Abstract
Objectives. We used longitudinal data to examine the relationship between confirmed awareness of a national, branded, mass media smoking cessation campaign and cessation outcomes.
Methods. We surveyed adult smokers (n = 4067) in 8 designated market areas (“media markets”) at baseline and again approximately 6 months later. We used multivariable models to examine campaign effects on cognitions about quitting, quit attempts, and 30-day abstinence.
Results. Respondents who demonstrated confirmed awareness of the EX campaign were significantly more likely to increase their level of agreement on a cessation-related cognitions index from baseline to follow-up (odds ratio [OR] = 1.6; P = .046). Individuals with confirmed campaign awareness had a 24% greater chance than did those who were not aware of the campaign of making a quit attempt between baseline and follow-up (OR = 1.24; P = .048).
Conclusions. A national, branded, mass media smoking cessation campaign can change smokers' cognitions about quitting and increase quit attempts. We strongly recommend that federal and state governments provide funding for media campaigns to increase smoking cessation, particularly for campaigns that have been shown to impact quit attempts and abstinence.
Mass media campaigns can be used to change smoking-related cognitions and to prompt quitting behavior, particularly when combined with other tobacco control efforts.1,2 Media campaigns at the national, community, and city level have been effectively used to increase smoking cessation among adults.3–8 The EX campaign (National Alliance for Tobacco Cessation, Washington, DC) was designed as a branded, mass media campaign aimed to encourage adult smokers to quit.9,10 This campaign was pilot tested in 4 US cities in 2006 and 2007.10 In a longitudinal pilot study, confirmed campaign awareness was associated with statistically significant change in campaign-related cognitions over approximately 6 months.10 Given these findings, in the spring of 2008 the National Alliance for Tobacco Cessation (NATC)—a partnership of states, national public health organizations, foundations, and corporations—launched EX as a national campaign.
The EX campaign is grounded in behavior change theory11–13 and the evidence regarding effective mass media campaigns.1,14–18 Given the evidence that branding can enhance the impact of a public health campaign, all messages are branded “EX.”19,20 The target audience was defined as “smokers who are open to quitting but may not know how to successfully quit.” The campaign message strategy was based on qualitative data from smokers at various stages in the quitting process, derived from more than 40 focus groups (more than 300 participants), 48 in-depth interviews, and a national survey of more than 1000 smokers. Messages are characterized by an empathetic, smoker-to-smoker voice that encourages smokers to relearn their life without cigarettes. Emphasis is placed on disassociating smoking from common daily activities that would otherwise function as smoking cues, such as driving or drinking coffee.
During the 6-month national campaign period, March 31 through September 28, 2008, EX advertisements aired on cable television at 549 average quarterly targeted rating points (TRPs). TRPs are the standard unit of measurement for media delivery and reflect both the reach and the frequency of an advertisement. Reach describes the total percentage of the targeted population that is exposed to the advertisement; frequency describes the number of times individuals in the targeted population saw the advertisement, on average. TRPs are identical to gross rating points (GRPs), except that they are delivered to, and measured within, a specific and defined audience.2 EX advertising was not evenly distributed across the campaign period; 68% of the EX TRPs aired in the first 3 months of the campaign. Pfizer's My Time to Quit campaign aired nationally at 382 average quarterly TRPs during the same period as the national EX campaign. The Phillip Morris campaign, Quit Assist, did not air during the study period; however, because it aired nationally in 2007 awareness of the campaign was measured and was included as a covariate in the present study to control for any residual campaign effects. No local or state-level tobacco control media was airing in 6 of the 8 designated market areas (DMAs) from which the study sample was drawn. In one DMA, occasional public service announcements aired; in another, no information was available as to whether public service announcements would air. Public service announcements generally air at a low TRP level.
According to the Centers for Disease Control and Prevention, campaigns that deliver 1200 or more average quarterly TRPs during the introductory year of a campaign can expect to reach 75% to 85% of the target audience, in which case evaluators may expect to detect campaign awareness at 6 months, attitude change at 12 to 18 months, and behavior change at 18 to 24 months.2 Given funding constraints, the total media delivery of the EX campaign was approximately 47% of the level recommended by the Centers for Disease Control and Prevention.2 Nevertheless, on the basis of the findings noted in the evaluation of the EX pilot campaign we hypothesized that EX awareness would be associated with significant change in campaign-related cognitions and behaviors despite the lower media delivery level. To test this hypothesis, we examined a longitudinal cohort of adult smokers drawn from 8 DMAs, with control for baseline and contextual variables.
We based our study on longitudinal data collected from a sample of 18- to 49-year-old current smokers from 8 US DMAs or media markets. A DMA is the standard geographic unit of measurement for mass media. Within DMAs, a population receives a uniform or a very similar mass media offering; across DMAs, however, levels of mass media delivery can vary markedly as a result of greater or lesser cable television penetration and population density. The DMAs from which this study sample was drawn were selected on the basis of several criteria. Each of the selected DMAs had at least 700 000 television households, as estimated by Nielsen in 2007 to 2008, and 5 DMAs had over 1 million television households (Table 1).21,22 In addition, most of the selected DMAs had the potential for greater media delivery, as compared with other DMAs, on the basis of Nielsen data. These factors likely increased the proportion of the sample that was exposed to the campaign, and thus the likelihood of detecting campaign effects. Each of the selected DMAs had a sufficient population size to ensure that a random sample would yield an adequate sample of smokers. Finally, the DMAs were selected to ensure cross-market variation with respect to key factors thought to potentially influence cessation outcomes: geographic location, racial/ethnic composition, strength of tobacco control policy efforts (clean indoor air legislation, state tobacco control expenditures, cigarette price), and smoking prevalence (Table 2). The 8 DMAs from which the sample was drawn were Birmingham, Alabama; Columbus, Ohio; Fort Smith–Fayetteville, Arkansas; Houston, Texas; Kansas City, Missouri; Phoenix–Prescott, Arizona; Pittsburgh, Pennsylvania; and Portland, Oregon.
TABLE 1 Characteristics of Selected Designated Market Areas: EX Campaign, 8 US States, 2007–2008
| Designated Market Area | Sample Size, No. of Individuals | No. of Television Householdsa | Total TRPs Deliveredbc |
| Birmingham, AL | 756 | 730 430 | 1863.0 |
| Columbus, OH | 495 | 905 690 | 1367.4 |
| Ft. Smith–Fayetteville, AR | 456 | 1 039 890 | 875.5 |
| Houston, TX | 410 | 2 050 550 | 1279.8 |
| Kansas City, MO | 843 | 927 060 | 1336.7 |
| Phoenix–Prescott, AZ | 378 | 1 802 550 | 1091.5 |
| Pittsburgh, PA | 363 | 1 158 210 | 1381.2 |
| Portland, OR | 366 | 1 150 320 | 1566.6 |
Note. DMA = designated market area; TRP = targeted rating point.
a Source. Nielsen DMA Market Universe Estimates, 2007–2008.21
b Source. Nielsen Ad*Views data, 2008.22
c TRPs are the standard unit of measurement for media delivery and reflect both the reach and the frequency of an advertisement. Reach describes the total percentage of the targeted population that is exposed to the advertisement; frequency describes the number of times individuals in the targeted population saw the advertisement, on average.
TABLE 2 Characteristics of the Selected Designated Market Areas, by State: EX Campaign, 2007–2008
| State | State Smoking Prevalence,a % | Total Tax per cigarette pack,b $ | State Per Capita Funding,c $ | Clean Indoor Air Laws,d % Covered |
| Alabama | 22.1 | 1.44 | 0.45 | 13.3 |
| Ohio | 20.1 | 2.26 | 0.64 | 100.0 |
| Arkansas | 22.3 | 2.16 | 6.55 | 4.4 |
| Oklahoma | 24.7 | 2.04 | 5.72 | 0 |
| Texas | 18.5 | 2.42 | 0.54 | 39.0 |
| Missouri | 25.0 | 1.18 | 0.40 | 14.9 |
| Kansas | 17.9 | 1.80 | 0.82 | 22.8 |
| Arizona | 15.9 | 3.01 | 3.55 | 100.0 |
| Pennsylvania | 21.3 | 2.61 | 1.51 | 11.7 |
| Oregon | 16.3 | 2.19 | 2.40 | 8.5 |
| Washington | 15.7 | 3.04 | 2.58 | 100.0 |
We conducted the baseline survey from February 5 through April 15, 2008, before the national launch of the EX media campaign. We used a list-assisted, random-digit-dial method to select a single-stage, unclustered sample of telephone numbers across the 8 DMAs, which generated approximately 874 000 numbers. Roughly 24% of the sampled telephone numbers were determined to be residential after known nonworking and business-only numbers were classified as ineligible, and residential status was estimated for telephone numbers of unknown status. Of these, 6663 telephone numbers were for households consisting of at least one person who met the age and tobacco-use status eligibility criteria for this study. For each household contacted, up to 2 smokers were randomly selected and administered the survey in either English or Spanish. In this way, 8489 eligible respondents were identified. A total of 5616 of those eligible (66%) completed the baseline interview.
All baseline survey respondents were invited to participate in a follow-up survey conducted approximately 6 months after the campaign launch, August 23 through October 19, 2008. Among the baseline respondents, 4067 successfully completed the follow-up survey, resulting in a follow-up response rate of 73% and an overall response rate of 48% among known eligible households.27 Interviews were conducted as computer-assisted telephone interviews. Respondents were offered an incentive to complete each survey.
The primary independent variable in this study was exposure to the EX campaign as measured by confirmed awareness of individual EX advertisements. Confirmed awareness of EX advertisements was measured by asking respondents whether they had “recently seen an ad on TV” followed by a brief description of the beginning of the advertisement. Respondents were then asked to describe the end of the advertisement. Only those who were able to accurately describe one or more of the EX advertisements were classified as having confirmed awareness.
Control variables assessed at baseline included age, gender, race/ethnicity, educational attainment, number of cigarettes smoked per day, and having made a quit attempt within the 6 months before the baseline interview. Motivation to quit was also assessed at baseline with the item, “On a scale of 1 to 10, where 1 equals ‘not at all’ and 10 equals ‘very much,’ how much do you want to quit smoking?” Control variables assessed at follow-up included nicotine dependence, as measured by using the Fagerstrom Test for Nicotine Dependence item “Time to First Cigarette” of the day28; whether the respondent lived with another smoker; and hours of television, radio, and Internet use per day.
Awareness of other cessation-related campaigns, including Pfizer's My Time to Quit and Philip Morris' Quit Assist campaigns, was also measured. Aided awareness was measured by asking respondents “Have you seen a My Time to Quit ad such as the one that shows a woman describing the specific times during the day when she smokes?” and “Have you seen a Quit Assist ad by Philip Morris to help people quit smoking cigarettes?” Use of pharmacotherapy was assessed by using 2 items: (1) “Have you ever used nicotine replacement products to help you quit smoking?” and (2) “Have you ever used a prescription medication called Bupropion, Zyban, or Wellbutrin to help you quit smoking?” Respondents who answered “yes” to either item were classified as having a history of use of pharmacological cessation aids, whereas those who responded “no” to both items were classified as not having such a history.
Outcome variables included changes in a cessation-related cognitions index, having made a quit attempt of 24 hours or longer between the baseline and follow-up interviews, and 30-day point prevalence abstinence, defined as both not smoking at the time of the follow-up survey as well as not having smoked even 1 puff of a cigarette for 30 days or more before the date of the follow-up survey. The cognitions index was composed of 8 items. The first 4 items were statements, with responses measured along a 4-point Likert scale ranging from “strongly agree” to “strongly disagree”: “I have been thinking a lot about quitting smoking recently”; “I am eager for a life without smoking”; “Lately, I have been thinking about which cigarettes during my day would be the hardest to give up”; and “I am not prepared to make changes in my life to quit smoking.” The next 3 items measured motivation to quit, readiness to quit, and quitting as a priority by asking, “On a scale of 1–10, where 1 equals not at all and 10 equals very much, how much do you want to quit smoking?”; “Are you seriously thinking of quitting in the next 30 days, the next 6 months, or not at all?”; and “On a scale of 1–5, where 1 is the lowest and 5 is the highest, how would you rate quitting smoking as a priority in your life?” The final item asked respondents, “During the last 30 days, would you say you have thought about the changes you will have to make in your life to quit smoking?” Response options for this item were every day, most days, some days, or rarely. The cognitions index score (Cronbach α = 0.79) was calculated by recoding the items to a standard scale, which ranged from −24 to 40 and then averaging across the 8 items. A higher score on the index represented more favorable cognitions about quitting smoking.
All statistical analyses were performed by using SAS version 9.13 (SAS Institute Inc, Cary, NC). We weighted all data to account for differential sampling rates, to reduce the bias due to nonresponse to both the screening and the interview, and to weight the data to key demographic characteristics of the US population. The weights were constructed from 2007 population totals for persons aged 18 to 49 years in each DMA and 2008 smoking rates calculated by age, race, gender, and education level from the Behavioral Risk Factor Surveillance Study.23 Because of the probability that up to 2 adults per household could be selected for study inclusion, we made adjustments to account for clustering at the household level (intracluster correlation).
We conducted multivariable logistic and linear regression analyses to assess the strength of the association between the key independent variable, confirmed awareness of EX, and the cessation-related outcomes—cognitions and quit behaviors—at 6 months after the campaign launch. We used a multivariable linear regression model to model the cognitions index change score, with adjustment for study covariates. We analyzed quit attempts by using a multivariable logistic regression model with a dichotomous outcome of 1 or more attempts as compared with no quit attempts between baseline and the follow-up interview. We analyzed smoking abstinence in the past 30 days by using a multivariable logistic regression model with a dichotomous outcome of staying quit for 30 or more days as compared with less than 30 days. We used likelihood ratio tests to assess goodness of fit for all models. The models included a fixed-effect DMA indicator variable to account for any unmeasured contextual factors, including state tobacco control policies. An alternate set of models explored the effect of adding state tobacco control policy variables in addition to the DMA indicator; however, this resulted in multicollinearity. In the final models, the DMA indicator was included, and the policy variables were omitted, because the DMA indicator served to control for policy variables as well as any unknown, and therefore unmeasured, factor associated with the outcomes.
The longitudinal sample consisted of 4067 smokers at follow-up, of whom 74% were non-Hispanic White, 12% were non-Hispanic Black, and 7% were Hispanic (Table 3). The mean age of the sample was 37 years; 85% of the sample fell within the media campaign's primary age target of 25 to 49 years. The sample was skewed toward female. Approximately 63% of the sample reported earning a high school diploma or general equivalency diploma or having less than a high school education. More than half of the sample (59%) reported living with at least 1 other smoker.
TABLE 3 Demographics and Smoking Behaviors of a Longitudinal Sample of Smokers at Baseline and Follow-up: EX Campaign, 8 US States, 2007–2008
| Demographics and Smoking Behaviors | Baseline (n = 5616), % or Mean ±SE | Follow-upa (n = 4067), % or Mean ±SE |
| Designated Market Area | ||
| Birmingham, AL | 18.7 | 18.6 |
| Kansas City, MO | 19.6 | 20.7 |
| Columbus, OH | 11.4 | 12.2 |
| Fort Smith–Fayetteville, AR | 11.4 | 11.2 |
| Houston, TX | 11.2 | 10.1 |
| Phoenix–Prescott, AZ | 10.0 | 9.3 |
| Pittsburgh, PA | 8.5 | 8.9 |
| Portland, OR | 9.2 | 9.0 |
| Gender | ||
| Male | 46.9 | 45.2 |
| Female | 53.1 | 54.8 |
| Race/ethnicity | ||
| Non-Hispanic White | 71.9 | 74.1 |
| Non-Hispanic Black | 12.2 | 11.5 |
| Hispanic | 8.5 | 7.4 |
| Other | 7.3 | 7.0 |
| Age, y | ||
| 18–24 | 16.2 | 15.2 |
| 25–39 | 41.4 | 39.1 |
| 40–49 | 42.5 | 45.8 |
| Education level | ||
| Less than high school, high school diploma, or GED | 63.6 | 62.7 |
| Some college, technical or associate's degree | 26.1 | 26.6 |
| At least a college degree | 10.3 | 10.7 |
| Media exposure (daily h of television, radio, and Internet) | 8.5 ±0.07 | 8.5 ±0.08 |
| Smokers in household (yes) | 58.4 | 58.6 |
| Smoking status | ||
| Current smoker | 100.0 | 94.7 |
| Daily smoker | 87.2 | 83.7 |
| Some day smoker | 12.8 | 10.9 |
| Current smoker with at least 1 quit attempt | 46.3 | 40.3 |
| Former smoker | 0.0 | 5.3 |
| Recent quitter (quit in the past 30 d) | 0.0 | 3.9 |
| Time to first cigaretteb | ||
| Within 5 min | 29.9 | 30.0 |
| 6–30 min | 33.0 | 33.7 |
| > 30 min | 37.1 | 36.3 |
| Cigarettes smoked per d | 16.0 ±0.0.14 | 16.2 ±0.16 |
| Use of pharmacotherapy cessation aids | ||
| Yes | 39.1 | 41.2 |
| No | 60.9 | 58.8 |
| Motivation to quit (1–10 scale)bc | 6.78 ±0.0.039 | 6.78 ±0.046 |
| Readiness to quitb | ||
| Seriously thinking about quitting smoking in the next 30 d | 17.2 | 16.5 |
| Seriously thinking about quitting smoking sometime in the next 6 mo | 50.0 | 50.9 |
| Not thinking of quitting smoking | 32.9 | 32.7 |
| Quit attempt in past 6 mo (yes) | 46.3 | 45.6 |
| Confirmed awareness of EX campaign | n/a | 41.3 |
| Aided awareness of Philip Morris Quit Assist campaign | 49.8 | 41.7 |
| Aided awareness of Pfizer My Time to Quit campaign | 62.6 | 42.5 |
Note. GED = general equivalency diploma. Column percentages are unweighted.
a Includes 217 respondents who reported smoking at baseline and were not smoking at follow-up.
b For follow-up, n = 3850 respondents who reported smoking at both baseline and follow-up.
c On a scale of 1 to 10, where 1 equals not at all and 10 equals very much, how much do you want to quit smoking?
Approximately 64% of the sample reported smoking their first cigarette of the day within 30 minutes of waking. The mean number of cigarettes smoked per day was 16.2. More than two thirds of the sample (67%) was seriously considering a quit attempt within the next 6 months. Approximately 46% had made at least 1 quit attempt of 24 hours or longer between baseline and the follow-up interviews. At follow-up, 5.3% of the respondents (n = 217) reported having stopped smoking. Among those still smoking, the average number of cigarettes smoked per day did not decline.
At follow-up, approximately 41% of the respondents in the overall sample demonstrated confirmed awareness of EX advertisements. Confirmed awareness levels ranged from 30% to 51% across the 8 DMAs. Smokers with confirmed awareness did not differ significantly from those who were unaware of EX in terms of demographic characteristics or smoking-related variables, with the exception of DMA, gender, My Time to Quit ad awareness, and cognitions index change score. Female respondents were 20% more likely to be aware of EX (odds ratio [OR] = 1.2; P = .037) than were male respondents. Respondents who were aware of the My Time to Quit ads were 2.2 times as likely to demonstrate confirmed awareness of EX (OR = 2.2; P < .001) as were those who were not aware.
Respondents who demonstrated confirmed awareness of EX were significantly more likely to increase their level of agreement on the cessation-related cognitions index from baseline to follow-up (OR = 1.6; P = .046), as calculated from the β coefficient of 0.463 presented in Table 4. However, those who made 1 or more quit attempts before the baseline survey were less likely to report agreement on the cessation-related cognitions index (OR = 0.44; P < .001).
TABLE 4 Results of the Multivariable Linear Regression Predicting the Cognitions Index Change Score: EX Campaign, 8 US States, 2007–2008
| Independent Variable | β (SE) | Stratum-Specific P | P |
| Designated Market Area | .81 | ||
| Birmingham, AL (Ref) | 1.00 | NA | |
| Columbus, OH | 0.1717 (0.311) | .58 | |
| Fort Smith–Fayetteville, AR | 0.2253 (0.3767) | .55 | |
| Houston, TX | 0.4576 (0.3897) | .24 | |
| Kansas City, MO | −0.0211 (0.2763) | .94 | |
| Phoenix–Prescott, AZ | 0.4729 (0.4047) | .24 | |
| Pittsburg, PA | −0.0558 (0.3422) | .87 | |
| Portland, OR | −0.0912 (0.4329) | .83 | |
| Age, y | .97 | ||
| 18–24 (Ref) | 1.00 | NA | |
| 25–39 | 0.0705 (0.3369) | .83 | |
| 40–49 | 0.0200 (0.3141) | .94 | |
| Gender | .11 | ||
| Female (Ref) | 1.0 | NA | |
| Male | 0.3565 (0.2242) | .11 | |
| Race/Ethnicity | .36 | ||
| Non-Hispanic White (Ref) | 1.00 | NA | |
| Hispanic | −0.4468 (0.4653) | .34 | |
| Non-Hispanic Black | 0.4218 (0.3383) | .21 | |
| Other | −0.2873 (0.4674) | .54 | |
| Education level | .22 | ||
| High school or GED (Ref) | 1.00 | NA | |
| Less than high school | 0.0406 (0.2982) | .89 | |
| Some college, technical or associate's degree | 0.066 (0.2681) | .806 | |
| College degree or more | 0.7007 (0.3437) | .042 | |
| Time to first cigarette | .74 | ||
| Within 5 min (Ref) | 1.00 | NA | |
| 6–30 min | 0.1883 (0.2626) | .47 | |
| > 30 min | 0.0484 (0.3109) | .88 | |
| Cigarettes smokeda per day. | −0.0071 (0.0128) | .58 | .58 |
| Quit attempts in 6 mo before baseline | >.001 | ||
| 0 (Ref) | 1.00 | NA | |
| ≥ 1 | −0.8151 (0.2253) | <.001 | |
| Media exposure (television, radio, and Internet)b per day. | 0.0233 (0.0181) | .2 | .2 |
| Lives with a smoker | .3 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 0.221 (0.215) | .3 | |
| Aided awareness of Quit Assist | .24 | ||
| No | 1.000 | NA | |
| Yes | −0.2642 (0.2229) | .24 | |
| Aided awareness of My Time to Quit | .67 | ||
| No | 1.00 | NA | |
| Yes | 0.1001 (0.2347) | .67 | |
| Confirmed awareness of EX | .046 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 0.463 (0.2323) | .046 |
Note. GED = general equivalency diploma; NA = not applicable; SE = standard error.
a Measured in 1-cigarette increments and presented as a continuous variable.
b Measured in 1-hour increments and presented as a continuous variable.
Those with confirmed awareness of EX were more likely to make at least 1 quit attempt between baseline and the follow-up interviews (OR = 1.24; P = .048; Table 5). Other factors that were significantly related to having made a quit attempt within the study period included time to first cigarette (OR = 1.45; P = .022), motivation to quit (OR = 1.15; P < .001), recent quit attempts before baseline (OR = 4.6; P < .001), and media exposure (OR = 1.03; P = .014).
TABLE 5 Results of the Logistic Regression Model Predicting Quit Attempts: EX Campaign, 8 US States, 2007–2008
| Independent Variable | OR (95% CI) | Stratum-Specific P | Summary P |
| Designated Market Area | .6 | ||
| Birmingham, AL (Ref) | 1.00 (Ref) | NA | |
| Columbus, OH | 1.025 (0.75, 1.39) | .93 | |
| Fort Smith–Fayetteville, AR | 1.1 (0.77, 1.59) | .64 | |
| Houston, TX | 1.27 (0.85, 1.89) | .18 | |
| Kansas City, MO | 0.88 (0.66, 1.18) | .11 | |
| Phoenix–Prescott, AZ | 0.97 (0.69, 1.38) | .63 | |
| Pittsburg, PA | 0.92 (0.66, 1.28) | .32 | |
| Portland, OR | 1.16 (0.80, 1.68) | .4 | |
| Age, y | .13 | ||
| 18–24 (Ref) | 1.00 | NA | |
| 25–39 | 0.75 (0.56, 0.99) | .087 | |
| 40–49 | 0.80 (0.60, 1.07) | .49 | |
| Gender | .63 | ||
| Female (Ref) | 1.00 | NA | |
| Male | 1.05 (0.87, 1.27) | .63 | |
| Race/Ethnicity | .104 | ||
| Non-Hispanic White (Ref) | 1.00 | NA | |
| Hispanic | 1.09 (0.73, 1.65) | .83 | |
| Non-Hispanic Black | 1.57 (1.10, 2.26) | .038 | |
| Other | 0.96 (0.57, 1.63) | .44 | |
| Education level | .102 | ||
| High school or GED (Ref) | 1.00 | NA | |
| Less than high school | 1.15 (0.87, 1.53) | .95 | |
| Some college, technical, or associate's degree | 1.02 (0.80, 1.30) | .17 | |
| College degree or more | 1.47 (1.06, 2.05) | .036 | |
| Time to first cigarette | .022 | ||
| Within 5 min (Ref) | 1.00 | NA | |
| 6–30 min | 1.10 (0.85, 1.41) | .37 | |
| > 30 min | 1.45 (1.10, 1.92) | .006 | |
| Cigarettes smokeda | 0.989 (0.978, 1.00) | .072 | .072 |
| Motivation to quit: 1–10 scale | 1.15 (1.11, 1.19) | <.001 | <.001 |
| Quit attempts in 6 months before baseline | <.001 | ||
| 0 (Ref) | 1.00 | NA | |
| ≥ 1 | 4.60 (3.73, 5.67) | <.001 | |
| Media exposure (television, radio, and Internet)b | 1.03 (1.01, 1.05) | .014 | .014 |
| Lives with a smoker | .902 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 1.01 (0.83, 1.24) | .902 | |
| Aided awareness of Quit Assist | .36 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 0.91 (0.73, 1.12) | .36 | |
| Aided awareness of My Time to Quit | .54 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 1.07 (0.87, 1.31) | .54 | |
| Confirmed awareness of EX | .048 | ||
| No (Ref) | 1.00 | NA | |
| Yes | 1.24 (1.00, 1.54) | .0475 |
Note. CI = confidence interval; GED = general equivalency diploma; NA = not applicable; OR = odds ratio.
a Measured in 1-cigarette increments and presented as a continuous variable.
b Measured in 1-hour increments and presented as a continuous variable.
With respect to the 30-day point prevalence for abstinence, the results showed a trend toward greater abstinence among those with confirmed awareness of EX; however, this finding was not significant (OR = 1.51; P = .16; data available upon request from the authors). Other key covariates associated with the 30-day point prevalence for abstinence include fewer cigarettes smoked per day (OR = 0.95; P = .008), as well as Hispanic (OR = 1.7; P = .007) and other race/ethnicity (OR = 0.19; P = .019).
The results of our study showed that exposure to a branded, mass media smoking cessation campaign can shift smokers' cognitions about cessation and increase quit attempts over a relatively short period of time. These findings confirm those of the EX pilot campaign evaluation,10 which showed that confirmed awareness of EX was associated with change in campaign-related cognitions and a trend toward prompting quitting behavior. To our knowledge, this is the first longitudinal study of a national, branded, mass media smoking cessation campaign in the United States. Moreover, this is the first study to demonstrate an association between individual-level confirmed exposure to specific media messages and quit attempts, rather than linking GRPs or other measures of media delivery with declines in tobacco consumption or smoking prevalence at the population level.
There were several limitations to our study. First, our analysis may have been limited by the lack of randomization, which did not allow us to rule out the influence of an unknown factor related to the outcomes. However, our results do reflect a temporally ordered effect that controlled for known baseline factors before the campaign launched. Second, those who recalled the EX campaign messages may have differed from those who did not. However, additional analyses indicated that awareness of EX was not associated with baseline quit attempts, readiness to quit, or cessation-related cognitions, findings which suggested that selective attention bias did not affect the validity of the study. Third, we measured aided rather than confirmed awareness of the Phillip Morris and Pfizer advertisements. Analysis of EX pilot campaign data indicated that respondents were not able to differentiate between the highly similar Phillip Morris and Pfizer advertisements, thus resulting in low levels of confirmed awareness for these campaigns. Because aided awareness is a less conservative measure than is confirmed awareness, we used it as a control variable (although it may overestimate the effects of the Pfizer and Philip Morris campaigns) but was not suitable for use in comparing these campaigns with EX. Fourth, the sample was drawn from 8 DMAs; thus, the findings of the study may not reflect a national response to the campaign.
Fifth, the relatively brief duration of this study period made it difficult to detect longer-term effects, such as 30-day abstinence. We plan to examine this relationship further in the second follow-up. Sixth, because of the small proportion of the sample that achieved 30-day abstinence, we were underpowered to demonstrate a statistically significant effect between EX awareness and this outcome. Last, the attrition of the sample may have resulted in biases among the smokers at this follow-up. However, our analyses with baseline data indicated few differences between the respondents in the completed sample and those lost to follow-up.
Although the EX campaign was created by Legacy, the national implementation of the campaign is headed by the NATC, a public-private media collaborative of states, national public health organizations, foundations, and corporations. This model allows states and other localities to air EX in coordination with their quit line availability and other local services while leveraging exposure to the national branded campaign. As a result, states and localities can avoid or reduce the costly efforts associated with advertising concept development, testing, production, and evaluation.
Despite the strengths of the NATC, the EX campaign is expected to transition to a public service announcement campaign in the coming year. As a public service announcement campaign, EX will air at fewer GRPs than it did during the period of this study. Furthermore, given the annual changes to state budgets, many state NATC members have not been able to guarantee future support to the Alliance.
Our study suggests that a robust, evidence-based, national mass media campaign can change cessation-related cognitions and increase quit attempts over a relatively short period. Stronger campaign effects—and thus greater benefits to society—would likely be found if the campaign were aired at a higher level of media delivery and were sustained over the course of several years.
We strongly recommend that federal and state governments provide funding for mass media campaigns aimed at increasing smoking cessation, with a particular focus on those that have been shown to affect quit attempts and abstinence. Given that smoking remains the primary cause of death in the United States, and given the escalating costs of health care, reducing smoking may well be the simplest contribution to “bending the health care cost curve” in the future. This recommendation is a public health opportunity that is long overdue and can help to leverage the efforts of state and local public health organizations to reduce smoking rates in the United States and ultimately save lives.
Acknowledgments
The authors thank Cheryl G. Healton for her thoughtful comments on this study, Haijun Xiao for his assistance with data analysis, and Jeff Costantino for his help in obtaining and interpreting the gross rating point data.
Human Participant Protection
This study was approved by the human subjects review committees of Westat, the organization that conducted the data collection, and Copernicus Group Independent Review Board, the external institutional review board used by Legacy.
