Nancy A. Rigotti, MD; Melanie Wakefield, PhD
This article was published at www.annals.org on 25 September 2012.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1724.
Requests for Single Reprints: Nancy A. Rigotti, MD, General Medicine Division, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Rigotti: General Medicine Division, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.
Dr. Wakefield: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 1 Rathdowne Street, Carlton, Victoria 3053, Australia.
Author Contributions: Conception and design: N.A. Rigotti.
Analysis and interpretation of the data: N.A. Rigotti.
Drafting of the article: N.A. Rigotti, M. Wakefield.
Critical revision of the article for important intellectual content: M. Wakefield.
Final approval of the article: N.A. Rigotti, M. Wakefield.
Collection and assembly of data: N.A. Rigotti.
Rigotti N., Wakefield M.; Real People, Real Stories: A New Mass Media Campaign That Could Help Smokers Quit. Ann Intern Med. 2012;157:907-909. doi: 10.7326/0003-4819-156-1-201201010-00541
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Published: Ann Intern Med. 2012;157(12):907-909.
Imagine seeing these advertisements on your television or computer: A 31-year-old man with bilateral below-knee amputations describes losing his legs and fingertips to Buerger disease. Three people with head and neck cancer diagnosed before 50 years of age talk about daily life with a stoma (“Don't face the shower head.” and “Be very careful with shaving.”) (Figure). The mother of a young boy with severe asthma advises in English or Spanish, “Don't be too shy to tell people not to smoke around your kids.” Three former smokers talk about how they quit and urge viewers, “Do whatever it takes, no matter how many times it takes. We did it. You can, too.”
Billboard advertisements for the Centers for Disease Control and Prevention's Tips From Former Smokers mass media campaign.
Additional material available from www.cdc.gov/tobacco/campaign/tips/resources/.
These are some of the real-life Americans featured in Tips From Former Smokers from the Centers for Disease Control and Prevention (CDC), a $54 million national mass media campaign for public education supported by the Prevention and Public Health Fund of the Patient Protection and Affordable Care Act (1). The 12-week campaign, which began on 19 March 2012, was the first federally funded, nationwide mass media effort to encourage smokers to quit.
In 30-second television and radio spots, in print media, and on billboards, real people showed and told in graphic terms what it was like to live with disfiguring or disabling tobacco-related diseases that were diagnosed at a relatively young age. In other spots, former smokers gave tips about how they quit. Each message ended with a tag line referring viewers or listeners to free help available from a national telephone quit line (1-800-QUIT-NOW) and Web site (www.smokefree.gov). The campaign was also delivered online using digital video (for example, YouTube) and social media (for example, Facebook and Twitter) to reach the target audience, smokers aged 18 to 54 years. Advertisements were broadcast in English and Spanish.
The campaign's goal was to prompt smokers to try to quit and to build awareness of free government resources for smoking cessation (1). The short-term goal was achieved. According to Tim McAfee, MD, MPH, director of the CDC's Office on Smoking and Health, calls to the toll-free quit line more than doubled and Web site hits tripled during the 12-week campaign. “It far exceeded our expectations,” he said. The quit line received 207 519 additional calls in 2012 compared with the same 12-week period in 2011, and the Web site recorded 510 571 additional unique visitors, suggesting a substantial untapped public interest in information about quitting smoking (2). Paid advertising ended in June 2012, but public service announcements continued longer and campaign materials (for example, stories, videos, podcasts, and links) remain accessible on the Tips Web site (www.cdc.gov/tobacco/campaign/tips).
Whether the short-term positive response will translate into higher rates of smoking cessation and lower smoking prevalence is the key question. There are several reasons to be hopeful. Good empirical evidence shows that public education campaigns delivered by mass media influence health behaviors, especially tobacco smoking (3). Recent reviews find strong evidence that mass media campaigns increase quitting and reduce smoking prevalence when implemented within the context of a comprehensive tobacco control program (4–6).
Previous U.S. state and national efforts that resembled the Tips campaign had promising results. For example, the 2008 EX campaign, broadcast nationwide on cable television, also targeted adult smokers and promoted cessation. It was associated with an increase in quit attempts by smokers (7). Many other U.S. mass media campaigns targeted adolescents and young adults and aimed to reduce smoking initiation. The national “truth” campaign, which targeted adolescents and young adults from 2000 to 2004, reduced smoking initiation rates (8), as did earlier statewide mass media campaigns in Massachusetts and Florida (9, 10).
The effectiveness of a mass media campaign depends on its reach, intensity, and duration and on the type of messages used (6). The messages of the Tips campaign are grounded in health communication research. Emotive personal testimonials and narratives are powerful strategies for reaching and influencing the broad population of smokers, including those of lower socioeconomic status (6, 11, 12). The personal story format reduces the tendency for smokers to generate counterarguments (“That couldn't happen to me”) or discount adverse health outcomes as uncommon among the smokers whom they know, because the stories feature real people.
Emotionally laden stories show the risks of tobacco use in a far more potent way than abstract information can, and messages evoking negative emotions have been shown to be more effective than humorous or emotionally neutral ones (13). The intended result is to increase smokers' sense of personal vulnerability to serious disease and increase their sense of urgency for quitting. Pairing the personal testimonial in each advertisement with simple actionable information (a phone number or Web site address) allows smokers to access free assistance with smoking cessation that is effective but underused.
Besides its direct effects on the target audience of adult smokers, the Tips campaign may indirectly benefit nonsmokers and youth. The advertisements could increase the frequency and depth of discussion about tobacco use within individual social networks (14, 15). Smokers may receive encouragement to make a quit attempt from family and friends. Adolescents may be reminded that tobacco use is harmful. Mass media campaigns can change public attitudes and make tobacco use less socially acceptable, which may be why they can discourage youth tobacco use (4, 16), even when, like the Tips campaign, they are not explicitly aimed at youth.
The Tips campaign's relatively brief 3-month duration, presumably a consequence of resource limitations, will probably limit its effect. As evidence, the excess volume of quit line calls and Web site hits returned to baseline levels soon after paid advertising ended (2). Media campaigns have relatively short-term effects because they are countered by ongoing factors that encourage smoking, such as marketing by the tobacco industry and the addictiveness of nicotine (6). Longer campaigns can reach the population with repeated messages, which is especially important for smokers of lower socioeconomic status (6).
Fortunately, the CDC plans to use funds from the Affordable Care Act to run another 3-month campaign during the first quarter of 2013 and hopes to do so in future years (McAfee T. Personal communication). Meanwhile, the CDC might extend the campaign's effect by partnering with states and private-sector organizations, such as health care systems, that could reuse the advertisements as part of their own public education efforts.
To assess the impact of the Tips campaign, the CDC sponsored a longitudinal study of a national cohort of 5000 adult smokers and 2000 adult nonsmokers. They completed an online survey 1 month before the campaign launch and immediately after the 12-week campaign ended (McAfee T. Personal communication). Surveys assessed awareness of the campaign advertising and attitudes and beliefs about smoking cessation and secondhand smoke exposure. Smokers were asked about their intentions to quit smoking and attempts to quit. Nonsmokers were asked whether they had encouraged a friend or family member to quit. The analysis is statistically powered to detect an increase in the primary outcome measure, quit attempts by smokers, adjusting for campaign exposure. Results are expected by the end of this year.
In a separate effort, the U.S. Food and Drug Administration issued new warning labels for U.S. cigarette packages in 2011 (17). The labels feature large graphic images that, like those in the Tips media campaign, deliver emotionally evocative messages of the health harms of tobacco use and are paired with information on how to get help with quitting. The warning labels were to appear in September 2012, but implementation is delayed until resolution of legal challenges from the tobacco industry. If the U.S. Food and Drug Administration prevails, we urge them and the CDC to coordinate their future efforts. Pictorial warning labels and television advertising can work in a complementary manner to increase awareness of the health consequences of smoking and enhance motivation to quit (18).
In summary, the CDC's Tips campaign is bold in size, scope, and content. The $54 million investment of federal funds is unprecedented in U.S. tobacco control, although it pales in comparison to the $27 million spent daily by the tobacco industry to market its products (2, 16). The CDC deserves credit for grounding the design and implementation in the evidence base of health communication research and for supporting a comprehensive evaluation to determine whether it worked and why or why not. It is definitely a program to watch—and to recommend to your patients who smoke (Table).
Resources for Smokers Related to the Tips From Former Smokers Campaign
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The CDC Tips from Former Smokers campaign uses multimedia and social media to feature real people suffering as a result of smoking and exposure to secondhand smoke. For more information, go to http://www.cdc.gov/tobacco/campaign/tips/.
Cardiology, Tobacco, Alcohol, and Other Substance Abuse, Coronary Risk Factors, Smoking.
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