Name of Intervention/ Program
Dear Me: I’m Ready!

Background and Situation Analysis
Tobacco use is easy to start but hard to quit. According to the Surgeon General, nearly all tobacco use begins before 18 years of age. Trying smoking or using an electronic nicotine delivery system (also known as “vaping”) for the first time introduces nicotine to the brain and can quickly change a risk-taking behavior into an addiction. There are currently 127,900 New Hampshire (NH) adults who smoke. While NH has seen a decrease in adult smoking prevalence since 2011, differences emerge when comparing the data across different population groups. Smoking prevalence is highest across 3 age categories: 18-24, 25-34, and 35-44. Adults with less than a high school diploma and those with a GED or high school diploma smoke at a higher rate than those who have attended some post high school education. Data consistently demonstrates that food service, construction, health care, social services industries, and retail trade have higher percentages of smoking as compared to other industry sectors. Currently, the Centers for Medicare and Medicaid Services (CMS) estimates that 27% of adult Medicaid beneficiaries reported using tobacco products as compared to the national average of 18.1%. From August 2017 through January 2018 NH’s quitline service received 1,058 calls; 68% of the callers reported having a mental health condition, 32% reported a mobility limitation, 16% had a learning difficulty, and 3% reported a developmental disability. Additionally, 95% of users were first-time callers; people with learning difficulties were slightly more likely than others to be first-time callers; and people with learning difficulties reported that they had started smoking at a younger age (15.5 years old compared to 17 years old among other callers.3 These findings confirmed the previous data on disparate burden of tobacco use while also suggested that people with disabilities who use tobacco are likely to enroll in tobacco treatment resources via a quitline. There are communities and populations of people who are more vulnerable; namely those living with a substance use disorder (SUD) or a mental health condition and those with low income and low educational attainment. Nationally, individuals living with SUD and mental health conditions die between 5 to 25 years earlier than those without these chronic conditions. Smoking is one cause of these early deaths; individuals experiencing SUD or living with mental issues smoke at higher rates. They consume 40% of all cigarettes smoked by adults while representing only 25% of the population. Yet, they routinely have less access to tobacco treatment services across the healthcare spectrum including in the behavioral health treatment settings. Research was conducted to investigate the needs of the NH individuals who were living with SUD and mental health conditions, who were using tobacco (including vapes or e- cigarettes). Through a contract, new focus groups were assembled and conducted to understand the concerns of this population relative to their tobacco use and the effect this use had on their use of other substances, recovery path and mental health concerns and conditions.

Priority Audiences(s)
New Hampshire adults who smoke or vape, and those who may have mental health issues or a mental health diagnosis, and those who may also be living with a substance use disorder. Sub-audience break-outs: NH adults 18-26 and NH adults 27+ and NH adults who use cigarettes.

Behavioral Objectives
According to the theory of planned behavior (Ajzen, 1991), behaviors are influenced by intentions, which are determined by three factors: attitudes, subjective norms, and perceived behavioral control. It is also possible for external factors to directly force or prevent behaviors, regardless of the intention. The transtheoretical model of health behavior change (Prochaska, 1997), posits that change involves progress through six stages: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Focus group participants identified two chief concerns about their tobacco use: (1) Tobacco use controls their time, attention, and income. (2) Tobacco use negatively impacts their health. Behavioral objectives: – Increase the current level of knowledge around tobacco use of those with behavioral health conditions (i.e., substance use disorder or mis/use or mental health condition) regarding their tobacco dependence, harm reduction and cessation. – Increase awareness of the health consequences of tobacco use and dependence on adults with behavioral health conditions and the effectiveness of their medicines. – Increase adult contemplation around how tobacco use, dependence, harm reduction, and cessation fit into their lifestyle. – Motivate and inspire current tobacco users in New Hampshire to consider changing their tobacco use.

Description of Strategy/Intervention
Dear Me New Hampshire, a social marketing campaign designed to increase quit attempts among unemployed and lower wage-earning adults (ages 18-55), who use tobacco products, was originally launched in 2014. This multi-media campaign adopted and expanded the “Dear Me Washington” campaign. Years later, after significant market testing, Dear Me-NH was re-imagined as Dear Me: I’m Ready!. The campaign has always challenged NH residents to make videos, recordings, or write “Dear Me” letters to themselves about why they wanted to quit using tobacco. These musings realize the reasons individuals have inside them for quitting tobacco use, potentially moving them along the stages of change to preparation and action or keep them at maintenance. Not only do these letters motivate and inspire the writer, but they inspire others. By addressing the concerns of the population, we can offer solutions that are relevant to them. This population identified (in focus groups) two chief concerns about their addiction: (1) Tobacco use controls their time, attention, and income. (2) Tobacco use negatively impacts their health. Participants expressed having a cigarette or vaping quells anxious feelings. At the same time, they feel controlled by the need for nicotine and feel it is a compulsive behavior. Participants described waking up in the middle of the night, plugging in multiple devices so they always have one ready, vaping every time they were in the car, in between work calls, and on break. Using either cigarettes or vapes is a reflex. Communications should build on the concept of control or lack of control while providing information about nicotine addiction and build a connection to resilience and treatment resources. Multiple campaigns were tested during the focus groups, including the previous Dear Me – NH campaign and the CDC’s Tips From Former Smokers campaign – both were received very well. Videos highlighting personal stories or reasons to change are effective ways to convey this information. Theories applied in the strategy of this campaign are: The Social Cognitive Theory, The Transtheoretical Model/Stages of Change, the Health Belief Model, and the Theory of Planned Behavior. Writing (or journaling or recording) is a cognitive function; it may create sufficient cognitive defusion–looking at thoughts rather than being in them–to create the separation needed to accept our feelings and commit to the changes we need to make (Tartakovsky, 2022). It can also be a valuable and effective intervention for recovery from addiction. For additional motivation, a campaign was introduced at the beginning of the campaign – letter writers could agree to have their personal story for wanting to quit, trying to quit or affirming they were going to try to stay quit used to create further commercials that could inspire other people. State quitlines already follow best practices for reducing barriers to quitting tobacco use and accessing the services offered, once individuals clicked-through, searched or contacted, they were met with this information on how access and support was being made more easily accessible, convenient, and served without judgment and cost (in most cases). Individuals could submit letters, video or just audio, online via a form and read letters or watch videos there as well. Access to the quitline was available via phone, text, or website.

Dear Me – NH was re-launched in May 2023 to begin to reach NH audiences with encouragement to think about quitting and to connect with the existing letters written while potentially entering a contest by writing their own Dear Me letter. The updated campaign was refreshed as, Dear Me: I’m Ready! The campaign ran on broadcast radio and television, social and digital media for 6 months promoting the contest and then another 6 months after we refreshed the creative developed with the stories from the contest winners. At that time, print advertisements were added. In order to tap into the behavioral models, the campaign needed to address the stigma of having a substance use disorder (nicotine use disorder (NUD)) by normalizing the commonality of SUD/NUD, of the desire to quit and the motivational factors the individual needed to actively contemplate, as well as the belief that one was ready to try to quit, and possibly had a chance to quit successfully. The start of the campaign focused on letter-writing (a reflection on motivation) while the second half added in substantially emotive and recognizable content for the viewer to identify with and increase the belief that they could successfully quit. Communications built on the concept of control or lack of control while providing information about nicotine addiction and built a connection to resilience and treatment resources. These videos highlighting personal stories or reasons to change are effective ways to convey this information. Because most people in the focus groups were in the ‘Contemplation Stage’ in terms of the Prochaska’s Stages of Change, they were seriously thinking about making a change, but they are not ready to commit to any action. Therefore implementing videos/media that highlight personal stories that share feelings of ambiguity, pros/cons and readiness are appropriate. Participants also preferred the messages in the campaigns they saw that emphasized the positive opposite of the negative consequences. New videos focused on highlighting situations with people experiencing negative consequences in the past, but also showing how things have improved now that they have quit (i.e., more time and money, success surgery, improved self-esteem, less worry, more focus at work). Creative also needed to create a narrative of solutions. Most of the participants expressed worrying about the health effects of smoking or vaping. This presented an opportunity to develop stories that show how people have been impacted by using tobacco products to (1) educate the audience about the health impacts, (2) show them how to resolve to take action to quit, and (3) connect them to treatment resources. In James’s Video, we did just that. We also avoided directly telling the audience specific facts such as vaping causes depression or vaping worsens mental health – rather we shared how people have been impacted. The audience is likely to reject direct facts if they cannot personally relate to them. All videos were tagged with calls-to-action on taking a step and reaching out to get more motivation or to find help.

Evaluation Methods and Results
Key performance indicators for the campaign were: number of letters submitted, social channel followers, number of comments/engagement in the creative, click-through-rates on paid advertisements, number of users on the website and number of new users to the site, time on the website and campaign pages in-particular ( and interaction with pages on site. Partnering with our partner and funder, we are also able to access call-volume data to the state quitline. As the campaign is still running, call-volume has not yet been assessed. There were 17 letters submitted for the contest (with the size of the adult population in NH and the small incentive of $250, combined with the barrier to submitting a personal letter, we consider this a good number). Facebook page visits increased by 492.3% and page likes increased by 400%. Instagram reach increased by 63.6%. From August through October, the number of users and new users on the QuitNow-NH website increased by 53.8% and 58% and the average engagement time increased by 87.9%. The top pages visited during the campaign were the Dear Me landing page, Write a Letter, the homepage, and I Want To Quit Archives. Current campaign ads featuring the newest creative based-on the letter writers has an average click-through rate of .31% and view-through rate of 92%. James’s Ad in particular has a click-through rate of 60%.

Entry Letter: UU

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