Promoting Smoking Cessation Among Lesbian and Bisexual Women: Lessons Learned From a Location-Based Media Campaign in Western North Carolina

Abstract

Despite well-documented inequities in tobacco use for lesbian, gay, bisexual, and transgender populations, there is little practical guidance for local public health officials on developing and implementing media campaigns that prioritize lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. In this practice note article, we describe the development and lessons learned from a location-based media campaign to promote tobacco use cessation and raise awareness of QuitlineNC among lesbian and bisexual women in Western North Carolina. The campaign used a digital approach based on cell phone locations and marketing profiles to deliver messages across 4 years (2018–2021). Considerations for practitioners include how our project required messaging adaptation to meet Google’s restrictions against using the word “yours” and the importance of addressing privacy protection concerns with state officials to enable collection of outcome evaluation measures via a conversion pixel (code for capturing metrics).

Assessment of need

Smoking is a well-documented health inequity for lesbian, gay, bisexual, transgender, and queer (LGBTQ) people compared with their heterosexual and cisgender counterparts (Li et al., 2020). According to North Carolina’s (NC) 2011–2014 Behavioral Risk Factor Surveillance Survey, 47% of lesbian and bisexual (LB) women in NC were current smokers, as compared with 17% of NC heterosexual women (Barnhill et al., 2017). Yet, there are few published descriptions of community smoking cessation interventions for LB women to guide local and regional public health efforts (Lee et al., 2014; Plant et al., 2017). We know of none using location-based media campaigns.

In this practice note, we describe a location-based community media campaign for LB women, which was implemented in Western North Carolina by a regional tobacco control manager, a state public health media consultant, and a local media representative. Mass-reach health communications are a proven, evidence-based strategy in the field of tobacco prevention and control (Community Preventive Services Task Force, 2013). The objectives were to promote cessation among LB women and encourage use of QuitlineNC, North Carolina’s free, evidence-based tobacco cessation service. We next describe the campaign approach and follow with lessons learned.

Description of approach

Challenges of campaigns for LB women include the high cost of media campaigns and the difficulty of reaching a small audience efficiently. Thus, we sought a focused approach that could reach people visiting specific locations associated with LB communities. We identified display advertising approaches, including geofencing and location-based advertising commonly used in marketing. Geofencing is a targeting method used to identify and reach priority populations based on their presence in a broad geographic location (e.g., people within a zip code). Location-based advertising uses GPS technology to give pinpoint accuracy in reaching people who have visited a specific venue (e.g., coffee shops, bars, bookstores). Using GPS coordinates, we identified 13 locations popular within LB communities and captured the media access control (MAC) address of any smart phone carried into or within three feet of these locations. The audience was further limited to women who were likely LGBTQ-identified individuals. Then, iHeartMedia delivered campaign messaging to these users, across any device where they might access the internet. To maintain HIPAA and European Union General Data Protection Regulation compliance, we did not collect or receive other identifying information or IP addresses.

With limited funds and no tobacco cessation messages readily available to reach this population, we developed ads designed to influence LB women living in Western North Carolina. We began by creating four unique marketing messages and selecting 51 stock photos of women that were reflective of LB women, the local culture, and environment. We tested messages and photos in a 3-hour focus group of LB women. Ads rated most effective among participants were optimized to reflect feedback.

Working in collaboration with iHeartMedia, the campaign launched with eight different digital display ad sets (Figure 1). This digital media campaign has run four annual campaign flights 2018–2021. Alongside the digital ads, three 30-second streaming radio and traditional radio messages, featuring personal quitting stories voiced by focus group members, ran during the first 2 years. The call to action for all ads was to visit the QuitlineNC website for smoking cessation information and assistance.

Figure 1.

Four High-Performing Ads Placed in 2018 and 2019 Media Campaigns

Click-through rate (CTR) was used to measure the number of times a digital ad was clicked on to access cessation information and QuitlineNC. The CTRs for this campaign show a high level of success for most campaign flights, ranging from 0.16% to 0.63%. For full results, see Supplemental Table 1. A digital ad campaign can provide a feedback loop for improvement and is a valuable and efficient way to judge which ads work within a defined audience. Our digital ads were served and optimized by comparing two or more ads to determine which performs better; ads that are clicked on more are served more, and ads that are clicked on fewer times ultimately disappear from the collection.

The annual cost of this campaign to the health department was $11,000 to $12,000. Combined with the iHeartMedia trade (a budget for additional advertising, in exchange for iHeartMedia’s sponsorship of the campaign), the total advertising budget was $115,337.

Lessons Learned

While the media campaign using location-based advertising was successful, there have been lessons from challenges. The initial campaign message in 2018 was, “There are many reasons to quit. What are yours?” Although this was effective at reaching LB women, messages in the beginning of 2019 were flagged and rejected by Google due to a policy restriction based on “personalized advertising.” The problem related to using the second person pronoun “yours” in the copy. Therefore, we changed the campaign message to, “There are many reasons to quit. Think about it.” We had no subsequent rejections by Google.

In 2020, we modified the campaign to reflect the health concerns of smoking associated with higher risks of severe illness from COVID-19. We used ads like the CDC’s COVID-19 social media posts aimed at reaching a general audience. This less audience-focused campaign did not perform well with LB women. Therefore, during 2021, we switched back to using previous ads. As of this writing, campaign performance is on a gradual increase again and is doing well.

Although the CTRs have been very high for most flights (demonstrating that messages reached LB women), no outcome evaluation measures were set up to know whether individuals who clicked on ads accessed smoking cessation services. There is a mechanism for capturing these data on the QuitlineNC website. However, the website is operated by state government and concerns about personal privacy protections hindered our ability to implement a performance metric (conversion pixel) using the site. Reassuring website staff that the conversion pixel does not capture personally identifiable information could address this issue.

Our experience has demonstrated which aspects of the campaign have effectively reached LB women in Western North Carolina. We have adapted messages to evolving circumstances and learned what worked and what did not. We anticipate others aiming to reduce the smoking rates of LB women across the country can successfully use our approach and ads with the message, “There are many reasons to quit. Think about it.” Ads are available in the CDC Media Campaign Resource Center at https://nccd.cdc.gov/mcrc/. Use key word search: “lesbian.”