Journal of Adolescent Health
Volume 32, Issue 1 , Pages 36-43, January 2003

Effects of pro- and anti-tobacco advertising on nonsmoking adolescents’ intentions to smoke

  • Diane M Straub, M.D., M.P.H.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, San Francisco, California, USA
    • Corresponding Author InformationAddress correspondence to: Dr. Diane M. Straub, Department of Pediatrics, University of South Florida, 17 Davis Blvd., Suite 308, Tampa, FL 33606, USA.
    • ,
  • Nancy K Hills, M.A.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, San Francisco, California, USA
    • ,
  • Pamela J Thompson, M.P.H.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, San Francisco, California, USA
    • ,
  • Anna-Barbara Moscicki, M.D.

      Affiliations

    • Division of Adolescent Medicine, University of California, San Francisco, San Francisco, California, USA

Accepted 21 December 2001.

Article Outline

Abstract 

Purpose

To determine the effects of pro- and anti-tobacco advertising on nonsmoking adolescents’ intention to smoke in a single cohort.

Methods

All ninth graders at seven public high schools were invited to participate in a study on adolescent tobacco use; 59.0% participated (n = 1229; active positive parental consent required). Adolescents who self-identified as never having smoked even a puff of a cigarette (n = 512) completed a self-administered questionnaire that included questions on intention to smoke in the near future and tobacco advertising. Independent variables used to predict intention included exposure to, recognition of, and receptivity and attitudes toward pro-tobacco and anti-tobacco advertising. Potential confounding variables included gender, race/ethnicity, smoking influences (adult household members, siblings, and friends), socioeconomic status, stress, and depression. Data analysis used logistic regression.

Results

Demographics: 50.5% female, average age 14.9 ± 0.4 years old at baseline, and varied race. Those variables found to be significant predictors of intention to smoke included: (positive, or increased intention) recognition of brand of favorite advertisement, willingness to use or wear tobacco-branded products, stress, and having friends who smoke and (negative, or decreased intention) agreement with anti-tobacco advertising and having a live-in father who smokes.

Conclusions

Although anti-tobacco advertising has a protective effect, it was unable to counteract the effects of pro-tobacco advertising in the same cohort.

Keywords:  Adolescents, Advertising, Anti-tobacco, Media, Pro-tobacco, Smoking, Tobacco control

 

Although smoking rates in adults have declined in recent years, rates among adolescents have continued to rise [1]. Because 90% of adult smokers started as adolescents, the teenage years comprise the most crucial time for the implementation of effective strategies to prevent adult smoking.

Tobacco companies have long been known to design marketing strategies aimed at young potential smokers, targeting them not only with pro-tobacco messages but also with sales promotional features 2, 3, 4. Cigarette brands popular among adolescents are more likely than adult brands to be advertised in magazines with high youth readerships [5]. Several studies have found these marketing strategies to be effective in increasing adolescent smoking 6, 7, 8, 9, 10. Receptivity to tobacco advertising has been shown to be associated with intention to smoke in adolescents in several cross-sectional studies 11, 12, 13, 14, 15. Recent longitudinal studies by Biener and Siegel [16] and Pierce et al. [17] have shown that receptivity to tobacco advertising is strongly linked to smoking initiation.

The potential power of the media was also recognized by anti-tobacco coalitions. It was thought that because media messages can enhance initiation of adolescent smoking, they might also be effective in educating adolescents about its inherent dangers. Public service announcements, in general, have been shown to have a positive effect on adolescent sensibility and behavior [18]. Unfortunately, studies examining the effects of media campaigns on adolescent smoking initiation rates have had mixed results 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. There is evidence to support that strong anti-smoking attitudes are inversely linked to smoking behavior in teens 31, 32. However, much of this work focuses primarily on messages related to the long-term effects of smoking and predates the newer, hopefully more effective tobacco control messages and the current charged tobacco-related political climate.

To our knowledge, no studies to date have looked at the influence of both pro- and anti-tobacco advertising and intention to smoke in a single cohort. We therefore undertook this study with the objective of evaluating (a) the effects of current anti-smoking advertising messages on adolescents’ intentions to smoke in a longitudinal high school cohort, and (b) the potential relationship between the simultaneous effects of both pro- and anti-tobacco advertising on nonsmoking adolescents’ intentions to smoke.

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Methods 

Sample 

All ninth graders at seven ethnically/racially diverse public high schools in the San Francisco Bay Area were invited to participate in a longitudinal study on adolescent tobacco use. Of the 2199, 75.9% (n = 1668) returned signed parental consent forms, of which 78.8% granted consent, for an overall participation rate of 59.8%. Data for this cross-sectional study were obtained from the second data collection (6 months after the baseline survey) owing to a higher completion rate (95%) at that time for questions pertaining to tobacco advertising.

Of the 1229 participants completing the first follow-up survey, 885 were nonsmokers, as defined by having smoked <10 cigarettes in their lifetime. For this study, 373 participants who reported any experimentation with cigarette smoking were excluded from the analysis. Of the remaining 512 nonsmokers who self-identified as never having smoked even a puff of a cigarette, 260 were female (50.8%) and 242 were male (49.2%), with an average age of 14.9 ± 0.4 years. The racial distribution of participants was 43.1% (n = 218) white, 17.0% (n = 86) mixed ethnicity, 11.7% (n = 59) Filipino, 11.1% (n = 56) Asian/Pacific Islander, 10.7% (n = 54) Hispanic, 1.8% (n = 9) African-American, and 4.7% (n = 24) other ethnicity. Twenty-six percent of the participants’ mothers had a high school diploma or less, 40% had at least some college education, and 13% had completed some postgraduate education.

Procedures 

Parent(s) and each subject gave informed consent and assent, respectively, for participation in the study according to the guidelines set forth and approved by the Committee for Human Research, the Institutional Review Board for the University of California, San Francisco. At the outset of the study, participants completed a form providing information about their smoking experience to classify them into one of three categories of smoking status (“nonsmoker”, “smoker”, “ex-smoker”). Questionnaires specific to smoking status were then distributed, and were completed by students during one regular class period.

Measures: pro-tobacco predictor variables 

Exposure to Pro-Tobacco Advertising scale was adapted from the National Youth Tobacco Survey and includes additional items from the Youth Attitudes and Practices Survey, which analyzes tobacco use in California. The seven individual items questioned the frequency with which respondents saw or heard smoking advertisements in various types of media and locations (i.e., movies, internet, convenience stores). Responses were coded on a four-point Likert scale ranging from “never” to “most of the time.” The score was coded as an average of all responses and entered into the analysis as a continuous variable. Sample questions included: “How often do you: See ads for cigarettes or tobacco products on billboards or signs? See famous people smoking when you watch TV?” (Cronbach alpha = 0.74).

Recognition of Pro-Tobacco Advertising scale was adapted from the receptivity scale from Pierce et al.’s California Tobacco Survey [11]. To assess respondents’ cognitive attention to messages contained in tobacco advertising, respondents were asked if any of the tobacco advertisements they had seen contained any of nine messages. Responses were coded as “yes” or “no.” Positive responses were summed for a continuous variable. Sample questions included “Did any of the tobacco ads [that you have seen or heard] contain messages that: Smoking is an enjoyable experience? Smoking helps people relax?” (Cronbach alpha = 0.86).

Receptivity to Pro-Tobacco Advertising scale was also adapted from Pierce et al.’s receptivity scale [16]. To assess respondents’ affective response to tobacco advertising, a receptivity score was computed based on four items: (a) indication of having a favorite brand tobacco advertisement (subjects were given a list of 11 brands from which to choose, including “other”); (b) selection of a preferred brand if one were to purchase cigarettes (subjects were given the same choices as those listed for item a); (c) possession or receipt of tobacco promotional items (sample question included “Have you ever purchased an item with a tobacco brand name or logo on it?”); and (d) willingness to use items with a tobacco company logo (answers ranged from “definitely yes” to “definitely no”). Because of the highly significant (p < .0001) correlation between the first two items, we combined them into one item, and responses on each of the three items were then standardized to ensure equal weighting and summed for the final continuous receptivity score. In our analysis, the resultant scale was both predictive and significant, however our Cronbach alpha was 0.37. Omitting the first item increased the Cronbach alpha to 0.46, a score we felt was not high enough to warrant combining them. Consequently we elected to examine each item separately in the final analysis. The subscale examining possession/receipt of tobacco promotional items (item (c), above) was comprised of five separate questions and had a reliability coefficient of 0.66.

Anti-tobacco predictor variables 

Because anti-tobacco campaigns increase in effectiveness when their messages are geared specifically to adolescents [33], focus group studies have been used to identify the most salient messages for teenagers [34]. As part of the development of the California, Massachusetts, and Michigan anti-smoking advertising campaigns, the following messages were found to be effective with adolescents: (a) exposure of the tobacco industry’s predatory, manipulative marketing, which angered youth seeking to act independently; (b) messages about secondhand smoke, which provoked outrage and a “sense of injustice for the little guy,” and (c) addiction advertisements emphasizing both the addictive nature of nicotine and the industry’s use of this knowledge to hook smokers. Other less-effective messages included short-term effects, long-term health effects, and romantic rejection [34]. Items used as part of our anti-tobacco predictor variable scales were based upon this research [34], with some additional messages identified from various other anti-smoking campaigns.

Exposure to anti-tobacco advertising 

To assess respondent’s exposure to tobacco control messages, an eight-item scale corresponding with the exposure to pro-tobacco advertising scale was devised to query how often respondents saw tobacco control messages in various types of media. Corresponding four-point Likert scales were used; responses (ranging from “never” to “most of the time”) to the eight items were averaged and entered into the analysis as a continuous variable. Sample questions included: “How often do you: See anti-smoking commercials on TV? See anti-tobacco messages on billboards or outdoor signs?” (Cronbach alpha = 0.81).

Recognition of anti-tobacco advertising 

To assess whether respondents cognitively attend to tobacco control messages, participants were asked if any of the tobacco control advertisements they had seen contained any of 10 anti-tobacco messages. Positive responses were summed for a continuous variable. Sample questions included: “Did any of the anti-tobacco ads you’ve seen contain the following messages: Smoking cigarettes can kill you? Smoking cigarettes is harmful to babies and children?” (Cronbach alpha = 0.82).

Agreement with anti-tobacco advertising 

To determine their affective responses to the messages contained in the tobacco control advertising, respondents were asked their opinions on 12 messages, using a four-point Likert scale ranging from “strongly agree” to “strongly disagree.” Responses were averaged for a continuous variable. Sample questions included: “How much do you agree or disagree with the following statements: Tobacco companies lie or mislead young people about the effects of tobacco. Tobacco is addictive?” (Cronbach alpha = 0.87).

Outcome variable: intention to smoke 

Prior studies have validated an “intention to smoke” scale as a valid predictor of smoking initiation 35, 36, 37. Our expanded version of this scale, with its seven items, queried respondents regarding their intentions to smoke. A four-point Likert scale, with responses ranging from “definitely yes” to “definitely not,” was summed for a continuous variable. Sample questions included: “Do you think you will try a cigarette soon?” and “If one of your best friends offered you a cigarette, would you smoke it?” (Cronbach alpha = 0.90). Unlike the binary or similarly limited outcome used by previous studies, our continuous outcome variable allowed for a broad range of intention (from a low of 0 to 21 of a possible 21).

Potential confounding variables 

To examine the role of confounders in the relationship between intention to smoke and both pro- and anti-tobacco advertising, we evaluated several other variables that have been associated with smoking initiation in the literature. These included gender, race/ethnicity, smoking influences (adult household members, siblings, and close friends), socioeconomic status (maternal education level), stress (based on the 14-item Abbreviated Perceived Stress Scale [38]), and depression (based on the 8-item Center for Epidemiologic Studies Depression Scale [39]) 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56.

Data analysis 

To investigate the relationship between intention to smoke and various measures of recognition of, and response to, pro- and anti-tobacco messages in the media, regression analysis was performed using the continuous intention score as an outcome variable, and the following as possible predictors: exposure to pro-tobacco advertising, recognition of pro-tobacco advertising, receptivity to pro-tobacco advertising (defined as brand recognition/favorite pro-tobacco advertisement, receipt of tobacco-branded products, and willingness to use/wear tobacco-branded products), exposure to anti-tobacco advertising, recognition of anti-tobacco advertising, and agreement with anti-tobacco advertising. Each predictor was entered into the analysis individually, and those significant in univariate analysis at an alpha level of 0.05 were entered into a multivariate analysis.

To explore the potential association between pro-tobacco receptivity and professed agreement with anti-tobacco messages in terms of how their relationship with each other might influence their ability to predict intention to smoke, a path analysis was done. The pro-tobacco variable used for this analysis was willingness to use and/or wear products bearing a tobacco logo. Although recognizing tobacco brands was also highly significant in univariate analysis, we chose not to use this variable because a large majority of the students cited a favorite cigarette ad, a brand preference, or both, thus limiting the usefulness of this variable as a predictor. A correlation analysis confirmed a significant negative correlation between the pro-tobacco receptivity and agreement with anti-tobacco ads; we therefore performed path analysis as described by Baron and Kenny [57] to test whether either of these predictors might mediate the relationship between smoking intention and the other predictor.

Potential confounders were analyzed in univariate analysis; those shown to be significant were then examined using correlation analysis to determine their relationships to the relevant predictors. Those related both to the outcome and to at least one of the predictors were adjusted for in multivariate analysis.

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Results 

Table 1 displays the results of univariate analysis. Those variables found to be significant predictors of intention to smoke include: (negative predictors) agreement with anti-tobacco advertising and living with a father who smokes, and (positive predictors) brand recognition/favorite pro-tobacco advertisement, willingness to wear/use tobacco-branded products, having friends who smoke, stress, depression, and living with a step-father who smokes. Table 2 represents those predictors that remained significant in multivariate analysis: (negative predictors) agreement with anti-tobacco advertising and living with a father who smokes and (positive predictors) brand recognition/favorite pro-tobacco advertisement, willingness to wear/use tobacco-branded products, stress, and having friends who smoke.

Table 1. Predictors of Intention (Univariate Analysis)
VariableParameter Estimatep value
Pro- and anti-tobacco advertising variables
Agreement with anti-tobacco advertisinga−2.81.0001
Receptivity to pro-tobacco advertising:1.16< .0001
Brand recognition/favorite pro-tobacco advertisementa
Receptivity to pro-tobacco advertising:0.27.12
Receipt of tobacco-branded productsa
Receptivity to pro-tobacco advertising:1.11< .0001
Willingness to wear/use tobacco-branded productsa
Exposure to pro-tobacco advertisinga0.52.09
Exposure to anti-tobacco advertisinga.38.23
Recognition of anti-tobacco advertisinga−.054.48
Recognition of pro-tobacco advertisinga0.02.82
Potential Confounding Variables
Having friends who smoke1.62< .0001
Stress0.13< .0001
Depressionb0.19< .0001
Stepfather in household who smokesc3.77.002
Father in household who smokesc−1.05.04
Having any adults in the household who smoke−0.42.30
Stepmom smokesc−1.02.55
Total siblings in household who smoke (per sibling)0.29.57
Total adults in household who smokec (per adult)−0.11.69
Mother in household who smokesc−0.10.86
Socioeconomic status as measured by maternal education0.03.94

a Variables as explained above.

b Based on Center for Epidemiologic Studies Depression Scale.

c Does *** both live with you and smoke?

Table 2. Predictors of Intention (Multivariate Analysis)a
VariableParameter Estimatep value
Agreement with anti-tobacco advertising−1.94340< .0001
Receptivity to tobacco advertising: recognition of brands, favorite ads0.75788.01
Receptivity to tobacco advertising: willingness to wear/use tobacco products0.74714.0008
Stress0.08500< .0001
Friends who smoke1.00767.0018
Live-in dad smokes−1.31109.0065

a Gender and race were not significant in multivariate analysis and were not included in the final model.

Path model results 

In path analysis, receptivity to pro-tobacco advertising, as defined by willingness to wear/use tobacco products, and agreement with anti-tobacco advertising are significant predictors of smoking intention even when both are included in the regression equation. We therefore found no evidence that either functions as a mediator of the relationship between intention and the other; rather, each exerts its own strong independent effect (p < .0001 for each).

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Discussion 

Independent of known influences on adolescents’ intentions to smoke, we found that both receptivity to pro-tobacco advertising and agreement with anti-tobacco advertising were strong predictors of intention to smoke. The literature shows intention to smoke as a valid predictor of subsequent behavior; therefore the use of intention as an outcome measure is important in this study because it represents the first step in the decision-making process to smoke. Because adolescents are most likely exposed to the effects of both pro- and anti- tobacco advertising simultaneously, studying their independent effects in the same cohort is clearly important. To the best of our knowledge, this is the first study to do so.

The association between receptivity to tobacco advertising and intention to smoke is well-demonstrated in the literature 11, 12, 13, 14, 15, 17, with several constructs used to represent “receptivity.” Our initial scale sought to incorporate the concepts of affective response to tobacco advertisements and both passive and active involvement with sales promotional items. The first item, recognition of brands/favorite pro-tobacco advertisement, has been used as part of a broader receptivity scale in telephone surveys. Although the variable was a significant predictor of intention, the majority (92%) of our respondents did indicate a brand of their favorite advertisement, and we may have prompted responses by providing a list of possible brands in our pencil-and-paper questionnaire rather than asking an open-ended question. The second item on the original receptivity to tobacco advertising scale, receipt of tobacco-branded products, represents a passive role on the part of the respondent. In our study, this item was not predictive of intention to smoke. The third question, related to willingness to wear/use tobacco-branded products, was significantly associated with intention to smoke. Feighery et al. [12] illustrate the interrelationships among these constructs when they discuss the marketing strategy of using promotions to allow the consumer to “try on” an identity and thus move him or her closer to trying the product. Those adolescents attracted to the images seen in tobacco advertisements are then more likely to use or wear the corresponding tobacco products and finally are more susceptible to subsequent smoking behaviors. Our findings support this theory, and further confirm the relative strength of promotional goods as an advertising strategy.

Several studies have evaluated attitudes toward smoking and knowledge of and beliefs regarding health consequences, but not in the context of corresponding media messages 31, 32, 51, 52, 58, 59. No studies to date have directly examined the association between agreement with the messages presented in anti-tobacco advertising and intention to smoke. Flynn et al., during an evaluation of media and school-based intervention, found that the interventions positively affected students’ attitudes toward and perceptions of advantages and disadvantages of smoking, but did not report on the relationships of these variables with either intention or subsequent smoking behaviors [19]. Siegel and Biener looked at specific knowledge and attitude variables as possible mediators in an anti-smoking campaign; they report that exposure to the campaign was not associated with subsequent differences in these variables, but they do not comment on these variables’ interactions with either intention or smoking behaviors [27]. In our study, agreement with anti-tobacco advertising showed an independent strong inverse association with intention to smoke. That is, agreement with anti-tobacco messages is protective. Our scale inquired about specific anti-tobacco advertising messages, including long- and short-term health effects, secondhand smoke, manipulatory practices of the tobacco industry, and others. Unfortunately, owing to the high degree of collinearity, we were unable to ascertain which messages were the most effective.

As expected, receptivity to pro- and agreement with anti-tobacco advertising were inversely correlated. When we investigated this relationship further with path analysis, neither variable was found to mediate the relationship between intention and the other predictor. Clearly, youth are being simultaneously exposed to both pro- and anti-tobacco advertising, and it appears that each exerts an independent effect on their intention to smoke.

Other predictors of intention to smoke included experiencing stress, having friends who smoke, and living with a father who smokes. Stress as an independent predictor is consistent with other studies 55, 56. Interestingly, stress was also correlated with receptivity to pro-tobacco advertising and inversely correlated with anti-tobacco advertising. Those individuals with higher stress levels may be more vulnerable to the messages contained in pro-tobacco advertising, and those with lower stress levels may be receptive to anti-tobacco advertising. Depression did not maintain significance in multivariate analysis, probably owing to its high correlation with stress. As expected, having friends who smoke was predictive of intention to smoke. This finding continues to support the important contribution of peer influences on intention to smoke. It is interesting to note that in our sample, living with a father who smokes was inversely correlated with intention to smoke. One could theorize that firsthand exposure to the adverse effects of smoking and to secondhand smoke may make smoking less appealing to the adolescent. This is contrary to results found in other studies and may represent changing attitudes regarding smoking (e.g., it is not as socially acceptable as in the past), or changing motivations to smoke (e.g., it is no longer rebellious to smoke if your father smokes).

Exposure to, and recognition of, both pro- and anti-tobacco advertising were not significant in our analysis. This has been borne out by the literature. Feighery et al. found that 99% of respondents reported seeing tobacco advertising and promotions in a variety of venues [12], suggesting that exposure is universally high. Brown et al. showed that there is a high degree of recognition of anti-tobacco advertising, even in areas serving as controls for anti-smoking campaigns; only messages differing significantly from other campaign messages were not likely to be falsely recognized [60]. High exposure and recognition may be owing to general awareness of tobacco as a current political topic.

The historical context and political climate of tobacco during the time of our study warrants further discussion. The media messages we used for our agreement with anti-smoking advertising scale were taken largely from the focus groups used to design the California campaign, which has been ongoing (with a brief hiatus) since 1990. Thus, our analysis of attitudes toward anti-smoking messages should be reflective of the tobacco control messages to which adolescents were actually exposed. Regarding pro-tobacco advertising, the political climate at the time of these studies was influenced by the national debates on settlement money from the tobacco industry to former smokers and the aggressive tobacco control legislation enacted with the passage of California’s Prop 99 in 1988, including tobacco taxes and limitations on pro-tobacco advertising. Given these seeming setbacks for the tobacco industry, the fact that receptivity to pro-tobacco advertising was strongly predictive in our study continues to underscore its strength. Finally, Philip Morris’s national youth smoking prevention campaign, with its message that smoking is an “adult” behavior, seems a tantalizing dare designed to further enlist adolescent smokers. In fact, preliminary data from California in 1999 (1 year after its initiation) suggest that it is ineffective, and may even promote adolescent smoking [61], so it is difficult to determine the effect of the campaign on our current study.

Because our data are cross-sectional, generalizability regarding intentions to smoke is limited, and causal relationships cannot be determined. Although there is now support for the causal relationship between receptivity to pro-tobacco advertising and intention in the literature [16], the relationship between agreement with anti-tobacco advertising and intention is not so clear. It is possible that decisions regarding a refusal to smoke precede agreement with anti-tobacco advertising. Longitudinal analyses will help to further investigate this relationship. Specifically, the use of smoking behavior as an outcome will contribute significantly to understanding these relationships.

In conclusion, the ultimate influence of the tobacco company strategies is clear. Although anti-tobacco advertising has a protective effect, even with current tobacco control messages it was unable to counteract the effects of pro-tobacco advertising in the same cohort. Further studies to determine the most effective anti-tobacco messages for adolescents will continue to refine our media campaigns.

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Acknowledgements 

Funding support came from the California Tobacco-Related Disease Research Program.

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PII: S1054-139X(02)00451-2

Journal of Adolescent Health
Volume 32, Issue 1 , Pages 36-43, January 2003

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