The contribution of antismoking advertising to quitting: intra- and interpersonal processes

Face Value: Remote facial expression analysis adds predictive power to perceived effectiveness for selecting anti-tobacco PSAs

Perceived effectiveness (PE) is a validated tool for predicting the potential impact of anti-tobacco public service announcements (PSAs). We set out to evaluate the added predictive value of facial expression analysis when combined with PE in a remote (online) survey. Each of 302 tobacco users watched 3 PSAs and allowed transmission of webcam videos from which metrics for "attention" (head position) and "facial action units" (FAU) were computed. The participants completed scales for their subjective emotions, willingness to share on social media, and intention to quit smoking using the Tobacco Free Florida website. Based on PE, both ready to quit (RTQ) and not ready (NR) respondents favored the same PSAs but RTQs assigned higher PE scores. Negative PSAs ("sad" or "frightening") were more compelling overall but RTQs also favored surprising ads and were more willing to share them on social media. Logistic regression showed that the combination of Attention + FAU+ PE (AUC = .816, p < .0001) outperformed single factors or factor combinations in distinguishing RTQ from NR. This study demonstrates that on-line assessment of facial expressions enhances the predictive value of PE and can be deployed on large remote samples.

Global COVID-19 Advertisements: Use of Informational, Transformational and Narrative Advertising Strategies

This study employs the informational and transformational approaches from Taylor's Six-Segment Message Strategy Wheel and narrative transportation theory to understand the use of different advertising message strategies in COVID-19 advertisements on a global scale. Understanding how advertisers constructed their public messages during a global pandemic is a necessary first step before follow-up research can be done to assess which message strategies were most effective. Content analysis was performed on the entire COVID-19 video ad library (N = 354) from Ads of the World website that were published from March to September 2020 from 49 countries. Results suggested that most of the ads used a transformational strategy with a focus on the social aspect of limiting community spread instead of an informational approach. Many of the ads also employed a narrative message strategy that used storytelling to transport and persuade viewers. Perhaps the most interesting finding is that the use of narrative message strategy was related to storytelling, ad length, music, and humor, but independent from the use of informational strategies.

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.

Effect of a storytelling intervention on the retention of serodiscordant couples in ART/PrEP services at antenatal clinic in Namacurra province in Zambézia, Mozambique

Background

Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples.

Design

We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish “ideal” interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months.

Conclusions

PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.

Are anti-smoking social norms associated with tobacco control mass media campaigns, tax and policy changes? Findings from an Australian serial cross-sectional population study of smokers

BACKGROUND

Anti-smoking social norms are associated with subsequent quitting behaviours. We examined if exposure to tobacco control advertisements and policy changes predict subjective (perceived disapproval of smoking among close family and friends) and internalised injunctive norms (embarrassed about telling others you are a smoker).

METHODS

A serial cross-sectional population survey of Australian adult smokers (n=6649; 2012 to 2015). Logistic regression analyses examined associations of social norms with exposure to different types of tobacco control advertisements, tax increases and other tobacco control policies, adjusting for key demographic, smoking and media exposure covariates. Interaction analyses examined differences by age and socioeconomic status (SES).

RESULTS

Greater past month exposure to predominantly fear-evoking advertisements was associated with increased odds of perceiving disapproval (per 1000 gross rating points: adjusted OR (AOR) 2.69, 95% CI: 1.34 to 5.39), while exposure to advertisements evoking multiple negative emotions (fear, guilt, sadness) reduced perceived disapproval (AOR 0.61, 95% CI: 0.42 to 0.87). Increased perceived disapproval was also associated with anticipation (AOR 1.38, 95% CI: 1.02 to 1.88), and implementation of a series of annual 12.5% tobacco tax rises (AOR 1.41, 95% CI: 1.03 to 1.94). Associations were consistent across age and SES. There were no associations nor subgroup interactions between advertisement exposure or policy changes and feeling embarrassed about telling others you are a smoker.

CONCLUSION

Smokers' perceptions of family and friends' disapproval of their smoking was more common after exposure to fear-evoking tobacco control campaigns and after large tobacco tax increases were announced and implemented.

The effect of interpersonal communication in tobacco control campaigns: A longitudinal mediation analysis of a Ghanaian adolescent population

This study examined the effectiveness of anti-smoking messages in positively shifting perceptions of risks related to smoking among adolescents in urban Ghana, both directly through exposure to messaging and indirectly through catalyzing discussions among peers and adults. We used data from two waves of a population-based survey of 3775 adolescent girls and 3279 adolescent boys aged 13-16 years in the urban areas of Accra, Teshie, Kumasi and Sunyani in Ghana. Using an interviewer-directed questionnaire, information was collected on sociodemographic characteristics, tobacco knowledge, exposure to messages about tobacco, frequency of conversations with peers and adults about the health risks associated with smoking, as well as beliefs and attitudes towards smoking. The outcome measure is smoking risk perception in relation to shisha and cigarettes. Using causal mediation analysis, we examine the direct and indirect effects of social media relative to mass media as they work to spur discussions among peers, as well as between peers and adults, about smoking risks and about aligning risk perceptions with objective risk. We find that media exposure - both social and mass media - can impact risk perceptions. We find in particular an 8.6 percentage point increase in shisha smoking risk perceptions due to social media campaign exposure (95% CI: 3.71-13.50) and a 2.3 percentage point increase in cigarette smoking risk perception due to mass media campaign exposure (95% CI: 0.26-4.27). We further find that the indirect effect of conversations with peers mediated 16.3% of the total effect of mass media campaign exposure on cigarette smoking risk perception and 4.8% of the total effect of social media campaigns on shisha smoking risk perception. Social media campaigns increased shisha smoking risk perception among girls by 11.6 percentage points (95% CI: 5.59-17.61), of which 6.8% was mediated by conversations with peers, while conversations with peers did not significantly mediate campaign effect among boys. Conversations with adults were never found to significantly mediate smoking prevention campaigns effects in this sample of Ghanaian adolescents. Behavior change communication programs that rely solely on traditional mass media can miss important opportunities for shifting smoking risk perceptions and sharing information on the harms of smoking. Evaluations that ignore the indirect effects of conversations among peers mediating campaign effects may fail to identify important channels that can be targeted and triggered by mass and social media tobacco control campaigns.

PhenX: Environment measures for Tobacco Regulatory Research

OBJECTIVE

A Working Group (WG) of tobacco regulatory science experts identified measures for the tobacco environment domain.

METHODS

This article describes the methods by which measures were identified, selected, approved and placed in the PhenX Toolkit.

FINDINGS

The WG identified 20 initial elements relevant to tobacco regulatory science and determined whether they were already in the PhenX Toolkit or whether novel or improved measures existed. In addition to the 10 complementary measures already in the Toolkit, the WG recommended 13 additional measures: aided and confirmed awareness of televised antitobacco advertising, interpersonal communication about tobacco advertising, media use, perceived effectiveness of antitobacco advertising, exposure to smoking on television and in the movies, social norms about tobacco (for adults and for youth), worksite policies, youth cigarette purchase behaviours and experiences, compliance with cigarette packaging and labelling policies, local and state tobacco control public policies, and neighbourhood-level racial/ethnic composition. Supplemental measures included youth social capital and compliance with smoke-free air laws and with point of sale and internet tobacco marketing restrictions. Gaps were identified in the areas of policy environment (public and private), communications environment, community environment and social environment (ie, the norms/acceptability of tobacco use).

CONCLUSIONS

Consistent use of these tobacco environment measures will enhance rigor and reproducability of tobacco research.

Advancing Tobacco Product Warning Labels Research Methods and Theory: A Summary of a Grantee Meeting Held by the US National Cancer Institute

BACKGROUND

The World Health Organization's Framework Convention on Tobacco Control recommends prominent pictorial health warnings on tobacco products. To advance research methods, theory and understanding of how tobacco product warning labels (TPWLs) work, the US National Cancer Institute convened a grantee meeting. Our article describes the key insights that emerged from the meeting, situated within the context of the scientific literature.

RESULTS & RECOMMENDATIONS

First, presentations confirmed that large, pictorial TPWLs motivate people to try to quit and encourage smoking cessation. Second, pictorial TPWLs increase attention, knowledge, negative affect, and thinking about the warning. Third, TPWL studies have primarily used brief-exposure laboratory studies and observational studies of sustained exposure through national policy implementation, with a few randomized trials involving several weeks of exposure-with generally consistent results found across study designs. Fourth, novel assessment methods include brain imaging, eye tracking and "best-worst" discrete choice experiments. To make TPWL even more effective, research is needed to confirm the mechanisms of their influence, their impact across vulnerable populations, and their effect on social media posts about tobacco products. Research is also needed on the effect of trial design choices, the predictive validity of new measurement approaches, and warning labels for non-cigarette tobacco products.

IMPLICATIONS

To improve scientific understanding of TPWL effects, this grantee meeting summary describes emerging research methods, theory and study results. Directions for future research include examination of the mechanisms of how warning labels work across diverse tobacco products and across different populations and contexts.

Testing the Role of Narrative and Gain-Loss Framing in Messages to Promote Sleep Hygiene among High School Students

Insufficient sleep is common during high school and associated with adverse developmental and health outcomes. School-based health promotion efforts hold promise for improving student sleep health. This study examines two message strategies, short personal narratives and gain versus loss message framing, in shaping intentions to get healthy sleep and intentions to talk about the information received. We also examine the mediating roles of transportation and positive emotions (happy, content) and negative emotions (fear, anger). We utilize a 2 (narrative vs. non-narrative) by 2 (gain vs. loss framing) between-subjects, randomized experimental design, to test the effect of print messages on these outcomes among a sample of high school students (N = 378). Exposure to the narrative message was directly associated with greater talk intentions but not sleep intentions. Message framing was not directly associated with sleep intentions or talk intentions. Mediation analyses revealed that exposure to the narrative was indirectly associated with sleep intentions and talk intentions via transportation, and indirectly with talk intentions via both participant-reported happiness and fear. Exposure to gain-framed messages was indirectly associated with talk intentions via positive emotion. These findings extend and complicate our understanding of the roles of narrative and equivalence framing in shaping key health promotion outcomes.

Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence

BACKGROUND

Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior.

PURPOSE

We sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts.

METHODS

US adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models.

RESULTS

The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts.

CONCLUSIONS

Pictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.

The Effect of Campaign-Generated Interpersonal Communication on Campaign-Targeted Health Outcomes: A Meta-Analysis

This study examined the effect of mass media campaign-generated conversations on campaign-targeted health outcomes, via a systematic meta-analysis of 28 studies (including 124 sub-studies and a total of 138,898 participants). The study also conducted a series of moderation analyses to examine the conditions under which interpersonal communication has larger effects on bringing about the desired outcomes. The findings of this meta-analysis indicate that campaign-generated conversations have a positive effect on inducing campaign-targeted outcomes (OR = 1.28) and show that this effect is moderated by health topic addressed by the campaign, the type of outcome being targeted by the campaign, and with whom people converse, along with several other campaign-relevant and study-relevant variables. The implications of these findings for future research are discussed.

Testing the Replication and Extension of Why-Quit and How-To-Quit Antismoking Health Messages

Research on health campaigns and interpersonal communication has seldom examined how campaign message exposure can influence the transmission of campaign-relevant information into interpersonal communication. Specifically, an individual exposed to a campaign message may send the message's core argument (replication) or other campaign-consistent information (extension) to additional campaign targets. Replication and extension may enhance campaign effects because they are expected to extend a campaign's reach and produce more campaign-consistent communication. Using a randomized controlled experiment, this study examined how exposure to why-quit and how-to-quit themed antismoking messages influences replication and extension. Study results showed that while both why-quit and how-to-quit messages were successful in increasing replication, only why-quit messages were successful in influencing extension. The study results demonstrate that there is variation in the degree of how messages can successfully be replicated or extended in interpersonal contexts, which can inform campaign development.

Friends Don't Let Friends Smoke: How Storytelling and Social Distance Influence Nonsmokers' Responses to Antismoking Messages

This study examines nonsmokers' responses to antismoking messages. Informed by construal-level theory (CLT), it investigates whether and how evidence type (narrative vs. non-narrative) and social distance might interact to influence nonsmokers' attitudes toward others' quitting smoking and intentions to persuade others to quit smoking. Results of a controlled experiment (N = 281) revealed an approximately significant two-way interaction pertaining to attitudes. Simple effects analyses revealed that narratives produced less-favorable attitudes toward others' quitting smoking than nonnarratives when participants thought about their best friend. Yet, there was no difference in attitudes between narratives and nonnarratives when participants thought about socially distant others. The results also indicated that nonnarratives overpowered narratives to influence participants' attitudes toward others' quitting smoking. Moreover, social distance had a consistent impact on their risk beliefs, such that they perceive fewer health risks of their close friends than an average college student. Theoretical and practical implications of the results are discussed.

Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs

Introduction

Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings.

Methods

A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits.

Results

Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05).

Conclusions

Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact.

Implications

Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

Why Do Smokers Talk About Antismoking Campaigns? Predictors of the Occurrence and Content of Campaign-Generated Conversations

Smokers often talk about antismoking campaigns, and these conversations can contribute to campaign effectiveness. However, little is known about the predictors and content of naturally occurring campaign-generated conversations. In two studies (Study 1, N = 480; Study 2, N = 232), we systematically examined whether the occurrence and content of smokers' conversations after exposure to one of eight antismoking television advertisements were predicted by characteristics of (a) the message, (b) intrapersonal responses to the message, (c) the individual, and (d) the social context in which exposure occurred. In multivariable models, we found that conversations were more likely to occur when advertisement exposure occurred in the presence of others, and as the amount of anxiety elicited by the advertisement increased. Conversations were more likely to contain a favorable appraisal of the advertisement when the message elicited higher levels of sadness, and less likely to contain favorable appraisals when the respondent had finished secondary education (vs. lower levels of education). Stronger feelings of guilt reduced the likelihood that conversations contained unfavorable appraisals, and increased the likelihood that they contained quitting talk. These findings suggest several promising avenues for future investigations into why smokers talk and talk in particular ways.

Can functional magnetic resonance imaging studies help with the optimization of health messaging for lifestyle behavior change? A systematic review

Unhealthy behaviors, including smoking, poor nutrition, excessive alcohol consumption, physical inactivity and sedentary lifestyles, are global risk factors for non-communicable diseases and premature death. Functional magnetic resonance imaging (fMRI) offers a unique approach to optimize health messages by examining how the brain responds to information relating to health. Our aim was to systematically review fMRI studies that have investigated variations in brain activation in response to health messages relating to (i) smoking; (ii) alcohol consumption; (iii) physical activity; (iv) diet; and (v) sedentary behavior. The electronic databases used were Medline/PubMed, Web of Science (Core Collection), PsychINFO, SPORTDiscuss, Cochrane Library and Open Grey. Studies were included if they investigated subjects aged ≥10years and were published before January 2017. Of the 13,836 studies identified in the database search, 18 studies (smoking k=15; diet k=2; physical activity/sedentary behavior k=1) were included in the review. The prefrontal cortex was activated in seven (47%) of the smoking-related studies and the physical activity study. Results suggest that activation of the ventromedial, dorsolateral and medial prefrontal cortex regions were predictive of subsequent behavior change following exposure to aversive anti-smoking stimuli. Studies investigating the neurological responses to anti-smoking material were most abundant. Of note, the prefrontal cortex and amygdala were most commonly activated in response to health messages across lifestyle behaviors. The review highlights an important disparity between research focusing on different lifestyle behaviors. Insights from smoking literature suggest fMRI may help to optimize health messaging in relation to other lifestyle behaviors.

Role of Narrative Perspective and Modality in the Persuasiveness of Public Service Advertisements Promoting HPV Vaccination

In the context of public service advertisements promoting human papillomavirus (HPV) vaccination, the current research examines 1) the relative persuasiveness of narrative vs. non-narrative messages and 2) the influence of narrative perspective (first- vs. third-person) and modality (text-based vs. audio-based) on message effectiveness. Results of a controlled experiment (N = 121) suggested that both a non-narrative message and a first-person narrative message led to greater perceived risk of getting HPV than a third-person narrative message. There was no difference in risk perception between the non-narrative and first-person narrative conditions. These findings were confined to the text-based condition, however. When the messages were audio-based, no differential message effects were detected. The analysis also provided partial evidence for an indirect effect of narrative perspective on intentions to vaccinate against HPV through HPV risk perception. Theoretical and practical implications of the findings are discussed.

Graphic health warnings as activators of social networks: A field experiment among individuals of low socioeconomic position

RATIONALE

Graphic health warnings (GHWs) on cigarette packages present an important tobacco control opportunity, particularly for vulnerable populations suffering a disproportionate tobacco burden. One mechanism by which GHWs may influence smoking outcomes is by prompting interpersonal discussions within health discussion networks (the set of personal contacts with whom an individual discusses health issues).

OBJECTIVE

The study examined the association between GHW-prompted conversations within health discussion networks and key tobacco-related outcomes, with attention to valence and content of the discussions.

METHOD

Between August 2013 and April 2014, we recruited 1200 individuals from three communities in Massachusetts, emphasizing recruitment of individuals of low socioeconomic position (SEP) and members of other selected vulnerable groups. Respondents were exposed to the nine GHWs proposed by the FDA in 2011, asked a series of questions, and assessed at follow-up a few weeks later.

RESULTS

A total of 806 individuals were included in this analysis. About 51% of respondents reported having a health discussion network, with significantly lower reports among African-Americans and Hispanics compared to Whites. Around 70% of respondents (smokers and nonsmokers) with health discussion networks reported having one or more conversations about the GHWs with network members, the bulk of which were negative and focused on warning others about smoking. For smokers, we found a small but positive association between the percentage of network conversations that were negative and reports of quit attempts.

CONCLUSION

The results point to a potential mechanism by which GHWs may impact tobacco-related outcomes, prompting further inquiry into the role of health discussion networks (and discussion networks, more broadly) in tobacco control among low SEP individuals.

How peer conversations about HIV/AIDS media messages affect comprehension and beliefs of young South African women

Most existent research on the effects of interpersonal discussions about health campaign messages is based on surveys. In this study, we analysed actual conversations about an HIV/AIDS poster to find out possible effects. Young South African women in 59 dyads (n = 118) participated in conversations about a deliberately puzzling HIV and AIDS poster that cautioned the target group to be faithful to one sexual partner. We measured their comprehension of the poster and beliefs about the message, before and after the conversations. Overall, actual comprehension (AC) was low, and we observed a large discrepancy between actual and perceived comprehension. In general, conversations did not improve AC. It proved to be even more probable that a correct interpretation before a conversation turned into an incorrect interpretation than the other way around. However, having a well-informed conversation partner increased the chance of acquiring adequate subsequent comprehension. We found, in general, that conversations did not decrease undesirable beliefs. One important undesirable belief even became reinforced after the conversations. Conversations among peers might be valuable in health campaigns, but our study shows that intended positive effects do not automatically follow.

Population-based evaluation of the 'LiveLighter' healthy weight and lifestyle mass media campaign

The Western Australian (WA) 'LiveLighter' (LL) mass media campaign ran during June-August and September-October 2012. The principal campaign ad graphically depicts visceral fat of an overweight individual ('why' change message), whereas supporting ads demonstrate simple changes to increase activity and eat healthier ('how' to change message). Cross-sectional surveys among population samples aged 25-49 were undertaken pre-campaign (N= 2012) and following the two media waves (N= 2005 and N= 2009) in the intervention (WA) and comparison state (Victoria) to estimate the population impact of LL. Campaign awareness was 54% after the first media wave and overweight adults were more likely to recall LL and perceive it as personally relevant. Recall was also higher among parents, but equal between socio-economic groups. The 'why' message about health-harms of overweight rated higher than 'how' messages about lifestyle change, on perceived message effectiveness which is predictive of health-related intention and behaviour change. State-by-time interactions showed population-level increases in self-referent thoughts about the health-harms of overweight (P < 0.05) and physical activity intentions (P < 0.05). Endorsement of stereotypes of overweight individuals did not increase after LL aired. LL was associated with some population-level improvements in proximal and intermediate markers of campaign impact. However, sustained campaign activity will be needed to impact behaviour.

Social Interactions Sparked by Pictorial Warnings on Cigarette Packs

The Message Impact Framework suggests that social interactions may offer smokers the opportunity to process pictorial warnings on cigarette packs more deeply. We aimed to describe adult smokers’ social interactions about pictorial cigarette pack warnings in two longitudinal pilot studies. In Pilot Study 1, 30 smokers used cigarette packs with one of nine pictorial warnings for two weeks. In Pilot Study 2, 46 smokers used cigarette packs with one of five pictorial warnings for four weeks. Nearly all smokers (97%/96% in Pilot Study 1/2) talked about the warnings with other people, with the most common people being friends (67%/87%) and spouses/significant others (34%/42%). Pilot Study 2 found that 26% of smokers talked about the warnings with strangers. Discussions about the health effects of smoking and quitting smoking were more frequent during the first week of exposure to pictorial warnings than in the week prior to beginning the study (both p < 0.05). Pictorial warnings sparked social interactions about the warnings, the health effects of smoking, and quitting smoking, indicating that pictorial warnings may act as a social intervention reaching beyond the individual. Future research should examine social interactions as a potential mediator of the impact of pictorial warnings on smoking behavior.

Talking About Antismoking Campaigns: What Do Smokers Talk About, and How Does Talk Influence Campaign Effectiveness?

Campaign-stimulated conversations have been shown to increase the effectiveness of antismoking campaigns. In order to explore why such effects occur, in the current study we coded the content of naturally occurring conversations. We also examined whether the short-term effects of talking, and of different types of talk, on quitting intentions were mediated through intrapersonal message responses. Using the Natural Exposure(SM) methodology, we exposed 411 smokers to 1 of 6 antismoking advertisements while they were watching television at home. Responses to the advertisement-conversation participation and content, emotional responses, personalized perceived effectiveness, and changes in intentions to quit-were measured within 3 days of exposure. Conversations were coded for appraisal of the advertisement (favorable, neutral, or unfavorable) and the presence of quitting talk and emotion talk. Mediation analyses indicated that the positive effects of talking on intention change were mediated through personalized perceived effectiveness and that the positive effects were driven by conversations that contained a favorable appraisal and/or quitting talk. Conversely, conversations that contained an unfavorable appraisal of the advertisement were negatively associated with campaign effectiveness. These findings highlight the importance of measuring interpersonal communication when evaluating campaigns and the need for further research to identify the message characteristics that predict when smokers talk and when they talk only in desirable ways.

Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers' Cigarette Packs

INTRODUCTION

Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings.

METHODS

We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week.

RESULTS

Participants reported low avoidance (<34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels.

CONCLUSIONS

U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.

Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts

This study evaluated the relationship between interpersonal communication about cigarette health warning labels (HWLs), psychological responses to HWLs, and smoking cessation attempts. Data were analyzed from online consumer panels of adult smokers in Australia, Canada and Mexico, during implementation of new pictorial health warning labels (HWLs) on cigarette packs. Approximately 1000 adult smokers were surveyed in each country every four months (September 2012, January 2013, May 2013, September 2013, January 2014). Only smokers followed for at least two waves were included in the analytic sample. Participants reported the frequency of talking about HWLs in the last month (in general, with family members, and with friends). For each country, poisson generalized estimating equation (GEE) models were estimated to assess the bivariate and adjusted correlates of talking about HWLs. Logistic GEE models regressed having attempted to quit by the subsequent wave on HWL talk, socio-demographics and psychological responses to HWLs. The frequency of HWL talk gradually decreased in Canada (48%–36%) after new HWLs were implemented; an increase (30%–58%) in Australia corresponded with implementation of new HWLs, after which talking stabilized; and the frequency of HWL talk in Mexico was stable over time, where new HWLs are implemented every six months. Talk about HWLs was an independent predictor of subsequent quit attempts in Canada (AOR = 1.50; 95% CI = 1.11 –2.02), Australia (AOR = 1.41; 95% CI = 1.05–1.89), and Mexico (AOR = 1.53; 95% CI = 1.11–2.10), as was cognitive responses to HWLs (Australia AOR = 1.66; 95% CI = 1.22–2.24; Canada AOR = 1.56; 95% CI = 1.15–2.11; Mexico AOR = 1.30; 95% CI = 0.91–1.85). No interaction between talk and cognitive reactions to HWLs were found. These results suggest that interpersonal communication about HWLs influences smoking cessation attempts independent of other established predictors of smoking cessation, including cessation-related HWL responses. Future research should determine ways to catalyze interpersonal communication about HWLs and thereby potentiate HWL effects.

Talking About Quitting: Interpersonal Communication as a Mediator of Campaign Effects on Smokers' Quit Behaviors

This study examined the role of interpersonal communication in the context of a mass media anti-smoking campaign. Specifically, it explored whether conversations about campaign ads and/or about quitting mediated campaign exposure effects on 2 quitting behaviors (sought help to quit and tried to quit smoking completely), as well as the relation between ad-related and quitting-related conversations. Data were collected before the campaign and monthly for 16 months during the campaign through cross-sectional telephone surveys among a sample of 3,277 adult Philadelphia smokers. Follow-up interviews were conducted among 877 participants 3 months after their first survey. Cross-sectional and longitudinal mediation models with bootstrap procedures assessed the indirect effects of campaign exposure on outcomes through conversations, and the indirect effects of conversations about ads on outcomes through conversations about quitting. In addition, lagged regression analyses tested the causal direction of associations between the variables of interest. The results partially support hypotheses that conversations about quitting mediate campaign effects on quitting-related behaviors and, in line with previous research, that conversations about the ads have indirect effects on quitting-related behaviors by triggering conversations about quitting. These findings demonstrate the importance of considering interpersonal communication as a route of campaign exposure effects when evaluating and designing future public health campaigns.

Stimulating Dialogue: Measuring Success of the “Smoke Free Horry” Campaign

Smoke Free Horry was an anti-secondhand smoke media campaign that ran in Horry County, South Carolina in 2011 and 2012. The present study assessed the campaign's ability to stimulate interpersonal dialogue about the campaign—specifically its four television public service announcements (PSAs)—as well as about other smoking-related topics, among a sample of 285 Horry County young adults. Survey data suggested talking about anti-smoking PSAs was related to subsequent discussion about smoking-related topics and positive perceptions of the campaign's effectiveness. PSAs using emotional appeals and that discussed the negative health effects of smoking/secondhand smoke were related to the most interpersonal discussions about smoking, secondhand smoking, and smoking bans. Implications for future anti-smoking campaign design are discussed.

When your smoking is not just about you: antismoking advertising, interpersonal pressure, and quitting outcomes

The authors investigated the potential for antismoking advertising to generate interpersonal pressure on smokers to quit using the Cancer Institute NSW's Tobacco Tracking Survey, a telephone tracking survey of adult smokers conducted throughout the year with approximately 50 interviews per week (N = 5,448). The survey includes questions relating to recently broadcast antismoking advertisements, including whether smokers have received pressure from family and friends as a result of their seeing the advertisements. The authors conducted multivariate logistic regression analyses to predict: (a) receiving ad-stimulated interpersonal pressure; and (b) quitting outcomes. All analyses controlled for smoker characteristics and potential exposure to the advertisements. Compared with ads coded as having a low level of emotion (by independent coders), ads coded as highly emotional were more likely to have generated interpersonal pressure. Ad-stimulated interpersonal pressure was associated with an increased likelihood of recent quit attempts and with salient quitting thoughts, with a greater effect on quitting thoughts for interpersonal pressure generated by highly and moderately emotional ads. These results support previous research suggesting that highly emotional antismoking ads with personal stories or graphic imagery are effective in promoting smoking cessation, and these results help to identify communication processes that contribute to the ads' success.

The unintended target: assessing nonsmokers' reactions to gain- and loss-framed antismoking public service announcements

This study examined nonsmokers' emotional responses and intentions to promote smoking cessation after exposure to a gain- or loss-framed antismoking public service announcement (PSA). Participants were 183 nonsmokers, and results reveal that gain- and loss-framed antismoking PSAs elicited different types and levels of affect as a function of the message theme for the antismoking PSA. Although secondhand smoke PSAs elicited higher levels of anger toward smokers and fear of secondhand smoke, smoking addiction PSAs tended to elicit more guilt among nonsmokers. Elicited emotions were significant predictors of intentions, and overall, loss-framed appeals worked better than gain-framed appeals at increasing nonsmokers' intentions to talk to friends who smoke about quitting.

Predicting attitude toward methamphetamine use: the role of antidrug campaign exposure and conversations about meth in Montana

This investigation utilized the integrative model of behavioral prediction to assess the Montana Meth Project (MMP) campaign by testing theoretical antecedents of attitude toward methamphetamine (meth) use. College students in Montana (N = 403) were surveyed about their exposure to MMP ads and communication about meth in conversation. Structural equation modeling showed that the data fit the specified model well. Significant parameters indicated that only beliefs about the negative relational outcomes of meth use, and not about personal well-being or physical appearance, were related to attitude. Attention, rather than encoded exposure, to MMP ads related to each belief about meth use. Conversation frequency related to engagement with MMP ads, and a conversational partner's conveyed attitude toward meth use related to personal and physical beliefs as well as attitudes. Theoretical and practical implications of the findings are discussed.

Tobacco packaging and mass media campaigns: research needs for Articles 11 and 12 of the WHO Framework Convention on Tobacco Control

INTRODUCTION

Communicating the health risks of smoking remains a primary objective of tobacco-control policy. Articles 11 and 12 of the World Health Organization's Framework Convention on Tobacco Control establish standards for two important forms of communication: packaging regulations (Article 11), and mass media campaigns (Article 12).

METHODS

A narrative review approach was used to identify existing evidence in the areas of package labeling regulations (including health warnings, constituent and emission messages, and prohibitions on misleading information) and communication activities (including mass media campaigns and news media coverage). When available, recent reviews of the literature were used, updated with more recent high-quality studies from published literature.

RESULTS

Implementation of Articles 11 and 12 share several important research priorities: (a) identify existing consumer information needs and gaps, (b) research on the message source to identify effective types of content for health warnings and media campaigns, (c) research on how messages are processed and the extent to which the content and form of messages need to be tailored to different cultural and geographic groups, as well as subgroups within countries, and (d) research to identify the most cost-effective mix and best practices for sustaining health communications over time.

CONCLUSION

A unifying theme of effective health communication through tobacco packaging and mass media campaigns is the need to provide salient, timely, and engaging reminders of the consequences of tobacco use in ways that motivate and support tobacco users trying to quit and make tobacco use less appealing for those at risk of taking it up.

Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups?

To examine the efficacy of different types of mass media ads in driving lower socio-economic smokers (SES) to utilize quitlines. This study collected all 33 719 calls to the Victorian quitline in Australia over a 2-year period. Negative binomial regressions examined the relationship between weekly levels of exposure to different types of anti-smoking ads and quitline calls, after adjusting for covariates. Interaction terms were added to determine whether relationships differed by SES. In total, smokers were exposed 88.39 times to anti-smoking ads over the 2-year period, as estimated by target audience ratings points. Higher emotion narrative ad exposure had the strongest association with quitline calls, increasing call rates by 13% for every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001). Substantially, greater increases in calls to quitline from lower SES groups were observed when higher emotion narrative ads were on air compared with when other ad types were on air, and this advantage was not as strong among higher SES groups. Airing higher emotion narrative anti-smoking ads may contribute to reducing, but not eliminating, socio-economic disparities in calls to the quitline through maximizing the responses of the lower SES smokers.

Potential effectiveness of specific anti-smoking mass media advertisements among Australian Indigenous smokers

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) have more than twice the smoking prevalence of non-Indigenous Australians. Anti-smoking campaigns have demonstrated success in the general population but little is known about their impact among Indigenous people. A total of 143 Indigenous and a comparison group of 156 non-Indigenous smokers from South Australia were shown 10 anti-smoking advertisements representing a range of advertisements typically aired in Australia. Participants rated advertisements on a five-point Likert scale assessing factors including message acceptance and personalized effectiveness. On average, Indigenous people rated the mainstream advertisements higher than non-Indigenous people and were more likely to report that they provided new information. Advertisements with strong graphic imagery depicting the health effects of smoking were rated highest by Indigenous smokers. Advertisements featuring real people describing the serious health consequences of smoking received mixed responses. Those featuring an ill person were rated higher by Indigenous people than those featuring the family of the person affected by a smoking-related disease. With limited Indigenous-specific messages available and given the finite resources of most public health campaigns, exposure to mainstream strong graphic and emotive first-person narratives about the health effects of smoking are likely to be highly motivating for Indigenous smokers.

Employing interpersonal influence to promote multivitamin use

Boster, Kotowski, Andrews, and Serota (2011 ) proposed that superdiffusers are well connected, persuasive, and a maven in a content area. They proposed that superdiffusers, if recruited, could promote the adoption of health practices. In this article a model of this process is presented, and an intervention designed to test the efficacy of this influence strategy is introduced. Specifically, superdiffusers were recruited to persuade their peers to take a daily multivitamin. Evidence was found consistent with the intervention's effectiveness.

Reducing childhood obesity through policy change: acting now to prevent obesity

Childhood obesity is epidemic in the United States, and is expected to increase the rates of many chronic diseases. Increasing physical activity and improving nutrition are keys to obesity prevention and control. But changing individual behavior is difficult. A comprehensive, coordinated strategy is needed. Policy interventions that make healthy dietary and activity choices easier are likely to achieve the greatest benefits. There is emerging evidence on how to address childhood obesity, but we must take action now to begin to reverse the epidemic.

Talking "truth": predictors and consequences of conversations about a youth antismoking campaign for smokers and nonsmokers

Using data from the Legacy Media Tracking Survey II, this study investigated relations among youth's evaluations of the "truth" antismoking campaign, campaign-related interpersonal discussion, and campaign-relevant outcomes (n = 8,000). Regression analyses showed that smokers were less likely to have discussed the campaign than nonsmokers, and this effect was mediated by negative campaign evaluation. However, smokers with a negative evaluation of the campaign were more likely to talk about it than were nonsmokers reporting negative evaluation. Nonsmokers who talked about the campaign had beliefs, attitudes, and intentions in greater agreement with campaign messages than those who did not talk about the campaign. For smokers, talking about the campaign was associated with beliefs, attitudes, and intentions in greater agreement with campaign messages, but only if associated with positive campaign evaluation. For smokers with a negative campaign evaluation, talking about the campaign was associated with beliefs and attitudes counter to the campaign messages.

Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters

BACKGROUND

Increasing rates of smoking cessation is one of the most effective measures available to improve population health. To advance the goal of increasing successful cessation at the population level, it is imperative that we understand more about smokers' use of cessation methods, as well as the helpfulness of those methods in real-world experiences of quitting. In this survey of recent quitters, we simultaneously examined rates of use and perceived helpfulness of various cessation methods.

METHODS

Recent quitters (within 12 months; n = 1097) completed a telephone survey including questions relating to 13 cessation methods. Indices of use and perceived helpfulness for each method were plotted in a quadrant analysis. Socio-demographic differences were explored using bivariate and multivariate analyses.

RESULTS

From the quadrant analysis, cold turkey, NRT and gradual reduction before quitting had high use and helpfulness; GP advice had high use and lower helpfulness. Prescribed medication and online programs had low use but high helpfulness. Remaining methods had low use and helpfulness. Younger quitters were more likely to use unassisted methods such as cold turkey; older or less educated quitters were more likely to use assisted methods such as prescribed medication or advice from a general practitioner.

CONCLUSIONS

The majority of recent quitters quit cold turkey or cut down before quitting, and reported that these methods were helpful. Efforts to influence population smoking prevalence should attempt to provide support and motivation for smokers choosing these methods, in addition to assessing the effectiveness and accessibility of other methods for smokers who need or choose them.

Neural activity during health messaging predicts reductions in smoking above and beyond self-report

OBJECTIVE

The current study tested whether neural activity in response to messages designed to help smokers quit could predict smoking reduction, above and beyond self-report.

DESIGN

Using neural activity in an a priori region of interest (a subregion of medial prefrontal cortex [MPFC]), in response to ads designed to help smokers quit smoking, we prospectively predicted reductions in smoking in a community sample of smokers (N = 28) who were attempting to quit smoking. Smoking was assessed via expired carbon monoxide (CO; a biological measure of recent smoking) at baseline and 1 month following exposure to professionally developed quitting ads.

RESULTS

A positive relationship was observed between activity in the MPFC region of interest and successful quitting (increased activity in MPFC was associated with a greater decrease in expired CO). The addition of neural activity to a model predicting changes in CO from self-reported intentions, self-efficacy, and ability to relate to the messages significantly improved model fit, doubling the variance explained (R²self-report = .15, R²self-report + neural activity = .35, R²change = .20).

CONCLUSION

Neural activity is a useful complement to existing self-report measures. In this investigation, we extend prior work predicting behavior change based on neural activity in response to persuasive media to an important health domain and discuss potential psychological interpretations of the brain-behavior link. Our results support a novel use of neuroimaging technology for understanding the psychology of behavior change and facilitating health promotion.

Squeezing new life out of an old Sponge: how to modernise an anti-smoking media campaign to capture a new market

OBJECTIVES

The iconic Sponge anti-smoking television advertisement was first made in Sydney, Australia, in 1979. In 2007, it was re-made for a new generation of smokers. This paper examines the impact of the re-made Sponge advertisement.

METHODS

Qualitative evaluation of the original Sponge ad by younger and older smokers (n=51) was followed by an online pre-test survey of the modernised version (n=301). A continuous tracking telephone survey of smokers and recent quitters (quit in past 12 months) over 18 years monitored performance of the modernised version while on air in late 2007 (total n=453; seen ad n=380).

RESULTS

Qualitative research found that the concept of the original Sponge ad may motivate younger smokers--who had not previously seen the ad--to quit. Online pre-testing demonstrated that the modernised version provided new information to 54% of 18-24 year olds (compared to 31% of older smokers). Tracking survey results indicated that believability of the modernised version was highest among 18-24 year olds (92%), that the ad was 'attention-grabbing' (86%), and that it was effective at influencing quitting intentions. Effects were amplified by the generation of pressure from family and friends.

IMPLICATIONS

The re-made Sponge advertisement had a positive impact on smokers, and was particularly effective among the new market of smokers aged less than 40 years. Adapting successful mass media campaign material can be an effective and economical strategy to influence smokers.