Article Text

Testing antismoking messages for Air Force trainees
  1. Lucy Popova1,
  2. Brittany D Linde2,
  3. Zoran Bursac3,
  4. G Wayne Talcott4,
  5. Mary V Modayil5,
  6. Melissa A Little4,
  7. Pamela M Ling6,
  8. Stanton A Glantz7,
  9. Robert C Klesges4
  1. 1Center for Tobacco Control Research and Education, University of California, San Francisco, California, USA
  2. 2Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  3. 3Division of Biostatistics, Department of Preventive Medicine, Center for Population Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  4. 4Department of Preventive Medicine, Center for Population Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  5. 5Institute for Population Health Improvement, University of California, Davis Medical Center, Sacramento, California, USA
  6. 6Division of General Internal Medicine, Department of Medicine, Center for Tobacco Control Research and Education, University of California, San Francisco, California, USA
  7. 7Division of Cardiology, Department of Medicine, Center for Tobacco Control Research and Education, Cardiovascular Research Institute, University of California, San Francisco, California, USA
  1. Correspondence to Dr Lucy Popova, Center for Tobacco Control Research and Education, University of California, San Francisco, 530 Parnassus Ave., Ste. 366, San Francisco, CA 94143, USA; Lyudmila.Popova{at}ucsf.edu

Abstract

Introduction Young adults in the military are aggressively targeted by tobacco companies and are at high risk of tobacco use. Existing antismoking advertisements developed for the general population might be effective in educating young adults in the military. This study evaluated the effects of different themes of existing antismoking advertisements on perceived harm and intentions to use cigarettes and other tobacco products among Air Force trainees.

Methods In a pretest–post-test experiment, 782 Airmen were randomised to view antismoking advertisements in 1 of 6 conditions: anti-industry, health effects+anti-industry, sexual health, secondhand smoke, environment+anti-industry or control. We assessed the effect of different conditions on changes in perceived harm and intentions to use cigarettes, electronic cigarettes, smokeless tobacco, hookah and cigarillos from pretest to post-test with multivariable linear regression models (perceived harm) and zero-inflated Poisson regression model (intentions).

Results Antismoking advertisements increased perceived harm of various tobacco products and reduced intentions to use. Advertisements featuring negative effects of tobacco on health and sexual performance coupled with revealing tobacco industry manipulations had the most consistent pattern of effects on perceived harm and intentions.

Conclusions Antismoking advertisements produced for the general public might also be effective with a young adult military population and could have spillover effects on perceptions of harm and intentions to use other tobacco products besides cigarettes. Existing antismoking advertising may be a cost-effective tool to educate young adults in the military.

  • Advertising and Promotion
  • Media
  • Non-cigarette tobacco products
  • Priority/special populations

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Introduction

Young adults (aged 18–25 years) are a high-risk population for tobacco use. In 2013, they had higher past month tobacco use (37%) than youth aged 12–17 years (7.8%) or those 26 years old and older (25.7%).1 Tobacco companies specifically target this transitional period by positioning tobacco products as accessories to the new life roles and as stress relief for the pressures of new responsibilities.2

Young adults comprise the largest group among US military personnel.3 Tobacco companies have been aggressively targeting military service members4 ,5 since at least World War I, providing free tobacco samples in combat rations during World Wars I and II, the Korean War, the Vietnam War6 ,7 and Operation Desert Storm.8 Owing to ongoing tobacco industry lobbying, as of 2015, tobacco was continuing to be sold in military stores at deep discounts,8–10 despite the US Department of Defense policy that all tobacco products be within 5% of the going market rate.11 Tobacco products are heavily advertised through in-store merchandising and promotions,8 print ads historically placed in publications targeted to the military,12–14 and other creative ways, such as the 1990 Marlboro ‘voice card’4 ,15 recording a personal holiday greeting to soldiers stationed in Saudi Arabia.

Aggressive promotions contribute to smoking rates in the military that are consistently 10% higher than the general population.16 Among branches of service, the Air Force has the lowest rates of cigarette (16.7%), cigar (18.0%) and smokeless tobacco use (13.3%);17 even so, among a sample of Air Force trainees, known as ‘Airmen’ regardless of gender or rank, over one-quarter (26.7%) reported using tobacco prior to enlistment in 2014.18 Among this young group of trainees, cigarettes were the most prevalent tobacco product (11.2%) followed by hookah (10.4%), cigarillos (8.7%), smokeless tobacco (8.6%) and electronic cigarettes (e-cigarettes) (6%).18

Antitobacco media campaigns are effective counters to the tobacco industry's marketing.19 However, most antitobacco media campaigns focus on youth or the general population, and research directly evaluating effectiveness of antitobacco media campaigns on young adults in general and the military population in particular is scarce.13 ,14 ,20 There are content analyses studies that found that military installation newspapers devoted the least space to educating about tobacco use compared with other health topics,13 ,14 but no studies evaluated the effect of these messages.

Another gap in research on the effects of antismoking messages is the lack of information on whether these messages have spillover effects on perceptions of other tobacco products. Most media campaigns focused on cigarette smoking, with a few campaigns including messages about smokeless tobacco,19 but to our knowledge, effects of antismoking messages on perceptions and use of other tobacco products have not been examined. However, declining smoking rates have been accompanied by steady or increasing rates of use of other tobacco products, such as smokeless tobacco, e-cigarettes, hookah and cigarillos among youth and young adults.21–24

Using existing antismoking campaigns to educate military personnel may be a cost-effective approach to tobacco use prevention. We evaluated responses to existing antismoking advertisements with different themes (anti-industry, health effects+anti-industry, sexual health, secondhand smoke and environment+anti-industry) on perceptions of harm of cigarettes and other tobacco products and intentions to use tobacco products in the future among Air Force personnel.

Methods

Materials

We used existing print and video antitobacco advertisements developed by the California Department of Public Health Tobacco Control Program and Rescue Social Change Group (figure 1 and see online supplementary appendix 1). All of these ads have undergone rigorous qualitative and quantitative testing by the respective agency. The California's campaign 25 ,26 has used messages exposing tobacco industry as a manipulative threat to public health in combination with other campaign messages such as the effects of smoking and secondhand smoke. This combination of themes in the existing advertisements made it more difficult to classify messages into mutually exclusive categories. However, there have been calls to avoid categorising antitobacco messages along narrow lines that do not fully capture the blend of thematic approaches used in real-life campaigns.27 Therefore, the advertisements were categorised into five conditions based on the themes used by the California Tobacco Control Program with anti-industry messaging featured in three of them (anti-industry, health effects+anti-industry and environment+anti-industry):

  1. Anti-industry: highlight tobacco industry's use of deception and unethical tactics in order to get rich.

  2. Health effects+anti-industry: focus on negative health effects of tobacco use. (Advertisements in this category also mentioned tobacco industry as the knowing propagator of the ill effects.)

  3. Sexual health effects: portray smoking as a cause of male impotence.

  4. Secondhand smoke: emphasise the negative health effects of secondhand smoke.

  5. Environment+anti-industry: present the negative effects of the tobacco industry on the environment and the cigarette-caused pollution.

Figure 1

Antitobacco advertisements used in the study.

Each condition contained four advertisements with at least one print and one video, but this ratio varied by condition. All advertisements explicitly focused on cigarettes or on tobacco in general; none of the advertisements mentioned or featured any other tobacco products. Participants in the control condition saw four advertisements for bottled water.

Participants and procedure

All active duty Air Force personnel who entered Air Force Technical Training at Joint Base San Antonio-Lackland Air Force Base (AFB)/Ft. Sam Houston in September and October 2014 were offered study participation. Data were collected during orientation week of Technical Training (week 0). Study details, as well as the potential risks and benefits of participation, were described to all Airmen; they were given opportunity to ask questions and decline participation. Consent rate was 98% resulting in 782 participants. All study procedures were reviewed and approved as exempt by the Wilford Hall Ambulatory Surgical Center Institutional Review Board (IRB). No names or other personally identifying information were collected in the study, guaranteeing anonymity.

Four Technical Training squadrons at Joint Base San Antonio-Lackland AFB/Ft. Sam Houston were divided into 19 briefing groups of 30–50 participants, which were randomly assigned to one of five intervention conditions or a control condition (figure 2). All intervention conditions contained Airmen from at least three of the four training squadrons and the control condition covered two out of four squadrons.

Figure 2

Experimental design and procedure. Participants were randomised to one of five antismoking conditions or a control condition. In each condition, participants saw four advertisements. Participants answered questions about perceived harm and intentions to use tobacco products before and after seeing all the advertisements (pretest and post-test). Participants answered questions about perceived advertisement effectiveness after seeing each advertisement.

Each briefing group was seated in a classroom where they completed a pretest questionnaire, watched four ads on a 50-inch flat screen television, completed questions after each ad and then completed a post-test questionnaire. Participation took 45 min. In an actual intervention with a military population, it is likely that ads will be shown under similar conditions, for example, at the beginning or ending of briefings.

Measures

The main outcomes were changes from pretest to post-test in perceived harm and intentions to use for each of the following tobacco products: cigarettes, e-cigarettes, smokeless tobacco (chewing tobacco, snuff), hookah, and cigarillos or little cigars. One question measured perceived harm, ‘Please rate how harmful you think each of these products are?’ with answers on a nine-point Likert scale (1=‘Not at all harmful’ to 9=‘Extremely harmful’). We also asked about perceived harm of secondhand smoke. Intentions to use were measured with two questions, ‘What is the likelihood that you will use these products sometime over the next 12 months?’ and ‘If your friend handed you one of these products when you're first allowed to use tobacco (2.5 weeks into Technical Training), what is the chance you would use it?’ with answers on an 11-point scale (‘0%’ to ‘100%’ chance of use in 10% increments). Perceived harm and intentions to use were measured twice with the same questions before and after exposure to all the advertisements because we wanted to determine the amount of change in the dependent variables attributable to different themes and relative to the control group, for which the pretest was necessary.28 Questions were asked about each tobacco product separately.

Secondary outcomes were evaluations of individual advertisements which are reported in the online supplementary appendix 2, tables S1 and S2.

We asked participants if they have ever used tobacco cigarettes, e-cigarettes, smokeless tobacco, hookah and cigarillos. Current use of tobacco was not measured because tobacco abstinence is strictly enforced during the 8.5 weeks of Basic Military Training that preceded the data collection. We also measured demographics (gender, age, ethnicity, race).

Data analysis

Data were examined for distributional normality prior to any analyses, and appropriate methods described below were applied to normal and skewed outcomes. Randomisation validity was assessed by comparing conditions on demographic characteristics and ever tobacco product use at baseline, using a χ2 test, and multivariable analyses described below controlled for any significant differences found.

Effect of different conditions on changes in perceived harm of tobacco products from pretest to post-test was assessed with multivariable linear analysis of covariance regression models that controlled for pretest perceived harm as well as gender, race, ethnicity and ever use of a product being modelled (eg, when examining perceived harm of hookah we controlled for ever use of hookah). Change in per cent of ‘Don't Know’ responses for perceived harm from pretest to post-test was assessed using exact McNemar's test for paired proportions, overall and by condition.

Intentions of future use outcome were zero-inflated (skewed). We compared zero-inflated negative binomial model with zero-inflated Poisson regression model. Findings were similar due to low overdispersion parameter; therefore, results that are presented are based on zero-inflated Poisson regression model. We applied zero-inflated Poisson regression model to identify determinants of having some intentions to use tobacco products and change in these intentions. In zero-inflated Poisson regression, two models are estimated. First, the Poisson regression portion models change in intentions among participants who have some intentions. Second, the inflation component uses a logit model to estimate the odds of having zero intentions versus having some intentions. In this model, we controlled for the baseline intentions to use along with the same covariates as in the harm model.

Effect of themes on perceived harm and intentions to use relative to control group were considered significant at the α level of 0.01, as an adjustment for five comparisons within each outcome, while other results were considered significant at the α level of 0.05. For pairwise comparisons between themes regarding all outcomes, we applied Bonferroni corrections. All of the analyses were performed with SAS V.9.4.

Results

The 782 consenting participants were randomised to six conditions, 197 (25%) to anti-industry, 138 (18%) to health effects+anti-industry, 110 (14%) to sexual health, 93 (12%) to secondhand smoke, 127 (16%) to environment+anti-industry and 117 (15%) to the control condition (figure 2). Most of the participants were male (72%) and Caucasian (69%). Those of Hispanic decent comprised 17%, African-American (15%) and other race (all other races combined, 16%).

Ever use of cigarettes was reported by 39% of participants, smokeless tobacco by 27%, e-cigarettes by 39%, hookah by 48% and cigarillos by 47%. Ever use of more than one tobacco product was reported by 53% of participants. There were significant differences between conditions for gender and smokeless tobacco use but no differences for race, ethnicity or use of other tobacco products. Per cent of males ranged from 57% to 86% between conditions, and males have higher rates of smokeless tobacco use (34.4% vs 7.7% for females; p<0.001). We controlled for gender differences in our multivariable models.

Advertisements that were shown had been seen by less than 10% of participating Airmen, with the exception of ‘Icons’ advertisement within the health effects condition that was seen at least few or more times by nearly 50% of respondents.

Perceived harm of tobacco products

At pretest, participants rated cigarettes as the most harmful (8.4 on a 1–9-point scale), followed by secondhand smoke (7.7), smokeless tobacco (7.5), cigarillos (7.5), hookah (5.7) and e-cigarettes (5.2). Per cent of ‘Don't Know’ responses at baseline was highest for hookah and e-cigarettes (13% and 9.3%, respectively), while for all other products including secondhand smoke it was under 4%, with cigarettes being lowest at 0.5%. We did not detect any significant changes in the proportion of ‘Don't Know’ responses from pretest to post-test (exact McNemar's test for paired proportions, data not shown).

Perceived harm of cigarettes increased in the health effects+anti-industry condition compared with the control condition (table 1). Perceived harm of smokeless tobacco increased in the health effects+anti-industry and the environment+anti-industry condition. Perceived harm of cigarillos increased in the sexual health condition. Perceived harm of secondhand smoke increased in the secondhand smoke condition. Perceived harm of e-cigarettes and hookah did not change significantly in any condition.

Table 1

Post-test differences in perceived harm of tobacco products between each antitobacco condition and the control condition for various tobacco products

Intentions to use tobacco products in the next 12 months

At baseline, intentions to use were highest for hookah and e-cigarettes (17% and 14% chance of using, respectively), followed by cigarillos (12%), smokeless tobacco (11%) and cigarettes (8% chance). Proportion of participants with zero intentions ranged from 64% (for hookah) to 84% (for cigarettes). All conditions except secondhand smoke were associated with significant decrease in intent to use cigarettes and e-cigarettes relative to the control (table 2). Sexual health condition decreased the intent to use hookah, while both sexual health and secondhand smoke conditions decreased the intent to use cigarillos.

Table 2

Zero-inflated Poisson regression modelling determinants of having zero intentions to use tobacco products and change in intentions to use tobacco products in the next 12 months

Compared with participants who had some intentions to use tobacco products in the next 12 months, participants who had zero intentions were significantly less likely to have ever used the corresponding tobacco product, less likely to be male (for e-cigarettes, smokeless tobacco and cigarillos), more likely to be African-American (smokeless and cigarillos) and less likely to be other race (hookah; table 2).

Intentions to use tobacco products if offered by a friend

At baseline, mean chance of using tobacco products if offered by a friend was highest for hookah (21% chance), followed by e-cigarettes (17% chance), cigarillos (14% chance), smokeless tobacco (10% chance) and cigarettes (8% chance). Proportion of participants with zero intentions ranged from 64% (for hookah) to 85% (for cigarettes). Health effects advertisements decreased intentions to use cigarettes and hookah if offered by a friend compared with control (table 3). Secondhand smoke theme decreased the intentions to use hookah. The health effects theme increased intentions to try cigarillos if offered by a friend. No significant changes were observed for intentions to use e-cigarettes or smokeless tobacco if offered by a friend.

Table 3

Zero-inflated Poisson regression modelling determinants of having zero intentions to use tobacco products and change in intentions to use tobacco products if offered by a friend

Compared with participants who had some intentions to use tobacco products if offered by a friend, participants who had zero intentions were less likely to have ever used the corresponding tobacco product, less likely to be male (e-cigarettes, smokeless and cigarillos) and more likely to be African-American (cigarillos; table 3).

Discussion

To our knowledge, this is the first study of effects of antismoking advertisements on perceptions and intentions to use different tobacco products among young adult military personnel. Antismoking advertisements produced for the general public by the California Tobacco Control Program and Rescue Social Change Group increased perceived harm of smoking and lowered Airmen's intentions to smoke in the future. Advertisements featuring negative effects of tobacco on health and sexual performance had the largest effects on perceived harm and intentions to use across most tobacco products. It is possible that because health effects and sexual health themes also contained anti-industry sentiments (and were, essentially, two-theme messages) that they were particularly effective. Past studies found benefits of using health effects and anti-industry themes concurrently,27 and our study adds evidence to support this finding.

Advertisements discouraging smoking had some spillover effects on perceptions and intentions regarding other tobacco products. After seeing the antismoking advertisements, perceived harm of smokeless tobacco and cigarillos also increased. Likewise, some antismoking advertisements decreased intentions to use other products, specifically e-cigarettes, hookah and cigarillos.

E-cigarettes and hookah are gaining popularity in military population,29 perhaps because of a lack of knowledge and information about danger from these products which is reflected through the reported perceptions of harm (or lack thereof). E-cigarettes are widely advertised as a safer alternative to tobacco30 and are perceived as relatively harmless.31 Antismoking advertisements that do not mention e-cigarettes might not have an effect on perceived harm of e-cigarettes. However, advertisements focusing on deceptive practices and harms inflicted by the tobacco industry and its products reduced intentions to use e-cigarettes in the next 12 months.

Intentions to use tobacco products were measured with two different questions: intentions to use in the next 12 months and intentions to use if offered by a friend. The two different measures for intentions reflect the differences between two immediate antecedents for risk behaviour: behavioural intentions (a reasoned approach) and behavioural willingness (a social reaction approach), or the difference between deliberate and reactive behaviour.32 At pretest, participants had significantly higher intentions to use e-cigarettes, hookah and cigarillos if offered by a friend (behavioural willingness) as compared with intentions to use in the next 12 months (behavioural intentions), similar to findings in other studies.32 Antismoking advertisements had different effects on these measures. Intentions to use in the next 12 months decreased in four conditions for e-cigarettes, in two conditions for cigarillos and in one condition for hookah. However, intentions to use if offered by a friend did not change for e-cigarettes, decreased in two conditions for hookah and actually increased in one condition for cigarillos. It is likely that increases in perceived harm affect the reasoning behind behavioural intentions, and that is why we saw more effects of the ads on both perceived harm and intentions to use products in the next 6 months. This finding highlights the need to measure both behavioural intentions and willingness to use tobacco products. Intentions to use if offered by a friend are more situation-specific and might be more resistant to change than the general intentions. Some research shows that behavioural willingness is a better predictor of actual behaviour for younger adolescents and as they age, behavioural intentions become a stronger predictor.33 ,34 Future studies should examine whether this is also the case with the young adults in the military.

We evaluated changes in behavioural intentions and perceived harm of tobacco products based on exposure to four ads produced by two different agencies and using different media format (video and print) and different creative executions. While we cannot pinpoint the effects of individual ads, our design has higher external validity as campaigns in real-world frequently utilise a variety of media to reach their audiences. A military antitobacco campaign, for example, could show videos to trainees as part of the classroom learning and display print posters in the halls and recreational rooms. Furthermore, our findings on the effects of ads on intentions and perceived harm of tobacco products coupled with ratings of perceived effectiveness of individual ads could guide agencies in creating their own campaigns. For example, if an agency wanted to prevent or reduce the use of hookah by the military trainees, they should consider using advertisements portraying effects of tobacco on sexual health (they decreased intentions to use hookah, table 3). Based on the results in the online supplement material, among the four sexual health ads, participants rated the video ‘Gala event’ highest on various effectiveness measures. Thus, agencies could consider using this video (by requesting the use from the California Department of Public Health) or a similar video (created themselves).

Antitobacco messages produced by the state and local health agencies could be a cost-efficient addition to existing military efforts to kerb tobacco, such as the ‘Quit Tobacco—Make Everyone Proud’ (https://ucanquit2.org/) educational campaign. Advertisements developed for the general population often target some specific at-risk groups, such as advertisements focused on sexual health targeting young men. Because these at-risk groups might also be represented in the military, these ‘general audience’ advertisements might have effects on at least short-term perceptions of harm and intentions to use tobacco products in the military, and future studies should evaluate their effects on tobacco use behaviour.

Limitations of this study include participants coming from only two of the five major training Air Force facilities, which may limit the generalisability to all Air Force trainees or other service branches (Navy, Army, Marines). However, our sample represented about one-third of all Airmen entering technical training in the Air Force for this period, recruited from around the USA. Another limitation is the use of self-report measures, but self-report is commonly used in studies of message effectiveness.19 Our outcome measures were limited to perceived harm and intentions to use various tobacco products. Although both perceived harm35–37 and behavioural intentions38 are frequently used as predictors of and proxies for actual behaviour, future studies should measure long-term effects of media messages on behaviour. Owing to the practicality as well as constraints of intervention delivery in the military setting (group delivery by squadron at set times), group sample sizes were uneven and they differed on gender distribution, but not other demographic characteristics. While this can potentially impact the outcome, we controlled for all demographics in our models to minimise that. The ratio of print to video ads varied by condition, and video messages were perceived to be more powerful than print ads. However, our findings could not be explained by the difference in this ratio. For example, the anti-industry condition with three videos produced fewer significant effects than sexual health condition with only one video.

Similar to the US young adult civilian population, rates of tobacco use in the Air Force are high. Furthermore, the Air Force is the second largest of the service branches (after the Army) in terms of total active duty personnel. Airmen were intervened on at a point early in their military career, which in our case, is deliberate. It is the one time that active duty personnel are both alcohol and tobacco free. Over 100 000 young adults at high risk for tobacco use are tobacco free in the military every year39 and we would posit this is an ideal ‘teachable moment’ to intervene. Still, future studies should replicate and extend our findings in samples of military personnel who have been in service for a longer period of time and in other service branches.

In conclusion, antismoking advertisements produced for general public also were associated with changes in perceptions of harm and intentions to use tobacco products in a military population. Future communication campaigns aimed at decreasing tobacco use in the military should consider using messages featuring negative effects tobacco has on health in general and on sexual health in combination with portraying deception and manipulation by the tobacco industry, and employing video as opposed to print advertisements.

What this paper adds

  • Young adults in general and military personnel in particular are heavily targeted by tobacco companies and subsequently use tobacco at higher rates than the general population.

  • Antitobacco media campaigns have proven effective for counteracting aggressive tobacco marketing in the general population. These antismoking advertisements increase perceptions of harm and reduce intentions to use cigarettes and other tobacco products among Air Force trainees.

  • Advertising using themes of negative effects of tobacco on health and sexual performance combined with anti-industry sentiments were particularly effective at increasing perceived harm and reducing intents to use various tobacco products.

Acknowledgments

This study is a collaborative endeavour between the US Air Force and the University of Tennessee Health Science Center via a Cooperative Research and Development Agreement (11-118-WHMC-CRADA01). The authors gratefully acknowledge the support of 2nd Air Force, the leadership branch for training in the US Air Force, and the 37TRG for allowing us access to their Airmen for use in the study. Additionally, the authors acknowledge Major Daniel Cassidy, PhD, for his thoughtful comments on this manuscript and the California Department of Public Health and Rescue Social Change Group for developing the antismoking advertisements.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors LP, RCK, PML, SAG, MVM and GWT planned the study. BDL led the data collection. ZB conducted data analysis. MAL contributed to data analysis, interpretation and writing. LP wrote the initial draft and submitted the manuscript. All authors contributed to the writing and revision and approved the final version of the manuscript.

  • Funding Research reported in this publication was supported by the National Heart, Lung, and Blood Institute (HL095784, PI: Klesges) and National Cancer Institute of the National Institutes of Health (R01-CA141661, PI: Ling; K99CA187460, PI: Popova; and R01-CA-061021, PI: Glantz).

  • Competing interests None declared.

  • Ethics approval Wilford Hall Ambulatory Surgical Center Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.