Report on a formative evaluation conducted for the youth against tobacco counter marketing campaign.

Abstract: This paper reports the formative evaluation findings of a tobacco counter-marketing campaign and recommendations based on those findings. Focus groups were used to determine reactions to four messages for the Youth Against Tobacco (YAT) campaign. Participants aged eleven to eighteen years old who resided in the metropolitan New Orleans area, were selected from area schools using convenience sampling. Results indicated that while reactions to the messages were positive overall, some aspects of the messages seemed too complex to be used effectively in the campaign. These results helped to guide modification and selection of messages prior to use in the campaign.

*********

Cigarette smoking is the most prevalent form of dependence and one of the leading preventable causes of death. It is estimated that smoking is responsible for three million deaths annually (Morello, Duggan, Adger, Anthony; Joffe, 2001). If nothing is done to reduce smoking prevalence, by the year 2025 mortality rates are expected to reach 10 million.

Adolescents are especially vulnerable to the effects of tobacco use and nicotine addiction. Approximately 29% of high school students smoke, and while more than 80% have tried to stop smoking, only 13.5% have succeeded (Sisley, 2000). Nearly all first use of tobacco occurs before high school graduation; a finding that suggests that if adolescents can be prevented from initiating tobacco use, most will never start (U.S. Department of Health and Human Services [DHHS], 1994; Morello, et al., 2001).

Both individual factors (e.g. low self-image, use of tobacco as a stress reducer, lack of knowledge on the health risks associated with tobacco use, and poor tobacco resistance skills) and social environmental factors (e.g. access to cigarettes, peer pressure, and perception of smoking as a social norm) contribute to the problem of tobacco use among adolescents (DHHS, 1994; Higgs, Edwards, Harbin, & Higgs, 2000; Sisely, 2000). Social environmental factors are especially influential. For example, tobacco advertising and promotion activities appear to influence initiation among adolescents by affecting their perceptions of smoking's pervasiveness, image, and function. (DHHS, 1994; Higgs, Edwards, Harbin, & Higgs, 2000). Tobacco advertising appears to be quite effective. Not only do children buy the most heavily advertised brands, but one study found that about 34% of all California youth experimentation with smoking between 1993 and 1996 could be attributed to tobacco promotion activities (CDC, 1994; Pierce, et al., 1998).

Many groups in the United States have recognized this public health concern and have initiated anti-smoking campaigns (Siegel & Biener, 2000). Community-wide efforts such as youth-oriented mass media campaigns that focus on prevention rather than cessation have been found to be successful in reducing adolescent use of tobacco, especially when combined with other measures (DHHS, 1994).

Counter-advertising has emerged as an effective type of anti-tobacco campaign and programs using this approach are currently on-going in several states (DHHS, 1994; National Center for Chronic Diseases Prevention and Health Promotion [NCCDPHP], 1999; Sly, Hopkins, Trapido, Ray, 2001). Counter-advertising attempts to counter pro-tobacco influences and promote healthy messages through a range of mass media channels, media advocacy techniques, and replacing or reducing tobacco industry sponsorship and promotions (NCCDPHP, 1999). Counter-advertising is based on social marketing principles such as an emphasis on development of products and services from the consumer's point of view and the consumer. The consumers, in the case of anti-tobacco counter-advertising, are adolescents (Wallack, 1990). The social marketing concept of audience segmentation, a strategy that identifies homogeneous subgroups of people based on common defining characteristics, is also applied in counter-advertising campaigns. In addition, social marketing formative research techniques, such as focus groups, are applied in counter-marketing as a way to involve the target audience in program development.

The Louisiana State Games Foundation (1) developed a counter-advertising anti-tobacco campaign called Youth Against Tobacco (YAT). This campaign consisted of disseminating carefully designed messages targeting adolescents ages 11 to 18 years old, using sporting events as delivery channels. The messages were designed to provide adolescents with the knowledge necessary to develop critical thinking skills to effectively challenge the tobacco industry's advertising. Messages were displayed on large banners at sporting events sponsored by LA State Games Foundation. Other methods used to disseminate the messages were t-shirts, posters and an interactive web-site, www.wewontsmoke.com that included links.

The prevention goal of the YAT campaign was to reduce the level of tobacco use by adolescent between the ages of 11 and 18 years old. Specific program objectives are, by the year 2003:

[] Reduce the level of tobacco use by adolescents between the ages of 11 and 18 years old from 36% to less than 25%;

[] Demonstrate that after exposure to YAT campaign, 75% of all participants, spectators and those associated with the Louisiana Games sporting events will be able to identify examples of tobacco product deception fostered by the tobacco industry;

[] Demonstrate that after exposure to YAT campaign messages, 75% of all participants, spectators and those associated with the Louisiana Games will have a negative attitude (2) towards tobacco product marketing (Campaign for Tobacco Free Kids, 1999; Center for Disease Prevention and Promotion, 2000; US Department of Health and Human Services, 2000).

Program planners developed four messages for the YAT campaign (See Figure 1). Messages were developed based on a review of literature and on consultation with experienced individuals in the field (National Cancer Institute, 1992; NCCDPHP, 1999). The director of the LA State Games Foundation developed the logo, which was placed alongside each message that was disseminated (See Figure 2).

Figure 1: YAW anti-tobacco messages

(1) "Tobacco companies create loyal customers by using cigarettes as a
delivery system for nicotine. Think About It!"

(2) "it is a proven fact that smoking decreases lung capacity and
limits athletic performance. Don't let your game go up in smoke.
Think About It!".

(3) "Do you know how tobacco company executives responded when asked
why they don't smoke? We reserve that `right' for the young and the
stupid." Don't Be A Target. Think About It!"

(4) "7,000 Louisiana residents die each year from tobacco related
causes. Are you going to be a replacement customer? Think About It!",

[FIGURE 2 OMITTED]

In order to enhance the effectiveness of messages developed for the campaign, pre-testing, a component of formative evaluation, was conducted in the form of focus groups. Focus groups have been shown to be a useful qualitative research tool to obtain perceptions of participants in a permissive, non-threatening environment (Holman, 1993). The messages were pretested to assess comprehension, personal relevance, cultural relevance, and strengths and weaknesses.

METHODS

Adolescents from the metropolitan New Orleans area were pretested using focus groups to determine if any of the four messages or YAT logo were understandable, relevant, memorable, and/or acceptable. Inclusion criteria specified that participants be between the age of eleven and eighteen and reside in the metropolitan New Orleans area. Participants were recruited by convenience sampling from two schools. A total of 24 adolescents participated in the focus groups.

Instrumentation for the focus group consisted of an unstructured moderator's discussion guide with five open-ended questions (see Figure 3). The instrument was developed based on existing pre-test instruments (National Cancer Institute, 1992).

Figure 3: Focus Group Questions.

Question (1): Was there any part(s) of the message that you especially
liked?

Question (2): Was there anything about the message that you disliked?

Question (3): What was the main idea each message was trying to get
across?

Question (4): In your opinion, was there anything in particular that
was worth remembering about the message?

Question (5): Was there anything in any of the messages that was
confusing?

After approval by the University of New Orleans Human Subjects Committee, participants were recruited by convenience sampling. Gatekeepers at selected schools were identified and their permission sought and obtained to conduct the focus groups. Informed consent was obtained from teachers in the schools. Student participation was completely voluntary and anonymous.

Three focus groups (N = 8 each) were completed. One focus group was conducted with eighth graders at an all-girl private high school, the majority of who were Caucasian. The other two were conducted with ninth graders at a coed magnet public school consisting of predominantly African-American students. All were conducted during a physical education class.

The focus group moderator used a question guide to elicit responses and follow-up. In addition, the focus group discussions were audio-recorded. Focus group sessions ran for approximately thirty minutes. To encourage full cooperation and participation, food was provided as an incentive. In addition, the instructor of the class requested participation.

RESULTS

Audio recordings of each focus group were collected, and from these, verbatim transcripts were generated. Content analysis of the verbatim transcripts was performed and then the verbal and written responses were identified thematically; categorized, and then coded by theme using established methods (Vaughn, Schumm, Sinagub, 1996; Glense, 1998;Weiss, 1994).

A total of 24 participants attended one of the three focus groups. The age range of participants was 12-16 years old. The messages Tobacco companies create loyal customers by using cigarettes as a delivery system for nicotine. Think About It! and Do you know how tobacco company executives responded when asked why they don't smoke? We reserve that `right' for the young and the stupid. Don't Be A Target. Think About It! had the poorest reactions from focus group participants. They found nothing they especially liked about these messages, found nothing worth remembering about the messages, and could not state the main idea of the messages. In addition, many of the participants were confused or offended by these messages, especially the terms stupid and delivery system

The message It is a proven fact that smoking decreases lung capacity, and limits athletic performance. Don't let your game go up in smoke. Think About It! received an overall positive reaction from focus group participants who liked the message, understood the message's main idea, and found parts of the message worth remembering.

While participants liked the message 7,000 Louisiana residents die each year from tobacco related causes. Are you going to be a replacement customer? Think About It! but many were confused by the term replacement customer. The participants also liked the logo and understood the main idea of the logo.

DISCUSSION

Limitations of focus group methodology are the subjectivity of responses; therefore results can not be applied to the general population. However, this methodology is appropriate for the formative evaluation stage of this campaign, where it was used to develop message concepts and direct use of these messages for a tobacco counter-marketing campaign for adolescents in the Great New Orleans area.

Focus group participants had an overall positive reaction to the messages, especially when smoking was related to athletic performance. Some concepts such as delivery system and replacement customer seemed too complex for the participants to understand. The term stupid resulted in a negative response to the message.

Based on these formative evaluation results, YAT program planners made several changes regarding the messages used in the counter marketing campaign. Two messages Tobacco companies create loyal customers ... and Do you know how tobacco company executives responded ... were rejected for use in the campaign. The message It is a proven fact that smoking decreases lung capacity and limits athletic performance. Don't let your game go up in smoke. Think About It! was divided into two messages. The first was It is a proven fact that smoking decreases lung capacity and limits athletic performance, and the second was Don't let your game go up in Smoke! Stay Tobacco Free. Think About It. Both new messages were used in the campaign. Despite confusion about the term replacement customer the LA Games director personally liked the message 7,000 Louisiana residents die each year from tobacco related causes, Are you going to be a replacement customer? Think About It! well enough to modify it to The tobacco industry, loses 400,000 customers each year who die from using their product. Are you going to be a replacement customer? and use it in the campaign. The logo was recommended for use in the program unchanged.

In conclusion, a qualitative investigation, involving adolescents from area high schools, is an essential first step in planning targeted messages as part of counter-advertising interventions. Further outcome evaluation will be conducted at a later stage to determine the effects of the YAT counter-advertising anti-tobacco campaign.

(FOOTNOTES)

(1) The LA games foundation s a non-profit statewide organization that organizes and puts on sporting events in areas such as track meets, basketball matches, and swim meets.

(2) Negative attitude was measured by a post-intervention questionnaire that included a series of twelve attitude/belief statements based on the questionnaire used by Florida Tobacco counter marketing campaign (Sly D.F., Heald, G.R., Ray, S (2001). The Florida "truth" anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Tobacco Control, i0, 9-15

REFERENCES

Campaign for Tobacco Free Kids (2000) The Toll of Tobacco in Louisiana retrieved December 8, 2000 from Campaign for Tobacco Free Kids Website: http://tobaccofreekids.org/reports/settlements/TobaccoToll

Center for Disease Prevention and Promotion (1994). Changes in brand preference of adolescent smokers-United States, 1989-1993, MMWR,43,577-81. Retrieved September 18, 2001 from http://www.cdc.gov/ tobacco/ythbrnd.htm

Center for Disease Prevention and Promotion (2000). Reducing Tobacco Use. Surgeon General's report. Retrieved December 18, 2000 from http://www.cdc.gov/tobacco/sgr tobacco use.htm

Glense, C. (1998) Becoming Qualitative Researchers: An introduction(2nd ed.). New York, NY:Longman,

Higgs, P.E., Edwards, D., Harbin, R.E., & Higgs, P.C., (2000) Evaluation of a Self-Directed Smoking Prevention and Cessation Program. pediatric Nursing, 26:2,150-158.

Holman, H. R. (1993). Qualitative inquiry in medical research. Journal of Clinical Epidemiology, 46, 29-36.

Morello, P., Duggan, A., Adger, Jr., H., Anthony, J., & Joffe, A. (2001). Tobacco Use Among High School Students in Buenos Aires, Argentina. American Journal of Public Health, 91 (2), 219-224.

Morton, R. (1999) Youth Against Tobacco grant application. Baptist Community Ministries, New Orleans, LA.

National Cancer Institute (1992) Making health communication programs work: a planner's guide. NIH Publication no. 92-1493, Washington, DC:Author Retrieved September 18,2001 from http://oc.nci.nih.gov/ services/HCPW/HOME.HTM

National Center for Chronic Diseases Prevention and Health Promotion (1999), Best Practices for Comprehensive Tobacco Control Programs. Atlanta, GA:National Center for Chronic Diseases Prevention and Health Promotion, Office on Smoking and Health

Pierce, J; Choi, W; Gilpin, E; Frakas, A; Berry, C. (1998) Tobacco Industry Promotion of Cigarettes and Adolescent Smoking. JAMA., 279 (7):,511-5

Siegel, M., & Biener, L. (2000). The Impact of an Antismoking Media Campaign on Progression to Established Smoking: Results of a Longitudinal Youth Study. American Journal of Public Health, 90 (3), 380-386.

Sisley, S. (2000). Residents help young people understand the truth about tobacco. JAMA. 283 (17), 2312.

Sly D.F., Heald, G.R., Ray, S (2001). The Florida "truth" anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Tobacco Control, 10, 9-15

Sly D.F., Hopkins, R.S., Trapido, E. & Ray, S. (2001) Influence of a counter-advertising media campaign on initiation of smoking: the Florida "truth" campaign Am J Public Health, 91,233-238

U.S. Department of Health and Human Services (1994) Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, DC:Author. Retrieved September 18, 2001 from http://www.cdc.gov/ tobaco/sgryth2.htm

US Department of Health and Human Services.(2000) Healthy People 2010: National Health Promotion and Disease Prevention Objectives. Retrieved December 18, 2000 from: http://www.health.gov/healthypeople.

Vaughn, S., Schumm, J.S., and Sinagub, J. (1996) Focus Group Interviews in Education and psychology. Thousand Oaks, C.A.: Sage.

Wallack, L. (1990) Improving health promotion: media advocacy and social marketing approaches. In Atkin, C. and Wallack, L. (eds), Mass Communication and Public Health. Thousand Oaks, C.A.: Sage, pp. 129-146.

Weiss, RS (1994). Learning from strangers: the art and method of qualitative interview studies. New York, N.Y.:The Free Press.

Lorelei Cropley, DPH, CHES is an Assistant Professor in the Department of Human Performance and Health Promotion at the University of New Orleans. F. Mitchell MS is a Graduate Assistant in the Department of Human Performance and Health Promotion at the University of New Orleans. Peter B. Anderson, Ph.D. is a Professor and Graduate Coordinator in the Department of Human Performance and Health Promotion at the University of New Orleans. Address all correspondence to Lorelei Cropley, DPH, CHES, Assistant Professor, HPC Room # 109, Department of Human Performance and Health Promotion, University of New Orleans, New Orleans, LA 70148; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].