The Mobile County Health Department (MCHD) contracted with Lewis Communications to manage and assist in developing the Just Breathe educational media campaign. The campaign included television, radio, print, billboard, and online advertisements. MCHD produced an upbeat, animated television advertisement based on focus group research for this campaign and ran 3 additional television advertisements borrowed from previous campaigns that focused on the dangers of SHS. Additionally, MCHD ran 2 radio, 8 print, and 3 billboard advertisements.

From September 26, 2011, to September 30, 2012, the campaign placed the following paid advertisements: 1,700 television spots, 2,100 cable spots, 8,500 radio spots, and 200 print insertions in local newspapers and magazines. Billboard advertisements were placed between September 26, 2011, and August 31, 2012, with a daily effective circulation (the average number of adults 18 or older passing and potentially exposed to an advertisement each day) of 488,000. Paid online advertising was placed between September 26, 2011, and December 12, 2011, as follows: 14.2 million total impressions (the number of times an advertisement is displayed online) on Facebook resulting in 1,900 clicks and 6.3 million impressions on AL.com resulting in 6,800 clicks. The campaign also received earned media exposure, including editorials, news stories, and public service announcements, which added unpaid advertising in each media outlet.

CDC’s Tips campaign overlapped with the Just Breathe campaign. The Tips campaign lasted for 12 weeks, starting on March 19, 2012, and included television, radio, print, billboard, and website advertisements. In contrast to the Just Breathe campaign, the Tips campaign used hard-hitting, emotional advertisements, which depicted suffering caused by smoking. An evaluation of the Tips campaign found that it was effective at increasing population-level quit attempts (14).

A precampaign–postcampaign cross-sectional telephone survey was conducted by The University of Alabama to assess the effects of the educational media campaigns. Researchers at the university developed and pilot-tested survey questions to evaluate exposure to the educational media campaign and support for smoke-free policies. Questions regarding tobacco use, knowledge of the dangers of SHS, and awareness of the quitline were taken from previously validated surveys (15), including CDC’s Behavioral Risk Factor Surveillance System and Adult Tobacco Survey and previous tobacco studies conducted by the university. The baseline survey was conducted between August 8 and October 1, 2011, ending 6 days after paid advertising of the Just Breathe campaign began. The postcampaign survey occurred during the last several months of the educational media campaign from June 9 through September 5, 2012. This study was approved by the institutional review board at The University of Alabama and by the Alabama Department of Public Health.

Data collection for the study was conducted by the Capstone Poll at The University of Alabama. Random-digit dialing was used to select households in Mobile County, and in each household a respondent was randomly selected for participation. Mobile County residents aged 19 years or older were eligible to participate in the study. By using the American Association for Public Opinion Research’s response rate 1 formula (16), the participation rate in 2011 was 21.9%, based on 845 completions and 3,861 households, and in 2012 was 22.6%, based on 766 completions and 3,396 households. Approximately 52% (2011) and 49% (2012) of the telephone numbers provided were never reached after multiple attempts. Among the households that were reached, the cooperation rate was 45% in 2011 and 44% in 2012.

Exposure to antitobacco media messages was assessed in the precampaign and postcampaign surveys using 4 questions, which asked whether participants had seen advertisements about the dangers of smoking in different media outlets: television, radio, billboard, and newspaper or other print media. In the postcampaign survey, an open-ended follow-up question after the television and radio exposure questions helped identify recalled advertisements associated with the Just Breathe or Tips campaigns. Open-ended information was not solicited about the print advertisements. Interviewers were trained to recognize 11 television advertisements (4 Just Breathe, 7 Tips) and 9 radio advertisements (2 Just Breathe, 7 Tips), coding the open-ended responses using computer-assisted telephone interviewing software during the interview.

Respondents were asked 4 questions in both precampaign and postcampaign surveys to gauge attitudes toward smoke-free policies in workplaces, restaurants, and bars and a comprehensive policy for all public indoor areas. Knowledge about the dangers of SHS was assessed using 6 questions that came from CDC’s Adult Tobacco Survey. Participants were asked to rate the overall harmfulness of SHS to health and indicate whether breathing SHS causes lung cancer in adults, heart disease in adults, colon cancer in adults, respiratory problems in children, and sudden infant death syndrome.

Poststratification weights were calculated by raking along dimensions of age, sex, race, and education, using census-based proportions to correct for the underrepresentation or overrepresentation of demographic subgroups in the data. Descriptive statistics and binary logistic regression analyses were conducted using SPSS software version 20 (IBM Inc). Yates χ² tests of significance, corrected for continuity and for multiple comparisons (using Holm-Bonferroni) (17) were used to compare categorical survey responses between the precampaign and postcampaign surveys and to compare the demographic characteristics. Multivariate logistic regression was used to evaluate the effect of media exposure on support for smoke-free environments and knowledge about the dangers of SHS while controlling for smoking status, sex, race, and education level. For the regression analysis, media exposure was defined by whether respondents were able to describe 1 of the Just Breathe or Tips campaign advertisements unaided. Dichotomous categorical variables were established for questions about support for smoke-free environments and knowledge, with responses that expressed uncertainty such as “it depends” or “don’t know” being combined with the “no” responses.

On the basis of the weighted 2012 postcampaign survey results, 80.9% of survey participants reported seeing an advertisement on television, and 29.9% of participants reported hearing an advertisement on the radio, about the dangers of smoking during the 30 days before the survey. Almost half (49.0%) of participants reported seeing a billboard, and 23.0% of participants saw advertisements in print media about the dangers of smoking during the 30 days before the survey (Table 2). Significant differences in self-reported media exposure between black and white residents were found for television advertisements (black, 86.5%; white, 77.7%; P = .03), but not for radio, print, or billboard advertisements.

When asked to describe the television, radio, and billboard advertisements they remembered, 14.1% of survey respondents described a Just Breathe advertisement (and not a Tips advertisement), 29.6% described a Tips advertisement (and not a Just Breathe advertisement), and 7.7% described advertisements from both campaigns. Overall, 51.4% of respondents were able to describe at least 1 television advertisement from either campaign.

For the radio advertisements, 9.6% of participants described a Just Breathe radio advertisement and 2.7% of participants described a Tips radio advertisement. Open-ended descriptions of the billboards suggest that approximately 13% of all respondents saw a Just Breathe billboard.

Because the Just Breathe paid advertising began 6 days before completion of the precampaign survey, we compared responses of the individuals completing the survey before and after September 25, 2011, for questions regarding media exposure and found no significant differences.

Support for smoke-free bars increased significantly from precampaign to postcampaign (precampaign, 38.1%; postcampaign, 43.8%; P = .01). However, there were not significant changes in support for smoke-free workplaces, restaurants, or comprehensive protections for all public indoor areas. Stratified by race, there was a significant increase in support for smoke-free restaurants among black respondents (precampaign 83.2%; postcampaign 89.0%; P = .04) and for smoke-free bars among white respondents (precampaign, 34.2%; postcampaign, 41.4%; P = .02) (Table 2).

Knowledge of the dangers of SHS increased significantly for only 1 out of 6 measures. Belief that SHS causes heart disease in adults increased from 71.2% to 78.5% (P < .001). However, a stratified analysis showed significant differences in changes in knowledge based on racial group and suggests that the increases in knowledge occurred primarily among black respondents with small, nonsignificant increases among white respondents. For black respondents, we found significant increases in 4 of 6 measures: the belief that SHS is very harmful and that SHS causes lung cancer in adults, heart disease in adults, and respiratory problems in children (Table 2). There were no significant increases in knowledge among white respondents.

The multivariate logistic regression analyses showed that exposure to the educational media campaigns was associated with greater support for smoke-free environments (Table 3). Residents who reported exposure to 1 or both of the campaigns were significantly more likely than unexposed residents to support smoke-free workplaces, restaurants, and bars (P = .01 for each location). Among the other predictors included in our analysis, we found that nonsmokers were significantly more likely than smokers to support all of the smoke-free environments (P < .001), and that respondents with at least some college education were more likely than those with less than a high school education to support smoke-free workplaces (P = .001) and restaurants (P = .03).