Article Text

The association between advertising and calls to a tobacco quitline
1. Craig H Mosbaek1,
2. Donald F Austin2,
3. Michael J Stark1,
4. Lori C Lambert2
1. 1
Program Design and Evaluation Services, Multnomah County Health Department and Oregon Department of Human Services, Portland, OR, USA
2. 2
Oregon Health & Science University, Portland, OR, USA
1. Craig H Mosbaek, MPH, 800 NE Oregon Street, Portland, OR 97232, USA; craig.mosbaek{at}state.or.us

## Abstract

Objective: This study assessed the cost effectiveness of different types of television and radio advertisements and the time of day in which advertisements were placed in generating calls to the Oregon tobacco quitline.

Design: Cost effectiveness was measured by cost per call, calculated as the cost of advertising divided by the number of quitline calls generated by that advertising. Advertising was bought in one-week or two-week blocks and included 27 daytime television buys, 22 evening television buys and 31 radio buys.

Results: Cost effectiveness varied widely by medium, time of day and advertisement used. Daytime television was seven times more cost effective than evening television and also more cost effective than radio. The most effective advertisements at generating quitline calls were real life testimonials by people who lost family members to tobacco and advertisements that deal practically with how to quit.

Conclusions: Placement of television advertisements during the day versus the evening can increase an advertisement’s effectiveness in generating calls to a quitline. Some advertising messages were more effective than others in generating calls to a quitline. Quitline providers can apply findings from previous research when planning media campaigns. In addition, call volume should be monitored in order to assess the cost effectiveness of different strategies to promote use of the quitline.

• quitline
• cost effectiveness
• helpline
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More than 25 countries now have tobacco quitlines, sometimes operated at the state or province level.1 A 1996 meta-analysis concluded that, “While difficult to evaluate, [tobacco quitlines] appear to be efficacious and useful as a public intervention for large populations.”2 More recent reviews have bolstered the conclusion that telephone support increases tobacco cessation.3 4 Previous studies have shown that mass media advertising increases calls to tobacco quitlines515 and to helplines for other public health concerns.1622

A study from New Zealand showed that certain television channels and certain shows were better for generating calls to a quitline and daytime placement was more effective than evening placement.14 The New Zealand study looked at both quitline calls per TRP as well as cost effectiveness, defined as money spent on airing an advertisement divided by the number of calls generated by the advertisement. Cost effectiveness studies are more useful for deciding how to spend advertising dollars to most efficiently drive calls to a quitline.

For this study, we assessed the cost effectiveness of different advertising strategies in prompting tobacco users to call the Oregon tobacco quitline (OTQL). The OTQL is one component of the comprehensive tobacco control programme run by the Oregon Department of Human Services (ODHS).

## METHODS

Data were collected on advertising buys and calls to the OTQL from November 1998, when the OTQL became operational, to March 2002. Generally, media buy decisions were made for programmatic reasons and not for the purpose of this study of cost effectiveness.

Ad buys were usually one or two weeks in duration, starting on a Monday and ending on a Sunday. For any given television buy, advertisements were placed throughout the week, either exclusively in the daytime (5 am–4 pm) or in the evening (6:30 pm–1 am). There were 27 daytime television buys, with media placement costs ranging from $7000–$15 000 per week. There were 22 evening television buys with media placement costs ranging from $25 000–$35 000 per week. There were 31 radio buys, with costs ranging from $20 000–$35 000 per week. Television buys usually included two advertisements and radio buys always included two advertisements. When there were two advertisements, broadcast stations rotated the advertisements so that half the air time was used for each advertisement. In these cases, the two different advertisements did not air during the same commercial breaks.

### Data on OTQL callers

Calls to the OTQL were answered by the staff of Group Health Cooperative (now Center for Health Promotion) under a contract with the ODHS. The OTQL was generally open weekdays 8 am–8 pm and Saturdays 8 am–1 pm and closed Sunday. People who called when the OTQL was closed were not counted unless they left a message and were called back (86% of all OTQL calls occurred during open hours). The following data were available on OTQL callers: date of call, type of tobacco used, stage of change, sex, birth date, race/ethnicity, highest level of education and county of residence. In addition, callers were asked, “How did you hear about the quitline?” Callers were not asked which particular advertisement, if any, they saw. All data were self reported by the caller, except for date of call.

In the six television buys followed by no ads, the percentages of delayed callers averaged 10% (95% CI: 7% to 13%). For the 27 radio buys, the percentages of delayed callers averaged 14% (95% CI: 12% to 17%). We used these percentages (10% for television and 14% for radio) to assign delayed callers to the appropriate ad buy.

### Calculating cost per call

The cost per call for ad A is known, so “estimated calls from advertising costing D/2 using ad A alone” was calculated as (D/2)/(cost per call for ad A). The number of calls attributable to ad B was then derived and cost per call for ad B was calculated. An ad that does not mention the quitline was assumed to generate zero calls.

### Analyses

Costs per call were compared among all ad buys within three different media: daytime television, evening television and radio. p Values for statistical significance were calculated using the goodness of fit χ2 statistic to test the null hypothesis that costs per call were equal using the critical value of 0.05.26 When comparisons were made among three or more buys, the critical p value for statistical significance was calculated using the Bonferroni adjustment, the most conservative adjustment generally recommended for use when multiple comparisons are being tested.27

Characteristics of quitline callers were compared with the general adult population of tobacco users in Oregon (only 2% of quitline callers were under 18 years old). Data for adult tobacco users were derived from the 2000 Oregon Behavioural Risk Factor Surveillance System (BRFSS), which included 1606 respondents who identified themselves as smokers and 187 as smokeless tobacco users.

## RESULTS

### Tobacco use characteristics

Among callers from television buys, the percentage of smokers who planned to quit in the next 30 days was 92.0% (95% CI: 91.2% to 92.8%) and among callers from radio buys it was 91.2% (95% CI: 89.9% to 92.5%). Among BRFSS respondents who were smokers, 24.4% (95% CI: 21.2% to 27.9%) planned to quit in the next 30 days.

In response to television advertisements that deal with smoking, 4.3% (95% CI: 3.6% to 4.9%) of callers were smokeless tobacco users. In response to television buys that have smokeless tobacco messages, 39.1% (95% CI: 34.6% to 43.6%) of callers used smokeless tobacco. From the Oregon BRFSS, 12.8% (95% CI: 11.0% to 14.9%) of all tobacco users were smokeless tobacco users.

Five television advertisements were aired by themselves during daytime television buys (table 1). “Quitting Takes Practice” is a cartoon advertisement showing smokers how to quit, including calling the quitline. “Funeral” and “Cigarette Pack” are advertisements describing reasons to quit. “Tina Cary” is a testimonial advertisement by a woman who lost her husband to cancer caused by smokeless tobacco. “Bedroom” shows a man smoking in bed, exposing his wife to secondhand smoke.

“Krystell Memorial,” a testimonial advertisement by a girl who lost her mother to smoking, had the lowest cost per call among evening television buys (p<0.0004 for each comparison). “Quitting Takes Practice” had the next lowest cost per call, significantly lower than the other ads (p<0.0025 for each comparison). “Bedroom” had the highest cost per call among advertisements aired on evening television (p<0.0077 for each comparison). The costs per call for “Debi-Voicebox,” “Funeral,” “Tina Cary” and “Cigarette Pack” were not significantly different from each other (p = 0.24 or greater for each comparison).

### Cost effectiveness of daytime versus evening television

Three television advertisements were aired in separate buys in both daytime and evening—“Tina Cary,” “Funeral” and “Bedroom.” For each of these three advertisements, the cost per call was significantly higher when the advertisement ran during the evening versus daytime (p<0.0001). The ratio of the cost per call for an evening buy versus the cost per call for a daytime buy was 5.0 for “Tina Cary,” 6.9 for “Funeral” and 9.3 for “Bedroom,” averaging 7.1.

### Evaluating assumptions

To test the assumption that ads that do not mention the quitline generate few, if any, calls, we looked at data from January 1999 through March 2000. During this time period, television advertisements were aired periodically, but none of the ads mention the quitline. The number of callers who heard about the quitline from television was small and did not vary significantly between weeks when advertisements were running and when advertisements were not running (average calls per week: 2.0 versus 2.1, p = 0.99).

In assigning delayed callers to ad buys, it was assumed that 10% or 14% (for television and radio, respectively) of callers called the week after the ad stopped airing. Additional analyses were done assuming that the percentages of delayed callers were at either the high or low end of the 95% confidence interval for the average delayed callers (7%–13% for television buys and 12%–17% for radio buys). Under these assumptions, the cost per call changed an average of 2% but did not affect the conclusions of this study.

Costs per call for some advertisements were derived from a formula which assumed that two ads airing in the same time period did not interact either synergistically or negatively. This study, however, indicated that the interaction may be negative. For example, the cost per call for a buy with “Quitting Takes Practice” and “Funeral” airing together ($104) was higher than both the cost per call for “Quitting Takes Practice” ($70) and the cost per call for “Funeral” ($90) (table 1). ## DISCUSSION The results of this study suggest that the cost effectiveness of advertising to generate calls to a tobacco quitline varies greatly by media used and by advertisement. ### Cost effectiveness of different media Daytime television was more cost effective than evening television by an average multiple of 7.1, after adjusting for advertisements used. Some of the difference in cost effectiveness between daytime and evening television can be attributed to the cost per viewer. In this study, cost per viewer for evening television buys was twice that for daytime television. Thus, given the same number of viewers seeing an ad in daytime and evening, the daytime ad would generate 3.5 times as many calls as the evening ad. The cost per viewer was higher for evening television buys because evening television viewers are generally paying more attention to the television broadcast than daytime viewers. This may help explain why daytime television generates more calls—viewers who are more engaged in a programme may be less likely to stop watching and make a telephone call.5 A previous study of quitline calls14 and studies of retail product sales24 25 28 have shown that direct response advertisements were more cost effective during the daytime versus the evening. Approximately 35%–40% of the evening advertisements were shown after 8 pm, when the quitline was closed. Callers after 8 pm could leave a message and get called back, but it is likely that the quitline’s hours reduced the effectiveness of evening buys. An accurate cost effectiveness comparison cannot be made between television and radio because identical ads cannot be aired on radio and television. But, the most effective television advertisement had a cost per call of$70, while the cost per call for the most effective radio advertisement was \$332.

These ads were more cost effective than testimonials by tobacco users that described the health consequences of tobacco. In tobacco users’ testimonials, real people who have suffered greatly from a tobacco related illness give the message: “I used tobacco and look what it did to me; you should quit so this doesn’t happen to you.” It may be more difficult for tobacco users to deny the message of the affected family testimonials, as opposed to advertisements that show tobacco users suffering. Tobacco users may think that their health is their concern alone, but the family testimonials may help them understand the huge impact their death or serious illness would have on people they love.

The only advertisement that deals practically with how to quit was “Quitting Takes Practice,” which when shown during daytime was the most cost effective advertisement. “Quitting Takes Practice” was more effective than the advertisements that used actors to deliver messages about reasons to quit. Among ads that mention the quitline, secondhand smoke ads were the least effective at generating calls. Ads that do not mention the quitline generated few, if any, calls.

### Study limitations

This study’s methodology required measuring the number of quitline calls generated by an ad buy that spanned two weeks. Thus, this study could not assess the effects of characteristics of individual ad placements such as type of programme, day of the week and exact time of day. Other studies have assessed the effectiveness of single ad placements by measuring the number of quitline callers within one hour of an ad placement.5 14 Studies that assign callers to single ad placements may be more difficult to implement, but that methodology allows for analyses of additional factors that may influence the number of quitline callers.

## CONCLUSION

Calls to a quitline may be the most easily measured outcome of an ad campaign, but not necessarily the most important outcome of a campaign. Studies have shown that anti-tobacco advertising can have multiple beneficial effects for tobacco control.3 Secondhand smoke ads were least effective at generating quitline calls, but messages about the dangers of secondhand smoke are very important. Exposure to secondhand smoke increases a person’s risk for many serious diseases,29 and advertising about the dangers of secondhand smoke may increase support for smoking restrictions at home and in workplaces.

The results of this study may be helpful for organisations designing direct response advertising campaigns in the public health arena. An organisation promoting a helpline should continually assess the effectiveness of their outreach efforts. Callers to a helpline should be asked how they heard about the helpline and accurate records should be kept about helpline promotions, including costs. Organisations should consider trying multiple advertising strategies at the beginning of a campaign in order to determine the most cost effective strategies and then plan their campaign accordingly.

• Clinical trials as well as population based studies have shown that use of tobacco quitlines increased the quit rate of tobacco users. A number of studies have shown that advertising increases calls to quitlines or other types of helplines. But only a few limited studies have analysed the relative effectiveness of different advertising strategies in generating calls to a quitline.

• The objective of this study was to assess the cost effectiveness of different advertising strategies in generating calls to a quitline. Daytime television was far more cost effective than evening television and also more cost effective than radio. The most effective advertisements at generating quitline calls were real life testimonials by people who lost family members to tobacco and advertisements that deal practically with how to quit.

• Quitline providers should consider trying multiple advertising strategies at the beginning of a campaign in order to determine the most cost effective strategies and then plan their campaign accordingly.

## Acknowledgments

We are grateful for the support and guidance from the staff of the Oregon Tobacco Prevention and Education Program and staff from Program Design and Evaluation Services, especially Julie Maher, Barbara Pizacani and Kristen Rohde. We would also like to acknowledge Richard Leman, Jane Moore and Mel Kohn from the Oregon Department of Human Services for their contributions to this work. We received important information and insights from Center for Health Promotion, PacWest Communications and Darcey Price, media buyer for Cappelli Miles Wiltz Kelly.

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## Footnotes

• Competing interests: The authors do not have any competing interests to report.

• Funding: This work was funded by the Oregon Tobacco Prevention and Education Program.

• Abbreviations:
BRFSS
Behavioural Risk Factor Surveillance System
ODHS
Oregon Department of Human Services
OTQL
Oregon tobacco quitline
TRPs
target rating points

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