Media campaigns to promote smoking cessation among socioeconomically disadvantaged populations: What do we know, what do we need to learn, and what should we do now?

Social Science & Medicine 67 (2008) 1343–1355

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

Media campaigns to promote smoking cessation among socioeconomically disadvantaged populations: What do we know, what do we need to learn, and what should we do now? Jeff Niederdeppe a, *, Xiaodong Kuang b, Brittney Crock c, Ashley Skelton d a

Department of Communication, Cornell University, Ithaca, NY, United States Communication Department, Central Washington University, Ellensburg, WA, United States c Law School, University of Minnesota, Minneapolis, MN, United States d Department of Population Health Sciences, University of Wisconsin, Madison, WI, United States b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 7 August 2008

Little is known about whether media campaigns are effective strategies to promote smoking cessation among socioeconomically disadvantaged populations or whether media campaigns may unintentionally maintain or widen disparities in smoking cessation by socioeconomic status (SES). This paper presents a systematic review of the literature on the effectiveness of media campaigns to promote smoking cessation among low SES populations in the USA and countries with comparable political systems and demographic profiles such as Canada, Australia and Western European nations. We reviewed 29 articles, summarizing results from 18 studies, which made explicit statistical comparisons of media campaign effectiveness by SES, and 21 articles, summarizing results from 13 studies, which assessed the effectiveness of media campaigns targeted specifically to low SES populations. We find that there is considerable evidence that media campaigns to promote smoking cessation are often less effective, sometimes equally effective, and rarely more effective among socioeconomically disadvantaged populations relative to more advantaged populations. Disparities in the effectiveness of media campaigns between SES groups may occur at any of three stages: differences in meaningful exposure, differences in motivational response, or differences in opportunity to sustain long-term cessation. There remains a need to conduct research that examines the effectiveness of media campaigns by SES; these studies should employ research designs that are sensitive to various ways that SES differences in smoking cessation media effects might occur. Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Smoking cessation Health disparities Media campaigns Community interventions Socioeconomic status (SES)

Introduction Large-scale anti-tobacco media campaigns, when combined with other tobacco control activities, are associated with reductions in smoking prevalence and increased

* Corresponding author. Department of Communication, 336 Kennedy Hall, Cornell University, Ithaca, NY 14853-4203, United States. Tel.: +1 607 255 2111. E-mail addresses: [email protected] (J. Niederdeppe), xkuang@ wisc.edu (X. Kuang), [email protected] (B. Crock), [email protected] (A. Skelton). 0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.06.037

quit rates among smokers (Hopkins et al., 2001; Ranney et al., 2006). The prevalence of smoking among US adults has declined steadily over the past 40 years (Mariolis et al., 2006), and media campaigns have contributed to these reductions. At the same time, disparities in smoking rates by education have increased over this time period (Pierce, Fiore, Novotny, Hatziandreu, & Davis, 1989). There are now large disparities in smoking prevalence and quit rates by socioeconomic status (SES) in the United States (Mariolis et al., 2006). These factors underscore the need to assess the effectiveness of smoking cessation media campaigns across SES groups and identify promising media

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strategies to increase cessation among low SES populations. This paper presents a systematic review of the literature on the effectiveness of media campaigns to promote smoking cessation among lower SES populations.

campaigns targeted specifically to low SES smokers’ effective strategies to promote smoking cessation (RQ2)? Which media campaigns exemplify best practices and promising strategies for future efforts to reduce SES disparities in smoking cessation (RQ3)?

Media campaigns and SES disparities in smoking cessation Methods SES refers to an individual’s material resources, social resources, and prestige within a social hierarchy (Krieger, Williams, & Moss, 1997). While SES can be assessed in a variety of ways, it is often measured in terms of education, income, employment status, or occupational prestige. Socioeconomically disadvantaged populations are those with a relative deprivation of material resources, social resources, or occupational prestige. SES disparities in smoking prevalence and quit rates in the United States are most commonly reported in terms of education and income. Adults with a graduate degree (smoking rate ¼ 7.1%) and those above the threshold of poverty (smoking rate ¼ 20.6%) are far less likely to smoke than those with only 9–11 years of education (smoking rate ¼ 32.6%) or those living in poverty (smoking rate ¼ 29.9%; Mariolis et al., 2006). SES disparities often receive greater attention in the smoking literature than racial/ethnic disparities. While African Americans and Hispanics who want to quit have greater difficulty doing so compared to Caucasians, and African Americans suffer disproportionately high rates of tobacco-related morbidity and mortality (U.S. Department of Health and Human Services, 1998), smoking rates are comparable between Caucasians (21.9%) and African Americans (21.5%) and lower among Hispanic adults (16.2%; Mariolis et al., 2006). Several authors propose that media campaigns (including paid advertising campaigns, media advocacy, or direct marketing) are effective strategies to reduce disparities in smoking cessation by SES (Levy, Mumford, & Compton, 2006; Macaskill, Pierce, Simpson, & Lyle, 1992). At the same time, however, Fagan and colleagues concluded that there is insufficient evidence to determine whether or not media campaigns are effective strategies to increase cessation among socioeconomically disadvantaged populations. This group did not publish a comprehensive review of the literature, but reached their conclusions based on expert panel recommendations (Fagan et al., 2004). A comprehensive review of the effects of smoking cessation media campaigns among disadvantaged populations has yet to be published. We fill this gap with a systematic review of cessation media campaign effects on lower SES smokers. Study objectives This study has two overall objectives: (1) to conduct a systematic review of existing literature on the effectiveness of media campaigns to promote smoking cessation among low SES smokers, and (2) to identify promising media campaign strategies to increase smoking cessation and reduce tobacco-related disparities among socioeconomically disadvantaged populations. To reach these objectives, we proposed three research questions: Does the effectiveness of media campaigns targeted to the general population of smokers differ by SES (RQ1)? Are media

We conducted a comprehensive search for literature on media campaigns to promote adult (aged 18 and older) smoking cessation. Media campaigns were defined as any smoking cessation campaign or intervention that utilized media (including paid advertising, ‘‘earned’’ media through media advocacy, donated media time, or direct marketing) to publicize a program, promote the use of services, or persuade smokers to quit. We restricted our review to articles published after 1990 and those presenting original data on the effectiveness of a media campaign in the United States or countries with comparable political systems and demographic profiles as the US, including Canada, Western European nations, and Australia. Search strategy The logic of our search strategy is outlined in Fig. 1. We began the article selection process by reviewing reference lists from several major literature reviews of media campaigns and smoking cessation, including those conducted by the Centers for Disease Control (CDC; Schar & Gutierrez, 2001), the National Cancer Institute (NCI; Sparks & Green, 2000) and the Task Force on Community Preventive Services (TFCPS; Hopkins et al., 2001). We also reviewed reference lists of several literature reviews on smoking cessation campaigns among specific racial or ethnic populations (e.g., U.S. Department of Health and Human Services, 1998). We obtained articles from these reviews that were deemed potentially relevant based on their title or abstract. We next reviewed the reference lists of the articles obtained from the initial search, identifying relevant articles through this ‘‘snowball’’ technique. We continued this process until our database of potentially relevant articles appeared to reach saturation, where no new articles were identified by reviewing additional reference lists. We also conducted a comprehensive search of PubMed and Communication Abstracts for articles that described media campaigns targeted to low SES, African American, or Hispanic smokers. We explored various search terms in order to identify media campaigns to promote smoking cessation, including terms such as ‘‘smoking cessation,’’ and ‘‘quit smoking,’’ in conjunction with ‘‘community intervention,’’ ‘‘targeted media,’’ ‘‘media,’’ ‘‘campaign,’’ and ‘‘selfhelp.’’ We also combined these phrases with terms to identify lower SES populations, including (but not limited to) ‘‘socioeconomic status,’’ ‘‘SES,’’ ‘‘low education,’’ ‘‘low income,’’ ‘‘blue collar,’’ ‘‘poverty,’’ ‘‘African American,’’ ‘‘Black,’’ ‘‘Hispanic,’’ and ‘‘Latino.’’ While this paper does not specifically explore racial/ethnic differences in response to media campaigns, we reviewed abstracts that reported on campaigns targeting racial/ethnic minority populations to identify articles that explicitly targeted low SES smokers

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• • • • •

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Reviewed abstracts of articles referenced in major reviews of media campaigns and smoking cessation Reviewed abstracts of articles referenced in literature reviews on cessation interventions among specific racial/ethnic populations Searched PubMed and Communication Abstracts databases for campaigns targeted to low SES smokers Identified articles published after 1990 and those presenting original data on the effectiveness of a media campaign in the United States, Canada, Western European nations, or Australia. Reviewed abstracts of articles obtained from these three search strategies n = 253 potentially relevant articles for in-depth review

•

•

Identified articles that report on a media campaign targeting the general population of smokers

Identified and reviewed articles that report on a media campaign targeting low SES smokers (RQ2)

n = 117 articles

•

n = 21 articles

Identified and reviewed articles that made explicit, statistical comparisons concerning the campaign’s effectiveness by SES (RQ1) n = 29 articles

•

Compiled information about media and message strategies, theoretical frameworks, intervention components, evidence of overall campaign effectiveness, and evidence for differences in effectiveness by SES to identify best practices (RQ3) n = 50 articles

Fig. 1. Logic model of systematic review search strategy, inclusion criteria and classification strategy.

within particular racial/ethnic groups. Overall, this process identified 253 potentially relevant articles for subsequent in-depth review. Inclusion criteria Next, we conducted a thorough review of each potentially relevant article to identify studies presenting original, empirical data that either (1) explicitly compared the effectiveness of general population media campaigns between lower and higher SES populations, or (2) assessed the overall effectiveness of media campaigns targeted specifically to low SES populations. General population media campaigns were those that did not specify disadvantaged populations as their exclusive population target, although these campaigns may have included some targeted messages or programs. A total of 117 general population media campaign articles, published since 1990, presented original data on the campaign’s effectiveness. We identified 29 articles, derived from 18 different campaigns, which made explicit, statistical comparisons concerning the campaign’s effectiveness by an indicator of SES (defined by income, education, occupation, or insurance status). While categories of occupation may have different meaning across countries, we focused on explicit comparisons made between classes deemed relevant by the authors in the country where the study was conducted. For instance, in England we examined differences between manual laborers and white collar workers (Owen, 2000), whereas in Sweden we explored differences between white and blue collar workers (Tillgren, Haglund, Ainetdin, & Holm,

1995). The set of 29 articles was reviewed and categorized to address RQ1. Targeted media campaigns were those that explicitly identified low SES smokers, operationally defined as low income (more than half the sample at <$25K annual income) or low education smokers (more than half the sample with a high school diploma or less) as the primary population target. Targeted media campaigns also included studies that explicitly targeted racial/ethnic minority populations with low median levels of education or income. We identified 21 additional articles, derived from 13 different targeted campaigns, which assessed the effectiveness of media campaigns targeted specifically to low SES populations. These 21 articles were reviewed and categorized to address RQ2. Logic framework Fig. 2 illustrates the logic framework that we employed during the review process. The framework combines insights from Viswanath’s (2006) concept of communication inequality and social epidemiological perspectives on smoking cessation (e.g., Link & Phelan, 1995; Sorensen, Barbeau, Hunt, & Emmons, 2004) to understand how and when cessation media campaign effects might differ by SES. The model first proposes a chain of events that link a media campaign to sustained smoking cessation. Effective smoking cessation media campaigns produce substantial levels of message recall and comprehension among smokers. If a media campaign is successful, those who are exposed to the message will be motivated to seek

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Differences in Access, Exposure, Attention, or Retention

Media Intervention (Paid Campaign, Media Advocacy, Direct Marketing)

Differences in Persuasion and Motivational Response

Media Message Recall and Comprehension

Differences in Opportunity To Act or Maintain Action

Information Seeking, Treatment Seeking, or Quit Attempts

Sustained Abstinence from Cigarette Smoking

Lower levels of meaningful exposure among lower SES smokers = increased disparities

Lower levels of motivational response among lower SES smokers = increased disparities

Lower levels of opportunity to act among lower SES smokers = increased disparities

Equivalent levels of meaningful exposure between SES groups = maintained disparities

Equivalent levels of motivational response between SES groups = maintained disparities

Equivalent levels of opportunity to act between SES groups = maintained disparities

Higher levels of meaningful exposure among lower SES smokers = reduced disparities

Higher levels of motivational response among lower SES smokers = reduced disparities

Higher levels of opportunity to act among lower SES smokers = reduced disparities

Fig. 2. Logic framework depicting potential sources of disparity in response to smoking cessation media campaigns. Note: this figure was adapted from Viswanath’s (2006) concept of communication inequality, incorporating social epidemiological perspectives on smoking cessation (e.g., Sorensen, Barbeau, Hunt, & Emmons, 2004).

additional information about quitting, obtain cessation treatments, and attempt to quit smoking. Truly successful media campaigns will also ensure that a substantial proportion of those who try to quit smoking is able to sustain abstinence from cigarettes over a long period of time. The logic framework recognizes that the causal chain of events linking media campaigns to sustained smoking cessation can lead to differences in effects between socioeconomically disadvantaged and advantaged populations in at least three ways: differences in (1) meaningful exposure (comprehended and remembered) to media messages; (2) motivational response to media messages; and/or (3) opportunity to act in response to media messages. First, low SES smokers may differ from high SES smokers in their access to particular media (e.g., the internet; Hoffman & Novak, 1998), their media use patterns (e.g., Flay, McFall, Burton, Cook, & Warnecke, 1993), or their attention to particular media content (e.g., Viswanath et al., 2006). Differences in any of these factors could produce disparities in meaningful exposure. Second, even if a media campaign succeeded in generating high levels of meaningful exposure among disadvantaged populations, messages may produce differences in motivational response. Low SES smokers may differ from high SES smokers in the relative proportion of calls to a telephone quitline following a media campaign (e.g., Zhu, Anderson, Johnson, Tedeschi, & Roeseler, 2000) or in the wake of publicity about the distribution of free NRT (e.g., Miller et al., 2005). Third, even if a media campaign succeeds in producing substantial motivational response among high and low SES smokers, low SES smokers may have less opportunity than high SES smokers to turn this motivation into sustained abstinence from cigarettes. Lower SES populations have fewer social (social capital, social networks,

workplace cultures) and structural resources (health care access, exposure to smoking bans) to support behavior change even when motivation is high (e.g., Sorensen et al., 2004). SES differences in any one of these three stages would ultimately lead to disparities in media campaign effects on sustained smoking cessation. Consequently, a review of the evidence on media campaigns to promote smoking cessation among low SES populations should carefully assess the evidence for differences in meaningful exposure, motivational response, and long-term smoking abstinence. Data synthesis We used the logic framework to guide the interpretation of data from general population and targeted media campaigns. We undertook a qualitative analysis due to wide variation between studies in measurement of outcomes. For general population campaigns, we assessed whether an article examined differences in (1) message recall, (2) motivational response, and/or (3) long-term abstinence from smoking. When smoking or quit rates were reported at multiple time points, we focused on the last time point as the primary cessation outcome. Studies that showed lower levels of recall, motivational response, and/or longterm abstinence among low SES versus high SES populations were considered likely to increase disparities. Studies that showed equivalent levels of response among low versus high SES populations, at all three stages, were considered likely to maintain disparities. Studies that showed higher levels of response among low versus high SES populations in at least one of the three stages, without showing lower levels of response in another stage, were considered likely to reduce disparities (RQ1).

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For targeted media campaigns, we assessed evidence of the target population’s (1) level of media recall, (2) motivational response, and/or (3) long-term rates of abstinence from smoking. Studies that found these campaigns to be ineffective at increasing motivational response or longterm smoking abstinence were considered likely to increase or maintain disparities. Studies that provided evidence that a targeted media campaign increased motivational response or smoking abstinence were considered likely to reduce disparities (RQ2). Finally, we categorized articles according to their media strategy (e.g., paid media, donated media, earned media, and/or direct marketing), message strategies (e.g., why to quit, how to quit, self-help, and/or quit and win contests), theoretical framework (e.g., whether or not behavior change or persuasion theory was used to guide the intervention), and the presence or absence of other intervention components (e.g., telephone counseling, free NRT, community organizing). These details were used to identify and exemplify best practices for future smoking cessation media campaigns among disadvantaged populations (RQ3). We describe each campaign’s media strategy, message strategy, theoretical framework(s), and presence of other intervention components throughout the Results section, but reserve our recommendations for best practices for the Discussion. Results General population media campaigns comparing effectiveness by SES We identified 18 general population media campaigns that tested for differences in effectiveness by SES (summarized in Table 1). Nine were less effective among lower SES relative to higher SES smokers. Reduced effectiveness among lower versus higher SES populations was observed at each stage of the hypothesized causal chain, including message recall (e.g., Jackson, Winkleby, Flora, & Fortmann, 1991), motivational response (e.g., Elder, Campbell, Mielchen, Hovell, & Litrownik, 1991; Platt, Tannahill, Watson, & Fraser, 1997), and long-term smoking abstinence (e.g., Fortmann, Taylor, Flora, & Jatulis, 1993; Shuster, Utz, & Merwin, 1996). Four of the nine campaigns that were less effective among low SES populations might be characterized as low-cost, ‘‘self-help’’ campaigns. These programs encouraged smokers to request self-help print materials (Ossip-Klein et al., 1991; Shuster et al., 1996) or register for a drawing to win a paid vacation (Elder et al., 1991; Tillgren et al., 1995). Each of these programs used minimal resources for promotion or relied entirely on donated and earned media coverage. Another campaign, the Stanford 5-City Project to reduce cardiovascular disease (CVD), developed the intervention using a variety of persuasion and behavior change theories but failed to achieve meaningful levels of exposure among less educated smokers (Jackson et al., 1991; see also Hornik, 2002) and was consequently less effective in reducing smoking rates among this population (Fortmann et al., 1993; Winkleby, Flora, & Kraemer, 1994). Two media campaigns were less effective

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among lower SES relative to higher SES smokers in promoting telephone calls to smoking quitlines, including wellfunded efforts in Scotland (Platt et al., 1997) and California (Zhu et al., 2000). Two other media campaigns were equally effective in promoting quitline calls by SES, but observed large SES differences in long-term quit rates among these callers. One campaign, capitalizing on widespread news coverage of the quitline’s free NRT distribution and utilizing Social Cognitive Theory (Bandura, 1986) to guide telephone counseling, generated large spikes in call volume across SES categories but found substantially higher quit rates among callers with high education (An et al., 2006). The other campaign, featuring paid ads with evocative testimonials and offering reasons to quit, found no differences in call volume by occupation but observed that manual laborers and unemployed ex-smokers were more likely to relapse than white collar workers (Owen, 2000). These nine campaigns likely contributed to increased disparities in smoking cessation by SES. Six media campaigns were equally effective in promoting smoking cessation among low and high SES smokers. These campaigns used a diverse set of approaches, but were generally large in scale, implemented in the context of other tobacco control programs or activities, and often featured graphic portrayals of the health effects of tobacco. For instance, Biener et al. (2006) found no differences by education in the use of television ads as a catalyst to quit smoking. This study was conducted in the context of the Massachusetts tobacco control program, which relied heavily on ads using evocative testimonials to show tobacco’s long-term health effects. Although some of the evidence is mixed, several studies (e.g., Warnecke, Langenberg, Wong, Flay, & Cook, 1992) also provide evidence that the ‘‘Freedom from Smoking in 20 Days’’ program, a media campaign featuring 20 televised news segments about smoking cessation in Chicago, was successful in promoting long-term smoking cessation among both lower and higher educated populations. Lando, Hellerstedt, Pirie, Fruetel, and Huttner (1991) reported comparable response by education and occupation to a well-promoted ‘‘quit to win’’ contest in Bloomington, Minnesota. Unlike the aforementioned ‘‘quit to win’’ contests (e.g., Elder et al., 1991), the Bloomington effort was implemented as part of the Minnesota Heart Health Program, a statewide CVD intervention program guided by a variety of communication and behavior change theories. Miller et al. (2005) reported tremendous response by both low and high SES smokers to media promotion of free NRT distribution through a telephone quitline in New York City, implemented in the context of a larger tobacco control program in New York State. The authors estimated that 5% of all heavy smokers in New York City called the quitline to receive free NRT and found no differences in quitline call volume or quit success among callers by education or income. Two large-scale media campaigns in Australia reported equal success in promoting calls to a telephone quitline (Siahpush, Wakefield, Spittal, & Durkin, 2007) and, with one exception, in reducing smoking rates among low and high SES smokers (Macaskill et al., 1992). Both of these campaigns featured ads with graphic portrayals of the health effects of smoking, while the more recent campaign also included ads that modeled an

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Table 1 Differences in effectiveness of media campaigns targeting the general population of smokers Example study authors and location

Campaign title

Media strategy and Other program components use of theoretical framework

Which groups Examines differences compared? in message Difference found?* exposure or recall?

Examines differences in media effects on motivated response?

Which groups compared? Difference found?*

Examines differences in media effects on quit success?

Which cessation outcome?

Which groups compared? Difference found?*

An et al., 2006, MN, USA Biener et al., 2006, MA, USA

Free NRT promotion MA anti-smoking campaign

Earned media; theory cited Paid media; no theory mentioned

NO

Not compared

YES

YES

Not compared

NO

Elder et al., 1991, San Diego, CA, USA Fortmann et al., 1993, Northern CA, USA

Quit to win contest Donated and earned media; no theory mentioned Donated and Stanford 5-city project earned media, direct marketing; theories cited Quit date ’88 Earned and paid media, direct marketing; theories cited Paid media; no Large-scale state theory mentioned programs with media campaigns

NO

Not compared

YES

Income (YES) Education (NO)

YES

6 month quit rates Use of TV ads in quitting among successful quitters 8 week quit rates

Education (YES)

NO

Education (NO) Insurance (NO) Not compared

Group programs; school prevention

YES

Education (YES) Income (YES)

NO

Not compared

YES

6 year declines in smoking prevalence

Education (YES)

Large community intervention program

NO

Not compared

NO

Not compared

YES

3 to 4 month quit rates

Education (NO) Occupation (NO)

Cigarette prices, Local clean indoor air laws

NO

Not compared

NO

Not compared

YES

Paid media; no theory mentioned

Not reported

NO

Not compared

NO

Not compared

YES

Education (YES, but greater effects for low SES) Education (NO, one exception)

Quitline counseling NO

Not compared

YES

Income (NO)

YES

Access to a toll-free NO quitline

Not compared

YES

Education (YES)

NO

Quitline counseling NO

Not compared

YES

Occupation (NO)

YES

Quitline counseling NO

Not compared

YES

Platt et al., 1997, Scotland

Paid media; no theory mentioned

Quitline counseling; Selfhelp guide Large community intervention program

NO

Not compared

YES

Education (YES, but NO greater effects for low SES) Employed (YES) NO

NO

Not compared

NO

Not compared

YES

No cessation outcome reported 1 year relapse rates No cessation outcome reported No cessation outcome reported 4 year declines in smoking prevalence

Not compared

Owen, 2000, United Quitline campaign Kingdom Pierce et al., 1992, CDC anti-smoking USA PSA campaign

Earned and paid media; no theory mentioned Paid media, direct marketing; no theory mentioned Paid media; no theory mentioned Donated media; no theory mentioned

10 year declines in smoking prevalence among women 5 year declines in smoking prevalence 6 month quit rates

NONE

NO

Not compared

NO

Not compared

YES

Levy et al., 2006, USA

Macaskill et al., 1992, Australia Miller et al., 2005, New York City, USA Ossip-Klein et al., 1991, NY, USA

Australian 2-city anti-smoking media campaign Free NRT promotion Freedom from smoking

Smokeline campaign

Community Secker-Walker et al., 2000, New coalitions to help women quit England, USA smoking Shuster et al., 1996, Freedom from VA, USA smoking for you and your family

Earned and paid media; theories cited Donated media, direct marketing; theories cited

YES

3 month quit rates

Education (NO)

Income (NO) Education (NO)

Education (NO) Income (NO)

Occupation (YES) Not compared

Not compared

Income (YES, but greater effects for low SES) Education (YES)

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Lando et al., 1991, Bloomington, MN, USA

Free NRT; quitline counseling NRT; self-help; quitlines; webbased help; doctor advice NONE

Zhu et al., 2000, California, USA

In columns identified by an asterisk (*), YES denotes that the campaign was more effective among high SES populations for a particular outcome, unless otherwise specified. NO denotes that the campaign was equally effective among low and high SES populations.

Not compared No cessation outcome reported NO Education (YES) YES Not compared

YES Education (mixed evidence) Income (mixed evidence) YES Education (mixed evidence) Income (mixed evidence) YES For randomized subsets of participants

Quitline counseling, NO large state tobacco control program

Occupation (YES) Education (NO) YES Not Compared NO Not compared NO NONE

Paid media; theory cited Freedom from Donated and smoking in 20 days earned media, direct marketing; no theory mentioned Paid media; no California antitheory mentioned tobacco media campaign Quit and win

Siahpush et al., 2007, Victoria, Australia Tillgren et al., 1995, Sweden Warnecke et al., 1992; Chicago, IL, USA

Victoria state antismoking campaign

Paid media; no theory mentioned

Quitline counseling

NO

Not compared

YES

SES index (NO)

NO

No cessation outcome reported 12 month quit rates 24 month quit rates

Not compared

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actual call to the telephone quitline (Siahpush et al., 2007). Nevertheless, all six of these campaigns, while equally effective by SES, were unlikely to have reduced disparities in smoking cessation observed between low and high SES populations. Three general population media campaigns provided evidence of greater effectiveness among low SES compared to high SES smokers. One study compared call rates to the Cancer Information Service’s telephone quitline service before and after the airing of three media campaign ads (Pierce, Anderson, Romano, Meissner, & Odenkirchen, 1992). While these campaigns relied on donated media time, their broadcast availability was equivalent to over $2 million worth of paid advertising. The authors found that a higher proportion of callers during the ad campaign periods had low education, relative to periods prior to each campaign. At the same time, however, the study did not follow quitline callers over time, so it is unclear whether high and low educated callers shared equal success in long-term abstinence from smoking. A second campaign utilized paid media ads in the context of a comprehensive community program, informed by persuasion and behavior change theory, to promote smoking cessation among women in New England, USA (Secker-Walker et al., 2000). The authors found higher quit rates among low income women in campaign communities compared to control sites, but no such effects for women with higher incomes. While this might be viewed as evidence of media campaign success at promoting quitting among low SES populations, the fact that the program included multiple components (telephone counseling, support groups, primary care interventions, cessation classes, workplace initiatives, health fairs, and public events) makes it difficult to attribute these effects to the media campaign. In fact, based on the authors’ description of the campaign, paid media appears to have been a relatively minor component of the larger program. A third study compared the effectiveness of paid media, cigarette prices, and clean indoor air laws on declines in smoking rates among high and low SES women in the United States (Levy, Mumford, & Compton, 2006). The authors concluded that low education women were particularly responsive to media messages and cigarette price. However, the study’s method for deciding whether or not a woman was exposed to a media campaign was based solely on whether or not her state of residence funded a comprehensive tobacco control program with a significant media component. The fact that smoking rates declined faster among low education women in these states than in other states is noteworthy, but it is possible that these effects can be attributed to other, non-media components of the state programs. In sum, only three studies find greater media effectiveness among low SES smokers relative to higher SES smokers. The vast majority find comparable (n ¼ 6) or lower effectiveness (n ¼ 9) among lower versus higher SES smokers. Effectiveness of media campaigns exclusively targeted to low SES smokers We identified 13 media campaigns that exclusively targeted low SES populations, several of which focused

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Table 2 Media campaigns targeted to low SES smokers Authors and study location

Intervention title

Media strategy and use of theoretical framework

Other intervention components

Target population(s)

Sample description

Level of media recall?

Media effects on motivational response?

Media effects on long-term abstinence?

Which cessation outcome?

Ahijevych & Wewers, 1995, USA

Mailed behavior change intervention

Direct marketing; no theory mentioned

Weekly telephone support calls

African American (AA) women smokers, largely low SES

52% High School (HS) degree or less; 48% income <$20K

Not reported

Not reported

12 week confirmed quit rates

Campbell et al., 2002, NC, USA

Health works for women

Direct marketing; theories cited

Community role models

Rural female blue collar employees

86% recalled receiving the magazine; 76% read it

47% said materials caused to think about behavior change

Campion et al., 1994, England

Smoking and pregnancy campaign

Earned and paid media; no theory mentioned

Access to quitline counseling

Lower-middle and working class pregnant women

No pre- to postintervention difference for pregnant women

2 week postintervention smoking rates

Neighbors for a smoke free north side

Large community intervention program

AA smokers in low income neighborhoods

Not reported

Bluegrass 2001 quit and win contest

Low income smokers

53% >HS degree; 90% White; all <$25K income

91% recall postcard, 53% radio, 71% any advertising

8% quitline use at 3 months

Lipkus et al., 1999, Durham, NC, USA

Tailored intervention

AA smokers, primarily low income

Most had
Not reported

Not reported

Marı´n & Pe´rezStable, 1995, San Francisco, CA, USA

Programa latino para dejar de fumar

Provider and workplace promotion, quitline assistance, classes Tailored provider advice and telephone counseling Large community intervention program

Hispanic/Latino (HL) smokers, primarily low income

100% HL, 3543%
43% program awareness, 20% guide awareness

Exposure associated with quit attempts and quit knowledge

McAlister et al., 1992, TX, USA and Mexico

Programa a su salud

HL smokers in low income communities

88100% HL; 62 74% with
Not reported

Not reported

Decline in intervention communities (p < 0.05); no decline in control Intervention greater quit rate (9%) vs. control (1%); not related to exposure Patterns between intervention and control groups were mixed Trend toward lower prevalence; cessation not associated w/ exposure Quit rates favored intervention vs. control, but not significant

2 year declines in smoking prevalence

Hahn et al., 2004, Kentucky, USA

Earned and paid media, direct marketing; no theory mentioned Earned and paid media, direct marketing; no theory mentioned Direct marketing; theory cited

Recall: 22% for TV, 29% for magazine. Aided recall ranged from 3 to 41% Not reported

94 calls to quitline, a 14% increase among pregnant women

Fisher et al., 1998, St. Louis, MO, USA

6474% of women had HS degree or less; more than half AA 52% in social grade C2DE; 60% finished education at age 15 or 16 >75% AA; 30%
No women in either intervention or control group quit smoking No difference between intervention and control

Nevid & Javier, 1997, Queens, NY, USA

Si, puedo

HL smokers with low income

100% HL, median income $15K– $20K

Not reported

149 of 451 eligible respondents attended an orientation meeting

Paid media, video, direct marketing; theory cited

Community network programs with interpersonal contact Behavioral treatment, social support, video

No difference between intervention and control

12 month confirmed quit rates

16 month quit rates

7 year declines in smoking prevalence

5 year confirmed quit rates

12 month quit rates

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Earned and paid media, direct marketing; no theory mentioned Earned and paid media, direct marketing; theories cited

18 month smoking rates

12 week quit rates

18 month quit rates

No difference between intervention and control Quit rates between 21 (standard) and 27 percent (enhanced) Average education 10.9 years; 55% <$20K income; 75% no insurance Low income HL smokers

Direct marketing; no theory mentioned Alliance of black churches health project

Adios al fumar

Schorling et al., 1997, Rural VA, USA

Wetter et al., 2007, TX, USA

O’Loughlin et al., 1999, Montreal, Canada Resnicow et al., 1997, New York City, USA

Kick it!

Earned and paid media, direct marketing; theories cited Video, direct marketing; theory cited Coeur en sante’ St.-Henri

Paid media, direct marketing; no theory mentioned

100% AA, >half with HS diploma or less AA smokers in rural communities

Not reported

Intervention greater progress along stages of change vs. control Increase from 0.4 to 17.8 monthly calls pre- to postintervention

100% AA; 81% HS diploma or less; 88% income <$5K AA smokers in low income neighborhood

Two quit and win contests, telephone counseling session, quit contract One-on-one counseling, community activities Quitline counseling

Not reported

6 month quit rates 6-month quit attempts not different between intervention and control

22% income insufficient; 65% HS degree or less Lower SES Large community intervention program

Direct mail recall 22%, read by 11%; newsletter recall 39%, read by 28% 36% watched most of the video; 60% read most of the guide

21% of direct mail readers reduced smoking

No difference between intervention and comparison No difference between intervention and control

5 year declines in smoking prevalence

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on low SES smokers of African American race or Hispanic ethnicity (summarized in Table 2). None of these studies provided unequivocal evidence that a media campaign promoted sustained cessation among socioeconomically disadvantaged smokers. A total of eight campaigns provided mixed or inconclusive evidence of effectiveness in promoting smoking cessation among low SES populations. Three of these campaigns targeted low SES, African American smokers. Lipkus, Lyna, and Rimer (1999) compared low SES, African American smokers’ responses to three combinations of tailored selfhelp materials, provider advice, and tailored telephone counseling that were guided by the Transtheoretical Model of Health Behavior Change (Prochaska & Velicer, 1997). Smokers that were exposed to both the self-help materials and the provider advice achieved greater 16-month quit rates compared to provider advice alone, but smokers who received self-help, provider advice, and telephone counseling did not quit at higher rates compared to provider advice only. The lack of a dose–response pattern raises questions about the study’s conclusion that the tailored self-help materials were effective in promoting smoking cessation. Fisher et al. (1998) found greater declines in smoking prevalence in low SES, African American communities that received a media campaign (paid media through billboards, earned media, and direct marketing through selfhelp brochures) in concert with a community mobilization campaign (cessation classes, door-to-door campaigns, a gospel festival) relative to communities that received the media campaign only. However, it is impossible from these data to draw conclusions about the media campaign’s effects. Resnicow et al. (1997) compared low income African American smokers living in communities that received a video and a self-help booklet, whose development was guided by the Transtheoretical Model, as part of the larger ‘‘Harlem Health Connection’’ initiative. The authors found no differences in 6-month quit rates between campaign and control communities. However, they did find significant differences in quit rates between low SES, African American smokers that saw the video and read these materials (16%) relative to the control group (8%). The fact that the campaign was unable to generate sufficient levels of exposure suggests that this type of program may not appeal to a large number of low SES smokers. Four campaigns also provided mixed or inconclusive evidence regarding the effectiveness of media campaigns among low SES, Hispanic smokers. The extensively studied ‘‘Programa Latino para Dejar de Fumar’’ (the Latino program to stop smoking) used targeted paid media, earned media, and tailored self-help materials in conjunction with community interventions, cessation groups, and telephone counseling to increase quit motivation and sustained cessation among low SES, Hispanic residents of San Francisco. Several authors found substantial levels of program awareness and observed changes in tobacco knowledge and social pressures to quit (Marı´n, 1994; Marı´n, & Pe´rezStable, 1995). However, while there was a trend toward lower prevalence rates in San Francisco, exposure to the campaign was not associated with quitting smoking (Marı´n, 1994). The declines in smoking rates may be

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attributable to tax increases or the provision of smokefree workplace laws implemented in conjunction with the larger California tobacco control program. McAlister et al. (1992) evaluated the ‘‘Programa a Su Salud’’ (Program for your health) in low income border towns in Texas and Mexico. The campaign, developed using principles derived from the Transtheoretical Model and Social Cognitive Theory, utilized paid media advertisements on television, radio, and newspapers, as well as self-help materials and community network programs with volunteers providing interpersonal support for quitting smoking. The authors observed an 8% verified quit rate in campaign communities compared to a 2% quit rate in control communities. These differences were not statistically significant, however, and it is impossible to isolate the contributions of the media campaign and interpersonal support. Wetter et al. (2007) evaluated the ‘‘Adios al Fumar’’ (Goodbye to smoking) campaign in Houston, San Antonio, El Paso, and the Rio Grande valley in Texas. The campaign featured Spanish- and English-language ads, largely on Spanish television and radio, to drive calls to the Cancer Information Service smoking cessation service among low SES, Hispanic smokers. While the authors witnessed statistically significant increases in the volume of calls, in practical terms the increase was very small: from 1 call pre-campaign to 18 calls per month during the campaign. Nevid and Javier (1997) studied the effects of the ‘‘Si, Puedo’’ (Yes, I can) program, which recruited low SES, Hispanic participants through radio and print advertisements and compared the effectiveness of a video plus behavioral counseling with a standard self-help guide to quitting. The authors found significantly higher quit rates post-treatment for the video condition (21%) than the self-help condition (6%), but these differences were not sustained at 6 or 12 months (8% vs. 7% quit rates, respectively). Finally, Hahn et al. (2004) evaluated the ‘‘Bluegrass 2001 Quit and Win Contest’’ targeting low income smokers of any race and ethnicity in Kentucky. The authors found high levels of media message recall, large motivational response in the form of calls to a quitline, and higher one-year abstinence rates among program participants relative to those that did not call a quitline or register for the contest. However, self-reported exposure to paid media (television, radio, billboards), earned media (newspaper features), and direct marketing (weekly postcards) was not associated with abstinence from smoking, suggesting that other components of the program (e.g., provider advice, worksite promotion, cessation classes) may have been responsible for the effects on quitting. Five studies provided clear evidence that targeted media campaigns were not successful among low SES smokers. Campbell et al. (2002) evaluated ‘‘Health Works for Women,’’ a computer campaign guided by ecological perspectives, behavior change theory and communication theory to develop tailored, direct marketing messages about multiple behaviors to rural, female, blue collar employees. While the authors found differences between the campaign and control groups for several preventive behaviors (e.g., fruit and vegetable consumption, fat intake), there were no differences in rates of smoking

cessation 6 or 18 months after the conclusion of the program. O’Loughlin and colleagues evaluated a multicomponent, CVD risk reduction intervention targeting urban, low income women in Montreal, Canada. Despite being guided by behavior change theory and using a combination of paid and earned media, direct marketing, educational workshops, and free screening interventions, the evaluation reported low levels of media recall (O’Loughlin, Paradis, & Meshefedjian, 1997), minimal participation in a cessation contest (Paradis et al., 1995), and no program effects on smoking rates (O’Loughlin, Paradis, Gray-Donald, & Renaud 1999). Campion, Owen, McNeill, and McGuire (1994) developed the ‘‘Smoking and Pregnancy Campaign’’ to reduce smoking rates among lower-middle and working class pregnant women and their partners in England. The program used paid newspaper advertisements and earned media to encourage pregnant smokers to call a telephone quitline. About one-fourth of pregnant women recalled seeing the ads and the quitline reported increased call volume, but the authors observed no difference in smoking rates pre- and post-campaign for pregnant women or their partners. Schorling et al. (1997) reported no differences in quit rates between a control group and low income, African American smokers who received a church-based smoking cessation program and received spiritually-guided selfhelp booklets. Finally, Ahijevych and Wewers (1995) implemented a small scale campaign relying exclusively on direct marketing of self-help materials to promote quitting. They found no differences in 12-week or 6-month quit rates between those assigned to receive the materials and those that did not. Overall, researchers have yet to identify targeted media strategies that are clearly effective in promoting long-term smoking cessation among low SES populations. Discussion What do we know? Our comprehensive review of the existing literature on media strategies to promote smoking cessation among disadvantaged populations reveals three major findings. First, there is considerable evidence that media campaigns to promote smoking cessation at the overall population level are often less effective, sometimes equally effective, and rarely more effective among low SES populations relative to high SES populations. Many of these campaigns could have the unintended effect of increasing or maintaining existing disparities in smoking rates and the mortality burden of tobacco by SES. Second, disparities in the effectiveness of media campaigns between SES groups may occur at any of three stages: differences in meaningful exposure, differences in motivational response, or differences in opportunity to sustain cessation in the longterm. Third, media campaigns appear most effective among low SES smokers when they are implemented alongside larger tobacco control programs that include community mobilization, free NRT, telephone counseling, social support, or policy changes to change the social and structural context of cigarette use.

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What do we need to learn? Need for research comparing effects by SES The literature review reveals substantial gaps in our knowledge of effective media campaign strategies for disadvantaged populations. The vast majority of general population media campaign studies (88 of 117, or 75%) did not test for differences in effectiveness by SES. It is unclear whether this finding can be explained by journal space constraints (which may inhibit evaluators from stratifying data by sub-population), a file drawer problem (whereby studies that find no differences between groups fail to publish these null findings), or a lack of attention to issues of disparities in smoking cessation. In light of the tremendous gradient in smoking rates by SES, it is essential for future research efforts to test for heterogeneity in effects and present these data in media campaign evaluations, regardless of whether or not they find group differences. Need for sensitive research designs The nature of media research imposes limitations on what can be learned from any particular study. As Hornik (2002) notes, media campaigns are diffuse, and both practical and political considerations often make it difficult or impossible to evaluate a media campaign using traditional methods of causal attribution (e.g., clinical trials, controlled experiments). In fact, many of the evaluations we reviewed implemented media campaigns in concert with other events or programs, making it very difficult to isolate the independent contributions of the campaigns. The fact that we failed to identify a single, targeted media campaign that provided clear evidence of success among low SES smokers suggests that this population may require comprehensive, multifaceted interventions that promote behavior change as well as social/structural changes to reduce barriers to long-term smoking cessation. Need to resolve contradictory findings Several studies reached different conclusions on the effectiveness of particular strategies for disadvantaged populations. For instance, there was mixed evidence about whether hard-hitting testimonials discussing the health effects of smoking leads to SES differences in quitline calls. On one hand, evaluations in California (Zhu et al., 2000) and Scotland (Platt et al., 1997) found lower response among low SES populations, while evaluations in England (Owen, 2000) and Australia (Siahpush et al., 2007) observed comparable response among both low and high SES groups. The fact that all 50 US states are now required to have a telephone quitline suggests that there will be opportunities for future research in comparing motivational response to media messages by SES. These studies might compare the effectiveness of various message approaches on call volume among disadvantaged and advantaged groups. Need to consider theory in media campaign design Our review also highlights the importance of broader thinking about ways that general population media campaigns might not meet the needs of disadvantaged populations, as well as ways that media might produce

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differences in response between groups. The majority of media campaigns did not report the use of an explicit communication or behavior change theory in campaign development. Nevertheless, the use of an explicit theoretical model by no means guaranteed success among low SES smokers. These results highlight the need to develop broader theoretical frameworks to understand campaign effects among low SES smokers. The logic framework used in this study highlights at least three stages where a media campaign could produce SES or racial/ethnic differences in response. Indeed, our review found evidence of differences in response to media campaigns at each of these three stages. Social marketing has focused considerable attention on the importance of targeting media messages to specific populations (Grier & Bryant, 2005). A growing body of research on tailored communications has likewise raised awareness of the importance of designing messages to meet the literacy, language, cultural, and motivational needs of various populations (Strecher, Wang, Derry, Wildenhaus, & Johnson, 2002). However, while social epidemiology has emphasized social and structural barriers to behavior change (e.g., Sorensen et al., 2004), we know far less about how to use media strategies to change social conditions (e.g., community social capital, workplace policies, health care access, municipal smoking bans) than we know about how to motivate behavior change. Reducing these barriers will be essential for any comprehensive effort to reduce tobacco-related disparities in the US and elsewhere. There is much to learn about effective use of media to reduce barriers to smoking cessation through policy change. Need to consider theory in media research Researchers who study the effectiveness of media campaigns and disadvantaged populations also need to test for differences at multiple stages of response. For instance, several studies compared the volume of quitline calls in response to media campaigns by SES and found no differences in call volume. These studies are certainly useful, but low SES quitline callers may still experience far greater difficulty in quitting than high SES callers. As a result, a campaign that produces an equal volume of quitline calls may still provide greater long-term benefit to socioeconomically advantaged smokers. We hope that the logic framework will highlight these considerations and prompt researchers to consider multiple ways that media campaigns might inadvertently contribute to widening disparities in smoking cessation. Limitations of this review Several limitations are worth noting. First, we focused our search strategy on identifying low SES smokers, with particular attention to African American and Hispanic smokers. While we believe that this search strategy successfully identified all published articles related to low SES smokers, it is possible that we may have inadvertently excluded articles on low SES Asian American or Native American smokers. Second, there was large variation in the time frame used to report long-term cessation outcomes in the studies we reviewed. Finally, we used a variety of operational definitions to identify low SES smokers. It is

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possible that best practices to promote sustained smoking cessation among low income smokers could be different from best practices among smokers with low education or among blue collar workers. Each of these issues could have influenced our conclusions.

What should we do now? Despite these gaps in the literature, we believe that there is sufficient evidence to recommend five best practices for media campaigns among disadvantaged populations. (1) The simple promotion of self-help materials or a quit to win contest, in isolation, should not be undertaken. These efforts tend not to benefit low SES populations (see Ahijevych & Wewers, 1995; Elder et al., 1991; Tillgren et al., 1995). (2) Media campaigns should strive to ensure as much exposure as possible, including paid media campaigns, earned media coverage, donated media time, and direct marketing (see Fisher et al., 1998; McAlister et al., 1992). (3) Media campaigns should be combined, whenever possible, with other tobacco control program components, including community mobilization, social support, quitline counseling, provider initiatives, tax increases, free NRT distribution, and policy changes (see Miller et al., 2005; Secker-Walker et al., 2000). (4) Media campaigns should conduct formative research to understand the media use preferences and healthrelated behavior among low SES smokers to ensure that this population is adequately exposed to, and motivated by, the campaign (see Marı´n & Pe´rez-Stable, 1995; Warnecke et al., 1992). (5) Media campaigns should consider the literacy needs, language preferences, and cultural values of low SES smokers, including (where applicable) African American and Hispanic smokers when designing messages (see Marı´n & Pe´rez-Stable, 1995; Warnecke et al., 1992). It is noteworthy that these recommendations echo those made in broader reviews of media campaign strategies for smoking cessation at the population level (e.g., Hopkins et al., 2001; Ranney et al., 2006). There is currently insufficient evidence with which to draw stronger conclusions about the most promising messages (why to quit vs. how to quit) or executional styles (evocative testimonials vs. less emotional portrayals) to promote smoking cessation among low SES populations, but these issues should be addressed in future research. Conclusion This paper reviewed literature on the effectiveness of media campaigns to promote smoking cessation among low SES populations based on a logic framework that described how media strategies might lead to differences in smoking cessation between groups. We found considerable evidence that media campaigns to promote overall

smoking cessation among the general population are often less effective, sometimes equally effective, and rarely more effective among disadvantaged populations relative to more advantaged populations. There is much left to learn. In the meantime, states and communities should combine large-scale media strategies with other tobacco control programs and policies. In combination, these strategies hold potential to change the social and structural climate of tobacco use across diverse populations. Acknowledgements We are grateful to David Gundersen and the Wisconsin Tobacco Prevention and Control Program, as well as the Robert Wood Johnson Foundation Health and Society Scholars Program, for funding this study. We are also grateful to Pat Remington, Lezli Redmond, Gloria Meyer, Rob Adsit, Wendy Theobald, Paula Keller, Robin Perry, and Chris Hollenback for help in finding relevant articles. References Ahijevych, K., & Wewers, M. E. (1995). Low-intensity smoking cessation intervention among African-American women cigarette smokers: a pilot study. American Journal of Health Promotion, 9, 337–339. An, L. C., Schillo, B. A., Kavanaugh, A. M., Lachter, R. B., Luxenberg, M. G., Wendling, A. H., et al. (2006). Increased reach and effectiveness of a statewide tobacco Quitline after the addition of access to free nicotine replacement therapy. Tobacco Control, 15, 286–293. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Biener, L., Reimer, R. L., Wakefield, M., Szczypka, G., Rigotti, N., & Connolly, G. (2006). Impact of smoking cessation aids and mass media among recent quitters. American Journal of Preventive Medicine, 30(3), 217–224. Campbell, M. K., Tessaro, I., DeVellis, B., Benedict, S., Kelsey, K., Belton, L., et al. (2002). Effects of a tailored health promotion program for female blue-collar workers: health works for women. Preventive Medicine, 34, 313–323. Campion, P., Owen, L., McNeill, A., & McGuire, C. (1994). Evaluation of a mass media campaign on smoking and pregnancy. Addiction, 89, 1245–1254. Elder, J. P., Campbell, N. R., Mielchen, S. D., Hovell, M. F., & Litrownik, A. J. (1991). Implementation and evaluation of a community-sponsored smoking cessation contest. American Journal of Health Promotion, 5, 200–207. Fagan, P., King, G., Lawrence, D., Petrucci, S. A., Robinson, R. G., Banks, D., et al. (2004). Eliminating tobacco-related health disparities: directions for future research. American Journal of Public Health, 94, 211–217. Fisher, E. B., Auslander, W. F., Munro, J. F., Arfken, C. L., Brownson, R. C., & Owens, N. W. (1998). Neighbors for a smoke free north side: evaluation of a community organization approach to promoting smoking cessation among African Americans. American Journal of Public Health, 88, 1658–1663. Flay, B. R., McFall, S., Burton, D., Cook, T. D., & Warnecke, R. B. (1993). Health behavior changes through television: the roles of de facto and motivated selection processes. Journal of Health and Social Behavior, 34, 322–335. Fortmann, S. P., Taylor, C. B., Flora, J. A., & Jatulis, D. E. (1993). Changes in adult cigarette-smoking prevalence after 5 years of communityhealth education – the Stanford 5-city Project. American Journal of Epidemiology, 137, 82–96. Grier, S., & Bryant, C. A. (2005). Social marketing in public health. Annual Review of Public Health, 26, 319–339. Hahn, E. J., Rayens, M. K., Chirila, C., Riker, C. A., Paul, T. P., & Warnick, T. A. (2004). Effectiveness of a quit and win contest with a low-income population. Preventive Medicine, 39, 543–550. Hoffman, D. L., & Novak, T. P. (April 17, 1998). Bridging the racial divide on the internet. Science, 180, 390–391. Hopkins, D. P., Briss, P. A., Ricard, C. J., Husten, C. G., Carande-Kulis, V. G., Fielding, J. E., et al. (2001). Reviews of evidence regarding

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