Attitudes of Female Smokers / Non-Smokers towards Smoke-Free Air Zone Ad Campaign

Turkish government and NGO’s have been broadcasting or publishing some health communication campaigns every year. In these campaigns, the messages generally related to giving up smoking cigarettes, keeping the heart healthy and such an early prognosis of cancers. In Turkey, except in houses for accommodation, smoking was banned in closed areas of all public and private buildings as well as in public transportation vehicles on the 19 th of July, 2009. The Ministry of Health named this project as “Smoke-Free Air Zone”.The main aim of this research is to reveal attitudes of female smokers /non-smokers towards SmokeFree Air Zone Ad Campaign. A survey conducted to reach this aim. Attitudes towards a print ad, which contains anti-smoking claims analyzed among the women who smoke and nonsmoke.Sample of the research consist of the female students who are attending Anadolu University, Faculty of Communication Sciences, Department of Advertising and Public Relations.


Health Communication Campaigns
Health communication campaigns have been broadcasting or publishing frequently in Turkey.
In these campaigns, the messages generally related to giving up smoking cigarettes, keeping the hearth healthy and such an early prognosis of cancers.A health communication campaign must disseminate of health messages through public education campaigns that seek to change the social climate to encourage healthy behaviors, create awareness, change attitudes, and motivate individuals to adopt recommended behaviors.On the other hand, health communication campaigns use communication strategically to improve health.Attitudes are composed of evaluations of people, events, products, policies, institutions, or behaviors (Cassell, Jackson and Cheuvront, 1998: 71-79).A meta-analysis by Snyder (2002) demonstrated that health campaigns reach small and short-term effects when strategically planned (Dutta-Bergman, 2002: 103-122).The most important theories guide to explain health communication programs are, health belief model, the theory of reasoned action, social learning /cognitive theory, diffusion of innovation, and social marketing (Airhihenbuwa& Obregon, 2000: 5-15).The health belief model proposes that in order for someone to perform a recommended health behavior, the person must first believe that he or she is at risk for acquiring a serious and severe negative health outcome (e.g., coronary heart disease, HIV/AIDS) (Fishbein and Yzer,2003: 164-183).
Within the field of public health, much attention has been devoted to potential uses of the mass media to modify attitudes, shape behavior, and generally persuade audiences to protect their health (Cassell, Jackson and Cheuvront, 1998: 71-79).According to social cognitive theory (Bandura, 1977(Bandura, , 1986(Bandura, , 1997)), there are also two primary factors that determine the likelihood that someone will adopt a health-protective behavior.First, the person must believe that the positive outcomes (benefits) of performing the behavior outweigh the negative outcomes (costs).Second, the person must have a sense of personal agency or self-efficacy with respect to performing the behavior (Fishbein and Yzer, 2003: 164-183).Theory of reasoned action assumes that people rationally calculate the cost and benefits of engaging in a particular action and think carefully about how important others will view the behavior under consideration.There are four components of the theory.The first is attitude toward to behavior (the person's judgment that performing the behavior is good or bad); the second is subjective norm (the person's perceptions of the social pressures put on him to perform or not perform the behavior in question).The third component is behavioral intention, the intent or plan to perform the behavior.The final aspect is behavior itself-action in a particular situation (Perloff, 2003: 90).Diffusion of Innovation (DOI) Theory, developed by E.M. Rogers in 1962, is one of the oldest social science theories.It originated in communication to explain how, over time; an idea or product gains momentum and diffuses (or spreads) through a specific population or social system.The end result of this diffusion is that people, as part of a social system, adopt a new idea, behavior, or product.Adoption means that a person does something differently than what they had previously (i.e., purchase or use a new product, acquire and perform a new behavior, etc.).The key to adoption is that the person must perceive the idea, behavior, or product as new or innovative.It is through this that diffusion is possible (http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models4.html).
The term social marketing was formally introduced in 1971, when Kotler and Zaltman (1971) coined the term.Kotler and Zaltman (1971) defined social marketing as: the design, implementation, and control of programs calculated to influence the acceptability of social ideas and involving considerations of product planning, pricing, communication, distribution, and marketing research (Cheng, Kotler and Lee, 2011: 2).

Campaigns against Smoking
Preventing smoking is a public health priority.Public health practitioners have begun to use counter advertising to prevent smoking initiation.Despite the growing use of antismoking media campaigns, little is known about their effectiveness (Siegel and Biener, 2000: 380-386).Educational mass media campaigns against smoking can be an effective means of changing attitudes and behaviors related to tobacco use.Media campaigns have the potential to change social perceptions of smoking and knowledge about the dangers of secondhand smoke (SHS) and thus may increase support for smoke-free environments (Fosson,McCallum and Conaway, 2014: 1-9).Sims et al (2013: 1-7) examined the effects of tobacco control television advertisements with positive and negative emotional content on adult smoking prevalence and cigarette consumption in England from 2004 to 2010.They found that both positive and negative emotive campaigns are effective in reducing tobacco use.Fosson, McCallum and Conaway (2014: 1-9) investigated the effect of an educational media campaign on support for smoke-free environments before the implementation of smoke-free protections.On the post campaign survey, 80.9% of respondents reported seeing a television advertisement.Overall, support for smoke-free bars increased significantly after the intervention but not for workplaces or restaurants.Self-reported exposure to the media campaign was associated with higher levels of support for smoke-free workplaces, restaurants, and bars.
There is considerable evidence that emotional arousal mediates the effectiveness of advertising.For example, emotional messages are better remembered than non-emotional ones and are more likely to promote higher order cognitive processing.Furthermore, ads high in sensation value (reflecting content that is novel, graphic, stimulating etc.) are more likely to increase viewer's attention, motivation to call a hotline, ad recall and intention to perform the target behavior, than those with lower sensation value.Thus, there is evidence emotional responsiveness to advertising might be a key element of advertising effectiveness (Wakefield et al, 2002: 1-33).
The scientific evidence is substantial and clear: public education campaigns reduce the number of youth who start smoking, increase the number of smokers who quit, and make tobacco industry marketing less effective, saving lives and health care dollars.The 2012 Report of the Surgeon General, Preventing Tobacco Use Among Youth and Young Adults, concluded specifically and unequivocally: mass media campaigns "prevent the initiation of tobacco use and reduce its prevalence among youth."The recently released 2014 Surgeon General's Report, The Health Consequences of Smoking-50 Years of Progress, affirms this conclusion and recommends, among other actions, "high impact national media campaigns…at a high frequency level and exposure for 12 months a year for a decade or more."(http://www.tobaccofreekids.org/research/factsheets/pdf/0051.pdf) The Target of the Tobacco Industry: Women We started a new life, a fully non-smoking life, in Turkey on the 19 th of July, 2009.The related Law was put into force after being revised to protect the whole society and especially the future generations from the damaging effects of cigarette smoke.Except in houses for accommodation, smoking was banned in closed areas of all public and private buildings as well as in public transportation vehicles on the 19 th of July, 2009.The Ministry of Health named this project as "Smoke-Free Air Zone".In the world, hypertension is the first cause of death followed by smoking, and in all over the world, and one out of 10 adults' dies of smoking.WHO (World Health Organization) celebrates 31 st of May as the "World No Tobacco Day" every year to draw the attention to the increasing consumption of tobacco and to point to effective policies for decreasing the consumption of tobacco and to the bad effects of smoking on health.WHO especially pointed to the damaging effects of smoking and marketing tobacco on women and young girls via the theme of "The Target of the Tobacco Industry: Women" on the World No Tobacco Day in 2010.Women smokers are likely to increase as a percentage of the total.Women are adopting more dominant roles in society: they have increased spending power, they live longer than men.And as a recent official report showed, they seem to be less influenced by the anti-smoking campaigns than their male counterparts.All in all, that makes women a prime target.The tobacco industry has long emphasized that women and young girls should be free, independent and attractive.Today, the tobacco industry goes on targeting women by using the same theme in direct or indirect advertisements.Cigarette is advertised by associating it with independence, attractiveness, weight-control, culture and power; at the same time, new marketing tactics are developed to increase smoking among women.
Getting the outbreak of smoking among women under control is an important part of comprehensive tobacco-control strategies.Women constitute about one-fifth of one billion smoking people.In addition, use of tobacco is gradually increasing among women especially in developing countries.Therefore, the main target of the tobacco industry that need new customers is not only the current tobacco users likely to die of diseases that occur due to tobacco use but also women who have the potential to take place of those who will die due to tobacco use.The tobacco companies have long understood the importance of women and girls in the overall market for cigarettes and as a source of new customers.Tobacco companies have conducted extensive market research on the attitudes of women and girls to better understand how to target their products and their advertising.By focusing their research on how females view themselves, their aspirations and the social pressures they face, the cigarette companies have developed some of the most aggressive and sophisticated marketing campaigns in history for reaching and influencing women and girls.In addition, internal tobacco documents show the tobacco industry's deliberate strategy to target women and girls.
For example, according to internal tobacco documents, Philip Morris strategically donated to women's organizations, participated in women's forums, and engaged with women they identified as 'active moms' in order to soften women's attitudes against the industry and, in some cases, ask them to support tobacco industry's issues (McDaniel and Malone, 2009: 441-74).Smoking kills over half a million women around the world each year and this number is increasing rapidly.It is estimated that between 1950 and 2000, 10 million women will have died from their smoking habit.In several developed countries, such as the USA and the UK, cigarette smoking is now the single most important preventable cause of premature death in women, accounting for at least a third of all deaths in women aged 35 to 691.Yet, despite these figures, smoking is still regarded in many countries as being a mainly male problem (Amos, 1996: 74-89).
The biggest rise in female smoking will be in less developed countries, where the current rate of around 7% will increase to 20% by 2025.In Europe where in most EU countries girls now have higher smoking rates than boys, the gap between male and female smoking rates will continue to narrow (Haglund and Amos, 2000: 3-8).In the research of Edward et al. (2004: 277-282) to evaluate the effect of an anti-smoking advertisement on young women's perceptions of smoking in movies and their intention to smoke, 2038 females aged 12-17 years attending cinemas in New South Wales, Australia were surveyed after having viewed a movie at their local cinema.The control group was surveyed during week 1 and the intervention group, during week 2. Before seeing the movie in week 2, a 30 second antismoking advertisement was shown, which featured a well-known female actor drawing attention to the prevalence of smoking in movies.The study suggests that placing an antismoking advertisement before movies containing smoking scenes can help to "immunize" young women against the influences of film stars smoking.It is essential that girls and women have the knowledge, attitudes and skills to help them make informed decisions about smoking.To be effective, programs need to be culturally appropriate, relevant to girls' and women's needs at different points in their lives, and related to the stage of the smoking epidemic in the country.Each country needs to design a strategy, which meets their circumstances and takes into account gender differences.There is a need for gender-sensitive and gender specific programs (Amos, 1996: 74-89).

Smoking Prevalence in Turkey
The prevalence of smoking is presented by "current tobacco smoker" and "non-smoker." Current tobacco smokers are categorized into "daily smokers" and "occasional smokers." Occasional smokers are divided two groups-"former daily" and "never daily."Non-smokers are categorized as "former daily smokers" and "never daily smokers".Never daily smokers are divided into two groups-"former occasional" and "never" (Global adult tobacco survey Turkey 2012):  The overall current smoking prevalence among adults 15 years or older was 27.1%, representing 14.8 million adults.Men (41.5%) were more likely to smoke tobacco than women (13.1%).Approximately 11.1 million men and 3.6 million women were current smokers in the country. Among all adults, 23.8% were daily smokers and 3.3% were occasional smokers.The daily smoking prevalence rate among men was higher than women (37.3% vs. 10.7%).
Over 10 million men and nearly 3 million women were daily smokers.The percentages of occasional smokers were lower than daily smokers among both men and women.The occasional smoker prevalence rate was 4.1% among men and 2.4% among women.
 Non-smokers' account for 72.9% of the population, representing over 39.8 million adults (more than 15.7 million men and 24.1 million women).The percentage of former daily smokers was 9.4%, and 63.5% were never daily smokers.The percentage of never daily smokers among women was higher than the percentage of men (82.3% vs. 44.1%).Inversely, the percentage of former daily smokers among men was higher than women (14.4% and 4.6%).
 Of all Turkish adults, 59.8% (men, 39.9%; women, 79.1%) had never smoked tobacco in their lifetimes.Approximately 32.6 million adults (10.7 million men and 21.9 million women) were never smokers.

Aim of the Research
The main aim of this research is to reveal attitudestowards health communication message In order to reach this aim, these research questions should be addressed.
1. What are the attitudes of all respondents toward the ad? 2. What is the overall evaluation of the ad? 3. What are the attitudes of smokers toward the ad? 4. What is the overall evaluation of smokers towards the ad? 5. What are the attitudes of non-smokers toward the ad? 6.What is the overall evaluation of non-smokers toward the ad?

Methodology
This research is quantitative.The data obtain from the research was analyzed with SPSS 11.5 statistical program.Frequency analysis was applied to the data.Health communication This ad is the one of the original ads used by the Ministry of Health of Turkish Republic during the Smoke-Free Air Zone Campaign.There were three print ads used in this campaign.
The subject of the each print ad is lip, throat and gangrene.The reason why the jury chooses this ad was the other ads included highly disturbing images about the throat cancer and gangrene.They were evaluated as they couldcause high fear among the respondents and it would make the respondents to avoid from the main message of the ad.Fear can be used as an appeal but using fear appeal in an ad is a risk.
An appeal is the motive to which an ad is directed.Its purpose is to move the audience toward a goal set by the advertiser.Fear appeals are commonly used in many types of marketing communications, e.g., the marketing of products, services, social causes, and ideas.The basic message is "if you don't do this (buy, vote, believe, support, learn, etc.), some particular dire consequences will occur" (Williams, 2012: 1-21).Fear appeals are persuasive messages designed to scare people by describing the terrible things that will happen to them if they do not do what the message recommends (Witte, 1992).Since Janis and Feshbach's influential research on the use of fear in dental hygiene education in the early 1950s, several generations of health educators have often uncritically accepted as near holy writ thatyou should not try to scare people into healthy practices including smoking prevention and cessation (Hill, Chapman, Donovan, 1998).Recently, however, evidence is emerging to suggest that when used properly, "gory" and "hard-hitting" campaigns do have a place in health communication (http://www.ohpe.ca/node/113).

The Questionnaire
The questionnaire was derived from the scale developed by Robert E Smith; Jiemiao Chen; Xiaojing Yang "The Impact of Advertising Creativity on the Hierarchy of Effects" (Journal of Advertising;Winter 2008;37, 4;pg.: 47-61).The original scale has 15 variables and 39 scale items about commercial advertising but this study is limited by social advertising.So the irrelevant items were eliminated.5 point Likert Scale was used in this research and the items were evaluated as 1-Strongly agree, 2-Agree, 3-Undecided, 4-Disagree, 5-Strongly Disagree.
The questionnaire was applied to the respondents between 15.11.2014 -05.01.2015

Findings
This research is quantitative.The data obtain from the research was analyzed with SPSS 11.5 statistical program.Frequency analysis was applied to the data.shows the age of the respondents.66% of the respondents are between the ages of 18-23, 18% of the respondents are between the ages of 24-29 and 16% of them are 30 and older.When we look at the smoking habits of the respondents we see that 56% of them smoke and 44% of them do not smoke.Table 4 shows the results of the 13th item that asks the respondents what is the overall evaluation of the ad they saw.Table 5 indicates that 59 % of the respondents are positive about the ad.17% of them are undecided and 24 % ofthem are negative about the ad.

Table 5.Attitudes of all respondents toward the ad
There are 12 attitude items about the evaluation of ad.The first item is concerning "the ad demanded my attention" 48 % of the respondents are strongly agreed on this statement.In Table 2, 48% of the respondents strongly agree with the statement that the ad demanded their attention.%49 of the respondents strongly agree that the ad claims were easy to understand and %63 of them strongly agrees with the third statement that they were able to comprehend the claims made in the ad.

Table 6.Attitudes of toward the ad
Table 6, identifies the frequency of smokers.As it seen in the table 5, 50 % of the respondents who smokes strongly agree on the ad demanded their attention.69,6% of the respondent answer the statement three as strongly agree.While 55,4% of the respondents strongly agree that the ad claims were easy to understand %50 of them strongly agree that the ad demanded their attention.It is shown that (Table 7), 71,4% of the respondents who smokes evaluates the ad as positive, 10,7% of the respondents is undecided and 17,9% of them evaluates the ad as negative.

Table 8.Attitudes of non-smokers toward the ad
When we look at the Table 8, we can see that 54,5% of the respondents strongly agree that they were able to comprehend the claims made in the ad.45,5% of the nonsmokers strongly agrees that the ad demanded their attention.40,9% of the respondents answer the second statement as strongly agree that the as claims were easy to understand.When we look at the Table 9, we see that 43,2% of the respondents evaluate the ad as positive, 25% of them are undecided and 31,8% of the respondents' decision is negative.

Conclusion
The first item in the questionnaire is belonging to the Attention variable and it can be said that the ad demands the attention of the respondents.Second, third and the fourth items are related with the Comprehension variable.The answers of the respondents show that the claim of the ad is understandable.5th and the 6th items are take place under the Depth of Processing variable and it can be said that the respondents gave the ad a lot of consideration more over they thought about their own life when they looked at the ad.
The next variable is Memorable that includes the 7th and the 8th items.According to the respondents the claims and the message of the ad was easy to learn and remember.9th and the 10th items belong to Change Mind variable.The result shows that the smoker respondents are undecided about changing their minds toward smoking after seeing this ad.
When we analyze the 11th and the 12th items related with the Resistance variable, it could be said that the ad got the smoker respondents more flexible in their views and consider about different views.So the resistance is very against the message.The last variable is Ad Attitude.The overall evaluation of the respondents about the ad they saw is positive.
There is now considerable evidence that mass media anti-smoking counter advertising campaigns can stimulate quitting activity and can lead to detectable declines in smoking prevalence.It seems likely that for each smoker who successfully quits as a result of a campaign, several more will try and fail, and others will be motivated to think about quitting, but not get as far as trying.Currently, remarkably little is known about the mechanisms by which campaigns have their effects.The simple model of effects is that evidence about health effects of smoking changes beliefs, which in turn affects attitudes, driving interest in behavior change (Borland and Balmford, 2003: 45-52).
The anti-smoking ads were very effective in the short-run, it is plausible that their marginal effectiveness would have diminished over time as their early successes reduced the smoking population to more "hard-core" smokers (Warner, 1977: 645-650).There is still confusion among researchers about which ads are most effective but there is increasing evidence that ads using personal stories are effective.Several research findings indicate that there is no single recipe for anti-smoking advertising that leads to reduce smoking.Additional studies must be conducted before any definitive conclusions can be drawn.
claims of Smoke-Free Air Zone Ad Campaign among female smokers/non-smokers.A survey conducted to reach this aim.In this paper, attitudes towards an ad which contains antismoking claims analyzed among the women who smoke and non-smoke.Sample of the research consist of the female students who are attending Faculty of Communication Sciences, Department of Advertising and Public Relations at Anadolu University.

Figure
Figure 1.Currentsmokingprevalencebyagegroupandgender, GATS Turkey 2012 in Anadolu University Communication Sciences Faculty.Female students from department of Public Relations and Advertising were selected for this research on purpose.Because these students have enough knowledge about advertising and how it works that can gives them strength to be persuaded easy.A meeting room was organized for this research including a projection device to show the selected ad to the respondents.Every time only one student took into the meeting room to avoid an interaction with the other respondents during to answer the questionnaire.After a short brief about the research and the questionnaire by the researcher the students answered the questions.The statements in this questionnaire wereexamined under these topics: ad demanded my attention Comprehension 2. The ad claims were easy to understand 3. I was able to comprehend the claims made in the ad 4. The ad claims were hard to understand Depth of Processing 5. I gave the ad a lot of consideration 6.I thought about my own life when I looked at the ad Memorable 7. The claims made in the ad were memorable 8.The ad message was easy to learn and remember Change Mind 9.The ad changed my mind about smoking 10.After viewing the ad, I see things differently Resistance 11.The ad got me consider views different from my own 12.The ad got me more flexible in my views Brand Attitude 13.What is your over all evaluation about the ad you saw?

Table 3 .Smoking habit of respondents
to comprehend the claims made in the ad.% The ad claims were hard to understand.% I gav e the ad a lot of consideration.% I thought about my own lif e when I looked at the ad.% The claims made in the ad were memorable.% The ad message was easy to learn and remember.% The ad changed my mind about the smoking.% Af ter v iewing the ad, I see things dif ferently .% The ad got me consider v iews diff erent f rom my own.% The ad got me more flexible in my v iews.