. £554.: .2: . Eu 72m. Ii... «MUN was... .fimuu. ., . "m J. E ,r r M. 3&3.» .. ‘ g . i ,. a»... 9g . n 2 A: . 51.3... 3.3., . . arm“ . a” i , u. . :3 «a t 2... V #3. .. a {.37}. ‘.h3 Jaws: .rsa :ys. . A... .. .Mmau ,Jwazavk. 7.2 .. 3'3 6 . a 3 53:331. .36. 5.5.. . i: #1.. in; .1? 3' . a ‘i‘. upé.... iji This is to certify that the thesis entitled CAN MEXICANS BE PERSUADED T0 QUIT SMOKING? presented by Harold Mondol has been accepted towards fulfillment of the requirements for 0&th Major professor [hue December 3, 2002 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State University PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 cJCIRC/DateDuepGSop. 15 CAN MEXICANS BE PERSUADED TO QUIT SMOKING? By Harold Mondol A THESIS Submitted to Michigan State University In partial fulfillment of the requirements For the degree of MASTER OF ARTS Department of Telecommunications 2002 ABSTRACT CAN MEXICANS BE PERSUADED TO QUIT SMOKING? By Harold Mondol The thesis is an assessment of the impact of thirty-second smoking cessation television commercials on adult Mexican audiences. It attempts to answer whether these ads in Spanish, professionally produced in the United States, can affect the attitudes of smokers and non-smokers. The study was conducted in the spring of 2002 in Mexico and evaluated the impact of two types of persuasive appeals: "family oriented" and "personal fear" messages. The focus group method was used with college students at four universities in Mexico. Questionnaires were completed both before and after the viewing of the commercials. A Moderators Guideline enabled the researcher to gain feedback on the participants’ knowledge and attitudes about many smoking issues - from the addictive qualities of nicotine to the effects of secondary smoke. Results showed a substantial positive impact among both smokers and non-smokers in changing opinions and attitudes towards smoking cessation. All six commercials received high ratings of 7 to 10 (1 =not effective; 10= extremely effective). The researchers hypothesis contending greater effectiveness for the “Family” ads was not supported. The “Personal” ads were marginally more effective for this relatively young college age Mexican audience. TABLE OF CONTENTS INTRODUCTION .......................................................... 1 Nature of the Problem .................................................... 2 Purpose of the Study ..................................................... 3 Research Question ....................................................... 5 Assumptions ................................................................ 6 Importance of Study ...................................................... 7 Definition of Terms ........................................................ 8 REVIEW OF THE LITERATURE ..................................... 10 First Generation ........................................................... 10 Second Generation ...................................................... 12 Third Generation .......................................................... 13 Third World Research ................................................... 14 EXPERIMENT AND HYPOTHESIS .................................. 16 Pilot Study ................................................................... 16 Selection of TV Messages ............................................... 16 Key Variables ................................................................ 18 The Focus Groups ......................................................... 19 Research Question and Hypothesis ................................... 21 METHODS .................................................................. 23 Overview ..................................................................... 23 Materials and Procedures ................................................ 24 Delimitations ................................................................. 24 Family Oriented ............................................................. 26 Personal Oriented ........................................................... 27 Procedure for Experiment ................................................ 29 Translation Procedure ..................................................... 29 Measures ...................................................................... 3O Participants and Demographic Variables ............................. 31 Analysis Procedures ........................................................ 32 RESULTS ..................................................................... 33 Themes ........................................................................ 33 Sample Differences ......................................................... 37 Descriptive Statistical Analysis .......................................... 38 Impact of Collectivism versus Individualism .......................... 39 iii VI. VII. VIII. DISCUSSION ............................................................... 41 Interpretation and Implication of Findings ............................ 42 Direction of Future Research ............................................ 46 Conclusion .................................................................... 48 APPENDICES ............................................................... 50 APPENDIX A ................................................................ 51 Questionnaire and UCHRIS Approval APPENDIX B ................................................................ 58 Moderator Guideline APPENDIX C ................................................................ 62 The TV Commercials APPENDIX D ................................................................ 70 The Tables BIBLIOGRAPHY ............................................................ 71 iv INTRODUCTION During the past three decades research efforts on smoking cessation by both the tobacco industry and the anti-tobacco advocates have clearly increased. A number of books have been printed, among the most recent being Glantz (1999), Chaloupka (2000) and Prabhat Jha (1999). Also hundreds of research studies have been published by the Center for Disease Control (CDC), the World Health Organization (WHO), and in the major scholarly journals in the USA and Europe in a wide range of fields such as: Psychology (Journal of Applied Psychology), Social Psychology (Journal of Social Psychology), Marketing (Journal of Marketing), Medicine (Journal of the American Medical Association, British Medical Journal), Public Health (Journal of Public Health), and Communications (Journal of Communications Research). Hundreds of millions of dollars have been spent on anti-tobacco media research and production in the USA by states such as California, Massachusetts, Florida and Arizona. Similar media have been created, produced and broadcast by nations as diverse as Australia, Canada, Poland and Thailand (Tobacco Control 2001 ). Additionally, extensive “secret” research on tobacco addiction was conducted in the “703 by the tobacco industry but not revealed to the public until the success of the US. tobacco lawsuits in the ‘90s. These documents are primarily accessed through websites such as www.librarv.ucsf.edq/tobacco The Nature of the Problem According to the World Bank’s recent report Curbing the Epidemic “with current smoking patterns, about 500 million people alive today will eventually be killed by tobacco use... by 2030, tobacco is expected to be the single biggest cause of death wondwide, accounting for about 10 million deaths per year.” (World Bank, 1999). In Mexico the Federal Govemment’s Department of Public Health estimates that 44,000 deaths occur annually as a result of the illnesses that can be attributed to tobacco smoking as a root cause (Tabaquismo, 2000,p.3) At the same time antismoking public health campaigns have been shown to be effective. “An independent‘study showed that the percentage of people in Massachusetts who smoked regularly fell from 23.5 in 1990 to 19.4 percent in 1999" (Boston Globe 6/26/2002). ‘ In particular, the use of television commercials for smoking cessation has been shown to be effective (Australian National Tobacco Campaign 2000). Purpose of the sum The two underlying principles for this study were: a) to undertake a preliminary formative evaluation of an adult Mexican population in regards to their attitudes towards smoking, and b) to take advantage of some of the current anti-tobacco media resources available in the developed world and apply them to a Third World setting. In undertaking one of the preliminary formative evaluation steps (Pre-Production Media Research) it is recognized that a much larger audience analysis would need to be done prior to the launching of any public health smoking cessation campaign in Mexico. However, the second objective of this study was to take existing, well-researched and excellently produced 30-second smoking-cessation television commercials from the USA and Australia, and assess their impact on both the smoker and non-smoker adult Mexican populations. Currently (2002) the laws of Mexico restrict smoking in some public places (e.g.: hospitals, schools, airports and some government offices). However, newspaper, magazine and billboard ads for tobacco are virtually unrestricted, and the radio and TV media have a few restrictions placed on their broadcasting (Tabaquismo, pp. 7,12). Right now Mexican TV is allowed to show cigarette ads on commercial stations daily after 10 PM. The content and persuasive appeal of these ads are identical to the familiar “70$ cigarette ads in the ‘ As this] USA - the “cowboy” ads of Marlboro, and the “glamorous” and “pleasure” ads of the other brands targeted at women. Music and background atmosphere are added to enhance their appeal. These tobacco industry commercials are well financed and professionally produced for prime time scheduling. (Tabaquismo p.33). By contrast, the Mexican Federal Department of Public Health produces low-budget “educational” TV spots that are shown during lower- viewing schedule times (comments by focus group members). As a result of this media and marketing environment, the prevalence of smoking rates in Mexico have been rising in the past two years, especially among youth and among female populations. (Tabaquismo p. 27). In launching this study two years ago, and then in conducting and writing this thesis the investigator was to able to focus on the interesting topic: st_udvinq effe_ct§/e methods of making an impact on smoking cessation in the third world. He was also able to answer all the relevant mass media research questions regarding topic relevance: 1) Is the topic too broad? 2) Can the problems really be investigated? 3) Are the data susceptible to analysis? 4) Is the problem significant? 5) Can the results of the study be generalized? 6) What costs and time are involved in the analysis? 7) Is the planned approach appropriate to the project? And, 8) Is there any potential harm to the subjects? (Wimmer, pp. 20-22). The answers to these questions follow below. The investigator was able to narrow the research question down, and then to develop a method that was relatively fast, reliable and valid for the adult Mexican population. It is hoped that these strategies will pave the road to more effective future tobacco research in other third world settings. Research Question The general research questi_o_r1 in this study was: To what degree can thirty-second smoking-cessation television commercials affect the attitudes of adult Mexican smokers and non-smokers about smoking? The researcher made a decision to use the focus group method in a location in Mexico to test this question, with appropriate scientific tools. An experiment was proposed for use with adult Mexicans in Mexico in which they would view a number of well researched and excellently produced smoking-cessation television commercials. Then with the use of pre and post questionnaires it would be possible to assess if these viewings would significantly impact the attitudes of these Mexicans smokers and non-smokers about smoking. Assumptions The assumptions upon which this thesis experiment was based are as follows: ' 1) That this population (having been born, raised and educated in Mexico) would have a general awareness of the tobacco smoking issue comparable to the general awareness of the Mexican population in other urban areas. 2) That their attitudes regarding smoking would be generally reflective of the attitudes of the average Mexican urban population. 3) That the age of this cohort (18 - 28 years) included the prime years of being susceptible to persuasions for either continuing to smoke (from ads by the tobacco industry) or quit smoking (from ads by the Federal Mexican Department of Public Health). 4) That other demographics such as income, and education would reflect typical urban middle-income comparables. This would include their health values and life styles. 5) That this cohort would have seen both pro and anti- smoking commercials on commercial Mexican Television in the recent past. 6) That this cohort was accustomed to testing in a classroom setting. 7) That this cohort was willing to sit for 60 —90 minutes and take the test and answer it truthfully — with the nominal compensation provided. Importance of the Study Since the leading preventable cause of illnesses and death in Mexico is tobacco- related (44,000 deaths annually — Tabaquismo, p. 7), the significance of the need for this study is self-evident. However, it was the investigator‘s intention to study the most effective ways in which to present the case for smoking cessation to smokers and non-smokers in Mexico. For this reason a comprehensive review was conducted into the anti-tobacco media efforts by all the states in the USA, and also the efforts by Australia, Canada and European countries. Representatives of more than 100 countries attended the World Conference on Tobacco and Health (WCTOH) for six days in Chicago in August, 2000, and world leaders such as former Surgeon General C. Everett Koop, Dr. Gro Brundtland, President of the World Health Organization, and many others made presentations. Altogether more than 1,000 abstracts, reports and poster presentations were made. The investigator attended this event, engaged in discussion with many presenters from all over the world, and reviewed all the papers submitted. In addition the investigator has continued an on-going research into all the antismoking literature and media produced since that time. Therefore, this thesis may be regarded as the first attempt to address the issue of smoking cessation and the media in Mexico in a systematic and methodical way. Although this experiment took place in an academic setting (college classrooms), its ultimate benefit is intended to advance the public health initiatives in Mexico, as well as other third world settings. Definitjon of Terms 1. This study uses a focus group. A focus group is “a research strategy for understanding audience/consumer attitudes and behaviors.” (Wimmer, 1983). 2. Moderator Guideline. This was the format used by the moderator for conducting the experiment with the subjects. 3. Family Oriented messages. Messages which are designed to call attention to family membership and its distinctiveness as a source of group identity (Hui, 1988) — and use persuasive appeals to further their message in that way. These use emotions that a viewer may have for his/her own family members, such as: love, respect, embarrassment, admiration, grief, caring, fear, concern, loyalty, anxiety, sorrow. 4. Personal-Oriented messages. “lndividualistic” messages, which convey appeals directed to the emotions a viewer, may have towards himself/herself, such as: anxiety, fear, horror, self- respect, confidence, pride, and trust. 5. Impact. The intellectual and emotional effect of a message on a viewer’s attitudes and opinions on a subject. REVIEW OF THE LITERATURE A huge volume of literature has been produced over the past three decades on the subject of the use of the mass media in smoking cessation campaigns in the USA, Canada, Australia, the United Kingdom, several European countries (Eastern and Western), and in several Asian countries. In reviewing this literature, a useful general framework was originally proposed by Yankelovich in his book Making Democracv work in a @mplex World (1991) and has been updated by Logan and Longo in their article “Rethinking Anti-smoking Media Campaigns” (Journal of Health Care Finance Summer 1999). This theory places anti-smoking campaigns in a three-tiered historical perspective: The First Generation, “Consciousness Raising Stage,” the Second Generation, “The Working Through Stage,” and the Third Generation “The Resolution Stage.” First Generation In the First Generation, “Consciousness Raising,” numerous researchers such as Kenneth Warner of the University of Michigan (“An Update,” 1977) pointed out that smoking campaign research was directed at the knowledge, information and temporary opinion stage. It presumed that tobacco use was influenced by the information the public received 10 from the mass media — such as the glamorization and “macho” images of smoking projected in popular entertainment. Novotny (1993) observed that the combination of favorable images about smoking in advertising resulted in one of the most significant barriers to reverse public smoking habfis. Glantz (1996) and Salmon (1989) noted that smoking cessation strategies needed to be seen in a broader context and warned against a one-dimensional approach to understanding smoking control. The National Cancer Institute (1991) essentially divided the history of media participation in smoking control campaigns into two generations of applied research. They found that initial campaign researchers were able to use the news and mass media to increase public awareness about anti-smoking campaigns. And this resulted in modest public information gains about smoking's health effects (Flay 1987). Unfortunately, at this stage, a better-informed audience did not result necessarily in a shift in public attitudes about smoking or cessation. In the 19705, Bandura's Social Learning theory (1977) seemed to explain the early disappointment of these information models. Social learning theory explained how a shift in attitudes about smoking was not necessarily linked to increases in public awareness. Social learning theory distinguished the intervening steps of public awareness, information, knowledge, and the formation of temporary opinions versus attitudes and deep-seated belief structures (Azjen 1980). It also suggested that the 11 mass media were a strong influence on public awareness and could help provide more constructive information about smoking to adults and young persons. The mass media were also seen as important in influencing opinions that persons maintain about the social desirability of smoking behaviors (McAlister 1981 ). According to the National Cancer Institute, the core critique of the first generation of social learning models in anti-smoking media campaigns was that “the individual must also possess the skills to carry out the desired behaviors and that the behaviors (tobacco use control) will have the desired effect” ( National Cancer Institute 1991 ). Second Generation The second generation of campaign research was more interpersonal and educational in nature than the first generation and refocused attention towards small audiences. It was focused on the development of life skills, and even used theater productions to help young people role-model effective behaviors. Called by Yankelovich, the “Working Through” Stage, campaigns and programs were directed to schools and work sites rather than mass audiences. Within school settings, the optimistic expectations about smoking among young persons were corrected. Smoking resistance behaviors were modeled, role played, and even turned into theater productions (Tobacco Control: “2 12 Smart 2 Smoke” 1999). The use of mass media was not abandoned, but it was seen as a supplement to interpersonal instruction (National Cancer Institute 1991). This second generation, the Social Influence model, was described by Evans as “social innoculation” (Evans 1990). It trained persons to “cope with not only overt social influences, but also subtle influences” (p.154) including advertising and peer pressures. Under this social influence model, adults and young persons were provided more information about smoking's negative social effects, the immediate physiological results of tobacco use, and how peer pressures and media advertisements influenced smoking ( Evans, 1990). Adults and adolescents were taught to manage smoking impulses, improve self efficacy, and reward themselves when they made appropriate decisions ( Kendall 1979). This larger life skills model provided. broader training that reinforced the values of diet, exercise, clinical, self examination, alcohol moderation, and smoking cessation as part of a healthy lifestyle (Botvin, 1982). Third Generation The Third Generation, called by Yankelovich “The Resolution Stage” attempted to combine strategies derived from both generations of research. Using this approach, and relying on the previous expertise of 13 numerous communications researchers before them, Logan and Longo identified the characteristics of this superior anti-smoking media campaign as having: (1) high-quality messages, credible information sources, and media channels; (2) frequent dissemination of media messages at optimum times to well-targeted audiences; (3) media messages that are well tailored to the characteristics, predispositions, and attitudes of the targeted audience; (4) an emphasis on interpersonal reinforcement about the goals of the campaign among targeted audience members; (5) the encouragement of a dialogue between smokers and nonsmokers; (6) starting a wider debate about social norms and the impact of smoking on public policy, and, most importantly; (7) providing smokers with the requisite skills to quit (1999, p. 81). Third World Research While research now being conducted in the developed countries is continuing in this third “Resolution Stage," it would appear-from this investigator’s review of the literature that much of the mass media anti- smoking research currently being conducted in the Third World countries is at the First Generation “Consciousness Raising” stage” or Second Generation “Working Through” stage. Many of the papers, posters and abstracts presented at the Chicago WCTOH tended to be similar to the media research that was being conducted in the USA in the ‘705 and ‘805. 14 Any international visitor spending even a few days in a country outside the USA is immediately made intensely aware of the different cultural and social climate of that nation regarding smoking these days. Mexico, for example, with its cigarette advertising and media milieu is similar to the USA of the ‘70s - with glamorized or “macho" images of smoking surrounding the public on every side in billboards, radio and TV, newspapers and magazines. At the Chicago WCTOH the major sections into which the relevant research reports and documents were divided were: Addiction Science, Advocacy, Cessation and Dependency Treatment, Communications, Cultural Approaches, Nicotine and Tobacco Industry , Prevention, and finally, Public Policy (WCTOH 2000). There is a continuing lively worldwide community keeping up its research efforts on the anti-tobacco subject. Dialogue and communication in the past few years has been greatly enhanced through the intemet and electronic journals and websites. Two of the most useful are “Globalink,” the Geneva-based anti-tobacco website of the UICC and Tobacco Control, a subsidiary publication of the British Medical Journal. Dozens of research articles on various aspects of tobacco control are published each month. Some of these will be cited in this thesis. 15 EXPERIMENT AND HYPOTHESIS Pilot Study In the winter of 2000, with the assistance of a Mexican friend and recent ex-smoker, the investigator conducted a preliminary informal experiment of the smoking cessation subject with adult Mexican residents on the island of Cozumel, Mexico. The independent variables consisted of 30-second smoking cessation commercials substantially similar to the ones used in the thesis experiment. The subjects were 9 adult Mexican residents of the island (smokers and non-smokers) who were recruited by a variety of friends of the investigator. The responses to the commercials in this pilot study appeared to be surprisingly strong. Thus this led to decision to use this approach for the more formalized structure of this thesis experiment. Selection of Lhe TV Messages In attempting to utilize the best of the insights of “Third Generation” media research on anti-smoking campaigns, the investigator contacted all possible media centers available to him. He received the smoking- cessation TV commercials from the various national, state and local sources, and requested and was given permission to use them in an 16 experimental setting. Many of these contacts were made as a result of participation in the Chicago meeting of the WCTOH. A total of 123 such TV and radio commercials were received. These messages had been widely developed geographically - from Australia to Canada, and from California to Massachusetts in the USA. They used a extensive range of persuasive appeals, such as: humor, anger, grief, fear, pride, economics, sarcasm, peer-pressure, reason, common sense, irony and other emotions. Some used a documentary style. Some were done with cartoons. Some were story-style. Some were interviews. The summative evaluation research that had been performed on these television media presentations in the early ‘905 indicated relatively little audience impact. For example, in Massachusetts (Tobacco Control 2002). Others, especially from the Australia National Tobacco TV campaign, appeared to be having a substantial impact (Australian National Campaign, Vol 2). Much of this summative evaluation research work on the media is still quite new (less than 10 years). The investigator then. engaged the services of a Ph.D. candidate in Media Effects in the Department of Telecommunications at Michigan State University, who participated as a media expert in the process of narrowing these down to the six commercials that were used in this experiment. These were selected because of a) their use of Spanish in the message, b) the excellence of their production values, and 0) because of their 17 perceived viewer impact. Of the six selected, four were in Spanish, and two in English. The two English commercials were the ones that were found to have the greatest impact on viewers in Australia and Massachusetts. In the focus groups of this experiment, verbal Spanish translations were provided for these particular commercials both before and after each showing, and each of these English commercials was shown twice before participants were asked to write their reactions. Key Variables The Independent variable was the contrast between the four 30- second commercials with “family oriented” persuasive appeals, and the two 30-second commercials with “personal” persuasive appeals. The Dependent Variables were: a) the self-perceived impact of the commercials on the subjects measured by questions on the questionnaire, and scored on 11-point rating scales, and b) the comments recorded about the viewers knowledge and attitude towards smoking during focus group interviews. 18 The Focgs Gregg Four focus groups were conducted during March and April, 2002, in four Universities in Mexico. Teachers or directors of departments of communications in each University were requested to provide 10 subjects for each group, with approximately half smokers and half non-smokers, and half male and half female. They then picked a two-hour time period in the afternoon that would not conflict with other classes. A total of 39 students participated, ranging from 18 - 28 years of age. Approximately half of the students were smokers and half non-smokers, and half male and half female (see Appendix D). Each was paid 100 pesos (approximately $10 USD for their participation). All the students had been born and raised in urban areas of Mexico. They represented largely a middle and upper-middle income segment of the Mexican population. The investigator (who is fluent in Spanish) moderated each group, using the same guidelines, questionnaires and format for each focus group. The location for the focus groups was a regular classroom in each university. The equipment for showing the commercials was a large, 29- inch television screen, and all the students were required to sit in the front seats of the classroom within 12 feet of the screen. 19 The questionnaires were designed first to get the demographics of the viewers, and then to provide them with both structured and unstructured means for responding to the stimulus of the smoking- cessation commercials (See Appendix C). The investigator, acting as moderator, probed comments that participants made during the session. At times (especially during the third and fourth sessions) there were lines of questioning that were pursued that had not been thought of during the development of the questionnaires. These turned out to be among the most informative materials gathered in the experiment. 20 Research Question and Hypothesis As previously cited, the basic research question was: To what degree can thirty-second smoking-cessation television commercials affect the attitudes of adult Mexican smokers and non-smokers about smoking? The researcher was interested in a corollary hypothesis: Would Mexican adults be more persuaded by “Family-Oriented" messages than by. “Personal-Oriented” messages? Thus, the research question and hypothesis were proposed to test for these questions: Research Question Would the viewing of well-researched and excellently produced 30- second smoking-cessation TV commercials have a measurable impact on the knowledge and attitudes of adult Mexicans smokers and non-smokers regarding smoking? How positive will be the attitudes towards the ads on the dimensions of: interesting, usefuI,credible,professional, on target and persuasive? Hypothesis 1 That the viewing of “Family-oriented” persuasive appeals of smoking-cessation ads will have more impact on the attitudes towards ads regarding smoking of adult Mexican smokers and non-smokers than “personal-oriented” persuasive appeals. 21 The framework for the researcher’s second hypothesis was based on the individualism-collectivism dimension identified by cross-cultural researchers (Hofstede 1980; Triandis 1990). Individualism has been defined as emotional independence from “groups, organizations, and other collectivities" (Hofstede p. 221 ), lack of attention to the views of others, relatively little concern for family and relatives and tendencies towards competition (Triandis 1990). On the other hand, collectivists see the self as an aspect of a group and value this interdependence. Collectivist societies emphasize the goals, needs and views of the in-group over those of the individual... the social norms of the in-group as opposed to personal pleasure (Marin 1995). Social scientists tend to agree that Latin American cultures are generally collectivist and that the characteristics of the Mexican culture at collectivistic, valuing family membership and its distinctiveness as a source of group identity and solidarity (Ramirez 1998). 22 IV. METHODS Overview The elements used for this experiment were designed in a manner for efficient, inexpensive and rapid replication in other parts of Mexico, or other Third World settings. The use of University students as respondents was done as a convenience sample, and also for gaining a comparatively homogenous cross-section of the general population of smokers and non- smokers. The 30—second smoking cessation TV commercials were played on the TV monitors with the use of a laptop computer. But it would have been possible to play these with the use of a standard VCR. These materials and equipment are available in many classrooms of the universities throughout the world. As other kinds of anti-tobacco media are developed in the USA, Canada or Australia, (which are presently the most active nations in public health smoking-cessation campaigns), it will be relatively simple to test these with similar populations in future follow-up research. Similarly, questionnaires and guidelines for future focus groups can be easily and inexpensively developed. 23 Material and Procedures In order to keep a uniform presentation style for each group in the experiment, PowerPoint slides in Spanish were developed containing the full text of the moderator’s orientation and discussion guide outline. This reduced bias caused by the investigator moving between different University settings with different student groups (See Appendix D). As mentioned, there were two sets of commercials to test for the two hypotheses. These were “family oriented” and “personal.” Two types of ads were selected. Four of the ads had “family oriented” themes and used persuasive messages attempting to convince the viewers to quit smoking out of loyalty towards the family. Two of the ads were “personal oriented” with individualistic themes and targeted to convince viewers to quit smoking in order to avoid doing damage to their own bodies (aorta or lung) Qelimiflons In order to keep the study relatively efficient, reliable and valid, the following delimitations were set: 1) Only the focus group method was used for all the tests, evaluations and commentaries. Four focus groups were conducted, with 10 subjects in each of the first three groups and 9 in the fourth. 24 2) Only college students were used from four different colleges that were geographically located in the same urban area. The groups were comprised almost equally of smoker and non-smoker populations. 3) 99% of the total experiment was conducted in the local Spanish language. 4) After a thorough media search, only the 6 of the best TV ads were selected and used for the experiment. 5) All the reactions of the focus groups were recorded either in writing or by means of audiotape. 25 Family Oriented The four “family oriented” ads portrayed children and/or parents in various stressful situations which were either causing major or minor pain, fear, sorrow or anguish due to smoking to one or more members of a family - in a family setting. The (persuasive) tag line in these commercials was an appeal for the smoker (parent) to quit smoking for the sake of the family (See Appendix C). 1) EB]: was an ad filmed in the kitchen of a Hispanic home where the children are expected to unquestioningly accept a father’s smoking habit in their presence. They reluctantly allow this to happen but their faces subtly display their personal displeasure at their father’s behavior. The voice-over (aimed at the parent- viewer) says that children learn behaviors from parents, and gently admonishes, “Be a good father." 2) MADRE This ad, filmed in a cemetery, has a close-up of a Hispanic father weeping bitterly at a gravesite with his children at his side, and the voice-over speaks of the deadly consequences to a family - of a mother’s smoking habit. 3) CIGARILLO This ad make one feel like being inside a chemistry lab with numerous bottles of bubbling and repulsive— looking liquids. One by one various family members take turns drinking out of these nauseating bottles as the voice-over recites 26 the poisonous contents contained in the smoke of tobacco. The final scene shows a baby drinking a brownish colored liquid from a baby bottle. 4) VENENOS (Poisons). The camera in this ad pans across the inside of an auto workshop where workers are inhaling exhaust fumes from a car, spraying insecticides on cockroaches, and making repairs with tar. As the voice-over enumerates the many poisons in this environment, the camera suddenly cuts to a family’s living room next door. The mother, father and two children are watching TV. Thick smoke fills the atmosphere of this room as the parents are smoking cigarettes and the children coughing. The voice-over states that these are same poisons filling the family’s living space. Personal Oriented The two “personal” ads depicted a single person smoking and vividly demonstrating his/her own organs (aorta or lungs) being damaged by their own smoking habit. A strong fear appeal was linked to these threats. 5) AORTA This ad begins with a close-up of a man under stress, 27 nervously lighting a cigarette. The camera then follows the smoke that the man inhales with a deep breath right into his mouth and then down his esophagus down to his chest cavity. There is a cut away to a surgeon’s table where a surgeon is holding a piece of an aorta, and squeezing some greasy substance (looking like a toothpaste tube) as he says that the effects of smoking cause the linings of arteries to collect dangerous fatty substances (cholesterol), and “this much” was found in the aorta of a man 32 years of age. The tag line is: Every Cigarette is Doing you Damage". (This ad was considered the most effective one of the Australian National campaign). 6) PULMON (Lungs) This is an ad of a 32-year-old emphysema patient speaking directly into the camera saying,“Oh my God, I can’t tell you what it’s like not be able to breathe.” The scene cuts away to another surgeon’s table where this surgeon is showing two recently removed lungs on a tray, one the color of a dark gray, and the other a healthy pink. He points to the gray one and he says smoking damages the lungs and causes difficulty in breathing. (This ad was considered the most effective one of the Massachusetts campaign). The tag line used in both these campaigns use the personal persuasive appeal “Every cigarette is doing you damage” ( See Appendix D). 28 Procedure for Experiment Following the showing of each commercial, ample time was given for the participants to fill in their answers to the questionnaires. Each of the 6 commercials was rated on an 11-point rating scale from 0 = lowest effectiveness to 10 = highest effectiveness. This measured the viewer’s perceived effectiveness of the message for producing an impact on the attitudes of the target audience. Before beginning to fill in their answers, the moderator went through each of the descriptive Spanish words, and asked if there were any questions about their meanings. Brief additional clarifying descriptors for these words were added when questions were raised. Participants were asked to stay focused on their own answers to their questionnaire, and not to comment, talk to their neighbors or disturb others. lgnsla_tion Procedures After the development and refinement of the questionnaires in English, the researcher asked two of the Mexican University professors to aid in the process of translating them into Spanish. The first Spanish translation was back translated into English for accuracy and integrity. 29 Then another professor was requested to double check the final Spanish translation for accuracy and understandability. Measures The first five questions of the Questionnaire dealt with the demographics of the participants. All were assured of complete confidentiality, in harmony with the standards set forth by the UCHRIS of Michigan State University. All were provided with the standard release form, and all participants willingly signed it (See Appendix A). All comments made by the students during the focus groups were recorded and transcribed in Spanish and then later translated into English with the assistance of two bi-lingual professors. These comments were then grouped into themes for analysis. Participants were asked to evaluate each of the 6 commercial on each of 6 descriptive words after viewing it on an 11- point rating scale from 0 = lowest effectiveness to 10 = highest effectiveness. Following the suggestions of Atkin (2001, p. 141) regarding audience surveys, the following six descriptive words were used: Interesting (tells you something new and increases your knowledge), M (valuable information and helpful advice worth remembering), Credible (accurate information and sincere/trustworthy characters are used who know what they are talking about), Professional (production quality is high), On-Target (content is personally meaningful and people 30 and situations are used with which you can identify), Persuasive (presents influential reasons to prompt change in behavior). These descriptive words were commonly used Spanish words delineating the kind of impact perceived by the subjects of the experiment. All participants were asked to be sure they understood the meanings of each word. Participants and Demographic Variables Since the primary purpose of the study was to engage in focus group discussions with young Mexicans in the cohort most likely to be influenced by tobacco advertising, a convenience sample of students from four universities was sought out. The student participants were not randomized, but selected by Chairpersons from the communications departments of these universities. Two of the universities were branches of well-established private institutions in Mexico (La Salle and Anahuac), and two were public universities (UTC, and University del Caribe). All were located in a populous urban area of Mexico. The age range of the students was 18 to 28. This is considered in the USA the age at which smokers are most likely to initiate and consolidate smoking (Pierce et al. 1998). The median age of the students in this experiment was 22. 31 The study was conducted in March and April, 2002. A total of 39 students participated. 10 in each of the first three focus groups and 9 in the last. All were enrolled in classes in their respective universities, and had 2 to 4 years of college. 20 were male and 19 were female. 16 were smokers and 23 were non-smokers. The majority of them, 33, were from middle and upper-income families. Only 6 were from lower-middle income families. _A_p_a_lysis Procedures With this relatively small database, it was possible to use only the simple mode of descriptive statistics, not inferential statistics. All data from the written responses to the questionnaires were entered into the SPSS software and manipulations for statistical processes handled with that software. The verbal responses to the moderator were tape recorded, transcribed and then translated from Spanish into English with the assistance of two professors. Qualitative analysis of these transcribed sessions was clustered into themes that tracked with the moderators outline. 32 V. RESULTS Themes The opening questions in the introductory section of the Moderator’s guideline probed into what the subjects considered to be the major public health problems in Mexico. In all groups the first health problem mentioned was alcoholism, and the second drug addiction. Poor nutrition was listed third in three groups, and diabetes and AIDS was mentioned in all groups. Only one group mentioned “tabaquismo” (smoking addiction as a disease) among the major health problems. Thereafter, the commentaries followed the line of the moderators questioning and proceeded along the following seven themes: 1) How pepple beqin smoking; All of the groups cited the following reasons that young people get started smoking, with two groups observing that this typically happens between the ages of 12 to 14. Curiosity was the reason most frequently mentioned. Imitation and following the role model of the father was next. Peer group pressure, and the feeling of wanting to belong to and be accepted by a group were mentioned in all groups. A comment that caused reverberations and nodding heads in one group summed it up, “I 33 think because they are neurotic, or stressed, and then they go to the ‘disco’ where everyone smokes, and so they do the same.” 2) Why they continue smoking The simple reason people continue smoking, according to all groups, was the addiction caused by nicotine. All these college-age students seemed to be quite knowledgeable and conscious about the difference between a habit and an addiction. One stated it thus, “It starts as a habit and becomes an addition.” Additionally, the continuing association with friends who smoke and belong to this group where they feel accepted. “They have nothing to do, so they want to have something in their hands, so they use a cigarette to feel safety,” as one student put it. Or, “How can I be considered a social person if I do not smoke?” as another stated. 3) The role of Mexican TV. All four groups expressed parallel opinions about the strong role Mexican television plays in the promotion of cigarette smoking among young people. Although the tobacco industry is limited to placement of cigarette ads after 10 PM daily, all participants had seen these ads, which are heavily sponsored throughout Mexico. As one student put it, “TV has a bad influence - like the Marlboro cowboy — everyone thinks they are like him. 34 At the same time there were comments in all groups about the relatively few govemment— sponsored anti-tobacco ads, which they felt lacked impact. “We have just a few ads about quit smoking. They show few ads about the danger of smoking. There are more commercials about selling cigarettes than about warning against smoke.” 4) Secondary Smoke. The groups were divided in their opinions concerning the potential dangers about the role of secondary smoke. An example of a typically undecided student, in answer to the question of the damaging effect of secondary smoke was, “It depends on the strength of the nicotine in the cigarette.” Whereas the majority of the students lived in family settings where one or more members of the family smoked, they expressed little concern during the “orientation” stage of the experiment about the issue of secondary smoke (This was prior to seeing the commercials of this experiment). Yet after viewing the commercials of the experiment, their eyes seemed suddenly opened to this subject, and they became quite vocal about the issue of secondary smoke. 5) How Can Smokers Quit? All groups seemed to know about the “patches" for smoking cessation, and they generally agreed about their efficacy, but there were two students who expressed the opinion that they were not 100% 35 successful — citing the experience of parents as proof. Other methods cited by all groups were: chewing gum, will power, hypnosis, audio tapes and family support. One unusual semi-religious remedy suggested was for the use of the “promise” (for smoking cessation) that a Catholic smoker might make to the Virgen de Guadalupe. This was considered to be an important component to the psychological makeup of a religious Mexican who is a smoker. 6) Could the Experimental Ads make a difference? After the viewing of the experimental ads, all groups made a variety of comments pin-pointing their opinions as to the effectiveness of these in contrast to the Mexican govemment-sponsored anti-tobacco ads. Among the comments: “Unfortunately, the Mexican ads lack the impact that the commercials made in the USA do.” “It seems to me that the images of the TV commercials of the US are very strong. That is what we need here.” “The last two ones were very good. It was a real story. They explain what happens to a person 32 years old because of cigarettes. They show you a picture of how your organs are damaged by smoking.” 7) Which Ads were the most Persuasive? As indicated by two of the comments above, the final two experimental commercials (Aorta and Lungs see Appendix C) were found 36 to be the most persuasive by the focus groups. The Spanish word used by two of the students was translated as “impactant”. As clearly indicated by the descriptive statistics cited below, all the groups in all measures rated the two “personal-oriented” commercials as most effective. The comments included: “The pictures capture you attention.” “It is a dramatic story.” “The lady says she cannot breathe.” “They show the difference between a healthy lung and a sick one.” Sample Differences The variation between the four universities was compared to see if there were any demographic differences between the subjects. Tabulations on several items were compared between the four groups of respondents. No significant differences between the groups were found on: sex, age, smoker/non smoker and family income. The differences found were primarily related to a slightly higher income in the private universities than in the public universities. Aside from this, the common urban Mexican environment for all the groups was the same, and therefore, the samples were pooled for this analysis. 37 Descriptive Statistical Analysis The reactions of the viewers to the stimulus ads (the six smoking cessation TV commercials) were charted using rather simple tabulations (see Table in Appendix D). These reactions (the dependent variables) were then cross-tabulated by the following arrangements: by gender, age, income and smoker/nonsmoker. Generally there appeared to be relatively small differences in reaction between various age groups, genders, income groups and smoker/non-smoker. Differences between the mean scores were seldom greater than 1 or 2. Males scored slightly lower (8.85) than females (9.33) in their overall reaction to the effectiveness of the six ads. Similarly smokers were less impressed with these ads overall (8.85) than nonsmokers (9.25). Low-income viewers were more affected and scored higher (9.18) than high-income viewers (8.85). Younger viewers scored lower (8.91) than older viewers (9.15). Thus, it was the younger, higher income, male smokers who were the least impressed. The older, low-income, female, non-smokers were the most impressed. A typical statistical analysis was not conducted because of the modest size of the population, and these small differentials. 38 All the ads were seen to be effective in each of the factors (6 descriptive words) rated by the viewers. The lowest-rated ad (“Papi”) generated a mean score of 7.85 across the six dimensions from all 39 participants in the experiment. The hiqhest rated ad (“Pulmon”) achieved a mean score of 9.88 across the six dimensions for all 39 participants. The Impact of Collectivism vs. Individualism The most marked differences in the tabulated data were found when comparing the relative impact of the “collectivist” versus the “individualist” commercials (Hofstede and Triandis, op. cit). Unfortunately for the investigator, exactly the opposite effect was found than had been posed as an hypothesis by the investigator. Namely, whereas the investigator had hypothesized that adult Mexican viewers would be more persuaded by “family-oriented” ads than by “personal- oriented” ones, the analysis of the data clearly demonstrated that this cohort of Mexicans were more affected by the personal ones than by the family ones. Each of the personal ads, “Aorta" and “Pulmon” received mean scores of 9.81 and 9.88 across the six dimensions. The family ads received mean scores from 7.85 to 9.35 across the six dimensions. 39 Possible explanations of the lack of support for this hypothesis include: a) The fact that the members of this particular adult Mexican cohort (college students) are not playing the “parental” role in a family, and are not affected by the typical family situations depicted in the commercials. b) That, having relatively little concern for the family, they have strong competitiveness and individualistic tendencies at this time in their lives. c) According to Triandis, “Affluence leads to individualism” (Triandis, op cit.). These students are relatively affluent Mexicans and one can expect some individualism to begin emerging - which substantially influences the values and attitudes they grew up with in their traditional Mexican rearing. 4O VI. DISCUSSION The purposes of this Thesis were, first, to undertake one of the preliminary steps (Pre-Production Media Research) that are necessary for a much larger formative evaluation that would need to be done prior to the launching of any comprehensive community based smoking cessation campaign in Mexico. It attempted to use a qualitative method to explore both general knowledge, attitudes and opinions about smoking and smoking cessation. The second purpose, simultaneously, was to gauge the relative effectiveness of USA, Canadian, and Australian TV commercials with the adult Mexicans. While a huge body of research examining smoking cessation has been published in the past 3 decades, most of the research is empirical, using quantitative measures that seek to establish relationships among variables. However, very few studies using a qualitative, descriptive approach have been reported. This study attempted to use the focus group to examine what are some of the most convincing elements for attaining opinion and attitude change among adult smokers in Mexico. 41 Interpretation and Implication of Findings The objective of these interpretations of the focus group findings are to suggest that they be included among the general goals of any future smoking cessation campaigns in Mexico — either nationally or at the state or local level. At the outset it is interesting to note that even though tobacco- related illness is recognized internationally (WHO statistics) as the leading preventable cause of illness and death in Mexico, only one of these four focus groups even mentioned “tabaquismo” as one of the major public health problems. The news media in Mexico frequently (almost daily) report on the drug traffic, and individual Mexicans personally experience the alcoholism, and so these were the most frequently mentioned public health problems perceived. Obviously the general education of the Mexican news media about smoking and health would need to be a primary campaign target. Next, the 7 principal themes articulated by the students during the focus groups provide important understandings for the media researchers who are attempting to be helpful in designing creative-persuasive messages for smokers trying to quit. 1) Smoking Initiation - the key roles of the father and the role of the peer group in the beginning of the smoking process should be targeted in designing messages aimed at influencing 42 2) 3) (counter-influencing) the values and life style of the young person. Continuation of Smoking - the focus group comments about the social acceptability and conformity of the smoking habit that becomes an addiction should be vigorously attacked. For example, the young Mexicans (who are ardent admirers of United States values) should be given clear cautionary messages that smoking in many restaurants and public places in the USA is prohibited, and in fact, in places like California smokers are virtually outcasts in public places. This is the opposite of one student’s plaintive comment, “How can I be considered a social person if I do not smoke?” Role of Mexican TV Since all of the focus groups, and most of the participants cited the “bad influence” of tobacco advertising on Mexican TV (even after the 9 PM curfew), it is clear that the laws of the country will need to be changed. Already there are reports that the current President, Vicente Fox, is making plans in that direction (article in newspaper Excelsior, April 12, 2002). As for the apparently weak federal government anti-tobacco campaign, a whole new campaign initiative with substantially increased funding will need to be undertaken. Hopefully it will be able to maximize its 43 4) 5) effectiveness with the use of the experiences from anti-tobacco campaigns in Canada, Australia, California and Massachusetts. Secondary Smoke Using the information gained from the experience of these focus groups it is obvious that rather speedy attitude changes can be achieved regarding the understandings of Mexicans towards secondary smoke. While the family-oriented ads in this experiment were not quite as effective as the personal ones, nevertheless they were perceived as quite effective. It is still the case that Mexican families and the culture in general are authentically collectivist, in the sense suggested by Hofstede (1980) and Triandis (1984). How Smokers Qgfi Almost certainly the most difficult issue in any anti-tobacco campaign is the matter of actually getting smokers to quit. The sophisticated knowledge of both smokers and non-smokers in these focus groups of the various methods of smoking cessation was encouraging. The additional new tool of calling and getting assistance from an 800 number telephone quitline could be a valuable new supplement to the smoking cessation efforts in Mexico in the future. 44 6) 7) Can Ads make a difference The vivid images and gripping stories in the experimental ads plainly had a persuasive effect on the attitudes towards smoking of these focus group members. Their ratings scores on the questionnaires across the six dimensions (from 7.85 to 9.88) on both the family and the personal ads demonstrated an unmistakably persuasive effect. The comment “the images of the US commercials are very strong...that is what we need here” gives a clear-cut direction for the design and production of future anti-tobacco messages in Mexico. Most Persuasive Ads An oft-repeated comment that became a continuing theme in all the groups was the complaint that the Mexican Government anti-smoking “informational” ads were a weak answer to the pervasive Marlboro images all around them in the various media. All groups were amazed at the strong (“fuerte” ) ads in this experiment, and expressed the felt need for a much stronger anti-tobacco campaign in Mexico. Thus, their near- unanimous reactions showed the final two ads (Aorta and Lung) with their stunning and deadly images to be the most effective. They were amazed how “impactant” these two ads were. Although they did not put it exactly in these words, their intent 45 was to redefine smoking from a socially pleasurable act to a deadly addiction. Direcyions for Future Research This study represents a first on-site attempt to use “Third Generation” formative evaluation pre-production media research on smoking cessation in Mexico. It attempted to use the best currently available media resources of the developed countries with a third world locale. And it was designed to be rapid, reliable and valid. However, there is substantial additional formative evaluation that needs to be done prior to launching a public health campaign. Areas needing further research include: other target audiences, specific target behaviors, media mix, and additional survey research. Additional Tarqet Audiences. This study was limited to college students for greater ease and speed in gaining a convenience sample. Expanding the age groups in future research would greatly enhance the systematic analysis of audience reactions in Mexico. Would middle aged and older Mexicans with families react differently to the family-oriented ads? How would rural families react to these same ads? Research questions might also probe the extent that public perceptions are associated with Mexican public health initiatives. 46 Specifying Tapqet Behaviors. More focus group research is needed to identify specific behavioral objectives within the Mexican culture. Can smokers in Mexico be persuaded with these ads to actually take the behavior step of reaching for the telephone and calling the 800 quitline number? (As happened in Australia and California). Could the appeal of the “glamour” tobacco ads be “deglamorized” in Mexico in light of the new smoking cultural cues in the USA? Could Mexico follow the lead of Massachusetts in “redefining smoking from a socially acceptable act to a deadly addiction”? (Boston Globe, 6/26/2002). How can ads be designed to deal with peer pressure - for the beginning smoker and also the continuing smoker in Mexico? Media Mix. While TV was rated by the respondents in this experiment as the most effective component of a smoking cessation media mix for Mexico, it would be useful to gauge audience reaction to: radio ads, newspaper ads, and billboards. The tobacco industry in Mexico obviously has huge budgets for billboard advertising — and is reaching millions of customers in that way. Would this medium (billboards) be an effective counter-advertising method for “deglamorizing” the macho and “sexy” tobacco appeals in Mexico? 47 Sprvey Research. This study used only 6 factors for audience evaluations and reactions to the ads presented. Instruments measuring many more factors should be developed for the Mexican audience, as identified from the responses of this study. These could be cheaply and efficiently administered in a wide variety of public Mexican settings such as urban malls, rural markets, hospitals, public schools and the like. A more professional, but expensive, method would be to make use of the newly established survey research companies emerging in the larger metropolitan areas of Mexico. 48 Conclpsion The forthcoming “global epidemic” of tobacco-related illness and deaths (World Health Organization, 2000) merits continuing research in all academic fields across the world. Recent media research and action in the developing world has revealed that with sufficient resources, and intelligently researched and designed messages, public health campaigns can help to ameliorate the deluge somewhat. All effective media campaigns must begin with good formative evaluation, which includes a close analysis of the target audience and its culture and values. Social scientists, such as Triandis, claim that the cultures of much of the Third World (including Mexico) are collectivist and tend to value family membership as a source of group identity and solidarity. This study began with this notion but was not successful in proving its hypothesis about this subject in Mexico with this audience. Nevertheless, the study has added some useful preliminary first steps in designing the foundations of what may, hopefully, some day be a major public health campaign throughout Mexico and the Third World. 49 APPENDICES 50 APPENDIX A __pestionnaire and UCHRIS Approval 51 CONSENT FORM F ORJMA DE CONSENT WIENT 0 1.Te invite a participar en este Grupe Muestra, al cual agradezce su valiesa ayuda. La infermacien que me preprcienen Ies participantes la utilizare para realizar mi tesis sobre el Use de la Television en Pregramas de Salud, a fin de ebterner mi diploma “Masters in Telecommunications” (Maestn'a en Telecemunicacienes) en Michigan State University, de East Lansing, Michigan, EUA 2. Unicamente me interesa conocer sus ideas acerca del tabaquisme y tu opinion sebre algunes cemerciales utilizados en Pregramas para Dejar de Fumar. Tus respuestas seran anemimas. Nadie sabra tu nombre, ni que participaste en esta encuesta. 3. Esta entrevista durara entre hora y media y dos horas. Si aceptas participar, a1 finalizar te dare en agradecimiento la cantidad de $100.00. No desee ferzar a ninguna persona a participar. Espero que tu participacion sea veluntan'a. Si per alguna razon no deseas fermar parte del grupo muestra puedes cementarle y concluir con tu participacion en este memento. 4. Si participas pedras ebtener infermacien y mayor cenecimiente sebre les efectes que puede preducir el tabaquisme en tu salud. Si eres furnader quizas dejaras de fumar despues 'de participar en esta entrevista y tu salud, se beneficiara. 5. Estey de acuerde en participar con estas cendicienes. FIRMA: FECHA: (Per F aver, escnbe en letras abaje) En case tu tienes algunas preguntas e preecupadas acerca tus dereches come ayudante en este investigacien, per favor centactar: Harold Mendel, Investigader, hasta 15 de abril 2002, en eficina de Pref. Julian Aguilar Estrada, Universidad Tecnelegica Cancun, KM. 11 5 Carretera Cancun-Aerepuerte Cancun, Q. Ree, Mexico, 0: Dr. Ashir Kumar, Michigan State University’s Chair 0f University Committee on Research Involving Human Subject at (517) 355-2180, 202 Olds Hall, MSU 48824, 0 con email a 52 Numero: CUESTIONARIO 1. gCuantas persenas viven en su casa? 2. Per favor, indique e1 numere de personas que viven con usted per ranges de edad ___Menes de 20 '___20-30 _30-40 _40-50 _Mis de cincuenta 3. LCuantas hemres y... e mujeres viven con usted? hombres mujeres 4. LAlguna(s) de las personas que v iven cen usted fuman ? _Si _Ne Si su respuesta es si, cuantas persenas fuman? S. gEres filmader? __ Si _N0 6. Para fumaderes y ex-fumaderes . Ahera cuantes cigarilles flimas (aprex.) a1 dia LHa tratade de dejar de fiimar? {,Cuantes veces? 7. Después de haber fumade cuantes cigan'illes una persona puede quedar atrapada y llegar a ser un adicte a1 tabace? g, a) 1-5, h) 5-10, 0) 10 e mas? 8. Si suma les ingreses de les miembres de su familia, mensualmente, a cuante (apron) ascienden _menes de 3,000 _de 3,000 a 5000 5,000 a 10,000 _10,000 a 20,000 __+20,000 ' - 'I'RANSICION —- DESPUES MOSTRAMOS LOS COMERCIALES: Per favor evalue les siguientes COMERCIALES en cada une de las siguientes escalas, con puntuacienes extendiéndese desde 0 - a -10 (10, estan mas altos): #1, “PAPISEEBUENBMLQW, Interesante _0 _1 _72 _3 _4 _S _6 _7 _8 _9 _10 Util (1a infermacien es valiesa, e1 censeje es util) __0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Creible (verdadere, cenfiable) ._0 _1 _2 _3 _4 _S _6 _7 _8 _9 _10 Prefesienal (la preduccien alta de ealidad, atractiva y motivante. _0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Centundente (persenalmente muy significative, pertinente para las necesidades) _0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Persuasive 0 l 2 3 4 5 6 7 8 9 10 53 #2, LA MADRE MUEO MU X JQVEN. ,, - . Interesante _0 _1 _72 _3 _4 _5 _6 _7 _8 _9 _10 Util (la informacien es valiesa, e1 censeje es util) ___0 _1 ___2 _3 _4 _5 _6 _7 _8 _9 _10 Creible (verdadere, confiable) _0 _1 _2 _3 _4 _5 _6 _7 __8 _9 _10 ' Prefesienal (la preduccien alta de calidad, atractiva y motivante. _O _l _2 _3 _4 _5 _6 ___7 _8 _9 _10 Centundente (persenalmente muy significative, pertinente para las necesidades) _0 _1 _2 _3 ___4 _5 _6 _7 _8 _9 _10 Persuasive 0 1 i 2 3 4 5 6 7 8 9 10 #3. CIGARILLOS CONTIENEN LOS TOXINAS. . .. Interesante _0 _1 _r2 _3 _4 _5 __6 _7 _8 _9 _10 Util (Ia informacien es valiesa, e1 censeje es (mil) _0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Creible (verdadere, eenfiable) _0 __1 _2 _3 _4 _S _6 _7 _8 _9 _10 Prefesienal (1a preduccien alta de calidad, atractiva y motivante. _0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Centundente (persenalmente muy significativo, pertinente para las necesidades) _0 _1 _2 _3 ._4 _5 _6 _7 _8 _9 _10 Persuasive 0 1 2 3 4 5 6 7 8 9 10 #4, L95 VENENOS ENLASALA..., Interesante _0 _1 _72 _3 _4 _5 _6 _7 _8 _9 _10 Util (1a infermacien es valiesa, el censeje es util) _0 _l _2 _3 _4 _5 _6 _7 8 _9 _10 Creible (verdadere, cenfiable) _0 _1 _2 _3 _4 _S _'_6 __7 _8 _9 _10 Prefesienal (la preduccien alta de calidad, atractiva y motivante. __0 _1 _2 _3 _4 _5. _6 _7 _8 _9 _10 Centundente (persenalmente muy significative, pertinente para las necesidades) _0 _1 _2 _3 _4 _S _6 _7 _8 _9 _10 Persuasive 0 1 2 3 4 5 6 7 8 9 10 54 #5. AORTA ...... I en ingles) Interesante _0 __.1 __'_2 _3 _4 __S _6 _7 _8 _9 _10 Util (1a infonnacion es valiesa, e1 censeje es util) _—0 _1 ___2 _3 __4 _5 _6 _7 _8 _9 _10 Creible (verdadere, cenfiable) _0 __l _2 _3 _4 _5 _6 _7 _8 _9 _10 Prefesienal (la produccien alta de calidad, atractiva y motivante. ____0 _1 _2 _3 ___4 _5 _6 _7 _8 _9 _10 Centundente (persenalmente muy significativo, pertinente para las necesidades) _0 __1 _2 _3 ___4 _5 ____6 _7 _8 _9 _10 Persuasive 0 1 2 3 4 S 6 7 8 9 10 #6. LOS PULMONES . .. (en ingles) ' Interesante _O _1 _72 _3 __4 _5 _6 _7 _8 _9 _10 Util (la infermacien es valiesa, e1 censeje es 661) _0 _1 __2 _3 _4‘ _5 _6 ___7 _8 _9 _10 Creible (verdadere, confiable) ___0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Prefesienal (1a preduccien alta de calidad, atractiva y motivante. _0 _1 _2 _3 _4 __5 _6 _7 _8 __9 _10 Centundente (persenalmente muy significative, pertinente para las necesidades) _0 _1 _2 _3 _4 _5 _6 _7 _8 _9 _10 Persuasive 0 1 2 3 4 5 6 7 8 9 _10 Tienes alge mas cementaries sebre les cemerciales. .. 55 MEN SAJES Per favor evalue estes cuatre “ mensajes”. En una escala del 0 a1 10 de una punctuacion a cada comercial. (El numere 10 sera 1a puntuacien mas alta):' l. “Cada Cigarille dar‘ia su cuerpe ” 2. “Hagames que el FUMAR pase a la historia” O ' 1 2 3 4 5 6 7 8 9 10 3. “Dejalo! Entre mas pronto deje el cigarro, su cuerpo estara mejor. 0 1 2 3 4 5 6 7 8 9 10 — __—._——__—-— 4. “Es mejer hacer frente a las situacienes que fumar.” MEDIOS PARA MEN SAJES... (En su opinion, cuales son los mejeres medics para premever e1 DEJAR DE FUMAR? Marcar #1, #2, #3 y #4: A)._ les Periodices B).__ Radio C). __ TV? D).__ Anuncies espectaculares 56 MICHIGAN STATE. UNIVERSITY February 18,2002 TO: Chanes ATKIN 4738 Comm Arts Bldg RE: IRB# 02-020 CATEGORY: EXEMPT 1-B APPROVAL DATE. February 11, 2002 ‘ TITLE: AN INVESTIGATION OF PERSUASIVE MESSAGES REGARDING SMOKING AND SMOKING CESSATION AMONG ADULTS IN URBAN MEXICO The University Committee, on Research Involving Human Subjects' (UCRIHS) review of this project is complete and I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore, the UCRIHS approved this project. RENEWALS: UCRIHS approval is valid for one calendar year, beginning with the approval date shown above. Projects continuing beyond one year must be renewed with the green renewal form. A maximum of four such expedited renewals possible. Investigators wishing to continue a project beyond that time need to submit it again for a complete review. REVISIONS: UCRIHS must review any changes In procedures involving human subjects, prior to initiation of the change If this is done at the time of renewal, please use the green renewal form. To revise an approved protocol at any other time during the year, ‘send your written request to the UCRIHS Chair, requesting revised approval and referencing the project's IRB# and title. Include in your request a description of the change and any revised instruments, . consent forms or advertisements that ’are applicable. PROBLEMSICHANGES: Should either of the following arise during the course of the work, notify UCRIHS promptly. 1) problems (unexpected side effects, complaints, etc.) involving human" subjects or 2) changes in the research environment or new information indicating greater risk to the human subjects than existed when the protocol was previously reviewed and approved. RESEARCH If we can be of further assistance, please contact us at (517) 355-2180 or via email: UCRIHS@msu.edu. Please note that all UCRIHS forms are located on the web: AND . htthMwwmsuedu/user/ucrihs ' GRADUATE STUDIES Sincerely, ' Mancunian": _ amulmnm ’ . 'Illman Subjects ' I II M *’ ir r M D. moIIIomsmuIIIvesIIy . 246 Mninistratlon Building UCRI HS Chair Est Lansing, Michlgm AK' 48824-1046 CC: ' kj 517f355-21w FAX: 517/353—2976 Web: mean/Infinite ' , m W- Harold Mondol ' 1 1 19 Kimberly Dr. #5 Lansing, MI The Wile-Isa m DEA a WWW): mmnm 5 7 APPENDIX '8 Moderator Guideline for Focus Group We want to find out what you think about smoking so we can design the kind of health education programs that fit the needs of help people like you. We want to know what you really think about smoking, whether you are a smoker or not. And also about ways of quitting smoking. We want each of you to be free to say exactly what you think — no matter how silly or crazy your idea may seem. Everything you say here will be kept confidential and anonymous. No one will ever know what you personally said - only what everybody’s combined responses are. Please speak up even if you disagree with what someone else says. We want lots of different ideas and opinions from you on this subject. What I’ll do is to begin the process by asking some general questions to get the discussion going. We will be recording all this on a small tape recorder, so that it can be transcribed later - with no names, of course. This is totally anonymous. Any questions before we start? Who the Investigator is 8 why the students have been asked to participate. SECTION I - GENERAL HEALTH IN MEXICO 1. What do you feel is the most important health problem in Mexico? 2. What are other health problems? 58 3. Do you feel that smoking is a significant health problem in Mexico? - Why? - Why not? SECTION II - LET’S FOCUS ON SMOKING 4. How do people get started smoking? 5. How do some of your friends think you might get started smoking? SECTION III - WAYS TO QUIT SMOKING 6. What are some of the things your friends have told you about quitting smoking? 7. Any other things you’ve heard of people doing to quit smoking? SECTION IV 8. Are you concerned about smoking? - Why? - Why not? 9. Do you think smoking leads to illness? To death? - Why? - Why not? 10.What do your family and friends think about smoking? 11.Are you concerned about getting illness from smoking? 12.Who do you think is at risk for getting illness? - The smoker? - The people getting second-hand smoke? 13. Is smoking a habit or an addiction? 14.After how many cigarettes do you think that people might get hooked? 1 - 5? 5 — 10? More than 10? 59 SECTION V - WHAT PEOPLE SAY ABOUT QUITTING 15.Are “patches” effective for quitting? - Why? - Why not? 16.What do you think might be the benefits of using patches? 17. Is self-control effective in quitting smoking? - Why? - Why not? 18.Are other medicines effective in quitting smoking? 19. Do you think that smokers would be willing to try patches to quit smoking? EVALUATIONS OF THE COMMERCIALS New we’d like to find out your opinions about some smoking cessation commercials used on TV in the USA and Australia, so we can design the kind of health programs that fit your needs. We want to find out what you really think about these TV ads — whether they work or not. Also, we’d like your ideas about what kind of messages you think would motivate smokers to quit. Do you have any questions? Please rate the following TV commercials on each of the items listed on your questionnaires — with scores ranging from “0” to “10”. 10 is the highest. The six words describing the commercials are: 0 Interesting - Useful 0 Credible 0 Professional 0 On Target - Persuasive 6O And in the last part of the session we’d like to find out what you think would work best in getting Mexicans to quit smoking. 1. 2. What do you think keeps people from quitting smoking? What do you think is the greatest barrier to keep people from quitting? . Do you think smoking cessation campaigns work or not? . What should such campaigns talk about, but they don’t? What king of campaign materials would make you believe that smoking is harmful? What kind of campaigns materials would make you believe that you might be susceptible to getting ill due to smoking? What are the best ways to promote smoking cessation? - newspapers? - TV? -Radio? - Billboards? How can campaign materials persuade people that they can perform the recommended responses? 9. Finally, are there any particular Mexican beliefs that you think should be addressed? Thank you very much for your participation. I appreciate it very much. Here is your compensation for having helped me in this experiment. (Investigator personally gives each respondent 100 pesos). 61 APPENDIX C THE TV COMMERCIALS ADVERTISEMENT # 1 Papi Commercial This commercial was largely filmed in the side yard and kitchen of a Hispanic home where the children are expected to unquestioningly accept a father’s smoking habit in their presence. They reluctantly allow this to happen but their faces subtly display their personal displeasure at their father’s behavior. The voice-over (aimed at the parent-viewer) says that children learn from the example and behaviors of their parents, and ends by gently admonishing, “Be a good father." This ad produced by the California Department of Health Services in 2000, is in Spanish, and was aired statewide many times as part of their anti-tobacco campaign targeted specifically for the Hispanic audience. 62 ADVERTISEMENT # 2 Madre Commercial This ad, filmed in a cemetery, has a close-up of a Hispanic father weeping bitterly at a gravesite of his dead wife with his children at his side. There is powerful, emotional music In the audio background... As the voice-over speaks of the deadly consequences to the whole family - of a mother’s smoking habit. This ad produced by the California Department of Health Services in 2000, is in Spanish, and was aired statewide many times as part of their anti-tobacco campaign targeted specifically for the Hispanic audience. 63 ADVERTISEMENT # 3 Venenos “Poisons" Commercial This ad make one feel like being inside a chemistry lab with numerous bottles of bubbling and repulsive—looking liquids. One by one various family members take turns drinking out of these nauseating bottles as the voice-ever recites the poisonous contents contained in the smoke of tobacco. The final scene shows a baby drinking a repulsive brownish colored liquid from a baby bottle. This ad produced by the California Department of Health Services in 2000, is in Spanish, and was aired statewide many times as part of their anti- tobacco campaign targeted specifically for the Hispanic audience. 64 ADVERTISEMENT # 4 Auto shop commercial The camera in this ad pans across the inside of an auto workshop where workers are inhaling exhaust fumes from a car, spraying insecticides on cockroaches, and making repairs with tar. As the voice-over enumerates the many poisons in this environment — including the chemicals contained in insecticides. The camera suddenly cuts to a family’s living room next door. The mother, father and two children are watching TV. Thick smoke fills the atmosphere of this room as the parents are smoking cigarettes and the children coughing. The voice-over states that these are same poisons filling the family’s living space. This ad produced by the California Department of Health Services in 2000, is in Spanish, and was aired statewide many times as part of their anti-tobacco campaign targeted for the Hispanic audience. 65 VIDEO A young man lights his first cigarette of the day. As he inhales, we follow the swirling smoke down his esophagus. We see a section of a human aorta en a dish of surgeon’s table. A Doctors hand picks it up and squeezes it along its length. Yellow cheesy gunk comes out like toothpaste. He finishes squeezing and lays the artery down. As our smoker exhales, we see him puff away, blissfully unaware. ADVERTISEMENT. # 5 Aorta Ad AUDIO Voice Over: Every Cigarette is doing you damage. This is part of an aorta... the main artery of the heart. Smoking makes the artery walls sticky and collect dangerous deposits. This much was found in the aorta of a typical smoker... aged thirty-two Every cigarette is doing you damage. IMAGE See Image 1 Next Pages See Image 2 Next Pages See Image 3 Next Pages See Image 4 Next Pages See Image 5 Next Pages This ad was considered the most effecfive one of Australia’s 2000 campaign. 66 Image 2 Image 3 67 Image 4 Image 5 68 ADV#6 Lung Ad (“Pulmon”) This is an ad, developed by the Massachusetts Department of Health, of a 32-year-old emphysema patient, Pam Laffer, Speaking directly into the camera saying,“Oh my God, I can’t tell you what it’s like not be able to breathe.” The scene cuts away to a surgeon's table where this surgeon is showing two recently removed lungs on a tray, one the color of a dark gray, and the other a healthy pink. He points to the gray one and he says smoking damages the lungs and causes difficulty in breathing. (This ad was considered the most effective one of the Massachusetts campaign of the late 1990’s). The tag line used in both the Australian and Massachusetts campaigns was a personal persuasive appeal: “Every cigarette is doing you damage”. 69 APPENDIX D The Tables TABLE I Rating Comparisons Between Subgroups Across All Six Messages Adv. 1 — “Papi” Adv. 2 — “Madre” Adv. 3 — “Venenos” Adv. 4 - “Cigarillo” Adv. 5 - “Aorta” Adv. 6 — “Pulmon” Rating scale based on 0 = not effective; 10 = Extremely Effective Subgroup Adv. 1 Adv. 2 Adv.3 Adv. 4 Adv. 5 Adv. 6 All Smokers 7.3 8.1 8.9 9.4 9.4 10.0 8.85 Non-smokers 8.1 9.2 8.2 9.7 10.0 10.0 9.25 Females 8.2 9.4 8.6 9.8 10.0 10.0 9.33 Males 7.3 8.5 8.1 9.2 10.0 10.0 8.85 Low Income 8.6 9.3 8.8 9.6 9.3 9.5 9.18 High Income 7.2 8.2 8.5 9.2 10.0 10.0 8.85 Younger 7.4 9.2 8.3 9.2 9.8 9.6 8.91 Older 8.7 8.6 8.7 8.7 10.0 10.0 9.15 OVERALL 7.85 8.81 8.51 9.35 9.81 9.88 9.04 7O BIBLIOGRAPHY Atkin, Charles K. and Rice, Ronald E. 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Yach, Derek and Douglas Bettcher (2000) Globalisation of tobacco industry influence and new global responses, Tobacco Contrgl 9: 206-216 75 Websites for the Tobacco Papers: One is a recent grant from the American Legacy Foundation to the University of California at San Francisco (www.library.ucsf.edu@bacco) to mount and maintain 3 documents database, and the other is Tobacco Documents Online, a site run by Michael Tacelovsky (www.tobaccodocuments.orq) with the involvement of several recipients of grants from the National Cancer Institute. These efforts to create sites that are easier to use are essential, because under the terms of litigation settlements, the Minnesota Depository is scheduled to close in 2008, and the tobacco companies are no longer required to maintain their websites after 2010. 76 IllllllilillllliI