14.4 Examining effectiveness of public education campaigns

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As indicated earlier, Australia has had a long history of conducting mass media anti-smoking campaigns and has established a sound evidence base for understanding how these campaigns can have a positive effect in reducing smoking.68,17,25 Evidence from the National Tobacco Campaign demonstrates that campaigns can reach vast numbers of people, including those groups with highest smoking prevalence, can prompt negative thoughts about smoking, can increase knowledge about the health effects of smoking, can prompt calls to the Quitline, can help smokers quit and can reinforce successful quitters to remain ex-smokers.1 A further examination of research on campaign effects is now presented.

14.4.1 Comprehensive campaigns in the United States

By the end of the 1990s there were five major state-wide comprehensive tobacco control programs operating in the United States in California, Massachusetts, Arizona, Oregon and Florida. In addition to mass media anti-smoking advertising campaigns, these comprehensive programs also typically comprised local policy initiatives, school-based prevention initiatives and smoking cessation services, including workplace cessation initiatives. Recognising that many programs were funded by increases in tobacco taxation, increased prices of cigarettes can be also seen as exerting a concomitant downward pressure on smoking. Evaluation studies have demonstrated the effectiveness of these comprehensive programs including the contribution of anti-smoking mass media advertising and impact on teenage smoking.69,70,7

With the influx of funding from the Master Settlement Agreement between 46 US states and tobacco companies, more states began to launch state mass media campaigns from 1999. By 2002, 35 states had anti-tobacco programs. In addition, in February 2000, the American Legacy Foundation launched its national Truth campaign, a mass media campaign highlighting the marketing tactics used by the tobacco industry, which has been aimed at reducing smoking among youth. Studies of household and youth exposure to public health-sponsored mass media campaigns from these sources showed that exposure levels increased to 2002, and then plateaued.71,72 Most state-sponsored advertising is directed at adult smokers rather than youth.73 Studies assessing the extent to which state-sponsored media campaigns had influenced youth smoking over the period demonstrated that increasing campaign exposure was associated with more protective attitudes and less likelihood of smoking after accounting for cigarette prices and strength of smokefree policies,74 and that effects were similar across gender and race/ethnicity subgroups.75 Increasing exposure to Legacy's national Truth campaign found the campaign to be related to stronger anti-tobacco industry attitudes, lower intention to smoke and less likelihood of smoking among teenagers.76,77 Evaluations of specific US state campaigns have generally found positive effects on youth and declines in adult smoking have been observed in states with media campaigns, compared to those without.78–82

14.4.2 The contribution of anti-smoking television advertisements to quitting

In evaluation studies for Australia's NTC, smokers reported that the campaign had helped them move toward quitting and ex-smokers reported it had helped them remain quit. In considering the relative contribution of smoking cessation aids and anti-tobacco advertising campaigns, Beiner and colleagues undertook a study in Massachusetts with nearly 800 ex-smokers who had quit within the previous two years and investigated what these ex-smokers perceived to have offered the greatest help for them to quit.83

These recent quitters were more likely to cite anti-tobacco television advertisements as sources of help with their quitting than they were to cite conventional cessation aids. They found that 30.5% of recent quitters reported that anti-tobacco advertisements had contributed to their quitting compared with the most commonly mentioned conventional cessation aids, nicotine replacement therapies (21%), professional help or advice (11%), self-help materials (8%) and prescribed medications (7%). While older and more dependent smokers were most likely to find conventional aids helpful, younger smokers and those who had successfully remained abstinent for more than six months were more likely to report being helped by the television advertisements. The majority of advertisements cited by these ex-smokers as the ones that helped them quit were those that depicted serious illness resulting from smoking (70%) or inspirational quit tips (7%). These advertisements were designed to achieve strong emotional arousal and the findings confirm the results of earlier studies based on respondents' perceived effectiveness of anti-smoking advertising that found similar high ratings for this type of approach.84,85

14.4.3 Effective media campaign approaches for youth and adults

Many campaigns create different types of advertisements for youth and for adults. Beaudoin performed a content analysis of 197 anti-smoking advertisements produced between 1991 and 1999,86 and coded:

• the type of consequence presented (health, social, or both)
• whether the consequences were short term, long term, or both
• whether the appeal used humour, fear, sociability, or several other strategies.

The study found that advertisements targeting youth commonly used sociability and humour appeals and presented short-term consequences, while advertisements targeting adults commonly used fear appeals and addressed the long-term health consequences.

At face value, these differences seem logical and appropriate. Objectives such as making cigarettes appear in a negative light and having the audience reject them are common for both youth and adult advertisements. However, issues relevant for adult smokers such as overcoming the addiction, coping with withdrawal or giving up one's 'best friend'87 are quite different from those relevant for youthful non-smokers, such as conforming to group norms or establishing an identity. Nevertheless, as indicated in the following section, the empirical findings indicate that, like adults, youth tend to respond more favourably to advertisements featuring the serious long-term health consequences of smoking that are presented in an emotionally evocative way.

Several studies that explicitly compared teenagers' responses to youth- versus adult-targeted advertisements found that youth respond favourably to adult-targeted advertisements. As presented earlier, studies conducted on youth response to the Australian NTC showed that youth perceived the adult campaign as relevant to them and effective in promoting anti-smoking attitudes52 as well as being as likely to make teenagers feel they should not smoke as was a teenager-targeted campaign.53 Consistent with this, Schar and Guterriez outlined an evaluation of an English testimonial campaign that targeted adults and featured a 34-year-old man with lung cancer and a teenage girl speaking about her father who has lung cancer.88 Surveys of youth (11–15 years old) and adults indicated comparable levels of campaign awareness and perceived effectiveness among the two groups.

In their 2003 major review of the use of mass media to reduce smoking among youth, following Flay's 1987 review,89 Wakefield, Flay and colleagues90 examined studies from field experiments, evaluations of government-funded campaigns in the United States, studies of the comparative effectiveness of different anti-smoking themes and studies of the relationships between anti-smoking advertising and cigarette advertising. Evaluation studies of these state-wide programs provided further evidence of their effect in preventing smoking uptake amongst youth, particularly younger adolescents. Consistently, studies of US state-sponsored media campaigns, which are primarily directed at adult smoking, exert positive effects on youth smoking attitudes and behaviours.74,75

Debate has occurred about whether tobacco control campaigns primarily should focus on youth (because most people start smoking before age 18) or on adults.51,91 The findings to date suggest there is no need to choose between the two options, since an effective adult-targeted campaign appears to be as effective in communicating with youth as with adults. This may be partly due to such adult-targeted campaigns changing broader social norms about smoking, possibly by reducing perceptions among youth of the prevalence of smoking, and thus countering the social normative influence of commonly inflated perceptions of this prevalence.51, 90 However, as the primary focus in many of these evaluation studies related to the population level changes observed over the duration of campaign periods, there was less focus on trying to generate a greater understanding of which particular approaches are more effective with which particular targeted audiences under what particular conditions. These questions will now be explored.

14.4.4 Effectiveness of different anti-smoking themes

In recent years, a strong evidence base has emerged suggesting that advertisements that arouse strong negative emotions perform better than those that do not.71,76,84,85,92–97 These advertisements tend to depict serious harm caused by smoking or secondhand smoke in an authentic way and sometimes include depictions of tobacco industry awareness of the harm of smoking. Experimental research on information processing supports the hypothesis that advertisements that evoke high arousal will receive greater viewer attention and will be remembered more readily than those that do not.98 Further, negative content tends to produce higher levels of arousal than does positive content. By contrast, advertisements that used humour, whether to make fun of teenagers who smoked, or portray the health benefits of not smoking in an exaggerated way (e.g. a Massachusetts advertisement showing an infant performing gymnastics because of the healthy air in his home), performed relatively poorly.84 In addition, those suggesting that young people just need to make a choice about smoking, such as Philip Morris's Think. Don't smoke advertisements, also performed relatively poorly.

In a further example, a recent study by Pechmann and Reibling94 randomly exposed 1725 ninth-grade students in Californian schools to one of nine videotapes containing a television show embedded with a range of anti-smoking advertisements or control advertisements. Advertisements focusing on young victims suffering from serious tobacco-related diseases elicited disgust, enhanced anti-industry attitudes, and reduced intentions to smoke among all participating adolescents, except those with conduct disorders.

Biener and colleagues84 also noted the consistency of findings regarding effectiveness of particular advertisement themes between adults and youth. In examining a range of anti-smoking advertisements their findings confirmed that those perceived as most effective by youth were those that evoked a strong negative emotion such as fear or sadness and conveyed a thought-provoking and believable message about the serious long-term consequences of smoking. These were perceived as more effective than advertisements that were designed as humourous or entertaining, or normative advertisements that had low emotional content or generated low cognitive engagement. These perceptions were consistent between teenage boys and girls.

While the industry manipulation approach has not been extensively employed in Australia there is significant research evidence relating to its effective use in the United States. For instance there is evidence from the American Legacy Foundation's national launch of Truth that strong industry manipulation counter-marketing campaign had a significant impact on attitudes toward smoking among young people in a relatively short period.76 The national campaign delivers stark facts about the tobacco industry and its marketing practices, building on the positive results achieved by the campaign in Florida.99

14.4.5 Tobacco industry funded campaigns

A study comparing the influence of the Truth campaign with the tobacco industry funded Think. Don't Smoke campaign found that exposure to this industry advertising was associated with more favourable attitudes toward the tobacco industry than was observed in those who had not been exposed to the advertising.76 A later study, designed to specifically examine the effects of exposure to this tobacco industry campaign, adopted a method of comparing levels of exposure to this advertising on television with smoking attitudes and behaviour among youth.100 The study found no associations between exposure to the campaign advertising and smoking attitudes or behaviour. However Phillip Morris had also launched a parent campaign called Talk. They'll Listen emphasising parental responsibility for talking to their children about smoking, as a follow up to their Think. Don't smoke campaign. In contrast to the lack of effect of the teenagers' campaign, the study found that increased exposure to this parent campaign advertising was associated with stronger intention to smoke in the future among youth, as well as more pro-tobacco beliefs and an increased likelihood of smoking among older adolescents.

14.4.6 International comparisons of response by youth

To further explore some of these questions and examine the consistency of response to anti-smoking advertisements in different countries, 615 teenagers in Australia, the United States and Britain, recruited as susceptible non-smokers or experimenting smokers, were exposed to a group of 37 US anti-smoking advertisements.97 These advertisements represented a range of different approaches, some directly targeted toward young people and others targeted more broadly.

While the designated target audience for whom the advertisement had been produced was not significantly related to the key effectiveness ratings for the advertisement, specific appeal and executional characteristics of the advertisements were related to these measures. The advertisements that were consistently most commonly rated by young people as 'the most effective advertisement', 'an advertisement that would make you stop and think' and 'an advertisement they had talked about after seeing it' were those that featured a personal testimonial or generated a visceral negative ('yuck') response.

Another key finding from the study was that there was a high level of consistency in the ratings from teenagers in each of the three countries. This points to the potential for greater sharing of anti-smoking advertisements between countries, with appropriate modifications if necessary.

14.4.7 Implications for production of tobacco campaign advertisements

It is now recognised that short-term media campaigns are unlikely to achieve behaviour change, but that sustained well designed and constructed campaigns can achieve reduced tobacco use among youth.101 Further, it is clear that these campaigns have much greater potential to achieve positive change when they are grounded in a comprehensive social marketing framework with targeted, potent messages that are executed well, and when they achieve a high level of exposure to their target audiences over a sustained period of implementation.

There is still a great deal to learn about how successful advertisements achieve their effects and the range of potential variables that mediate this effect. Further research is also needed to add to our understanding of the particular characteristics of the most effective advertisements for specific target audience segments, such as for instance, high sensation seeking youth.102

The research discussed earlier provides some useful guidelines for effective appeals and messages but it is important to recognise that there are many variables relating to the design, production and media placement of an anti-tobacco advertisement that will influence its effectiveness in its real world exposure. These include:

• executional characteristics such as lighting, sound, setting, editing style and general production values
• casting and actors' quality of performances
• novelty of the executional style
• appropriateness of fit and cut-through within the program context of where the advertisement is placed
• novelty and/or complexity of the execution, thereby requiring sufficient frequency and duration of exposure, and
• mix of messages within a single campaign, possibly targeting complementary effects such as emotional arousal, prompt to action, self efficacy and response efficacy of the prompted action.

As emphasised later, efforts to maximise the effectiveness of campaign communication materials can be valuably guided by appropriate use of formative research, including creative development research and pre-testing.

14.4.8 Executional considerations

When designing television advertisements, there are also executional issues that need to be considered such as the depiction of an actor smoking. Noting that adolescents tend to overestimate smoking rates among both peers and adults and that these inflated perceptions can lead to smoking initiation, a US review of state-based campaigns and research from the United States and Canada examined this issue. However the study found no indication that depictions of smoking in anti-tobacco advertising undermined campaign effectiveness by inadvertently implying smoking prevalence.103

Nevertheless social cognitive theory104 emphasises the potential influence exerted by the depiction of people modelling behaviours such as smoking and that a positive appraisal of the model can lead to transfer of those positive characteristics to the behaviour. It is important to ensure that the positive portrayal of smoking and smokers in tobacco marketing is not reinforced by attractive depiction of young people smoking in tobacco counter-marketing advertisements, regardless of the appeal or message the advertisement is designed to communicate at a cognitive level.

Wakefield and colleagues90 cite a study in which seeing anti-smoking ads were found to subsequently lower perceptions of common sense, personal appeal, maturity and glamour of a teenage smoker, whereas viewing cigarette advertisements resulted in more positive thoughts about the smoker. This is an interesting example of the dynamic relationship between tobacco advertising and tobacco counter-marketing advertising in influencing perceptions about smoking behaviour and consequently of a person who engages in that behaviour.