Original Paper
Online Advertising to Reach and Recruit Latino Smokers to an Internet Cessation Program: Impact and Costs
Amanda L Graham1,2, PhD; Ye Fang1, MS; Jose L Moreno1, MA; Shawn L Streiff3; Jorge Villegas4, PhD; Ricardo F Mu?oz5, PhD; Kenneth P Tercyak2, PhD; Jeanne S Mandelblatt2, PhD; Donna M Vallone6, PhD, MPH
1Schroeder Institute for Tobacco Research & Policy Studies, American Legacy Foundation, Washington, DC, United States
2Department of Oncology, Georgetown University Medical Center/ Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Washington, DC, United States
3Marketing Department, American Legacy Foundation, Washington, DC, United States
4Business Administration, University of Illinois at Springfield, Springfield, IL, United States
5Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
6Research and Evaluation Department, American Legacy Foundation, Washington, DC, United States
Corresponding Author:Amanda L Graham, PhD
Schroeder Institute for Tobacco Research & Policy Studies
American Legacy Foundation
1724 Massachusetts Ave NW
Washington, DC, 20036
United States
Phone: 1 202 454 5938
Fax: 1 202 454 5785
Email:
ABSTRACT
Background: Tobacco cessation among Latinos is a public health priority in the United States, particularly given the relatively high growth of this population segment. Although a substantial percentage of American Latinos use the Internet, they have not engaged in Web-based cessation programs as readily as other racial/ethnic subgroups. A lack of culturally specific advertising efforts may partly explain this disparity.
Objective: Phase I of this study focused on the development of four Spanish-language online banner advertisements to promote a free Spanish-language smoking cessation website (es.BecomeAnEX.org). Phase II examined the relative effectiveness of the four banner ads in reaching and recruiting Latino smokers to the cessation website.
Methods: In Phase I, 200 Spanish-speaking Latino smokers completed an online survey to indicate their preference for Spanish-language banner ads that incorporated either the cultural value of family (familismo) or fatalism (fatalismo). Ads included variations on message framing (gain vs loss) and depth of cultural targeting (surface vs deep). In Phase II, a Latin square design evaluated the effectiveness of the four preferred ads from Phase I. Ads were systematically rotated across four popular Latino websites (MySpace Latino, MSN Latino, MiGente, and Yahoo! en Espa?ol) over four months from August to November 2009. Tracking software recorded ad clicks and registrants on the cessation website. Negative binomial regression and general linear modeling examined the main and interacting effects of message framing and depth of cultural targeting for four outcomes: number of clicks, click-through rate, number of registrants, and cost per registrant.
Results: In Phase I, smokers preferred the four ads featuring familismo. In Phase II, 24,829,007 impressions were placed, yielding 24,822 clicks, an overall click-through rate of 0.10%, and 500 registrants (2.77% conversion rate). Advertising costs totaled US $104,669.49, resulting in an overall cost per click of US $4.22 and cost per registrant of US $209.34. Website placement predicted all four outcomes (all P values < .01). Yahoo! en Espa?ol yielded the highest click-through rate (0.167%) and number of registrants (n = 267). The message framing and cultural targeting interaction was not significant. Contrary to hypotheses, loss-framed ads yielded a higher click-through rate than gain-framed ads (point estimate = 1.08, 95% CI 1.03 1.14, P = 0.004), and surface-targeted ads outperformed deep-targeted ads for clicks (point estimate = 1.20, 95% CI 1.13 1.28, P < .001), click-through rate (point estimate = 1.22, 95% CI 1.16 1.29, P < .001), and number of registrants (point estimate = 2.73, 95% CI 2.14 3.48, P < .001).
Conclusions: Online advertising can be an effective and cost-efficient strategy to reach and engage Spanish-speaking Latino smokers in an evidence-based Internet cessation program. Cultural targeting and smoking-relevant images may be important factors for banner ad design. Online advertising holds potential for Web-based cessation program implementation and research.
(J Med Internet Res 2012;14(4):e116)
doi:10.2196/jmir.2162
KEYWORDS
Internet; smoking cessation; recruitment; Hispanic/Latino; advertising
Cigarette smoking is a major cause of disease and death in Latinos [1]. Approximately 12.5% of Latinos currently smoke [2] translating into roughly 6.3 million Latino smokers. With a projected growth of the Latino population to 133 million by 2050 (30.2% of the US population) [3,4] and the potential for smoking prevalence to increase as Latinos become more acculturated [5,6], there may be more than 16 million Latino smokers by 2050 if smoking rates remain unchecked. Tobacco cessation among Latinos is a public health priority [7,8].
Web-based cessation programs are a promising approach to reach Latino smokers with evidence-based cessation treatment. More than 60% of Latinos (32 million) are online?projected to increase to 70% by 2014 [9]?and almost half of online Latinos (45%) have used the Internet to search for health information [10]. A growing body of evidence supports the reach, efficacy, and cost-efficiency of Web-based cessation programs [11-19], but additional research is needed to understand their impact among subgroups of online smokers, including racial/ethnic minorities. In general, there are few studies of smoking cessation interventions developed specifically for Latinos [20,21], and only two studies of the effectiveness of Web-based interventions for Latinos [12,22]. One of the challenges in conducting Web-based cessation research with Latinos in the United States is that they have not engaged in Internet cessation programs as readily as other racial/ethnic subgroups [23] and recruitment of Latinos into Internet cessation trials has been challenging [11,12,22,24].
Online advertising is widely acknowledged as an increasingly important method to reach Latinos who use the Internet [25-28]. Also known as ?display ads,? banner advertisements appear as graphical ads embedded into a webpage, typically including a combination of static/animated images, text, and/or video designed to convey a marketing message and/or cause the user to take an action [29]. Unlike ?offline? ads (eg, billboards, newspapers, and flyers), banner ads can immediately link smokers to Web-based cessation programs, thus capitalizing on the motivation to quit when it occurs which can be critical to engaging consumers with cessation treatment [23,30]. Moreover, banner ads can target consumers by strategic placement on selected websites with synergistic content, known demographic profiles, or past online behavior. Therefore, online advertising may represent a ?participant-friendly? and cost-efficient solution to reach and recruit online Latino smokers to Web-based cessation programs [31-34].
Reaching online Latino smokers requires not only efficient and effective advertising channels, but also an understanding of the target audiences? preferred content and context of messages [32,33,35]. Approximately half of online Latinos use the Internet either primarily in Spanish (19%) or in both English and Spanish (28%), with the growth of both segments outpacing English language usage as more Spanish content becomes available online [36]. Therefore, we tested ads in Spanish to reach this large and growing segment of online Latinos. With regard to message content, Prospect Theory [37,38] suggests that people respond differently to factually equivalent messages depending on whether they are framed to emphasize benefits through gain-framed messages (eg, ?if you quit smoking, you will live longer?) or costs through loss-framed messages (eg, ?if you do not quit smoking, you will die sooner?). Applied to health behaviors, research suggests that when behaviors have a relatively certain outcome, gain-framed messages are more persuasive; if behaviors result in an uncertain outcome, loss-framed messages are more effective [39]. Because quitting smoking will almost certainly prevent disease, Prospect Theory predicts that gain-framed messages will be more persuasive than loss-framed messages. Recent evidence suggests that highlighting the benefits of quitting (through gain-framed messages) is more effective to encourage preventive behaviors such as smoking cessation [40-42]. However, there have been few studies that have examined the impact of message framing in health interventions designed specifically for racial/ethnic minorities [43,44].
With regard to message context, research with Latinos indicates that addressing cultural elements is critical in developing smoking cessation interventions [5,45-48]. The process of designing messages around group-level characteristics has been referred to as both cultural tailoring and cultural targeting [49-50]. We use the term ?cultural targeting? in this study to refer to the delineation of a particular population segment. Cultural targeting can be done at a surface level (eg, attending to the visual characteristics or language of intervention materials) or at a deep level (eg, incorporating specific Latino cultural values) [51]. In general, few studies have investigated how surface- and deep-targeted messaging functions in specific subgroups of racial/ethnic minorities [52].
The purpose of this study was: (1) to investigate whether online advertising is an effective strategy to promote engagement with a Spanish-language cessation website among online Latino smokers, and (2) to identify the optimal message characteristics for this audience. To address these questions, we conducted a two-phased, mixed-methods study. In Phase I, formative research with online Latino smokers guided the development of four Spanish-language banner ad prototypes (deep-targeted/gain-framed, deep-targeted/loss-framed, surface-targeted/gain-framed, and surface-targeted/loss-framed). In Phase II, we tested the effectiveness of these four ads in reaching and recruiting Latino smokers to a free Spanish-language smoking cessation website. The primary outcomes in Phase II were: (1) the absolute number of clicks on an ad, (2) the click-through rate to the smoking cessation website, (3) the number of ad responders who went on to register on the cessation website (?registrants?), and (4) the cost per registrant. We hypothesized there would be an interaction between message framing and cultural targeting, such that the deep-targeted/gain-framed ad would outperform all others on all metrics. Based on Prospect Theory, we also hypothesized that gain-framed messages would outperform loss-framed messages on all metrics holding constant cultural targeting. Finally, we hypothesized that deep-targeted ads would outperform surface-targeted ads on all metrics holding constant the message frame.
Phase I: Advertising Development and Pre-testing
A multicultural, multidisciplinary, and bilingual expert panel with expertise in behavioral science, marketing, communication technology, and advertising identified two dominant cultural values to consider for cultural targeting of messages to Latino smokers: familismo and fatalismo. Familismo is central to the Latino health experience; family and close friends are often consulted for general health issues before a medical professional, and family is often a strong motivator of health behavior. Fatalismo refers to the belief ?si Dios quiere? (?what God wants?) which often guides Latino perceptions about their control over health and wellness. Our formative Phase I focused on developing banner ad prototypes for each cultural value that crossed message frame (gain vs loss) with level of cultural targeting (surface vs deep) resulting in a total of eight Spanish-language ads (see Figure 1). All ads were written in Spanish, developed in Adobe Flash with animation and motion by a professional creative developer, and included a call to action (ie, ?click here for more information?).
To examine preferences for ad characteristics, 200 American Spanish-speaking smokers were recruited from two Spanish-language websites: MSN Latino [53] and MySpace Latino [54]. A study invitation banner ad transferred potential participants to an online screening form where eligible individuals (ie, current smokers, aged 18 or older, and Hispanic/Latino ethnicity of any race) provided online consent and completed a survey. Survey items included demographics, smoking history, Internet use, general receptivity to online ads, and the language subscale of the Short Acculturation Scale for Hispanics (SASH) [55]. Next, each participant sequentially viewed two of the eight ads. The two ads differed on cultural value (familismo vs fatalismo), but were identical in message frame and depth of cultural targeting (eg, gain-framed/deep-targeted) for direct comparison of message characteristics. Ad presentation was counterbalanced so that an equal number of participants saw each of the 8 ads first. Participants were asked to indicate their receptivity to the ads using a 10-point Likert scale (1 = not at all, 10 = very much). Participants also responded to 12 statements that addressed the strength of cultural targeting (eg, this ad is for someone like me), ad credibility (eg, this ad is believable), perceived efficacy of the ad (eg, this ad has me thinking about quitting smoking), and intention to respond (eg, I would click on this ad if I saw it) using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Finally, both ads were presented in tandem, and participants were asked which one they liked the most and why. An equal number of participants viewed each ad pair. The survey was administered in Spanish.
Source: http://www.jmir.org/2012/4/e116/
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