. We evaluated phase 2 of the 2014 campaign by using a nationally representative longitudinal cohort.

Methods

Cigarette smokers who participated in a baseline survey were re-contacted for follow-up (n = 4,248) approximately 4 months later, immediately after the campaign’s conclusion. The primary outcomes were incidence of a quit attempt in the previous 3 months, intention to quit within 30 days, and intention to quit within 6 months during the postcampaign period. We used multivariate logistic regression models to estimate the odds of each outcome. We also stratified models by race/ethnicity, education, and mental health status. Postcampaign rates of quit attempts, intentions to quit, and sustained quits were also estimated.

Results

Exposure to the campaign was associated with increased odds of a quit attempt in the previous 3 months (OR, 1.17; P = .03) among baseline smokers and intentions to quit within the next 6 months (OR, 1.28; P = .01) among current smokers at follow-up. The Tips campaign was associated with an estimated 1.83 million additional quit attempts, 1.73 million additional smokers intending to quit within 6 months, and 104,000 sustained quits of at least 6 months.

Conclusion

The Tips campaign continued to have a significant impact on cessation-related behaviors, providing further justification for the continued use of tobacco education campaigns to accelerate progress toward the goal of reducing adult smoking in the United States.