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1. Lois Biener,
2. Garth McCallum-Keeler,
3. Amy L Nyman
1. Center for Survey Research, University of Massachusetts, Boston, Massachusetts, USA
1. Lois Biener, PhD, Center for Survey Research, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA 02125, USA;lois.biener{at}umb.edu

## Abstract

OBJECTIVE To assess adults' receptivity to the Massachusetts television anti-tobacco campaign. Reactions were examined as a function of respondents' demographics, baseline tobacco control attitudes, changes in smoking status during the campaign, and advertisements' affective qualities.

DESIGN A random digit dial telephone survey in 1993 at the start of the media campaign and re-interview in 1996 of respondents to the baseline survey.

PARTICIPANTS Respondents were 1544 adults who completed the baseline and follow up interview.

### MEASURES: PREDICTORS

#### Smoking status category at follow up

Following standard definitions, smokers were defined as those who reported that they had smoked at least 100 cigarettes in their life and that they smoked “some days” or “every day” at the time of the interview. Former smokers were those who reported smoking at least 100 cigarettes in their lifetime and now smoked “not at all”. Never smokers were those who reported not having smoked 100 cigarettes in their lifetime. Respondents were assigned to one of three categories according to the change in their smoking status from baseline to follow up: (1) “quitters” were individuals who reported being smokers at baseline and former smokers at follow-up; (2) “continuing smokers” reported being smokers at both baseline and follow up; (3) “continuing non-smokers” were those who reported being former or never smokers at both baseline and follow up. Relapsers and initiators (those who went from being former to current smokers and never to current smokers) were relatively rare, and were omitted from these analyses.

#### Demographic, smoking, and attitudinal characteristics at baseline

Items querying age, sex, marital status, and education level were included on the baseline survey. Respondents' attitudes toward tobacco control were assessed with a series of items on preferred smoking policies for restaurants, public buildings, and sporting events, and a series of items on attitudes toward tobacco promotion and marketing. Attitudes towards these two types of policies tended to be correlated and were combined to form a scale from 2 (low) to 12 (high) indicative of support for tobacco control policies. Smokers were queried about the number of cigarettes they smoked each day, and how “ready” they were to quit (within 30 days, six months, or longer).

In order to obtain independent assessments of ad characteristics, 15 adults were recruited though newspaper advertisements to serve as a panel of judges. The panel of judges included seven women and eight men between the ages of 19 and 64 years (median age 23 years). Three of the 15 judges had completed at least four years of college and the others had no more than a high school education. Twelve of the judges were white and three were from minority groups; six were smokers. In groups of three to five individuals, they were shown the nine TV spots evaluated in the telephone survey. After viewing each ad, the judges filled out rating forms on which they indicated on a scale of 1 to 7 the extent to which they found the presentation sad, frightening, funny, believable, thought provoking, silly, confusing, emotionally moving, entertaining, offensive, phony, reassuring, helpful, and interesting (1 = not at all; 7 = extremely). These scales were the result of several rounds of pre-tests with different groups of judges. The items that were retained were ones that had clear meaning to the judges and appeared to capture the variety of reactions elicited by the group of videos.

Judges' ratings for each spot were used to construct scores on five scales: positive emotions (funny, entertaining) negative emotions (frightening, sad); strength of emotion elicited (emotionally moving); cognitive quality (interesting, thought provoking, believable); and helpfulness (helpful, reassuring). Scale construction proceeded by examining the internal consistency of ratings on selected combinations of adjectives across the spots rated. Items that reduced internal consistency were dropped until the highest score on Cronbach's α was achieved. Scores on the five scales were constructed for each ad by computing for each judge the mean of the ratings on items included in the scale and then computing the mean for the 15 judges.

The resulting scales were not independent of each other. Negative emotion, strength of emotional appeal, and cognitive quality were all positively correlated in the group of ads being rated. Negative emotion and strength of emotional appeal were each negatively correlated with positive emotion. In spite of the intercorrelations among the five scales, we retained them as distinct scores in order to assess their relative importance as predictors of perceived effectiveness among Massachusetts adults. The fact that they were intercorrelated for this particular group of ads does not mean that they would necessarily be correlated in other groups. It is conceivable that an ad could be made that would elicit both negative emotions (for example, illness and suffering) and positive emotions (for example, love and caring). Scores on the five scales for the nine anti-tobacco ads rated by the judges are shown in table 1. The ads are listed in order of their rating on negative emotion (frightening and sad).

Table 1

Mean scale values (95% CI) for nine advertisement as rated by panel of 15 judges

The ratings have a good deal of face validity. The four ads which attained a score of 5 or higher on negative emotion (sad and frightening) all depicted illness and suffering caused by smoking. They all also condemn the tobacco industry, either implicitly or explicitly. The ads scoring highest on positive emotion (funny and entertaining) were designed to be humorous. Strength of emotional appeal was high for all the ads that were high in negative emotion, but was also high for “Cigarette pack” which portrays family love or attachment.

### OUTCOME VARIABLES

#### Exposure

Two different measures of exposure were computed. A three level indicator of exposure (none, less than once per week, at least once per week) was constructed from responses to two questions: whether the respondent had seen any anti-tobacco messages on TV during the past three years and, if so, about how frequently he or she had seen them. To measure recognition, each of the nine ads selected for study was briefly described to the respondent during the follow up interview. After each description, the respondent was asked whether he or she recalled seeing the ad. The recognition score (0 to 9) was the number of ads recognised.

#### Receptivity

Lastly, in addition to assessing respondents' perceptions of the effectiveness of the nine ads as a group, the perceived effectiveness of each individual ad was assessed by computing the average effectiveness rating assigned to it by respondents who recalled seeing it. Three ratings were computed for each ad: one for quitters, one for continuing smokers, and one for continuing non-smokers.

### ANALYSES

The survey data were weighted to account for the original sampling design. Analyses of the relationship between respondent characteristics and reactions to the anti-tobacco campaign (in which the N is based on the number of respondents) were done with the SUDAAN program.19 Bivariate relationships were assessed with either χ2 or least square regression analyses depending on whether the dependent variable was categorical or continuous. Multiple regression analyses were used to assess predictors of perceived effectiveness and number of ads recognised.

Analyses of reactions to particular ads according to smoking status category use the individual ad as the unit of analysis (that is, the N is 9). These analyses are based on Pearson correlations and were done with SPSS.20

## Results

### RESPONSE RATES

Interviewers were unable to trace 40% of the sample. Of the remaining 1990 individuals, interviews were completed with 83% for a final cohort of 1660 and an overall response rate of 50%. The response rate was higher for baseline non-smokers than smokers (52%v 48%). Comparison of baseline characteristics of those who were interviewed and those who were not indicates that the response rate was higher for those with more than a high school education than for those with no post-secondary education (55% v 46%), and those 45 years of age or older rather than under 45 (58% v 46%). Therefore, younger, less educated adults are somewhat under-represented in these analyses. Among respondents who were smokers at baseline, those who were interviewed at follow up were not significantly different from non-interviewees on the number of cigarettes smoked per day, but a greater proportion had indicated at baseline an intention to quit smoking within the coming six months (68.5%v 58%).

One hundred and sixteen individuals were eliminated from these analyses for the following reasons. In 69 cases, the data suggest that the individual interviewed at follow up was not the same person interviewed at baseline. Forty three individuals were relapsers and four were smoking initiators. These individuals were eliminated because there were too few to represent those two smoking status experiences. The resulting sample was comprised of 1544 people who either quit smoking between baseline and follow up, continued to smoke between baseline and follow up, or were non-smokers at baseline and follow up. Table 2 shows the demographic characteristics of the sample and their responses to the anti-tobacco TV campaign according to their smoking status category at follow up.

Table 2

Demographic characteristics and reactions to anti-tobacco TV campaign by outcome smoking status

### OVERALL EXPOSURE AND RECEPTIVITY BY SMOKING STATUS GROUP

There was a high level of exposure to the anti-tobacco TV campaign for the cohort as a whole. Eighty eight per cent reported at least some exposure to the ads; 56% reported seeing them at least once a week (not shown). The three groups differed significantly in exposure, with continuing smokers and quitters reporting higher levels of exposure to anti-tobacco messages on TV and slightly higher levels of recognition for the nine ads queried than non-smokers.

In general, the cohort had a favourable response to the quality of the anti-tobacco ads: almost 60% reported at least one that was particularly good, only 12% reported at least one that was particularly poorly done. The average effectiveness rating was 7.29 on a scale from 0 to 10. Continuing smokers were significantly less likely than the other groups to mention having seen a particularly good ad. On average, non-smokers rated the specific ads they remembered seeing as significantly more effective than did either the quitters or continuing smokers.

### IMPACT OF RESPONDENT CHARACTERISTICS

In order to explore the effects of respondent characteristics on perceived effectiveness of ads, three multiple regression analyses were performed, one for each smoking status group, in which the dependent variable was average perceived effectiveness of all ads recalled and the predictors were demographic characteristics (age, sex, education, marital status), daily smoking rate, and readiness to quit at baseline (for continuing smokers and quitters), and attitude toward tobacco control policies. The results are shown in table 3. Among quitters, the only significant predictors of perceived effectiveness were being unmarried and being supportive of tobacco control policies. The same predictors were significant among continuing smokers. In addition, continuing smokers who were less educated and those at higher levels of readiness to quit at baseline rated the ads more favourably than those who were more educated and less ready to quit. For continuing non-smokers, perceived effectiveness was significantly associated only with attitudes toward tobacco control policies, with those more strongly in favour of tobacco control rating the ads more favourably than those less supportive of tobacco control.

Table 3

Unstandardised regression coefficients for analysis of predictors of perceived effectiveness of TV advertisements

A similar set of analyses was done to examine predictors of the number of ads recognised within each smoking status group. The only significant predictor was age among quitters and continuing smokers. In those groups, younger respondents recognised more of the nine ads than their older counterparts.

### AD CHARACTERISTICS AND PERCEIVED EFFECTIVENESS

Table 4

In order to see whether continuing smokers differed in their responses to ads evoking negative emotions according to their readiness to quit at baseline, we computed for each continuing smoker the average effectiveness rating they assigned to the four ads that judges rated 5 or higher on negative emotion. An average score was computed for all ads recalled for all continuing smokers who recalled seeing at least one of the ads. Multiple regression analysis examined the perceived effectiveness of ads evoking negative emotions as a function of respondents' intentions to quit smoking while controlling for age, sex, education level, and marital status. Results indicated that readiness to quit at baseline was a significant predictor of the perceived effectiveness of the ads evoking high levels of negative emotion (Wald F = 13.63; degrees of freedom = 2; p < 0.0001), with respondents who planned to quit within 30 days rating these ads as more effective than those not planning to quit within six months.

## Discussion

Analyses indicate that, as predicted, the ads were most salient to respondents who were smokers at the start of the campaign. These groups reported higher levels of exposure to anti-tobacco messages on television and recognised significantly more of the nine ads than their non-smoking counterparts. This may be a consequence of heavier television viewing among smokers than non-smokers, but regardless of the underlying cause, the consequence is that the ads are most likely to be seen by an important target audience.

The anti-tobacco ads were seen as more effective by respondents who, at baseline, were more supportive of the goals of tobacco control. Although this finding is consistent with common sense and with theories of cognitive consistency,21 22 it is conceivable that if the anti-tobacco ads were poorly produced, the strongest proponents of the tobacco control programme might be the most critical and disappointed. The fact that fewer continuing smokers than quitters recalled an ad as being “particularly good” may indicate that the ads evoked cognitive dissonance in smokers who were not ready to quit. This is supported by the additional finding that among continuing smokers, those at higher stages of readiness to quit at baseline rated the ads as significantly more effective than those at lower stages of readiness.

There are several important limitations of this study. It could well be argued that the perceived effectiveness is not necessarily related to its actual effectiveness in motivating smoking cessation and increasing support for tobacco control policies. For two reasons, however, we believe that perceived effectiveness is a useful outcome to assess. First, a great deal of consumer research has documented that attitude toward an ad mediates attitude toward the product being advertised.9 27 In the present case, what is being advertised is a general anti-tobacco orientation. It is not unreasonable to consider the findings of consumer research applicable to counter advertising, and to argue that the higher the perceived effectiveness of an anti-tobacco ad, the greater the likelihood that the message is being accepted by the viewer. Second, it is important that a statewide intervention supported by public funds be seen by the public as being effective.

One could also take issue with our use of aided recall. Respondents who indicated recognition of the briefly described ads may have been confusing the ad with another of the many that were shown over the three year period. A better technique would include some check on the accuracy of recall, such as the respondent's ability to relate specific details about the ad.

To our knowledge this is the first study to examine differential reactions to specific anti-tobacco advertisements in a population based sample. Given the expense of mass media campaigns and the increasing reliance on them for tobacco control interventions, continued research on their effectiveness is of great importance. Future research is needed that simultaneously assesses the cognitive (that is, message) and affective characteristics of anti-tobacco ads. Since a great deal of the mass media advertising being produced is aimed at a youth audience, these methods need to be applied to the responses of youth.

## Acknowledgments

This work was supported by grants from the Robert Wood Johnson Foundation, Substance Abuse Policy Research Program (grant 28809), and the Massachusetts Department of Public Health, Massachusetts Tobacco Control Program (Health Protection Fund). The authors are grateful for the helpful comments of Drs June Flora, Michael Siegel, Elizabeth Gilpin and Cornelia Pechmann. We also wish to acknowledge the cooperation of Lisa Unsworth, Anne Miller, Kevin Fay, and Cindy Lovell of Arnold Advertising and Communication who made generous contributions of time and information that were essential to the conduct of this study. G McCallum-Keelor is now located at Applied Marketing Science, Inc, Waltham, Massachusetts.

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