14.2 The role of mass media campaigns within a comprehensive smoking control program

The strength of evidence for public education campaigns within the context of a comprehensive tobacco-control program continues to grow. Almost 60 years ago (1962) the Royal College of Physicians of London, in its report on smoking and health,¹ called on governments to:

• provide more education to the public and especially children concerning the hazards of smoking
• more effectively restrict the sale of tobacco to children
• restrict tobacco advertising
• more widely restrict smoking in public places
• increase tax on cigarettes, perhaps by adjusting the tax on pipe and cigar tobaccos
• inform purchasers of the tar and nicotine content of the smoke of cigarettes
• investigate the value of anti-smoking clinics to help those who find difficulty in giving up smoking.

In 1980 the World Health Organization and the International Union Against Cancer (UICC) advocated that a reduction in tobacco consumption could be achieved through a number of interrelated measures.² They named the objectives of a comprehensive smoking control program as:

• achieving lower smoking rates in all age groups by applying all practical downward pressures on smoking rates, including health warnings on tobacco packets, increased taxation, restrictions on smoking opportunities, support for the rights of non-smokers, and information and education programs
• encouraging non-smokers to remain non-smokers
• ceasing all forms of tobacco advertising and promotion
• encouraging those who had not yet stopped smoking, and therefore remained at high risk, to reduce, as far as possible, their exposure to the harmful components of tobacco smoke
• liaising with other health organisations and authorities to ensure maximum effectiveness and to avoid conflict of activities.

This recommended tobacco-control program recognised that synergies are created when all components of a program are implemented, rather than simply individual strategies. As more evidence has emerged from tobacco-control programs internationally, the importance of social marketing and public education campaigns within a comprehensive program of strategies and activities has continued to be emphasised.³ Subsequently, the World Health Organization launched the MPOWER package in 2008 to facilitate country-level implementation of the guidelines of the Framework Convention on Tobacco Control (FCTC)—see Section 14.2.1 below. Australians with expertise in tobacco control policy have had considerable input into these and other WHO FCTC Guidelines. Sections 14.2.2 and 14.2.3 describe how mass media has comprised an integral part of Australia’s National Tobacco Strategies.

14.2.1 The Framework Convention on Tobacco Control

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was adopted at the Fifty-sixth World Health Assembly in 2003 and entered into force on 27 February 2005.⁴ The Australian Government formally ratified the WHO FCTC on 27 October 2004.⁵ (See Chapter 19 for a detailed description.) Article 12 of the Convention (Education, communication, training and public awareness) calls for the use of all available communication tools to promote and strengthen public awareness of tobacco-control issues. Guidance on education, communication and training measures concerning tobacco dependence and cessation is outlined in Article 14: Demand reduction measures concerning tobacco dependence and cessation.

Since the ratification of the treaty, parties to the WHO FCTC have developed, refined and adopted guidelines ⁱ to assist signatories to draft legislation and administer programs that will embody its provisions. These guidelines recognise that awareness of tobacco-control issues is essential for public acceptance of policy changes. This includes bans on advertising and promoting tobacco products.ⁱⁱ Public awareness can help to bring about change in the behavioural norms around tobacco consumption and exposure to tobacco smoke.ⁱⁱⁱ It is recognised that health warnings will be more effective when part of a broader public education campaign.^iv

In the recommended actions for demand reduction approaches concerning dependence and promotion, mass communication and education programs are seen as essential both for encouraging tobacco cessation (Section 44) and encouraging tobacco users to draw on this support (Section 60).^v These programs can include unpaid and paid media placements. The guidelines for population approaches also recommend brief advice by healthcare workers, establishing smoking cessation telephone helplines (quitlines) and monitoring and evaluating programs to measure progress and impact. Guidelines for Article 12^vi  spell out how countries might go about developing, implementing and evaluating effective tobacco-control education campaigns.

Further to these guidelines, the MPOWER package, launched in 2008 by the World Health Organization, provides a set of six measures that are aimed to facilitate the implementation of the FCTC.⁶ MPOWER encourages countries to:

1. Monitor tobacco use and prevention policies
2. Protect people from tobacco smoke
3. Offer help to quit tobacco use
4. Warn about the dangers of tobacco
5. Enforce bans on tobacco advertising, promotion and sponsorship
6. Raise taxes on tobacco

The recommended best practice measures to ‘Warn about the dangers of tobacco’ are to implement graphic health warnings on tobacco packs and run national mass media campaigns.⁷ Best practice mass media campaigns are defined as meeting at least seven of the eight following characteristics:

• The campaign formed part of a comprehensive tobacco control program.
• Formative research was undertaken to gain insight into the target audience of the campaign.
• Campaign materials were pre-tested with the target audience and then refined as necessary.
• Campaign air time and/or placements were strategically obtained in order to reach the target audience.
• Publicity and news coverage of the campaign were sought.
• The effectiveness of the implementation of the campaign was evaluated.
• The impact of the campaign was evaluated.
• The campaign was aired on television and/or radio.

WHO monitors the global implementation of the MPOWER package. Between 2016 and 2018, the proportion of the world population covered by best-practice mass media campaign activity fell by 21%, to 45%.⁷ Only four countries—Australia, Turkey, United Kingdom and Vietnam—have maintained best-practice mass media campaign activity since MPOWER monitoring of this measure began in 2009-2010. The 2017 report on MPOWER implementation noted that securing sustainable funding for mass media is a significant barrier to successfully running mass media campaigns. They recommend that countries adopt policies to either shift costs to other entities, such as requiring broadcasters to provide free air time for public health campaigns, or creating special funds designated for tobacco control campaigns, for example through hypothecating a percentage of tobacco tax revenue.⁸

14.2.2 The National Tobacco Strategy 2004–09

The key role played by tobacco control campaigns has been recognised in Australia’s National Drug Strategic Framework. As part of this framework, the National Tobacco Strategy 2004–09 had the goal of significantly improving health and reducing the social costs caused by, and the inequity exacerbated by, tobacco in all its forms.⁹ The objectives of the strategy, among all social groups, were to prevent uptake of smoking, encourage and assist cessation, reduce secondhand smoke exposure, and, where feasible, to reduce the harms of continuing use of tobacco and nicotine.

Quit and Smokefree messages were central to the National Tobacco Strategy 2004–09. The strategy noted that ‘[discouraging] initiation to smoking and [promoting] quitting, as well as not smoking around children, requires sustained and commercially realistic funding for campaigns’.¹⁰ Sustained activity is necessary to maintain quitting as a priority for smokers, increasing the likelihood of reaching smokers at times when they might be most susceptible to messages about smoking and encouragement to quit.

The National Tobacco Strategy 2004–09 encouraged 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
• promote treatments and services.¹⁰

The National Tobacco Strategy 2004–09 also encouraged 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.  The increased promotion of Quit and Smokefree messages nationally supported other components of the National Tobacco Strategy 2004–09, such as increasing support for tobacco control regulation, including policies that reduce disadvantage, promote healthy lifestyles for children, and foster collaboration in program policy and development.

14.2.3 The National Tobacco Strategy 2012–2018

The second National Tobacco Strategy was agreed upon in 2012 by the Council of Australian Governments. The Strategy set a performance benchmark target of reducing national smoking prevalence to 10% of the Australian population by 2018, and a halving of Indigenous smoking prevalence from 2009 to 2018.¹¹ This was to be achieved through nine priority areas for reducing tobacco-related harm, based on international evidence of best-practice tobacco control measures.

Among nine priority areas the Strategy included:

1. Strengthen mass media campaigns to: motivate smokers to quit and recent quitters to remain quit; discourage uptake of smoking; and reshape social norms about smoking¹¹

The National Tobacco Strategy 2012–18 outlined eight specific actions to be undertaken to address the second priority area of strengthening mass media campaigns. These actions—listed in full below—included targeting of priority groups, factoring in changing media consumption habits and emerging digital media, using mass media to complement or enhance the effects of other policies, and continue collaboration across government and non-government organisations within Australia and globally.

1. Run effective mass media campaigns (including television radio, print and digital media formats) at levels of reach and frequency demonstrated to reduce smoking and based on current best practice principles.
2. Continue mass media campaigns targeted to Aboriginal and Torres Strait Islander people, including robust evaluation to inform future campaign strategies.
3. Continue to monitor the appropriateness and effectiveness of recommended media weights and media types/channels, including exploration of the potential role of digital media such as YouTube, Facebook and Twitter.
4. Continue to implement national tobacco campaigns and state and territory campaigns, including a balance of existing material with proven effectiveness and a suite of new materials.
5. Enhance collaborative action between the Australian Government, state and territory governments and non-government organisations to maximise the effectiveness of mass media campaigns.
6. Complement the implementation of tobacco control policies (e.g. new health warnings on packs and plain packaging) with mass media campaigns to enhance cessation efforts by smokers.
7. Continue to build the evidence base on the effectiveness of mass media to inform and refine future campaign development, including specific analysis of the effectiveness of these campaigns among groups with a high prevalence of smoking.
8. Continue to share campaign materials, evaluations and other evidence of effectiveness of mass media campaigns with the global tobacco control community.¹¹
   
   

References

1. Royal College of Physicians. Smoking and health: report of the Royal College of Physicians on smoking in relation to cancer of the lung and other diseases. London: Pitman Medical Publishing Co Ltd., 1962.

2. Gray N and Daube M. Guidelines for smoking control. UICC technical report series no. 52, Geneva: International Union Against Cancer, 1980.

3. Centers for Disease Control and Prevention. Designing and implementing an effective tobacco counter-marketing campaign. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2003.

4. WHO Framework Convention on Tobacco Control. New York: United Nations, 2003. Available from: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf.

5. Australian Government Department of Health and Ageing. Framework Convention on Tobacco Control. Canberra: Government of Australia, 2004. Last update: Viewed Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-tobacco-fctc.htm

6. World Health Organization. MPOWER: A policy package to reverse the tobacco epidemic. Geneva: World Health Organization, 2008. Available from: https://www.who.int/tobacco/mpower/mpower_english.pdf.

7. World Health Organization. WHO report on the global tobacco epidemic 2019. Geneva: World Health Organization, 2019. Available from: https://www.who.int/tobacco/global_report/en/.

8. World Health Organization. WHO report on the global tobacco epidemic, 2017. Monitoring tobacco use and prevention policies Geneva: WHO, 2017. Available from: http://apps.who.int/iris/bitstream/10665/255874/1/9789241512824-eng.pdf?ua=1.

9. Ministerial Council on Drug Strategy. Australian National Tobacco Strategy 2004-2009. Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-strat.

10. Ministerial Council on Drug Strategy. Meeting the challenges of the next five years-2: Ideas and resources for increasing promotion of Quit and Smokefree messages. National Tobacco Strategy, supporting documents, Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pub-tobacco-tobccstrat2-cnt.htm/.

11. Intergovernmental Committee on Drugs. National Tobacco Strategy 2012-2018. Canberra: Invergovernmental Committee on Drugs, 2012. Available from: https://www.health.gov.au/sites/default/files/national-tobacco-strategy-2012-2018_1.pdf.