Commentary on Simset al. (2014) and Langleyet al. (2014): Mass media campaigns require adequate and sustained funding to change population health behaviours

Highly successful commercial brands understand that consistent ongoing bursts of advertising are necessary for maintaining brand awareness and sales 1. Public health campaigns are rarely funded at the levels of commercial advertisers, yet the extent of campaign exposure while on air and the lack of an ongoing campaign presence (campaign duration) are rarely examined as determinants of campaign success or failure 2. Research examining anti-smoking campaign intensity and duration has been vastly outweighed by research focusing on advertising content and style 3, perhaps because advertisement message attributes are more amenable to experimental study and/or more theoretically interesting to behavioural scientists, communication scholars and marketing researchers. Considering the influence of these critical factors in the success of tobacco control campaigns aired in the United Kingdom over the past 10 years, the recent papers by Sims et al. 4 and Langley et al. 5 are a welcome addition to the literature. Sims and colleagues' study 4 indicates that each person in the population needs to be exposed to approximately four anti-smoking advertisements per month to result in a detectable impact on smoking prevalence. These findings have a remarkably high degree of consistency with previous studies from Australia 6, 7 and the United States 8, 9, which indicate that moderate to high levels of intensity (i.e. exposure to four to eight advertisements per month per person) are necessary for campaigns to ‘cut through’ the competing clutter of commercial advertising. These levels of campaign intensity enable messages to be seen multiple times so they can be processed as intended and, thus, achieve population-wide influence. While research shows that part of the population-wide effect is generated by smokers quitting in direct response to such messages, another key effect is to increase community discussion 10 and to change broader social norms that reduce the social acceptability of smoking, leading to higher support for policy change and more social support and services to help smokers quit 11. Adding to this is Langley et al.'s paper 5, which shows a decline in the demand for quitting information and assistance after the United Kingdom's anti-tobacco campaign funding was cut. This study underlines the importance of smokers being exposed to regular ongoing campaign activity to inform and remind them of the importance of quitting and to re-energize their desire to quit, so that they put quitting at the top of their priority list. This is consistent with the relatively low durability of commercial advertising impact on sales 1 and with recent studies that indicate that anti-smoking campaign effects on behaviour last for just a few weeks or months 6, 7, 12. Ongoing exposure to anti-smoking messages is especially important to counter an addictive behaviour such as smoking, where the weight of addiction does not disappear when the campaigns do 11. In addition, the constant backdrop of tobacco industry marketing in many countries means that when there is no anti-smoking campaign presence, the balance of the dominant share-of-voice shifts towards industry messages designed to recruit new smokers, affirm current smokers and recapture recent quitters 11. Marketing is also very relevant as a driver of risky alcohol use 13. Alcohol-reduction social marketing campaigns have so far had limited success 11, 14, a fact that is unsurprising, given the widespread advertising and promotion for alcohol and the social norms in many countries that paint non-drinking as anomalous 13. It is unreasonable to expect social marketing campaigns with low intensity, limited reach (i.e. reaching only those underage or those in certain schools or communities) or with short duration to combat risky alcohol use in this context. A comprehensive strategy including restrictions on marketing and access to alcohol, price increases and well-funded ongoing mass media campaigns will be required to start reducing the harm caused by risky alcohol use 15, as is gradually being achieved in tobacco control in many countries 16, 17. Dependable long-term funding for public health prevention campaigns as part of a comprehensive strategy has the potential to reduce suffering and loss of life 18. To achieve the greatest population impact, these types of campaigns need to be seen as ongoing services which are integrated into public health systems. To do so will pay handsome dividends for future generations, not only in terms of disease averted, but also health-care costs avoided 19. None declared.