Research articleImpact of Smoking Cessation Aids and Mass Media Among Recent Quitters
Introduction
Seventy percent of adults in the United States who are currently smoking want to quit, and approximately 41% annually do make a serious attempt to quit and succeed for at least 1 day.1 Unfortunately, only 4.7% of those who try to quit are able to maintain abstinence for 3 months or more. In order to improve the rate of smoking cessation, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health published a National Action Plan for Tobacco Cessation.2 This comprehensive plan includes six main initiatives with the primary mechanism for promoting cessation being a national telephone quit line, marketed through a national, paid media campaign and including insurance coverage for cessation medications. To date, only the national quit line has been implemented and at a much lower funding level than was recommended. To advance the goal of increasing the cessation rate, it is important to consider which types of assistance will have the greatest impact on the population. The National Action Plan was based on efficacy and effectiveness studies, but as Prochaska and Velicer3 note, finding effective strategies may not be enough. The impact of a particular quitting aid is measured by multiplying the efficacy rate by its participation rate or penetration into the population. This paper explores the rate at which a representative sample of adults who recently quit smoking reported receiving effective help from conventional quitting aids as well as the proportion who report receiving effective help from televised anti-tobacco advertisements.
A recent analysis of the 2000 National Health Interview Survey found that of past-year smokers who had quit for at least 24 hours in the previous year, 21.7% had used some form of pharmacotherapy, and 1.3% percent used some form of behavioral therapy including self-help booklets and formal programs.4 Population access to conventional cessation aids is heavily reliant on cost and availability. Utilization information derived from population surveys in Massachusetts and California, where well-funded statewide tobacco control programs have subsidized costs and increased availability of cessation aids, provides a best-case scenario for the rate at which various forms of assistance are used. Nicotine replacement therapy (NRT) is one of the most frequently chosen cessation aids. Population surveys in the 1990s in Massachusetts5 and California6, 7 report that between 14% and 21% of smokers who made a quit attempt in the previous year used NRT. Self-help materials (i.e., books, pamphlets, and videos) have the next highest rate of penetration at between 10% and 11% (CA and MA). Formal cessation programs demonstrate much lower rates of penetration, attracting between 2% and 4% of individuals making quit attempts.8, 9
Telephone quit lines are highly dependent on mass communication advertising.10 Miller et al.11 report that an estimated 3.6% of smokers called the Australian quit line in 1997–1998. Estimates from a 1998 Massachusetts survey indicate that 4.8% of those making a quit attempt used the telephone quit line.
There is a growing body of research on the efficacy of Internet-based smoking cessation programs,12, 13, 14 but considerably less information available about the percentage of the general population of smokers that has accessed Internet cessation resources. The 2003 Pew Report15 lists that figure at 6% of Internet users. Assuming that some of those users were nonsmokers searching for cessation information for others, and that not all smokers are Internet users, the estimated rate of smokers using Internet cessation resources is likely to be considerably less than 6%.
Unlike the traditional forms of assistance, televised anti-tobacco messages are disseminated to smokers proactively. Consequently, their population penetration rate is vast. In Massachusetts, where a well-funded mass media campaign was in place between 1993 and 2001, more than 80% of smokers surveyed reported having been exposed to anti-tobacco messages on television in the past year.16 The impact of such advertising on Californians who had quit smoking during the early years of that state’s campaign was investigated by Popham et al.,17 who found that 288 of a sample of 417 past-year quitters (69%) said that they had seen or heard the ads, and 143 said that the ads played a role in their decision to quit, for an impact estimate of 34%.
There is a large literature on efficacy and effectiveness of various quit methods18, 19, 20, 21; however, the studies tend to take place in the context of small clinical trials or selected groups and consequently are difficult to generalize to the general population of smokers. The present study is designed to provide information on penetration or utilization as well as impact by relying on reports of a representative sample of individuals who had quit smoking during the previous 2 years and were still abstinent at the time of the survey. The following questions are addressed: (1) What is the penetration or utilization rate of cessation aids including anti-tobacco television advertisements among those in the population who have recently stopped smoking? (2) What is the impact of the various cessation aids, defined as the proportion of quitters who both used an aid and reported that it was helpful? (3) What characterizes the differences among recent quitters helped by conventional cessation resources, those helped by televised anti-tobacco messages only, and those who find no cessation aids helpful? (4) Of the various types of televised messages broadcast, which are perceived as helpful?
During the period covered in the survey, a wide range of quitting aids were available in Massachusetts including more than 130 funded community-based groups providing support, counseling, and subsidized access to NRT products. A smoker’s quit line provided free counseling over the phone, and the website maintained by the same group (www.trytostop.org) provided interested smokers with customized quitting plans.
The media campaign was in process from 1993 to 2001. The goal was to educate Massachusetts residents about the health consequences of smoking, resources to help smokers quit smoking (including the quit line), the danger of secondhand smoke, product content, and tobacco industry practices that promote use.22 In addition to advertisements produced for the Massachusetts Tobacco Control Program, other tobacco-relevant television ads were being broadcast in Massachusetts by the American Legacy Foundation, Philip Morris and Lorillard Tobacco Companies, and the pharmaceutical manufacturers of NRT and Zyban.
Section snippets
Sample
A random-digit-dial telephone survey of Massachusetts adults was conducted between January 2001 and June 2002. After screening interviews in which the household was enumerated, one adult was randomly selected for extended interview. Current smokers, recent quitters, and young adults aged 18 to 30 were over-sampled. Sixty-six percent of households were successfully screened, and interviews were completed with 71% of the eligible respondents for an overall response rate of 47% and a sample size
Sample Characteristics
Two respondents did not respond to the questions about cessation aids and were eliminated from all analyses. Among the remaining 785 respondents, 57% were female, 66% were aged <45 years, 60% had >12 years of education, and 86% were non-Hispanic white. Eighty-five percent had been abstinent for >1 month, and 52% had been abstinent for >6 months. More than a third (36.6%) had been dependent smokers (i.e., smoking ≥20 cigarettes a day and smoked the first cigarette within 30 minutes of waking) in
Discussion and Conclusions
In this population-based study, recent quitters more often cited anti-tobacco television advertisements than conventional cessation aids as sources of help with quitting smoking. Furthermore, television ads that depicted the serious harm done to health in an emotional or graphic way were the ones that were most often recalled as helpful. These findings suggest that television advertising ought to be considered an important component of population-based cessation programs. It is likely to be the
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