14.3 Tobacco control campaigns in Australia: experience and effectiveness

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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.

14.3.1 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 education campaigns 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 non-smoking message among certain target groups. The Quit message was also promoted through special community events such as No-smoking days or education campaigns 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.

14.3.2 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.

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).16

14.3.3 Effectiveness of early state-based anti-smoking education campaigns

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 education campaigns 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 education campaigns 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 15.19

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 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.

14.3.4 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.

14.3.5 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 1995.

14.3.6 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 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 2001.25

The NTC was a cessation campaign aimed at 18–40 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.

14.3.6.1 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

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.

14.3.6.2 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.
• 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.

14.3.6.3 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 www.quitnow.info.au (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 1997. 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 31 2000, 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)[1] 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

14.3.7 Evaluating the National Tobacco Campaign

Three evaluation volumes31–33 and a dedicated supplement to the Tobacco Control journal1 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.

14.3.7.1 Annual evaluation surveys

The primary means of evaluating the NTC during its most active years 1997–2000 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 2000. The surveys, and other research and evaluation studies for the campaign, were managed by the NTC Research and Evaluation Committee.31–33 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 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 2000.

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 2000.39 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 cigarettes41 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.35

14.3.7.2 Continuous tracking in the National Tobacco Campaign

In addition to the annual cross sectional surveys conducted each November from 1997–2000, 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 18–40 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 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 colleagues44 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.

14.3.7.3 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 quitting45 and this national Quitline number was promoted through all NTC 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 apparent46,47 as shown in Figure 14.1.

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 issue49 and the nature of the relationship between advertising and call generation50 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.

14.3.7.4 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 study52 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 colleagues52 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 campaign53,54 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 colleagues53 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.

14.3.7.5 Impact of the National Tobacco Campaign across socio-demographic 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 of smoking in the Australian population.55 An examination of the demographic trends in smoking over the course of the NTC was undertaken to assess whether the campaign was achieving a similar impact across socio-demographic groups.56 The study examined data from the baseline and annual NTC evaluation surveys from May 1997 to November 2000. Age was categorised into three age groups: 18–34 years, 35–60 years and over 60 years. Occupation was categorised into professional, white collar and blue collar groupings. Calculating odds ratios between age groups and occupational categories revealed that within the downward trend observed in smoking prevalence over the period of the NTC the socio-demographic differences observed between age and occupational categories at baseline remained stable. This indicated that the NTC appeared to achieve an equal impact across socio-demographic groups, thereby achieving greater results in the groups with highest prevalence at baseline, younger smokers and those in the blue collar occupation category.

14.3.7.6 Reaching Australians from culturally and linguistically diverse backgrounds.

As a component of the NTC, a communication strategy targeting Australians from culturally and linguistically diverse backgrounds was developed in eight languages other than English and launched in February 1998.28 Strategy development was informed by the higher smoking prevalence among some ethnic groups, their varying levels of English language proficiency, the length of time since migration and their use of mainstream and ethnic language media. Based on these data the language groups chosen for the campaign were: Arabic, Chinese, Greek, Italian, Korean, Spanish, Turkish and Vietnamese, at the time representing approximately 1.4 million people and 57.5% of the total Australian population who spoke a language other than English at home.57 Consistent with the mainstream campaign, this strategy targeted smokers and recent quitters aged 18–40 years.

Qualitative research undertaken in developing the strategy indicated that the strong imagery of the mainstream campaign advertising was well recognised in these communities. With some modifications to the mainstream advertising guided by this research, the strategy comprised:

• ethnic radio advertising
• ethnic press advertising
• publicity and public relations activities
• workplace initiatives
• service provider strategies with doctors and other health workers in key geographical locations
• print resources for consumers, health workers and the media
• a dedicated page on the NTC website.

An evaluation study carried out on response to this strategy58 found that many smokers in these communities reported discussing smoking in the home and being influenced by family members to quit during the campaign. A fuller outline of the campaign strategy and evaluation is described by Carroll and colleagues58, including an examination of the differences between communities in their media consumption and response.

14.3.7.7 Impact on Indigenous communities

A qualitative research study conducted with Indigenous communities in Victoria in the initial years of the NTC found high levels of awareness of the campaign television advertisements and message take-out similar to the broader population evaluation studies.59 Further, the health issues conveyed through the campaign television advertisements were generally understood, with young people in particular frequently describing the health effects of smoking in the language and imagery of these advertisements. However smoking was not perceived as a major health concern and quitting intention was observed to be lower than in the general population.

A number of characteristics of Indigenous communities appeared to be diminishing the potential campaign impact. The high prevalence of smoking within the communities results in very common modelling of smoking behaviours by parents, grandparents and community elders, as well as community health and resource workers. In addition, the acceptance of sharing goods within the culture was believed to contribute to this high smoking prevalence and to impede quitting. Cigarettes were seen to be always available and the practice of sharing them around was reported to be part of the ritual of community and friendship. The important influence of these cultural factors have also been emphasised in other research, including the normalisation of tobacco use and its role in reinforcing family relationships and friendships, and adding to the difficulty of quitting and maintaining cessation.60

While the teenage and adult participants in the study recognised the contribution of mass media smoking and health campaigns, they also provided suggestions for future specific indigenous strategies. The key principles underpinning these suggested strategies were:

• the need for locally based programs with local content
• the involvement of elders and significant community members in their design and delivery
• the need for a broad community focus.59

In 2003 the Australian Government Department of Health and Ageing funded the establishment of the Centre for Excellence in Indigenous Tobacco Control, based within the Onemda VicHealth Koori Health Unit at the University of Melbourne.61 This initiative represents a very positive step forward in building capacity for Indigenous tobacco control programs in Australia.

14.3.7.8 International use of the National Tobacco Campaign materials

The National Tobacco Campaign has been Australia's greatest export in tobacco control materials. The NTC advertisements have been used in numerous countries around the world including Cambodia, Canada, Iceland, Mongolia, New Zealand, Norway, Poland, Singapore, the United States (various states) and Vietnam. Some jurisdictions have re-recorded the voice-over of the television advertisements with local voices and modified the end-frame in line with the local sponsor while others have filmed their own culturally relevant 'smoker moment' to open the advertisement. The structure of the advertisement allows for relatively inexpensive modifications to increase local relevance while maintaining the graphic depiction of the universally human internal health consequences of smoking.

14.3.7.9 Cost and cost-effectiveness of the National Tobacco Campaign

The NTC was the largest tobacco control campaign Australia had ever mounted. An important adjunct to the NTC campaign evaluation program was a cost-effectiveness study62 based on the initial phase of the campaign. The NTC was not operating as a stand alone initiative separate from other tobacco control programs being undertaken by states and territories. Rather, it represented a significant additional contribution from the Federal Government to augment and galvanise the existing expertise and experience of the range of government and non-government organisations working toward tobacco control objectives. To assess the return on this investment it was necessary to undertake the painstaking process of estimating the total expenditure by these organisations to develop, implement, support and evaluate the NTC, against which the achievements of the campaign could be measured.

The study estimated this total investment in the first six month phase of the NTC to be approximately $9 million, with $7.1 million being contributed by the Federal Government and $1.85 million by the state and territory Quit campaigns and partner organisations. Using the initial baseline survey (May 1997) and the first evaluation survey (November 1997), estimates were made regarding the reduction in number of smokers that could be attributed to the NTC. From this calculation it was estimated that in its first six months of operation the NTC achieved a reduction of 190,000 fewer smokers, preventing 920 premature deaths, achieving 3338 additional years of life prior to age 75 years and yielding cost offsets of approximately $24.2 million. This represented the campaign paying for itself more than twice over and offered positive support for viewing the investment in tobacco control campaigns as sound in delivering economic returns as well as providing health gains. An outline of the study's methodology is provided by Carter and Scollo.62

Of the $4.5 million spent on the NTC advertising media in the initial phase of campaign activity (June–October 1997), the Federal Government's contribution represented 75% of this total media spend. In subsequent phases of the campaign the relative contributions to NTC activity of the Federal Government and state and territory Quit organisations and partners reversed. By 2000 the federal contribution was estimated at $2.18 million compared with $3.29 million from the state and territory Quit organisations.39

14.3.8 Further state and territory-based campaigns

The significant cooperation between state and territory Quit organisations has continued since the major collaboration of the National Tobacco Campaign. Since the launch of the NTC, several new campaigns have also been created, focusing on a range of themes and primarily aimed at adults, with a good deal of sharing of these advertisements between campaign organisations. Details of campaigns, including links to campaign advertising materials, are available on the websites of Quit organisations and other government and non-government organisations listed in Attachment 14.1.

Themes of these campaigns have included:

• serious health outcomes of smoking, focusing on
• cancer
• emphysema
• how the serious health outcomes for smokers affects their relationship with loved ones—targeting parents
• incapacitation from smoking-related diseases
• personal testimonials
• the toxic contents of cigarette smoke
• secondhand smoke
• addiction
• promotion of quitting and quit services
• industry manipulation
• financial costs of smoking
• fashion.

In addition, the youth targeted Smarter than Smoking program undertaken by the Heart Foundation WA produced a number of television advertisements with the following themes:

• short term health effects of smoking
• smoking image
• industry manipulation.

14.3.9 Current national and state and territory campaign activity

14.3.9.1 Australian Competition and Consumer Commission

During 2006 there was a major increase in the level of tobacco campaign activity at the national level and among the state Quit organisations. In December 2005, the Australian Competition and Consumer Commission (ACCC) launched a $9 million campaign to advise smokers that 'light' and 'mild' cigarettes are not a healthier option than smoking other cigarettes. The campaign was funded by Phillip Morris Limited, British American Tobacco Australia Limited and Imperial Tobacco Australia Limited as part of a court-enforceable undertaking obtained by the ACCC after finding that these tobacco companies had represented that cigarettes marketed and packaged as 'light', 'mild' or similar descriptors had certain health benefits in comparison to those marketed as regular or higher yield cigarettes.63

This campaign featured prominent television and outdoor advertising over the early months of 2006.

14.3.9.2 Introduction of graphic health warnings

In mid-February 2006 the Australian Government launched the first stage of its new National Tobacco Campaign to address youth smoking rates, with a funding commitment of $25 million over four years.64 This initial stage focussed public attention on the release of a new system of graphic health warnings on tobacco product packaging. From 1 March 2006 tobacco products manufactured or imported into Australia were required to be printed with the new health warnings images. See Chapter 12 for further information about these new graphic health warnings on tobacco products.65 This campaign was staged from February to April 2006 including the national broadcast of a television advertisement featuring the mouth and throat cancer graphic health warning.

14.3.9.3 Graphic health warnings campaign collaboration

A major collaborative effort between state and territory Quit organisations, spearheaded by Quit Victoria and the NSW Cancer Institute was also in development from late 2005. This initiative adopted an innovative cost-sharing model for development and production of campaign advertisements and was designed to build upon the impact of the initial NTC and its successful use of hard-hitting graphic health effects advertisements. The initiative sought to dramatically capitalise on the advent of the graphic health warnings by creating a series of television and outdoor advertisements focusing on a number of specific tobacco-related health conditions. Responding to consumer insights66, the most salient health effects were chosen as the targets for television advertisements. As was the case in the Australian Government Health Warnings campaign, this is an excellent example of how social marketing activity and policy initiatives can be mutually reinforcing in their effects. The graphic health warnings serve to remind smokers of the health consequences of smoking every time they have a cigarette and exposure to the health warnings advertisements serves to increase the salience of these consequences. Evaluation studies showed high levels of awareness and engagement with these advertisements, and prompting of significant discussion and quitting attempts.67

The first two advertisements created very graphic depictions of a woman with mouth cancer, and of surgery to remove a man's gangrenous leg, and were launched around World No Tobacco Day at the end of May 2006. Three further advertisements were launched around World No Tobacco Day 2007 and focused on a smoker's choice of packets with different health warnings, the graphic depiction of an operation to remove plaque from a woman's carotid artery and a chilling portrayal of a man's thoughts about the consequences of his smoking after experiencing a stroke. These powerful advertisements have been broadcast by a number of Quit organisations as components of their state-based tobacco control programs, with heaviest exposure being bought in the most populous states of New South Wales and Victoria. These advertisements can be viewed on Quit campaign websites at Attachment 14.1 .

14.3.9.4 The National Tobacco Youth Campaign

At the national level, the second stage of the Australian Government's new National Tobacco Campaign targeting smoking rates among young adults and teenagers was launched at the end of December 2006 and the initial phase continued until March 2007. The new national campaign featuring television, cinema, magazines, radio and outdoor advertising graphically depicted the range of toxic chemicals in cigarette smoke, as well as linking to the graphic health warnings.64 Campaign advertisements can be viewed at the www.quitnow.info.au website.