1. TOBACCO RELATED MEDIA EXPOSURE AND INDICATORS OF SMOKING CESSATION Andrew Hyland, PhD Cheryl Higbee Melanie Wakefield, PhD Glen Szczypka, PhD Joseph Bauer, PhD Gary A. Giovino, PhD K. Michael Cummings, PhD, MPH Presented at 2003 National Conference on Tobacco or Health Boston, Massachusetts December 11, 2003

2. Acknowledgement NCI State and Community Tobacco Control Intervention Grants Program. Bob Vollinger and other NCI TCP staff

3. Objective To assess the relationship between exposure to tobacco control and pharmaceutical company advertising on cessation and use of stop smoking medications.

4. 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.

5. Narrator: Secondhand smoke kills. (c) California Department of Health Services

6. Methods Data Sources 1)Community Intervention Trial for Smoking Cessation (COMMIT). 2)Gross Rating Points (GRP’s) from Nielsen Media Research.

7. 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

8. 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

9. COMMIT Communities NEW YORK Binghamton/ Johnson City, New Rochelle, Utica, Yonkers WASHINGTON Bellingham, Longview/ Kelso NEW MEXICO Las Cruces, Sante Fe NEW JERSEY Trenton, Paterson OREGON Albany/ Corvallis, Medford/ Ashland NORTH CAROLINA Greensboro, Raleigh IOWA Cedar Rapids, Davenport MASSACHUSETTS Lowell, Fitchburg/ Leominster ONTARIO Brantford, Peterboro CALIFORNIA Hayward, Vallejo

10. 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

11. 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

14. 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

16. 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

17. 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

18. 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

19. 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 19992,949

20. Gross Rating Points (GRP’s) for State-sponsored Advertisements by Community, 2000

21. Gross Rating Points (GRP’s) for NRT and Zyban Advertisements by Community, 2000

22. Gross Rating Points (GRP’s) for Tobacco Company Advertisements by Community, 2000

23. Analysis – Outcomes 1)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.

24. Analysis – Predictors 1)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.

25. 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).

26. Analysis – Control Variables

27. *Assuming these smokers buy 50% of the cigarettes that they smoke from Indian Reservations and that they smoke 16 cigarettes per day. Results - Cessation “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.

28. “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.

29. “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.

30. “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.

31. 0250050007500 State GRP's 4 6 8 10 12 % Quit A A A A A A A A A A A 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. R 2 =.1157

32. * *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.

33. * *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.

34. * *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.

35. *

36. Results – NRT Use 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)

37. 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'

38. 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)

39. 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'

40. 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 % Used NRT 16 14 12 10 8 6 4 R 2 = 0.0111 A A A A A A A A A A A

41. *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. *

42. *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. *

43. *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. *

44. *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. *

45. 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%.

46. Conclusions Exposure to NRT or Zyban advertisements did not increase the probability of utilization of these products.