Measuring exposure to pro- and anti-tobacco marketing among adolescents: intercorrelations among measures and associations with smoking status.

Exposure to tobacco-related marketing has been implicated as one of the risk factors for tobacco use among adolescents. However, tobacco-related marketing exposure has been measured in different ways in different studies, including perceived pervasiveness, receptivity, recognition, recall, and affect. It is not known whether these measures represent one or more underlying constructs and how these underlying constructs are associated with adolescent smoking status. This study analyzed data from 5,870 eighth-grade students in California, collected in 1996-1997 as part of the Independent Evaluation of the California Tobacco Control, Prevention, and Education Program. An exploratory factor analysis of multiple measures of tobacco-related marketing exposure revealed four distinct factors: perceived pervasiveness of protobacco marketing, perceived pervasiveness of antitobacco marketing, recognition of specific anti-tobacco advertisements, and receptivity to protobacco marketing. Receptivity to pro-tobacco marketing showed the strongest association with smoking status; higher levels of receptivity were associated with higher levels of smoking. Two measures of exposure to anti-tobacco marketing (perceived pervasiveness of anti-tobacco marketing and recognition of specific anti-tobacco ads) were highest among established smokers and lowest among susceptible nonsmokers. The same pattern was evident for perceived pervasiveness of pro-tobacco marketing. Results suggest that exposure to tobacco-related marketing is a multidimensional construct, and each dimension may have a unique contribution to the process of smoking initiation. Because adolescents are exposed to numerous pro- and anti-tobacco messages, it is important to develop anti-tobacco media campaigns that can successfully counter pro-tobacco marketing efforts. Potential strategies include targeting the susceptible nonsmokers who are at high risk for smoking and developing messages to decrease receptivity.

HIV/AIDS communication campaigns: progress and prospects.

The mass media have been the primary method for disseminating human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) prevention messages worldwide. In this article, we update previous reviews by systematically examining published articles (n = 41) of empirical evaluations of international HIV/AIDS prevention campaigns. Of the 41 studies identified, 17 countries are represented. In this review, we examine six components related to media campaign design and evaluation: target audience, communication channel(s), message content, campaign theme, exposure, and outcomes. Of the studies included in this sample, each one described the target audience; 93% reported on channel selection; 75% described message content; 63% mentioned a campaign theme; and 62% documented campaign exposure. We investigate also the extent to which HIV/AIDS prevention efforts have moved beyond media campaigns to comprehensive communitywide programs. We conclude that HIV/AIDS prevention efforts would benefit from: (1) better reporting of media campaign components and outcomes, (2) more systematic evaluation, (3) greater integration of theory, and (4) increased attention to communitywide intervention strategies.

Opinion leaders' support for tobacco control policies and participation in tobacco control activities.

OBJECTIVES: Because opinion leaders hold positions from which they may influence tobacco control efforts, this study examined their support for tobacco control policies and their involvement in tobacco control activities. METHODS: A telephone survey was administered to 712 California opinion leaders who were randomly selected from constructed lists representing 8 types of organizations: health, education, law enforcement, media, government, business, ethnic, and youth. Hierarchical regression analysis was used to identify predictors of support for and participation in tobacco control activities. RESULTS: Approximately one half to two thirds of opinion leaders supported the tobacco control policies queried; 60% reported involvement in tobacco control-related activities during the previous year. Organizational affiliation was a strong predictor of support and involvement, with leaders from health and educational organizations reporting the highest levels and business and media leaders reporting the lowest. Tobacco issue involvement variables (e.g., having a friend or family member with a smoking-related illness) were significantly associated with the outcomes, while sociodemographics, for the most part, were not. CONCLUSIONS: Study results can be used to mobilize opinion leaders' support for tobacco control more effectively.

The perceived influence of cigarette advertisements and smoking susceptibility among seventh graders.

A perceptual bias, the third person effect, has been observed where individuals believe themselves to differ from others regarding the perceived influence of media messages. Given the frequency with which youth encounter prosmoking messages and the reported negative effects of these messages, it is of value to study whether youth perceive cigarette advertisements to influence themselves and their friends and peers. This study examined the associations between exposure to social and information prosmoking environments, the perceived influence of cigarette advertisements on self, best friends, and other youth, and smoking susceptibility. A sample of 571 seventh graders completed surveys on tobacco advertisements and promotions. Using Student's-t, chi-square, ANOVA tests and proportional odds models, we found significant associations between perceived influence of cigarette advertisements and exposure to social and information prosmoking environments as well as smoking susceptibility. These data suggest that youth be taught that everyone is vulnerable to the tobacco industry's strategies and be given skills to resist prosmoking advertising.

Seventh graders' self-reported exposure to cigarette marketing and its relationship to their smoking behavior.

OBJECTIVES: This study examined among youth the extent of their perceived exposure to cigarette marketing and the relationship of their perceptions to their smoking behavior. METHODS: Surveys measuring exposure to cigarette advertisements and promotions were completed by 571 seventh graders in San Jose, Calif. RESULTS: Eighty-eight percent of these 13-year-olds reported exposure to cigarette marketing: the majority often saw ads in magazines, on billboards, and at stores and events, and one quarter owned cigarette promotional items. After social influences to smoke were controlled for, exposure to cigarette marketing was related to self-reported smoking behavior. Likelihood of experimenting with smoking was 2.2 times greater among those who owned promotional items and 2.8 times greater among those who had received mail from a tobacco company. Seeing cigarette advertisements in magazines increased this likelihood by 21%, and seeing tobacco marketing in stores increased it by 38%. CONCLUSIONS: Youth are daily and widely exposed to tobacco industry marketing efforts; this exposure is related to smoking behavior. More effective regulation is needed.

A community-based heart disease intervention: predictors of change.

OBJECTIVES: This paper presents a prospective examination of sociodemographic, psychosocial, and physiologic characteristics associated with positive change in cardiovascular disease risk factors during a 6-year multiple risk factor intervention study. METHODS: Data are presented on 221 women and 190 men (aged 25 through 74 years) who participated in four cohort surveys (1979 through 1985). A signal detection model was used to identify baseline variables that best divide the sample into subgroups on the basis of the probability of positive change in a composite risk factor score. RESULTS: Sixty-nine percent of the respondents showed a positive change in risk factor score during the intervention. The subgroup with the highest proportion of positive changers (83%) was composed of older adults (> 55 years) with the highest perceived risk, highest health media use, and highest blood pressure and cholesterol levels. The subgroup with the lowest proportion of positive changers (42%) was the least educated, was the most likely to be Hispanic, and had the lowest health knowledge and self-efficacy scores. CONCLUSIONS: The differing composition of subgroups who respond or do not respond to community cardiovascular disease interventions illustrates the need to develop specific interventions that target different age, socioeconomic, and cultural subgroups.

Effect of community health education on plasma cholesterol levels and diet: the Stanford Five-City Project.

This paper examines the effects of community-wide health education on diet-related knowledge and behavior and on plasma cholesterol levels during an experimental field study in medium-sized cities in northern California. Samples of the population aged 12-74 years were drawn at baseline and every 2 years thereafter to obtain four cross-sectional surveys; participants aged 25-74 years are included in this paper (n = 6,814 or about 425 per city per survey). The baseline sample was asked to return to three follow-up surveys, also 2 years apart, constituting the cohort survey sample (n = 777). Diet was assessed by 24-hour recalls. In the serial cross-sectional survey samples, nutritional knowledge increased over time in both men and women in all cities; among women, this increase was significantly greater in the treatment cities. Plasma cholesterol declined significantly only in men and in neither sex was there evidence of a larger decline in treatment than in control cities. Dietary saturated fat intake tended to decline, but not significantly in either sex, and there was no evidence of treatment impact. Dietary cholesterol intake declined in both sexes. Results in the cohort samples were similar, except plasma cholesterol levels were unchanged over time in men and increased in women, and dietary saturated fat intake declined significantly among women. Secular improvements in knowledge of nutrition and in dietary cholesterol intake occurred during the early 1980s in both men and women in these four cities, while there was less consistent improvement in dietary saturated fat intake. Only nutritional knowledge among women achieved greater improvement in treatment cities than in control cities. Continued and greater change in nutrition probably requires more sustained effort and broader methods, including changes in the food supply.

Changes in adult cigarette smoking prevalence after 5 years of community health education: the Stanford Five-City Project.

To determine the effects of 5 years of community-wide cardiovascular health education on smoking prevalence and cessation, the authors analyzed data from the Stanford Five-City Project, an experimental field study with two treatment cities and two control cities. Representative samples of the population aged 12-74 years were drawn at baseline and every 2 years thereafter to obtain four independent cross-sectional surveys; participants aged 25-74 years are included in this paper (n approximately 440 per city per survey; total n = 6,981). The baseline sample was asked to return to three follow-up surveys, also 2 years apart, and those that did (n = 805) constitute the cohort survey sample. Self-reported cigarette smoking was confirmed by plasma thiocyanate and expired-air carbon monoxide levels. Smoking prevalence decreased over time in all cities, but in the cohort the decrease tended to be greater in treatment than in control cities (p = 0.10, two-tailed); the treatment-control difference was consistent over time (-1.51 percentage points/year in treatment vs. -0.78 percentage points/year in control, p = 0.007, two-tailed). In contrast, smoking prevalence in the independent samples declined similarly in treatment and control cities, changes were not linear, and rates varied within cities between times. Baseline smokers in both the cohort and the follow-up independent surveys were significantly more likely to quit in the treatment cities than in the control cities.

A comparison of participants and nonparticipants in a worksite cholesterol screening.

PURPOSE: The purpose of this study is to determine if worksite cholesterol screening reaches only those who are already aware of their cholesterol and interested in lifestyle modification. DESIGN: A voluntary worksite cholesterol screening was conducted followed by a survey of a random sample of nonparticipants. SETTING: A large university worksite was the setting for this study. SUBJECTS: Out of 9,137 university employees, 1,583 attended the voluntary screening, and a random sample of nonparticipants was obtained (n = 154), of which 87% (n = 138) responded. MEASURES: Subjects completed a questionnaire on health behaviors, perceived risk, self-efficacy for diet change, and attention to media messages. A capillary blood cholesterol level was also taken. RESULTS: Nonparticipants were more likely to be male (64% versus 39%) and smokers (17% versus 9%), more likely to exercise, to have had a prior cholesterol measurement (64% versus 49%), and to "know" their cholesterol value (56% versus 26%). The two groups were otherwise similar. Over half (51%) of the participants were receiving their first cholesterol measurement. These subjects were younger, less educated, had less perceived risk, were less attentive to media messages, and more likely to be from a minority group than those individuals who had prior measurements. DISCUSSION: These findings suggest that worksite cholesterol screening does not only reach those already aware of their cholesterols, but also can reach some persons not previously screened or concerned.

The impact of public cholesterol screening on diet, general well-being, and physician referral.

Public cholesterol screenings have become common. To evaluate the public health impact of such events, we conducted a public cholesterol screening and, three months later, invited participants between the ages of 18 and 72 to return for follow-up. More than 77% (N = 143) returned. We collected information on diet and general well-being at baseline and follow-up, and we obtained information on further medical evaluation of the initial cholesterol value at follow-up. Diet improved regardless of baseline cholesterol level (overall diet score 2.10 baseline, 1.75 follow-up, P less than .001). There were no adverse psychosocial ("labeling") effects in persons told of elevated cholesterol levels. About one-third of individuals referred to their physicians for elevated cholesterol values discussed the cholesterol issue with their physicians, as did a similar proportion of those told of a desirable cholesterol level. Total cholesterol decreased from 218.5 to 211.6 mg/dL (P = 0.18, 95% CI for the change, -18.5 to +4.7 mg/dL). Public cholesterol screening did not appear to have any adverse effects and may lead to beneficial changes in diet in persons screened.

Health lifestyles: audience segmentation analysis for public health interventions.

This article is concerned with the application of market segmentation techniques in order to improve the planning and implementation of public health education programs. Seven distinctive patterns of health attitudes, social influences, and behaviors are identified using cluster analytic techniques in a sample drawn from four central California cities, and are subjected to construct and predictive validation: The lifestyle clusters predict behaviors including seatbelt use, vitamin C use, and attention to health information. The clusters also predict self-reported improvements in health behavior as measured in a two-year follow-up survey, e.g., eating less salt and losing weight, and self-reported new moderate and new vigorous exercise. Implications of these lifestyle clusters for public health education and intervention planning, and the larger potential of lifestyle clustering techniques in public health efforts, are discussed.

Effects of communitywide education on cardiovascular disease risk factors. The Stanford Five-City Project.

To test whether communitywide health education can reduce stroke and coronary heart disease, we compared two treatment cities (N = 122,800) and two control cities (N = 197,500) for changes in knowledge of risk factors, blood pressure, plasma cholesterol level, smoking rate, body weight, and resting pulse rate. Treatment cities received a 5-year, low-cost, comprehensive program using social learning theory, a communication-behavior change model, community organization principles, and social marketing methods that resulted in about 26 hours of exposure to multichannel and multifactor education. Risk factors were assessed in representative cohort and cross-sectional surveys at baseline and in three later surveys. After 30 to 64 months of education, significant net reductions in community averages favoring treatment occurred in plasma cholesterol level (2%), blood pressure (4%), resting pulse rate (3%), and smoking rate (13%) of the cohort sample. These risk factor changes resulted in important decreases in composite total mortality risk scores (15%) and coronary heart disease risk scores (16%). Thus, such low-cost programs can have an impact on risk factors in broad population groups.

Smokers' challenge: immediate and long-term findings of a community smoking cessation contest.

The present study examined the effectiveness of a community-based smoking contest in helping 500 smokers maintain three months postcontest and one year postcontest abstinence. The majority were chronic smokers with a limited number of previous quit attempts. The three- and 12-month postcontest quit rates were 19 per cent and 15 per cent, respectively, rates exceeding naturally occurring community cessation rates. The contest was found to be more cost-effective than quit smoking classes.

The cost-effectiveness of three smoking cessation programs.

This study analyzed the cost-effectiveness and distribution of costs by program stage of three smoking cessation programs: a smoking cessation class; an incentive-based quit smoking contest; and a self-help quit smoking kit. The self-help program had the lowest total cost, lowest per cent quit rate, lowest time requirement for participants, and was the most cost-effective. The most effective program, the smoking cessation class, required the most time from participants, had the highest total cost, and was the least cost-effective. The smoking contest was in-between the other two programs in total costs, per cent quit rate, and cost-effectiveness; it required the same time commitment from participants as the self-help program. These findings are interpreted within the context of community-based intervention in which the argument is made that cost-effectiveness is only one of several factors that should determine the selection of smoking cessation programs.

Efficacy of self-help behavior modification materials in smoking cessation.

We evaluated the efficacy of the Stanford Quit Kit, an eight-page self-administered smoking cessation program. Subjects were randomly assigned to receive the Quit Kit (n = 142) or a delayed intervention (n = 65). Confirmed abstinence (p less than .05) and reduced smoking among continuing smokers (p less than .002) were greater in the Quit Kit group than in the control group at the two-month follow-up. At the six-month follow-up 10.6 percent of the Quit Kit subjects were confirmed as abstinent. From these results we conclude that well-designed, self-administered behavior change materials can assist chronic smokers in quitting.

The Stanford Five-City Project: design and methods.

The Stanford Five-City Project is a large experimental field study of community health education for the prevention of cardiovascular disease. It will provide data on fundamental questions in cardiovascular disease epidemiology, communication, health education, behavior change, and community organization, and will also test the ability of a potentially cost-effective program to prevent cardiovascular disease at the community level. This paper describes the purposes, hypotheses, design, and methods of the Five-City Project as a reference for future papers describing results. It is hypothesized that a 20% decrease in cardiovascular disease risk will lead to a significant decline in cardiovascular disease event rates in two treatment communities compared with three reference communities as a result of a six-year intervention program of community-wide health education and organization. Risk factor change will be assessed through four surveys of independent samples and in a repeatedly surveyed cohort. Cardiovascular disease event rates will be assessed through continuous community surveillance of fatal and nonfatal myocardial infarction and stroke.

Mediated smoking cessation programs in the Stanford Five-City Project.

Two mediated smoking cessation programs were subjected to a field evaluation. The Quit Kit is a printed self-help package, and "Calling It Quits" consists of five segments which were aired on the local television news. A sample of 239 persons requested the Quit Kit and were followed. At the 2-month and 12-month follow-ups, respectively, 13.6% and 17.9% of those surveyed reported abstinence. Results indicate the potential of mediated interventions.