Building the Evidence Base for Adaptation of Best Practice Tobacco Control Mass Media Campaign Messages in LMICs Tahir Turk (PhD) – Senior Technical Advisor Public Communication, World Lung Foundation World Cancer Congress, Melbourne, Australia, December 2014 (Title read out and highlight dual presentation) I first wanted to recap on some of the points from the meeting with state representatives to discuss state level tobacco control communication campaigns, conducted june 2012, then Dr Tahir Turk will outline how WLF can support States to fully utilise tobacco control communication campaigns in their States

WLF - What We Do Work with country partners to develop comprehensive ‘high- impact’ communication campaigns to support tobacco control in LMICs. Since 2007 WLF have supported more than 100 ‘population level’ National/Regional tobacco control communication campaigns in 26 LMICs to support cessation, prevention and policy initiatives. Campaigns have been evaluated for behavioural impact to build the evidence base. www.worldlungfoundation.org

What’s the Evidence? Metanalyses from HICs identify that ‘Population level’ mass media campaigns can achieve tremendous reach and impact, and are associated with a decline in smoking among youth, adults* The impact is multi-fold, and ultimately prompts quitting. Gain new insights, knowledge about tobacco usage and Motivate cessation Increase interpersonal discussion about tobacco use Influence and create social norms Increase support for policy change Increase compliance with laws Durkin S, Brennan E, Wakefield M (2012). Mass media campaigns to promote smoking cessation among adults: an integrative review. Tobacco Control, 21:127e138 * cancercontrol.cancer.gov/tcrb/monographs/19/m19_complete.pdf

What about LMICs? Growing evidence and experience from LMICs* shows that, when applied effectively and within the appropriate context, population level, strategic communication campaigns can also provide a powerful tool to change social norms for tobacco * Turk, T., Murukutla, N., Gupta, S., Kaur, J., Mullin, S., Saradhi, R., & Chaturvedi, P. (2012). Using a smokeless tobacco control mass media campaign and other synergistic elements to address social inequalities in India. Cancer Causes and Control, 23(S1):81-90. Mullin, S., Prasad, V., Kaur, J., Turk, T. (2011). Increasing evidence for the efficacy of tobacco control mass media communication programming in low-and middle- income countries. Journal of Health Communication, (16), 1–10. DOI: 10.1080/10810730.2011.601395 Well some of you may say that this evidence is mainly from high income countries which have been running these campaigns now for nearly 4 decades. In fact the evidence of the efficacy of these population level communication campaigns is now rapidly emerging in LMICs with WLF and our programming partners publishing a number of seminal papers on their behavioural impact in Internationally refereed journals (see citations below) and we can provide you with these articles which highlight the good work done in India which has been one of the most successful programming countries.

10 Country Study Rationale Ads that have performed well in high-income countries should also perform well in low- and middle-  income countries (LMICs)  If so, LMICs may be able to adapt existing high performing tobacco control ads for their mass media campaigns at a  lower cost than creating new  announcements.  

10 Country Study Objectives Evaluate existing high performing anti-smoking ads from HICs in 10 high tobacco burden low- and  middle- income countries.   Assess the comprehension, acceptability and potential  effectiveness of these ads 

Sponge – Bangladesh Adaptation

Method – Ad Treatment Each ad was translated into local language(s) Back-translations of ad content to ensure accuracy and appropriateness All voice-overs and speech were dubbed Quit line end-frames were removed or replaced with local information The same five ads were tested in every country

Ads Tested Artery Sponge Bubblewrap From the Australian National Tobacco Campaign (Damage series). Strong graphic imagery, Health effects message. Cancer Institute of NSW Visual metaphor: sponges as human lungs Graphic imagery of black tar squeezed from lungs Quit Victoria Visual metaphor: plastic bubblewrap as human lungs. Specific health message: emphysema

Ads Tested (cont.) Zita Eating You Alive Brain Cancer Council WA Personal testimonial (story) Zita Roberts describes her experience Montage of family photos and videos. New York City (Dept. Of Health). Extremely graphic imagery. Uses repetition of message and imagery. (Optional) From the Australian National Tobacco Campaign (Damage series). Strong graphic imagery, Health effects message.

Eating Your Child Alive Ads Tested (cont.) Lung Eating Your Child Alive Heart (Optional) From the Australian National Tobacco Campaign (Damage series). Strong graphic imagery, Health effects message. (Optional) New York City Graphic emotive imagery of sick children. Uses repetition of message and imagery. (Optional) From the Australian National Tobacco Campaign. Strong graphic imagery, Health effects message.

% smoked 1-15 cigarettes per day % completed university degree Participant Demographic Characteristics (Sample=2,399 smokers) N % male % aged 18-24 years % smoked 1-15 cigarettes per day % large urban city % completed university degree Bangladesh 192 100 50 79 46 China 240 67 68 5 Egypt 53 44 India 270 70 93 43 Indonesia 83 23 Mexico 226 66 95 52 39 Philippines 280 12 Russia 231 65 7 Turkey Vietnam 48 85 18

Research Protocol 24 groups of 8-12 smokers Ad rating First ad viewed twice Completed 10-item rating questionnaire Process repeated for the remaining ads Group discussion Each ad was replayed to the group Group discussion regarding message comprehension, acceptability and cultural appropriateness

Method – Outcome Measures 5-point Likert scales: strongly disagree to strongly agree Agree or strongly agree = positive scores. Message acceptance Understand Believable Personalised perceived effectiveness Taught me something new Stop and think Relevant Concerned More likely to try to quit Effective Feel Uncomfortable Likely to Discuss

Results – Effectiveness Estimated probabilities of positive ratings for Personalised Perceived Effectiveness by country Artery Sponge Bubblewrap Zita Eating you alive Bangladesh 91% 92% 79% 66% 90% China 93% 84% Egypt 88% 82% India 87% 85% 89% Indonesia 94% Mexico 81% Philippines 86% Russia Turkey 83% Vietnam 78%

Results – Uncomfortable Estimated probabilities of positive ratings for Uncomfortable by country Artery Sponge Bubblewrap Zita Eating you alive Bangladesh 69% 59% 40% 71% China 84% 77% 61% 54% 79% Egypt 85% 83% 73% 87% India 63% 70% 66% 64% Indonesia 74% 81% 65% Mexico 57% 56% 67% Philippines 78% Russia 82% 51% 53% 80% Turkey 88% Vietnam 34% 35% 27% 41%

Results – Discuss Bangladesh 78% 82% 77% 64% China 76% 66% 60% 53% 59% Estimated probabilities of positive ratings for Discuss by country Artery Sponge Bubblewrap Zita Eating you alive Bangladesh 78% 82% 77% 64% China 76% 66% 60% 53% 59% Egypt 75% 69% 74% India 79% 80% 70% Indonesia 63% Mexico 85% Philippines 81% 83% Russia 68% 58% 56% 55% 65% Turkey 73% 71% Vietnam 62%

WLF 10 Country Study Summary Ads that graphically communicate the serious harms of tobacco use performed consistently highly across all countries. Ads with complex medical terms or metaphors, or those that feature personal testimonials, are more variable. Graphic ads can be readily translated and adapted for local use. *Wakefield, M. Bayly, M. Durkin, S. et al. (2011). Smokers’ responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries. Tobacco Control. doi:10.1136/tobaccocontrol-2011-050171

Lessons Learned Important to build the evidence base for programming in resource constrained LMIC settings. The 10 Country Study has identified excellent potential to recycle existing anti-smoking ads for mass media campaigns in LMICs A number of countries have already adapted and aired these campaigns including: China, India, Russia, Vietnam, Bangladesh, Mexico, Philippines and Kenya. Furthermore, outcome evaluations identify good performance against a range of indicators.

Impact of Campaign Awareness on Behavioral Intentions and Behaviors: Sponge (Bangladesh) SMOKERS N = 4352

Senior Technical Advisor – Public Communication Thank You www.worldlungfoundation.org Tahir Turk (PhD) Senior Technical Advisor – Public Communication tturk@worldlungfoundation.org