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NIHR Signal Mixed evidence shows some impact of mass media campaigns promoting tobacco control, physical activity and sexual health

Published on 23 July 2019

doi: 10.3310/signal-000795

Mass media campaigns have demonstrated effectiveness for promoting tobacco control, physical activity and sexual health. Most of the evidence relates to improving awareness of health risks or the availability of services. However, for those aimed at the risks associated with sedentary lifestyles, smoking or sexual behaviours, there are signs that the campaigns also achieved positive changes to the target behaviour.

This large review, funded by NIHR, identified 36 systematic reviews and individual studies looking at the effect of mass media campaigns on six preventable risk factors. The review identified several research gaps. For example, few campaigns directed at drinking or eating behaviours showed positive changes. Only tobacco control campaigns have demonstrated cost-effectiveness, with limited research available on the others.

This broad review shows that a better understanding of the optimal delivery format is still needed, but media campaigns appear to be more effective when intense, long-running and well-targeted to a population group.

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Why was this study needed?

The World Health Organization reports that non-infectious diseases account for 71% of global deaths (41 million) every year. In the UK they account for the majority. More than a third of deaths are due to cardiovascular disease, over a quarter from cancer and approaching one in five from respiratory disease. Modifiable health behaviours are the underlying cause for many. Smoking, alcohol and obesity are together estimated to cost the UK economy around £30 billion a year. Behaviour change is a vital step in improving public health and reducing the chronic disease burden.

Mass media campaigns can use various formats, such as digital, television, radio, social media, magazines and posters, to reach large numbers of people at relatively low cost. Prior research has looked at the effect of individual campaigns, such as smoking.

This multi-stage review took a broader view, gathering the evidence on the effect of media campaigns across multiple health behaviours, and aimed to find out how best to communicate public health messages through these media.

What did this study do?

The study involved four literature reviews. A ‘review of reviews’ identified systematic reviews assessing the effectiveness of mass media campaigns on six health topics: smoking, substance use, alcohol use, diet, physical activity and sexual health.

The researchers undertook two further systematic reviews of primary studies. One identified individual studies looking at the effect of media campaigns on alcohol consumption and related harms (due to the limited number of reviews already in this area). A second identified studies informing the campaign characteristics that were associated with effectiveness across the six topics. Finally, there was a review of cost-effectiveness studies.

The work was underpinned by a logic model developed with stakeholders to understand how the different interventions worked to effect change across the topics.

All literature was published after 2000. There was considerable variation between the study characteristics and results. The certainty of findings was low for all topics.

What did it find?

  • Thirty-six systematic reviews assessed the effectiveness of media campaigns, mostly smoking (12 reviews), sexual health (9) and physical activity (7 reviews).
    There was evidence that tobacco control campaigns increase the intention to quit smoking, but evidence was conflicting on whether this resulted in behaviour change.
    Media campaigns were shown to raise awareness around physical activity, with some evidence this may result in behaviour change such as reduced sedentary time, increased walking and use of stairs. However, it was uncertain whether they increase physical activity levels overall.
    Media campaigns generally had positive effects on sexual health, improving awareness and knowledge, increasing condom use and use of sexual health services. There was very limited evidence that media campaigns improve diet and reduce substance use.
  • There were no systematic reviews of alcohol campaigns. The review of 24 primary studies found evidence that alcohol campaigns can be recalled by the public and increase awareness around the risks of alcohol and recommended units. However, there was little evidence that exposure to media campaigns is associated with reduced alcohol consumption. 
  • Twenty cost-effectiveness reviews were identified: eight on smoking campaigns, others on sexual health, diet and activity and multiple behaviours. There was moderate evidence that mass media campaigns for tobacco control are cost-effective. There was also weak evidence that campaigns to increase physical activity and reduce salt intake can be cost-effective. However, the reviews found no studies had assessed whether sexual health campaigns were cost-effective.
  • Looking at programme characteristics, several reviews found that longer duration or higher intensity campaigns had greater effectiveness (mostly in relation to tobacco and sexual health). There was some evidence that negative messages, pushing the health risks, are effective, but it was unclear whether this is better than positive messages.
    There was also evidence that media campaigns affect population groups differently. Smoking and drug campaigns, in particular, were found to have the greatest impact on children and young people. Gearing campaigns towards the target audience may be most effective.

What does current guidance say on this issue?

Public Health England’s marketing strategy (2014-17) outlined how it intended to use marketing to support people in making sustainable changes to improve their health. Marketing campaigns include Start4Life and Change4Life, which promote healthy diet and activity patterns for childhood and families. The Smokefree campaign supports people in quitting smoking, accompanied by mass activity campaigns such as ‘Stoptober’. PHE is reviewing new campaigns to promote safe alcohol consumption (initiatives such as ‘Dry January’) and improve sexual health.

Several NICE guidelines recommend using mass media campaigns both to convey the risks and negative images of smoking (particularly to young people) and to raise awareness of stop smoking services. Several public health guidelines cover the use of media in raising awareness around healthy diet and activity, alcohol and sexual health.

What are the implications?

This review demonstrates the complexity of evidence around mass media campaigns. The campaigns, assessed outcomes and their effects were diverse.

The content and context of interventions are likely to have considerable bearing on effectiveness. The review identifies some beneficial campaign characteristics, particularly making sure messages are appropriate to the target audience who may be most engaged with/at risk of the behaviour.

The researchers call for further research into alcohol and dietary campaigns, and into the important question of whether these campaigns provide value for money.

Citation and Funding

Stead M, Angus K, Langley T et al. Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence. Public Health Research. 2019;7(8).

This project was funded by the NIHR Public Health Research Programme (project number 13/163/17).

Bibliography

NICE. Smoking: preventing uptake in children and young people. PH14. London: National Institute for Health and Care Excellence; 2014.

NICE. Smoking: reducing and preventing tobacco use. QS82. London: National Institute for Health and Care Excellence; 2015.

NICE. Stop smoking interventions and services. NG92. London: National Institute for Health and Care Excellence; 2018.

NICE. Behaviour change: general approaches. PH6. London: National Institute for Health and Care Excellence; 2007.

NICE. Physical activity for children and young people. PH17. London: National Institute for Health and Care Excellence; 2009.

NICE. Obesity prevention. CG43. London: National Institute for Health and Care Excellence; 2006 (updated 2015).

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

Public Health England. Marketing strategy 2014–2017. London: Public Health England; 2014.

Public Health England. Marketing strategy 2017–2020. London: Public Health England; 2017.

WHO. Non-communicable diseases. Geneva: World Health Organization; 2017.

Why was this study needed?

The World Health Organization reports that non-infectious diseases account for 71% of global deaths (41 million) every year. In the UK they account for the majority. More than a third of deaths are due to cardiovascular disease, over a quarter from cancer and approaching one in five from respiratory disease. Modifiable health behaviours are the underlying cause for many. Smoking, alcohol and obesity are together estimated to cost the UK economy around £30 billion a year. Behaviour change is a vital step in improving public health and reducing the chronic disease burden.

Mass media campaigns can use various formats, such as digital, television, radio, social media, magazines and posters, to reach large numbers of people at relatively low cost. Prior research has looked at the effect of individual campaigns, such as smoking.

This multi-stage review took a broader view, gathering the evidence on the effect of media campaigns across multiple health behaviours, and aimed to find out how best to communicate public health messages through these media.

What did this study do?

The study involved four literature reviews. A ‘review of reviews’ identified systematic reviews assessing the effectiveness of mass media campaigns on six health topics: smoking, substance use, alcohol use, diet, physical activity and sexual health.

The researchers undertook two further systematic reviews of primary studies. One identified individual studies looking at the effect of media campaigns on alcohol consumption and related harms (due to the limited number of reviews already in this area). A second identified studies informing the campaign characteristics that were associated with effectiveness across the six topics. Finally, there was a review of cost-effectiveness studies.

The work was underpinned by a logic model developed with stakeholders to understand how the different interventions worked to effect change across the topics.

All literature was published after 2000. There was considerable variation between the study characteristics and results. The certainty of findings was low for all topics.

What did it find?

  • Thirty-six systematic reviews assessed the effectiveness of media campaigns, mostly smoking (12 reviews), sexual health (9) and physical activity (7 reviews).
    There was evidence that tobacco control campaigns increase the intention to quit smoking, but evidence was conflicting on whether this resulted in behaviour change.
    Media campaigns were shown to raise awareness around physical activity, with some evidence this may result in behaviour change such as reduced sedentary time, increased walking and use of stairs. However, it was uncertain whether they increase physical activity levels overall.
    Media campaigns generally had positive effects on sexual health, improving awareness and knowledge, increasing condom use and use of sexual health services. There was very limited evidence that media campaigns improve diet and reduce substance use.
  • There were no systematic reviews of alcohol campaigns. The review of 24 primary studies found evidence that alcohol campaigns can be recalled by the public and increase awareness around the risks of alcohol and recommended units. However, there was little evidence that exposure to media campaigns is associated with reduced alcohol consumption. 
  • Twenty cost-effectiveness reviews were identified: eight on smoking campaigns, others on sexual health, diet and activity and multiple behaviours. There was moderate evidence that mass media campaigns for tobacco control are cost-effective. There was also weak evidence that campaigns to increase physical activity and reduce salt intake can be cost-effective. However, the reviews found no studies had assessed whether sexual health campaigns were cost-effective.
  • Looking at programme characteristics, several reviews found that longer duration or higher intensity campaigns had greater effectiveness (mostly in relation to tobacco and sexual health). There was some evidence that negative messages, pushing the health risks, are effective, but it was unclear whether this is better than positive messages.
    There was also evidence that media campaigns affect population groups differently. Smoking and drug campaigns, in particular, were found to have the greatest impact on children and young people. Gearing campaigns towards the target audience may be most effective.

What does current guidance say on this issue?

Public Health England’s marketing strategy (2014-17) outlined how it intended to use marketing to support people in making sustainable changes to improve their health. Marketing campaigns include Start4Life and Change4Life, which promote healthy diet and activity patterns for childhood and families. The Smokefree campaign supports people in quitting smoking, accompanied by mass activity campaigns such as ‘Stoptober’. PHE is reviewing new campaigns to promote safe alcohol consumption (initiatives such as ‘Dry January’) and improve sexual health.

Several NICE guidelines recommend using mass media campaigns both to convey the risks and negative images of smoking (particularly to young people) and to raise awareness of stop smoking services. Several public health guidelines cover the use of media in raising awareness around healthy diet and activity, alcohol and sexual health.

What are the implications?

This review demonstrates the complexity of evidence around mass media campaigns. The campaigns, assessed outcomes and their effects were diverse.

The content and context of interventions are likely to have considerable bearing on effectiveness. The review identifies some beneficial campaign characteristics, particularly making sure messages are appropriate to the target audience who may be most engaged with/at risk of the behaviour.

The researchers call for further research into alcohol and dietary campaigns, and into the important question of whether these campaigns provide value for money.

Citation and Funding

Stead M, Angus K, Langley T et al. Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence. Public Health Research. 2019;7(8).

This project was funded by the NIHR Public Health Research Programme (project number 13/163/17).

Bibliography

NICE. Smoking: preventing uptake in children and young people. PH14. London: National Institute for Health and Care Excellence; 2014.

NICE. Smoking: reducing and preventing tobacco use. QS82. London: National Institute for Health and Care Excellence; 2015.

NICE. Stop smoking interventions and services. NG92. London: National Institute for Health and Care Excellence; 2018.

NICE. Behaviour change: general approaches. PH6. London: National Institute for Health and Care Excellence; 2007.

NICE. Physical activity for children and young people. PH17. London: National Institute for Health and Care Excellence; 2009.

NICE. Obesity prevention. CG43. London: National Institute for Health and Care Excellence; 2006 (updated 2015).

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

Public Health England. Marketing strategy 2014–2017. London: Public Health England; 2014.

Public Health England. Marketing strategy 2017–2020. London: Public Health England; 2017.

WHO. Non-communicable diseases. Geneva: World Health Organization; 2017.

Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence

Published on 2 May 2019

Stead M, Angus K, Langley T, Katikireddi S V, Hinds K, Hilton S, Lewis S, Thomas J, Campbell M, Young B & Bauld L.

Public Health Research Volume 7 Issue 8 , 2019

Background Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours. Objectives To (1) review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health and tobacco), (2) examine whether or not effectiveness varies with different target populations, (3) identify characteristics of mass media campaigns associated with effectiveness and (4) identify key research gaps. Design The study comprised (1) a systematic review of reviews, (2) a review of primary studies examining alcohol mass media campaigns, (3) a review of cost-effectiveness evidence and (4) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people. Results The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (e.g. use of smoking quitlines and sexual health services). The impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and there was no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by sex, ethnicity or socioeconomic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but there was weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media. Limitations Statistical synthesis was not possible owing to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail. Conclusions Overall, the evidence is mixed but suggests that (1) campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation, (2) tobacco control campaigns can be cost-effective, (3) longer and more intensive campaigns are likely to be more effective and (4) message design and targeting campaigns to particular population groups can be effective. Future work Future work could fill evidence gaps regarding diet mass media campaigns and new-media campaigns, examine cost-effectiveness in areas other than tobacco and explore the specific contribution of mass media campaigns to multicomponent interventions and how local, regional and national campaigns can work together. Funding The National Institute for Health Research Public Health Research programme.

Expert commentary

The key benefits of this research are in how it helps us understand which kind of campaigns might be effective in which circumstances. For example, that tobacco campaigns are best aimed at children and young people, and that longer and more intensive campaigns may work better.

There is a risk of adopting a ‘one size fits all’ approach to such campaigns, so understanding the best ‘ingredients’ and ‘dose’ of a campaign for any particular behaviour or target group is a very positive step forward.

More work is needed on their cost-effectiveness to support commissioners investing in these important prevention measures. 

Simon Fraser, Associate Professor of Public Health, School of Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital

The commentator declares no conflicting interests

Expert commentary

Mass media campaigns are an often-used tool to communicate public health messages to the public. This study comprises an extensive and thorough set of reviews of the published evidence on the effectiveness of mass media campaigns across a variety of health topics. The evidence is quite sobering in that the impact of these campaigns is small at best, with only evidence of cost-effectiveness for tobacco control campaigns.

However, this study also provides a welcome reminder of some recommendations for the design of future campaigns, and highlight that to improve their effectiveness they should be designed as a longer and intensive campaign and should be targeting to particular groups rather than communicate generic messages.

Frank de Vocht, Reader in Epidemiology and Public Health, University of Bristol

The commentator declares collaborating on another study with one of the co-authors