Australia's National Tobacco Campaign Evaluation report ... - CiteSeerX

Chapter One BACKGROUND TO THE CAMPAIGN\ David Hill Centre for Behavioural Research in Cancer Jennifer Alcock Commonwealth Department of Health and Aged Care

A COLLABORATIVE APPROACH In Australia anti-tobacco campaigns are developed and implemented within each state and territory as part of a comprehensive tobacco control program within each jurisdiction. In addition to this the federal government and a range of nongovernment organisations also undertake campaign activity. Although a cooperative approach occurs between these agencies, until 1996 the potential for a sustained and coordinated national program of activity had not been fully realised. In 1996, the Federal Minister for Health Dr Michael Wooldridge recognised the potential gains that could be derived from a pooling of knowledge and resources for a collaborative national anti-tobacco campaign. He committed $7m over two financial years to a national campaign and established the Ministerial Tobacco Advisory Group (MTAG). The overall charter of MTAG was to provide advice on a range of tobacco control issues within the context of the National Drug Strategy. The initial task was to develop a national campaign strategy and facilitate the involvement of existing state-based Quit programs and other key partner organisations. MTAG included in its membership experts in research, campaigns and policy, representing government and non-government organisations. Three national campaign working groups with wider membership were formed in association with MTAG. These groups were responsible for research and evaluation, implementation support and communication, and coordination of services for smokers such as the national Quitline telephone service.

DEVELOPMENT OF THE CAMPAIGN STRATEGY MTAG’s strategic advice to the Minister was to target smokers aged 18–40 in a cessation-focused campaign. For the federal government this represented a departure from a recent history of prevention-oriented campaigns. The cessationfirst strategy was subsequently strongly endorsed in Richard Peto’s opening plenary presentation of the 1997 10th World Conference on Tobacco and Health in Beijing, China. Despite this, MTAG recognised the need to tackle prevention of smoking among young people as part of a comprehensive tobacco control program. It was intended that the campaign would provide an opportunity to ascertain whether

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Australia’s National Tobacco Campaign

messages and strategies designed to provide highly salient reasons for quitting are also effective at discouraging uptake. Components of the campaign evaluation strategy were designed to test this proposition.

THEORY AND RESEARCH UNDERPINNING THE CREATIVE STRATEGY To inform the development of the advertising strategy, a review was undertaken of existing data consisting of 40 years of psychological research and more than a decade of largely unpublished market research reports commissioned by various Australian state Quit campaigns. More than 100 of the latter were identified, providing at little cost an invaluable perspective for determining the approach that was to be taken. In what was arguably a simplification of the stages-of-change behaviour (Prochaska, DiClemente & Norcross, 1992), the brief to the advertising agency proposed an individual model based on a ‘personal agenda’ about smoking. The model assumed the following: (a) the day-to-day actions of individuals are largely explained by the existence of an unwritten personal agenda with items on it implicitly ranked for importance/urgency and grouped along the following lines: today; tomorrow; sometime soon; if I ever get the chance; when I eventually get around to it (b) for intentions to become actions they must at least make it to today’s agenda (c) behaviours (like quitting) that require action over many days and which are difficult, require resources and reinforcements external to the individual. It is known that most smokers ‘intend’ to quit (Mullins, Morand & Borland, 1996) but clearly for most smokers, for most of the time quitting was not on today’s agenda. Hence the major communication objective in the brief to the agency was that the campaign should elevate quitting on smokers’ personal agendas. The brief also listed seven key facilitators of behaviour change. It stated that to potentiate an existing intention, an individual should be stimulated toward some or all of the following. He or she should: 1. Gain FRESH INSIGHTS on the recommended behaviour. 2. Reassess the IMPORTANCE of the behaviour. 3. Reassess the URGENCY of carrying out the behaviour. Chapter 1: Background To The Campaign

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4. Reassess the PERSONAL RELEVANCE of the behaviour. 5. Have confidence in their own ABILITY to carry out the behaviour (self-efficacy). 6. REMEMBER or be reminded to do it. 7. For long-term change, GAIN more than is lost by carrying out the behaviour (response efficacy). Further, taking account of results of the review of the qualitative research undertaken, the advertising brief indicated that the campaign should: (a) show the damage of smoking in new insightful ways that are both enlightening (“Now I see what the doctors are on about.”) and chilling (“I can’t bear to think of that happening to me.”); and (b) develop a conditioned association between the images of bodily harm and the act of smoking such that those images are evoked when smoking is contemplated or seen. Unlike traffic accidents where people ‘know’ the mechanisms of cause and effect, knowledge of the serious consequences of smoking are known to most smokers only in the abstract. Most know the long-term effects of smoking only because they have been told third-hand what scientists have discovered about it. People have a poor ability to perceive, understand, evaluate and respond to statements about risk (Borland, 1997). The evidence about smoking is often stated in probabilistic terms, but we know this lets people distort and objectify the hazard, and self-exempt themselves with various rationalisations (Chapman, Wong & Smith, 1993). Past campaigns may, paradoxically, have been weakened by emphasising how ‘risky’ smoking is. Given that people are more likely to act on the basis of what they experience than what they are told, the communication challenge for the campaign was to translate the scientific knowledge about smoking into ‘felt’ experience, rather than cognitive appreciation of risk. Since people do not think probabilistically or behave ‘rationally’ in relation to probabilities (Fischhoff, Slovic & Lichtenstein, 1992), it may be more effective to describe the certain consequences of smoking, even if they are less dire than the uncertain ones, such as lung cancer and heart attacks. This was a core rationale behind the content of the campaign as executed. To convey the doctor’s eye view of the damage caused by smoking, it was felt important to bring the advertising agency’s creative team in direct contact

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with medical specialists in the cardio-vascular, neurology and respiratory fields. These provided important insights to the creative development team in understanding the mechanisms and manifestations of tobacco-related disease and in particular visualising ways to describe it in lay language. The process yielded dividends best exemplified by the cardiologist who finally said of atherosclerotic damage: “I suppose you could liken a severe case of artherosclerosis to squeezing brie cheese from a toothpaste tube, except it’s an artery”. And so was born the advertisement known as Artery. The medical experts who provided this inspiration were to become an integral part of the process of developing and launching the advertisements. They provided clinical research data to ensure the accuracy of the disease mechanisms depicted in the advertisements, offered relevant advice in filming the clinical aspects of advertisements and acted as media spokespeople. As well, scientists from two leading United States institutes that had recently published new findings on tobacco-related damage were involved.

THE CREATIVE STRATEGY In response to the written brief and insights from clinical experts, the advertising agency (Brown Melhuish Fishlock) produced three television commercials that created a journey into the lungs. The viewer travels with the smoke as it is inhaled down the trachea and into the lungs where it begins its deadly work. Artery, which features ‘gruel’ (fatty deposits) being squeezed by a surgeon’s gloved hand from a human aorta, was the first advertisement developed. The second, Lung, depicts emphysematous damage and the third, Tumour, outlined the recent discovery of a mechanism by which smoking damages the p53 tumour suppressor gene in lung tissue (Denissenko et al, 1996). These advertisements (together with radio advertisements) are on the CD ROM inside the back cover of this report. Ten months later a further health effects advertisement, Brain, was developed. This utilised the same creative approach as the initial three, outlining the mechanism of smoking-related stroke. The impact of this later phase of the campaign will be reported in Volume 2. Each advertisement brought smokers some ‘new news’ about smoking, but more than this the message was framed in such a way as to maximise the effect on Chapter 1: Background To The Campaign

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behaviour. First, the emphasis was on relatively certain rather than less probable effects. So the campaign slogan was ‘Every cigarette is doing you damage’ with the advertisements focusing upon ongoing damage, that is, the things that happen as you smoke now, rather than long-delayed clinical outcomes. Realism and relevance to the 18–40 year old target group was enhanced by modelling the Artery advertisement on the actual pathology described for a 32 year old smoker recently reported in the medical literature. Second, since beliefs about consequences of actions are only able to determine behaviour if they are salient (top of mind) at the time the behavioural decisions are made (Fishbein & Ajzen, 1975; Shavitt & Brock, 1994), a device was needed to bring these consequences to the smokers mind at the time smoking was contemplated. A scene in each of the advertisements immediately follows a brief typical moment in which the smoker lights up and inhales, ignorant it seems, of the damage being done. Great care was taken in crafting these ‘smoker moments’ to maximise their ability to engage the viewer/smoker and convey empathy for the smoker’s situation. Pre-testing of this component showed that smokers are mildly self-deprecating in relation to their smoking and respond empathically to depictions of awkward ‘desperate’ smoking situations, such as a smoker reduced to lighting a cigarette from the flame of a gas stove. Extensive preliminary testing of the Artery advertisement in particular showed that the pictures produced a strong visceral “yuk!” response, hence qualifying it as ‘fear appeal’. Fear or threat appeals have great potential for stimulating behavioural change, if used correctly (Sutton, 1992). Fear is the negatively valenced emotion that may be felt by a person exposed to a threat appeal. It may be dealt with adaptively by a behavioural response that removes the reason to be fearful, such as quitting smoking, or maladaptively by a psychological response meant to dispose of the fear, for example denying the truth or personal relevance of the message. To maximise the chance of the intended behavioural response, each advertisement carried the number of the Quitline telephone service. Smokers who were stimulated to quit, but wanted assistance, could contact the Quitline (and did in large numbers).

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CAMPAIGN ADVERTISING COMPONENTS The image of the aorta depicted in the Artery advertisement was to become the primary image utilised in other components of the advertising strategy such as 24 sheet outdoor advertising, bus and tram sides, the campaign web site (www.quitnow.info.au) and z-card fold out information sheets containing quitting tips. Print advertisements (also produced as A3 posters) were developed utilising the images from Artery, Lung, and Tumour. These were distributed to general practitioners and pharmacists and extensively through state and territory Quit campaign networks. Examples of these campaign promotional materials are in Appendix A at the end of this report. In addition to the television advertisements described earlier, nine radio advertisements were developed for airing in the first six months of the campaign. These four health effects advertisements, Artery, Lung, Tumour and See the damage, reinforced the information depicted in the television advertisements. The remaining five radio advertisements; Cravings, Coffee break, Money, Recovery rate and Call Quit first provided supportive messages about the quitting process such as dealing with cravings and avoiding triggers, and outlined the benefits of quitting such as financial savings, and reversal of disease processes. The implementation timetable in Table 1.1 describes the timing of campaign and evaluation activity. It should be noted that most of the evaluation chapters in this volume refer to work carried out in the six month period from June to December 1997. TABLE 1.1

IMPLEMENTATION AND EVALUATION MILESTONES

May 1997

Evaluation survey (benchmark)

May – December 1997

Continuous tracking evaluation (Phase 1)

31 May 1997

World No Tobacco Day events,publicity and radio promotion*

12 June 1997

Campaign launch event

Commencement of advertising schedule (Artery and Lung) 16 July 1997

Launching event Tumour television advertisement

November 1997

End of advertising schedule

November – December 1997

Evaluation survey (follow-up)

*This activity may have affected baseline measures. Chapter 1: Background To The Campaign

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MEDIA STRATEGY Within the target group of 18–40 year old smokers, a lower socioeconomic bias was introduced into the choice of media placement to reflect the social class gradient of smoking in Australia. Television was selected as the primary medium. The level of exposure achieved in the first six months of the campaign by placement of the advertising on television, radio, print, outdoor and supermarket trolleys served to achieve the objective of an important component of the behaviour change model, that is, in this case remembering or being reminded to quit. The campaign was launched in June 1997 with a high profile event and commencement of the advertising schedule for Artery and Lung. Four weeks of relatively high weight advertising activity followed. The Tumour advertisement was also launched with a high profile event. The airing of the advertisements during the news and current affairs programs following these launch events considerably extended the reach of the paid advertising. After the initial weeks of high level advertising, a one week break preceded the launch of Tumour which was placed for three weeks at medium weight. A break of three weeks in August was followed by a week-on/week-off regimen of medium to low level maintenance activity for three months ending in November 1998. After the first six months, over 80% of 18–40 year old smokers reported having seen the television advertising. An outline of the advertising weight and schedules appears in Chapter 3 (Appendix 3A).

CAPACITY BUILDING OF CESSATION SERVICES In recognition that a successful national advertising campaign would create demand for cessation support and information, building the capacity of the Quitline service throughout Australia was an integral part of the campaign strategy. The Quitline telephone service is administered and funded separately by each state and territory. Prior to the National Tobacco Campaign the level of service provided by each jurisdiction varied considerably. Funding from the Commonwealth Department of Health and Family Services enabled the Services to Smokers Committee to facilitate considerable upgrading of the service. This involved funding to support upgrading of equipment, use of a telecommunications service in large states (so that a large number of calls could be Page 16


answered simultaneously), training of staff and national monitoring of call numbers and response rates. Simultaneously, a quality improvement program resulted in a greater consistency of service and measures to ensure service compatibility with research evidence. Reported in Chapter 3 is the follow-up survey of a sample of callers undertaken twelve months after calling the Quitline.

CAMPAIGN INFRASTRUCTURE AND FUNDING The first phase of the campaign was funded and coordinated by the then Commonwealth Department of Health and Family Services under the direction and expert advice of MTAG. State and territory governments and Quit campaigns contributed resources and funding to a range of support initiatives, absorbed many of the costs associated with an increased demand on cessation services, and many provided additional funding to enhance the weight of Commonwealth advertising activity. A range of organisations contributed to the coordination of components of the strategy, such as data analysis and reporting by the Centre for Behavioural Research in Cancer, partnership development by Quit Victoria, and services to smokers by the South Australian Smoking and Health Project and Quit Victoria. At the time of printing the campaign will have been in operation for almost two years. During this time some $11m of Commonwealth funding has been devoted to it. The level of funding and ‘in kind’ support provided by state and territory Quit campaigns and other partner organisations is likely to have, at least, equalled this amount. An analysis of the funding contributions of partner organisations will be included in the next evaluation volume.

PARTNERSHIPS AND STRATEGIC ALLIANCES The generic branding ‘National Tobacco Campaign – A federal, state, and territory health initiative’ encouraged broad ownership of campaign materials and facilitated the involvement of a range of partner organisations. A partnership strategy was developed in recognition that strategic alliances would reinforce the credibility of the campaign, extend the reach of its messages, and provide wider access to the target group. Although a broad range of organisations and industries were identified within the strategy, health sector organisations were the focus of activity in the initial

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phase. The participation of representatives from many peak medical and health organisations at campaign launch events provided a platform to profile their support and endorsement of the campaign. Representatives of these organisations attended briefing sessions prior to the campaign launches and acted as media spokespeople in their various areas of specialty. For the launch of the Tumour advertisement, The Australian Cancer Society arranged the attendance of Dr John Kovach from the City of Hope National Medical Centre, California, where research into genes conclusively demonstrated the causal link between smoking and cancer through damage to the p53 gene. The National Heart Foundation generated substantial publicity in support for the launch of the Artery advertisement and organised for a cardiovascular expert in each state and territory to be available for local media interviews. The extensive ‘expert’ involvement in launch events reinforced the credibility of the campaign amongst the media. A general practitioner working group was established, consisting of representatives from the Australian Medical Association, the Royal Australian College of General Practitioners, and Divisions of General Practice. The group identified the need to ensure that general practitioners were aware of and supportive of the campaign prior to the launch of advertising. This was achieved via two national mailouts to general practitioners. These contained information to support the campaign such as fact sheets outlining the scientific basis of the advertisements, motivational materials outlining the efficacy of general practitioners in smoking cessation, and fact sheets providing advice on helping patients with quitting. The materials were distributed with a letter co-signed by the Minister for Health and Family Services and working group representatives. Increased marketing and availability of nicotine replacement therapy (NRT) following changes in the scheduling of these products in September 1997, increased opportunities for pharmacists to be involved in cessation support. A pharmacy working group with representation from a range of peak pharmacy organisations was formed in parallel to the general practitioner group. Their work included the development of a pharmacist’s kit for the launch of the campaign and production of publicity materials targeted at pharmaceutical industry publications. In recognition of the need for cessation services to be providing current evidence-based information on NRT, Professor Chris Silagy conducted a metaPage 18


analysis of published literature on the topic. This resulted in the publication of a literature review on the efficacy of NRT in smoking cessation. The findings were disseminated through a series of national workshops organised by state and territory Quit campaigns from June to November 1997. A conclusion of the review, that NRT roughly doubled the chance of quitting for a heavily addicted smoker, was extensively disseminated by the pharmaceutical industry within NRT product advertising. The influence of pharmaceutical industry marketing of NRT products on campaign outcomes will be reported in the next volume of this series.

NON-ENGLISH SPEAKING BACKGROUND STRATEGY A communication strategy specifically targeting people from non-English speaking backgrounds (NESB) was launched in February 1998. This strategy was developed in recognition of the particular characteristics of smoking prevalence among different ethnic groups, as well as their varying levels of English language proficiency, length of time since migration and their use of mainstream and ethnic communication media. The target audience for the strategy was male and female smokers and recent quitters aged 18–40. Demographic and smoking prevalence data amongst people from culturally and linguistically diverse backgrounds informed the language groups to be targeted. These were; Italian, Greek, Arabic, Vietnamese, Chinese (Mandarin and Cantonese), Spanish, Korean, and Turkish. Based on language spoken at home these groups number approximately 1.4 million people (Australian Bureau of Statistics, 1996). The formative stage of the strategy involved obtaining information on the social and cultural aspects of smoking in each community. Qualitative research conducted with selected language groups suggested that the main campaign was widely recognised because of the bold imagery and strong visual narrative of the television advertisements. The components of the strategy were ethnic radio and press advertising; publicity; initiatives with workplaces; general practitioners and bilingual health and medical community members. With some refinement, the mainstream campaign materials provided a strong platform on which to build communications with non-English speaking Chapter 1: Background To The Campaign

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audiences. The Tumour image featured on multilingual print materials is depicted in Appendix A at the end of this report. The advertising schedule provided Australia-wide coverage. Other strategies were focused on Sydney and Melbourne where the largest numbers of the target group reside. The Quit campaigns in Victoria and NSW, drawing on resources from existing non-English speaking initiatives, provided considerable support in the development and implementation of the strategy. A more detailed description of the intervention appears in Chapter 5.

INTERNATIONAL RECOGNITION The television advertising has been described repeatedly as ‘hard hitting’, ‘gory’ and ‘something smokers will see once and never forget’. It has received critical acclaim within the advertising industry, winning awards at the Kinsale International Advertising Festival of Ireland in 1998 and the Australian Writers and Art Directors Awards in 1999. The campaign advertising has since been used by the USA (Massachusetts), New Zealand, Canada (British Columbia) and Singapore. The tag line ‘Every cigarette is doing you damage’ was used in a recent campaign in the United Kingdom. Stimulated by the success of the Quitline as an integral component of the campaign, technical advice has been provided to countries that have set up, or are considering development of a Quitline service based on the Australian model.

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References Australian Bureau of Statistics. Census of Population and Housing: CDATA96, Australia. Cat. No. 2019.0.30.001. Canberra: Australian Bureau of Statistics, 1996. Borland R. What do people’s estimates of smoking related risk mean? Psychology and Health 1997; 12: 513–21. Chapman S, Wong WL, Smith W. Self-exempting beliefs about smoking and health: smoker and ex-smoker differences in a low socio-economic sample. American Journal of Public Health 1993; 83: 215–9. Fischhoff B, Slovic P, Lichtenstein S. Lay foibles and expert fables in judgements about risk. The American Statistician 1992; 36(3): 240–55. Denissenko M, Pao A, Tang M, Pfeifer G. Preferential formation of benzo[a]pyrene adducts at lung cancer mutational hotspots in p53. Science 1996; 274: 430–2. Fishbein M, Ajzen I. Belief, Attitude, Intention and Behaviour. Reading, Massachusetts: AddisonWesley publishing company, 1975. Sutton SR. Shock tactics and the myth of the inverted U. British Journal of Addiction 1992; 87: 517–19. Shavitt S, Brock TC. Persuasion: Psychological Insights and Perspectives. Boston: Allyn and Bacon, 1994. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to the addictive behaviours. American Psychologist 1992; 47: 1102–1114. Mullins R, Morand M, Borland R. Key findings of the 1994 and 1995 household surveys. In: Mullins R (ed). Quit Evaluation Studies No.8 1994-1995. Victorian Smoking and Health Program, 1996.

Chapter 1: Background To The Campaign

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