Provocative appeals in anti-smoking mass media campaigns targeting adolescents--the accumulated effect of multiple exposures

Exposure to pro-tobacco and anti-tobacco media messages and events and smoking behaviour among adolescents in Gambia

BACKGROUND

Despite the widespread prevalence of adolescent smoking in Gambia, a West African country, there is limited research exploring the relationships between exposure to pro-tobacco and anti-tobacco media messages and events and smoking behaviour among young people. This study investigates the interplay of these exposures and smoking behaviour among 11-17-year-old adolescents in Gambia.

METHODS

Secondary data analysis was conducted using the 2017 Gambia Global Youth and Tobacco Survey (GYTS), which included a total of 9,127 respondents. Descriptive and inferential analyses, including proportions, Pearson's chi-squared tests, and multivariable logistic regression models, were employed to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

The final model revealed significant associations between exposure to anti-tobacco media messages and events and smoking behaviour. Adolescents exposed to anti-tobacco media messages had a 29% increased odds of smoking (aOR 1.29,CI = 1.08,1.53) compared to those unexposed, while exposure to anti-tobacco media events showed a 31% increased odds (aOR 1.31,CI = 1.09,1.59) compared to those unexposed. Exposure to pro-tobacco messages, such as witnessing tobacco use on TV (aOR 1.41, CI = 1.17,1.69) and owning objects with tobacco brand logos (aOR 1.49,CI = 1.19,1.86), was associated with higher odds of smoking. Covariates, including sex, age, and exposure to smoking behaviour by significant others, also demonstrated associations with smoking behaviour. Notably, male respondents showed significantly higher odds of smoking (aOR = 4.01,CI = 3.28,4.89) compared to females. Respondents aged 15 years and older had increased odds of smoking (aOR = 1.47,CI = 1.22,1.76) compared to those below 15 years old. Those whose fathers smoke displayed higher odds of smoking (aOR = 1.35, CI = 1.04,1.76) compared to individuals with non-smoking parents. Additionally, those whose closest friends smoke showed remarkably higher odds of smoking (aOR = 2.87,CI = 2.37, 3.48) compared to those without such influence.

CONCLUSION

This study underscores the significant impact of exposure to both anti-tobacco and pro-tobacco media messages and events on smoking behaviour among adolescents in Gambia. However, pro-tobacco messages had a greater influence on smoking prevalence than anti-tobacco messages and events. Understanding these associations is crucial for devising effective public health interventions aimed at reducing tobacco use in this population.

The role of social norms in the relationship between anti-smoking advertising campaigns and smoking cessation: a scoping review

A systematic scoping review of anti-smoking mass media campaign literature provided opportunity to explore how social normative theories and constructs are used to influence smoking cessation. Synthesis of findings was constrained by significant heterogeneity. Nevertheless, the results indicate that a broader conceptualization of social norm is worthy of further exploration. Perceptions of what others think and do contributed in multiple ways to the relationship between anti-smoking messaging and quitting outcomes. Furthermore, integrating research on social norms, social identity and communication may improve understanding of why quitting intentions are enhanced in some circumstances but reactance and counter-arguing responses corresponding to lower quitting intentions occur in others. Integrating a broader theoretical understanding of normative influences into campaign development and evaluation may prove useful in demonstrating the effectiveness of this approach in behaviour change campaigns.

The effects of antismoking campaigns on nonsmokers in South Korea: perceived threat, attribution, and help-giving

Notwithstanding their good intentions, health communication campaigns may have inadvertent effects on an unintended audience. To explore the potential unintended consequences of an antismoking campaign on nonsmokers in South Korea, a survey of nonsmokers (N = 599) was conducted. The analysis revealed positive effects of campaign exposure on nonsmokers' perceived threat of smoking, which in turn led them to focus on smokers' personal responsibility over social responsibility. Both perceived threat and attribution of responsibility were related to nonsmokers' attitudes toward giving help to smokers, but in opposite directions. Theoretical and practical implications of the results are discussed.

Consumer Health Information Technology in the Prevention of Substance Abuse: Scoping Review

BACKGROUND

Addiction is one of the most rapidly growing epidemics that currently plagues nations around the world. In the United States, it has cost the government more than US $700 billion a year in terms of health care and other associated costs and is also associated with serious social, physical, and mental consequences. Increasing efforts have been made to tackle this issue at different levels, from primary prevention to rehabilitation across the globe. With the use of digital technology rapidly increasing, an effort to leverage the consumer health information technologies (CHITs) to combat the rising substance abuse epidemic has been underway. CHITs are identified as patient-focused technological platforms aimed to improve patient engagement in health care and aid them in navigating the complex health care system.

OBJECTIVE

This review aimed to provide a holistic and overarching view of the breadth of research on primary prevention of substance abuse using CHIT conducted over nearly past five decades. It also aimed to map out the changing landscape of CHIT over this period.

METHODS

We conducted a scoping review using the Arksey and O'Malley's modified methodological framework. We searched 4 electronic databases (PubMed, Cochrane, Scopus, and EMBASE). Papers were included if the studies addressed the use of CHIT for primary prevention of substance abuse and were published in English between 1809 and 2018. Studies that did not focus solely on primary prevention or assessed additional comorbid conditions were eliminated.

RESULTS

Forty-two papers that met our inclusion criteria were included in the review. These studies were published between 1970 and 2018 and were not restricted by geography, age, race, or sex. The review mapped studies using the most commonly used CHIT platforms for substance abuse prevention from mass media in the 1970s to mobile and social media in 2018. Moreover, 191 studies that were exclusively focused on alcohol prevention were excluded and will be addressed in a separate paper. The studies included had diverse research designs although the majority were randomized controlled trials (RCT) or review papers. Many of the RCTs used interventions based on different behavioral theories such as family interactions, social cognitive theories, and harm-minimization framework.

CONCLUSIONS

This review found CHIT platforms to be efficacious and cost-effective in the real-world settings. We also observed a gradual shift in the types and use of CHIT platforms over the past few decades and mapped out their progression. In addition, the review detected a shift in consumer preferences and behaviors from face-to-face interactions to technology-based platforms. However, the studies included in this review only focused on the aspect of primary prevention. Future reviews could assess the effectiveness of platforms for secondary prevention and for prevention of substance abuse among comorbid populations.

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.

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.

Mass media interventions for preventing smoking in young people

BACKGROUND

Mass media interventions can be used as a way of delivering preventive health messages. They have the potential to reach and modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To assess the effects of mass media interventions on preventing smoking in young people, and whether it can reduce smoking uptake among youth (under 25 years), improve smoking attitudes, intentions and knowledge, improve self-efficacy/self-esteem, and improve perceptions about smoking, including the choice to follow positive role models.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE and Embase in June 2016. This is an update of a review first published in 1998.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and interrupted time-series studies that assessed the effect of mass media campaigns (defined as channels of communication such as television, radio, newspapers, social media, billboards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person-to-person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years. We define smoking behaviour as the presence or absence of tobacco smoking or other tobacco use, or both, and the frequency of tobacco use. Eligible comparators included education or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risks of bias. We combined studies using qualitative narrative synthesis. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool, alongside additional domains to account for the nature of the intervention. We assessed the quality of evidence contributing to outcomes using GRADE.

MAIN RESULTS

We identified eight eligible studies reporting information about mass media smoking campaigns, one of which is new for this update. Seven of the studies used a controlled trial design and one an interrupted time-series analysis. Risks of bias were high across all included studies and there was considerable heterogeneity in study design, intervention and population being assessed.Three studies (n = 17,385), one of which compared a mass media intervention to no intervention and two of which evaluated mass media interventions as adjuncts to school-based interventions, found that the mass media interventions reduced the smoking behaviour of young people. The remaining five studies (n = 72,740) did not detect a significant effect on smoking behaviour. These included three studies comparing a mass media intervention to no intervention, one study evaluating a mass media intervention as an adjunct to a school-based intervention, and one interrupted time-series study of a social media intervention. The three campaigns which found a significant effect described their theoretical basis, used formative research in designing the campaign messages, and used message broadcast of reasonable intensity over extensive periods of time. However, some of the campaigns which did not detect an effect also exhibited these characteristics. Effective campaigns tended to last longer (minimum 3 years) and were more intense (more contact time) for both school-based lessons (minimum eight lessons per grade) and media spots (minimum four weeks' duration across multiple media channels with between 167 and 350 TV and radio spots). Implementation of combined school-based components (e.g. school posters) and the use of repetitive media messages delivered by multiple channels (e.g. newspapers, radio, television) appeared to contribute to successful campaigns.

AUTHORS' CONCLUSIONS

Certainty about the effects of mass media campaigns on smoking behaviour in youth is very low, due to inconsistency between studies in both design and results, and due to methodological issues amongst the included studies. It would therefore be unwise to offer firm conclusions based on the evidence in this review. Methodologically rigorous studies investigating the effect of social media and novel forms of technology as part of tobacco prevention campaigns for youth are needed.

Adolescents' Responses to Pictorial Warnings on Their Parents' Cigarette Packs

PURPOSE

Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents' responses to pictorial warnings, particularly in real-world settings.

METHODS

Participants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents' recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs.

RESULTS

Adolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p < .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p < .001). Pictorial warnings drew greater attention (p < .001), elicited greater negative emotional reactions (p < .05), and sparked more social interactions (p < .01) than text-only warnings.

CONCLUSIONS

Pictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents' susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations.

Measuring the Effectiveness of Mass-Mediated Health Campaigns Through Meta-Analysis

A meta-analytic review was undertaken to examine the effects of mass communication campaigns on changes in behavior, knowledge, and self-efficacy in the general public. A review of the academic literature was undertaken and identified 1,638 articles from 1966 through 2012. Using strict inclusion criteria, we included 63 studies for coding and analyses. Results from these efforts indicated that campaigns produced positive effects in behavior change (r = .05, k = 61) and knowledge (r = .10, k = 26) but failed to produce significant increases in self-efficacy (r = .02, k = 14). Several moderators (e.g., health topic, the theory underlying the campaign) were examined in relation to campaign principles that are prescribed to increase campaign effects. The major findings are reviewed, and the implications for future campaign design are discussed.

Adolescents' Communication with Parents, Other Adult Family Members and Teachers on Sexuality: Effects of School-Based Interventions in South Africa and Tanzania

Cluster-randomized controlled trials were carried out to examine effects on sexual practices of school-based interventions among adolescents in three sites in sub-Saharan Africa. In this publication, effects on communication about sexuality with significant adults (including parents) and such communication as a mediator of other outcomes were examined. Belonging to the intervention group was significantly associated with fewer reported sexual debuts in Dar es Salaam only (OR 0.648). Effects on communication with adults about sexuality issues were stronger for Dar es Salaam than for the other sites. In Dar, increase in communication with adults proved to partially mediate associations between intervention and a number of social cognition outcomes. The hypothesized mediational effect of communication on sexual debut was not confirmed. Promoting intergenerational communication on sexuality issues is associated with several positive outcomes and therefore important. Future research should search for mediating factors influencing behavior beyond those examined in the present study.

Using Mass Media Campaigns to Reduce Youth Tobacco Use: A Review

Objective.

This review synthesizes the published literature on using mass media campaigns to reduce youth tobacco use, with particular focus on effects within population subgroups and the relative effectiveness of campaign characteristics.

Data Source.

A search of PubMed and PsycINFO conducted in March of 2014 yielded 397 studies with 34 suitable for inclusion.

Study Inclusion and Exclusion Criteria.

Included were quantitative studies that evaluate an antitobacco media campaign intended to influence youth cognitions or behavior or explore the relative effectiveness of campaign characteristics among youth.

Data Extraction.

An automated search and assessment of suitability for inclusion was done.

Data Synthesis.

Study outcomes were compared and synthesized.

Results.

Antitobacco media campaigns can be effective across racial/ethnic populations, although the size of the campaign effect may differ by race/ethnicity. Evidence is insufficient to determine whether campaign outcomes differ by socioeconomic status (SES) and population density. Youth are more likely to recall and think about advertising that includes personal testimonials; a surprising narrative; and intense images, sound, and editing. Evidence in support of using a health consequences message theme is mixed; an industry manipulation theme may be effective in combination with a health consequences message. Research is insufficient to determine whether advertising with a secondhand smoke or social norms theme influences youth tobacco use.

Conclusion.

Our recommendation is to develop antitobacco campaigns designed to reach all at-risk youth, which can be effective across racial/ethnic populations. Research priorities include assessing campaign influence among lower SES and rural youth, disentangling the effects of message characteristics, and assessing the degree to which this body of evidence may have changed as a result of changes in youth culture and communication technology.

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.

Dissonance-based interventions for health behaviour change: a systematic review

PURPOSE

Increasing evidence suggests that various health behaviours are amenable to change following the induction of cognitive dissonance. This systematic review sought to evaluate the effectiveness and methodological quality of dissonance-based health behaviour interventions and to explore identified sources of heterogeneity in intervention effects.

METHODS

Bibliographic databases were searched for relevant articles from inception to March 2012. Only studies targeting non-clinical health behaviour in non-clinical populations were included in the review. One author extracted data and assessed quality of evidence and a second author verified all content.

RESULTS

Reports of 20 studies were included. A variety of health behaviours and outcome measures were addressed across studies. Most studies produced one or more significant effects on measures of behaviour, attitude or intention. Across studies, methodological risk for bias was frequently high, particularly for selection bias. Gender and self-esteem were identified as potential moderator variables.

CONCLUSIONS

The evidence for the effectiveness of dissonance-based interventions was generally positive. The hypocrisy paradigm was found to be the most commonly applied research paradigm and was most effective at inciting change across a range of health behaviours. There was no observable link between type of target behaviour and positive outcomes. Researchers are encouraged to minimize potential for bias in future studies and explore moderators of the dissonance effect.

STATEMENT OF CONTRIBUTION

What is already known on this subject? A recent meta-analysis indicates that dissonance-based interventions primarily based on the induced compliance paradigm are effective for eating disorder prevention (Stice, Shaw, Becker, & Rohde, 2008, Prev. Sci., 9, 114). However, it is currently unclear whether such outcomes are generalizable to interventions targeting non-clinical health behaviours such as smoking, sun protection and sexual risk taking. Other research indicates that studies based on the hypocrisy paradigm may lead to changes in non-clinical health behaviours (Stone & Fernandez, 2008, Soc. Personal. Psychol. Compass, 2, 1024; Stone & Focella, 2011, Self Identity, 10, 295) although this literature lacks systematic evaluation of interventions across a range of experimental paradigms. What does this study add? The hypocrisy paradigm appears most effective in inciting change across a range of non-clinical health behaviours. The dissonance effect may be moderated by variables such as self-esteem and gender. Risk of bias needs to be minimised to increase the validity of studies within this topic area.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

Background. Policymakers need estimates of the impact of tobacco control (TC) policies to set priorities and targets for reducing tobacco use. We systematically reviewed the independent effects of TC policies on smoking behavior. Methods. We searched MEDLINE (through January 2012) and EMBASE and other databases through February 2009, looking for studies published after 1989 in any language that assessed the effects of each TC intervention on smoking prevalence, initiation, cessation, or price participation elasticity. Paired reviewers extracted data from studies that isolated the impact of a single TC intervention. Findings. We included 84 studies. The strength of evidence quantifying the independent effect on smoking prevalence was high for increasing tobacco prices and moderate for smoking bans in public places and antitobacco mass media campaigns. Limited direct evidence was available to quantify the effects of health warning labels and bans on advertising and sponsorship. Studies were too heterogeneous to pool effect estimates. Interpretations. We found evidence of an independent effect for several TC policies on smoking prevalence. However, we could not derive precise estimates of the effects across different settings because of variability in the characteristics of the intervention, level of policy enforcement, and underlying tobacco control environment.

Cost effectiveness of tobacco control policies in Vietnam: the case of population-level interventions

BACKGROUND

Tobacco smoking is one of the leading public health problems in the world. It is also possible to prevent and/or reduce the harm from tobacco use through the use of cost-effective tobacco control measures. However, most of this evidence comes from developed countries and little research has been conducted on this issue in developing countries.

OBJECTIVE

The objective of this study was to analyse the cost effectiveness of four population-level tobacco control interventions in Vietnam.

METHODS

Four tobacco control interventions were evaluated: excise tax increase; graphic warning labels on cigarette packs; mass media campaigns; and smoking bans (in public or in work places). A multi-state life table model was constructed in Microsoft® Excel to examine the cost effectiveness of the tobacco control intervention options. A government perspective was adopted, with costing conducted using a bottom-up approach. Health improvement was considered in terms of disability-adjusted life-years (DALYs) averted. All assumptions were subject to sensitivity and uncertainty analysis.

RESULTS

All the interventions fell within the definition of being very cost effective according to the threshold level suggested by the WHO (i.e. <GDP per capita). Graphic warning labels on cigarette packs was the most cost-effective option, followed by excise tax increases, mass media campaigns, public smoking bans and work place smoking bans. If the cost offset was included in the analysis, all interventions would provide cost savings to the government health sector.

CONCLUSIONS

All four interventions to reduce the harm from tobacco use appear to be highly cost effective and should be considered as priorities in the context of Vietnam. The government may initially consider graphic warning labels and tax increase, followed by other interventions.

Content analysis of antismoking videos on YouTube: message sensation value, message appeals, and their relationships with viewer responses

Focusing on several message features that are prominent in antismoking campaign literature, this content-analytic study examines 934 antismoking video clips on YouTube for the following characteristics: message sensation value (MSV) and three types of message appeal (threat, social and humor). These four characteristics are then linked to YouTube's interactive audience response mechanisms (number of viewers, viewer ratings and number of comments) to capture message reach, viewer preference and viewer engagement. The findings suggest the following: (i) antismoking messages are prevalent on YouTube, (ii) MSV levels of online antismoking videos are relatively low compared with MSV levels of televised antismoking messages, (iii) threat appeals are the videos' predominant message strategy and (iv) message characteristics are related to viewer reach and viewer preference.

Mass media interventions for preventing smoking in young people

BACKGROUND

The mass media have been used as a way of delivering preventive health messages. They have the potential to reach and to modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To evaluate the effectiveness of mass media interventions to prevent smoking in young people in terms of reduced smoking uptake, in addition to secondary outcomes including improved smoking outcomes, attitudes, behaviours, knowledge, self-efficacy and perception.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of MEDLINE and EMBASE in July 2010.

SELECTION CRITERIA

Randomized trials, controlled trials without randomization and time series studies that assessed the effectiveness of mass media campaigns (defined as channels of communication such as television, radio, newspapers, bill boards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person to person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of media interventions, participants, outcomes, methods of the study and risk of bias was abstracted by two independent reviewers. Studies were combined using qualitative narrative synthesis.

MAIN RESULTS

Seven out of a total of 84 studies reporting information about mass media smoking campaigns met all of the inclusion criteria. All seven studies used a controlled trial design. Three studies concluded that mass media reduced the smoking behaviour of young people. All of the effective campaigns had a solid theoretical basis, used formative research in designing the campaign messages, and message broadcast was of reasonable intensity over extensive periods of time.

AUTHORS' CONCLUSIONS

There is some evidence that mass media can prevent the uptake of smoking in young people, however the evidence is not strong and contains a number of methodological flaws.

Assessing the relationship between ad volume and awareness of a tobacco education media campaign

BACKGROUND

The relation between aided ad recall and level of television ad placement in a public health setting is not well established. We examine this association by looking back at 8 years of the California's Tobacco Control Program's (CTCP) media campaign.

METHODS

Starting in July 2001, California's campaign was continuously monitored using five telephone series of surveys and six web-based series of surveys immediately following a media flight. We used population-based statewide surveys to measure aided recall for advertisements that were placed in each of these media flights. Targeted rating points (TRPs) were used to measure ad placement intensity throughout the state.

RESULTS

Cumulative TRPs exhibited a stronger relation with aided ad recall than flight TRPs or TRP density. This association increased after log-transforming cumulative TRP values. We found that a one-unit increase in log-cumulative TRPs led to a 13.6% increase in aided ad recall using web-based survey data, compared to a 5.3% increase in aided ad recall using telephone survey data.

CONCLUSIONS

In California, the relation between aided ad recall and cumulative TRPs showed a diminishing return after a large volume of ad placements These findings may be useful in planning future ad placement for CTCP's media campaign.

Differences in the perception of a mass media information campaign on drug and alcohol consumption

The two-month mass media campaign in Belgium on drug and alcohol consumption "Alcohol and other drugs. The facts and fictions" initiated in January 2008 has been evaluated shortly after by a phone survey. This article reports some indicators on the public awareness of the campaign, and the differences in the perception according to age groups and education levels.

About 1,000 respondents (n = 1,002) accepted to participate in the campaign evaluation. Response rate is 37.1%. Global perception of the campaign - measured by the capacity to identify the campaign adequately - is 18.8%. This perception varies between age groups and education levels: 30% of the youngest age group (14-35 yrs) have seen the campaign, 13% of people aged 56 and over (p<0.001). The lower the education level, the lower the probability to have seen the campaign (11% in the lowest group, 25% in the highest one, p<0.001).

Among the respondents who have seen the campaign, newspapers are the most often cited media for the oldest age groups. Inversely, young people have mainly identified the campaign on street boards or on post cards.

The privileged type of media is also function of the education level. People belonging to the lowest educational level report more often to have seen the campaign on TV (85% vs 51% in the highest group, p<0.01), while the reverse is true for seeing the campaign via the newspapers or the street boards.

The results indicate that there are socio-economic variations in the perception of the campaign. In health promotion, reaching lower socio-economic groups still remains a real challenge. Channels for such campaigns have to be carefully chosen to reach their target groups and ask to be complemented with community based interventions.

Development and evaluation of an early detection intervention for mouth cancer using a mass media approach

Background:

Scotland has a high incidence of mouth cancer, but public awareness and knowledge are low compared with other cancers. The West of Scotland Cancer Awareness Project sought to increase public awareness and knowledge of mouth cancer and to encourage early detection of symptoms among an at-risk population of people aged over 40 years from lower socio-economic groups using a mass media approach. The media campaign aimed to increase people's feelings of personal risk, while also enhancing feelings of efficacy and control. To achieve this, a testimonial approach (using real people to tell their own stories) was adopted.

Methods:

Campaign impact and reach was assessed using in-home interviews with a representative sample of the target population in both the campaign area and controls outside of the target area. Surveys were conducted at three stages: at baseline before the campaign was launched, and at 7 and 12 months thereafter.

Results:

Awareness of media coverage was higher at both follow-up points in the intervention area than in the control area, the differences largely being accounted for by television advertising. The campaign had a short-term, but not a long-term impact on awareness of the disease and intention to respond to the symptoms targeted by the campaign. Awareness of two of the symptoms featured in the campaign (ulcers and lumps) increased, post-campaign, among the intervention group.

Conclusions:

While the study provides evidence for the effectiveness of the self-referral model, further work is needed to assess its ability to build public capacity to respond appropriately to symptoms and to compare the cost-effectiveness of a mass media approach against alternative communication approaches and more conventional mass screening.

Sustaining 'truth': changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign

This study examines how the American Legacy Foundation's 'truth' campaign and Philip Morris's 'Think. Don't Smoke' (TDS) campaign have influenced youth's tobacco-related attitudes, beliefs and intentions during the first 3 years of the truth campaign. We use data from eight nationally representative cross-sectional telephone surveys of 35 074 12- to 17-year olds to estimate cross-sectional time series logistic regressions that assess the association between recall of truth and TDS and attitudes, beliefs, and intentions toward smoking. An alternative measure of exposure to TDS was also used. Findings indicate that exposure to truth advertisements (ads) was associated with steady positive changes in attitudes, beliefs and intentions to smoke, whereas exposure to Philip Morris ads was associated with more favorable beliefs and attitudes toward the tobacco industry. Our findings suggest that well-executed antismoking campaigns can positively and consistently change youth's beliefs and attitudes, whereas a tobacco industry-sponsored campaign can have a counterproductive influence.

A wakeup call to the prevention field: are prevention programs for substance use effective for girls?

Substance misuse in adolescent girls has increased dramatically since 1992. This article reviews trends in use rates and etiological theories tested by gender that suggest that family protective factors have more influence on girls. Next, a literature review reveals that few prevention programs have published their outcomes by gender or developed gender-specific programs. Nationwide community coalition results found positive effects on boys but increased drug use in young girls. The most effective programs are family focused targeting family bonding, supervision, and communication. Recent gender-specific prevention programs with positive results address stress, depression, social assertiveness, and body image. The authors recommend additional research testing programs by gender and also gender-specific versus generic versions of evidence-based programs to determine how to improve prevention program effectiveness for girls.

The effectiveness of mass communication to change public behavior

This article provides an overview of the ways in which mass communication has been used -- or can be used -- to promote beneficial changes in behavior among members of populations. We use an ecological perspective to examine the ways in which mass media interventions can be used to influence public behavior both directly and indirectly. Mass media interventions that seek to influence people directly -- by directly targeting the people burdened by the public health problem of concern and/or the people who influence them -- have a long basis in public health history, and recent reviews have clarified our expectations about what can be expected from such approaches. Mass media interventions that seek to influence people indirectly -- by creating beneficial changes in the places (or environments) in which people live and work -- have equal if not greater potential to promote beneficial changes in population health behaviors, but these are currently less explored options. To have the greatest possible beneficial influence on public behavior with the public health resources available, we recommend that public health program planners assess their opportunities to use media to target both people and places in a manner that complements and extends other investments being made in population health enhancement.

Smoking cessation attempts among adolescent smokers: a systematic review of prevalence studies

OBJECTIVE

To synthesise estimates of the prevalence of cessation attempts among adolescent smokers generally, and according to age and level of cigarette consumption.

DATA SOURCES

PubMed, ERIC, and PsychInfo databases and Internet searches of central data collection agencies.

STUDY SELECTION

National population-based studies published in English between 1990 and 2005 reporting the prevalence, frequency and/or duration of cessation attempts among smokers aged >or=10 to <20 years.

DATA EXTRACTION

Five reviewers determined inclusion criteria for full-text reports. One reviewer extracted data on the design, population characteristics and results from the reports.

DATA SYNTHESIS

In total, 52 studies conformed to the inclusion criteria. The marked heterogeneity that characterised the study populations and survey questions precluded a meta-analysis. Among adolescent current smokers, the median 6-month, 12-month and lifetime cessation attempt prevalence was 58% (range: 22-73%), 68% (range 43-92%) and 71% (range 28-84%), respectively. More than half had made multiple attempts. Among smokers who had attempted cessation, the median prevalence of relapse was 34, 56, 89 and 92% within 1 week, 1 month, 6 months, and 1 year, respectively, following the longest attempt. Younger (age<16 years) and non-daily smokers experienced a similar or higher prevalence of cessation attempts compared with older (age >or=16 years) or daily smokers. Moreover, the prevalence of relapse by 6 months following the longest cessation attempt was similar across age and smoking frequency.

CONCLUSIONS

The high prevalence of cessation attempts and relapse among adolescent smokers extends to young adolescents and non-daily smokers. Cessation surveillance, research and program development should be more inclusive of these subgroups.

Mass media for smoking cessation in adolescents

Theory-driven, mass media interventions prevent smoking among youth. This study examined effects of a media campaign on adolescent smoking cessation. Four matched pairs of media markets in four states were randomized to receive or not receive a 3-year television/radio campaign aimed at adolescent smoking cessation based on social cognitive theory. The authors enrolled 2,030 adolescent smokers into the cohort (n = 987 experimental; n = 1,043 comparison) and assessed them via annual telephone surveys for 3 years. Although the condition by time interaction was not significant, the proportion of adolescents smoking in the past month was significantly lower in the experimental than comparison condition at 3-year follow-up when adjusted for baseline smoking status. The media campaign did not impact targeted mediating variables. A media campaign based on social cognitive constructs produced a modest overall effect on smoking prevalence among adolescents, but the role of theory-based constructs is unclear.

Explicit and implicit effects of anti-marijuana and anti-tobacco TV advertisements

Effects of anti-tobacco and anti-marijuana TV advertisements on explicit (i.e., semantic differential ratings) and implicit (i.e. Implicit Association Test, IAT) attitudes toward tobacco and marijuana were compared. Two hundred twenty nine, 18- to 19-year-old U.S. college students were randomly assigned to anti-tobacco or anti-marijuana PSA viewing conditions. Participants completed a short survey on attitudes to tobacco and marijuana. Afterwards they watched 15 PSAs embedded in a 15-min science program. At the end, all participants completed IAT for marijuana, IAT for tobacco and the assessment of explicit attitudes. Results of ANCOVA revealed a significant interaction between type of TV PSAs watched and implicit attitudes, F(1,223)=7.12, p<0.01 when controlling for preexisting attitudes to both substances; the implicit attitudes were more negative toward the substance that corresponded to the content of advertisements watched (i.e., anti-tobacco or anti-marijuana). However, analogical analysis on explicit measures showed that attitudes to marijuana became less negative among students that watched anti-marijuana ads than the group with anti-tobacco ads, F(1,222)=5.79, p<0.02. The discussion focused on the practical and theoretical implications of the observed dissociation between implicit and explicit attitudes to marijuana after the exposure to anti-marijuana PSAs.

Trends in recall and appraisal of anti-smoking advertising among American youth: national survey results, 1997-2001

Public health efforts to reduce the harms related to tobacco use currently include a significant emphasis on anti-smoking media campaigns. This paper provides (a) data on the overall extent of exposure to anti-smoking media among American youth from 1997 to 2001, (b) an appraisal of general youth reactions to such advertising, and (c) an examination of how exposure levels and reactions vary by socio-demographic characteristics. Data were obtained from the Monitoring the Future study, an ongoing nationwide study of youth. Data were collected each year from nationally representative separate and nonoverlapping school samples of 8th, 10th, and 12th grade students (N = 29,724; 24,639; and 12,138, respectively). Self-reported levels of recalled exposure to both electronic and print anti-smoking advertising were measured, as well as the judged impact and perceived exaggeration of such advertising. Data indicate that significant increases in overall exposure to anti-smoking advertising occurred over the study time period. These increases were associated with (a) increases in the self-reported likelihood that anti-smoking advertising diminished the probability of individual smoking behaviors, and (b) increases in the perceived level to which anti-smoking advertising exaggerates the risks associated with smoking. Further, these trends were significantly associated with various characteristics-most notably, ethnicity, smoking behaviors, and residence in a state with an ongoing tobacco-control program having a media component.

Marketing a hard-to-swallow message: recommendations for the design of media campaigns to increase awareness about the risks of binge drinking

BACKGROUND

Binge drinking, commonly defined as having more than five drinks on a single occasion, is a public health issue affecting two thirds of Canadian young adults between the ages of 19-24 years. To educate young adults about alcohol poisoning, a network of 16 Ontario Health Units developed and implemented a mass-media campaign. The focus of this article is to report on post-secondary students' perceptions about key media campaign strategies, elements and messages for future campaigns designed to increase awareness about the risks of binge drinking.

METHODS

As part of a multi-method process evaluation, nine focus groups were facilitated to explore the young adults' knowledge, attitudes and beliefs about binge drinking and the campaign messages. Participants were also asked to identify specific marketing messages and techniques that would increase their level of awareness about the risks of binge drinking.

RESULTS

Participants recommended that campaigns be targeted towards parents and high school and post-secondary school students. Participants provided recommendations for the types of messages, images, and language they perceived would capture the attention of young adults. Television, posters and the internet were identified as key media channels for disseminating health information about the risks associated with excessive alcohol consumption.

CONCLUSION

The problem of binge drinking is pervasive across Canadian campuses and students are largely unaware of the risks associated with excessive alcohol consumption. To reach this target population, it is important for future media campaign developers to utilize language, definitions, graphics and channels of communication to which this group relates.

Effects of a media campaign on back beliefs is sustained 3 years after its cessation

STUDY DESIGN

Quasi-experimental, nonrandomized, nonequivalent, parallel group-controlled study involving before and after telephone surveys of the general population.

OBJECTIVE

To measure the magnitude of any sustained change in population beliefs about back pain 3 years after cessation of a population-based intervention designed to alter beliefs about back pain.

SUMMARY OF BACKGROUND DATA

A media campaign, which ran between September 1997 and December 1999 in Victoria, Australia, provided simple evidence-based advice about back pain. Following the campaign, there were significant improvements in both community and physicians' beliefs about back pain, as well as a decline in number of workers' compensation back claims.

METHODS

The campaign's impact on population beliefs about back pain and fear-avoidance beliefs was measured using telephone surveys. Demographically identical population groups in Victoria and the adjacent control state, New South Wales, were surveyed at 4 times: before, during, immediately after, and 3 years after the media campaign in Victoria (surveys 1-4, respectively). Back beliefs were measured using the Back Beliefs Questionnaire (BBQ) (possible score 9-45, for which a higher score indicates a more positive belief about low back trouble). Fear-avoidance beliefs were measured using the Fear-Avoidance Beliefs Questionnaire consisting of 2 subscales for physical activity and work activity (possible scores 0-24 and 0-36, respectively), for which a lower score indicates fewer fear-avoidance beliefs.

RESULTS

A total of 6230 individuals in the general population completed the surveys. Large statistically significant improvements in population beliefs about back pain were still observed in Victoria 3 years after cessation of the campaign (mean scores on the BBQ were 26.5, 28.4, 29.7, and 28.8 for surveys 1-4, respectively). No changes were observed in New South Wales (mean scores on the BBQ were 26.3, 26.2, 26.3, and 26.1 for surveys 1-4, respectively). Of those individuals who reported back pain during the previous year, fear-avoidance beliefs about physical activity in Victoria were also significantly better than at baseline (mean scores on the Fear-Avoidance Beliefs Questionnaire for physical activity were 14.0, 12.5, 11.6, and 12.3 for surveys 1-4, respectively).

CONCLUSIONS

Significant sustained improvements in population beliefs about back pain were observed 3 years after cessation of a media campaign of provision of positive messages about back pain. This result provides further evidence that a primary preventive strategy of altering population beliefs about back pain may be a highly effective way for reducing back-related disability.

Risk Markers of Oral Cancer in Clinically Normal Mucosa As an Aid in Smoking Cessation Counseling

Purpose

Quitting smoking may prevent oral cancer. Behavioral intervention to quit smoking may be more efficient if persons are assigned an individual risk of cancer.

Patients and Methods

In this prospective study, we provided counseling and behavioral intervention toward smoking cessation, supplemented by genetic analyses in clinically normal oral mucosa of heavy smokers. Measurement of serum cotinine was used to assess changes in smoking habits.

Results

In cytologic scrapings from 275 heavy smokers with clinically normal mucosa, we found tetraploidy in four and aneuploidy in 19 persons (23 of 275; 8%). Twenty one (91%) of 23 persons with aneuploidy had quit or reduced their smoking habits at the 3-month follow-up, 20 (87%) of 23 persons had done so at 12 months, and 21 (91%) of 23 persons had done so at 24 months. Fifty-one (20%) of the 252 persons without genetic changes in their mucosa had quit or reduced their tobacco habits at the 3-month follow-up, 23 (9%) had done so at 12 months, and 17 (7%) had done so at 24 months (P < .001). After 24 months, normalization of DNA content to diploidy was observed in two of four persons with tetraploid (50%), and in 11 of 19 persons (58%) with aneuploid scrapings. One patient developed an oral carcinoma in the floor of the mouth: this patient had an aneuploid scraping obtained 43 months earlier and developed a leukoplakia 28 months before the carcinoma.

Conclusion

Risk markers of oral cancer are present in clinically normal mucosa of heavy smokers, and such findings enhance the adherence to smoking cessation on counseling. Cytogenetic aberrations may normalize after quitting smoking.

A systematic review of school-based smoking prevention trials with long-term follow-up

BACKGROUND

Several systematic reviews of school-based smoking prevention trials have shown short-term decreases in smoking prevalence but have not examined long-term follow-up evaluation. The purpose of this study was to conduct a systematic review of rigorously evaluated interventions for school-based smoking prevention with long-term follow-up data.

METHODS

We searched online bibliographic databases and reference lists from review articles and selected studies. We included all school-based, randomized, controlled trials of smoking prevention with follow-up evaluation to age 18 or 12th grade and at least 1 year after intervention ended, and that had smoking prevalence as a primary outcome. The primary outcome was current smoking prevalence (defined as at least 1 cigarette in the past month).

RESULTS

The abstracts or full-text articles of 177 relevant studies were examined, of which 8 met the selection criteria. The 8 articles included studies differing in intervention intensity, presence of booster sessions, follow-up periods, and attrition rates. Only one study showed decreased smoking prevalence in the intervention group.

CONCLUSIONS

Few studies have evaluated the long-term impact of school-based smoking prevention programs rigorously. Among the 8 programs that have follow-up data to age 18 or 12th grade, we found little to no evidence of long-term effectiveness.

The effect of antismoking advertisement executional characteristics on youth comprehension, appraisal, recall, and engagement

This article examines how two executional characteristics of antismoking advertising may interact with other relevant advertising features to affect youth comprehension, appraisal, recall of, and engagement with antismoking ads. Fifty antismoking ads made by tobacco control agencies, tobacco companies, and pharmaceutical companies were appraised by 268 youth using an audience response methodology with a follow-up component. Analyses show that thematic and executional characteristics varied both across and within ad sponsor, and that executional characteristics of "personal testimonial" and "visceral negative" clearly had the strongest and most consistent effect on appraisal, recall, and level of engagement. Antismoking advertisements are not alike in their ability to engage youth. Advocates attempting to develop increasingly successful antismoking campaigns should consider the executional characteristics of proposed ads.

Youth tobacco prevention mass media campaigns: past, present, and future directions

This paper focuses on countermarketing efforts aimed at curbing youth smoking. We review the literature on the effectiveness of tobacco countermarketing campaigns, characterise current state and national campaign approaches, present findings from qualitative approaches and laboratory experiments that explore a variety of messages (for example, health consequences, industry manipulation), and discuss newer, non-traditional approaches to countermarketing. In conclusion, we outline research needed to fill gaps in our existing knowledge and discuss future directions in tobacco countermarketing aimed at youth.

Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke

This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.

The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study

OBJECTIVES

We examined the impact of a statewide antismoking media campaign on progression to established smoking among Massachusetts adolescents.

METHODS

We conducted a 4-year longitudinal survey of 592 Massachusetts youths, aged 12 to 15 years at baseline in 1993. We examined the effect of baseline exposure to television, radio, and outdoor antismoking advertisements on progression to established smoking (defined as having smoked 100 or more cigarettes), using multiple logistic regression and controlling for age; sex; race; baseline smoking status; smoking by parents, friends, and siblings; television viewing; and exposure to antismoking messages not related to the media campaign.

RESULTS

Among younger adolescents (aged 12 to 13 years at baseline), those reporting baseline exposure to television antismoking advertisements were significantly less likely to progress to established smoking (odds ratio = 0.49, 95% confidence interval = 0.26, 0.93). Exposure to television antismoking advertisements had no effect on progression to established smoking among older adolescents (aged 14 to 15 years at baseline), and there were no effects of exposure to radio or outdoor advertisements.

CONCLUSIONS

These results suggest that the television component of the Massachusetts antismoking media campaign may have reduced the rate of progression to established smoking among young adolescents.

Mass media interventions for preventing smoking in young people

BACKGROUND

The mass media have been used as a way of delivering preventive health messages. They have the potential to reach and to modify the knowledge, attitudes and behaviour of a large proportion of the community.

OBJECTIVES

To determine the effectiveness of mass media campaigns in preventing the uptake of smoking in young people.

SEARCH STRATEGY

We searched Medline, and 28 other electronic databases. Handsearching of key journals was also carried out, the bibliographies of identified studies were checked for additional references and contact with content area specialists was made. Date of last search June 1998.

SELECTION CRITERIA

Randomised trials, controlled trials without randomisation and time series studies that assessed the effectiveness of mass media campaigns (defined as channels of communication such as television, radio, newspapers, bill boards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person to person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and the content of media interventions, participants, outcomes and methods of the study was abstracted by one reviewer and checked by a second. Studies were combined using qualitative narrative synthesis.

MAIN RESULTS

Six out of a total of 63 studies reporting information about mass media smoking campaigns met all of the inclusion criteria. All six studies used a controlled trial design. Two studies concluded that the mass media were effective in influencing the smoking behaviour of young people. Both of the effective campaigns had a solid theoretical basis, used formative research in designing the campaign messages and message broadcast was of reasonable intensity over extensive periods of time.

REVIEWER'S CONCLUSIONS

There is some evidence that the mass media can be effective in preventing the uptake of smoking in young people, but overall the evidence is not strong.

Preventing problems from psychoactive substance use

The range of harms to health from psychoactive substances is considered, and current data are presented on the health burden of alcohol, tobacco, and illicit drugs. Four major strategies for preventing or reducing harm are discussed: education and persuasion, treatment, insulating use from harm, and regulating the availability and conditions of use. Education and treatment are necessary parts of an overall public health approach, but are not very effective in themselves in reducing rates of harm in the population. Insulating use from harm and regulating availability have often proved effective components of a public health approach.