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Tobacco Use and Secondhand Smoke Exposure: Mass-Reach Health Communication Interventions


What the CPSTF Found

About The Systematic Review

The Task Force finding is based on evidence from a Community Guide systematic review published in 2001 (27 studies, search period 1980-2000) combined with more recent evidence (70 studies, search period January 2000- July 2012). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure. The finding updates and replaces two previous Task Force findings on mass media campaigns used to increase cessation [PDF - 231 kB] and reduce initiation [PDF - 225 kB].


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Summary of Results

The Task Force finding is based on results from 64 of the studies that evaluated interventions using television as the sole or primary media channel. Mass-reach health communication interventions were associated with decreased tobacco use prevalence, increased cessation and use of available cessation services, and decreased initiation of tobacco use among young people.

  • Tobacco Use
    • Prevalence of tobacco use among adults: median decrease of 5.0 percentage points (range of values: -5.2 to -1.9 percentage points; 4 studies)
      • Increased exposure to anti-tobacco media messages was significantly associated with decreased tobacco use prevalence (4 studies).
    • Prevalence of tobacco use among young people (11 to 24 years of age): median decrease of 3.4 percentage points (interquartile interval [IQI]: -5.3 to -1.6 percentage points; 11 studies)
      • Increased exposure to anti-tobacco media messages correlated with a decrease in adolescent tobacco users (1 study).
      • Increased exposure to and appeal of anti-tobacco media messages were associated with an increased sense of tobacco independence and positive social imagery of not smoking, both of which strongly correlated with not smoking (1 study).
    • Cessation of tobacco use: median increase of 3.5 percentage points (IQI: 2.0 to 5.0 percentage points; 12 studies)
      • Increased intervention intensity was associated with increased odds of quitting (2 studies).
      • Exposure to anti-tobacco media did not significantly increase cessation in 3 studies.
  • Use of Cessation Services
    • Number of calls to quitlines: median relative increase of 132% (IQI: 39% to 378%; 11 studies)
    • Interventions were effective in increasing use of cessation services, especially quitlines (17 studies).
  • Tobacco Use Initiation Among Young People
    • Initiation among young people (11 to 24 years of age): decrease of 6.7 percentage points (95% confidence interval: -13.0 to -0.4 percentage points, 1 study)
    • Higher intervention exposure or higher intervention recall or appeal was associated with reduced tobacco use initiation (5 studies).
    • Awareness of anti-tobacco advertising was associated with reduced smoking initiation among high-sensation-seeking young people (1 study).

Included studies also reported favorable results of the intervention on other outcomes such as changes in quit attempts (12 studies), exposure to secondhand smoke (1 study), and adoption of smoke-free policies in private homes (3 studies).

Previous Review (search period 1980-2000)

  • Tobacco Use
    • Prevalence of tobacco use among adults: median decrease of 3.4 percentage points (range of values: -7.0 to 0.2 percentage points; 7 studies)
    • Prevalence of tobacco use among young people (11 to 24 years of age): median decrease of 6 percentage points (range of values: -11 to 0.02 percentage points; 6 studies)
      • Prevalence of tobacco use was significantly lower among young people who were exposed to mass-reach health communication interventions (odds ratio [OR] = 0.60, range of values: 0.49 to 0.74; 4 studies).
    • 2 studies found no effect.
    • Tobacco consumption (measured as state per capita consumption compared to rest of the U.S.): median decrease of 15 cigarette packs per capita per year (range of values: 24.5 to -9; 3 studies); and relative decrease of 12.8% (range of values: 17.5% to 9.8%; 3 studies)
    • Cessation of tobacco use: median increase of 2.2 percentage points (range of values: -2 to 35 percentage points, 5 studies)
  • Use of Cessation Services
    • Number of calls to quitlines increased by 392% (1 study)

Summary of Economic Evidence

Sixteen studies were included in the economic review. Review conclusions are based on results from 13 studies that provided cost-effectiveness measurements and cost-benefit comparisons. All monetary values are reported in 2011 U.S. dollars.

  • Cost-effectiveness estimates (10 studies)
    • Cost per quality-adjusted life year (QALY): median estimate of $577 (range of values: $97 to $1,622; 3 studies)
    • Cost per life year saved (LYS): median estimate of $213 (range of values: $128 to $718; 3 studies)
    • Cost per additional caller to quitlines (costs of media campaigns and associated increase in calls to quitlines): median estimate of $260 (range of values: $24 to $399; 4 studies)
  • Cost-benefit estimates (3 studies)
    • Benefit-to-cost ratio estimates ranged from 7:1 to 74:1

Estimates of cost-effectiveness were assessed in comparison to a conservative threshold of $50,000 per QALY saved. Overall, the economic evidence indicates mass-reach health communication interventions are cost-effective and savings from averted healthcare costs exceed intervention costs.


Based on results for different settings and populations, findings are applicable to the following:

  • U.S. and non-U.S. settings
  • National, state or regional, city and local levels
  • Adults and young people
  • Males and females
  • Population groups with high prevalence of tobacco use or limited access to cessation services, including Arabic speaking, Latino, Spanish speaking, or Maori tobacco users
  • Population groups with different SES, educational attainment, or race/ethnicity

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

Many studies from the updated search period evaluated the impact of specific intervention characteristics, but several questions remain for future research.

  • What are thresholds of effectiveness for intervention intensity, duration of intervention, message placements, and frequency of new message introduction to maintain audience engagement and lead to behavior change?
  • What are costs associated with different intervention components?
  • Given that current evidence is dominated by interventions that used television as the only or primary media channel, how will changing media consumption habits affect intervention effectiveness?
  • How effective are interventions that use newer content delivery formats and media channels, especially digital media?
  • How effective are these types of interventions at reducing use of tobacco products other than cigarettes, for example cigars, cigarillos, and smokeless tobacco products?

Study Characteristics

  • Included studies assessed mass-reach health communication interventions in the United States (44 studies), Australia (13 studies), Canada (2 studies), Israel (1 study), New Zealand (2 studies), Switzerland (1 study), Taiwan (1 study), the Netherlands (3 studies), and the United Kingdom (3 studies).
  • Most of the studies evaluated these interventions at the state or regional level (42 studies) with the remaining studies at the national (23 studies) and city or local (5 studies) level.
  • Interventions were implemented alone (17 studies), with other components (21 studies), or as part of a comprehensive tobacco control program (27 studies). Eight studies did not report on this characteristic.
  • Interventions were implemented with adults (49 studies) or young people (21 studies) as the main audience.