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

Messages about climate, pollution and social justice harms of tobacco as motivators to quit: an untapped communication opportunity?

BACKGROUND

Campaigns highlighting the health harms of smoking have demonstrated success in motivating people who smoke to quit. Tobacco production and use also exert a toll on the environment, sustainable development and human rights. However, messages highlighting these harms of tobacco have been relatively unexplored as a cessation motivation strategy. In this study, we examined the extent to which a range of messages about climate, pollution and social justice harms of tobacco are perceived as motivating among people who smoke, overall and by sociodemographics.

DATA AND METHODS

Australian adults who smoke (n=395) aged 18-59 years reported the 'extent to which each of the following motivated them to quit smoking' and were then presented with messages about climate (four items), pollution (three items) and social justice (three items) harms of tobacco, which they rated on a 5-point scale ranging from 1 'Not at all' to 5 'Very much so' in this online cross-sectional survey. Differences by age, education, gender, socioeconomic status (SES) and geographical region were examined using prevalence ratios from generalised linear models with log-link (Poisson regression).

RESULTS

For each of the 10 messages, between one-half and two-thirds of the overall sample perceived them as motivating (49-65%), particularly messages highlighting harms to human or animal life and welfare (all ≥60%). Across all message themes, younger adults (18-35 years) and those who completed tertiary education were more likely to perceive some messages as motivating. Perceived motivation did not vary significantly by gender, SES or geographical region.

CONCLUSION

Findings suggest that value-based messaging featuring the environmental and social justice footprint of tobacco is perceived as motivating for smoking cessation, especially among younger people and those with higher education who may be more engaged with these issues. Inclusion of such messages as part of a comprehensive antitobacco communication strategy may provide an untapped opportunity by potentially providing people who smoke with additional compelling reasons to quit.

The Validity of Impressions as a Media Dose Metric in a Tobacco Public Education Campaign Evaluation: Observational Study

BACKGROUND

Evaluation research increasingly needs alternatives to target or gross rating points to comprehensively measure total exposure to modern multichannel public education campaigns that use multiple channels, including TV, radio, digital video, and paid social media, among others. Ratings data typically only capture delivery of broadcast media (TV and radio) and excludes other channels. Studies are needed to validate objective cross-channel metrics such as impressions against self-reported exposure to campaign messages.

OBJECTIVE

This study aimed to examine whether higher a volume of total media campaign impressions is predictive of individual-level self-reported campaign exposure in California.

METHODS

We analyzed over 3 years of advertisement impressions from the California Tobacco Prevention Program's statewide tobacco education campaigns from August 2019 through December 2022. Impressions data varied across designated market areas (DMAs) and across time. These data were merged to individual respondents from 45 waves of panel survey data of Californians aged 18-55 years (N=151,649). Impressions were merged to respondents based on respondents' DMAs and time of survey completion. We used logistic regression to estimate the odds of respondents' campaign recall as a function of cumulative and past 3-month impressions delivered to each respondent's DMA.

RESULTS

Cumulative impressions were positively and significantly associated with recall of each of the Flavors Hook Kids (odds ratio [OR] 1.15, P<.001), Dark Balloons and Apartment (OR 1.20, P<.001), We Are Not Profit (OR 1.36, P<.001), Tell Your Story (E-cigarette, or Vaping, product use Associated Lung Injury; OR 1.06, P<.05), and Thrown Away and Little Big Lies (OR 1.05, P<.01) campaigns. Impressions delivered in the past 3 months were associated with recall of the Flavors Hook Kids (OR 1.13, P<.001), Dark Balloons and Apartment (OR 1.08, P<.001), We Are Not Profit (OR 1.14, P<.001), and Thrown Away and Little Big Lies (OR 1.04, P<.001) campaigns. Past 3-month impressions were not significantly associated with Tell Your Story campaign recall. Overall, magnitudes of these associations were greater for cumulative impressions. We visualize recall based on postestimation predicted values from our multivariate logistic regression models.

CONCLUSIONS

Variation in cumulative impressions for California Tobacco Prevention Program's long-term multichannel tobacco education campaign is predictive of increased self-reported campaign recall, suggesting that impressions may be a valid proxy for potential campaign exposure. The use of impressions for purposes of evaluating public education campaigns may help address current methodological limitations arising from the fragmented nature of modern multichannel media campaigns.

Quitting on TikTok: Effects of Message Themes, Frames, and Sources on Engagement with Vaping Cessation Videos

This study examined how message themes, frames, and sources in vaping cessation videos on TikTok influenced positive (i.e. likes, shares, positive comments regarding quitting vaping) and negative video engagement (i.e. negative comments regarding quitting vaping). TikTok videos (N = 412) with the hashtags #quitvaping and #quittingvaping were analyzed. Aspect-based sentiment analysis was conducted to evaluate the sentiment of quitting vaping in comments. Negative binomial regression models predicted video engagement from six message themes, ratios of gain and loss frames, and message sources. Themes related to nicotine addiction and physical health effectively drove positive engagement, such as likes and shares. The theme of harmful chemicals elicited mixed responses, generating both positive and negative comments regarding quitting vaping. Videos with a higher ratio of gain frames led to more positive engagement, including likes, shares, and positive comments regarding quitting vaping. Sources with informal expertise (e.g. those who have successfully quit vaping) and current e-cigarette users were more effective in engaging the TikTok audience than non-expert and non-user sources. These findings provide insights into messaging strategies that can effectively engage TikTok audiences and encourage vaping cessation.

The Effect of Anti-Tobacco Ad Length and Skippability on Perceived Message Effectiveness and Emotional Responsiveness

The media landscape changes have resulted in significantly more people viewing content in shorter and skippable formats. There is limited evidence about the impact of these formats on anti-tobacco campaign effectiveness. This study examined the effect of anti-tobacco ad length and skippability on perceived message effectiveness (PME) and emotional responsiveness among people who smoke. Initially, 805 people who smoke were randomized to a message type (anti-tobacco vs. control) × message length (15 vs. 30 seconds) condition. A week later, participants saw the same message, but were randomized to a skippable or non-skippable version. Following ad exposure, outcomes were measured and examined in mixed-effects linear regression models. We found that at initial exposure, participants in the 30-second anti-tobacco condition reported significantly higher scores on personal relevance (75% cf. 68%), motivation to act (61% cf. 52%), action-oriented negative emotion (62% cf. 53%) and positive emotion (37% cf. 28%) relative to participants in the 15-second anti-tobacco condition. At repeated exposure, there was no effect of ad skippability on PME or emotional responsiveness regardless of message type condition. However, participants in the 30-second anti-tobacco condition reported significantly higher scores on action-oriented negative emotion (60% cf. 50%) and inaction-oriented negative emotion (54% cf. 46%) relative to participants in the 15-second anti-tobacco condition. Our findings suggest that initial exposure to non-skippable and longer novel anti-tobacco messages can lead to stronger personal relevance, motivation to act and emotional arousal, and ongoing negative emotional arousal, which may attenuate the negative effects of allowing individuals to skip later.

It's Not Just: Evaluation of a Media Campaign to Motivate Action Around Targeting of Menthol Tobacco in Black Communities

Introduction

For more than 60 years, tobacco companies have aggressively marketed menthol tobacco products in Black communities. In 2021, New York State Department of Health-funded grantees launched a media campaign aimed toward civically engaged New York adults to educate and mobilize community action to prevent targeted marketing of menthol tobacco. This study examined audience reactions to the campaign and associations between campaign awareness and key outcomes.

Methods

Following campaign implementation, we administered 2 online, cross-sectional surveys to 2,000 civically engaged New York adults to assess campaign awareness, audience reactions, and campaign-related attitudes and behaviors. We examined sociodemographic differences in audience reactions and assessed multivariate associations between campaign awareness and key outcomes.

Results

Overall, 40% of respondents were aware of the campaign. Perceived advertisement (ad) effectiveness was higher among Black, Hispanic, and nonsmoking respondents and those aware of the campaign. Negative reactions to ads were higher at wave 1, among non-Hispanic White and male respondents, and among current smokers. Campaign awareness was positively associated with campaign-related beliefs. The association between campaign awareness and support for a menthol ban varied by survey wave and race, with positive associations at wave 2 and among non-Hispanic White respondents only. Among wave 2 respondents only, campaign awareness was positively associated with actions to reduce the targeting of menthol in Black communities.

Conclusion

Media campaigns can play an important role in raising awareness of menthol tobacco product targeting in Black communities and building public support for local and statewide menthol restrictions that may be implemented before federal product standards are in place.

"I think we can do without [tobacco]": support for policies to end the tobacco epidemic among California adolescents

INTRODUCTION

The tobacco endgame, policies aiming to end the commercial tobacco epidemic, requires sustained public support, including among youth. We assessed endgame support among California (USA) adolescents, including their reasons and associated participant and policy-specific factors.

METHODS

Teens, Nicotine and Tobacco Project online surveys (n=4827) and focus groups were conducted in 2021 and 2022 among California residents aged 12-17 years. Cross-sectional survey participants were asked their agreement level with eight policy statements related to tobacco and/or cannabis sales restrictions, use in public places and use in multiunit housing. Ordered logistic regression modelled level of agreement according to respondent characteristics, behaviours and statement content. Qualitative data were collected through focus groups (n=51 participants), which were analysed to provide insight into support for different policies.

RESULTS

Most survey participants agreed or strongly agreed with tobacco product sales restrictions (72%-75%, depending on the policy), bans on use in public spaces (76%-82%) and smoke-free (79%) and vape-free (74%) apartment buildings. Support was stronger among younger, female, Asian and tobacco non-using participants and for policies directed at 'tobacco' (vs 'vapes' or cannabis), at flavoured tobacco (compared with all tobacco), and when statements featured 'should end' (vs 'not allowed'). Focus group participants who were supportive viewed policies as protecting children from harmful products, while those less supportive cited concerns about limiting adults' freedoms and unintended consequences.

CONCLUSIONS

Most participants supported strong tobacco control policies. Public communication that promotes broader endgame benefits besides protecting youth and accelerates industry denormalisation may counter youth concerns and further bolster their support.

Treatment-seeking young people enrolled in a United States vaping cessation intervention trial report high frequency of use and nicotine dependence

Objective

This study examines characteristics of participants enrolled in a vaping cessation intervention trial and study generalizability of the treatment-seeking sample to the broader population of young people interested in quitting vaping to evaluate dissemination of an evidence-based treatment program.

Methods

Data was obtained from 697 treatment-seeking participants (aged 13-24 years) from a vaping cessation intervention trial conducted between February and March 2023 with This is Quitting and 665 participants who expressed intent to quit vaping in the Truth Longitudinal Cohort, a nationally representative longitudinal study of United States youth and young adults (aged 15-24 years), collected October 2022 to February 2023. Comparisons were made using two-sample Pearson Chi-square tests and t-tests.

Results

Treatment-seeking young people were younger, less racially diverse, more diverse in sexual orientation, and reported higher psychological distress, frequency of e-cigarette use, and nicotine dependence, relative to the nationally representative sample of young people expressing intentions to quit vaping.

Conclusions

Participants enrolled in treatment reported higher levels of dependence and use frequency than the broader population, suggesting that many young e-cigarette users with lower dependence who want to quit might not be reached by current treatment dissemination efforts. The implication of these findings is that communications for vaping cessation programs may need to be adjusted to have broader appeal among young people.

Exploring motivations for engagement with the Healthy Lunch Box campaign on social media

Many health organisations seek social media engagement through their online health promotion campaigns, but there is little understanding of what engagement means in relation to the uptake of health messages. To understand the relevance of social media engagement, we need to look at the reasons why people engage with health content via social media. This exploratory study examined people's motivations for engaging with health content through a case study of the Healthy Lunch Box campaign. Data was collected via online focus groups (n = 7), with participants being a convenience sample of people who had seen or engaged with the Healthy Lunch Box resources (n = 24). The discussions covered reasons for engaging with the Healthy Lunch Box campaign, and more broadly with health content on social media in general. The data was analysed using a reflexive approach to thematic analysis, with themes developed inductively. The study found that some of the reasons for engagement aligned with the paradigm of social media engagement being an intermediary step in the process towards health behaviour change. However, people also described other reasons, such as alignment with their personal values, consideration of their online presentation, or as a way of curating the content they wanted to be shown on social media. These results demonstrate that people's decision to engage with health-related social media content involves more than consideration about the usefulness of the content, suggesting the need for a deeper examination of the assumptions made about the value of social media engagement in health campaign evaluations.

A Model of Social Media Effects in Public Health Communication Campaigns: Systematic Review

BACKGROUND

Social media platforms are frequently used in health communication campaigns. Common understandings of campaign effects posit a sequential and linear series of steps from exposure to behavior change, commonly known as the hierarchy of effects model (HOE). These concepts need to be reevaluated in the age of social media, which are interactional and communal.

OBJECTIVE

This review aims to update the traditional HOE for health communication campaigns in the context of social media, including identifying indicators of effectiveness and how these are conceptualized to lead to health-related outcomes.

METHODS

We conducted a systematic review of studies following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines reporting on the use of social media as part of health communication campaigns, extracting campaign information such as objectives, platforms used, and measures of campaign performance. We used these data, combined with our understanding of the HOE, to develop an updated conceptual model of social media campaign effects.

RESULTS

We identified 99 eligible studies reporting on 93 campaigns, published between 2012 and 2022. The campaigns were conducted in over 20 countries, but nearly half (n=42) were conducted in the United States. Campaigns targeted a variety of health issues and predominantly used Facebook, Twitter, Instagram, and YouTube. Most campaigns (n=81) set objectives targeting awareness or individual behavior change. Process measures (n=68; eg, reach and impressions) and engagement measures (n=73; eg, likes and retweets) were reported most frequently, while two-fifths (n=42) did not report any outcomes beyond engagement, such as changes in knowledge, behavior, or social norms. Most campaigns (n=55) collected measures that did not allow them to determine if the campaign objective had been met; that is, they were process evaluations only. Based on our review, our updated model suggests that campaign exposure can lead to individual behavior change and improved health outcomes, either through a direct or indirect pathway. Indirect pathways include exposure through social and policy changes. "Engagement" is positioned as critical to success, replacing awareness in the traditional HOE, and all types of engagement are treated as equal and good. No consideration is being given to potential negative engagement, such as the distribution of misinformation. Additionally, the process is no longer linear and sequential, with circular pathways evident, such as engagement not only influencing behavior change but also generating additional exposure to campaign messages.

CONCLUSIONS

Our review has highlighted a change in conventional understandings of how campaigns can influence health outcomes in the age of social media. The updated model we propose provides social media campaigners with a starting point to develop and tailor campaign messages and allows evaluators to identify critical assumptions to test, including the role and value of "engagement."

TRIAL REGISTRATION

PROSPERO CRD42021287257; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287257.

Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies

Vaping prevention messages are widely used to communicate the health harms and addiction risks of vaping and discourage vaping among adolescents and young adults. We conducted a meta-analysis of experimental studies to examine the effects of these messages and to understand their theoretical mechanisms. Systematic, comprehensive searches generated 4,451 references, among which 12 studies (cumulative N = 6,622) met inclusion criteria for the meta-analysis. Across these studies, a total of 35 different vaping-related outcomes were measured, and 14 outcomes assessed in two or more independent samples were meta-analyzed. Results showed that compared to control, exposure to vaping prevention messages led to higher vaping risk perceptions, including harm perceptions (d = 0.30, p < .001), perceived likelihood of harm (d = 0.23, p < .001), perceived relative harm (d = 0.14, p = .036), addiction perceptions (d = 0.39, p < .001), perceived likelihood of addiction (d = 0.22, p < .001), and perceived relative addiction (d = 0.33, p = .015). Also, compared to control, exposure to vaping prevention messages led to more vaping knowledge (d = 0.37, p < .001), lower intentions to vape (d = -0.09, p = .022), and higher perceived message effectiveness (message perceptions; d = 0.57, p < .001; effects perceptions; d = 0.55, p < .001). Findings suggest vaping prevention messages have an impact, yet may operate through different theoretical mechanisms than cigarette pack warnings.

Effectiveness of a Smoking Cessation Program during the COVID-19 Pandemic

The coronavirus disease-2019 pandemic has caused major obstacles for effective smoking cessation programs by significantly limiting access to healthcare. This cross-sectional analysis aimed to assess the effectiveness of a self-developed smoking cessation program during the pandemic. The program was based on remote lectures, educational interventions, and hybrid services provided by an outpatient clinic. We assessed 337 participants enrolled to the program between January 2019 and February 2022. Data on demographic characteristics, medical history, and smoking status at baseline and after at least 1-year follow-up were collected from medical records and a standardized self-developed questionnaire. Participants were classified into two groups according to their current smoking status. The smoking cessation rate at 1 year was 37% (95% confidence interval [CI]: 31-42%). Major predictors of smoking cessation were the place of residence, ability to refrain from smoking during severe illness, and the number of cigarettes smoked per day. The proportion of participants with high levels of nicotine dependence at baseline was 40.8% (95% CI: 34.5-47.5%) vs. 29.1% (95% CI: 23.4-35.5%) after the program. In the group that did not quit smoking, there were more participants who smoked within 5 min after waking up than before the program (40.4% [95% CI: 34.0-47.1%] vs. 25.4% [95% CI: 19.9-31.6%]). Effective smoking cessation interventions can be performed using remote counseling and education.

The impact of responsible gambling framing on people with lived experience of gambling harm

BACKGROUND

The framing of health issues influences how people think about and respond to these topics. Gambling has largely been framed as an issue of personal responsibility, with the gambling industry, governments and some researchers promoting responsible gambling strategies as a way to address gambling harm. While there is evidence that the internalization of personal responsibility can negatively impact gamblers, this study aimed to explore how people who have experienced gambling harm interpret and apply personal responsibility frames and 'gamble responsibly' messages in their lives.

METHODS

In-depth semi-structured interviews were conducted via Zoom and telephone with 15 gamblers who had been harmed by their own gambling and six affected others who had been harmed by someone else's gambling. This study was informed by public health and critical qualitative approaches to inquiry. The data were analyzed using reflexive thematic analysis.

RESULTS

Four themes were constructed from the data. First, gamblers and affected others generally conceptualized gambling and gambling harm as being the responsibility of the individual because it was perceived as the outcome of individual behavior. Second, they attempted to apply responsibility to their own experience either as gamblers who tried to stop or reduce their gambling, or affected others who felt responsible for helping the gambler in their lives. Third, gamblers and affected others were negatively impacted when it was perceived the gambler could not 'control' their gambling or had not done enough to take responsibility. Finally, gamblers and affected others recommended responsible gambling strategies be reframed to be more effective at addressing gambling harm.

CONCLUSION

This study provides evidence further supporting research demonstrating that personal responsibility frames may have unintended or negative consequences for gamblers and affected others. It underscores the need to reframe public messages about gambling away from responsible gambling, and toward research-based messages that can complement broader legislative changes and other measures to protect individuals.

"Aussies love a bet": Gamblers discuss the social acceptance and cultural accommodation of gambling in Australia

OBJECTIVE

This study aimed to explore regular gamblers' perceptions of the social acceptance and cultural accommodation of gambling in Australia, which are two dimensions of the normalisation of gambling.

METHODS

Qualitatively focused online survey with 363 adults in New South Wales and Victoria who gambled in a typical month. Open-text responses about the link between gambling and Australian culture were interpreted using reflexive thematic analysis to construct themes from the data.

RESULTS

Gambling was perceived to be a culturally significant part of Australian life due to existing traditions, the perception that gambling was central to the Australian identity, and perceived economic benefits. Participants considered that gambling was a common and socially accepted activity that was embedded in the activities of social networks. Participants also stated that gambling products, venues and marketing were embedded in everyday environments, although some believed that the embedding of gambling in society was harmful. Conclusion and public health implications: This study demonstrated that regular gamblers largely viewed gambling as being a socially accepted and culturally accommodated activity in Australia. There is scope for governments to develop comprehensive programs to denormalise gambling, including learning from research, evidence and experience in other areas of public health.

"Drugs and alcohol get talked about, why not betting?" Young men's qualitative insights about strategies to prevent gambling harm

ISSUES ADDRESSED

Research is needed to understand young people's perspectives about public health promotion strategies relevant for their health and wellbeing. This study provides suggestions from young male gamblers about sports betting harm prevention and reduction strategies.

METHODS

In-depth interviews were conducted with sixteen young men aged 18 to 24 years, from Melbourne, Victoria, who regularly engaged in sports betting. A critical qualitative inquiry approach, using methods of constructivist grounded theory guided the study. Reflexive thematic analysis was used to interpret and construct themes from the data.

RESULTS

Participants indicated three main harm prevention strategies. These were: online consumer protection and regulatory strategies; public education campaigns that highlighted sports betting risks and harms; and the creation of formal and informal support networks to reduce stigma and encourage help seeking. They also supported being engaged in the development of harm prevention strategies and suggested ways to help reduce barriers to engagement.

CONCLUSION

Young men recognise the need for regulatory, education, and engagement responses to counter the risks posed by new gambling products. Young men may be difficult to engage in formal prevention activities, however youth-led and informal interactive mechanisms may help to overcome this barrier, and contribute to a comprehensive public health approach to gambling harm prevention. SO WHAT?: Young men can draw upon their lived experiences of gambling to provide insights relevant for public health promotion. Mechanisms should be developed to engage young people in the co-production of strategies and policies aimed at gambling harm prevention and reduction.