As part of their PRIME programme to reduce health inequalities in the area, NHS Birmingham East and North (NHS BEN) worked in partnership with healthcare consultancy Dr Foster Intelligence to design and deliver a social marketing campaign to reduce smoking prevalence in male routine and manual workers, aged 35 to 55 and living in deprived wards of the NHS BEN area.
The campaign’s hard-hitting approach directly targeted this audience segment, who experience the greatest health needs relating to smoking-related conditions, by causing them to re-evaluate their relationship with cigarettes and to ‘Fight Back’ against them.
The campaign used a variety of media channels to deliver its message, including a Fight Back film, advans at local football events and an on-street delivery team who located a branded trailer near events and locations where the target audience were.
The campaign achieved an 87 per cent increase in the number of Quit Dates Set and a 65 per cent increase in successful quits, versus the same 2-month period in 2008. The campaign also resonated disproportionately with the target audience, a group which historically have accessed NHS BEN’s smoking cessation service in low numbers.
Smoking in England
In England in 2008 around 84,000 deaths were estimated to be caused by smoking, representing 18 per cent of all deaths in adults aged 35 and over. With over 440,000 hospital admissions attributed to smoking-related conditions annually amongst the same age group, it is clear that smoking represents a considerable threat to the health of the population. Furthermore, with the treatment of smoking-related illness costing the NHS an estimated £2.7 billion annually, the financial burden smoking places on the NHS is significant.
Smoking rates in England have declined over the long-term, from 39 per cent in 1980 to 21 per cent in 2007. The impact of the smoking ban in 2007 has also been well documented with an estimated 400,000 people quitting smoking as a result of its introduction. The current government target, announced in February 2010, is to reduce the adult smoking rate to 10 per cent by 2020.
Despite this progress, serious inequalities exist in smoking prevalence rates depending on people’s social status. In 2007, 28 per cent of adult manual workers were estimated to smoke, which compared unfavourably with 16 per cent in the non-manual population (The Marmot Review). A National Institute for Health and Clinical Excellence (NICE) report published in 2008 stated that smoking is the primary cause of health inequalities between the rich and poor in England.
Over 2009 the three Birmingham Primary Care Trusts (PCTs) – Heart of Birmingham Teaching PCT (HoBtPCT), NHS Birmingham East and North (NHS BEN), and NHS South Birmingham (NHS SB) – and the City Council all invested in ways to improve engagement with their services by targeting specific community groups.
A number of projects across the PCTs are increasingly utilising intelligence to support effective decision making in commissioning and communications. Among them NHS BEN has created PRIME (Programme for Relationships, Intelligence, Metrics and Equality), developed in partnership with healthcare consultancy Dr Foster Intelligence to address health inequalities across the region.
In 2009 within the NHS BEN region, overall smoking prevalence stood at 28 per cent, significantly above the national average and equating to 84,000 smokers.
As part of the three-year PRIME partnership programme, Dr Foster was tasked with developing a social marketing campaign that would reduce smoking prevalence among those most at risk from smoking-related health conditions. Its objectives were to:
- Increase the number of Quit Dates Set within the target audience by 40 per cent to 60 per cent during the campaign period
- Increase the number of people within the target audience recording a successful quit following the campaign period
The budget was provided by the PCT and ring-fenced for the PRIME programme. The project was managed by a Dr Foster Account Manager and the PCT Social Marketing Manager. The core team consisted of a Stop Smoking Manager, Stop Smoking Commissioner, PCT Social Marketing Manager, PCT Communications Representative and the Dr Foster Account Manager. The Director of Public Health was also fully engaged and led the process.
Desk research was undertaken and included:
- A review of the information and evidence that may be available at a national or global level. This also identified any relevant benchmarks or comparison
- A review of previous social marketing activity in the area
- A review of the local services and how they were promoted, including interviews with key staff and health professionals, to develop a picture of what was currently happening
Primary research was conducted to generate insight on:
- The barriers that were preventing the audience from quitting smoking
- Their motivations for continuing to smoke
- What had prevented them from successfully using the current smoking cessation services
- What would motivate them to stop smoking
Focus groups were undertaken with smokers between the ages of 35 and 65 wanting to quit. Smokers were recruited off the street and the focus groups were run by dedicated researchers. One-to-one interviews were also held with pharmacists delivering the pharmacy stop smoking service.
Benefits for continuing to smoke:
- Maintaining status quo – too hard to break the habit
- To cope with the stresses of daily life
- To alleviate boredom
- For relaxation or concentration
- To be sociable with friends
- To take a break from work
Benefits of quitting:
- For the family
Barriers to quitting:
- Lack of motivation
- Fear of the ‘pain’ of quitting
- Lack of confidence, having failed in the past
- Resigned to always being a smoker
- Friends smoke
- Associate drinking alcohol with smoking
- Belief that the damage to their health is irreversible (particularly amongst those over 35)
- Fear of gaining weight (particularly amongst women)
- Difficulty finding an alternative way of coping with the stresses of life
Awareness of and attitudes towards stop smoking services
- Most were positive toward the NHS and NHS stop smoking services, seeing them as free and fairly equal
- Most respondents were aware of the stop smoking services provided by GPs, but fewer respondents were aware of the stop smoking services provided by pharmacists and many said they would not think of approaching them for help
- A limited number of respondents were aware of the PCT’s drop-in sessions
- Many respondents were aware of the Call to Quit telephone line having heard it advertised on local radio or seen advertisements in the local press and GP practices
As part of the PRIME programme, Dr Foster and NHS BEN developed a population segmentation tool called Typologies. This was done by using a cluster analysis across a range of health data sets available through the PCT (such as local hospital admission and General Practice data) and used geographical and demographic information to supplement it. These audience segments were described as Red, Green and Blue typologies, with each typology broken down into further subsections, enabling the team to target their activity in a precise manner. This enabled the team to identify the typologies with the greatest health needs in regards to smoking-related conditions. This research was informed by the national body of evidence that exists around smoking cessation and tobacco control.
This process of creating unique ‘health typology’ audience segments grouped people together based on the degree of association that existed between them and provided insight into people’s health needs. The data showed that British males, from the lower deprivation quintiles between the ages of 35 to 55 were most at risk from conditions such as cancer, respiratory disorders and chronic obstructive pulmonary disease. Additionally, this audience were estimated to have a smoking prevalence rate of over 30 per cent, making them the target for campaign activity. This group primarily came from the Red health typology.
“Our core purpose is to tackle health inequalities and improve health and wellbeing. The health typologies that Dr Foster created have made a significant impact on our ability to tackle these inequalities by enabling us to focus on those that need our support the most. The Fight Back campaign is an excellent example of this approach in action.” Nicola Benge (Director of Health Improvement and Public Health, NHS BEN)
The key piece of insight that the research generated was that the target audience strongly disliked the control that smoking held over them and the feelings that being unable to quit engendered. This insight underpinned the development of the campaign.
“I’ll try anything because I want to give it up. I want to break that habit. And that’s what it is, it’s just habit.”
The team also found that almost all smokers had smoked for many years and made numerous unsuccessful quit attempts, which left them unmotivated and unsure of how to make another attempt to quit.
“I know that fags are going to kill me if I carry on, so I’ve got to stop. I will stop. How I’m going to do it, I don’t know.”
The research highlighted that the target audience were straight-talking and respected that quality in others, an insight that provided guidance for the tone of the campaign.
Smokers also reported some issues with the existing smoking cessation services, ranging from discomfort with discussing their battle to quit in a group environment, to difficulty accessing services at a time and a place that suited them. This generated recommendations for service redesign, which will help ensure there is a longer-term and sustainable output from the research.
Furthermore, it was agreed that the pharmacy service would be the most effective smoking cessation route for the audience, as it provides one-to-one support and flexibility of access that would better suit their lifestyle.
“Dr Foster has been very proactive in engaging with our population and their success in generating insights into entrenched health problems has been valuable. The research conducted as part of the Fight Back campaign helped us to identify the barriers affecting our target audience and to promote a service that would overcome them.” Nicola Benge (Director of Health Improvement and Public Health, NHS BEN)
To achieve the campaign’s targets, the team wanted their target audience to engage with their stop smoking services through their local pharmacist and ultimately set a quit date.
A top priority was to ensure that effective partnerships were built with pharmacists to gain buy-in and ensure that they were aware of the campaign, its core message and what would be required of them. Building this cohesion was paramount in ensuring that at the point smokers entered the service there was continuity of message to minimise the likelihood of smokers dropping out of the service.
This was achieved in three ways:
- By taking advantage of the existing communications channels that existed between NHS BEN and the pharmacists, plans for the campaign were shared through the pharmacy representative and feedback gathered to inform the development of the finer details of the campaign
- Information was provided to the NHS BEN representative of the Local Pharmaceutical Committee (LPC), enabling them to provide a campaign debrief at their monthly meeting
- All pharmacists were provided with a debriefing pack, which outlined the aims of the campaign, promoted the benefits the campaign would bring to their business and provided relevant materials such as posters, leaflets and giveaways
Other key stakeholders were the stop smoking team, who were key to the delivery and development of the stop smoking service, and the media. To manage stakeholder relations, a public relations (PR) company were contracted to develop a PR strategy.
Four campaign ideas, generated in response to the insight, were tested with the target audience. Each campaign idea focused on the key insight that quitting smoking would enable the audience to regain control, although that message was communicated in distinctly different ways.
The four ideas were concept tested with 6 focus groups of 8 members of the target audience (male routine and manual workers aged 35 to 55).
One of these concepts – ‘Fight Back’ – clearly struck a chord with the audience and was the most effective at engaging their interest.
The Fight Back concept confronted the target audience with a graphic metaphor for the damage that smoking does by enabling them to ‘see it’, but was also empathetic in acknowledging that successful quitting is a real fight.
The campaign challenged the audience to fight back and beat cigarettes. The audience were struck by its originality, clarity of message and impact.
“Fight Back undeniably contains challenging imagery, an approach that generated some controversy. Importantly though, it resonates with our target audience and the evidence shows that it has made a difference to the number of people quitting smoking.” Nicola Benge (Director of Health Improvement and Public Health, NHS BEN)
The marketing mix
Accessing the stop smoking service via the local pharmacies.
While accessing the stop smoking service is free, the target audience faced non-monetary costs such as time and effort required to quit smoking.
The target audience would be encouraged to use stop smoking services offered through the local pharmacies in the areas of BEN with high numbers of Red typologies. Promotional activity was planned for areas where this target audience were likely to be, plus areas as near as possible to pharmacies that were offering the stop smoking service. Thus if someone was captured by the promotional activity he/she would have the option to see a pharmacist almost immediately. This would reduce any likelihood that they would subsequently change their mind or take no further action.
The Fight Back campaign’s imagery was very effective in attracting attention and making people stop and think. To capitalise on this visual impact, six sheet posters carrying the Fight Back message and a text number that signposted to local pharmacy services would be displayed at over 50 sites.
A trailer, towed by a branded Land Rover Discovery vehicle, was hired for the campaign. This would be the focal point of activity and contained experiential elements, such as the lung age tester, as well as an LCD screen to show the Fight Back film and a seating area for the ambassadors to offer advice and guidance to smokers. Mocked up police incident boards would be displayed outside the trailer to grab attention and attract people inside. A trained team of paid sales personnel from a merchandising company recruited by Dr Foster would provide information, advice and guidance, helping smokers understand the hidden dangers of smoking and promote the pharmacy service.
To ensure Fight Back was delivered at the most effective time of the year, the team analysed smoking cessation trends within NHS BEN across a three-year period to investigate if there were times during the year when people were quitting in smaller numbers. This analysis highlighted that the autumn months were traditionally ‘quieter’ and there was capacity in the system to deal with additional quitters.
Capacity was a flagged as a valid concern as the team did not want to flood the system and have people keen to stop smoking waiting to be seen, as this might ultimately be demotivating. Additionally, they liaised with NHS BEN and the regional tobacco control lead to understand what local and regional social marketing activity was planned, and considered national campaign activity. Both these factors pointed to an autumn campaign, launching in October and running for eight weeks.
Beginning in October 2009 for two months, the Fight Back campaign was delivered in two waves. The strategy was designed to ensure that smokers had the maximum number of opportunities to see the message, understand it and act on the message. In essence, the message invited smokers to ‘fight back’ against cigarettes by setting a quit date at their local pharmacy smoking cessation service.
Wave One – Sharing the message
The objective of the first wave was to share the Fight Back message with the audience through a communications campaign that utilised a range of media channels. The campaign was displayed and promoted in places where the target audience lived, worked and spent their leisure time.
This activity was supplemented by the distribution of smaller posters, campaign leaflets and giveaways across 900 venues frequented by the target typologies, including cafes, public houses and trading estates.
Additionally, the team took advantage of large gatherings of the target audience. Mobile ‘advans’ were deployed on match days at Birmingham City and Aston Villa, patrolling the approaches to the football grounds and sharing the Fight Back message with thousands of people.
This locally focused activity was supported by a press and PR campaign focusing on local titles such as the Birmingham Post that the audience read.
The campaign was further promoted by a Fight Back film, which was created by internationally acclaimed filmmakers Rankin and Chris. This hard-hitting representation of the Fight Back message, showing a smoker felled by invisible blows each time he inhales on his cigarette, was released virally and recorded over 200,000 hits online during the campaign period.
Wave Two – Amplifying the message through on-street activity
Previous experience in delivering smoking cessation campaigns had shown that smokers can benefit enormously from receiving face-to-face advice and guidance. This personal interaction enables a dialogue with smokers and an opportunity to overcome barriers and provide encouragement and reassurance.
The overall objective of the face-to-face interaction was to provide smokers who were interested in quitting with the name, address and phone number of their local pharmacist, directing them straight into the smoking cessation service. The benefits of stopping smoking and of using the pharmacy service, and its ease of access, flexibility and the support provided were all promoted.
The team collected smokers’ details to create a contact database, which served two purposes. First, the database was used to contact smokers during the campaign by phone and text to remind them of their local pharmacy details and to offer further encouragement to take the next step to make an appointment and set a quit date at their local pharmacy. Second, the database allowed NHS BEN to track the progress of smokers and re-contact them where necessary to provide further advice about quitting. This ensured that support would be ongoing, thereby improving smokers’ chances of quitting.
To deliver this face-to-face activity a team of trained on-street ambassadors were employed, focusing on the areas where the audience lived, worked and shopped by using internal knowledge and the typology map. Experiential elements such as carbon monoxide and lung age testing were used, so that the target audience could understand the damage that smoking was doing to them, even if they could not see it. To maximise the likelihood of smokers engaging with the ambassadors an eye-catching and engaging on-street experience was created, making use of the Fight Back film and mocked up police incident boards to draw people to the trailer.
The on-street activity was very successful in generating large numbers of referrals at pharmacies close to the locations of the activity. Some changes had to be made to the initial implementation plans of street activity due to some pharmacies becoming very busy and capacity proving an issue. The teams therefore adapted the dates and locations of the on-street activity to maintain capacity and respond to the needs of the local pharmacies.
The response from the press and media to the violent and shocking imagery used in the campaign was both positive and negative, though both ultimately served to raise the profile of the campaign.
The project was evaluated by Dr Foster using pre- and post-surveys administered to the local pharmacists.
The Fight Back campaign’s primary objectives were to:
- Increase the number of Quit Dates Set by the target audience by 40 per cent to 60 per cent during the campaign period
- Increase the number of people within the target audience recording a successful quit following the campaign period
During the campaign period there was an 87 per cent increase in the number of Quit Dates Set at local pharmacies, versus the same 2-month period in the previous year (2008).
A 65 per cent increase in the number of successful quits was recorded over the campaign period, versus the same 2-month period in the previous year (2008).
The campaign was also shown to resonate disproportionately with the target audience, a group which historically have accessed NHS BEN’s smoking cessation service in low numbers. This is of particular importance when considering the impact on health inequalities, where it is not enough to only increase absolute numbers, but it is also necessary to increase the number of people from the audience with the greatest health needs.
As the chart above shows, all typologies experienced a significant increase in the number of people successfully quitting. However, Fight Back had the greatest effect on the Red typology audience.
“We’re delighted with the results, which bucks the trend of recent years and turns around a decline in quit rates and begins to prove what we believed – that investing in segmentation, research and a well constructed campaign will produce results when tackling health inequalities.” Nicola Benge (Director of Health Improvement and Public Health, NHS BEN)
There were also some unintended positive outcomes, with the campaign resonating with a wider audience, including the other typologies and men and women alike, increasing referrals outside the target audience.
75 per cent of the target audience had an average of 6 opportunities to see the posters over the campaign period. A tracker study showed that 64 per cent of people questioned were aware of the Fight Back campaign and 50 per cent of people recalled seeing the Fight Back poster, which is 2.5 times the industry average.
Return on investment (ROI)
ROI has been calculated and the results will be released soon.
Findings and learning were shared with regional tobacco control leads, pan-Birmingham and internal PCT staff, and at core cities events on smoking (where attendees included directors of public health, smoking leads and local authority tobacco control leads).
The team were keen to ensure Fight Back could be sustained beyond the life of the campaign period. To achieve this, during the face-to-face on-street activity they generated a contact database of another 1,300 smokers, whose progress towards quitting smoking has subsequently been tracked.
Six months after the campaign’s completion, the entire database was contacted with a response rate of 58 per cent. Of these:
- 27 per cent reported they had successfully quit smoking
- 55 per cent reported that although they had not quit smoking they were still interested in doing so and were provided with further encouragement, practical advice and guidance
Given the high smoking prevalence rate in the target audience, as well as NHS BEN’s target of reducing smoking prevalence to 18 per cent by 2018, a second phase of activity was delivered in May 2010 to build on the success of Phase One.
The campaign’s main focus remained on male smokers aged 35 to 55 who fall into the Red typology. However, data from Phase One showed that smokers from all typologies engaged with the campaign and that it also resonated with female smokers, so quits achieved from the broader audience will be recognised in the evaluation.
“The Fight Back campaign made a big difference to the number of people using our stop smoking service. We were able to help many more people quit smoking and it’s great news that the campaign has returned – I’m looking forward to welcoming many more people and working with them to help them quit.” Shazia Alam (Pharmacy Manager at the Co-Operative Pharmacy in Acocks Green)
The delivery model from Phase One was broadly replicated in the second phase of activity, with some amendments made based on learning from Phase One:
Local six sheet posters
The posting period was reduced from eight to four weeks. During Phase One 75 per cent of the target audience had an average of 6 opportunities to see the posters over the campaign period. In Phase Two, over the 4-week period 60 per cent of the audience will have an average of 8 opportunities to see the posters. In Phase One it was necessary to achieve higher coverage over a longer posting period to launch and establish the campaign. However, given that 64 per cent campaign awareness was achieved amongst the target audience in Phase One, it was not necessary to run Phase Two over as long a period.
On-street activity was also reduced from 28 days to 21 days, as engagement with the public was not from a ‘standing start’ position. Phase One provided solid evidence as to the most effective locations to engage with the public, and this information was used to plan highly targeted on-street activity in Phase Two.
Relationships with pharmacies were also better established and links made between the on-street activity and those pharmacies with the greatest capacity and willingness to engage with the campaign.
Phase Two utilised all campaign elements previously included, with the exception of the 48 sheet ad van and the viral seeding. Based on anecdotal feedback from on-street teams, these were not vital components for engaging people, who were more interested in interacting with other experiential elements.
“The success of the last campaign was really inspiring. We were confident that the approach would work but it was great to see such a huge increase in people trying to quit. This second phase is important to remind people about the service and encourage more people to give it a go and fight back.” Sally Brooks (previous Social Marketing Manager, NHS BEN)
Success of media coverage and on-street activity
Extensive media coverage, both locally and nationally, really helped drive the awareness and success of the campaign, and the on-street activity worked well to drive smokers to pharmacies. This was due to a combination of factors. First, the branded trailer, Land Rover and incident sign grabbed people’s attention. Second, the trained ambassadors not only encouraged smokers to try experiential elements within the trailer, but they also highlighted the ease and flexibility of using the pharmacies’ stop smoking service. In addition, as they were located near to these pharmacies, the team were able to direct those interested straight to the service, removing the chance that smokers would go home and change their mind or not take the necessary steps to quitting.
Engagement with pharmacists is essential
As a result of the success of the on-street activity, some pharmacies were over-stretched and unable to meet the demand for the stop smoking service. To address this, the team would have preferred to have briefed the pharmacists better about the campaign and prepare them for an increase in demand. Engagement with stakeholders who are key to delivery of a referred service is essential and should be developed as early as possible. The team would also recommend a different booking mechanism to avoid inundating pharmacists.
Learning from Phase One
In Phase One the advertising asked smokers to text a number, which they then received an automatic text from asking them to text back their postcode for their local pharmacy. The team found that very few people responded to this text. This was altered in the second phase, where a link was sent with the automatic text, which took smokers to the campaign website where they could find their local participating pharmacy.