Caixeta, Roberta B. - et al.
Antismoking mass media campaigns can help reduce the prevalence of smoking by discouraging young persons from initiating smoking and by encouraging current smokers to quit.1,2 Smoking cessation is a multistage process; intention to quit smoking precedes quit attempts.3 To assess whether awareness of anti-cigarette smoking information in four mass media channels (television, radio, billboards, and newspapers or magazines) was significantly associated with a current cigarette smoker's intention to quit, CDC analyzed data from 17 countries that participated in the Global Adult Tobacco Survey (GATS).
Logistic regression was used to analyze the relationship between awareness of antismoking messages and intent to quit smoking; odds ratios were adjusted to control for demographic factors, awareness of warning labels on cigarette packages, and awareness of tobacco advertisements. In nine of 17 countries, intent to quit was significantly associated with awareness of antismoking messages in a single media channel versus no awareness, with adjusted odds ratios ranging from 1.3 to 1.9.
In 14 countries, intent to quit was significantly associated with awareness of messages in multiple channels versus no awareness, with adjusted odds ratios ranging from 1.5 to 3.2.
Antismoking information in mass media channels can help reduce tobacco consumption by encouraging smokers to contemplate quitting and might be more effective when presented in multiple channels.
GATS is an ongoing, nationally representative household survey of non-institutionalized adults age 15 and over.4 This report used data from current cigarette smokers in 17 countries that participated in GATS during 2008-2011.
Current smokers who were categorized as intending to quit included (1) persons who indicated they planned to quit smoking in the next month; and (2) persons who indicated they were thinking about quitting smoking in the next 12 months. Survey questions asking whether current smokers noticed anti-cigarette smoking information during the last 30 days in any of the four media channels were used to measure awareness of the messages.
Logistic regression was used to analyze the relationship between awareness of antismoking messages and intention to quit smoking. Awareness of antismoking messages was classified into three categories:
- Did not notice antismoking information in any media channels;
- Noticed antismoking information in one of the four channels; and
- Noticed antismoking information in more than one of the channels.
Because intention to quit and exposure to antismoking information might both be associated with demographic characteristics, variables for sex, age, residence, education, and socioeconomic status5 were entered into the model. Additionally, to control for media influence, two indicators were entered into the model: whether the respondent noticed warning labels on cigarette packages in the last 30 days and whether the respondent was aware of pro-tobacco marketing in the last 30 days.
Awareness of pro-tobacco marketing was measured by affirmative responses to a series of questions asking whether the respondent had noticed such advertisements, promotions, or sponsorships in the last 30 days in various marketing channels.6
A total of 265,564 persons participated in the 17 country surveys. The response rates for the surveys ranged from 65.1 percent in Poland to 97.7 percent in Russia, with a median response rate of 93.6 percent. (Current cigarette smokers included those who smoked manufactured cigarettes, handrolled cigarettes, or kreteks, daily or less frequently than daily.
Of the participants, 50,209 reported they were current smokers.(Current smokers who were categorized as intending to quit included persons who indicated they planned to quit smoking in the next month and persons who indicated they were thinking about quitting smoking in the next 12 months.)
In all 17 countries, these respondents noticed antismoking information during the last 30 days in all four of the media channels. More than half of respondents noticed antismoking information in at least one of the four media channels in all countries, and more noticed antismoking information on television compared with the other three media channels.
Awareness of antismoking information on television was reported by more than 80 percent of smokers in four countries: Turkey (87.8%), Malaysia (86.7%), Vietnam (85.6%), and Mexico (82.8%). Awareness for radio was highest in Mexico (47.9%), followed by Malaysia (47.0%) and Uruguay (43.0%). Awareness for billboards ranged from 17.6% in Brazil to 73.9% in Malaysia, while awareness for newspapers or magazines ranged from 9.4% in Indonesia to 74.3% in Malaysia.
Among the respondents, 10,439 said they intended to quit. In five of the 17 countries, the number of respondents intending to quit was more than 30 percent (43.8% in Bangladesh, 34.6% in Mexico, 33.7% in Uruguay, 31.7% in Poland, and 30.2% in Vietnam).
Intention to quit smoking was less than 20 percent in five countries (18.7% in Brazil, 16.0% in China, 14.5% in Russia, 14.2% in Malaysia, and 10.5% in Indonesia).
The proportion of respondents who noticed a warning label in the previous 30 days was high in all countries, ranging from 70.7 percent in India to 97.9 percent in Romania. Wide variation was observed in the percentage of respondents who noticed any type of pro-tobacco marketing in the last 30 days, ranging from zero percent in three countries (Egypt, Thailand, and Vietnam) where all forms of tobacco advertising, promotions, and sponsorship are banned, to 87.3 percent in Indonesia, where only the distribution of free samples of cigarettes is banned.6,7
In nine of the 17 countries, the association between intent to quit and awareness of antismoking messages in a single channel versus no awareness was significant, with adjusted odds ratios ranging from 1.3 to 1.9.
The association between intent to quit and awareness of messages in multiple channels versus no awareness was significant in 14 of the 17 countries, with adjusted odds ratios ranging from 1.5 to 3.2. The strongest association (adjusted odds ratio of 3.2) was in Bangladesh.
The World Health Organization Framework Convention on Tobacco Control requires countries to provide widely accessible, comprehensive information about the addictiveness, risks, and harms of exposure to tobacco smoke.
Antismoking messages in the mass media are one means to accomplish this goal. Whereas awareness of antismoking messages demonstrates that the information has reached the public, smokers' intentions to quit are an indicator of the effectiveness of those messages. Campaign reach, intensity, duration, and the content of messages might influence effectiveness.8
Research has shown that mass media campaigns might be ineffective if they do not meet a threshold for sufficient population exposure. Among the GATS countries included in this study, such a threshold might be difficult to overcome without the use of television, the primary media channel associated with the greatest exposure.
The content of the messages also matters: Messages that convey the adverse health effects of tobacco use and secondhand smoke exposure have been found to be more effective than other message types.8
The findings in this report are subject to at least six limitations: First, awareness of mass media antismoking messages does not directly measure the frequency or duration of exposure to specific messages. The extent of the mass media campaigns in the countries studied was not reported.
Second, differences in content can be found in antismoking media messages as well as in protobacco marketing and warning labels on cigarette packages; these differences might account for differences in their association with intention to quit.
Third, additional factors (e.g., increases in tobacco prices or smokefree laws) not controlled for in this analysis might influence whether smokers intend to quit.8
Fourth, different types of smoked tobacco products other than cigarettes are common in several countries (e.g., bidis in Bangladesh and India and shisha in Egypt, Turkey, and Ukraine).
This report is limited to anti-cigarette smoking messages specifically and does not consider media messages aimed at the use of other types of smoked tobacco.
Fifth, although intention to quit has been correlated with actual quit behavior,3,8 it is not a direct measure of quit behavior.
Finally, the survey design is cross-sectional, and causality cannot be inferred from the associations described in this report.
Adds to Body of Evidence
This report adds to the body of evidence showing that awareness of mass media antismoking messages can be associated with intent to quit smoking. Mass media campaigns also can help reduce smoking prevalence by stimulating discussion and changing social norms regarding tobacco use and secondhand smoke exposure and are a crucial element of comprehensive tobacco control programs.8,9 These global findings provide additional support for CDC's Tips from Former Smokers mass media campaign.10
Reprinted (slightly edited) from Morbidity and Mortality Weekly Report 2013;62:417-422.
1. US Dept of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: CDC, 2012.
2. National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control monograph no. 19. Bethesda, MD: US Dept of Health and Human Services, NIH, NCI, 2008.
3. DiClemente CC, Prochaska JO, et al. The process of smoking cessation: an analysis of precontemplation, contemplation and preparation stages of change. J Consult Clin Psychol 1991; 59:295–304.
5. Palipudi KM, Gupta PC, et al. Social determinants of health and tobacco use in 13 low and middle income countries: evidence from Global Adult Tobacco Survey. PLoS One 2012; 7:e33466.
6. CDC. Adult awareness of tobacco advertising, promotion, and sponsorships—14 countries. MMWR 2012;61:365-369.
8. Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012; 21:127–138.
10. Rigotti NA, Wakefield M. Real people, real stories: a new mass media campaign that could help smokers quit. Ann Intern Med 2012; 157:907–909.