14.5 Understanding how campaigns work

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While significant evidence exists to indicate the potential effectiveness of mass reach public education campaigns, there is now an emerging research focus on seeking a more sophisticated understanding of the mechanisms through which these effects are achieved.

14.5.1 Agenda setting

The agenda setting function of mass media health campaigns was recognised as an important component of the early Australian Quit campaigns.68 In fact it has been suggested by some as comprising the most important component of campaigns using the mass media.105–107

Fundamentally, agenda setting theory108,109 predicts that an issue like tobacco smoking that is frequently and prominently presented in mass media will be perceived as important and will achieve a higher salience or be assigned a higher priority by those exposed to this media attention. The agenda setting function of heavy media emphasis on the issue is seen to result in people considering smoking to be a more significant problem, irrespective of any attitude change toward the issue, and associated with this sensitisation to the issue there is an increased probability of behavioural response.

Agenda setting theory can be conceptualised at the individual level and at the community level. The theoretical underpinnings of the National Tobacco Campaign emphasised the critical need to move the decision to quit smoking from the point of quitting some time in the future to quitting now.28 This was achieved by graphically emphasising the certain health consequences of smoking and continually reinforcing the notion that 'every cigarette is doing you damage'. The importance of surrounding and constantly reminding the smoker of the need to quit has been emphasised earlier.

But, of course, social marketing campaigns do not operate in a vacuum.110 Rather they represent one force operating within a competitive communication environment, where efforts to reduce the uptake of smoking and promote cessation compete for the hearts and minds of smokers and potential smokers against the range of smoking promotion strategies outlined in Chapter 11. As a participant in and commentator on this competition, the media are constantly present. Based on their analysis of newspaper articles in the Australian press, Durrant and colleagues111 estimated that more than two million of the Australian population of 19 million people were potentially exposed to tobacco related newspaper articles per day in 2001. Far from being a neutral voice, content analysis of the 1188 tobacco-focused articles published in Australian national and capital city newspapers in that year found this coverage to be generally positive for tobacco control objectives.

At the community level, this agenda setting effect also facilitates the implementation of policy initiatives, as people are more willing to accept policy changes when they recognise the seriousness of the issue being addressed. This once again confirms the utility of conceptualising mass media public education campaigns as an integral component of comprehensive public health programs.

14.5.2 The norm reinforcement approach

In a related perspective, the norm reinforcement approach suggests that mass communication interventions can effectively contribute to reducing health damaging behaviours by reinforcing social norms.112 This approach posits that unfavourable depiction of behaviours in the media directly reduces their perceived social acceptability. This offers a complementary model to that of direct media effects on health behaviour in considering how mass media health campaigns can work. Drawing from the constructs of Bandura's social cognitive theory104, the norm reinforcement approach suggests health behaviours such as smoking can be influenced by:

• convincing smokers that being a non/ex smoker is the social norm, and that smokers are quitting
• addressing inflated perceptions of the prevalence of smoking, and
• attaching social stigma to smoking.

14.5.3 Seeking to understand the process of change

In a study undertaken during the NTC, Borland and Bamford sought to examine the process of moving smokers toward quitting that may occur during a period of campaign activity.113 The study adopted a repeated measures design with two surveys of 1000 smokers aged 18–40 years in Sydney, Melbourne, Brisbane and Adelaide conducted two weeks apart over a phase of campaign activity in 2001. The design of the study was based on an adaptation of the transtheoretical model of behaviour change26, with two subdivisions (perspectives) in each of the three pre-cessation stages being introduced to add sensitivity to the examination of campaign effects and progression through the stages. The study sought to test an advertising effects model which postulates that the effect from advertising is generated initially by the advertising being noticed, then triggering relevant thoughts, which then stimulates quit related activity, leading eventually to increased cessation.

The study found that the frequency of negative thoughts about smoking was related to campaign activity. Further, the findings suggested that the campaign continued to generate negative thoughts about smoking and consequent action for at least the four week period of campaign advertising activity. The results suggested cumulative benefits for campaign activity over this period, providing support for the value of extended advertising periods.

As an ongoing contextual issue for analysis of campaign effects, the study found evidence of considerable naturally occurring cessation activity, with the majority of participants in the study reporting that they were open to the prospect of quitting, and many reporting concerns about their smoking and efforts to quit in the past. There was also considerable instability observed in smokers' propensity to move within and between stages and sub-stages of quitting. Only pre-contemplators were found to remain relatively stable, although even among this group there was some response to campaign advertising and progression toward quitting.

The findings suggest that remaining happy to be a smoker requires thoughts about smoking-related harm to be infrequent. However having these thoughts frequently does not guarantee moving closer toward quitting among those at a higher level of preparation to quit. The conclusions drawn from these thoughts seem at least as important for smokers as the thinking activity itself in influencing progression toward quitting. This led the authors to suggest that stages of change may be more usefully considered as states of mind or perspectives on change. They pointed to the need for further sophisticated analysis of the process of moving from thinking about performing a behaviour such as quitting to actually attempting it, and the range of factors at play in this process.

It appears then that campaigns may exert their influence by giving a focus and direction to the quitting activity that is naturally occurring among smokers, by stimulating negative thoughts about the consequences of their smoking, galvanising their progression toward effective action.113 In this sense the role of advertising would seem more influential in supporting and reinforcing those who are already considering the need to quit rather than introducing the idea of quitting to those who currently have no interest. Nevertheless, with an advertising campaign's considerable reach of the majority of smokers, there was also evidence of stimulating activity even among those who had shown no interest in quitting in the near future.

14.5.4 Effects of advertising exposure

The direct relationship between the weight of campaign advertising (TARPs) and number of calls generated to the Quitline in Australia's NTC has been discussed earlier. In essence, the studies showed that when advertising was broadcast many more smokers called the Quitline and when advertising activity ceased call rates declined almost immediately. Further research into this relationship between levels of exposure to anti-tobacco advertising and campaign effects has been undertaken in the United States. Hyland and colleagues114 sought to assess the relationship between exposure to state-funded anti-tobacco advertising and smoking cessation through the Community Intervention Trial for Smoking Cessation (COMMIT) cohort.115 As measures of individual exposure to the anti-tobacco advertising were not feasible, the aggregate amount of exposure in the market where the smoker lived was used as the exposure variable.

The results of the study were consistent with the finding that, after controlling for a range of factors related to smoking cessation, exposure to anti-tobacco advertising increases smoking cessation rates. Importantly, the study assists in seeking to quantify the relationship between amount of exposure to anti-tobacco advertising and smoking cessation rates. Findings suggested that for every 5000 gross rating points (GRPs)[2] bought on anti-tobacco advertising over a two-year period, the quit rate among adult smokers increased by approximately 10%. This amount of television advertising equates to about two anti-tobacco advertisements per month. Further analysis confirmed that this relationship held after controlling for other tobacco control policy initiatives such as taxation increases.

Similar evidence was found for the relationship between campaign effects and lowered youth smoking. In their national study of the effects of state-sponsored campaigns across the US, Emery and colleagues found that after controlling for a range of other potential influences on youth smoking, these media campaigns were associated with stronger anti-smoking attitudes and beliefs among youth and reduced youth smoking.74 Their analysis suggested that it was important in terms of maintaining anti-smoking attitudes and beliefs and reduced smoking that youth are exposed to an anti-tobacco advertisement at a minimal mean exposure rate of one advertisement every four months.

Farrelly and colleagues also found a dose-response relationship between exposure to the Legacy Truth campaign and youth smoking in the last 30 days.77 This effect diminished at very high levels of exposure. Positive effects of the campaign were increasingly found with increasing GRPs up to 10,000 GRPs over a two-year period (an average of four exposures per month per individual), but at higher levels the effect began to attenuate with greater doses of exposure, although still remaining in a positive direction.

Removing anti-smoking advertising can result in regression in smoking behaviour. For instance, a study examining the impact of de-funding the Minnesota youth tobacco-use prevention program116 found that a range of measures of susceptibility to smoking among youth, including openness to smoking, beliefs, attitudes and intentions to smoke consistently changed following the de-funding of the tobacco prevention campaign. Interestingly after this discontinuation of campaign activity, there was also an increase in the prevalence of youth reporting that they would wear 'pro-tobacco gear'.

Consistent with these studies, advertising research reveals that the effects of advertising linger over the days and weeks after broadcast ends, but are unlikely to linger over weeks to months.117 Although people may recall anti-tobacco advertisements long after they are discontinued, especially for memorable ads, the decay of behavioural effects occurs relatively quickly.116,74 In practical terms, this means that campaign advertising only has an opportunity to exert effects on smoking behaviour during periods of advertising activity, and that effects rapidly diminish once advertising is withdrawn. This is why advertising is sometimes referred to as acting 'like a spring, rather than a screw',118 in pushing down smoking prevalence. That is, advertising will not have a once-and-for-good effect in reducing smoking prevalence, but creates a prompt (and an ongoing reminder for those battling with the threat of relapse) as to why people need to avoid smoking, and where help can be accessed.

The implications of this research and the broad experience of campaigns in Australia and the United States, suggest that anti-smoking campaigns can potentially maximise their impact by buying advertising in sufficiently heavy pulses or bursts (also known as flights), rather than as a continuous lower weight stream of advertising activity.117 Nevertheless, recognising that smokers are cycling through stages of readiness to quit at different times throughout the year, it is important in maximising campaign effectiveness that sufficient funding be provided to enable bursts of advertising throughout the year.

[2] a similar measure of advertising weight to the Australian TARPs measure explained earlier.