1. 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

2. 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.

3. 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

4. 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: /
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.

5. 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.

6. 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 

7. Sponge – Bangladesh Adaptation

8. 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

9. 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

10. 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.

11. 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.

12. % smoked 1-15 cigarettes per day % completed university degree
Participant Demographic Characteristics (Sample=2,399 smokers) N
% male
% aged 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

13. 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

14. 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

15. 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%

16. 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%

17. 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%

18. 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: /tobaccocontrol

19. 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.

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

21. Senior Technical Advisor – Public Communication
Thank You
Tahir Turk (PhD)
Senior Technical Advisor – Public Communication