TOBACCO RELATED MEDIA EXPOSURE TOBACCO RELATED MEDIA EXPOSURE AND INDICATORS OF SMOKING AND INDICATORS OF SMOKING
CESSATION CESSATION
Andrew Hyland, PhD Cheryl Higbee
Melanie Wakefield, PhD Glen Szczypka, PhD Joseph Bauer, PhD
Gary A. Giovino, PhDK. Michael Cummings, PhD, MPH
Presented at
2003 National Conference on Tobacco or Health
Boston, Massachusetts
December 11, 2003
Acknowledgement
• NCI State and Community Tobacco Control Intervention Grants Program.
• Bob Vollinger and other NCI TCP staff
Objective
To assess the relationship between exposure to tobacco control and pharmaceutical company advertising on cessation and use of stop smoking medications.
Background
• Adults exposed to more anti-tobacco media promoted by state-sponsored programs may be more likely to stop smoking.
• Greater exposure to pharmaceutical ads for NRT or Zyban may increase utilization of these products.
• The COMMIT population provides individual smoking rates in geographically diverse areas.
Narrator: Secondhand smoke kills.(c) California Department of Health Services
MethodsData Sources
1) Community Intervention Trial for Smoking Cessation (COMMIT).
2) Gross Rating Points (GRP’s) from Nielsen Media Research.
Data Sources - COMMIT
• Community Intervention Trial for Smoking Cessation (COMMIT)
• Funded by NCI, conducted between 1988 and 1993• A match-pair, randomized trial of 22 small to medium
communities in 9 US states and 1 Canadian province• ~1,000 smokers from each community identified
surveyed in 1988 and followed until 1993• Smokers in intervention communities hypothesized to
have higher quit rates
• In 1988, over 10,000 heavy smokers (25+ cpd) and more than 10,000 light to moderate smokers (<25 cpd) completed a 20 minute tobacco use telephone survey.
• In 1993, over 13,000 members of this cohort were re-interviewed to assess the quit rate in each community
• Smokers in intervention communities hypothesized to have higher quit rates.
COMMIT
COMMIT CommunitiesNEW YORK
Binghamton/ Johnson City,New Rochelle, Utica, Yonkers
WASHINGTONBellingham, Longview/ Kelso
NEW MEXICOLas Cruces, Sante Fe
NEW JERSEYTrenton, Paterson
OREGONAlbany/
Corvallis, Medford/ Ashland
NORTH CAROLINAGreensboro, Raleigh
IOWACedar Rapids,
Davenport
MASSACHUSETTSLowell, Fitchburg/
LeominsterONTARIOBrantford, Peterboro
CALIFORNIAHayward, Vallejo
• Goal of COMMIT : test the hypothesis that an intervention, delivered through multiple community channels over a 4-year period, would result in higher quit rates, particularly among heavy smokers.
• Budgets - ~$220K per community per year.• COMMIT did help establish tobacco control
infrastructure in communities; however it stopped in 1993.
COMMIT Intervention
• The COMMIT intervention focused on (1) media and community-wide events, (2) health care providers, (3) work-sites and other community organizations, and (4) cessation resources.
• COMMIT intervention had 58 activities implemented through four primary channels: public education through the (1) media and community-wide events, (2) health care providers, (3) work-sites and other community organizations, and (4) cessation resources.
COMMIT Intervention
• Significantly higher quit rates in light to moderate smokers (<25 CPD) in intervention communities (30.6% vs. 27.5%)
• No effect in heavier smokers (25+ CPD) – 18.0% vs. 18.7%
COMMIT Results
• With NCI funding, we tried to re-interview all the U.S. participants from 20 communities who completed a 1993 survey in the summer of 2001 (n=13,544).
• 7,329 subjects were tracked and completed the telephone interview.
– Annual attrition rate was actually slightly less than during the original COMMIT study
– Younger, Hispanic, less educated, lower income people, and residents in CA, NM, NJ, and 1 MA town more likely to be lost to follow-up in 2001
COMMIT 2001 Follow-up Survey
•Media data was obtained for the top 75 media markets in the US for 1999 and 2000.
• The media data consists of Gross Rating Points (GRP’s) from Nielsen Media Research.
The sum of all rating points achieved by a schedule of advertisements for a particular time period.
•Every 100 GRP’s represent 1 exposure per person per year for a particular piece of media
Data Sources - Media Data
Data Sources - Media Data•The GRP’s for each month were summed over 1 year for 1999 and 2000.
•The categories of GRP’s were:
State Health Department Ads
Nicotine Replacement Therapy and Zyban
American Legacy Foundation Ads
Tobacco company Ads
Other – includes small, non-governmental organizations which purchased anti-smoking ads
COMMIT Sample Sizes
Completes in 1988 22,046
Completes in 2001 7,329
Included in top 75 media markets 5,214
Live in same community in
1988 and 2001 3,620
Smokers in 2000 2,807
Smokers in 1999 2,949
Gross Rating Points (GRP’s) for State-sponsored Advertisements by
Community, 2000
Gross Rating Points (GRP’s) for NRT and Zyban Advertisements by
Community, 2000
Gross Rating Points (GRP’s) for Tobacco Company Advertisements
by Community, 2000
Analysis – Outcomes1) Quitting
• Smoking status in 2001 determined from follow-up survey.
• Former smokers were asked the year that they quit. Those who quit during or after the year 2000 were considered
smokers in 2000.
Those who quit during or after 1999 were considered smokers in 1999.
2) Use of stop-smoking medications. Report of use of nicotine patch, nicotine gum, inhaler or nasal
spray or Zyban in 1999 or 2000.
Analysis – Predictors1) State GRP’s
• State sponsored anti-tobacco advertisements.
2) NRT GRP’s
• Advertisements for nicotine replacement therapies and Zyban.
Media Data was looked at in two different ways:
• Annual number of GRP’s for a particular type of advertisement (State or NRT).
• High or Low level of GRP’s for a particular type of advertisement based on the median GRP.
Analysis – Control Variables• Analyses control for:
– Age at baseline– Race– Gender– Education– Amount smoked in 1993– Quit attempts in 1993
• Analyses are stratified by responses to the question:– How much increase has there been in the amount of
information in the media on the dangers of smoking? (No increase or a decrease, increased a little, increased moderately, increased a lot).
Analysis – Control Variables
Results - CessationPercent Quit Smoking in 2000 by
Community
0%2%4%6%8%
10%12%
Haywar
d, CA
New R
oche
lle, N
Y
Lowell
, MA
Belling
ham
, WA
Fitchb
urg,
MA
Longv
iew, W
A
Utica,
NY
Trento
n, NJ
Raleig
h, NC
Green
sbor
o, NC
Santa
Fe, NM
Vallejo
, CA
Yonke
rs, N
Y
Alban
y, O
R
Paterso
n, NJ
% Q
uit
“High” Level of State GRP in 2000 (2000 GRP’s or more)
Note: Odds ratio = 1.09, 95% CI = (0.95 – 1.26) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
“High” Level of State GRP in 2000 (2000 GRP’s or more)
Note: Odds ratio = 1.24, 95% CI = (0.96 – 1.60) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Percent Quit Smoking in 1999 by Community
0%2%4%6%8%
10%12%
Paterso
n, NJ
Yonke
rs, N
Y
Utica,
NY
Raleig
h, NC
Vallejo
, CA
New R
oche
lle, N
Y
Green
sbor
o, NC
Alban
y/Cor
vali.
.
Lowell
, MA
Trento
n, NJ
Longv
iew, W
A
Fitchb
urg,
MA
Haywar
d, CA
Santa
Fe, NM
Belling
ham
, WA
% Q
uit
“High” Level of State GRP in 1999 (200 GRP’s or more)
Note: Odds ratio = 0.93, 95% CI = (0.78 – 1.12) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Percent Quit Smoking in 1999 by Community - Among those who responded that the media coverage has increased 'a lot'
02468
101214
Paterso
n
Trento
n
Yonke
rs
Longv
iew
Santa
Fe
Fitchb
urg
Raleig
h
Belling
ham
Utica
Green
sbor
o
Alban
y
Haywar
d
Lowell
New R
oche
lle
Vallejo
% Q
uit
“High” Level of State GRP in 1999 (200 GRP’s or more)
Note: Odds ratio = 1.03, 95% CI = (0.84 – 1.26) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
0 2500 5000 7500
State GRP's
4
6
8
10
12
% Q
uit
Percent Quit in 2000 by State GRP level, Among those who reported that the media coverage has increased ‘a lot’
Note: Odds ratio = 1.24, 95% CI = (0.96 – 1.60) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
R2 = .1157
Relative Risk of Quitting Smoking in 2000 as a Function of Smoker Characteristics, and Exposure to State-sponsored
Anti-smoking advertisements in 2000
1.09
1.24
1.15
1
1.05
1.1
1.15
1.21.25
1.3
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*
*95% CI = (0.96 – 1.60), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Relative Risk of Quitting Smoking in 2000 as a Function of Smoker Characteristics, and "High" Exposure to State-
sponsored Anti-smoking advertisements in 2000
1.74
5.08
2.05
0
1
2
3
45
6
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*
*95% CI = (0.67 – 38.32), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Relative Risk of Quitting Smoking in 1999 as a Function of Smoker Characteristics, and Exposure to State-sponsored
Anti-smoking advertisements in 1999
0.931.03
00
0.2
0.4
0.6
0.81
1.2
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*
*95% CI = (0.84 – 1.26), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Relative Risk of Quitting Smoking in 1999 as a Function of Smoker Characteristics, and "High" Exposure to State-
sponsored Anti-smoking advertisements in 1999
1.56
3.47
00
1
2
3
4
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*95% CI = (0.84 – 1.26), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
*
Results – NRT UseUsed NRT or Zyban in 2000 by
Community
02468
101214
Lowell
Belling
ham
Trento
n
Fitchb
urg/
Leomi..
.
Longv
iew/K
elso
New R
oche
lle
Alban
y/Cor
valli
s
Haywar
dUtic
a
Sante
Fe
Patters
on
Yonke
rs
Raleig
h
Green
sbor
o
Vallejo
% Q
uit
Note: Odds ratio = 1.15, 95% CI = (0.80 – 1.65) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
“High” Level of NRT GRP in 2000 (11,800 GRP’s or more)
02468
10121416
Belling
ham
Trento
n
Lowell
Alban
y/Cor
valli
s
Sante
Fe
New R
oche
lle
Raleig
h
Fitchb
urg/
Leomi..
.
Longv
iew/K
elso
Haywar
dUtic
a
Yonke
rs
Patters
on
Green
sbor
o
Vallejo
% U
sed
NR
T
“High” Level of NRT GRP in 2000 (11,800 GRP’s or more)
Note: Odds ratio = 1.27, 95% CI = (0.73 – 2.22) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
Used NRT or Zyban in 2000 by Community - Among those who Responded that the Media Coverage has
Increased 'A lot'
Note: Odds ratio = 0.79, 95% CI = (0.63 – 1.00) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
“High” Level of NRT GRP in 1999 (17,000 GRP’s or more)
Note: Odds ratio = 0.63, 95% CI = (0.45 – 0.87) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
“High” Level of NRT GRP in 1999 (17,000 GRP’s or more)
Used NRT or Zyban in 1999 by Community - Among those who Responded that the Media Coverage has
Increased 'A lot'
Percent Used NRT in 2000 by NRT GRP level, Among those who reported that the media coverage has increased ‘a lot’
Note: Odds ratio = 1.27, 95% CI = (0.73 – 2.22) from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
NRT GRP
1400012000100008000
% U
sed
NR
T
16
14
12
10
8
6
4
R2 = 0.0111
Relative Risk of Using NRT or Zyban in 2000 as a Function of Smoker Characteristics, and Exposure to NRT
advertisements in 2000
1.15 1.27
0.93
0
0.5
1
1.5
2
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*95% CI = (0.73 – 2.22), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
*
Relative Risk of Using NRT or Zyban in 2000 as a Function of Smoker Characteristics, and "High" Exposure
to NRT advertisements in 2000
0.870.58
0.85
0
0.5
1
1.5
2
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*95% CI = (0.19 – 1.80), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
*
Relative Risk of Using NRT or Zyban in 1999 as a Function of Smoker Characteristics, and Exposure to NRT
advertisements in 1999
0.790.63
0.94
0
0.5
1
1.5
2
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*95% CI = (0.45 – 0.87), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
*
Relative Risk of Using NRT or Zyban in 1999 as a Function of Smoker Characteristics, and "High" Exposure
to NRT advertisements in 1999
0.4 0.32 0.36
0
0.5
1
1.5
2
Overall "a lot" Not "a lot"Perception of Level of Increase in Media Coverage in Recent
Years
RR
*95% CI = (0.11 – 0.95), from a logistic regression model controlling for gender, age, race, amount smoked in 1993, education, and quit attempts in 1993.
*
Conclusions
• More exposure to state-sponsored anti-smoking advertisements increases the probability of cessation, particularly among those who report ‘a lot’ of increase in the media on the dangers of smoking.
• In this group, every 1000 additional GRP’s is estimated to increase cessation by 24%.
Conclusions
• Exposure to NRT or Zyban advertisements did not increase the probability of utilization of these products.
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