5.4 measures to assess the effectiveness of restrictions on - iarc

5.4 Measures to assess the effectiveness ofrestrictions on tobacco marketing communications

259

IInnttrroodduuccttiioonn

The WHO FCTC proposes acomprehensive ban on tobaccoadvertising, promotion, and spon-sorship, in recognition that it wouldreduce consumption of tobaccoproducts (Figure 5.12). This sectionwill explain how to go aboutmeasuring the effectiveness ofrestrictions on tobacco marketingcommunications, such as adver-tising bans or limitations on the useof specific media. First, terms aredefined and explanations given onhow promotional activity fits into thewider marketing strategy of tobaccocorporations. The importance ofrestrictions on tobacco promotion isdiscussed, as well as the need tomeasure their effectiveness. Dif-ferent ways of measuringeffectiveness are looked at, with anargument that consumer surveysare one of the most useful. Finally,specific measures that can be usedare offered.

DDeeffiinniinngg tteerrmmss:: ttoobbaaccccoo pprroo--mmoottiioonn aanndd mmaarrkkeettiinngg

Tobacco promotion covers all thecommunication efforts tobaccocorporations use to encourageconsumption of their products.These include mass media adver-tising (e.g. television, posters, andin the press), sponsorship ofsporting and cultural events, point-

of-sale promotion, merchandisingand give-aways, and publicrelations. Table 5.23 provides anillustrative list.The communication efforts, or

more accurately marketing commu-nications, outlined in Table 5.23,aim to encourage consumption oftobacco products by relaying avariety of messages to customers.As well as communicating basicproduct information and remindingthe world about its product,marketing communications areused to reassure current customersthat they have made the rightdecision, encourage new customersto try their product, and steercustomers away from competitors.In essence the goal is to tell thecustomer or potential customer howthe offering fulfils their needs.A well-established business

literature about the value ofintegrated marketing communi-cations (IMC) (Schultz & Kitchen,2000) argues for combining massmedia and other marketing com-munications in a marketingcommunications mix. IMC holds thatall company communications withtheir customers, through whateverchannels, should be coordinatedand coherent to articulate acompletely unified message. In thisway, the whole can become greaterthan the sum of the parts. Forexample, this comment from atobacco industry advertising agent

shows how merchandising,packaging, and advertising arepressed into joint service:

“What I would add is thatthere is a definite sub-cultureamong younger roll-your-ownsmokers, and I believe theirdesire to display their exclusivitycould be supported by provisionof unusually designed “badges”such as (transparent?) Rawlighters and rolling machines.This will enable them todifferentiate themselves fromuncool, older GV [GoldenVirginia] smokers, who I suspectwould not be particularlymotivated to buy the product byeither the advertising or thepackaging” (Collet DickensonPierce, 1999).For many fast moving consumer

goods (that have a quick turnoverand relatively low cost), the ultimateaim of integrated marketingcommunications is to build evo-cative brands; something thetobacco multinationals do well, andis crucial for their financial success.Brands and their carefully craftedimagery are the principal means ofmeeting the psychosocial needs ofone of their most important markets:young people. Ultimately, “if a brandof cigarettes does not convey muchin the way of image values, theremay well be little reason for a youngsmoker to persist with or adopt thebrand” (Rothmans Marketing

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IARC Handbooks of Cancer Prevention

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1. Parties recognize that a comprehensive ban on advertising, promotion and sponsorship would reduce theconsumption of tobacco products.

2. Each Party shall, in accordance with its constitution or constitutional principles, undertake a comprehensive banof all tobacco advertising, promotion and sponsorship. This shall include, subject to the legal environment andtechnical means available to that Party, a comprehensive ban on cross-border advertising, promotion andsponsorship originating from its territory. In this respect, within the period of five years after entry into force of thisConvention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/orother measures and report accordingly in conformity with Article 21.

3. A Party that is not in a position to undertake a comprehensive ban due to its constitution or constitutional principlesshall apply restrictions on all tobacco advertising, promotion and sponsorship. This shall include, subject to thelegal environment and technical means available to that Party, restrictions or a comprehensive ban on advertising,promotion and sponsorship originating from its territory with cross-border effects. In this respect, each Party shallundertake appropriate legislative, executive, administrative and/or other measures and report accordingly inconformity with Article 21.

4. As a minimum, and in accordance with its constitution or constitutional principles, each Party shall:(a) prohibit all forms of tobacco advertising, promotion and sponsorship that promote a tobacco product by any

means that are false, misleading or deceptive or likely to create an erroneous impression about itscharacteristics, health effects, hazards or emissions;

(b) require that health or other appropriate warnings or messages accompany all tobacco advertising and, asappropriate, promotion and sponsorship;

(c) restrict the use of direct or indirect incentives that encourage the purchase of tobacco products by the public;(d) require, if it does not have a comprehensive ban, the disclosure to relevant governmental authorities of

expenditures by the tobacco industry on advertising, promotion and sponsorship not yet prohibited. Thoseauthorities may decide to make those figures available, subject to national law, to the public and to theConference of the Parties, pursuant to Article 21;

(e) undertake a comprehensive ban or, in the case of a Party that is not in a position to undertake a comprehensiveban due to its constitution or constitutional principles, restrict tobacco advertising, promotion and sponsorshipon radio, television, print media and, as appropriate, other media, such as the internet, within a period of fiveyears; and

(f) prohibit, or in the case of a Party that is not in a position to prohibit due to its constitution or constitutionalprinciples restrict, tobacco sponsorship of international events, activities and/or participants therein.

5. Parties are encouraged to implement measures beyond the obligations set out in paragraph 4. 6. Parties shall cooperate in the development of technologies and other means necessary to facilitate the elimination

of cross-border advertising.7. Parties which have a ban on certain forms of tobacco advertising, promotion and sponsorship have the sovereign

right to ban those forms of cross-border tobacco advertising, promotion and sponsorship entering their territoryand to impose equal penalties as those applicable to domestic advertising, promotion and sponsorship originatingfrom their territory in accordance with their national law. This paragraph does not endorse or approve of anyparticular penalty.

8. Parties shall consider the elaboration of a protocol setting out appropriate measures that require internationalcollaboration for a comprehensive ban on cross-border advertising, promotion and sponsorship.

WHO (2003)

Figure 5.12 WHO FCTC Article 13: Tobacco Advertising, Promotion and Sponsorship

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Measures to assess the effectiveness of restrictions on tobacco marketing communications

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Services, 1998). The challengetherefore is to “cement the brandinto the repertoire of theexperimental smoker” (ColletDickenson Pierce, 1996).It has been found that younger

smokers give more weight to theimagery of cigarettes, and paymore attention and are receptiveto fashionable brands and thelatest designs (Hastings &MacFadyen, 2000). Well-knownbrands, most notably Marlboro

lights, exploit these emotionalneeds and insecurities: “thesuccess of Marlboro Lightsderives from its being…theaspirational lifestyle brand…“cool”…the Diet Coke of ciga-rettes” (The Leading EdgeConsultancy, 1997). The power of brand imagery is

not only used on the young. In thelow tar sector, branding, names,and liveries are used to createreassuring images and asso-

ciations. For example, a low tarproduct “is supported by thebrand’s imagery,” which has a “highassociation with ‘health consciouspeople’” (Marketing Trends, 1995).Also, the tobacco industry hasused images of happiness,physical well-being, harmony withnature, and a self-image ofintelligence to appeal to the older,“concerned” smokers to dis-courage them from quitting (Pollay,2000; Pollay & Dewhirst, 2002).

AAddvveerrttiissiinnggBroadcast media (TV, radio, cinema)Outdoor (billboards, posters outside stores)Press

SSppoonnssoorrsshhiipp ooff SSppoorrttss aanndd tthhee AArrttss

PPooiinntt--ooff--SSaalleePromotional material in shops (branded gantries, clocks, signage, staff clothing)

CCoouuppoonn SScchheemmeessCoupons included in packs of cigarettes that can be exchanged for free gifts

MMeerrcchhaannddiissiinnggLow cost items (pens, lighters or t-shirts), competitions, free cigarettes

SSppeecciiaall PPrriiccee OOffffeerrssShort-term low price offers advertised in-store, on pack flashes, or in other media

PPrroommoottiioonnaall MMaaiillMarketing communications sent straight to customers

BBrraanndd SSttrreettcchhiinnggNon-tobacco products with tobacco branding (Marlboro Classic clothes)

PPaacckk ddeessiiggnnss ttoo ccoommmmuunniiccaattee bbrraanndd iimmaaggee aanndd ttoo aadddd vvaalluuee

IInntteerrnneett ssiitteessWebsites promoting tobacco companies, cigarette brands, or smoking

PPrroodduucctt PPllaacceemmeennttPaid for placement of cigarette brands in films or television

Table 5.23 Examples of Tobacco Marketing Communications



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Evocative branding, createdthrough research to complementconsumers’ lifestyles and aspira-tions, is spread by integrated mar-keting communications. This com-munication effort dovetails with thecompany’s wider marketing effort,encompassing product design,pricing, and distribution, to ensureoptimal consumer satisfaction. The product’s marketing func-

tion is reinforced by itsprominence in the smoker’s life:“Smokers buy cigarettes fre-quently. They carry their brandaround with them and see otherbrands constantly. The product isa prime means of communicatinga change” (Collet DickensonPierce, 1998). New product development

ideas ensure that the needs ofconsumers are met and thatappropriate pharmacological andaspirational benefits are offered.The new smoker is assisted on thepassage from experimenter toregular smoker by lower pH levelsin cigarettes, which lowers the rateof absorption of nicotine, thusminimising the initial side-effects ofsmoking, such as dizziness andnausea (Claude, 1973). Tobaccomarketers have also developed“product line extensions” spe-cifically in response to increasinghealth propaganda. For virtuallyevery brand there is now a “light” or“low” alternative, providing theworried smoker with an excuse orrationalisation to continue smo-king. Other development ideasinclude an Espresso cigarette to fitthe new “café culture” and toprovide “quick hit (caffeine/nicotine) with young, streetwise

imagery” (e.g. “a lad’s cigarette,complete with scantily clad womenon the cigarette paper!”), and“nationalistic (but not jingoistic)”Scottish and Welsh cigarettes toexploit devolution (Hastings &MacFadyen, 2000). These ideasnever reached the street, but theydo illustrate how the product ismanipulated to create synergy withthe overall marketing effort. Pricing strategies are also

important to tobacco companies,and the relationship betweenquality, brand image, and price isparticularly so, as it feeds intofundamental decisions aboutsegmentation and targeting. Thus,for the starter segment, premiumpricing is appropriate. While ado-lescents tend to be more pricesensitive than adults, they attributea greater premium to the imageattached to the more expensiveproduct, if they are visible andsocially important. Therefore thepricing strategy should clearlydemonstrate the high quality andstyle of the brand, if the product isto meet the adolescent’s needs forimage and social status (DiFranzaet al., 1991; DiFranza, 1995;Barnard & Forsyth, 1996; Pollay etal., 1996). For established smokers, their

addiction and maturity makes theprice-quality relationship less of anissue, making them more willing totrade down. In response, theindustry runs coupon schemesand sales promotions to reducethe perceived price of smoking.These types of pricing strategiestie the established smoker to oneparticular brand and reward themfor their loyalty.

For the tobacco industry, thedistribution system helps build thebrand personality and target thespecific need of each segment.Despite bans on the sale ofcigarettes to minors, distributiontactics still play a big role intargeting them. Wide distributionensures cigarettes become omni-present and a cultural norm,encouraging adolescents to over-estimate the extent, andunderestimate the social disap-proval, of smoking (Davis, 1991;Wakefield et al., 1992; Evans etal., 1995). More prosaically,marketers can place their productsin those outlets where it is easierfor adolescents to buy cigarettesand many of them do sosuccessfully. In the UK, outletssuch as newsagents, tobac-conists, and sweetshops are themost popular source for sales toyoung smokers (Boreham &Shaw, 2001; Bates et al., 2005),making them a good option forunder-age distribution.For the established smoker,

wide distribution also helps createan environment of normalcy andreassurance. Furthermore, thedistribution network is so completethat the smoker can rest assuredthat cigarettes will always bereadily available.Thus, the industry’s use of

integrated marketing commu-nications is nested in their widermarketing effort involving aconsumer oriented strategy to get“the right product, at the right time,in the right place, with the rightprice” (Cannon, 1992).The issues of product design

and pricing, and how these can be



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measured, are discussed inSections 5.3 and 5.1, respectively.This section is concerned withexamining marketing communi-cations; the evidence base thatshows that these strategies doinfluence smoker’s behaviour andthat they need to be restricted.

WWhhyy rreessttrriiccttiioonnss oonn ttoobbaaccccoommaarrkkeettiinngg ccoommmmuunniiccaattiioonnssmmaatttteerr

To help understand the potentialeffect of removing or restrictingtobacco marketing communi-cations, it is helpful to first look at aselection of studies that haveexamined the influence exerted bytobacco marketing, and the ap-proaches and measures that havebeen used in these studies. Theycan be helpful, not only in guidingexpectations about attributes thatwill change as a result ofrestrictions, but also in identifyingwhich measures are important tocollect.

Modelling aggregate demand:

One of the first and mostinfluential studies into the effectsof tobacco promotion on con-sumption was conducted in theUK (McGuinness & Cowling,1975). It modelled the aggregatedemand for cigarettes in terms ofprice, income, and advertising.The advertising measure was anestimate of the number ofmessages received by a con-sumer rather than expenditure.Their findings suggested thatadvertising does have a significanteffect on cigarette sales, but that

publicity of adverse health effectsof smoking had reduced the saleseffect of cigarette advertising.

Evaluation of advertising bans:

Evidence from studies evaluatingthe effects of advertising bansalso show that marketingcommunications have a significanteffect on consumption. The SmeeReport, which analysed Norway’s1975 Tobacco Act, concluded thatthe Act decreased smokingdemand between 9% and 16%(Economics and OperationalResearch Division of theDepartment of Health in England,Smee et al., 1992 - Economicsand Operational’... England).Similarly a study of the effects ofthe 1971 Finland Tobacco Act,which analysed data from 1960 to1987, concluded that theadvertising ban produced a long-term reduction of 6.7% in cigarettesmoking (Pekurinen, 1989). Mea-sures of per capita annualconsumption of cigarettes andtobacco were analysed by extentof advertising bans across 22countries (Saffer & Chaloupka,2000). Minimal effect was foundfrom limited bans in reducingtobacco use, but clear effect fromcomprehensive bans. (See thefollowing section on “Advertisingbans of specific media” fordefinitions of the types of bans.)

Evaluation of individual cam-paigns:

Evaluation of individual cam-paigns reveals how the tobaccoindustry has targeted specific

groups. For example, an evalu-ation of a Camel cigarettecampaign in the early 1990srevealed that in a short period oftime, it had made a huge impactupon children’s smoking beha-viour (DiFranza et al., 1991). Thecampaign featured a cartoondrawn Camel, known as Joe theCamel, which was suspected ofhaving particular appeal to chil-dren. The study asked aboutbrand preference and compared itwith data from seven surveysconducted prior to the launch ofthe Camel campaign. In the threeyears following the start of thecampaign there was an increasefrom 0.5% to 32.8% in theproportion of young smokers(aged up to 18) who namedCamel as their preferred brand.The study measured awarenessof the campaign and identificationof product type and brand nameby showing an advert masking allclues (except Old Joe) to theproduct and brand being ad-vertised. The research found thatchildren were more aware of thecampaign and more able toidentify the product type andbrand name from the logo thanadults. A campaign “appeal score”was compiled by asking subjectsto rate six unmasked Old Joeadverts across four items: cool,stupid, interesting, or boring. Theywere asked if they thought Old Joewas “cool” and if they would like tobe “friends” with him. Positiveresponses to each item werescored 1 and negative responsescoded 0 and the appeal score wasthe arithmetic sum of these.Children were found to be more



264

likely than adults to find thecampaign appealing.

Brand awareness and appreci-ation:

Campaigns are also linked withincreases in brand awareness andappreciation. Qualitative work wasconducted which found that chil-dren, as young as six years old,were aware of cigarette ad-vertising, and that young primaryschool children had learned thebrand imagery or personality ofleading cigarette brands fromadvertisements (Aitken et al.,1985). A survey in Englandshowed that 17% of 9-10 year oldsand 23% of 12-13 year olds wereable to name a favourite cigaretteadvertisement (Charlton, 1986).The brands named most frequentlywere also those most heavilyadvertised in the area at the time.In addition, it was found that thechildren who named favouriteadvertisements were also morelikely to agree with some positivestatements about smoking and theimage of smokers. It concludedthat children receive positive mes-sages about smoking behaviourfrom advertising, which mayreinforce their decision to startsmoking during experimentation.Thus, if tobacco advertising isbanned, the expectation is thatthese positive messages willlessen or be eliminated.

Brand choice:

Studies have also examined brandchoice in relation to tobaccoadvertising. Young smokers tend

to be particularly attracted to themost heavily advertised products,and it is these brands that domi-nate under-age sales. Forexample, the three most heavilypromoted brands in the USA in1993 (Camel, Marlboro, andNewport), were the three mostlikely to be purchased by adol-escents (Centers for DiseaseControl and Prevention, 1994c).Similar patterns of preference forheavily advertised brands havealso been observed amongst UKadolescents (Barton, 1998), andprolonged advertising makesbrands seem popular (Sutherland& Galloway, 1981). Although the majority of stu-

dies have examined the impact ofmass media advertising on smo-king, many other forms ofmarketing communication havealso been studied (see Table5.24). It is important to keep inmind the discussion about inte-grated marketing communi-cations at this point, as none ofthese communication efforts areintended to work in isolation.Indeed the final study listed inTable 5.24 underlines this point bydemonstrating a cumulative im-pact: the more forms of marketingcommunications that young peo-ple are aware of, the more likelythey are to smoke.

Longitudinal designs:

The research discussed thus farhas provided convincing evidencethat there is a relationship betweentobacco marketing communica-tions and smoking behaviour.However, it has not established

cause and effect; longitudinaldesigns are needed to do this. Alongitudinal study was undertakento measure the predisposingeffects of cigarette advertising onchildren’s intentions to smokewhen they were older (Aitken et al.,1991). Two interviews wereconducted among children aged11-14 years: those who expresseda stronger intention to smokeduring the second interview ratherthan the first, were more likely tohave liked cigarette advertising atbaseline. This demonstrates thatnonsmokers, who felt that theymay smoke when they were older,were paying more attention tocigarette advertising than othernonsmokers. An important meta-analysis of

longitudinal surveys has recentlybeen published by the CochraneLibrary (Lovato et al., 2003). Theauthors asked the question: “isprior exposure to tobacco industryadvertising and promotion asso-ciated with future smoking amongadolescents?”. They analysed theoutcome of nine longitudinal stu-dies, including the study mentionedabove. All nine studies showed “apositive, consistent, and specificrelationship” between exposure totobacco advertising and influenceupon adolescents to smokecigarettes. The authors concluded:

“Longitudinal studiessuggest that exposure totobacco advertising andpromotion is associated withthe likelihood that adolescentswill start to smoke. Based onthe strength of this association,the consistency of findingsacross numerous observa-



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SSppoonnssoorrsshhiipp• Exposure to a cigarette sponsored sports advertisement reinforced existing smoking behaviour, and for non-

smokers created favourable attitudes towards smoking, increased awareness, and liking of brands ( Hoek et al., 1993)

• Children show a higher awareness of the sponsoring brand, and link the exposure to brand recall and understanding of brand imagery (Ledwith, 1984; Aitken et al., 1986; Piepe et al., 1986)

• Children’s preference for motor racing is a significant independent variable in move to regular smoking (Charlton et al., 1997)

• The statement “smoking can’t be all that dangerous, or the Government would ban sports sponsorship” was put to over 4000 11-16 yr olds; substantially more smokers than nonsmokers agreed with it (Bates, 1999)

MMeerrcchhaannddiissiinngg• Items such as branded lighters, t-shirts, baseball caps, and badges frequently reach adolescents at the point-

of-sale, special events, or through competitions (Coeytaux et al., 1995; Gilpin et al., 1997; Pierce et al., 1999) • There is a significant relationship between experience of tobacco promotions and susceptibility to tobacco

use (Altman et al., 1996; Gilpin et al., 1997; Feighery et al., 1998)• There is a relationship between the numbers of promotional items owned and a higher likelihood of smoking

(Sargent et al., 2000)• There are relationships between smoking initiation rates and levels of promotional expenditure, and

owning/using tobacco promotional items and the onset of smoking (Bauer & Johnson, 1999; Redmond, 1999)

BBrraanndd--SSttrreettcchhiinngg• For example, the endorsement of holidays, cafés and music; items that are then sold rather than given away

(Centre for Tobacco Control Research, 2001)• Initial research focussed mainly on advertising for such products, and shows that this is consistently seen as

advertising for the sponsoring tobacco brand rather than the product (Aitken et al., 1985; Centre for TobaccoControl Research, 2001)

• The awareness of brand stretching by 15 year olds is independently associated with being a smoker (MacFadyen et al., 2001)

PPaacckkaaggiinngg• Tobacco packaging both reinforces brand imagery and reduces the impact of health warnings (Beede &

Lawson, 1992; Carr-Greg & Gray, 1993; Goldberg et al., 1995; Rootman & Flay, 1995)• When fewer brand image cues were on the packaging, adolescents were able to recall more accurately non-

image health information (Beede & Lawson, 1992)• Plain packaging limits the ease with which consumers associate particular images with cigarette brands and

significantly influences smoking behaviour (Goldberg et al., 1995)

PPooiinntt--ooff--SSaallee ((PPOOSS))• Cigarette packets were displayed in such a way at the POS as to act like advertising (DiFranza et al., 1999)• Young adolescents who reported seeing tobacco advertising in stores were 38% more likely to experiment with

smoking, and the advertising was found to enhance brand imagery (Schooler et al., 1996; Donovan et al.,2002)

• The more youth-orientated ads were displayed outside shops, the more often children tried to buy cigarettes (Voorhees et al., 1998)

• There are greater levels of POS advertising in areas where there is likely to be a high prevalence of smoking(e.g. low-income / ethnic minority areas); young people are unduly exposed to them (Woodruff et al., 1995;Ruel et al., 2001; Laws et al., 2002)

Table 5.24 The Influence of Marketing Communications on Smoking Behaviour



266

tional studies, temporality ofexposure and smoking beha-viours observed, as well as thetheoretical plausibility regar-ding the impact of advertising,we conclude that tobaccoadvertising and promotionincreases the likelihood thatadolescents will start to smoke.From a policy perspective,attempts to eliminate tobaccoadvertising and promotionshould be supported.”

A useful codicil could be addedto the authors’ final sentence: thatthere is also a need to devise

robust methodologies to monitorthe effectiveness of any suchprohibitions. To a large extent, thestudies mentioned above haveconcentrated on measuring theinfluence of advertising. Whenmeasuring the effects andeffectiveness of tobacco mar-keting restrictions/bans it isimportant to consider all potentialforms of remaining tobaccomarketing, and thereby monitorwhether or not the tobaccoindustry diverts their marketingactivities to less restricted media.

AAlltteerrnnaattiivvee mmeetthhooddoollooggiieess

In discussing the evidence base, itis apparent that variousapproaches and measures havebeen used to examine the effectsof tobacco promotion. Thesesame approaches are relevantand provide guidance as studiesare designed to assess the effectsand effectiveness of restrictionson tobacco marketing commu-nications. Below, the two mainapproaches (econometric studiesand consumer surveys) forexamining the effects and effec-tiveness of tobacco marketing

PPrroodduucctt PPllaacceemmeenntt• The paid for placement of cigarette products in films and on TV is a controversial, but documented, marketing

communications tactic. Strong evidence links this with adolescent smoking (Hart, 1996; Chapman & Davis 1997;Dalton et al., 2003)

LLooyyaallttyy SScchheemmeess• There is significantly greater participation in low-income areas, and coupons may offset the effect of price

increases (Centre for Social Marketing, 1995)• Loyalty schemes involvement among 15 year olds is independently associated with smoking (MacFadyen et al.,

2001)

FFrreeee SSaammpplleess• A systematic search of tobacco industry documents confirms free samples as a popular strategy (Sepe et al.,

2002)• Receipt of free samples by young people independently associated with susceptibility to smoke (Altman et al.,

1996)

IInntteerrnneett• Tobacco manufacturers have their own websites and sponsor further sites unrelated to tobacco. Also pro-tobacco

sites (not related to industry) include chat rooms/message boards and celebrities/attractive role models smoking,which may appeal to the young (Center for Media Education, 1997; Center for Media Education, 1998; Hong &Cody, 2002)

MMaarrkkeettiinngg CCoommmmuunniiccaattiioonnss• Young people are aware of all forms of tobacco marketing communications; over half of all smokers had

participated in some form of promotion; and the greater the number of tobacco marketing techniques a youngperson was aware of, the more likely they were to be a smoker (MacFadyen et al., 2001)

Table 5.24 The Influence of Marketing Communications on Smoking Behaviour



267

restrictions are discussed. Inaddition, complementary appro-aches are addressed, includingmarketing surveillance and inter-nal document analysis that canhelp to contextualise, interpret,and support results that emergefrom consumer surveys andeconometric analysis.

Econometric studies:

One approach is to use eco-nometric1 studies that modelchanges in tobacco consumptionwith fluctuations in tobaccoadvertising expenditures. Thereare two main types of econometricstudies: comparative studies ofcountries with different levels ofcontrols on advertising (cross-country studies); and studieswhich model the effect of year-to-year fluctuations in advertisingexpenditure on consumptionwithin one particular country (time-series studies). Prior econometric studies of

tobacco consumption have usedone of three alternative empiricalmeasures of advertising: nationalaggregate expenditure data,cross-sectional measures ofadvertising, and advertising bans(Saffer & Chaloupka, 2000).

National aggregate expendi-ture data:

Annual national advertisingexpenditures are the yearly total ofall cigarette advertising expen-

ditures, for all advertisers, in allmedia, for all geographic marketareas. However, the high level ofaggregation of such data results init having very little variation, whichleaves little to correlate withconsumption. It is thereforeunlikely that any effect ofadvertising will be found from useof this type of data.

Cross-sectional data:

The types of cross-sectional datacan vary, but would typically belocal level (e.g. MetropolitanStatistical Area (MSA)) and forperiods of less than a year. Thistype of data can have greatervariation than national level data,as the cost of advertising, the mixof target markets, and relative sizevaries across local areas. Monthlyor quarterly local level data wouldinclude a relatively larger variationin advertising levels and inconsumption data, and be morelikely to find a positive relationshipbetween advertising and con-sumption.However, cross-sectional stu-

dies are rare as the data areexpensive and difficult toassemble. A report on 21 priorempirical studies, three of whichwere cross-sectional, found that ineach of the three cross-sectionalstudies, a significant positiveeffect of advertising was observed(Saffer & Chaloupka, 2000).

Advertising bans in specificmedia:

Tobacco advertisers use anumber of media, and while eachhas particular advantages anddisadvantages, a partial adver-tising ban will likely result intobacco advertisers substituting abanned media with a form ofmedia that is not banned. A partialban, therefore, will not necessarilyimply a reduction in totalexpenditure on tobacco adver-tising. For example, in the USAadvertising expenditure fellsubsequent to the 1971 TV ban,but rose quickly thereafter. Threestudies of advertising bans thatused pooled international datawere reported (Saffer &Chaloupka, 2000). Two of thesestudies showed no effect of a ban,while one showed that advertisingbans had no effect on con-sumption in the period prior to1973, but thereafter, cigaretteadvertising bans and warninglabels had a significant negativeeffect on consumption. Studiesthat use advertising bans as themeasure of advertising musttherefore include bans which aresufficiently comprehensive toensure that the industry cannotcompensate for lost media byincreasing advertising or othermarketing expenditures. Changesin the number of countries havingenacted more comprehensivetobacco advertising bans sincethe late 1980s provided the

1Application of mathematical and statistical techniques to economics in the study of problems, the analysis of data, and the develop-ment and testing of theories and models.



268

opportunity to re-examine theeffects of advertising bans ontobacco consumption (Saffer &Chaloupka, 2000). Comparableeconomic and social data wereavailable from 1960 for the 22Organisation for EconomicCooperation and Development(OECD) countries studied. Fourdependent variables were used inthe regressions: two measures ofper capita annual consumption ofcigarettes, and two measures ofper capita consumption of tobaccoby weight. The data came fromHealth New Zealand and theUnited States Department ofAgriculture. Advertising banvariables were created from dataon television, radio, print, outdoor,point-of-purchase, and movieadvertising, as well as spon-sorship bans. These wereconverted into a set of threedummy variables: “Weak Ban”was set to equal one if there werezero, one, or two bans in effect;“Limited Ban” was set to equal oneif there were three or four mediabanned; and “ComprehensiveBan” was set to equal one if therewere five, six, or seven mediabanned. The analysis allowedassessment of the effect of limitedand comprehensive bans,indicating minimal effect fromlimited bans in reducing tobaccouse and clear effect on con-sumption from comprehensivebans (Saffer & Chaloupka, 2000).Econometric studies of adver-

tising and consumption arecomplicated and have producedmixed results. Part of the difficultylies in the complexity of theprocedure; models must account

for a large number of other social,political, and economic factors,which may have a confoundingeffect on consumption patterns.Availability and completeness ofdata can also be problematic.Independent researchers, in theUK for example, have had to workwithin the limitations of incompleteadvertising data released by thetobacco industry. The dataprovides coverage of broadcastmedia and the press, but omitsbillboard advertising andsponsorship. Studies in the USA,however, benefit from com-prehensive data on advertisingexpenditure which is freelyavailable to independent re-searchers, albeit in aggregatedform. In the absence of suitabledata for advertising, dummyvariables can be used as proxies,like the dummy variables forstrength of ban discussed above.The inability of econometric

studies to examine all the forms ofmarketing communication used bythe tobacco industry, such asloyalty schemes or point-of-saledisplays, was examined (Chap-man, 1989). In addition, there aretwo further drawbacks witheconometric studies: they onlyexamine the effects of advertisingon overall sales, ignoring otherimportant influences on smoking-related cognition and beliefs; andthey usually only provide aggre-gated, population level data; inmost cases they are not able toexamine effects on sub-groups(e.g. young people, women, orthose on low income), some ofwhom may be particularlyvulnerable.

Consumer surveys:

Another approach to examine theeffects of tobacco promotion isthrough consumer surveys, whichcan overcome many of theproblems associated with eco-nometric studies. Consumersurveys can be appropriately timedto collect measures prior to theintroduction of marketing res-trictions and at a number ofsubsequent time points. At leastone baseline measure is requiredprior to policy introduction, againstwhich future changes can begauged. The number and timing ofpost measures will depend on thetiming of restrictions being posedand on the rate of changewitnessed. Consumer surveys allow social

scientists to develop and testmultiple hypotheses about tobaccomarketing communications, thepolicies designed to restrict them,and how they may be working. Inthis way, specific sub-groups and arange of variables can be studied.Whereas econometric studies tendto rely on aggregate data,consumer surveys enable hypo-theses about marketing commu-nications to be tested at a moreindividual/disaggregated level,taking into account influences ofindividual characteristics.This thinking can be built into a

conceptual model, as with TheInternational Tobacco ControlFour Country Study (ITC) (Fong etal., 2006a), where policies arecharacterised as potentiallyaffecting individuals along avariety of psychosocial andbehavioural variables, of which



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there are two classes: policyspecific variables and psycho-social mediators. Policy specific variables are

those that are proximal(conceptually closest), or mostspecifically related to the policyitself. For example, graphicwarning labels should increasethe prominence and noticeabilityof warnings, price should affectthe perceived costs of cigarettes,and lifting of restrictions onalternative nicotine productsshould lead to increasedawareness of their availability(Fong et al., 2006a). Discretebehavioural changes may alsooccur as a result of the policy,such as smokers hesitating, oreven abstaining from cigarettesbecause of the warning label. Similar examples can be

drawn in marketing commu-nications. Restrictions on theseshould lead to reductions inawareness of the specific types ofcommunication that have beenrestricted, such as billboards orpress ads. Given the links foundbetween tobacco advertisingawareness and brand awarenessand appreciation (Aitken et al.,1985), restrictions on marketingmay also reduce familiarity withtobacco brands. Psychosocial mediators are

those variables that are distal(conceptually distant) from thepolicy, and which are thought tobe affected by multiple means, notjust policies. Self-efficacy andintentions are amongst suchvariables. It is thought that policieswill affect these general mediating

variables indirectly, through theirprior effect on the policy-specific,proximal variables (Fong et al.,2006a).The ITC conceptual model

includes proximal and distalmeasures so as to construct acausal chain model. The routefrom policy specific variables tobehaviour can be traced throughthese measurements. For exam-ple, withdrawal of tobaccomarketing communications mayfirst decrease awareness oftobacco marketing activity, whichmay then affect awareness andfamiliarity with brands, per-ceptions of smoking norms,overall attitudes, intentions aboutquitting (or intention to smokeamong young people), andultimately effect behaviour, suchas quit attempts, quit success or,among young people, uptake ofsmoking (Figure 5.13). This modelallows researchers to test howpolicies impact or fail to impactanticipated behaviour.

Three different studies havebeen undertaken to assesstobacco marketing restrictions: theITC Four Country Survey(Thompson et al., 2006), theCentre for Tobacco ControlResearch (CTCR) study (http://www.ctcr.stir.ac.uk), and theGlobal Youth Tobacco Survey(GYTS) (The Global YouthTobacco Survey CollaborativeGroup, 2002).The ITC project brings

strengths to the consumer surveydesign. It is longitudinal, whichenables disentangling cause andaffect relationships. As a

multinational study covering morethan one jurisdiction, it allows fora quasi-experimental design:comparisons can be drawnbetween countries where specificpolicies are being introduced andothers where they are not. It alsois a telephone survey, whichbrings benefits in terms ofsampling and ease of respondentaccess, but limits the complexityof the questions that can be askedbecause it is not possible to useshow cards or any visual images. The ITC project is conducted

with adult smokers, and thereforeexamines effect amongst thosealready involved with tobaccoproducts. A sample of over 2000adult smokers is sought in eachcountry at each wave of fieldwork(Thompson et al., 2006).As previously noted, consumer

surveys have the advantage ofenabling specific sub-groups to bestudied, such as young people;some of whom will already beinvolved with tobacco productsand some of whom will not.Consumer surveys, unlike eco-nometric studies, enable thepotential impact of tobaccomarketing restrictions to beexamined separately for youngpeople. In particular, they enablethe examination of how youngpeople growing up in anenvironment surrounded by tobac-co marketing compare with thosegrowing up in an environment inwhich tobacco marketing isrestricted. The CTCR study and the

GYTS focus on youth. The CTCRstudy is an ongoing, face-to-face,



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in-home survey which, thoughlogistically challenging, enablescomplex questioning procedures(particularly the use of visual aidsdisplaying brand colours anddesign features). It uses cross-sectional surveys of 11-16 yearolds across the UK. Surveys areconducted at approximately twoyearly intervals to monitorchanges in key measures (suchas awareness of tobaccomarketing, engagement withtobacco marketing, brand aware-ness and familiarity, perceivedsmoking prevalence, intentions tosmoke, and smoking behaviour) atdifferent time points prior andsubsequent to the implementationof the UK ban on advertising andpromotions (Tobacco Advertisingand Promotions Act, 2002;http://www. opsi.gov.uk/acts/acts-2002/ukpga_20020036_en_1). Approaches to measuring the

marketing related measures arediscussed below.Two baseline surveys were

conducted: two years prior to theban and six months prior to theban. These surveys provide dataon young people’s response totobacco marketing prior to theregulations. Measures takenapproximately 18 months post-ban gave an indication ofshort-term response following theinitial phases of implementation ofthe tobacco marketing restrictions.Continuation at two year intervalswill provide insights into thepotential longer-term impact ofthese restrictions, and give anindication of the length of timebefore impacts may becomeapparent.

The GYTS is a school-basedsurvey of 13-15 year olds whichbegan in 1999 (The Global YouthTobacco Survey CollaborativeGroup, 2002). It includes questionson prevalence of cigarette andother tobacco use, attitudes towardtobacco, access to tobaccoproducts, exposure to secondhandsmoke, school curricula ontobacco, media, advertising, andsmoking cessation. The questionfocus, in relation to marketingrestrictions, is on marketingpenetration: awareness of mediamessages and receipt of tobaccobranded items/gifts. Like the ITCFour Country study, the GYTS alsouses multiple countries, a commonmethodology, and a corequestionnaire, which has thepotential to allow comparisonacross different levels of tobaccocontrol (for details see Section 4.3)

Limitations:

The consumer survey approachhas its limitations. It relies ongaining access to and cooperationfrom a representative sample ofrespondents, and on self-reportmeasures which participants mayunder- or over-report. The CTCR study is a national

study conducted over a number ofyears. It monitors response totobacco control policies as theychange over time, providing dataon reactions at different timepoints following staged imple-mentation of the tobaccoadvertising and promotions ban.The lack of a comparison countryor countries means that it cannotprovide conclusive evidence

concerning the impact of tobaccocontrol policies. Nevertheless, it isa valuable study that can add tothe understanding of the likelyeffect of marketing restrictions,particularly where consistenciesand overlaps can be seen with theITC Four Country study.

Enhancing benefits of con-sumer surveys:

The benefits of consumer surveysare enhanced when comple-mentary methods are used tomeasure both marketing andpolicy inputs; a clear notion ofwhat is happening out there willenhance the ability to measure itseffectiveness. The policy andmarketing arenas need to besystematically monitored in orderto gauge the effect ofdevelopments. For example,Figure 5.13 demonstrates some ofthe responses that the tobaccoindustry may take. First, there isthe issue of checking compliance,but equally, if not more important,is being aware of the innovativeways the industry may compensatefor newly imposed restrictions.Research tools, which aid work

in the fields of surveillance, industrydocument analysis, and policytracking, have been developedwhich enable the measurement ofinputs. Monitoring these inputs alsoassists in contextualising andinterpreting results from theconsumer surveys and may help toclarify any unusual or unexpectedsurvey results. Multiple studies can also help

to complement and reinforceresults from individual surveys.



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PPoolliiccyy vvaarriiaabblleess•• advertising bans• advertising restrictions• promotions bans• promotions restrictions• sponsorship restrictions•• sponsorship bans

MMooddeerraattiinngg vvaarriiaabblleess• socio-economic

measures• gender• age• income• education• parental smoking*• peer smoking*• sibling smoking*• other tobacco

control policies

PPrrooxxiimmaall vvaarriiaabblleess• tobacco company marketing expenditure• types of marketing/compliance• awareness of each marketing channel• engagement in types of marketing (eg. participation in

promotional offers)

TToobbaaccccoo UUssee BBeehhaavviioouurrss• smoking prevalence/uptake of smoking*• quit attempts• quit success• brand choice

DDiissttaall vvaarriiaabblleess• brand awareness and familiarity• attitudes/beliefs about brands• beliefs and attitudes towards tobacco industry• beliefs and attitudes towards tobacco control• self-efficacy• intention to quit• intention to smoke*• perception of health risks • perception of prevalence of smoking/perceived smoking norms

TToobbaaccccoo iinndduussttrryy iinnnnoovvaattiioonnChanges in:

•• Product design• Product promotion• Sponsorship• Tobacco point of sale marketing• Price Strategies

TToobbaaccccoo iinndduussttrryyccoommpplliiaannccee

FFiigguurree 55..1133 CCoonncceeppttuuaall ffrraammeewwoorrkk ffoorr tthhee eevvaalluuaattiioonn ooff ttoobbaaccccoo mmaarrkkeettiinngg rreessttrriiccttiioonn ppoolliicciieess*Appropriate measures for youth/adolescent studies



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For example, while the CTCRstudy is an appropriate design forexamining the responses ofadolescents to the advertising andpromotions ban, the lack of acomparison country limits theconclusions which can be drawn.The ITC Four Country surveymonitors similar issues with adultsmokers and does include com-parison countries. Therefore,where findings are consistentbetween the two studies, the ITCFour Country study helps lendsupport for any findings from theCTCR study that are indicative ofpolicy effects.

Marketing surveillance:

As part of the CTCR study, aseries of marketing surveillanceactivities were undertaken toprovide information about themarketing approaches being usedby the tobacco industry bothbefore and after the ban. Thisexercise was designed to capturethe range and nature of activities,rather than quantify the amount ofmarketing activity. An obser-vational protocol was developedto explore the tobacco industry’sresponse to regulation in retailoutlets (Devlin et al., 2006); allother forms of tobacco marketingcommunications had been pro-hibited, but point-of-sale was stillavailable. The protocol wasdesigned to be generic to allow it tobe adapted to cross-countrycomparisons, and to be executedlongitudinally so long-term patternscould be uncovered. It was mainlycomprised of closed questionsrequiring the trained observer to

check the applicable box. Table5.25 lists the types of measuresrecorded within the stores. A small panel of 28 retailers

were recruited to participate in thisprotocol, and a trained observervisited every two months. Thepanel consisted of a sample ofdifferent store types, but was notintended to be a representativesample. Rather, this study soughtinsight into the range of tobaccomarketing at point-of-sale and howthis might change over time and inresponse to new restrictions. This observational protocol

could be implemented with amuch larger and representativesample of stores to enablecomparison of data by differentstore types, area types, religions,and additional characteristics.Such an approach would enablecomparison of data by differentstore types, different area types,regions, and so on. Observations were conducted

in all 53 stores that sold cigaretteswithin the study community(Feighery et al., 2006). Twosurveyors used a protocol forcounting and categorising ciga-rette marketing materials and shelfspace allocated to cigarettes instores. Counts were made of thefeatures, such as number ofbranded signs, merchandisingfixtures, and functional items,along with amount of shelf spaceallocated to the three mostpopular cigarette brands amongyouth in the USA. These datawere used alongside surveyresponses to assist with develop-ment of multiple measures ofadolescents’ exposure to retail

cigarette marketing. Survey parti-cipants were shown photographsof the stores’ exteriors, along withthe names and addresses of 12 ofthe stores, and were asked toindicate the frequency of going toeach one. Those who reported atleast weekly visits to any of thespecific stores in the photographswere classed as having frequentexposure to cigarette marketing.This survey data was then

combined with the observation tocalculate a measure of “cigarettebrand impressions per week.” Thiswas computed by multiplying thefrequency of visits to the specificstores by the total number ofmarketing materials and productfacings in each, and thensumming all the individual storescores for each student.Additional surveillance under-

taken within the CTCR studyincludes regular audits of thepress to identify any marketing oreditorial coverage of tobaccoproducts or issues. A selection ofthe most widely read newspapersand magazines are purchasedover a one week period each sixmonths and are content analysedfor coverage of tobacco orsmoking. A bi-monthly audit of theretail press is similarly undertakento provide insight into the type ofcommunication and messagesbeing relayed from the tobaccoindustry to the retailers. A smallpanel of about 28 smokers alsocomplete a form each monthrecording any tobacco marketingthat they encounter, as well asrecording their cigarette/tobaccopurchases over a one weekperiod. This gives an idea of the



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wide range of marketing activities,and can include, for example,promotions that occur in night-clubs, direct mail, free gifts, andspecial price offers.

Internet:

Given the increasing restrictionson other routes for tobaccomarketing, the internet requirescareful monitoring. A represen-tative sample of websites with adominant tobacco theme wereresearched (Hong & Cody, 2002).Three lists of search terms weregenerated: general smoking terms(category A), terms commonlyassociated with smoking (categoryB), and brand names of American

tobacco corporations (category C)(see Table 5.26). All of the termsin category A, and all combinedterms from categories A and Bwere searched. Terms fromcategories B and C were com-bined, and five search termcombinations from each tobaccobrand name were randomlyselected using a website providingan algorithm for generatingrandom numbers. To account fordiffering results from differentsearch engines, three thatemployed different algorithmswere used. The first 200 pro-tobacco-related websites fromeach search term were recorded.After removal of duplicates, therewas a total of 716 websites from

which three sites were randomlyselected for coding each week forreliability purposes. A codingmanual and procedures weredesigned by a research team, incollaboration with a seniorresearch associate and a clinicalpsychologist. After training on 12websites and proving satisfactoryreliability, each coder wasassigned 15 websites to code perweek over the period fromNovember 1999 to May 2000. Thecontent analysis looked for thepresence or absence of fivefeatures: site category, onlinepurchasing of tobacco productsand consumer-awareness infor-mation, portrayal of humancharacters, lifestyle and message

SSttoorree IInnffoorrmmaattiioonnCharacteristics of surrounding area (residential or commercial)Presence or absence of tobacco ads on exterior of store Presence or absence of minimum age of purchase signageSize of outlet (number of cash registers)Whether tobacco products or counter visible on entry to store

CCiiggaarreettttee//TToobbaaccccoo AAvvaaiillaabbiilliittyyVisibility, variety of brands, variety of pack sizes, presence of any promotionsPositioning of tobacco productsWhich brands are most prominentAvailability, price, and price promotion of four particular brands

AAddvveerrttiissiinngg aanndd OOtthheerr TToobbaaccccoo MMaarrkkeettiinngg PPrraaccttiicceessPresence or absence of advertising for four particular brandsTypes of promotions observed in store and associated brandsPresence or absence of tobacco branded accessories

UUssee ooff FFuunnccttiioonnaall OObbjjeeccttss aatt PPooiinntt--ooff--SSaalleeMethod of displaying tobacco productsFeatures of the cigarette display cabinetAny noticeable changes in the cabinetPresence or absence of tobacco branded fixtures or fittings in the storePresence or absence of tobacco control signage

Table 5.25 Types of Measures Recorded within Retail Outlets to Monitor the Tobacco Industry’sResponse to Regulations



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appeals, and interactive sitefeatures. It is therefore recognizedthat this media is an unmonitored,unregulated source of tobaccomarketing targeting young people.

Internal tobacco industry docu-ment analysis:

Following the Master SettlementAgreement in the USA and theHealth Select Committee’sinvestigation into tobacco com-panies in the UK, online data-bases of the tobacco industry’sinternal documents are available

to search2 (http://www. tobacco-archives.com and http:// www.tobaccopapers.com). The analysisof industry documents has shownthat they clearly recognise thepower of advertising to retain andrecruit smokers, despite theirpublic pronouncements to thecontrary (Hastings & McFadyen,2000; Cummings et al., 2002a).Similarly, documents detailingindustry’s reactions to “inputs,”and their strategies for dealingwith them, can be used tomeasure the effects of tobaccorestrictions. For example, a studyinto how the tobacco industry

circumvented Singapore’s adver-tising ban based its findings oninternal industry documents(Assunta & Chapman, 2004b). Inthis study, document collectionwebsites, primarily the TobaccoArchives, were systematicallysearched using geographic termsand the names of public andprivate entities relating toSingapore. The resulting docu-ments were then dated, evaluatedaccording to their degree ofimportance, and a select groupwere subjected to further analysis.The findings allowed the re-searchers to examine how the

CCaatteeggoorryy AA CCaatteeggoorryy BB CCaatteeggoorryy CCGGeenneerraall SSmmookkiinngg TTeerrmmss TTeerrmmss CCoommmmoonnllyy AAssssoocciiaatteedd wwiitthh TToobbaaccccoo CCoommppaanniieess

TToobbaaccccoo

Tobacco Sports Vacations Brown & WilliamsonCigarettes Car racing Glamour Philip MorrisSmokeless tobacco Tennis Romance LiggetChew tobacco Rodeo Woman RJ ReynoldsCigars Celebrities FetishPipe tobacco Movies SexSnuff Film Gambling

Freedom WineRights CognacAdventure BeerTravel ChampagneCruises

Adapted from Hong & Cody (2002)

Table 5.26 Categories of Search Terms Used to Sample Pro-Tobacco Websites

2Marketing search terms for the database should include the following: above the line, advert, below the line, billboard, brand, campaign,coupon, customer, direct mail, email, internet, marketing, mass media, packaging, point-of-purchase, point-of-sale, poster, pricing,product placement, promotion, samples, SMS, target, text message, and website. This list is not exhaustive and care must be taken tosearch for variations and plurals, possibly by truncation, of the terms above. Brand names should also be included in the strategy (seeCummings et al., 2002a for further search strategies using online databases, and Mekemson & Glantz, 2002 for a sample strategy tolocate documents covering tobacco and smoking product placement in movies).



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tobacco companies conductedtheir business in the strict anti-tobacco environment present inthe country, and attempted tocounter some of the government’stobacco control measures. Withknowledge of this kind, it ispossible to both tackle the tobaccoindustry’s creative responses torestrictions and monitor the extentto which they are working.

Policy tracking:

Although there has beenincreased interest in the field oftobacco control policy research,there have been few publishedaccounts of the measurements ofthe comprehensiveness andstrengths of policies (Wakefield &Chaloupka, 1998). A ratingssystem was developed andimplemented which evaluated theextensiveness of state lawsrestricting youth access to tobaccoin the USA (Alciati et al., 1998).State laws were analysed onyouth access to tobacco andassigned ratings on nine items: sixon tobacco-control provisions, andthree on enforcement provisions.For each item, a target wasspecified reflecting public healthobjectives. Points were awardedfor achieving the target, whilecriteria for lower ratings wereestablished for situations when thetarget was not met. Ratingsproduced by this type of systemcan, by producing maximumvalues, indicate that all idealaspects of a law are in place,facilitate comparison among states(and possibly among countries),permit tracking of changes over

time, and make it theoreticallypossible to relate tobacco control“inputs” to ”outputs” (Wakefield &Chaloupka, 1998).

CCoonnssuummeerr ssuurrvveeyyss:: tthheeqquueessttiioonnss ttoo aasskk

The types of questions that can beused in consumer surveys will beexamined, as well as how toidentify the issues that should beaddressed and developing specificquestions to measure them.Previous studies on the

influence of tobacco advertisingand marketing can help form abasis for identifying the issues thatought to be examined whenmeasuring the impact of res-trictions on marketing. Under-standing the relationshipsbetween advertising/marketing,and other variables, helps todevelop hypotheses about whichvariables might be expected to beinfluenced by the elimination of, orsevere restrictions on, marketing.The focus here will be onmarketing-related proximal anddistal variables (see Figure 5.13).Proximal variables are concep-tually closest to the restrictionsbeing imposed on marketingcommunications. First, anassessment must be made ofawareness, familiarity, andengagement with specific types ofmarketing communication to seewhether, and to what extent, theselessen when marketing res-trictions are imposed. Identifyingsuitable measures requiresfamiliarity with the content of themarketing restrictions which are tobe implemented. This knowledge

gives an indication of whichmarketing practices are going tochange or be eliminated, andprovides a guide to which mea-sures would be expected to showan impact. For example, in 2003the UK introduced a com-prehensive ban on most forms oftobacco marketing commu-nication, which was implementedin phases from February 2003 untilJuly 2005. It was important tocheck whether awareness of eachprohibited medium, which duringthe first phase included billboardsand press advertising, hadreduced. At the same time, it wasalso useful to measure whetherremaining, unrestricted media,which included point-of-sale dis-plays, had increased. As well as specific media, it is

also crucial to monitor thecumulative effect that wideranging bans can have by dis-rupting the integrated marketingcommunications mix. As dis-cussed previously, this is a vitalpillar in the industry’s attempts tobuild and maintain evocativebrands. It therefore is logical todevelop measures of brandsalience and image, and monitorhow these fair, following policychanges. Sample questions are drawn

from the GYTS and the two on-going longitudinal studiesdiscussed previously (the ITCFour Country study and the CTCRstudy). These studies have slightlydiffering methodologies: the ITCFour Country study is a telephonesurvey which brings benefits interms of sampling and ease ofrespondent access, but limits the


complexity of the questions thatcan be asked because, forexample, it is not possible to useshow cards. The CTCR study is aface-to-face, in-home surveywhich is logistically more difficult,but enables complex questioningprocedures; particularly the use ofvisual aids displaying brandcolours and design features. TheGYTS is a school-based, self-completion survey of 13-15 yearolds, which again limits thecomplexity of the questions thatcan be asked.The studies also target different

sub-groups: the ITC consists of acohort of adult smokers, the CTCRstudy is conducted with a cross-section of young people aged 11 to16 years, and the GYTS consists ofstudents aged 13-15 years.Therefore, while some measuresmay be common, others will bespecific to the particular targetgroup. For example, in the ITCstudy, it makes sense to look atadult smokers’ cessation behaviourfollowing marketing restrictions,whereas, with young people in theCTCR study (the majority of whomdo not smoke), it is more relevant tolook at measures of intention tosmoke (see Figure 5.13).

SSppeecciiffiicc ttyyppeess ooff mmaarrkkeettiinnggccoommmmuunniiccaattiioonn

Despite a ban on marketing, andthus limited exposure, there canstill be significant penetration andcontinuation of the relationshipbetween marketing and youthsmoking (Braverman & AarØ,2004). Therefore, at the most basiclevel, there is a need to try and

establish how much marketingcommunication is still gettingthrough. It is difficult to ascertainthis, however, without confusingthe respondent. Terms like“marketing communications,”which are technically correct andcapture the generality of theconcept, are less likely to beunderstood than more familiarwords like “advertising” or “pro-motion,” which will not capture thebreadth of activity that may beinvolved (see Table 5.23), and maynot be consistently interpreted. Hence, qualitative research

played a crucial role in thedevelopment of the questionnairefor the CTCR study, ensuringappropriate and comprehensiblequestioning about a wide range oftobacco marketing activities.While young people couldvisualise and describe images ofconventional advertising (i.e.press, poster, and televisionadverts), it was much morechallenging to get them to thinkabout, and describe, other formsof marketing communications. The qualitative interviews

therefore tried to focus the youngrespondents’ minds on differentlocations where they might beexposed to tobacco marketingcommunications, and walk themthrough various circumstances,asking them to describe any waysthat they might see or have theirattention drawn to products. Forexample, they were asked toimagine themselves walking into ashop, and to describe all the thingsthey could see when theyapproached the door, entered theshop, approached the counter, etc.

In this way the interviewsopened their minds to the broaderrange of marketing practices andencouraged them to describethese in their own terminology. Thisnot only helped with understandingthe language and concepts youngpeople use to describe marketingcommunications, but also revealedthe range of promotional activity towhich they were aware of beingexposed to. In subsequent focus groups,

prompt cards, with descriptions ofdifferent forms of tobaccomarketing, were developed andpresented to respondents, toexamine whether or not they couldrelate to and understand thedescriptions. The final stage was topilot the questions using cognitiveinterview techniques, wherebyrespondents were interviewedusing the questionnaire and, uponcompletion, were interviewed toanalyse their comprehension ofspecific questions and their abilityto answer them.The result was the

development of questions thatdescribed specific tobacco mar-keting communications in a youngperson friendly way (see Figure5.14). Furthermore, becauserespondents might be interviewedin the presence of a familymember, their privacy was pro-tected by presenting the variousdescriptions on prompt cards, sothey could express their answersconfidentially. Figure 5.15 shows how the ITC

attempted to gain an overallmeasure of awareness of tobaccomarketing using very general layterminology. Whereas the CTCR

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question did not impose a timeframe, the ITC study tried to limitrecall to the previous six months tohelp participants focus theirattention on a specific andmanageable period. This is lessthan ideal; it could, for instance,pick up non-marketing influencessuch as peer smoking or beinterpreted differently byrespondents. Nonetheless, it doeshelp to start putting together apicture of what may be happening.When asked alongside other morespecific questions, it provides auseful gauge for the amount ofpro-smoking messages that arebeing perceived. Furthermore, it islikely to provide a general mea-sure of tobacco marketing, as ithas been argued that advertisingcan affect behaviour even if anadvert is not actively processedand respondents cannot recallseeing it (Shapiro et al., 1997).Figure 5.16 looks at specific

media and measures how suc-cessfully any controls are workingby examining awareness ofcommunications in each of these.The media included in this questioncan be varied to suit the jurisdiction(e.g. in the UK, where televisionadvertising for tobacco productshas been forbidden for nearly 20years, this option may be omitted). The GYTS survey takes a

slightly different approach. Itfocuses on specific media andasks young people to rate theamount they have seen within ashort prior time period of onemonth (Figure 5.17). While thesequestions are likely to sufficientlydiscriminate between those who doand do not recall each form of

advertising, there is the possibilityof some ambiguity over the amountrecalled. Response categories of“a lot” and “a few” may be tooambiguous to appropriately dis-tinguish between different amountsrecalled; one respondent’sperception of “a lot” may beanother’s perception of “a few”.Other forms of tobacco

marketing communications needto be addressed with separatequestions; sports and eventsponsorship need careful con-sideration. In the ITC survey it wasimportant to try and distinguishbetween overt brand sponsorship(e.g. Marlboro or Formula 1) frommore covert corporate socialresponsibility (e.g. the BritishAmerican Tobacco Company’ssupport for good causes, such asfarming methods in Malawi).Therefore, a rather complicatedset of questions were asked here(Figure 5.18).In the ITC survey, respondents

found it difficult to answer thisbank of questions, so it may bepreferable to use the slightly sim-pler version presented in Figure5.19. This is a classic example ofthe dilemma faced by ques-tionnaire designers: how to reflectthe complexities of the real worldby phrasing accurate questionsthat do not cause confusion (for adetailed discussion about issuesrelated to question wording seeOppenheim, 1992).The CTCR study was also

interested in which sports orevents young people associatedwith tobacco and, where possible,the brands they connected withthese (Figure 5.20).

The GYTS measures aware-ness of cigarette brands on TV,including those within coverage ofsporting events (see Figure 5.21).This is likely to provide a measureof overall awareness of cigarettebrands on television, but does notspecifically measure awareness ofsports sponsorship. Again, theresponse categories rate fre-quency, which may give rise toambiguity. The remaining form of

marketing communication is,rather confusingly, referred to as a“promotion.” This can come inmany guises: from money-offcoupons to free samples, asillustrated in Table 5.24. All thesevariants need to be covered. Anextra complexity is the need tomeasure not just awareness ofthese activities, but participation inthem (e.g. have people takenadvantage of price promotions, aswell as hearing about them). TheITC study drew on knowledgegained from the CTCR study andalso subdivided promotions downinto specific descriptions ofmarketing (Figure 5.22).

MMeeaassuurriinngg bbrraannddiinngg

Branding is a traditional adver-tising method used to create aresponse from a target audiencebased on cumulative impressionsand positive reinforcement. At onelevel, measuring branding is nomore complex than measuringindividual marketing commu-nications, and simple measurescan be constructed to determinespontaneous and promptedawareness of different brands



278

I’m going to show you some cards (SHOWCARDS 10-26) with descriptions of some other ways that companiesmight try to attract attention to cigarettes. For each one can you tell me if you have seen anything like this.

(Answer categories were: Yes; No; or Don’t Know. For each marketing type responders were aware of, theywere asked to say which make or brand it was connected with.)

a. SHOWCARD 10 Adverts for cigarettes on large posters or billboards in the streetb. SHOWCARD 11 Adverts for cigarettes in newspapers or magazinesc. SHOWCARD 12 Signs or posters about cigarettes in shops or on shopfronts:

on shop windowson shop doorson cigarette display units inside shopson clocks inside shopson staff aprons or overallson signing mats inside shopssome other sign or poster about cigarettes (in shops or on shopfronts)

d. SHOWCARD 13 Free trial cigarettes being given out or offers to send away for free cigarettese. SHOWCARD 14 Free gifts from the shop keeper when people buy cigarettesf. SHOWCARD 15 Free gifts when people save coupons or tokens from inside cigarette packsg. SHOWCARD 16 Free gifts when people save parts of cigarette packs (eg. pack fronts)h. SHOWCARD 17 Free gifts, showing cigarette brand logos, being given out at events such

as concerts, festivals or sports eventsi. SHOWCARD 18 Special price offers for cigarettesj. SHOWCARD 19 Promotional mail, from cigarette companies, being delivered to people’s homesk. SHOWCARD 20 Clothing or other items with cigarette brand names or logos on theml. SHOWCARD 21 Competitions or prize draws linked to cigarettesm. SHOWCARD 22 Famous people, in films or on TV, with a particular make or brand of cigarettesn. SHOWCARD 23 New pack design or sizeo. SHOWCARD 24 Internet sites promoting cigarettes or smoking (do nnoott include anti-smoking sites)p. SHOWCARD 25 Email messages or mobile phone text messages promoting cigarettes or smoking

(do nnoott include anti-smoking messages)q. SHOWCARD 26 Leaflets, notes or information inserted in cigarette packsr. NO SHOWCARD Have you come across any other ways that companies try to attract attention

to cigarettes?

FFiigguurree 55..1144 QQuueessttiioonn aasssseessssiinngg aawwaarreenneessss aanndd iinnvvoollvveemmeenntt iinn ttoobbaaccccoo pprroommoottiioonnss Centre for Tobacco Control Research (CTCR) Ad-ban study (University of Strathclyde)



279

(Figure 5.23). The latter of courserequires visual prompts depictinga selection of brands. However,there is the need to delve deeperand assess not just the ability torecall brands, with or withoutprompting, but familiarity andengagement with them. Theformer can be done by checking ifrespondents can complete par-

tially masked brand examples, asin Figure 5.24. Deeper engagement ventures

into the rather illusive area of“brand image:” the emotionalassociations and feelings that areattached to marques, such as forMarlboro or Benson & Hedges. Asnoted earlier, the tobacco industrygoes to great lengths and expense

to create evocative images fortheir brands, and arguably a keytask of tobacco control in general,and marketing restrictions inparticular, is to undermine them.Measuring the results is tricky; thistype of complexity lends itselfmore readily to qualitativemethods than quantitative ones.Nonetheless, questionnaires canbe used successfully to tackle theproblem. Figure 5.25 illustrateshow semantic scales can helpunravel dimensions like popularity,appeal to specific sub-groups, andmasculinity. Rating, ranking, and“pick-any” (in which respondentsare asked which brand(s), if any,they associate with a series ofattributes) measures of brandimage associations have beenreported to be comparable(Driesener & Romaniuk, 2006).

CCoonncclluussiioonnss

This section has explained what ismeant by tobacco marketingcommunications, that they doinfluence tobacco consumption,especially by the young, and that itis therefore crucial to instigatecontrols and measure theireffectiveness. It has been shownthat this can best be done bymonitoring a range of distal andproximal variables using con-sumer surveys. Consumer surveys are further

enhanced when surveillancesystems are put in place tomonitor changes in tobaccomarketing activity following res-trictions. This helps in con-textualising the findings and

Thinking about everything that happens around you, in the last 6 months howoften have you noticed things that promote smoking?

01 – Never02 – Rarely03 – Sometimes04 – Often05 – Very Often

Figure 5.15 General Measurement of Pro-Smoking Messages in the

Now I want to ask you about tobacco advertising. In the last 6 months, haveyou noticed cigarettes or tobacco products being advertised in any of thefollowing places?

(Read out each statement)01 – Yes02 – No

a. On televisionb. On radioc. At the [cinema/movie theatre], before or after the [film/movie]d. On posters or billboardse. In newspapers or magazinesf. On [shop store] windows or inside [shops/stores] where you buy tobacco

g. Other

Figure 5.16 Measuring Awareness of Tobacco Ads in Specific Mediain the International Tobacco Control Policy Evaluation Study


International Tobacco Control Policy Evaluation Study


280

During the past 30 days (one month), how many advertisements for cigarettes have you seen on billboards?

a. A lotb. A fewc. None

During the past 30 days (one month), how many advertisements or promotions for cigarettes have you seen innewspapers or magazines?

a. A lotb. A fewc. None

Figure 5.17 Measuring Awareness of Tobacco Ads in Specific Media in the Global Youth Tobacco Survey

Figure 5.18 Measuring Tobacco Sponsorship the Hard Way in the International Tobacco Control PolicyEvaluation Study

In the last 6 months, have you seen any advertising by tobacco companies that is NOT promoting particular productsor brands, but the COMPANY itself?

01 – Yes02 – No

Still thinking about the last 6 months, have you seen or heard about any sport or sporting event that is sponsored by orconnected with BRANDS of cigarettes?

01 – Yes02 – No

In the last 6 months, have you seen or heard about any sport or sporting event that is sponsored by or connected withtobacco COMPANIES?

01 – Yes 02 – No

In the last 6 months, have you seen or heard about any music, theatre, art, or fashion events that are sponsored by orconnected with BRANDS of cigarettes?

01 – Yes02 – No

In the last 6 months, have you seen or heard about any music, theatre, art, or fashion events that are sponsored by orconnected with tobacco COMPANIES?

01 – Yes02 – No



281

interpreting any changes or lack ofexpected changes. The consumer surveys need to

take baseline measures prior toany changes in marketing res-trictions, and several follow-upsurveys over a period of years tomonitor short-term and longer-term effects. The length offollow-up will partly be dictated bythe implementation time table ofthe restrictions. For example, inthe UK their ban was implemented

in phases, making it conducive toconducting follow-up surveys aftereach phase. The final subsection examined

specific questions that have beensuccessfully used to do thismonitoring and showed howparticular questions will varydepending on the target group andthe administration mode.In applying the methodologies

discussed here, however, it isimportant to recognise that the

precise wording of questions willvary according to the samplebeing interviewed. Before goinginto the field, therefore, it is crucialto conduct a thorough pilot study.This should include qualitativework to check matters of contentand language, and quantitativeresearch to check understandingand feasibility.

In the last 6 months, have you seen or heard about any sport or sporting event that is sponsored by or connected witha tobacco company or brand?

01 – Yes 02 – No

In the last 6 months, have you seen or heard about any music, theatre, art, or fashion events that are sponsored by orconnected with a tobacco company or brand?

01 – Yes02 – No

Figure 5.19 A Simpler Way of Measuring Tobacco Sponsorship in the International Tobacco ControlPolicy Evaluation Study



282

Can you think of any sports or games that are sponsored by or connected with any makes or brands of cigarettes?

FOR EACH SPORT or GAME MENTIONED, ASK: What make(s) or brand(s) is it connected with?

PROBE FOR SPORT/GAME AND MAKE(S)/BRAND(S)REPEAT FOR MAXIMUM OF 6 SPORTS/GAMES

SSppoorrtt oorr GGaammee MMaakkee((ss)) oorr BBrraanndd((ss))

1. ………………………………… …….………………………………………...........2.…………………………………… ….………………………………………...............3. ………………………………… …….……………………….…………………….4. ………………………………… …….………………………………………......... .5. …………………………………… .……………………………………….................6.…………………………………… . …………......…………………………..............

Can you think of any other events or shows that are sponsored by or connected with any makes or brands of cigarettes?

FOR EACH EVENT or SHOW MENTIONED, ASK: What make(s) or brand(s) is it connected with?

PROBE FOR EVENT? SHOW AND MAKE(S)/BRAND(S)REPEAT FOR MAXIMUM OF 6 SPORTS/GAMES

EEvveenntt oorr SShhooww MMaakkee((ss)) oorr BBrraanndd((ss))

1. ………………………………… …………………………………….......................2. ………………………………... ………………………………………...................3. ……………………………….... ………………………………………...................4. ………………………………... ………………………………………...................5. ……………………………….. ………………………………………..................6.…………………………………. …………......………………………….....................

Figure 5.20 Measuring Awareness of Tobacco Sponsorship Among Young People in the Centre forTobacco Control Resarch (CTCR) study at the University of Strathclyde



283

During the past 30 days (one month), when you have watched sports events or other programmes on TV how often didyou see cigarette brand names?

a. I never watch TVb. A lotc. Sometimesd. Never

Figure 5.21 Measuring Sponsorship in the Global Youth Tobacco Survey

In the last 6 months, have you nnoottiicceedd any of the following types of tobacco promotion:READ OUT EACH STATEMENT

01 – YES02 – NO

a. Free samples of cigarettes. IIff yyeess: Have yyoouu received free samples of cigarettes?b. Special price offers for cigarettes. If yyeess: have yyoouu used special price offers? c. Free gifts or special discount offers on other products when buying cigarettes? d. (IF YES) Were these free gifts or special discounts from:

1. the shop-keeper when buying cigarettes2. you or someone else saving coupons or tokens from inside cigarette packs3. you or someone else saving parts of cigarette packs (e.g. pack fronts)4. free gifts showing cigarette brand logos, given out at events such as concerts, festivals or sportsevents

IIff yyeess ttoo aannyy ooff tthhee aabboovvee aasskk:: Have you personally received such gifts?

e. Email messages promoting cigarettes or tobacco products. IIff yyeess: Have you received promotional email messages?

f. Mobile phone text messages promoting cigarettes or tobacco products. IIff yyeess:: Have you received mobile phone text messages…

g. Mail promoting cigarettes or tobacco products. IIff yyeess: Have you received…..h. Clothing or other items with a cigarette brand name or logo. If yes: have you received….i. Competitions linked to cigarettes. IIff yyeess:: have you participated in any competitions linked to

cigarettes?j. Internet sites promoting cigarettes or tobacco products. IIff yyeess: Have you visited any internet sites…..k. Leaflets promoting cigarettes or tobacco products. IIff yyeess: Have you received any leaflets …..l. Signs or posters or branded items in bars, pubs or clubs

Figure 5.22 Measuring Awareness and Involvement in Tobacco Promotions in the International TobaccoControl Policy Evaluation Study



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Can you tell me the names of as many makes or brands of cigarettes that you have either seen or heard of:

Record up to a maximum of 10 ……………………………………………..……………………………….

Question: Now can you tell me whether you have seen any of these makes before?

VISUAL PROMPTS 6-10POINT TO EACH PROMPT ONE AT A TIMEFOR EACH ONE ASK: Have you ever seen this one?

VViissuuaall pprroommpptt YYeess NNoo DDoonn’’tt KKnnooww

6. Windsor Blue7. Berkeley8. Benson & Hedges9. Lambert & Butler10. Marlboro

Figure 5.23 Measurement of Brand Awareness in the Centre for Tobacco Control Research (CTCR) studyat the Univ ersity of Strathclyde

I’m going to show you some packets of cigarettes that have the name covered up on them. For each one I’d like you totell me what make or brand you think it is. Please don’t worry if you don’t know the make or brand.

SHOW VISUAL PROMPTS

This brand is very popular with This brand is very unpopular with people my age people my age

DKBenson & Hedges 1 2 3 4 5 6Lambert & Butler 1 2 3 4 5 6Marlboro 1 2 3 4 5 6

You never see this brand in shops around here You always see this brand in shops around here

DKBenson & Hedges 1 2 3 4 5 6Lambert & Butler 1 2 3 4 5 6Marlboro 1 2 3 4 5 6

Figure 5.24 Measurement of Brand Familiarity in the Centre for Tobacco Control Research (CTCR) atthe University of Strathclyde



285

Most smokers smoke this brand Few smokers smoke this brand DK

Benson & Hedges 1 2 3 4 5 6Lambert & Butler 1 2 3 4 5 6Marlboro 1 2 3 4 5 6

Attractive looking brand Unattractive looking brandDK


Female brand Male brandDK


Figure 5.24 Measurement of Brand Familiarity in the Centre for Tobacco Control Research (CTCR) atthe University of Strathclyde


5.4 measures to assess the effectiveness of restrictions on - iarc

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