Elsevier

The Lancet

Volume 382, Issue 9909, 14–20 December 2013, Pages 2003-2011
The Lancet

Articles
Effect of the first federally funded US antismoking national media campaign

https://doi.org/10.1016/S0140-6736(13)61686-4Get rights and content

Summary

Background

Every year, smoking kills more than 5 million people globally, including 440 000 people in the USA, where the long-term decline in smoking prevalence has slowed. The US Centers for Disease Control and Prevention (CDC) delivered a national, 3-month antismoking campaign called Tips From Former Smokers (Tips) that started in March, 2012, in which hard-hitting, emotionally evocative television advertising was featured, depicting smoking-related suffering in real people. We aimed to assess the effects of the Tips campaign.

Methods

We undertook baseline and follow-up surveys of nationally representative cohorts of adult smokers and non-smokers. The national effect of the Tips campaign was estimated by applying rates of change in the cohort before and after the campaign to US census data.

Findings

3051 smokers and 2220 non-smokers completed baseline and follow-up assessments. 2395 (78%) smokers and 1632 (74%) non-smokers recalled seeing at least one Tips advertisement on television during the 3-month campaign. Quit attempts among smokers rose from 31·1% (95% CI 30·3–31·9) at baseline to 34·8% (34·0–35·7) at follow-up, a 12% relative increase. The prevalence of abstinence at follow-up among smokers who made a quit attempt was 13·4% (95% CI 9·7–17·2). Nationally, an estimated 1·64 million additional smokers made a quit attempt, and 220 000 (95% CI 159 000–282 000) remained abstinent at follow-up. Recommendations by non-smokers to quit grew from 2·6% at baseline to 5·1% at follow-up, and the prevalence of people talking with friends and family about the dangers of smoking rose from 31·9% (95% CI 31·3–32·5) to 35·2% (34·6–35·9), resulting in an estimated 4·7 million additional non-smokers recommending cessation services and more than 6 million talking about the dangers of smoking.

Interpretation

The high-exposure Tips media campaign was effective at increasing population-level quit attempts. The growth in smokers who quit and became sustained quitters could have added from a third to almost half a million quality-adjusted life-years to the US population. Expanded implementation of similar campaigns globally could accelerate progress on the WHO Framework Convention on Tobacco Control and reduce smoking prevalence globally.

Funding

CDC, US Department of Health and Human Services.

Introduction

Tobacco use remains the leading cause of preventable death worldwide, causing nearly 5 million deaths annually.1 For individuals, smoking shortens life expectancy by more than 10 years,2 whereas adults who quit before age 45 years regain almost a decade in life expectancy.2 Every year in the USA, cigarettes kill more than 440 000 people3, 4 and cost US$96 billion in direct medical costs and $97 billion in lost productivity.5 Despite these striking statistics, the long-term decline in smoking in the USA has slowed in recent years.3, 5, 6, 7 Although 50% of US smokers attempt to quit every year,7 the annual sustained cessation rate remains around 5%.8, 9 Intervention by doctors can increase quit rates, but competing demands, inadequate reimbursement policies, and insufficient training constrain their ability to reach the 45 million smokers in the USA.10 State and local mass-media campaigns have motivated smokers to quit,11, 12, 13, 14, 15 but these initiatives have typically been done sporadically or at low exposure levels. States vary widely by campaign implementation; a few (such as California and New York) have run consistent media campaigns for many years, whereas others have either never run media campaigns or have made intermittent efforts at low doses. Globally, several national media campaigns have taken place, but assessments of these have been based largely on regional samples, evaluated multiple state-based campaigns at the national level, used surrogate markers for quit-attempt rates, relied on differences in self-reported exposure to advertising, or used samples without prospective cohort designs or excluding non-smokers.16, 17, 18

In the USA, the Patient Protection and Affordable Care Act 2010 (ACA) provides opportunities to accelerate national progress in tackling tobacco use,4 including enhanced reimbursements for cessation services and mass-media support. In 2012, through the ACA, the US Centers for Disease Control and Prevention (CDC) launched the first, federally funded, national, antismoking, mass-media education campaign—Tips From Former Smokers (Tips). This $54 million initiative featured emotional true stories told by former smokers to increase awareness of the human suffering caused by smoking, encourage quitting, and motivate non-smokers to communicate with family and friends about the dangers of smoking. We aimed to measure changes in quit attempts by smokers, quit status at follow-up, and non-smokers' cessation support behaviour in nationally representative cohorts of smokers and non-smokers and to estimate the effect of the campaign nationally by applying cohort rates to US census data.

Section snippets

Study design

Advertisement development in the Tips campaign built on experiences from several countries11, 12, 14 and underwent rigorous formative testing19 with almost 10 000 smokers and non-smokers. Creative development first looked at the relevance and effect of potential messages, then multiple campaign ideas were assessed. Before production of the final advertisements, refinements were identified by screen-testing of rough versions online. On the basis of smokers' feedback, emotionally evocative and

Results

4108 (70%) of 5903 invited smokers and 3000 (58%) of 5203 invited non-smokers completed the baseline survey. At follow-up, 3051 (74%) of 4108 smokers and 2220 (74%) of 3000 non-smokers completed the survey. In the unweighted sample, slightly fewer young smokers (age 18–24 years) and slightly more older smokers (age ≥55 years) were noted at follow-up, compared with baseline (table 1). Moreover, fewer smokers with children in the household and fewer Hispanic non-smokers completed follow-up,

Discussion

The Tips campaign was the first, national, mass-media antismoking initiative to be funded by the US Government. It reached nearly 80% of US smokers and was associated with a 12% relative increase in quit attempts within a nationally representative cohort. Based on the absolute increase in quit attempts of 3·7%, the public health effect of Tips was substantial, with an estimated 1·64 million quit attempts made and 220 000 smokers abstinent at the campaign's culmination. Millions of non-smokers

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