Mass Media Communication Strategies

and฀posters.฀This฀2-year฀campaign฀had฀minimal฀success,฀relected฀in฀the฀fact฀that฀a฀high฀ proportion฀ of฀ the฀ key฀ target฀ audience฀ no฀ longer฀ recalled฀ the฀ adverts฀ and฀ only฀ 49฀ believed฀they฀could฀be฀motivated฀to฀quit฀smoking฀by฀these฀campaigns฀ [78,฀82] . • ฀ The฀“Quit฀for฀Life”฀campaign฀used฀TV฀and฀radio฀adverts฀to฀deliver฀messages฀designed฀ to฀encourage฀smoking฀cessation,฀primarily฀with฀practical฀tips฀on฀quitting.฀Despite฀posi- tive฀pre-testing,฀the฀TV฀adverts฀were฀not฀suficiently฀powerful฀to฀stimulate฀smokers฀into฀ taking฀action,฀whereas฀the฀radio฀adverts฀were฀received฀more฀favourably฀ [78,฀82] . • ฀ Running฀ from฀ 1997–1999,฀ the฀ “Testimonials”฀ campaign฀ used฀ older฀ smokers฀ to฀ tell฀ younger฀ smokers฀ about฀ their฀ tobacco-related฀ illnesses฀ in฀ the฀ hope฀ that฀ for฀ younger฀ smokers฀the฀future฀consequences฀of฀smoking฀would฀be฀brought฀into฀a฀more฀immediate฀ time฀ frame.฀ Special฀ TV฀ adverts฀ also฀ drew฀ the฀ attention฀ of฀ female฀ smokers฀ to฀ these฀ problems.฀Surveys฀revealed฀that฀72฀of฀women฀agreed฀that฀the฀adverts฀were฀aimed฀at฀ people฀like฀them฀and฀67฀stated฀that฀the฀adverts฀made฀them฀realise฀the฀possible฀health฀ risks฀of฀smoking.฀The฀adverts฀were฀ineffective฀among฀younger฀16–24-year฀old฀female฀ smokers฀ [78,฀82] . As฀shown฀by฀data฀from฀the฀various฀campaigns฀Table฀ 10.3 ,฀the฀“John฀Cleese฀Campaign”฀ produced฀the฀most฀sustained฀effect฀92฀recognition.฀One฀year฀after฀the฀campaign฀ended,฀ 90฀of฀those฀surveyed฀could฀still฀remember฀it. Smoking฀ cessation฀ programmes฀ using฀ a฀ range฀ of฀ mass฀ media฀ were฀ initiated฀ almost฀ simultaneously฀ in฀ Holland฀ “Quit฀ smoking฀ together”฀ and฀ in฀ the฀ USA฀ Bellingham,฀ Washington:฀ “Broadcast฀ cessation฀ clinics”฀ [83,฀ 84] ;฀ these฀ showed฀ initial฀ successes฀ in฀ terms฀of฀smoking฀cessation,฀with฀the฀combination฀of฀TV฀and฀radio฀proving฀to฀be฀beneicial฀ and฀having฀a฀lasting฀effect฀ [84] . Population฀surveys฀indicate฀that฀the฀combined฀use฀of฀various฀mass฀media฀components฀ TV,฀ radio,฀ billboards,฀ print฀ media,฀ as฀ in฀ the฀ California฀ Tobacco฀ Control฀ Program,฀ is฀ Question Campaign “Cleese”฀ 1992–1995 “Break”฀ 1995–1996 “Quit”฀ 1996–1997 “Testimonial”฀ 1997–1999 Prompted฀awareness฀of฀the฀ campaign 92 54 63 66 “Fed฀up฀with฀seeing฀the฀ adverts” 20–22 16 – – “Encouraged฀me฀to฀think฀ about฀giving฀up” – 50 44 57–60 “More฀conidence฀to฀give฀up” 35 42 49 41 “Made฀me฀feel฀guilty฀about฀ smoking” 42–43 38 38 49–55 “Unfair฀to฀smokers” 20–24 19 23 20–21 Cost฀in฀£฀millions 3,183 2,326 2,484 4,886 Table 10.3 ฀฀฀Results฀reported฀from฀four฀UK฀anti-smoking฀campaigns฀and฀their฀associated฀media฀cost฀ [79–82] –฀Question฀not฀asked;฀Statistics฀from฀various฀surveys advantageous:฀6.7฀of฀those฀surveyed฀quit฀smoking฀as฀a฀result฀of฀media-led฀motivation.฀ Among฀ex-smokers,฀69.1฀conirmed฀awareness฀of฀the฀campaign฀and฀34.3฀subsequently฀ cited฀this฀campaign฀as฀justifying฀their฀decision฀to฀quit฀smoking฀ [85] . As฀shown฀by฀the฀survey฀results฀summarised฀in฀Table฀ 10.4 ,฀only฀a฀very฀limited฀number฀ of฀messages฀communicated฀in฀the฀mass฀media฀have฀a฀positive฀effect,฀and฀this฀needs฀to฀be฀ borne฀in฀mind฀for฀future฀campaigns.฀Quit฀smoking฀TV฀campaigns฀“television฀clinics”฀in฀ the฀USA฀have฀been฀more฀successful฀and฀in฀Texas,฀an฀abstinence฀rate฀of฀22฀has฀even฀been฀ reported฀with฀one฀such฀campaign฀over฀a฀6-week฀period฀ [84] .฀Even฀though฀numerous฀pro- fessional฀groups฀work฀together฀in฀campaigns฀of฀this฀kind,฀the฀role฀of฀the฀physician฀in฀per- sonal฀counselling฀assumes฀high฀importance฀ [86] . Experience฀indicates฀that฀younger฀smokers฀are฀unreachable฀or฀very฀hard฀to฀reach฀with฀ such฀campaigns,฀whereas฀middle-aged฀smokers฀already฀have฀health฀issues฀related฀to฀ciga- rette฀smoking฀and฀also฀express฀a฀desire฀to฀quit฀smoking฀for฀the฀most฀varied฀reasons.฀Elderly฀ smokers฀are฀frequently฀heavily฀dependent:฀they฀are฀aware฀of฀this฀and฀know฀in฀some฀cases฀ that฀they฀already฀have฀major฀health฀problems.฀Left฀to฀their฀own฀devices,฀however,฀they฀are฀ not฀capable฀of฀achieving฀smoking฀cessation.฀This฀is฀where฀medical฀intervention฀comes฀into฀ its฀own,฀with฀extensive฀counselling฀being฀a฀necessary฀prerequisite฀for฀longer-term฀success.฀ For฀ex-smokers฀and฀non-smokers,฀mass฀media฀campaigns฀also฀strengthen฀their฀resolve฀not฀ to฀smoke฀in฀future. Fewer฀than฀10฀of฀the฀numerous฀studies฀6฀out฀of฀63฀satisfy฀the฀criteria฀of฀evidence- based฀medicine฀ [84,฀87] .฀These฀6฀studies฀also฀used฀a฀controlled฀trial฀design.฀Two฀of฀the฀ studies฀underline฀the฀effectiveness฀of฀mass฀media฀campaigns฀also฀in฀terms฀of฀inluencing฀ adolescents.฀On฀the฀one฀hand,฀these฀campaigns฀reach฀several฀tens฀or฀even฀hundreds฀of฀ thousands฀of฀people.฀On฀the฀other฀hand,฀given฀the฀considerable฀levels฀of฀media฀spend฀see฀ Table฀ 10.3 ,฀their฀effectiveness฀in฀terms฀of฀achieving฀smoking฀cessation฀is฀low฀to฀moderate,฀ as฀also฀shown฀by฀numerous฀studies฀in฀other฀countries.฀Mass฀media฀campaigns฀have฀been฀ conducted฀in฀Holland฀ [83,฀88] ,฀California฀ [83,฀89] ,฀Switzerland฀ [90] ,฀the฀UK฀ [91] ,฀and฀in฀ California฀with฀a฀centralised฀telephone฀counselling฀service฀ [92] ,฀in฀Chicago฀with฀a฀media- based฀workplace฀smoking฀cessation฀programme฀ [93] ฀and฀in฀Australia฀with฀a฀directly฀mailed฀ smoking฀cessation฀intervention฀ [94] .฀The฀results฀of฀the฀studies฀were฀generally฀not฀very฀ encouraging,฀a฀inding฀revealed฀by฀the฀analysis฀performed฀by฀the฀Cochrane฀Group฀ [87,฀95] .฀ Message฀content Adolescents Adults Tobacco฀industry฀manipulation ++ ++ Passive฀smoking ++ ++ Nicotine฀as฀a฀powerful฀addictive฀substance + + Reasons฀for฀and฀information฀on฀quitting฀ smoking ± + Easy฀youth฀access฀to฀cigarettes −− – Short-term฀negative฀effects − −− Long-term฀health฀effects −− – Romantic฀rejection −− −− Table 10.4 ฀฀฀Assumed฀effectiveness฀of฀various฀mass฀media฀messages฀ [95] :฀survey฀of฀1,500฀adolescents฀ and฀adults฀in฀California,฀Michigan฀and฀Massachusetts ++฀Very฀effective;฀+฀effective;฀±฀uncertain;฀–฀minimally฀effective;฀−−฀not฀effective Thought฀also฀needs฀to฀be฀given฀to฀the฀messages฀communicated฀during฀these฀campaigns฀ because฀these฀determine฀success฀to฀a฀considerable฀extent฀in฀terms฀of฀motivating฀people฀to฀ quit฀smoking฀or฀to฀think฀about฀doing฀so.฀Several฀campaigns฀frequently฀failed฀to฀reach฀2฀ of฀the฀target฀audience,฀while฀others฀reached฀up฀to฀10฀ [96] .฀In฀this฀context,฀the฀determining฀ factors฀were฀found฀to฀be฀the฀type฀of฀programme฀and฀the฀programme฀sponsor,฀as฀well฀as฀the฀ type฀of฀communication฀channel฀used฀including฀TV,฀radio฀and฀the฀segmentation฀of฀the฀ message฀by฀stage฀of฀change.฀In฀one฀campaign,฀the฀telephone฀was฀identiied฀as฀being฀a฀par- ticularly฀ important฀ recruitment฀ channel:฀ the฀ number฀ of฀ smokers฀ recruited฀ was฀ clearly฀ higher฀with฀the฀telephone฀than฀with฀passive฀recruitment฀strategies฀42.5฀vs.฀10฀ [96] .

10.9 Hypnosis

Hypnosis฀is฀a฀suggestive฀technique฀that฀aims฀to฀overcome฀short-term฀withdrawal฀symp- toms฀and฀to฀cancel฀out฀the฀cues฀for฀smoking.฀Hypnotherapy฀lacks฀any฀capacity฀to฀prevent฀ relapse฀and฀is฀of฀no฀consequence฀in฀coping฀with฀cravings. Hypnotherapy฀was฀investigated฀in฀10฀studies,฀but฀none฀of฀them฀measured฀biochemical฀ markers฀nicotine,฀cotinine,฀CO,฀etc.,฀with฀the฀result฀that฀success฀rates฀self-reported฀by฀ ex-smokers฀in฀many฀cases฀the฀information฀was฀elicited฀only฀over฀the฀telephone฀should฀be฀ categorised฀as฀uncertain฀ [27] . In฀ addition,฀ the฀ studies฀ differ฀ quite฀ considerably฀ in฀ terms฀ of฀ design฀ [97–99] .฀ Older฀ uncontrolled฀studies฀have฀also฀repeatedly฀reported฀abstinence฀success฀rates฀as฀high฀as฀50฀ over฀6–12฀months,฀but฀here฀too฀no฀biochemical฀markers฀were฀included. Over฀a฀follow-up฀observation฀period฀of฀6฀months,฀hypnotherapy฀to฀promote฀smoking฀ cessation฀did฀not฀prove฀more฀effective฀than฀programmes฀without฀interventions.฀Studies฀ reporting฀higher฀success฀rates฀for฀hypnotherapy,฀compared฀with฀no฀intervention฀groups,฀ displayed฀methodological฀defects,฀particularly฀since฀the฀effects฀of฀hypnotherapy฀may฀be฀ quite฀non-speciic:฀overall,฀the฀assessment฀of฀such฀studies฀is฀complicated฀by฀the฀heteroge- neity฀of฀the฀results฀Table฀ 10.2 ฀ [77] .฀The฀highly฀signiicant฀effects฀reported฀for฀hypno- therapy฀in฀an฀earlier฀study฀are฀due฀to฀the฀absence฀of฀a฀control฀group฀ [100] .

10.10 Acupuncture

In฀a฀review฀of฀18฀studies฀of฀the฀eficacy฀of฀acupuncture,฀only฀one฀showed฀a฀signiicant฀ effect฀after฀12฀months฀OR฀=฀2.44;฀CI:฀1.15–5.20฀ [101] .฀In฀a฀comparison฀of฀18฀studies฀ using฀hard฀criteria,฀acupuncture฀was฀not฀superior฀to฀sham฀acupuncture฀in฀terms฀of฀achiev- ing฀smoking฀cessation฀OR฀=฀1.22;฀CI:฀0.99–1.49฀after฀a฀few฀days;฀OR฀=฀1.38;฀CI:฀0.90– 2.11฀after฀6฀months;฀and฀OR฀=฀1.02;฀CI:฀0.72–1.43฀after฀12฀months฀ [102–105] .฀Also,฀in฀a฀ comparison฀with฀other฀smoking฀cessation฀methods,฀the฀odds฀ratios฀were฀similar฀OR฀=฀ 0.80–1.05฀for฀the฀best฀and฀worst฀results.฀Comparison฀of฀acupuncture฀with฀other฀interven- tions฀for฀promoting฀smoking฀cessation฀did฀not฀reveal฀differences฀in฀outcome฀at฀any฀time฀ point.฀Acupuncture฀appeared฀to฀be฀superior฀to฀no฀intervention฀in฀terms฀of฀early฀results฀ OR฀=฀5.88;฀CI:฀2.66–13.01,฀but฀this฀effect฀could฀not฀be฀conirmed฀after฀6-months฀OR฀=฀0.99;฀ CI:฀ 0.30–3.24฀ Table฀ 10.2 ฀ [106] .฀ Differences฀ in฀ acupuncture฀ technique฀ auricular฀ vs.฀ other฀body฀location฀also฀had฀no฀effect฀on฀success฀rates.฀It฀remains฀to฀be฀seen฀whether฀ acupuncture฀is฀useful฀during฀the฀acute฀withdrawal฀phase฀ [104] .

10.11 Reduced Smoking

Gradual฀ reduction฀ of฀ the฀ nicotine฀ dose฀ administered฀ in฀ cigarettes฀ has฀ been฀ tested฀ as฀ a฀ method฀of฀promoting฀smoking฀cessation.฀These฀studies฀were฀designed฀to฀investigate฀the฀ following: 1.฀ Different฀ilter฀sizes฀to฀reduce฀the฀absorbed฀nicotine฀dose 2.฀ Cigarettes฀with฀differing฀nicotine฀yields 3.฀ Gradual฀daily฀reduction฀in฀cigarette฀consumption฀ [100,฀107–109] The฀ statistically฀ non-signiicant฀ success฀ rate฀ associated฀ with฀ this฀ technique฀ was฀ 5฀ 2–11฀on฀average.฀Methods฀based฀on฀smokers’฀intentions฀to฀quit฀smoking฀by฀a฀gradual฀ reduction฀ in฀ consumption฀ or฀ other฀ related฀ techniques฀ e.g.฀ using฀ ilter฀ tips฀ of฀ differing฀ lengths฀are฀unusable฀and฀should฀be฀discarded.

10.12 Pregnancy

As฀is฀evident฀from฀the฀data฀reviewed฀in฀ Chap.฀9 ,฀pregnant฀women฀who฀smoke฀run฀a฀con- siderable฀risk฀for฀their฀children฀–฀and฀this฀risk฀increases฀as฀a฀function฀of฀the฀number฀of฀ cigarettes฀smoked฀daily.฀Since฀women฀ideally฀should฀not฀receive฀any฀medication฀during฀ pregnancy,฀numerous฀smoking฀cessation฀programmes฀have฀been฀designed,฀based฀solely฀on฀ the฀provision฀of฀counselling฀to฀women.฀Data฀obtained฀in฀37฀trials฀including฀16,916฀women฀ offer฀grounds฀for฀optimism:฀a฀signiicant฀reduction฀in฀smoking฀smoking฀cessation฀was฀ achieved฀by฀medical฀counselling฀in฀34฀studies฀OR฀=฀0.53;฀CI:฀0.47–0.60฀and฀the฀percent- age฀of฀women฀continuing฀to฀smoke฀was฀lowered฀by฀6.4฀ [105] .฀In฀8฀studies฀with฀validated฀ smoking฀cessation,฀high-intensity฀counselling฀and฀very฀stringent฀assessment฀criteria,฀the฀ percentage฀of฀women฀continuing฀to฀smoke฀fell฀by฀8.1฀OR฀=฀0.53;฀CI:฀0.44–0.63฀ [105] .฀ The฀subset฀of฀trials฀with฀information฀on฀fetal฀outcome฀revealed฀reductions฀in฀low฀birth฀ weight฀OR฀=฀0.80;฀CI:฀0.67–0.95฀and฀preterm฀births฀OR฀=฀0.83;฀CI:฀0.69–0.99฀and฀an฀ increase฀in฀mean฀birth฀weight฀of฀28฀g฀9–49฀g.฀Ultimately,฀therefore,฀these฀techniques฀may฀ be฀regarded฀as฀useful฀for฀reducing฀perinatal฀mortality฀ [110] . Counselling฀ guidelines฀ for฀ use฀ in฀ gynaecological฀ practice฀ have฀ been฀ published฀ in฀ Germany,฀providing฀advice฀to฀pregnant฀women฀and฀indicating฀where฀additional฀information฀ can฀be฀purchased฀ [23] .