14.6 Developing, implementing and evaluating tobacco control campaigns

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In 2003 the Centers for Disease Control and Prevention (CDC) in the United States produced an extensive manual for designing and implementing an effective tobacco counter-marketing campaign.7 The manual provides a valuable hands-on resource for tobacco control campaign planners (and is available at http://www.cdc.gov/tobacco/media_communications/countermarketing/campaign/). The qualities the CDC identifies as characteristic of an effective counter-marketing program are as follows.

An effective counter-marketing program:

• must be long term
• should be comprehensive and consist of integrated, not isolated, components
• must be integrated into the larger tobacco control program
• must be culturally competent
• should be strategic
• should be evaluated, and
• should be adequately funded.

It is further noted that programs are more likely to succeed when they:

• designate specific outcomes
• have multiple target audiences
• integrate multiple tactics
• seek multiple types of change (e.g. individual, policy)
• adopt specific messages that directly support intended changes
• adopt tailored messages and activities for different target audiences
• are guided by formative research
• have consistency in their messages and activities
• commit to the long term, and
• have a focus on changing social norms.

Consistent with evidence presented earlier, the US Centers for Disease Control and Prevention's Best Practices publication emphasises the need for counter-marketing efforts to have sufficient reach, frequency and duration of exposure to its target audiences and recommends that these campaigns should:

• use a combination of messages on prevention, cessation and protection from second-hand smoke
• target both young people and adults
• address both individual behaviours and public policies
• include community promotion, local media advocacy and event sponsorships
• maximise the number, variety and novelty of messages and production styles, and
• use non-authoritarian appeals that avoid directly telling people not to smoke.11

Building on these recommendations, and consistent with evidence discussed earlier, an analysis of most effective approaches for youth tobacco use prevention by the CDC119 provided some specific conclusions about improving the success of campaigns. In addition to being part of a broader comprehensive tobacco control program and ensuring adequate exposure to its messages over a significant period of time, other key characteristics emerging for campaign planners are:

• inclusion of advertisements with strong negative emotional appeal that generate a sense of loss, disgust or fear
• introduction of persuasive new information or new perspectives about health risks to smokers and non-smokers
• use of personal-testimony or graphic depiction formats that youth find emotionally engaging but not authoritarian
• development of a range of message strategies, advertising executions and media channels to consistently attract, engage, and influence diverse youth with varying levels of susceptibility to smoking, and
• incorporation of comprehensive formative, process and outcome evaluation plans.

14.6.1 A social marketing approach

The framework of social marketing119,120 provides a useful approach to developing comprehensive campaigns as integral parts of broad population health strategies. The social marketing framework provides an ordered sequential approach to planning and implementation,121 a model for integrating a range of plan elements,122 including policy, education and communication components, and facilitates a staged research approach.123

Through the marketing process of:

• analysis, including needs assessment
• planning
• development, testing and refining of plan elements
• implementation
• assessment of 'in -market' effectiveness and
• feedback to analysis stage,

a campaign planner can take into account consumer wants, needs, expectations, and satisfactions or dissatisfactions; formulate program objectives; utilise an integrated marketing approach and marketing mix (product, price, communication/promotion, placement/distribution); and continuously track and respond to consumer and competitive actions.121

14.6.2 Key aspects of public health social marketing

Key aspects of the social marketing framework include:124

• A consumer orientation, emphasising that the target audience for the intervention is the central focus of planning, strategy formulation and material development, rather than the content of the intervention being driven by the needs of the organisation;
• The application of exchange theory, which recognises that an individual will only be likely to take up whatever the campaign is offering or promoting if there is a perception that the costs (psychological, social, financial) are justified or exceeded by the benefits being promised;
• Assessments of internal and external environments, signifying the need for thorough definition of the problem to be addressed, an examination of external factors potentially influencing the problem being addressed and of internal structural and resource issues relevant to planning and implementation of the intervention
• Channel analysis, an examination of potential ways to reach and effectively engage and communicate with the target audiences;
• Market segmentation and audience analysis, breaking down the mass market into smaller sub-groups, or segments, according to relevant demographic, psychographic or behavioural variables to identify the most appropriate target audience for components of the intervention, and examination of relevant cognitive and behavioural characteristics of these target audience segments;
• Use of marketing research, a systematic, staged approach to undertaking various forms of qualitative and quantitative research to inform the process of market segmentation and audience analysis, environmental and channel analysis, strategy formulation, communication material development and pre-testing, and process and outcome evaluation;
• Use of the marketing mix, formulating the optimal combination of the four inter-related marketing components of 'product' (what is being promoted or offered), 'price' (the psychological, social, financial costs required to take up the offer), 'promotion' (the communication and other marketing aspects of promoting the offer) and placement (opportunities to access or practice the offer). That is, the promotional strategy should be formulated in line with the 'product', its 'price', the intended channels of distribution and the particular target audience;
• Process tracking and outcome evaluation, measuring both the effectiveness of implementation of the social marketing strategy and achievement of desired outcomes;
• A profit orientation, recognising the importance of cost-effectiveness in strategy formulation and other planning; and
• An integrated strategic planning and management system, to ensure all elements of the strategy (e.g. policy, communication, education and other initiatives) work effectively together toward the achievement of desired outcomes.

These principles, when applied in the marketing process model, provide a means of translating complex educational messages and behaviour change techniques into communication concepts and promotional strategies to effectively communicate with large segments of the population, in concert with other policy, education and other marketing initiatives.125 This marketing approach and consideration of these key aspects of population health social marketing are incorporated within the Model for Comprehensive Social Marketing Campaign Development124 which follows.

14.6.3 Model for Comprehensive Social Marketing Campaign Development

The Model for Comprehensive Social Marketing Campaign Development provides a framework within which to assess the need for, and to develop a comprehensive and integrated approach to developing marketing, communication and education components of population health strategies such as the National Tobacco Strategy and its steps are outlined below.

1.  Problem analysis

• The gathering and analysis of currently available epidemiological data and other relevant research to clearly define the nature and extent of the problem or issue to be addressed.

2.  External environment analysis

• Identification of organisations and individuals who are, or potentially will be, key stakeholders (both partners and competitors) with respect to the issue being addressed, and assessment of the degree and direction of their current activity and influence.

3.  Internal environment analysis

• Identification and quantification of the available resources (human, financial, technical) to devote toward achieving the desired outcomes, current organisational arrangements and management processes.

4.  Identification of the role for marketing, communication and education activity and audit of complementary health promotion strategies

• Definition of the role for social marketing activities and conducting an audit of other relevant health promotion strategies (including policy initiatives).

5.  Target audience identification and analysis

• Identification of the most appropriate target audiences for social marketing activity, including market segmentation by relevant demographic (e.g. age, gender, geographic location), psychographic (e.g. lifestyle, attitudinal), behavioural (e.g. smoking status) variables, or preparedness for change (stages of change) according to the nature and extent of the issue to be addressed.
• Undertaking formative research as needed with these audiences to identify key beliefs, attitudes and behaviour relevant to the issue or problem.

6.  Channel analysis

• Analysis of the range of potential options (media and non-media/lifestyle) for effectively and efficiently reaching, engaging and communicating with the designated target audience/s.

7.  Strategic planning for social marketing activity

• Undertaking a planning process entailing formulation of behavioural objectives and communication objectives (awareness, attitudes, intention) grounded in a sound theoretical framework (in information processing models and attitude and behaviour change models), incorporating lessons from previous experience.
• Formulation of the marketing mix for the intervention. That is:
• what is it that we will be offering the target audience consumer (including benefits) and how can we increase its perceived value?
• what will be the cost (psychological, social, financial) to the consumer to take up this offer and how can we lower this cost?
• where are we making the offering available and how can we maximise opportunities to facilitate the promoted behaviour in a range of settings?
• how are we going to effectively engage with the target audience and promote this offering?

8.  Formulation of the marketing plan and integrated management system

• Formulation of a comprehensive marketing plan synthesising the body of strategic information generated so far in the process and laying out a blueprint for action with clear roles and responsibilities, time lines and budgets.
• Incorporates key decisions about the range of integrated communication and other marketing strategies to be implemented within the available budget and time frame to achieve the designated objectives.
• Includes a clear articulation of how the various components of the strategy will be coordinated and managed to achieve its objectives most effectively and efficiently.

9.  Development of creative strategies and materials through formative research

• Development and critical pre-testing of communication strategies and materials with target audiences (and intermediaries) to ensure engagement and effective communication in line with the relevant strategy objective; assessing variables such as ability to attract the attention of target audience individuals, comprehensibility, identification and persuasion.
• Development of an integrated mix of social marketing strategies and activities including public relations and publicity strategies and resource materials, in conjunction with policy initiatives to facilitate and support the promoted behaviour.

10. Implementation of strategies and process monitoring

• Launch and implementation of the range of campaign strategies, tactics and activities.
• Process monitoring to assess effectiveness of the campaign implementation and initial response; assessment of awareness of the intervention (e.g. advertising recall and recognition), message recall and other relevant cognitive measures.

11. Summative evaluation of the strategy and activity

• Undertaking quantitative outcome evaluation of the campaign against baseline measures of target audience beliefs, attitudes, intentions and behaviour, constructed against the framework of objectives designated for the strategy.

12. Review and analysis of the problem and environment for subsequent phases of activity

• Integration of new information gained through the process of developing, implementing and evaluating a phase of activity into the re-analysis of the problem or issue
• This re-commences the marketing process cycle for the subsequent phase of activity.

While the specific duration of time within any individual phase of activity will vary according to the particular scope of a campaign intervention, it is clear that in the field of tobacco control, consistent interventions over many years are required to achieve long-term sustainable change.

14.6.4 Evaluating social marketing campaigns

The most common methodologies adopted in the evaluation of tobacco control campaigns tend to be repeated cross-sectional surveys of a random sample of the target population prior to a campaign commencing and then at appropriate intervals over the duration of the campaign and continuous information tracking studies where smaller samples are interviewed over the course of a phase of campaign activity. Both these approaches have been referred to earlier in the context of the National Tobacco Campaign evaluations where they were used extensively.

A more recent addition to evaluation methodologies employed in Australian campaign evaluations is natural exposure advertising research. This approach has been adopted in the state-territory graphic health warnings campaign collaboration over the last few years. In natural exposure advertising research, individuals representing the target audience for a campaign are recruited from a research agency database and asked to watch a particular program (one they regularly watch), during which the campaign advertisement is screened. They are then followed up and interviewed regarding the advertisement and their response to it.

Online methodologies are also now becoming more viable as Internet use has grown, particularly for youth audiences, and as higher speed connections are becoming more prevalent. Online surveys, using previously recruited panels of respondents, can be undertaken with large sample sizes over a shorter period of time and at lower cost than telephone or face-to-face surveys. Notwithstanding the challenges for achieving representative samples for some audience segments, this methodology also provides the valuable opportunity to actually play participants a radio or television advertisement as a prompt when measuring advertising recognition. A useful review of campaign formative research and evaluations of Australian tobacco control advertising over the period 1997–2005 was commissioned by the Cancer Council Western Australia in 2006.126 The report also contains a helpful discussion of different advertising research terminology used across studies.

14.6.5 Funding for tobacco control campaigns

As discussed earlier, smokers cycle through stages of preparedness to quit throughout a year and without reinforcement successful quitters can also lose motivation to remain ex-smokers.5 In addition, different approaches and appeals are more effective with different segments of the population. Therefore it is important that adequate comprehensive campaigns of sufficient duration are funded to maximise their impact in reducing smoking-related morbidity and mortality in Australia.

Research from the United States suggests that the more states spent on comprehensive tobacco control programs, including mass reach campaigns, the greater were the reductions in smoking prevalence observed, and that the longer states invested in these programs, the more rapid and significant were these reductions.127 Based on this tobacco control campaign experience in the US, a simulated model of tobacco control mass media interventions was developed to examine the relationship between expenditure on mass media campaign activity and the size of effect.128 The simulation model suggested that media interventions directed at all smokers can result in substantial reductions in smoking rates. With campaign expenditure of US3$ per head over a sustained period, there is a predicted reduction in smoking prevalence of almost 2% after one year, more than 3% after two years and 6% after 10 years, with a slower rate of further reductions in subsequent years.

Australia's Guide to Planning and Investing in Tobacco Control document129 accompanying the Australian National Tobacco Strategy 2004–2009 contains a range of estimates for recommended annual total expenditure (by Australian, state and territory governments and non-government organisations) on tobacco control. These estimates range from $80 million to $200 million or $4 to $10 per capita per year (in A$ 2004). This includes specific recommendations for expenditure on campaigns to promote quitting and smokefree messages of approximately $32 million to $90 million. An earlier estimate for recommended campaign expenditure in the VicHealth Centre for Tobacco Control document Tobacco control: A Blue Chip Investment in Public Health was in the middle of this range at $64 million.130