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When smokers enter a smoking cessation programme, their success in quitting depends on their stage of readiness to quit (precontemplation, contemplation, preparation, action, and maintenance). In a study of 570 smokers who were followed over 18 months following treatment, Prochaska and Goldstein1 found that the quit rate was lowest among precontemplators, higher among contemplators, and highest among those prepared for action.
To enhance smokers’ motivation to quit smoking, we designed a gallery of posters showing in a humorous way the different health disorders and damage associated with tobacco smoking. The National Institute of Respiratory Diseases in Mexico City developed the concept behind the campaign and sponsored and funded it. It is targeted to the general population of Mexico.
Nineteen posters were developed by students of graphic design from the National University of Mexico; their work was coordinated by the authors of this essay. Four posters related to cancer, one to chronic obstructive pulmonary disease, six to environmental tobacco smoke exposure, one to osteoporosis, one to periodontal diseases, one to cutaneous lesions, three to vascular and heart diseases, and two to mortality.
To be included in the gallery, the posters had to be witty and visually attractive. Each poster has a legend, a saying, or a proverb referring to a particular disease or risk associated with smoking. In addition, each has an informational statement on the topic with a corresponding scientific citation.
We have offered the poster gallery to as many cultural, scientific, and academic centres (schools, colleges, and universities) as possible. Since the gallery was first distributed in 1997, more than 500 000 people per year have been exposed to it.
Posters on the cover
Four of the posters are shown on the cover of this issue ofTobacco Control. The poster in the upper left corner is about smoking and osteoporosis. The saying in the poster translates literally into English as: “Although you smoke silk, broken you remain.” The meaning of the original saying in Spanish is that even if you wear expensive things, you yourself do not change. Extending this saying to smoking, the meaning is that although you smoke expensive cigarettes, you can get osteoporosis (that is, be broken). The informational statement at the bottom of the poster explains that women who smoke have a greater risk of suffering from osteoporosis.
The poster in the upper right corner addresses otitis media. The saying is: “Stop it!” (“¡Ya Ciérrale!”). The informational statement at the bottom is, “Exposure to tobacco smoke in children is associated with an increase in fluid in the middle ear, known as Otitis Media.” The Tobacco Control citation is to a summary of the report on passive smoking issued by the United States Environmental Protection Agency.2
The eye-catching poster in the lower left corner deals with breast cancer. The saying means: “Smoking can cause you to stop wearing it.” The informational statement at the bottom is, “Exposure to tobacco smoke increases the risk of breast cancer.” An article in theAmerican Journal of Epidemiology is cited as a reference.3
The poster in the lower right corner addresses smoking and cerebrovascular disease. The saying (quite catchy in Spanish) is: “Drop by drop . . . your brain is used up.” The informational statement at the bottom is, “Tobacco use can cause cerebral hemorrhages.” An article is the Archives of Neurology is cited as a reference.4
Most anti-tobacco educational campaigns focus on smoking-attributable diseases that are more well known to the public, such as lung cancer, emphysema, and heart disease. The four posters shown on the cover of this issue, like several other posters in the gallery, focus on associations between smoking and illness that are not so well known. Addressing the large number of diseases related to smoking in the poster gallery helps to keep visitors engaged, through the diversity of messages and the novelty of much of the information provided.
Impact of the campaign
We surveyed a sample of 1177 people visiting the gallery from May 1997 to October 1998, including 20–30 consecutive visitors at each of 45 shows. Subjects were asked about the scientific aspect of the posters and their novelty, as well as the impact of the messages in them. Their impact was measured by asking smokers: “After looking at these posters, would you seriously consider the possibility of quitting smoking?”; and by asking non-smokers: “After looking at these posters, would you consistently recommend to smokers that they quit smoking?”
In this sample, 50% were female and 76% had a high school or university education. Smoking prevalence was 41% among the visitors (the national prevalence of smoking in Mexico is 25%), and there was no significant difference in education between smokers and non-smokers.
Seventy-six per cent of the visitors believed that the messages in the posters were quickly understood, useful, and very good; 22% considered them to be good; and 3% found them to be complicated. Smokers (4%) were more likely than non-smokers (0.3%) to find the messages complicated (odds ratio (OR) = 4.76, 95% confidence interval (CI) = 1.78 to 13.42).
In regards to the novelty of the information in the posters, 22% considered it totally new, 59% not very new, and 19% totally known. There was no significant difference between smokers and non-smokers in their assessment of the newness of the information (OR = 0.96, 95% CI = 0.66 to 1.41).
Eighty-four per cent of the smokers said that, after seeing the gallery, they would seriously consider the possibility of quitting smoking, whereas 95% of the non-smokers said they would recommend more regularly to smokers that they quit.
Our results suggest that this type of campaign may be a good instrument for mass promotion of non-smoking. Independent of smoking status, the message is perceived to be quickly understood, new, and useful. An impressive number of smokers have visited the gallery, which is likely to have increased the desire to quit smoking among many of them. Exposure to the gallery may stimulate a transition from the precontemplation to the contemplation stage, and thus this type of campaign may facilitate the process of quitting smoking.
Two posters from the gallery of posters produced by the National Institute of Respiratory Diseases in Mexico City. The poster on the left deals with heart disease; the statement at the bottom indicates that tobacco use causes cardiovascular disease. The heading “Ojos que no ven, corazón que resiente” comes from a traditional Mexican saying that goes “Ojos que no ven, corazón que no siente”. The literal translation of this saying is “eyes that don’t see, heart that doesn’t feel”. In other words, you don’t have feelings for someone or something that you don’t see (somewhat equivalent to the expression “out of sight, out of mind”). In the poster, the verb in the original saying was changed from “siente” (from sentir, “to feel”) to “resiente” (from resentir, “to suffer”); thus, “heart that doesn’t feel” becomes “heart that suffers”. In the poster on the right, the heading “Te traen entre dientes” means literally that “I’ve got you between my teeth”. The true meaning of this phrase would be something like “I am checking you out” or “I am chewing you up”. The statement at the bottom of the poster indicates that smoking causes tooth stains and weakens the gums. The message of this poster is that, besides the dental problems related to smoking, tobacco can damage your overall health status; in other words, your health is in the hands of tobacco.