Tobacco Control
The Impact of a National Tobacco Education Campaign on State-Specific Quitline Calls
American Journal of Health Promotion 2016, Vol. 30(5) 374-381 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890117116646344 ajhp.sagepub.com
Lei Zhang, PhD1, Ann Malarcher, PhD1, Steve Babb, MPH1, Nathan Mann, BA2, Kevin Davis, MS2, Kelsey Campbell, BS2, Gillian Schauer, MPH1, Robert Alexander, PhD1, Karen Debrot, DrPH1, and Robert Rodes, MS1
Abstract Purpose: The ads from the first federally funded national tobacco education campaign, Tips From Former Smokers (Tips), considerably increased quitline calls nationwide. This study evaluates the effect of Tips on state-specific quitline calls. Design: Precampaign, during-campaign, and postcampaign comparison; regression modeling. Setting: All fifty states as well as the District of Columbia. Subjects: Calls to state quitlines. Intervention: Tips. Measures: Tips campaign exposure was measured by gross rating points (GRPs). Calls to quitline’s 1-800-QUIT-NOW were assigned to markets in each state based on their area codes. Analysis: Multivariate regression was used to assess the relationship between calls to state quitlines and media market-level Tips GRPs, while controlling for market and area code characteristics. Results: Nationally, every 100 Tips GRPs per week at the market level was associated with an average of 45 additional quitline calls in each area code (b ¼ 44.65, p < .001). Tips GRPs were associated with significant increases in quitline calls in 46 states and the District of Columbia, of which 11 experienced effects significantly larger than the national average and 5 experienced significantly smaller effects. We were unable to detect statistically significant effects of GRPs on call volumes for four states. Graphically, call volumes in those states followed Tips GRPs. Conclusion: The Tips campaign significantly increased calls to quitlines for almost all the states. These findings underscore the effectiveness of national tobacco media campaigns for reaching state audiences. Keywords tobacco control, quitline, mass media campaign, state, prevention research
Introduction Evidence-based mass media antismoking campaigns are successful in increasing cessation and use of available cessation services such as quitlines and decreasing the prevalence of tobacco use.1,2 Campaigns featuring hard-hitting, emotionally evocative ads that use graphic images and personal testimonials showing the health effects of smoking are especially effective in motivating smokers to quit.3-6 Media campaigns that include a tobacco quitline number are also effective at motivating smokers to call telephone quitlines for help with quitting.1,7,8 Quitlines are telephone-based tobacco cessation services that help tobacco users quit. Services offered by quitlines include coaching and counseling, referrals, mailed materials, training to health care providers, Web-based services, and, in
some instances, free medications such as nicotine replacement therapy.9 Quitlines increase the odds of quitting smoking when compared to minimal interventions, self-help, or no counseling.10 In the United States, quitlines exist in all 50 states, the
1
Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA 2 RTI International, Research Triangle Park, NC, USA Corresponding Author: Lei Zhang, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop F79, Atlanta, GA 30341, USA. Email:
[email protected]
Zhang et al. District of Columbia, Guam, and Puerto Rico. The National Network of Tobacco Cessation Quitlines, with its number 1-800-QUIT-NOW, serves as a national portal, routing calls to the callers’ state quitline providers.11 Currently, quitlines reach only 1% to 2% of all U.S. smokers.12,13 Hence, the success of quitlines in reducing tobacco use at the population level largely depends on promoting their use. During March 19 through June 10, 2012, the Centers for Disease Control and Prevention (CDC) aired Tips From Former Smokers (Tips), the first federally funded, nationwide, paidmedia tobacco education campaign in the United States. The Tips campaign featured former smokers talking about their experiences and their families’ experiences living with diseases caused by smoking and secondhand smoke exposure.1,14 The campaign was intended to encourage adult smokers to quit and to inform them that free help was available from the national telephone quitline portal, 1-800-QUIT-NOW, or the National Cancer Institute (NCI) Web site (http://www.smokefree.gov) if they wanted assistance with quitting. Approximately one-third of the campaign’s television ads were tagged with 1-800QUIT-NOW; the remaining ads were tagged with NCI’s Web site. Although cable television was the primary media channel for the campaign, Tips advertising appeared on radio (limited to 17 select local markets), digital video, online banners, and print. CDC also made Tips ads available to states via the CDC Media Campaign Resource Center (MCRC).15 MCRC provides access to CDC-licensed ads that have been developed by state health departments, nonprofit health organizations, and federal agencies (including Tips ads), and also provides resources for finding, learning about, and ordering CDC-licensed countertobacco advertisements. Nine states, covering 12 total media markets, aired additional Tips ads from the MCRC using their own advertising budgets. Recent studies found that calls to 1-800-QUIT-NOW substantially increased during the 2012 Tips campaign, and that the 2012 Tips campaign had a demonstrated effect on increased quit attempts among cigarette smokers.7,14 Specifically, calls to the portal from the 50 states and the District of Columbia increased by 132% during the Tips campaign compared to the same 12-week period in 2011.7 An estimated 1.6 million cigarette smokers attempted to quit smoking because of the campaign and more than 100,000 of them would likely quit smoking permanently.14 Although there was a substantial impact on overall 1-800-QUIT-NOW calls nationwide, no studies have examined whether the magnitude of this impact varied across states. Variations could occur because of statespecific differences in Tips campaign delivery, differences in residents’ exposure to Tips ads across states, or differences in other state characteristics (e.g., other state tobacco control programs and state smoking prevalence). Additionally, some state tobacco control programs may have run their own paid tobacco education media, including additional state placements of ads from the CDC MCRC, during the Tips campaign. The purpose of this study is to extend the preliminary evidence on the 2012 Tips campaign’s impact on nationwide quitline call volume by assessing the impact of the Tips campaign on quitline call
375 volumes at the state level and identifying groups of states where the campaign’s impact was below, at, or above the national average. We also discuss the potential benefits of using additional state-supplemented advertising in states where the Tips campaign did not have a significant impact on call volumes. Results from this study will be helpful to state governments when considering their own advertising efforts during a national tobacco education campaign.
Methods Data and Measures Quitline call volume data from all 50 states as well as the District of Columbia were collected from 4 weeks prior to 4 weeks after the 2012 Tips campaign (February 20 through July 8, 2012). The main outcome measure, state quitline call volume, was collected from NCI’s national quitline portal, 1-800-QUIT-NOW. Calls were assigned to specific designated market areas (DMAs) within each state, based on their area code origin. DMAs are geographic units made up of contiguous counties that define the 210 major television markets in the United States. Because the penetration of cable television networks on which the Tips campaign advertised varies across markets, DMAs represent the primary source of geographic variation in Tips advertising levels. These data did not include calls to telephone numbers other than 1-800-QUIT-NOW that some state quitlines use as their primary/secondary number. We measured exposure to the 2012 Tips campaign using weekly television gross rating points (GRPs) in each DMA. GRPs are an industry-standard measure of the relative ‘‘dose’’ of advertising delivered to a specific audience (e.g., general adults) in a given DMA over a given period of time. They are defined as the product of reach (i.e., the proportion of the audience that is exposed to a given advertisement) and frequency (i.e., the number of times the audience is exposed to an advertisement) during a given period of time.1 For example, if 50% of a television audience in a given media market is exposed to Tips ads three times in a week, the television GRP for that week in that market equals 150 (50 3). GRPs have been utilized as a measure of antismoking campaign exposure in multiple evaluations of tobacco prevention campaigns.5,6,16 Calls were totaled by week and area code, and then assigned to their corresponding DMA and state. In instances where an area code overlapped multiple DMAs, we assigned the area code to the DMA that contained the largest proportion of the area code’s adult population.
Analysis We first summarized average weekly calls to the quitlines, nationally and by state, for the 4 weeks preceding, the 12 weeks during, and the 4 weeks following the 2012 Tips campaign. GRPs were weighted using a DMA-level estimate of total homes that had televisions. We then performed multivariate linear regression models that estimated area code-level weekly
376 calls to 1-800-QUIT-NOW as a function of DMA-level weekly television GRPs (in hundreds), Spanish-language television GRPs (in hundreds), radio GRPs (in hundreds), and GRPs (in hundreds) for ads that were purchased via MCRC and placed by states. Each model also included control variables for DMA and area code characteristics, including the area code population measured in hundreds of thousands of persons; percentages of the DMA population that were non-Hispanic black or Hispanic; percentage of the DMA population that had a bachelor’s degree or higher; and the median annual household income in tens of thousands within the DMA. We also controlled for DMA-level adult smoking prevalence in 2012, which was derived by aggregating recently published17 county-level estimates of smoking prevalence to the DMA level, weighted by county population. We included a time trend variable to capture secular trends in call volume that may have occurred independent of Tips GRPs and other covariates in the model. Because of small population sizes in some states and the corresponding low absolute call volume, some of the area code- or DMA-level control variables were omitted because of multicollinearity. For the national model, we included dichotomous indicator variables for each state to account for fixed differences in call volume across states and other unobserved potential state-level influences on call volume, such as state-level cigarette taxes and tobacco control policies (e.g., smoke-free laws). We also computed elasticities for the GRP variable, which yield the percentage change in calls for a given percentage change in GRPs. For example, if the GRP elasticity is .2, this indicates that a 10% increase in advertising GRPs would lead to a 2% increase in weekly calls. For each state where a significant 2012 Tips campaign effect was demonstrated, we tested whether this effect was larger or smaller than the overall national effect that was observed. This was done by reestimating the national fixed-effects model with an additional variable for the interaction between 2012 Tips GRPs and the state of interest. This interaction provides a test of whether the 2012 Tips GRP effect on calls was significantly greater (or smaller) in that state than the average effect of Tips nationally. To simplify the interpretation of this interaction and avoid multicollinearity, separate models were estimated with each state-GRP interaction of interest as opposed to using a single model with all state-GRP interactions entered into the model simultaneously. For states where there were significant main effects of GRPs, we also performed postestimation predictions to estimate what the quitline call volume would have been in that state in the absence of the 2012 Tips campaign.
Results Summary of Calls by State Table 1 summarizes national and state average weekly quitline calls per market, average weekly Tips GRPs per market, and the number of media markets airing Tips campaign GRPs in each state. All state quitlines experienced a marked increase in calls during the Tips campaign from their precampaign weeks.
American Journal of Health Promotion 30(5) Quitline calls decreased soon after the campaign ended in all but one state (Oklahoma). Compared with the period of the Tips campaign, Oklahoma experienced a 13% increase in average weekly quitline calls to the quitline during the 4 weeks after the Tips campaign. The Tips campaign aired via radio in 14 states, and 9 states (Alaska, California, Minnesota, North Carolina, North Dakota, South Carolina, South Dakota, Utah, and Vermont) aired additional placements of Tips TV ads via MCRC in their local markets using state funds during the Tips campaign (Table 1).
Relations Between Calls and GRPs Our multivariate models showed that nationally, an increase of 100 additional Tips GRPs per week at the market level was associated with 45 additional quitline calls per week in an average area code (b ¼ 44.65, p < .001) (Table 2). The 2012 Tips GRPs were associated with significant increases in quitline call volume in 47 out of the 50 states and the District of Columbia. Call volumes were not significantly associated with the 2012 Tips campaign GRPs in four states: Massachusetts, North Dakota, Oklahoma, and West Virginia (Table 2). Across all states where the 2012 Tips campaign had significant effects on calls, Minnesota had the lowest increases in calls per week per area code (b ¼ 10.42, p < .001) and South Carolina demonstrated the highest increases in calls per week per area code (b ¼ 207.55, p < .001) (Table 2). Georgia had the highest elasticity (.53) among all states with significant coefficients, suggesting that a 10% increase in GRPs increased calls to Georgia’s quitline by slightly more than 5%. Vermont and Montana had the lowest elasticities (.13) of all the states where significant campaign effects were observed. We performed postestimation predictions of what the total call volume would have been in the absence of the 2012 Tips campaign for states that had significant main effects of GRPs (Table 2). We found that South Dakota had the lowest total number of campaign-attributable calls (N ¼ 245), whereas Texas had the highest total number of quitline calls attributable to the Tips campaign (N ¼ 13,071).
State and National Comparison Table 2 also shows that for each state where a significant 2012 Tips campaign effect was demonstrated, we tested whether this effect was larger or smaller than the overall national effect. Of the 47 states with significant GRP effects, the effects of GRPs on call volume were significantly larger than the average national effect in 11 states (Alabama, Arkansas, District of Columbia, Georgia, Maryland, Mississippi, New Mexico, North Carolina, Oregon, South Carolina, and Texas), and five states (Iowa, Kansas, Michigan, Minnesota, and Wisconsin) experienced Tips GRP effects that were significantly smaller than the national average effect. The effects of GRPs on quitline call volumes were not significantly different than the national average for 31 states.
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Table 1. Summary of Tips Campaign GRPs, State Quitline Call Volumes, and Number of Media Markets Airing Campaign GRPs.* Average Weighted Weekly Quitline Calls Per Media Market State National Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Average Weighted Weekly Campaign GRPs Per Media Market
Number of Media Markets Airing Campaign GRPs
Precampaign Campaign Postcampaign Television Radio MCRC Television Television Radio MCRC Television 155 92 74 26 298 47 525 261 22 165 43 41 199 87 55 52 127 22 39 30 12 128 237 97 36 123 52 308 68 59 32 36 324 70 238 122 122 466 158 442 22 341 5 39 22 443 58 40 278 148 61 131
379 228 109 168 471 323 769 277 81 252 230 403 213 166 374 136 163 77 174 130 54 282 325 298 146 218 203 363 103 118 64 213 484 393 446 125 303 748 220 540 67 453 28 191 234 502 92 156 459 324 164 152
168 125 75 35 282 69 532 161 32 129 91 81 158 94 192 85 119 33 53 41 14 162 299 115 41 136 90 261 61 41 44 70 331 81 245 78 122 847 142 252 33 214 10 56 60 338 78 53 283 162 85 88
124 173 63 108 113 88 97 94 117 97 140 108 134 57 95 123 97 173 178 145 124 107 90 161 136 85 155 64 120 127 93 98 199 104 155 63 206 198 85 131 106 138 63 184 89 82 68 140 113 184 173 69
4 24 0 0 36 0 0 0 0 0 4 0 0 0 0 0 0 15 35 16 0 0 0 14 0 0 5 0 0 0 0 0 0 0 0 0 15 46 0 5 0 12 0 0 0 0 0 0 0 96 11 0
4 0 2 0 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35 0 0 0 0 0 0 0 0 0 22 32 0 0 0 0 0 17 8 0 0 108 61 0 0 0 0 0
137 4 1 2 2 7 2 2 1 1 7 4 1 1 4 5 4 3 3 4 1 2 2 6 2 3 4 1 2 2 1 2 1 6 5 1 5 2 2 5 1 3 1 4 13 1 1 5 2 1 4 1
17 2 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 2 2 0 1 0 1 0 0 0 0 0 0 0 1 1 0
12 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 3 1 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0
*Precampaign: February 20–March 18, 2012; campaign: March 19–June 10, 2012; postcampaign: June 11–July 8, 2012. GRP indicates gross rating point; and MCRC, Media Campaign Resource Center.
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Table 2. Multivariate Model of Tips Campaign GRPs and QL Call Volumes.y Total Television Campaign GRPs (Hundreds) State
Coefficient (p) (Confidence Interval)
Counterfactuals
Actual QL Calls Predicted QL Calls if Predicted QL Calls Attributable Elasticity During Campaign Television GRPs ¼ 0 to 2012 Tips Media (% Change)
National 44.65*** (41.46, 47.84) 0.30 States with significant television GRP effects on QL call volume GRP effects significantly above the national effect South Carolina 207.55*** (116.93, 298.16) 0.35 Maryland 126.40*** (94.71, 158.08) 0.28 District of Columbia 120.36*** (74.11, 166.61) 0.28 Arkansas 107.46*** (57.74, 157.19) 0.27 North Carolina 104.16*** (86.50, 121.82) 0.27 Mississippi 103.03*** (75.34, 130.72) 0.34 Georgia 96.98*** (81.41, 112.56) 0.53 New Mexico 95.41*** (61.63, 129.18) 0.24 Oregon 80.65*** (42.91, 118.39) 0.18 Alabama 68.50*** (49.66, 87.33) 0.29 Texas 59.01*** (48.08, 69.95) 0.48 GRP effects not significantly different than the national effect Idaho 142.23*** (95.23, 189.24) 0.30 Montana 121.25** (53.43, 189.06) 0.13 Colorado 103.09*** (64.62, 141.55) 0.22 Wyoming 69.02*** (44.37, 93.67) 0.19 Illinois 63.84*** (49.11, 78.57) 0.46 Connecticut 63.09*** (39.79, 86.40) 0.14 Pennsylvania 59.12** (18.06, 100.17) 0.26 Utah 55.72* (4.31, 107.14) 0.17 Nevada 51.44*** (38.71, 64.17) 0.36 Delaware 50.93*** (35.02, 66.84) 0.44 New Jersey 50.51*** (41.19, 59.83) 0.48 Washington 47.71*** (33.10, 62.32) 0.24 Kentucky 44.91*** (32.13, 57.69) 0.34 New York 44.32*** (35.76, 52.88) 0.44 Florida 42.78*** (37.58, 47.99) 0.45 California 42.19*** (37.19, 47.19) 0.52 Alaska 41.88** (13.98, 69.78) 0.14 Tennessee 39.31*** (32.37, 46.25) 0.41 Indiana 38.97*** (31.71, 46.23) 0.27 Missouri 37.82*** (26.03, 49.62) 0.37 Louisiana 37.70*** (30.15, 45.25) 0.36 Arizona 36.74*** (29.48, 44.00) 0.49 Hawaii 36.11* (7.27, 64.95) 0.14 Rhode Island 35.68*** (25.02, 46.33) 0.34 Nebraska 33.92*** (24.51, 43.33) 0.30 Virginia 33.85*** (26.77, 40.93) 0.33 Ohio 33.49*** (25.87, 41.11) 0.28 South Dakota 31.94** (12.54, 51.34) 0.43 Vermont 28.61* (6.67, 50.56) 0.13 Maine 24.25** (8.92, 39.57) 0.35 New Hampshire 23.22** (9.67, 36.76) 0.20 GRP effects significantly below the national effect Michigan 35.27*** (27.51, 43.02) 0.38 Kansas 27.70*** (19.51, 35.90) 0.42 Wisconsin 27.26*** (20.38, 34.14) 0.26 Iowa 25.02*** (17.72, 32.32) 0.15 Minnesota 10.42*** (5.97, 14.88) 0.31
363,656
190,416
173,241 (91.0)
17,832 7455 3029 9769 24,660 6743 8621 5807 5012 10,203 16,530
11,007 3935 1777 6139 13,380 4053 1204 3912 3283 5040 3459
6826 (62.0) 3520 (89.5) 1252 (70.5) 3630 (59.1) 11,280 (84.3) 2690 (66.4) 7417 (615.7) 1895 (48.4) 1729 (52.7) 5163 (102.4) 13,071 (377.8)
1989 4356 13,542 1819 9352 6881 19,313 6019 2339 975 4597 8404 6150 9290 15,554 15,234 1312 7916 8777 8453 5498 2980 2560 809 2189 6943 14,600 336 1106 652 765
1092 3413 9626 1327 3505 5215 12,145 4675 963 322 1133 5212 1909 2332 4869 3899 955 2352 4908 3407 1789 609 2163 337 1328 2252 5800 91 747 167 460
897 (82.2) 943 (27.6) 3916 (40.7) 492 (37.1) 5847 (166.8) 1666 (32.0) 7168 (59.0) 1344 (28.7) 1376 (142.9) 653 (203.1) 3464 (305.7) 3192 (61.2) 4241 (222.2) 6958 (298.4) 10,685 (219.4) 11,335 (290.7) 357 (37.4) 5564 (236.6) 3869 (78.8) 5046 (148.1) 3709 (207.3) 2371 (389.4) 397 (18.4) 472 (140.0) 861 (64.8) 4691 (208.3) 8800 (151.7) 245 (268.8) 359 (48.0) 485 (290.4) 305 (66.2)
11,542 2689 6023 6823 2323
4501 1156 3089 5232 719
7041 (156.4) 1533 (132.6) 2934 (95.0) 1591 (30.4) 1604 (222.9) (continued)
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Table 2. (continued) Total Television Campaign GRPs (Hundreds) State States not assessed North Dakota Massachusetts West Virginia Oklahoma
Coefficient (p) (Confidence Interval) 29.38 15.55 16.57 18.17
(16.94, 75.70) (4.16, 35.26) (195.71, 162.56) (83.63, 47.29)
Counterfactuals
Actual QL Calls Predicted QL Calls if Predicted QL Calls Attributable Elasticity During Campaign Television GRPs ¼ 0 to 2012 Tips Media (% Change) 0.09 0.10 0.06 0.05
1504 4905 3882 17,594
Not Not Not Not
Estimated Estimated Estimated Estimated
y The outcome variable is weekly calls at the area code level. The independent variable presented here is television GRPs (in hundreds). GRP indicates gross rating point; and QL, quitline. *p < 0.01. **p < 0.05. ***p < 0.001.
Discussion We found that a national tobacco education campaign featuring emotionally evocative personal testimonials and a quitline number can markedly increase calls to a national tobacco quitline portal. The national results and the results from 47 states also indicate a dose-response relationship, with higher GRP levels resulting in higher call volume. While previous studies have arrived at similar findings,7,18 it is significant to have these findings borne out in a large-scale study of the first federally funded, time-limited, nationwide tobacco education campaign ever conducted in the United States. Although we find strong evidence of a broad national effect of the Tips campaign on quitline calls, our analysis reveals four states (Massachusetts, North Dakota, Oklahoma, and West Virginia) where there was no significant relationship between campaign GRPs and calls to 1-800-QUIT-NOW. One reason for not being able to demonstrate a significant effect for North Dakota may be that North Dakota has a large migrant worker population who call the quitline from out-of-state cell phone numbers. Because calls to the national toll-free number are routed based on their area codes, it is possible that calls from the migrant workers were assigned to a different state. Another reason we were not able to detect a statistically significant effect may be that North Dakota supplemented the national Tips campaign with additional placements of Tips ads via MCRC in their local market using state funds. GRPs for the additional Tips ads were associated with significant increases in calls to 1-800-QUIT-NOW (data not shown). This suggests that additional placements of national ads available through MCRC can be an effective strategy for states to augment the impact of national campaigns. In addition to the purchased ads from CDC’s MCRC, North Dakota also ran their own media right before Tips campaign started. This led to a less noticeable change in call volume from precampaign to campaign (average weekly call volume pre-Tips: 122 vs. 125 during Tips) (Table 1). Our model was not able to detect a significant
relationship for Oklahoma because Oklahoma had a sustained increase in quitline call volumes after the Tips campaign ended: a 13% increase in average weekly call volume during the 4 weeks after the campaign was over compared with the Tips campaign time period. Our communication with Oklahoma revealed that their state tobacco control program implemented its own campaign after Tips was off air to leverage resources. This helped sustain the call volume to Oklahoma’s quitline at a level comparable to that during Tips. When we examined the relationship between Tips GRPs and calls to West Virginia’s quitline graphically, we found that call volumes followed closely with Tips GRPs (data not shown). Given that West Virginia has only one DMA in our sample, our model may be underpowered to detect a significant effect for West Virginia. Similarly, the statistical power for our Massachusetts model may have also been influenced by the number of DMAs (N ¼ 2) in our sample. Massachusetts Tobacco Control Program provided us with the number of self-referred callers (i.e., tobacco users who called quitline directly for assistance with quitting) and those referred via health care providers. We examined the changes in the number of selfreferred callers to Massachusetts’ quitline during the Tips campaign. The weekly average number of callers during the 2 months prior to the Tips campaign was 13 compared with a weekly average of 84 during the Tips campaign. The number of callers referred via health care providers remained stable over time (data not shown). This finding is consistent with our graph showing a positive relationship between call volume in Massachusetts and Tips GRPs. The 2012 Tips campaign did not feature a call to action for health care providers, which represented a missed opportunity to increase the number of tobacco users who visited a doctor during the Tips campaign time period and were provided with information on quitlines as a free cessation resource. For 1 week during the 2013 Tips campaign, most ads featured the message ‘‘You can quit—talk with your doctor for help’’ as a call to
380 action for health care providers. Future evaluation of antismoking campaigns should assess the impact of promotion via health care providers. We found variations in both campaign delivery and quitline responses across states. Of the 47 states with a significant relationship between 2012 Tips GRPs and quitline call volume, there were 11 states where the 2012 Tips campaign had a greater impact than the national average, five states where the campaign had a lesser impact, and 31 states where the campaign’s impact was not statistically different than the national average. Moreover, states in the South were more likely to have a larger effect, and states in the upper Midwest were more likely to have a smaller effect. Several factors could have resulted in the varying increases in call volume across state quitlines that were observed during the Tips campaign. Most notably, differences in call volume increases could have been driven by state-level differences in 2012 Tips campaign GRPs, and thus, residents’ exposure to Tips ads across states. In addition, some state tobacco control programs ran their own paid media (including additional state placements of Tips ads or placement of other ads) during the 2012 Tips campaign, or carried out earned media initiatives or other promotions to complement or leverage Tips, potentially enhancing the impact of the campaign in increasing calls to the state quitline. For example, North Carolina purchased additional Tips ads from the MCRC during the Tips campaign, which resulted in significantly higher call volumes to their quitline. Future research is needed to determine the reasons why some states experienced a higher or lower campaign effect when compared to the national average. Determining these specific reasons can help states make the most of future national tobacco education campaigns. It may also help CDC to tailor its technical assistance to state tobacco control programs to help them leverage the Tips campaign and maximize the impact of their health communication activities. Our results also may reflect substantial variation across states with respect to residents’ previous exposure to evidence-based, hard-hitting state paid media campaigns prior to the 2012 Tips campaign. Residents in states that had previously run such campaigns might be either more or less responsive to the Tips campaign than residents in states that had not done so, depending on whether prior exposure had primed smokers in the former states to take cessation action (such as calling a quitline), or whether, alternatively, smokers of the latter states might respond more strongly to the campaign because its content was novel to them and therefore more impactful.19 More research is needed to determine how a state’s previous tobacco paid media efforts mediate smokers’ responsiveness to national media campaigns. States vary widely in the extent to which they have implemented comprehensive, well-funded, and sustained tobacco control programs and proven population-based interventions such as smoke-free policies and price increases. These variations could also mediate the effect of the Tips campaign on call volumes, with residents of states with more developed programs and policies either being more primed to respond to the
American Journal of Health Promotion 30(5) ads or, alternatively, being less responsive because of a ceiling effect.19 Furthermore, states that use 1-800-QUIT-NOW as their primary or exclusive quitline number would be expected to have experienced larger increases in their 1-800-QUIT-NOW call volume during the Tips campaign, whereas states that have a separate primary quitline number and that typically only receive a minority of their calls through 1-800-QUITNOW would be expected to have experienced smaller increases in their 1-800-QUIT-NOW call volume. This may be due to the fact that in states with a primary quitline number other than 1-800-QUIT-NOW that have extensively promoted this other number over time, smokers are less familiar with the 1-800-QUIT-NOW number, which could lead to their being less likely to call this number in response to the Tips ads. Finally, the fact that 1-800-QUIT-NOW call volumes fell sharply in most states shortly after the 2012 Tips campaign ended suggests that longer or more frequent national campaigns could be beneficial in sustaining high levels of quitline call volume over time. Alternatively, state tobacco education media campaigns, fax or electronic referrals from health care practices, or state time-limited quitline promotions of free cessation medications could help sustain quitline call volumes during periods when no national campaign is on the air.1,2 Several limitations should be considered when interpreting the results of this study. First, data came from the national quitline portal (1-800-QUIT-NOW). As briefly described, many states have their own separate quitline numbers that they use and promote. The results reported here do not reflect calls to those other numbers and thus may be conservative estimates of the Tips campaign’s true impact. Second, our Tips campaign GRPs captured only paid Tips television ads. This measure did not reflect donated Tips public service announcements or earned media. Future studies should include metrics that help quantify the amount of these unpaid antismoking media messages as a result of the paid Tips media. Lastly, we could have misassigned calls that were transferred to another state that was different from the area code origin of the call (e.g., in situations where a quitline caller kept a cellphone number when moving to another state). In summary, this study demonstrates that the 2012 Tips campaign had consistent effects on state quitline call volume across a majority of states. Among the 47 states where the campaign had a significant impact on call volumes, 11 experienced effects that were greater than the national average. Our evidence also suggests that among the few states where the campaign was less effective, supplemental campaign advertising funded by those states may be effective in increasing quitline calls. This may be a particularly important observation for states that receive lower levels of exposure to national tobacco education media campaigns. In addition, repeated national/state antismoking messaging has the potential to sustain quitline use and ultimately lead to reduced prevalence in tobacco use.
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SO WHAT? Implications for Health Promotion Practitioners and Researchers
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4.
What is already known on this topic? Antismoking mass media campaigns increase calls to quitlines. Existing evidence on the effects of media campaigns on quitline calls has, to date, been limited to state-based campaign evaluations in a single state.
What does this article add?
5.
6.
This study extends the existing evidence by assessing the impact of the first federally funded national tobacco education campaign on quitline call volumes across the United States.
7.
What are the implications for health promotion practice or research?
8.
This study suggests that campaign effects varied across states because of a variety of state-specific factors. Among the few states where the campaign was less effective, supplemental campaign advertising funded by those states may be effective in increasing quitline calls. This may be a particularly important observation for states that receive lower levels of exposure to national tobacco education media campaigns. In addition, repeated national/state antismoking messaging has the potential to sustain quitline use and ultimately lead to reduced prevalence in tobacco use.
9. 10.
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Acknowledgment The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
13.
Declaration of Conflicting Interests
14.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Centers for Disease Control and Prevention (task order: 200-2007-20016/0021).
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