Impact of different types of tobacco control advertising content on six-month

campaign recall in England

Sol Richardson

UK Centre for Tobacco Control Studies (UKCTCS)University of Nottingham

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Background

• In industrialised countries, tobacco use accounts for around half the inequalities in adult mortality

• While overall rates of tobacco use in the UK declined from 2001 to 2008, no progress was made in multiply disadvantaged groups

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Background

• Tobacco control mass media campaigns play a key role in encouraging smoking cessation among adults (Bala et al., 2012)

• Campaigns featuring emotive or graphic content are more effective than those which do not, especially among socioeconomically disadvantaged groups (Durkin et al., 2011)

• Although many studies have measures recall in children and adolescents, little is known about the relationship between campaign exposure and recall in adults

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Adult Recall

• Campaigns with highly emotive content, or those delivered using testimonials, tend to generate greater recall

• Recall tends to rise in line with campaign exposure, although increased exposure to emotive campaigns generated a greater increase in recall

• Recall tends to rise with level of education. The differences in levels of recall generated by each campaign type tend to narrow with higher levels of education

Dunlop et al., 2012Niederdeppe et al., 2011

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Background

Why study campaign recall?

• To be effective in modifying behaviour, advertisements must be observed and recalled

• Campaign recall provides a direct measure of the possible effectiveness of campaigns in reaching smokers, and could be considered a proxy measure of effective campaign exposure

• Can provide insight into the mechanisms through which tobacco control campaigns impact on rates of smoking prevalence and cessation

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Opportunities

• The UK provides an ideal setting in which to evaluate the effectiveness of different campaign types due to the variety of televised tobacco control advertising content

This contrasts with other settings:

• Australia: Overwhelming majority of campaigns employ graphic images and hard-hitting messages.

• USA: Fragmented media market and a range of organisations disseminating tobacco control advertising

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Challenges

• Small individual-level effects of advertising

- Large samples and high levels of exposure are therefore required to detect significant effects

• Confounding factors, including underlying trends, other concurrent policies and initiatives, individual-level characteristics…

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Hypotheses

1. Increased exposure to tobacco control campaigns results in increased recall, and that negative emotive campaigns achieve a greater size of effect

2. Exposure to different types of televised tobacco control campaigns has differential effects in different socioeconomic groups

3. Campaigns designed to elicit negative emotions achieve higher rates and longer durations of recall

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Methods

The International Tobacco Control Four Country Survey (ITC-4)

• An eight-wave prospective longitudinal cohort study of adult smokers in the United Kingdom, Australia, Canada and the United States

• The selection procedure used stratified random digit dialling to yield a representative sample of the UK smoking population aged ≥18 years who have smoked more than 100 cigarettes in their lifetime and who have smoked at least once in the past 30 days

• Participants were rewarded with a £7 pharmacy voucher to encourage retention

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Follow-up

• Smokers residing in England aged 18 or over

• 3,641 unique individuals recruited in waves 1 to 6 of the study’s UK arm (from January 2002 to February 2008)

• 1,987 (or 55%) were followed up at least once in waves 4 to 7 between April 2005 and March 2009 and had valid exposure and recall data, giving 3,972 observations over four iterations of the survey

Apr-05

4

0May-05 160.4Jun-05 461.8Jul-05 557.7

Aug-05 95.2Sep-05 514.6Oct-05 212.1Nov-05 151Dec-05 278.4Jan-06 0Feb-06 459.7Mar-06 641.6Apr-06

5

0May-06 0Jun-06 0Jul-06 0

Aug-06 0Sep-06 394.6Oct-06 17Nov-06 0Dec-06 0Jan-07 707.6Feb-07 126.2Mar-07

6

454Apr-07 100.5

May-07 328.4Jun-07 615.7Jul-07 95.1

Aug-07 0Sep-07 0Oct-07 219.1Nov-07 92.7Dec-07 85.4Jan-08 718.1Feb-08 487.4Mar-08 411.5Apr-08

7

14.6May-08 0Jun-08 604.2Jul-08 469.3

Aug-08 147.6Sep-08 174.6Oct-08 247.1Nov-08 644Dec-08 272.5Jan-09 608.5Feb-09 723.5Mar-09 984.3

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Socio-Economic Status

• Around a third of responses for income were missing

• Respondents were classified according to level of education:

- Low: Compulsory education up to age 16

- Middle: A-level or Level 3 vocational qualifications, any course of higher education below degree level

- High: Any degree-level university education or above

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Campaign Exposure: TVRsTelevision ratings (TVRs) / Gross rating points (GRPs):

- Expressed as the percentage of all potential viewers capable of receiving broadcast signals in a given media market

exposed to an advertisement during a given time period

e.g. 1000 TVRs = each person has viewed an ad 10 times, or 50% have viewed it 20 times

On an individual level, actual exposure will vary according to a range of factors, including frequency and time of television viewing

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Campaign Exposure

• From April 2005 to March 2009 ranged from 0 to 1,051 TVRs, with a mean of 276.6. The total exposure over the period was 13,276 TVRs

• There was no discernible long-term trend in tobacco control TVRs, although campaign exposure tended to peak in January

TVRs: 2004-2012

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Campaign Exposure Intensity

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q12005 2006 2007 2008 2009

0

500

1000

1500

2000

2500

Overall Quarterly TVRs

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Characterisation of campaigns• Advertising content was categorised according to:

- Theme- Informational content- Emotional content- Style of delivery

• Coded by Tessa Langley (University of Nottingham) and Michelle Sims (University of Bath)

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Characterisation of campaigns

• For the purposes of our study, campaigns were categorised as having either:

“Positive” emotional content: eliciting happiness, satisfaction or hope (48.3%)

“Negative” emotional content: eliciting fear, sadness, guilt, anger or disgust (46.5%)

… or no emotional content at all (5.2%)

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Outcome Variable

• Question:

“In the last 6 months, have you noticed advertising or information that talks about the dangers of smoking, or encourages quitting on

television?”

• Operationalised as a binary variable

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Analysis

• We generated mutually adjusted variables for exposure to each campaign type in the 1-3, 4-6 and 1-6 months before survey

• Generalised estimating equations (GEE) for binary outcomes

• We tested the associations between exposure to different campaign types campaign recall, stratified by level of education

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Results

All Participants (n = 3972)

Campaign Category TVRs* Period OR (95% CI) p

All Campaigns 1-6 months ago 1.25 (1.10 - 1.41) < 0.001

Elicits Negative Emotions 1-6 months ago 1.42 (1.24 - 1.62) < 0.001

Elicits Positive Emotions 1-6 months ago 0.89 (0.72 - 1.09) 0.256

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Results

Low Education (n = 1240) Mid Education (n = 1942) High Education (n = 750)

Model Campaign Category TVRs* Period OR (95% CI) p OR (95% CI) p OR (95% CI) p

1 All Campaigns 1-6 months ago 1.10 (0.90 - 1.34) 0.368 1.39 (1.15 - 1.68) 0.001 1.28 (0.97 - 1.68) 0.079

2 Elicits Negative Emotions 1-6 months ago 1.25 (1.01 - 1.56) 0.042 1.60 (1.30 - 1.95) < 0.001 1.43 (1.03 - 1.99) 0.035

Elicits Positive Emotions 1-6 months ago 0.74 (0.53- 1.03) 0.070 0.98 (0.70 - 1.36) 0.887 0.97 (0.60 - 1.55) 0.886

*in units of 1,000 TVRs, adjusted for gender, age group, cohort of recruitment

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Results: Duration of Recall

Model Campaign Category TVRs* Period OR (95% CI) (n = 3,972) p

1All Campaigns 1-3 months ago 1.38 (1.04 - 1.83) 0.025

All Campaigns 4-6 months ago 1.15 (0.91 - 1.45) 0.239

2

Elicits Negative Emotions 1-3 months ago 1.48 (1.07 - 2.04) 0.019

Elicits Negative Emotions 4-6 months ago 1.44 (1.12 - 1.85) 0.004

Elicits Positive Emotions 1-3 months ago 0.75 (0.43 - 1.32) 0.319

Elicits Positive Emotions 4-6 months ago 1.18 (0.48 - 2.94) 0.717

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Limitations

• The outcome measure, recall, was based on self-reporting

• False reporting may have occurred due to recall of campaign exposure through other media such as billboards, radio, newspapers and the internet

• We were unable to control for the timing of the launch phase of individual campaigns

• We could not evaluate unprompted recall of specific content

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Key Findings

• Increased exposure to campaigns with negative emotive content in the six months prior to each survey was associated with higher recall, with the greatest effect in the higher SES groups

• Increased exposure to “positive” campaigns was ineffective at generating recall in any SES group

• “Negative” campaigns were also found to achieve longer durations of recall (over 3 months)

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Conclusions

• Campaigns designed to elicit negative emotions achieved higher rates and longer durations of recall

• Previous UK tobacco control campaigns may have been ineffective in reducing inequalities due to lower rates of recall in low socioeconomic status groups

• There may have been missed opportunities to reduce smoking prevalence over the last decade due to high expenditures on campaigns carrying “positive” messages

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Acknowledgements

Research team

Nottingham: Sarah Lewis, Tessa Langley, Lisa SzatkowskiBath: Michelle Sims, Anna Gilmore, Ruth Salway

KCL: Ann McNeill

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AcknowledgementsFunding

This project was funded by the National Prevention Research Initiative. For more information about the NRPI, visit http://www.npri.org.uk.

The NPRI Funding Partners relevant to this award are (in alphabetical order): Alzheimer's Research Trust; Alzheimer's Society; Biotechnology and Biological Sciences Research Council; British Heart Foundation; Cancer Research UK; Chief Scientist Office, Scottish Government Health Directorate; Department of Health; Diabetes UK; Economic and Social Research Council; Health and Social Care Research and Development Division of the Public Health Agency (HSC R&D Division); Medical Research Council; The Stroke Association; Wellcome Trust; and Welsh Assembly Government.

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Thank you for your attention

Any Questions?

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ReferencesJha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006;368(9533):367-70.

Hiscock R, Bauld L, Amos A, Platt S. Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker. J Public Health (Oxf). 2012;34(3):390-6.

Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev. 2008(1):CD004704.

Durkin SJ, Wakefield MA, Spittal MJ. Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups? Health Educ Res. 2011;26(6):998-1009.

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References (Continued)Dunlop SM, Perez D, Cotter T. The natural history of antismoking advertising recall: the influence of broadcasting parameters, emotional intensity and executional features. Tob Control. 2012;0:1-8.

Niederdeppe J, Farrelly MC, Nonnemaker J, Davis KC, Wagner L. Socioeconomic variation in recall and perceived effectiveness of campaign advertisements to promote smoking cessation. Soc Sci Med. 2011;72(5):773-80.

For more information on the ITC-4 Survey methodology:

Thompson ME, Fong GT, Hammond D, Boudreau C, Driezen P, Hyland A, et al. Methods of the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15 Suppl 3:iii12-8