Public education campaigns may be designed so that the campaign materials and/or media buying strategy aim to particularly reach and influence demographic sub-groups of interest. Researchers may also examine how public education campaigns differently impact people from demographic sub-groups, and how different media channels perform in delivering anti-smoking public education campaigns. This section also describes the ways advertising of pharmaceutical cessation aids might influence smoking and quitting behaviour.
14.5.1 Targeting and demographic sub-groups
There is no clear consensus from the relatively few studies examining the effectiveness of how public education campaigns that specifically target priority demographic sub-groups, for example, education levels, ethnic groups, sex, and socio-economic status. 1, 2 Differences in effectiveness of media campaigns between SES groups may result from different levels of exposure and promotion. 2 Data from the European arm of the International Tobacco Control survey found that all smokers were similarly likely to be influenced by anti-tobacco messages (of all types, not just television, but that lower educated smokers were less likely to report seeing these messages. 3
Australia’s first major National Tobacco Campaign from 1997–2001 was designed to maximise exposure of campaign advertising, especially among lower SES smokers. Demographic trends in smoking monitored over the course of the campaign indicated an equal impact across socio-demographic groups, thereby achieving greater relative decline in the groups with highest prevalence at baseline, which included younger smokers and those in blue collar occupations. 4, 5
The effectiveness of different types non-targeted campaigns on demographic sub-groups has been analysed more extensively, particularly among socio-economic groups. 6-9 Durkin and colleagues 7 found that exposure to high emotion and/or personal testimonial-style ads was associated with quitting and increased quitline calls for low- and mid-level SES smokers, but not high-level SES smokers. Niederdeppe and colleagues 9 found that differences in perceived effectiveness between ‘why to quit’ and ‘how to quit’ ads were more pronounced among lower educated smokers compared to higher educated smokers. Given that ‘why to quit’ ads were more effective than ‘how to quit’ ads across all educational levels, the authors concluded that these types of ads may work best for all smokers, while at the same time contributing to a reduction in the SES disparities in smoking.
In another examination of SES effects, Niederdeppe and colleagues 9 found that differences in perceived effectiveness between graphic and testimonial-style ‘why to quit’ ads and ‘how to quit’ ads were more pronounced among lower educated smokers compared to higher educated smokers. They found that baseline recall of ‘keep trying to quit’ ads was associated with lower quit attempts among those without tertiary education, but with a greater probability of making a quit attempt among higher educated smokers. In contrast, they found no association between baseline recall of ‘secondhand smoke health effects’ messages on quit attempts or behaviour at 12-month follow-up. 10
A 2012 systematic review specifically examining anti-tobacco mass media campaigns among socially disadvantaged groups concluded that, of the 17 relevant studies identified, there were too many methodological weaknesses to draw firm conclusions. 11 However, the 2008 National Cancer Institute review 12 noted that the types of advertisements that perform well tend to do so across many population groups. In their updated review, Durkin and colleagues 13 acknowledged that though developing anti-smoking ads targeted to specific audience groups may increase message relevance and persuasion, the increased costs of this strategy may result in reduced funds being available for broadcast, resulting in lower rates of overall campaign effectiveness.
Differences in public education campaign effectiveness on youth smoking by demographic subgroups have not been widely examined. 14-16 A 2016 review did explore this in depth, and concluded that while the size of the effect may vary, public education campaigns are generally effective across racial and ethnic groups within a population, and similar for males and females. 17 Further, the 2012 US Surgeon General’s report on youth smoking 14 noted that the characteristics of advertisements themselves are more important to campaign effectiveness than the characteristics of the audience.
Summary
- Negative health consequences (‘why to quit’) advertisements may work best for all smokers, and may contribute to reductions in SES disparities in smoking.
14.5.2 Reaching Australians from culturally and linguistically diverse backgrounds
Very little research has examined how Australians from culturally and linguistically diverse backgrounds respond to anti-smoking public education campaigns, even though developing campaign materials in multiple languages is a common feature of recent national campaigns (see Section 14.3.6). Examples of mass media campaigns developed for specific populations include a mass media campaign aimed at Māori smokers and recent quitters in New Zealand, which found that 54% reported the campaign made them more likely to quit, but there was no movement in quitting ‘stage of change’ before versus after the campaign. 18 A study in Sydney reported beneficial effects of a localised mass media campaign for Arabic-speaking smokers on reducing Arabic smoking prevalence, compared with state and Sydney area non-Arabic smoking prevalence. 19
14.5.3 Reaching Indigenous smokers
Few studies have evaluated the impact of media campaigns on Australian Indigenous communities, or Indigenous populations globally. A 2013 systematic review explored whether anti-smoking public education campaigns should be targeted for Indigenous communities using evidence from Australia, New Zealand, US Pacific Islanders and Native Hawaiians, American Indians and Alaskan Natives. 20 Twenty-one studies were identified, using a broad range of methodologies, including qualitative studies, randomised controlled studies, and mixed-methods evaluations. The review found qualitative evidence that Indigenous populations reported preferring culturally targeted messages, and some preliminary evidence of positive effects on smoking-related knowledge, attitudes and behaviours of these messages. More research into this topic is needed, given the diverse range of populations, study approaches and campaign characteristics (including various media channels). 20
One of the first Australian studies to examine public education campaigns among Aboriginal and Torres Strait Islanders smokers was conducted with Indigenous communities in Victoria in the early years of the first National Tobacco Campaign. This qualitative study found high levels of awareness of the campaign’s television advertisements and good message take-out, similar to the broader population evaluation studies. 21 The health issues conveyed were generally understood, with young people in particular frequently describing the health effects of smoking in the language and imagery of these advertisements. However, smoking was not perceived as a major health concern and quitting intention was observed to be lower than in the general population.
A 2010 qualitative review of tobacco control activities in three remote communities in the Northern Territory reported generally good recall of mainstream anti-tobacco mass media messages. 22 An evaluation of the ‘Bubblewrap’ campaign among Aboriginal smokers in Western Australia in 2010 suggested that mainstream mass media campaigns could positively influence the thoughts and behaviours of Aboriginal smokers. 23 However, the authors also suggested that advertisers look for better ways to integrate Aboriginal themes in mainstream messages and ensure campaigns reach Aboriginal populations in regional and remote Australia. 20 Stewart and colleagues 24 used a quantitative ad rating study to compare responses to different styles of anti-smoking advertisements from Indigenous and non-Indigenous participants. They found that Indigenous people rated many mainstream advertisements more favourably than did non-Indigenous people and were more likely to report that these advertisements provided new information. Advertisements with strong graphic imagery depicting the health effects of smoking and those with emotive first-person narratives were rated highly by Indigenous smokers, indicating that these styles of campaigns are likely to be highly motivating for Indigenous smokers.
More recently, Nicholson and colleagues 25 examined advertising recall and attitudes toward smoking and quitting among more than 1,600 people recruited through 35 Aboriginal and Torres Strait Islander community health services. Recall of television campaigns and local health promotion materials was high. Further, recall of Indigenous-targeted campaigns and local advertising materials were associated with higher levels of motivation to quit. This type of advertising may be more potent than mainstream advertising in these communities and may enhance the effects of broader campaigns.
14.5.4 Media channels (including new media)
Understanding communication channels and their audiences makes it possible to develop and deliver messages most likely to resonate with target audiences and reach them more frequently. 26 Knowledge of communication channels is especially important, given the substantial costs required to mount effective mass media campaigns.
Recently, researchers have attempted to compare the effectiveness of different media channels in producing campaign outcomes. For example, Clayforth and colleagues 27 compared elements of the same public education campaign broadcast on radio, online, press, and a combination of these media channels. They found the online-only burst of activity drove more quitting-related activity such as website visits and was much lower cost than the other media channels, suggesting superior cost-effectiveness. However, because the study occurred in a single media market over seven weeks and these media channels were tested sequentially, it may be that the cumulative effects of the previous radio, print, and combined activity further enhanced the online campaign. A similar study, also from Western Australia, compared television, online video (for example, ads shown at the start of YouTube videos), and online display (static or animated images placed within websites, such as banner ads on news sites). 28 Similar to the Clayforth et al study, 27 these campaign elements were run alone and in combination over a thirteen week period, including periods of no activity. The online display condition was found to be most cost-effective in terms of driving quitting-related behaviours such as website hits and quitline calls. Television alone was found to be least cost-effective at producing these outcomes, although again, these results may have been affected by cumulative exposure to the campaign on various media channels over time.
14.5.4.1 Television
Potentially one of the greatest challenges for tobacco control campaigns is the changing media environment and changing media habits of smokers, particularly younger smokers. As the amount of free-to-air television watched by young people declines and is displaced by digital and subscription television channels, catch-up television and other online activities, the cost of reaching these audiences with the desired frequency is increasing. Until recently, there has been limited Australian analysis of the media channels smokers use and their media consumption habits.
In 2018, Durkin and Wakefield 29 conducted a detailed review of changing media use trends in Australia and the implications for anti-smoking public education campaigns. They concluded that, despite the diffusion of media channels and changes in media consumption habits in some demographic groups, ‘television is still by far the most efficient channel for reaching large proportions of the population with video-based messages’, with commercial television still reaching almost 20 million Australians per week. Further, two key demographic groups that are over-represented among smokers—lower SES people and older people—tend to watch more commercial television than other Australians. Despite declines in television watching among all age groups since 2007, Durkin and Wakefield noted that 70% of people aged 18-24 years (the group with the lowest television consumption) still watched at least some commercial television on an average weekday. However, dual-screening and multi-tasking while watching television is increasingly common. 30
14.5.4.2 Radio and cinema
Much of the research in this chapter has focused on television. This is not surprising: television advertisements can more easily generate emotion through the skilful fusion of sound and vision, and the medium can reach a broad range of a target population in a short period of time. Television campaigns are also commonly used in cinema and the Internet is now providing further opportunities for exposure to these advertisements, and other static and video-based messages. However, the potential impact of other media channels should not be downplayed. Durkin and Wakefield concluded that even in a modern media landscape, media channels such as radio and outdoor advertising provide important ‘supportive channels’ that serve to boost the reach of public education campaigns. 29
Radio advertising is also particularly useful where campaign funding is limited. One study comparing responses to radio and television anti-smoking advertisements 31 showed emotionally evocative radio advertising could be an effective adjunct or alternative to television advertising in areas where there are substantial limits on funds available for broadcast or where the reach of radio outstrips other media. These findings were supported by a message pre-testing study in three African countries. 32 Participants from Kenya, Nigeria, and Senegal tended to give positive ratings on measures of perceived effectiveness to radio ads that depicted the negative health effects of smoking and secondhand smoke through sounds such as coughing and laboured breathing. Likewise, strong graphic health effects television advertisements tended to be rated highest by the same participants.
14.5.4.3 Social media
The participatory web, which encompasses social networking and user generated content, continues to foster intense online participation. As of 2018, more than 55% of all Australians with social media accounts interacted with them daily, with use declining with age so that 73% of those aged 14–28 years interacted with social networks daily, compared to 34% of those aged over 70 years. 30 Among social media users, Facebook was by far the most commonly used social media platform among all age groups (77% overall), and even more popular among older users than younger groups (70% of those 14–28 years compared to 84% of those aged over 70 years). YouTube was the second most popular platform at 44% overall, but far higher in those aged 14–28 years compared to those 52–70 years (30%) and those older than 70 (15%). 30
Social media can potentially play a powerful adjunct role in mass media campaigns, crossing the divide from broadcast media (offering incidental, passive delivery of campaigns) to interpersonal communication (offering personalised, responsive two-way messaging). Campaigns delivered through Facebook can be highly targeted to user characteristics. However, exposure to campaign elements on social media is usually opt-in, requiring the user to click on a video, or stop scrolling to view an advertisement on their Facebook feed. 29 Facebook is almost ubiquitous for all age groups and represents both an opportunity for engagement as well as a challenge to develop appropriate approaches to both message delivery and evaluation. In one of the few published papers to evaluate this approach, van den Putte 33 described how an anti-tobacco mass media campaign generated conversations among personal and online social networks and demonstrated that those conversations generated quit attempts in people not exposed to the media campaigns.
Figure 14.5.1 shows some of the potential areas for engaging with social media.
Source: Hamil S 2011. Innovation and Social Media. Presentation at World Lung Foundation Global Communications meeting, Bangkok, Thailand. March 2011
Summary
- Regardless of whether they are new or old, choices of which media to use in communicating with smokers must balance cost, accessibility, effort, timeliness and most importantly, ability to reach the target group.
14.5.5 Pharmaceutical advertising
Advertising for nicotine replacement therapy (NRT) and other pharmaceutical aids has a significant presence in Australia. A US study of all tobacco-related advertising in the US from 1999 to 2003 found that the volume of anti-smoking campaigns was matched or exceeded by both advertising of tobacco products and pharmaceutical cessation product advertising. 34
In considering the relative contribution of NRT and anti-tobacco advertising campaigns, Biener 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 thought offered the greatest help for them to quit. 35 Smokers were more likely to cite anti-tobacco television public education campaigns than many other conventional cessation aids, and few individuals mentioned NRT advertisements as having influenced their quitting.
An Australian time-series analysis found that even though NRT sales increased in response to NRT advertising, higher monthly sales of NRT and the smoking cessation medication bupropion did not have a detectable impact on monthly smoking prevalence. 36 A follow-up analysis by the same group found that neither NRT gross ratings points or units sold of smoking cessation medications were related to smoking prevalence in a time series analysis of smoking in Australia from 2001 to 2011. 37 A UK time-series analysis compared the effects of anti-smoking advertising and NRT advertising on quitline calls. They found that while NRT advertising had a positive effect on NRT sales within the same month, any effects on quitting behaviour were not present after adjusting for seasonality effects. The authors concluded that anti-smoking advertising is more effective at prompting quitting-related behaviour than NRT advertising. 38
Few studies have examined the impact of pharmaceutical advertising on youth smoking. An experimental study of Australian teens aged 14–16 years found no consistent evidence that exposure to NRT or stop smoking medication advertising influenced beliefs about smoking, even among those susceptible to becoming a smoker. 39 However, a population-level study of US youth found that while potential exposure to NRT advertising had no effect on smoking uptake, it did increase cigarette consumption among those who already smoked. 40
An important area for future research about how this pharmaceutical advertising may interact with anti-tobacco advertising is the impact on smokers’ self-efficacy regarding quitting. For instance, do the pharmaceutical advertisements increase smokers’ confidence because of the availability of this aid, or does the suggestion that you may need a pharmaceutical aid to quit smoking make the task seem more difficult and less achievable for some smokers?
Relevant news and research
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