NICE Guidance on tobacco control communication campaigns: an effective approach for encouraging positive behaviour change and promoting Smoking Cessation Services? Development, implementation and evaluation of a new anti-tobacco public information campaign in Northern Ireland Paul Schofield, Research and Information Officer, Public Health Agency

Relating NICE guidance to the campaign - Development Development Campaign stage Recommended NICE action Action taken by PHA -Be developed using audience research; -Consider tailoring campaigns toward low income groups; -Use ‘why to’ and ‘how to’ quit messages that are non-judgemental, empathetic, respectful. -Primary focus on C2DE / routine and manual workers from early stages; -Qualitative development research with proposed target audience; -Refining of proposed concepts and campaign messages through feedback with target audience; -Two strand approach to the campaign to incorporate ‘why’ quit and ‘how to’ quit messages.

Qualitative research was undertaken with adult smokers. Total of 8 groups across Northern Ireland. Research participants consisted of adults smokers; recruitment on the basis of- Age (20-49 year olds); Socio-economic group (emphasis on C2DE profile groups); Intention to quit (not intending to quit v intention to quit in the future). Group discussions were arranged by research participants with similar demographic characteristics and by similar quitting intention. Series of concepts were tested in each group; participants with no expressed intention to quit tested ‘Why’ quit approaches / participants with expressed intention to quit tested ‘How’ quit approaches. Development – Overview

Participants indicated that the impact that a smoking related illness had on family and loved ones was motivating in terms of initiating a quit attempt. They were aware of the risks of smoking, but had not thought about the impact of a debilitating illness on the impact of others. The concept selected for development was felt to be empowering, on-side and non- judgemental. Campaign aimed at smokers with no explicit intention to quit, predominantly targeted at lower socio-economic groups and smokers aged years old. Development – Strand 1 ‘Why’ quit approach Campaign summary Message -‘Smokers. Things to do before you die’ -Shows the long term health effects of smoking, personalising how it feels to experience a smoking related illness Campaign focus -Why smokers should quit and in particular, reinforcing the health risks and the consequences of their smoking -Highlights signposting support services

An approach which involved a long-term smoker relating their quit journey and the different support available was felt to be motivating and believable. Approach was also considered to reinforce the message that quitting is achievable with the right support and motivation. This strand of the campaign is predominantly aimed at smokers from lower SEGs, smokers aged years old and smokers who feel that they would like to quit. Development – Strand 2 ‘Why’ quit approach Campaign summary Diary approach – Story told backwards and recorded as if on home video camera (TV), other materials follow similar ‘stages of the journey’ approach - Challenges of quitting outlined and shown to have been overcome Campaign focus -Highlighting the range of support available -Focusing on the positive; that quitting is achievable.

Development – Services promoted within the campaign Campaign Want2stop.info Stop Smoking Services – GP, Pharmacy, Community Settings Smokers Helpline Quit Kit self- help initiative Services promoted as part of the campaign

Relating NICE guidance to the campaign - Implementation Implementation Campaign stage Recommended NICE action Action taken by PHA -Coordinate strategy to support delivery of services / involve community pharmacy & professional groups; -Ensure campaign is extensive and sustained; -Consider targeting campaigns towards low income groups to address inequalities. -Promotion of Stop Smoking Services (pharmacy, GP, community based providers), Quit Kit, Smokers’ Helpline; -Multiple campaign elements (TV, radio, print, online), media booked at a sustained level throughout campaign period; -C2DE / routine & manual workers identified as a key target audience group.

Implementation – Media The campaign was launched on 5 January 2011 and ran throughout all of 2011 and early 2012 at a sustained level. Both strands of the campaign used the following media elements: TV advertising Advertisements developed for each campaign strand and broadcast on the regional ITV and Channel 4 broadcast stations. Radio advertising Four radio advertisements developed; three focusing on Strand 1 ‘Why quit’ message, one advertisement focused on Strand 2 ‘How to quit’ message. Broadcast on regional radio channels. Outdoor advertising Outdoor advertising for each campaign strand displayed throughout Northern Ireland in Advertising shown in various formats and venues including advertisements on the side of buses (streetliners) and commuter cards, bus stop poster formats and washroom panels in pubs and clubs. Online advertising Online advertising was also utilized in this campaign with interactive and display advertising used to promote each strand of the campaign across news / media and social media websites.

Implementation – Helpline requests Higher helpline requests during campaign period (Q requests) v periods of non-campaign activity (Q requests). Sustained campaign periodNo campaign activity TV Radio Outdoor Online

Implementation – Quit Kit requests Higher quit kit requests during campaign period (Q requests) v periods of non-campaign activity (Q requests). Sustained campaign periodNo campaign activity TV Radio Outdoor Online

Stop Smoking Services uptake 2010* Implementation – Overall uptake of Stop Smoking Services During 2011 when the new campaign ran at a sustained level throughout the year, there was an increase in service uptake of 39.6% in comparison with the previous year which had limited campaign activity across Northern Ireland % v Q % v Q % v Q % v Q *Note: Some tobacco control public information campaign activity took place throughout 2010 with older campaign materials however campaign activity was not extensive or at a sustained level.

Implementation – Outcomes Stop Smoking Services data monitoring during campaign period (Q1, Q2, Q3, Q Q1 2012): Uptake – 54,333 clients set a quit date; Not previously attended – 12,461 clients (22.9%) Quit rate – 28,458 clients quit at 4 weeks (52.4% quit rate). Total of 17,496 Quit Kit requests; survey of Quit Kit requesters indicated: 74.7% made a quit attempt since receiving a Quit Kit; 90.6% were regular smokers when they received a Quit Kit; 73.1% regular smokers one month after receiving a Quit Kit. 2,818 helpline calls, mainly Quit Kit requests but with further information, advice and support provided on calls by helpline staff. *PHA Quit Kit evaluation survey, conducted by Millward Brown Ulster, Dec 2011

Relating NICE guidance to the campaign - Evaluation Evaluation Campaign stage Recommended NICE action Action taken by PHA -Evaluation using audience research -Evaluation using a general population survey (n=1,512) to test awareness and impact of the campaign

Evaluation – Post campaign evaluation A post-campaign evaluation was undertaken to establish the awareness, impact and outcomes of the campaign. 1,512 interviews secured via face to face interviews. General population sample (1,012) secured; Boost strategy of additional smokers ( year olds, year olds) principally to explore campaign impact on key target audience age groups. Given the disproportionate sampling by age group and smokers, to establish impact at a population level, sample was weighted back to be reflective of the Northern Ireland population, (results presented by applied weights unless otherwise stated).

Evaluation – Post campaign evaluation NI* population profile % Sample % (n) Weighted Gender Male (734) Female (777) Age (252) (664) (354) (242) Social class ABC (686) C2DE (822) Smokers / non-smokers Smoker (369) Non-smoker (1143) Sample profile compared with NI population profile by gender, age and social class (NI population aged 16+) for achieved sample *Population profile source: NISRA mid-year population estimates 2009/10 / NI Health Survey 2010/11

Evaluation – Overall awareness across general population Base=1,512 Strand 1 (Why) Strand 2 (How) Overall awareness (%) % High overall awareness across the general population for both campaign strands (74.8%, Strand 1 ‘Why’ / 64.5% Strand 2 ‘How’). Q. Have you seen this TV/radio/poster/online advertisement?

Evaluation – Awareness by groups % n Gender Male Female Age (X 2 [4] = , p<0.001, unweighted) Social class ABC C2DE Smokers / non-smokers Smoker Non-smoker % n Gender Male Female Age (X 2 [4] = , p<0.01, unweighted) Social class ABC C2DE Smokers / non-smokers Smoker Non-smoker Strand 1 Overall awareness by key demographic groups Strand 2 Overall awareness by key demographic groups

Evaluation – Impact and outcomes Respondents who had seen TV advertisement and/or heard the radio advertisement for any campaign strand were asked if they had done anything to change their smoking behaviour. Behaviour change (either quit or reduced the amount they smoked) was highest for those smokers who had been exposed to both campaigns. Q. Did you do anything as a result of seeing this TV/radio advertisement? (Prompted) % who indicated behaviour change (quit or reduction in smoking) as a result of seeing campaign strands % Base=551 (smokers who saw TV and/or radio ads in either campaign strand [unweighted])

Evaluation – Impact and outcomes For those exposed to both campaigns, no significant differences in terms of change behaviour by target groups or by age group, however variations observed. Q. Did you do anything as a result of seeing this TV/radio advertisement? (Prompted) % who indicated behaviour change as a result of seeing campaign (quit or reduction in smoking) Age group Smoker target group % Base=370 (smokers who saw TV and/or radio both campaign strands [unweighted])

Summary How we can embrace message further – focus on parental aspect affecting lives of their children, universal - effective for targeting DE smokers? Emotive messages which place an emphasis on the effects of their smoking on others can stimulate reflection and changed behaviour Summary findingsFuture challenges Campaign approaches which show the challenges but also show strategies for how these can be overcome are empowering, motivating Moving from reduction in the amount smoked to a (sustained) quit attempt. Possible learning from the ‘Mass participation’ approach, e.g. Stoptober? Public information campaigns act as a key driver in promoting stop smoking support services. Should be considered as one part of an overall tobacco control programme. Using multiple strands in campaigns to differentiate smokers by type can help tailor messages and promote services more effectively Which services and for whom? -Possible further engaging smokers through new approaches – text, social media, online chat