Facts & Issues. Tobacco in Australia. A comprehensive online resource. tobaccoinaustralia.org.au

Transcription

1 Tobacco in Australia A comprehensive online resource Facts & Issues tobaccoinaustralia.org.au

2 Book excerpt List of chapters available at tobaccoinaustralia.org.au Introduction Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Trends in the prevalence of smoking Trends in tobacco consumption The health effects of active smoking The health effects of secondhand smoke Factors influencing the uptake and prevention of smoking Addiction Smoking cessation Tobacco use among Aboriginal peoples and Torres Strait Islanders Smoking and social disadvantage Chapter 10 The tobacco industry in Australian society Chapter 11 Tobacco advertising and promotion Chapter 12 The construction and labelling of Australian cigarettes Chapter 13 The pricing and taxation of tobacco products in Australia Chapter 14 Social marketing and public Chapter 15 Smokefree environments Chapter 16 Tobacco litigation in Australia Chapter 17 The economics of tobacco control Chapter 18 The WHO Framework Convention on Tobacco Control Appendix 1 Useful weblinks to tobacco resources Tobacco in Australia: Facts and Issues. Third Edition A comprehensive review of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria. First edition published by ASH (Australia) Limited, Surry Hills, NSW, 1989 Second edition published by the Victorian Smoking and Health Program, Carlton South, Victoria (Quit Victoria), 1995 Third edition published by Cancer Council Victoria 2008 in electronic format only. ISBN number: Suggested citation: Scollo, MM, Winstanley, MH [editors]. Tobacco in Australia: Facts and Issues. Third Edition. Melbourne: Cancer Council Victoria; Available from: Tobacco in Australia: Facts and Issues; 3rd Edition updates earlier editions of the book published in 1995 and This edition is greatly expanded, comprising chapters written and reviewed by authors with expertise in each subject area. Tobacco in Australia: Facts and Issues is available online, free of charge. A hard copy version of this publication has not been produced. This work has been produced with the objective of bringing about a reduction in death and disease caused by tobacco use. Much of it has been derived from other published sources and these should be quoted where appropriate. The text may be freely reproduced and figures and graphs (except where reproduced from other sources) may be used, giving appropriate acknowledgement to Cancer Council Victoria. Editors and authors of this work have tried to ensure that the text is free from errors or inconsistencies. However in a resource of this size it is probable that some irregularities remain. Please notify Cancer Council Victoria if you become aware of matters in the text that require correction. Editorial views expressed in Tobacco in Australia: Facts and Issues. Third Edition are those of the authors. The update of this publication was funded by the Australian Government Department of Health and Ageing. Cancer Council Victoria 1 Rathdowne Street Carlton VIC 3053 Project manager: Kylie Lindorff, Policy Manager, Quit Victoria and VicHealth Centre for Tobacco Control Website design: Creative Services, Cancer Council Victoria Design and production: Jean Anselmi Communications

3 Tobacco in Australia Facts & Issues A comprehensive online resource tobaccoinaustralia.org.au Chapter 14 Social marketing and public

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5 Chapter 14: Social marketing and public 1 Chapter 14 Social marketing and public Table of contents Tom Carroll PhD 14.0 Introduction Social marketing and public The role of social marketing and public within a comprehensive tobacco control program The Framework Convention on Tobacco Control The National Tobacco Strategy Counter-marketing and international experience in youth tobacco prevention Tobacco control campaigns in Australia: experience and effectiveness State and territory campaigns Health Promotion Foundations Effectiveness of early state-based anti-smoking education campaigns Federal government initiated programs The National Campaign Against Drug Abuse The National Tobacco Campaign Campaign strategy development Campaign advertising materials Media placement strategy Evaluating the National Tobacco Campaign Annual evaluation surveys Continuous tracking in the National Tobacco Campaign Generating calls to the Quitline Impact of the National Tobacco Campaign on youth... 19

6 2 Tobacco in Australia: Facts and Issues Impact of the National Tobacco Campaign across socio-demographic groups Reaching Australians from culturally and linguistically diverse backgrounds Impact on Indigenous communities International use of the National Tobacco Campaign materials Cost and cost-effectiveness of the National Tobacco Campaign Further state and territory-based campaigns Current national and state and territory campaign activity Australian Competition and Consumer Commission Introduction of graphic health warnings Graphic health warnings campaign collaboration The National Tobacco Youth Campaign Examining effectiveness of public Comprehensive campaigns in the United States The contribution of anti-smoking television advertisements to quitting Effective media campaign approaches for youth and adults Effectiveness of different anti-smoking themes Tobacco industry funded campaigns International comparisons of response by youth Implications for production of tobacco campaign advertisements Executional considerations Understanding how campaigns work Agenda setting The norm reinforcement approach Seeking to understand the process of change Effects of advertising exposure Developing, implementing and evaluating tobacco control campaigns A social marketing approach Key aspects of public health social marketing Model for Comprehensive Social Marketing Campaign Development Evaluating social marketing campaigns... 39

7 Chapter 14: Social marketing and public Funding for tobacco control campaigns Challenges and opportunities for tobacco control campaigns Media fragmentation and the continuing emergence of new communication channels Cigarette smoking on the cinema screen Branded content and promotional marketing Pharmaceutical advertising Radio as a medium The Bloomberg Global Tobacco Control Initiative in developing countries Acknowledgement Attachment 14.1 National, State and Territory Contacts...45 AUSTRALIAN GOVERNMENT NEW SOUTH WALES VICTORIA QUEENSLAND SOUTH AUSTRALIA WESTERN AUSTRALIA TASMANIA AUSTRALIAN CAPITAL TERRITORY NORTHERN TERRITORY... 46

8 4 Tobacco in Australia: Facts and Issues Tables and figures Figure 14.1 National TARPs versus Quitline call response (18 May January 1999)...18

9 Social marketing and public Chapter 14: Social marketing and public Introduction In the context of Australia s comprehensive National Tobacco Strategies, social marketing campaigns have played a significant role in raising awareness of smokingrelated health risks and have been associated with significant changes in attitudes toward smoking, with increased quitting attempts, and with significant downward trends in smoking prevalence, initiated particularly over the period of Australia s most concerted campaign effort, the National Tobacco Campaign. 1 This chapter examines the history and progress of Australian tobacco control campaigns, draws out key lessons from the extensive Australian and international experience and evidence about the most effective approaches for campaigns, and points to some key issues for future tobacco control prevention and cessation efforts. These efforts need to be consistently reinforced in light of the competitive influences of tobacco industry marketing activities and other efforts designed to reduce the effectiveness and impact of tobacco control campaigns 2 examined in Chapter Social marketing and public education campaigns An initial community trial of the use of mass media advertising for health promotion was conducted in New South Wales in the late 1970s, including the first use of the wellknown Sponge advertisement in the original Quit. for life campaign. 3 Since this initial trial the use of mass media advertising has been a common characteristic of tobacco control campaigns in Australia. Through the decades, formative research has been used more and more extensively to inform campaign design and development, and the campaigns have grown in sophistication and complexity. Tracking and other evaluation research has contributed significantly to the understanding of what campaigns can achieve and how campaigns work. Campaigns are now viewed as performing particular roles within national and state/territory comprehensive tobacco control strategies, to achieve prevention objectives as well as motivating and encouraging smokers to quit. In addition, these campaigns increase community understanding and recognition of the harms associated with tobacco smoking and facilitate the introduction of policy initiatives to reduce this harm. To an increasing extent the body of knowledge generated through the field of social marketing for health behaviour change is being adopted in the development, implementation and evaluation of tobacco control campaigns. This application of social Section: 14.1

10 6 Tobacco in Australia: Facts and Issues marketing incorporates theory and practice from the fields of psychology, sociology and commercial marketing and communications to achieve campaign aims. Within a social marketing approach, campaigns are developed with a long term, strategic outlook, incorporating formative research to define the problem and guide the formulation of aims, objectives and strategic approach and to pre-test campaign communication materials. Social marketing involves influencing the behaviour not only of individuals, but of groups, organisations and society as a whole. 4 These campaigns work most effectively when they are part of an integrated multi-component strategy. Consistent with this thinking, social marketing plays an integral role in reducing the uptake of smoking and promoting and facilitating quitting within Australia s National Tobacco Strategy The role of social marketing and public within a comprehensive tobacco control program Almost three decades ago the World Health Organization and the International Union Against Cancer (UICC) advocated that an effective reduction in tobacco consumption can be achieved by a number of interrelated measures being taken. 6 The essential UICC objectives of a comprehensive tobacco control program were stated as: << the achievement of lower smoking rates in all age groups of the population, by the application of all practical downward pressures on smoking rates, including health warnings on tobacco packets, increased taxation, restrictions on smoking opportunities, support for the rights of the non-smoker, and information and education programs << the encouragement of non-smokers to remain non-smokers << the cessation of all forms of tobacco advertising and promotion << the encouragement of those who have not yet stopped smoking, and therefore remain at high risk, to reduce, as far as possible, their exposure to the harmful components of tobacco smoke << maintaining liaison with other health organisations and authorities to ensure maximum effectiveness and to avoid conflict of activities. In addition, a key feature of this recommended tobacco control program was the recognition that synergies are created when all components of the program are implemented, rather than simply considering the potential impact of individual strategies. As more evidence has emerged from tobacco control programs internationally, the importance of viewing social marketing and public education campaigns within this comprehensive program of strategies and activities has continued to be emphasised. 7 Section: 14.2

11 Chapter 14: Social marketing and public The Framework Convention on Tobacco Control The role of tobacco control campaigns within comprehensive tobacco control programs is now recognised at a number of levels. At the global level the WHO Framework Convention on Tobacco Control (FCTC) was adopted at the Fifty-sixth World Health Assembly in 2003 and entered into force on 27 February The FCTC outlines (article 12) that each party to the Convention shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. Further, the FCTC notes that in order to achieve this outcome, each party shall adopt and implement effective legislative, executive, administrative or other measures to promote: << broad access to effective and comprehensive educational and public awareness programs on the health risks including addictive characteristics of tobacco consumption and exposure to tobacco smoke << public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of cessation of tobacco use and tobacco-free lifestyles << public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption << public access to a wide range of information on the tobacco industry << effective and appropriate training or sensitisation and awareness programs on tobacco control for health workers, community workers, social workers, media professionals, educators, decision-makers and administrators, and << awareness and participation of public and private agencies and non-governmental organisations in developing and implementing intersectoral programs and strategies for tobacco control. The Australian Government formally ratified the FCTC on 27 October The National Tobacco Strategy At the national level in Australia the key role played by tobacco control campaigns within a comprehensive program of activity has been recognised within Australia s National Drug Strategic Framework. As part of this framework, the current National Tobacco Strategy (NTS ) has the goal of significantly improving health and reducing the social costs caused by, and the inequity exacerbated by, tobacco in all its forms. 5 The designated objectives of the strategy are, among all social groups: << to prevent uptake of smoking << to encourage and assist as many smokers as possible to quit as soon as possible << to eliminate harmful exposure to tobacco smoke among non-smokers and where feasible, to reduce harm associated with continuing use of, and dependence << on, tobacco and nicotine. Section:

12 8 Tobacco in Australia: Facts and Issues The promotion of Quit and Smokefree messages is a central component of the NTS The Strategy notes that in order to discourage initiation to smoking and to promote quitting, as well as smoking around children, requires sustained and commercially realistic funding for campaigns. This is necessary: << to keep quitting on people s agenda and to reach people as they cycle in and out of readiness to quit at many times each year, and << to reach people at times in their life that they are vulnerable to messages about smoking, and times when they are more likely than usual to be responsive to encouragement to change. The Strategy encourages the promotion of hard-hitting, well researched campaigns to: << encourage smokers to personalise the health risks of smoking << keep quitting on smokers agenda << increase understanding of the quitting process, and < < promote treatments and services. 10 The Strategy also specifically encourages promoting the advantages of not starting and of stopping before quitting becomes more difficult, as well as the advantages of parents quitting while their children are still young. In addition, the Strategy recognises the advantages of promoting the benefits of not smoking, of quitting, and of not smoking around others at teachable moments and crucial life transitions such as: << graduating from primary to early secondary school << moving from school to work or post-secondary study << leaving home to live independently << seeking or starting a (new) job << forming or seeking a more permanent relationship << in the period where the majority of Australians contemplate or strive for home ownership << prior to and after becoming a parent << when children are at pre-school or primary school << becoming a grandparent << thinking seriously about retirement << after diagnosis with a risk factor for, or onset of, a serious medical condition. Recognising the potential synergies generated between the components of the Strategy, increasing the promotion of Quit and Smokefree messages by Australian jurisdictions will serve to support other components of the NTS such as: << generating greater support for further regulation << promoting greater utilisation of services and treatment for smokers << providing support for parents, carers and educators helping children develop a healthy lifestyle << supporting policies that reduce smoking as a means of addressing disadvantage << targeting communication messages and services to ensure access by disadvantaged groups, and << fostering collaboration in program policy and development. Section:

13 Chapter 14: Social marketing and public Counter-marketing and international experience in youth tobacco prevention Although not frequently used in Australia, the term counter-marketing is used in the United States to encompass a wide range of activities beyond simply mass media advertising. This broader marketing framework is consistent with the social marketing approach to population health behaviour change mentioned earlier. The US Centers for Disease Control and Prevention s (CDC) Best Practices publication describes countermarketing as comprising paid television, radio, billboard and print advertising; media advocacy and other public relations techniques and tactics such as press releases, local events and health promotion activities; and efforts to reduce or replace tobacco industry sponsorship and promotions. 11 A recent review of youth tobacco prevention campaign research and evaluation in Australia, Canada, England, Finland, Germany, the Netherlands, Norway, Poland and the United States confirmed that tobacco prevention and counter-marketing campaigns achieve most successful outcomes when they are part of broader tobacco control programs including components such as environmental and policy changes, taxation measures, school curriculum programs, smoking cessation treatment programs and community activism. 12 As emphasised previously, it is the synergy created by these components that works toward changing community attitudes about smoking Tobacco control campaigns in Australia: experience and effectiveness As early as 1971, Dr Nigel Gray, then Director of the Anti-Cancer Council of Victoria, encouraged production of anti-smoking television advertisements. A series of about 26 low-budget black and white advertisements were created, mostly humourous and featuring English actors Warren Mitchell, Fred Parslowe and Miriam Karlin. Also during these early years of tobacco control, Sir MacFarlane Burnett appeared in two television advertisements about lung cancer and teenage smoking. 13 Following the initial Quit.for life campaign community trial in the late 1970s as part of the New South Wales North Coast Healthy Lifestyle Program, 3 state-wide tobacco control campaigns were developed in Australia by some state jurisdictions through the early 1980s. These commenced in New South Wales, Victoria, Western Australia and South Australia, and were funded through a combination of government and other sources. In Queensland, Tasmania, the Australian Capital Territory and the Northern Territory, activities followed through a range of organisations. 14 Since then, campaigns have been developed and implemented across states and territories as part of increasingly comprehensive tobacco control programs, and additional campaign activity has been undertaken by the Federal Government and non-government organisations. Section: 14.3

14 10 Tobacco in Australia: Facts and Issues State and territory campaigns The initial state and territory-based smoking control activity was often undertaken in conjunction with a range of specialist organisations such as the state Cancer Councils and the National Heart Foundation of Australia. The combination of the finances and expertise of these groups resulted in a high standard of and tobacco policy development in Australia. These campaigns typically focused on a Quit week of activities, but varied in their level of activity throughout the year. Smokers were encouraged to quit through the provision of information on smoking, advice on quitting, and the opportunity of attending cessation courses. Young people were targeted through schools, where resources for class use were designed for specific age groups. The Quit organisations also provided support and resources for health professionals, including medical practitioners, to assist with counselling and to support community-based activities. In some states a Quitline (telephone information service) was available, delivering a recorded message that provided advice on quitting and directed callers to trained staff for individual counselling and self-help resources. Informed by campaign research and evaluation studies, specific population groups were identified and targeted, including children, young women, Aboriginal and Torres Strait Islander smokers and smokers in non-english speaking communities, as well as older smokers. As frontline information resources for the community, these organisations needed to keep abreast of the most current information on smoking and respond to issues as they emerged. Programs assisting workplaces which required general information or specific guidance on becoming smokefree were developed and delivered by Quit groups, as well as programs aimed at restaurants and other public places. A variety of means were used to promote messages about smoking and health. Mass media campaigns were the most visible, but in some regions Quit organisations sponsored a number of sports and other activities as a way of promoting the nonsmoking message among certain target groups. The Quit message was also promoted through special community events such as No-smoking days or run in schools, hospitals, worksites, health centres and other community-based venues, through press and media coverage generated by these events or as a response to an externally prompted news story on smoking Health Promotion Foundations During the late 1980s and the 1990s an added source of funding for health education campaigns was provided in Victoria, South Australia, the ACT and Western Australia, where Health Promotion Foundations were established by legislation encompassing a wide range of tobacco control measures. Financed by an increased levy on state or territory tobacco licence fees, these foundations shared the objectives of: << providing sponsorship of activities related to the promotion of health or to the prevention and early detection of disease << increasing awareness of programs promoting good health through sponsorship of sports, the arts and popular culture, and << funding research and development of activities in support of these aims. Section:

15 Chapter 14: Social marketing and public 11 In 1993, the Queensland Health Promotion Council was also established to fund health promotion (though promotion via funding of sports was excluded). The Tasmanian Health Promotion Council was established along similar lines in the same year. The establishment of the foundations gave rise to a range of new opportunities and issues, especially relating to the capacity of the foundations to provide an alternative source of funding from tobacco companies for sponsorships of sport and the arts. The foundations were also able to purchase advertising space (particularly on billboards and in cinemas) previously used by the tobacco companies, thereby assisting the advertising industry during the transition period surrounding the introduction of tobacco advertising bans. Entering sponsorship agreements brought about major opportunities for health promotion. 15 Target groups were expanded to include participants and spectators of sports or cultural events who may not have been reached by previous health promotion strategies. Not only were messages about smoking prevention and smoking cessation seen more often, but the messages could also be tailored for specific audiences and adjusted to maintain a fresh and contemporary image. Importantly, the relationships which developed as a result of sponsorship contracts could also be used to encourage the adoption of structural changes such as policies on smoke-free areas at venues (as well as the provision of low alcohol drinks, healthy food choices and sun protection policies) Effectiveness of early state-based anti-smoking Quit campaigns in the larger states were evaluated annually. A study examining changes in smoking prevalence in Australia during the 1980s concluded that anti-smoking had exerted a significant downward effect on smoking rates. The study observed prevalence trends prior to the commencement of, and following, the Sydney Quit for Life campaign (initiated in 1983), and the Melbourne Quit campaigns (initiated in 1984). With no observable trend in smoking prevalence in either city prior to these campaigns, the study found that the campaigns led to an immediate 2.6% drop in overall adult smoking rates, and a continued 1.5% decline annually among men. 17 A further study using the same data set found that the Sydney and Melbourne campaigns during the 1980s were effective for almost all educational groups (women with lower levels of educaton in one city being the exception). The campaigns were promoted through the mass media, doctors surgeries, schools, and through a broad range of community-based activities. Overall, the campaigns achieved high public awareness and improved smoker education, and also served to mobilise health professionals, especially doctors, against smoking. This research provided strong support for the use of mass media for reaching a range of population subgroups. 18 There was further evidence from subsequent studies on children s smoking prevalence that the campaigns brought about a major decline in the uptake of smoking among children, particularly among those aged less than When considering the measurement of campaign effectiveness it is always necessary to recognise the policy and program context within which campaigns are operating and the impossibility of exactly attributing changes observed in a measure such as smoking prevalence to any single factor. Throughout the 1980s a number of Australia states and territories experienced increases in state tobacco licence fees and federal Section:

16 12 Tobacco in Australia: Facts and Issues excise, the widespread introduction of smokefree workplaces accompanied by a heightened public awareness of the issues surrounding passive smoking, and the introduction of comprehensive tobacco control legislation, including bans on most forms of tobacco advertising. Recognising the synergistic contribution of these various factors in contributing to a downward effect on smoking rates is the very foundation of comprehensive tobacco control programs highlighted earlier Federal government initiated programs The first federal campaign on smoking was the $1.5 million National Warning Against Smoking conducted between 1972 and 1975 at a cost of $500,000 per annum over three years. 20 The campaign used posters and slogans with anti-smoking messages. As part of the campaign the Commonwealth Department of Health printed and made available, free-of-charge to the public, cardboard signs requesting smokers not to smoke in their vicinity. Because the campaign was not formally evaluated no information is available about its impact The National Campaign Against Drug Abuse The Ministerial Council on Drug Strategy (MCDS) was formed in 1985, comprising all Australian state and territory Health Ministers, Commonwealth Ministers for Health and Customs, and the Attorney-General. 21 An early initiative of the MCDS was the launch of the National Campaign Against Drug Abuse (NCADA), with the stated aims of reducing drug use in the community through education, rehabilitation and law enforcement. This program was later renamed as the National Drug Strategy. Importantly, the NCADA acknowledged tobacco smoking as the major contributor to drug-related deaths in Australia. 21 This ensured that tobacco issues maintained a high profile among health professionals and the media. As part of the social marketing arm of the National Campaign Against Drug Abuse, The Drug Offensive, a $2 million national television, cinema and print advertising campaign Smoking who needs it? was launched in 1990 and continued through 1991 aimed at teenage girls and young adult women. 22 Designed to complement existing state-based programs, campaign evaluation surveys showed significant increases in negative perceptions of smoking among the target audience, and an elevation in the percentage of young girls intending to reduce their rate of smoking. 23 A further low-key cinema campaign aimed at teenage smoking was conducted in The National Tobacco Campaign Through the 1990s a wide degree of cooperation was developed between the Quit organisations working across Australia, with materials being shared or adapted where possible. However it was not until 1997 that a truly national tobacco campaign, galvanising the collective expertise and resources of all Australian Quit campaigns and the Commonwealth was to be launched. The development of the National Tobacco Campaign followed a stalling of the steady reductions in smoking prevalence observed through the 1980s and early 1990s (see Chapter 1). In 1995, the Australian Government allocated research funds toward Section:

17 Chapter 14: Social marketing and public 13 regaining the tobacco control momentum and in 1996, a firm new Australian Government funding commitment was made to pool the extensive tobacco control expertise and resources in Australia to develop a collaborative national anti-smoking campaign. 24 Managed by the Commonwealth Department of Health and Aged Care with advice from a Ministerial Tobacco Advisory Group chaired by Professor David Hill, the National Tobacco Campaign (NTC) was launched in June 1997 with funding of $7 million over two years. With the advent of the NTC, funding for tobacco control programs in Australia increased from 26 cents per adult in 1996 to 55 cents per adult in 1998 and continued at 49 cents per adult in The NTC was a cessation campaign aimed at year old smokers and represents Australia s most intense and enduring mass media tobacco control campaign. One of the great strengths of the campaign was the truly collaborative nature of its development and operation with a strong partnership approach between the federal, state and territory governments and relevant non-government organisations. The Federal Government-funded national mass media advertising activity was supported by state and territory governments and Quit campaign organisations contributing funding to a range of supporting initiatives including Quitline services and extending the media buy in some jurisdictions Campaign strategy development The process of developing the National Tobacco Campaign strategy was informed by assembling and analysing relevant psychological research and the significant body of market and communications research undertaken by Quit campaigns and organisations over the previous decade. In a simplification of the stages of change model and other significant behavioural theory and research, 26 the campaign strategy was grounded in an individual model based on a personal agenda about smoking. 27 The model assumed that: << An individual s daily actions are largely explained by an unwritten personal agenda with items implicitly ranked for importance/urgency and grouped for today, tomorrow, sometime soon, if I ever get the chance, when I eventually get around to it. << For intentions to become actions they must at least make it onto today s agenda. << Behaviours (such as quitting) that require action over many days and which are difficult, require external resources and reinforcements. 28 The primary objective designated in the communication brief to the campaign advertising agency was to elevate quitting on smokers personal agendas, underpinned by the premise that to potentiate an existing intention (i.e. to quit smoking), an individual should be stimulated toward some or all of the following: < < Gain fresh insights on the recommended behaviour < < Reassess the importance of the behaviour < < Reassess the urgency of carrying out the behaviour < < Reassess the personal relevance of the behaviour < < Have confidence in their own ability to carry out the behaviour (self-efficacy) < < Remember or be reminded to do it, and < < For long-term change, gain more than is lost by carrying out the behaviour (response efficacy). 28 Section:

18 14 Tobacco in Australia: Facts and Issues Key points guiding the creative strategy for campaign communication were: << show the health damage from smoking in new insightful ways that are both enlightening and chilling << develop a conditioned association between the images of harm to the body and the act of smoking << translate the scientific knowledge about smoking into felt experience, rather than a cognitive appreciation of risk, and << describe the certain consequences of smoking to diminish self-exemption Campaign advertising materials At the centre of the NTC were powerful health effects television advertisements, constructed with four distinct components: << an opening smoker moment an empathetic portrayal of a somewhat awkward but typical smoker situation, designed to show that the intent of the advertisement is to understand and help smokers, not harass them << a sequence of visuals to forge a strong associative link between the acts of lighting/ inhaling a cigarette and images of the harm when smoke enters the body << new news about the damage smoking does to the body, presented as graphic negative health effects < < the slogan Every cigarette is doing you damage to stress the ongoing effects of smoking and to counter the rationalisation that smoking is like a lottery (that you will be fine unless your number comes up), and << the national Quitline number for smokers to call and speak with a smoking cessation counsellor. Close collaboration between the advertising agency s creative team and medical experts in the cardiovascular, neurology and respiratory fields became a critical component of the creative development process and between 1997 and 2000 resulted in the production of six health effects advertisements (Artery, Lung, Tumour, Brain, Eye, and Tar) and one Call for help advertisement modelling a caller to the Quitline. The health effects highlighted through these television advertisements were portrayed graphically as follows: < < Artery: We hear that smoking makes artery walls sticky and collect dangerous fatty deposits. A glutinous plug of atherosclerotic deposit is squeezed through a disembodied human aorta. < < Lung: We hear that every breath of tobacco smoke attacks the millions of tiny air sacks in the lungs. As smoke is pulled and pushed through a healthy red delicate sponge-like lung, the membrane begins rotting, forming ugly black, tar-rimmed chambers, and turning grey/brown. < < Tumour: We hear that smoke damages a vital gene that protects the lung cells from cancer and that one damaged cell is all it takes. We see a large cancerous growth spread rapidly through a smoker s airway. < < Brain: We hear that smoking creates blood clots that can cause strokes and that these can kill, blind or paralyse. We view a brain that is cut in half to show the damaged section of the brain that oozes tissue and blood. < < Eye: We hear that chemicals from tobacco smoke get into the blood stream and can damage the eye. We view a close up eye and zoom in through the pupil. The surface of the retina becomes blotchy as a capillary bursts. Section:

19 Chapter 14: Social marketing and public 15 < < Tar: We hear that every time a smoker inhales, tobacco smoke condenses in the lungs to form tar. A full beaker of tar is poured onto the cut surface of a healthy lung and we view the tar closely as it seeps into the delicate sponge like tissue. Adopting a behavioural modelling approach of depicting a smoker calling the Quitline, the Call for help advertisement was designed to: << position the Quitline service as accessible, friendly and professional << increase belief in the efficacy and acceptability of seeking support, and << provide encouragement to call the Quitline Media placement strategy Reflecting the social class gradient of smoking in Australia, 29 a lower socioeconomic bias was adopted in advertising media placement. In support of the primary campaign advertising medium of television, other media utilised through the campaign were: << print advertisements (also produced as posters for health settings) << radio << 24 sheet outdoor billboards << bus and tram sides << printed resources with quitting tips < < a campaign website (where all campaign electronic and print advertising materials can be downloaded). Public relations and publicity strategies were adopted as integral parts of the campaign mix, featuring high-profile launches for each new television advertisement and phase of activity. The campaign launched in June 1997 with three television advertisements (Artery, Lung and Tumour) being shown over the period June to October In the November 1997 to October 1998 campaign phase, two new advertisements were added to the advertising mix, Brain and Call for help. On World No Tobacco Day, May , a further two campaign advertisements were introduced, Eye and Tar. The Tar advertisement was produced with the intent of extending the campaign and its relevance to youth and featured a younger woman in the opening smoker moment. The media placement strategy for the campaign followed three general principles. << The first was to create a cyclical advertising flighting schedule that would incorporate natural quit dates such as World No Tobacco Day and New Year. << The second was to continue to use television as the primary advertising medium with target audience rating point (TARP) * levels of between 100 and 200 per week to maintain Quitline call levels with maximum efficiency. << The third was to avoid the December pre-christmas period when there is both substantial retail advertising clutter and a diminished interest in quitting smoking. 30 For a fuller outline of the NTC development and implementation process and media expenditure over the campaign, see Hill and Carroll. 28 * TARPs are the conventional units for buying media time on television. TARPs represent the potential weight of advertising exposure to a designated target audience in terms of the proportion of the target audience exposed to a television advertisement, and the number of times they are exposed. Section:

20 16 Tobacco in Australia: Facts and Issues Evaluating the National Tobacco Campaign Three evaluation volumes and a dedicated supplement to the Tobacco Control journal 1 have been published on the extensive research and evaluation program undertaken on the campaign. Overall the evaluation program demonstrated both the effectiveness of the campaign in achieving attitude change and promoting readiness to quit and the cost-effectiveness of the investment in the campaign. 34 Some of the studies from this significant body of work are summarised below Annual evaluation surveys The primary means of evaluating the NTC during its most active years was through a series of national cross sectional surveys undertaken in May 1997 prior to commencement of the campaign and then in November 1997, 1998, 1999 and The surveys, and other research and evaluation studies for the campaign, were managed by the NTC Research and Evaluation Committee The surveys were commissioned by the Commonwealth Department of Health and Aged Care and conducted by Roy Morgan Research. The challenges of evaluating a national campaign like the NTC, where the whole population is potentially exposed to campaign activity, are significant. 35 Firstly, there is no unexposed group which could be used as a comparison. Secondly, it is difficult to attribute any change in smoking prevalence to a campaign effect, since the change could be a result of some other influence. Thirdly, observing no change in smoking prevalence may not necessarily represent no effect, since the campaign may have resulted in counteracting an upward trend that may have otherwise occurred in the absence of the campaign. 35 However, rather than simply focusing on changes in smoking prevalence as an outcome indicator, there are more proximal indicators that are useful to measure in order to assess whether a campaign is working in line with its designated communication objectives. This approach draws from information processing models of communication and persuasion. 36 The premises underlying the analysis of findings from NTC evaluation surveys were as follows. In assessing whether a campaign is likely to have directly influenced smoking prevalence, the following need to have occurred: << smokers need to have seen the campaign communication and remembered it << they must have appraised the information presented in the campaign as believable and personally relevant << this must have made them think about quitting < < there must have been changes in health beliefs and attitudes. 37 The evaluation studies needed to assess whether the first three of these conditions could be linked to the changes in health beliefs and attitudes which in turn could be plausibly linked to changes observed in smoking prevalence. Results from these more proximal indicators were reported from various stages of the campaign. 35,37 39 The full methodology of these surveys is described by Wakefield and colleagues. 37 Overall, the results of campaign surveys indicated that the campaign advertising was seen and recalled by the majority of the target audience, with levels of prompted recognition of campaign advertising at approximately 90%. Levels of unprompted Section:

21 Chapter 14: Social marketing and public 17 recall reflected the levels of television advertising in the period prior to the surveys. Approximately half of smokers who recognised the campaign advertising reported that this had made them more likely to quit. In the initial follow-up survey in November 1997, 60% of recent quitters reported that the campaign advertising had made them more likely to stay quit, although this effect was observed to diminish over the survey series to a level of 44% by Over the campaign there were significant increases in the proportion of smokers and recent quitters who reported something new about the effects of cigarette smoking, particularly in the initial campaign stages. Significant increases were observed in beliefs about smoking blocking up arteries with fatty deposits and smoking causing damage to the genes in lung cells, associated with the introduction of these advertisements in the first phase of the campaign. While there was no change observed in beliefs about smoking decay in the lungs, the initial level of agreement was already at approximately 95%. With the introduction of the Brain advertisement in 1998 there was an increase in reported new learning about strokes or clots in the brain. Similarly in 2000 new learning about the effects of smoking on loss of eyesight was associated with the introduction of the Eye advertisement. As outlined in Chapter 1 there was a significant reduction in smoking prevalence among Australian adults observed over the period of the NTC. 40 Campaign surveys indicated a decline from 23.5% in May 1997 to 20.4% in November For the reasons outlined above, it is difficult to identify how much of this decline in smoking prevalence can be specifically attributed to the NTC, 25 as opposed to other tobacco control policy initiatives such as increased taxes on cigarettes 41 or other trends. Nevertheless, campaign survey findings regarding advertising recall, recognition, appraisal, new learning and changes in health beliefs and attitudes are consistent with predicting these changes in smoking prevalence Continuous tracking in the National Tobacco Campaign In addition to the annual cross sectional surveys conducted each November from , a continuous tracking study was initiated at the commencement of the campaign to assess cut-through of campaign advertising, response to this advertising and to consider levels of response generated at different levels of campaign advertising weight. 30 Two further phases of continuous tracking were carried out over later campaign phases. 42,43 These studies involved telephone interviews with random cross sectional samples of smokers or recent quitters aged years, carried out on a weekly basis over a campaign phase. The main purpose of the continuous tracking studies was to explore the relationship between campaign advertising and output measures such as awareness and response to the advertising and indicators of interest in quitting. The phases of the NTC were evaluated variously in Sydney, Melbourne and Adelaide using continuous tracking. 30,42 44 A full outline of the methodology employed in the continuous tracking studies is described by Donovan and colleagues. 30 Unprompted recall and cued recall of anti-smoking advertising, validated recall of campaign advertising (correctly describing one or more campaign advertisements) and correct recognition of campaign advertisements were all found to be related to advertising weight (measured in TARPs). Further, the studies found that the greater the advertising weight for a particular advertisement or the campaign as a whole, the greater the levels of recall and recognition. 44 However, they also found that cut-through for a particular advertisement was clearly mediated by its message and creative execution. For instance, the health effects advertisements were found to have greater Section:

22 18 Tobacco in Australia: Facts and Issues impact on smokers in general than the Call for help Quitline modeling advertisement, whereas Call for help probably acts directly on those smokers who are ready to take action toward quitting. In terms of executional style, the three advertisements with a clear figure ground creative format, Artery, Brain and Tar achieved the highest cut-through per TARP of the health effects advertisements. To learn more about some of these interactions for future campaign planning, Donovan and colleagues 44 recommended systematically varying TARP levels, flighting schedules and advertisement type during continuous tracking studies and to explore the continuing effects of advertisements once they are no longer broadcast Generating calls to the Quitline Another very useful means of monitoring response to the NTC was through callers to the national Quitline. The establishment of this single national Quitline service was a major achievement for the NTC and reflected the collaboration and coordination of Quit organisations throughout Australia. A Quitline service is a valuable component of a national tobacco control program to assist smokers to access information and advice about quitting 45 and this national Quitline number was promoted through all NTC TARPS 650 World No Tobacco Day May Artery and Lung launched 12 June Brain and Call for help launched 22 April CALLS 10, Tumour launched 16 July CALLS New Year PR activity May-97 1-Jun 15-Jun 29-Jun 13-Jul 27-Jul 10-Aug 24-Aug 7-Sep 21-Sep 5-Oct 19-Oct 2-Nov 16-Nov 30-Nov 14-Dec 28-Dec 11-Jan Jan 8-Feb 22-Feb 8-Mar 22-Mar 5-Apr 19-Apr 3-May 17-May 31-May 14-Jun 28-Jun TARPS 12-Jul 26-Jul 9-Aug 23-Aug 6-Sep 20-Sep 4-Oct 18-Oct 1-Nov 15-Nov 29-Nov 13-Dec 27-Dec-98 0 Figure 14.1 National TARPs versus Quitline call response (18 May January 1999). Source: Tan and Hassard 47 p136 advertising, including on the end-frame of campaign television advertisements. From the onset of campaign advertising, a causal relationship between campaign television advertising and Quitline calls was apparent 46,47 as shown in Figure Section:

23 Chapter 14: Social marketing and public 19 Regression analyses of campaign advertising data and calls to the Quitline demonstrated a clear linear relationship between the weight of adverting (TARPs) and numbers of calls to the Quitline. 45 The introduction of the Call for help advertisement modeling a smoker calling the Quitline resulted in an even greater rate of calls to the Quitline generated by the advertising. In a separate study, it was found that the very graphic Eye advertisement was more efficient than the Tar advertisement in generating calls to the Quitline, and that combining either of these health effect advertisements with Call for help tended to increase the efficiency of generating Quitline calls. 48 This study also examined the relative efficiency of placing NTC advertisements in different types of television programs. It found that placing advertisements in lower involvement programs provided greater efficiencies in generating Quitline calls than higher involvement programs. For an outline of the program typologies used see Carroll and Rock. 48 Further studies exploring this program placement issue 49 and the nature of the relationship between advertising and call generation 50 have been recently undertaken by Quit Victoria and provide valuable information to inform campaign media planning, particularly targeting smokers at the ready for action stage Impact of the National Tobacco Campaign on youth While the NTC was an adult-targeted cessation campaign, there was also a desire and intention that this adult focus and broad exposure of the campaign advertising would be effective in reducing the appeal of smoking to children and adolescents. 51 An NTC study 52 utilised two cross sectional surveys of adolescents, one a national survey and the second a large sample Victorian school student survey, to examine their awareness of the campaign and response to it. The findings indicated high levels of awareness of campaign advertising amongst youth and perceived relevance of this advertising for them, as well as agreement with campaign related beliefs about the effects of smoking. Nine out of 10 non-smokers reported that the campaign had made it easier for them to remain a non-smoker and about two-thirds of the 49 smokers in the national evaluation survey reported that the campaign had made it more likely they would quit. As White and colleagues 52 note, there were no baseline surveys or control groups to compare these findings with, so it is not possible to conclude from these studies that the campaign had directly influenced adolescent smoking intentions or behaviour, in the context of many other potential influences. Nevertheless the studies are consistent with other surveys reporting young people s positive response to the campaign 53,54 and lend strong support to the proposition that adult-targeted campaigns using graphic imagery such as the NTC can capture the attention of young people and be perceived as personally relevant for them. For example, Wakefield and colleagues 53 showed that the adult cessation focus of the NTC was as likely to make teenagers in South Australia feel they should not smoke as was a teenager-targeted campaign which had tested favourably with this youth audience Impact of the National Tobacco Campaign across sociodemographic groups The media buy for the NTC was designed to maximise exposure of campaign advertising, with a lower socioeconomic bias, reflecting a similar bias in the prevalence Section: