14.2 The role of social marketing and public education campaigns within a comprehensive tobacco control program

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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

14.2.1 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 2005.8 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 2004.9

14.2.2 The National Tobacco Strategy 2004–2009

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 2004–2009 (NTS 2004–2009) 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.

The promotion of Quit and Smokefree messages is a central component of the NTS 2004–2009. 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 2004–2009 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.

14.2.3 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 counter-marketing 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.