Evidence on Mass Marketing’s Effectiveness in Preventing Smoking in Children and Young People

One of the pieces of public health guidance that NICE are currently developing is about preventing the uptake of smoking by young people.

They have now published the review of the evidence, which looks at the effectiveness of mass media and point of sales measures in achieving that aim. I’ll focus on the findings in relation to marketing campaigns, and given the restraints on my time I’ll caveat what I put here by admitting I’ve only been able to skim the report which as you’ll see a 193 page document.

The report starts by saying:

There is evidence that mass media campaigns can prevent the uptake of smoking and also influence knowledge, attitudes and intentions of children and young people.

But, as you’d expect, some mass media interventions are more effective than others. In particular they find that:

adolescents perceive tobacco industry sponsored advertisements less favourably and as less effective (i.e. participants rated these ads as less convincing and less helpful in keeping friends from smoking and starting smoking) in reducing smoking (specifically, fewer people taking up smoking based on the following outcome measures: intention to smoke, curiosity of tobacco use, tobacco industry sympathy) than other smoking prevention advertisements, but also express greater sympathy with the tobacco companies after viewing their advertisements. Yet, neither the industry sponsored nor other prevention ads changed adolescent’s intention to smoke.

Turning to messages, which they say can influence effectiveness they point to a UK qualitative study (it’s behind a pay-per-view wall) which found:

that social norms messages were more effective than fear messages at encouraging more committed smokers to consider their smoking behaviours and reinforcing awareness of the dangers of smoking in less committed smokers

Given that this is one of the only UK based pieces of evidence about the impact of marketing campaigns that the reviewers refer to I thought it would be helpful to give you the full paragraph they devote to its findings later in the report:

Devlin and co-workers ( 2007) conducted a UK based qualitative study using focus groups that explored young people’s responses to different types of message appeal. The three appeals compared were “fear appeals,” “social norms,” and “industry manipulation.” In terms of fear appeals ads, interviewees did not see themselves as targets of these messages and, as a consequence, did not feel it necessary to respond to these threats. In terms of social norms ads, many interviewees said that the advertisements spoke to them at their level and were realistic in terms of social pressure without preaching or telling them what to do. Actors that were slightly older than the target audience also were more effective. In terms of industry manipulation ads, many respondents found them attractive, slick, and sophisticated; however many rejected the idea that the industry might be manipulating their own behaviour by encouraging them to smoke or to smoke certain brands. Using a qualitative research design, the authors concluded that no single anti-smoking message appeal is likely to have universal appeal and that young people’s responses to message appeals are mediated by the values they attach to smoking.

The lack of UK research is something the report returns to later:

none of the key informants were aware of any evidence published in the UK that specifically describes interventions that are effective in delaying the onset of smoking. However, Gerard Hastings (University of Stirling) and Lawrence Moore (University of Cardiff) indicated that some school-based campaigns may have a role to play in postponing the uptake of smoking. Amanda Sandford (ASH) pointed out that delaying the onset of smoking is important because the long-term health damage from smoking is much more severe the younger the uptake occurs; someone who begins smoking at 12-13 years of age is much more likely to develop a smoking related disease in later life than someone who starts smoking at 16 or 17 years of age, for example.

As well as looking at published research it seems that the researchers have spoken to a number of academics and anti-tobacco campaigners. And their views are interesting. The report takes a look at developing mass media campaigns working with young people, which receives a positive response from the people they’ve spoken with:

Gerard Hastings (University of Stirling) also discussed the importance of collaborating with youth when developing mass media interventions. He thought the Florida “Truth” campaign was one of the best examples of a well-evaluated mass media intervention to prevent smoking uptake. The campaign was successful because it was youth endorsed, lead and driven. Young people acted as youth ambassadors for the anti-smoking promotion. Extensive preparation also contributed to the campaign’s success. The programme developers engaged youth leaders and undertook a comprehensive educational campaign on the activities and influence of the tobacco industry, through a series of weekend workshops. Both Karen Gutierrez (tobacco control) and Ruth Bosworth (QUIT) also argued that interventions must ideally be tested and refined with young people. When developing the recent webfilms, for example, Quit tested ideas and the formats with focus groups of boys and girls, via their school-based work. This is an approach they’ve also used for past media interventions.

Social norms also receive positive feedback from the academics:

Gerard Hastings (University of Stirling) believed that campaigns employing a social norms approach could be useful for denormalising smoking among youth. Good social norms campaigns reach beyond mass media by: educating youth about the actual activities of the tobacco industry, condemning/revealing the activities of the tobacco industry, restricting point of sales, and dealing with packaging/branding issues.

Another interviewee points to Health Scotland’s ‘Think About It’ campaign, which:

were not expected to have immediate impacts on young people’s behaviour but rather to engage them in reflecting on their attitudes and behaviours, and to support face-to-face prevention work in other settings such as schools.

There seems to be broad agreement that mass media marketing works best when also supported by other interventions, such as by schools or other education settings, but there are words of caution about expecting too much:

Hein de Vries (Maastrict University) and Martin Raymond (Cloudline) both highlighted that there is a lack of evidence indicating that mass media interventions alone lead to behaviour change. Martin Raymond (Cloudline) argued that this would not only be difficult to measure, but behavioural change is often not an appropriate or realistic goal for youth campaigns. Hein de Vries stated that where there is evidence, the effect sizes are very small. In particular, there is little or no evidence that mass media interventions are effective in changing self-efficacy or goal-setting behaviour amongst young people. Hein) argued that both are needed if a decision not to smoke (or to quit) is made. Furthermore, he felt that very few studies have focused on the ‘intention-behaviour’ gap. Hein noted that it is often easier to ask young people what they think of a campaign rather than measure its effect on behaviour. Finally, he argued that published evidence about the effectiveness of mass media interventions alone suffers from the ‘attribution’ problem. In other words, it is difficult to demonstrate that the campaign was what changed people’s behaviour, especially when many studies have not use a controlled design.

They also discuss whether schools are good setting to deliver tobacco prevention initiatives:

Hein commented that schools are a good setting for prevention efforts because large numbers of youth can be reached. However, it was recognised that delivering prevention messages in schools can be difficult since they often compete with other topics. Furthermore, some schools and/or teachers may not be keen to deliver prevention campaigns. Alternatively, schools can still be a good access point to get information home to parents and families. For example, accessing address details through schools enables researchers/agencies to send children a personal letter about a prevention campaign.

There is, as I’m sure you’ll appreciate, a lot more in the document which I’m sure will repay close study, but I’ll leave you with the conclusion that the researchers draw from their work:

Findings from this review suggest that when interventions are implemented in a comprehensive, multi-component manner, they can influence children and young people. As highlighted throughout the review, interventions may positively change the anti-tobacco attitudes, beliefs, intentions and behaviours of young people. However, a variety of factors can influence effectiveness including the way that an intervention is delivered, the person who is delivering the intervention, and the site/setting of the intervention. It is also important to note that not all interventions impact all young people in the same way. The effectiveness of both mass media and access restriction interventions can be affected by age, sex, and diversity. Finally, while there is a body of literature examining both mass media and access restriction interventions to prevent the uptake of smoking in children and youth, there is a lack of information (particularly UK based) regarding specific research questions. There is also limited evidence regarding the impact of access restrictions on smoking behaviours. As a result, it has not been possible to determine to what extent, the findings of this review are directly applicable to the UK.

Filed under: NICE, tobacco , Interventions to Prevent the Uptake of Smoking in Child, NICE