Becky Freeman

Markers of the denormalisation of smoking and the tobacco industry

Background: In nations with histories of declining smoking prevalence and comprehensive tobacco control policies, smoking-positive cultures have been severely eroded. Smoking, smokers and the tobacco industry are today routinely depicted in everyday discourse and media representations in a variety of overwhelmingly negative ways. Several authors have invoked Erving Goffman’s notions of stigmatisation to describe the process and impact of this radical transformation, which importantly includes motivating smoking cessation. Efforts to describe nations’ progress toward comprehensive tobacco control have hitherto taken little account of the role of cultural change to the meaning of smoking and the many ways in which it has become denormalised. Methods: This paper identifies a diversity of generally undocumented yet pervasive markers of the “spoiled identity” of smoking, smokers and the tobacco industry, illustrated with examples from Australia, a nation with advanced tobacco control. Results: We caution about some important negative consequences arising from the stigmatisation of smokers. Conclusions: We recommend that schemes rating the comprehensiveness of national tobacco control should be supplemented by documentation of markers of this denormalisation.

Is "YouTube" telling or selling you something? Tobacco content on the YouTube video-sharing website

With advertising bans eroding direct tobacco advertising and promotional opportunities, tobacco companies are embracing more covert means of keeping their products in the minds of current and potential consumers. Compared with the breadth of published research on “above-the-line” tobacco advertising, research examining “below-the-line”1 indirect forms of tobacco promotion is in its infancy. Promotions at dance parties,2 themed nights in hip clubs,3 bars and music festivals,4 and disguising market research as sampling promotions5 are examples of identified strategies. Just as tobacco company marketers have infiltrated youth-friendly venues, it is conceivable that they also have a presence on youth-friendly websites. While the world wide web (WWW) is being used extensively to sell cigarettes,6 its largely unregulated status holds much potential as a vehicle for both promoting smoking and particular brands of tobacco products, and for promoting antismoking discourse. The WWW is no longer a vehicle to simply retrieve information and purchase goods, it is now a fully interactive and participatory platform.7 Coined in 2004 as Web 2.0, the WWW is increasingly being driven by consumer-generated content.8 It is both timely and critical to examine tobacco marketing in the Web 2.0 era. We are particularly interested in websites that appeal to youth and young adults, the same target population for tobacco companies. Internet use by young people is part of their everyday life; in 2006, more than half of youth and young adult Australians (aged 15–24 years) used the internet on a daily basis.9 The website YouTube (www.youtube.com) is an ideal example of a youth-friendly website that embodies the Web 2.0 principles of participation. It has the potential to be a fruitful place for tobacco marketers to turn their efforts. ### What is YouTube? YouTube was founded in February 2005, as a “consumer media company for people to …

Should the health community promote smokeless tobacco (snus) as a harm reduction measure

Background to the debate: The tobacco control community is divided on whether or not to inform the public that using oral, smokeless tobacco (Swedish snus) is less hazardous to health than smoking tobacco. Proponents of “harm reduction” point to the Swedish experience. Snus seems to be widely used as an alternative to cigarettes in Sweden, say these proponents, contributing to the low overall prevalence of smoking and smoking-related disease. Harm reduction proponents thus argue that the health community should actively inform inveterate cigarette smokers of the benefits of switching to snus. However, critics of harm reduction say that snus has its own risks, that no form of tobacco should ever be promoted, and that Swedens experience is likely to be specific to that culture and not transferable to other settings. Critics also remain deeply suspicious that the tobacco industry will use snus marketing as a “gateway” to promote cigarettes. In the interests of promoting debate, the authors (who are collaborators on a research project on the future of tobacco control) have agreed to outline the strongest arguments for and against promoting Swedish snus as a form of harm reduction.

New media and tobacco control

Objective This paper reviews how the tobacco industry is promoting its products online and examines possible regulation models to limit exposure to this form of marketing. Opportunities to use new media to advance tobacco control are also discussed and future research possibilities are proposed. Data sources Published articles and grey literature reports were identified through searches of the electronic databases, PUBMED and Google Scholar using a combination of the following search terms: tobacco or smoking and new media, online media, social media, internet media, Web 2.0, Facebook, YouTube and Twitter. Results A possible obstacle to fully realising the benefits of regulating tobacco marketing activities and effectively communicating tobacco control messages is the rapid evolution of the media landscape. New media also offer the tobacco industry a powerful and efficient channel for rapidly countering the denormalising strategies and policies of tobacco control. Evidence of tobacco promotion through online media is emerging, with YouTube being the most researched social media site in the tobacco control field. Conclusions The explosive rise in Internet use and the shift to these new media being driven by consumer generated content through social platforms may mean that fresh approaches to regulating tobacco industry marketing are needed.

British American Tobacco on Facebook: undermining article 13 of the global World Health Organization Framework Convention on Tobacco Control

Background The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) bans all forms of tobacco advertising, promotion and sponsorship. The comprehensiveness of this ban has yet to be tested by online social networking media such as Facebook. In this paper, the activities of employees of the transnational tobacco company, British American Tobacco, (BAT) on Facebook and the type of content associated with two globally popular BAT brands (Dunhill and Lucky Strike) are mapped. Methods BAT employees on Facebook were identified and then the term ‘British American Tobacco’ was searched for in the Facebook search engine and results recorded, including titles, descriptions, names and the number of Facebook participants involved for each search result. To further detail any potential promotional activities, a search for two of BATs global brands, ‘Dunhill’ and ‘Lucky Strike’, was conducted. Results Each of the 3 search terms generated more than 500 items across a variety of Facebook subsections. Discussion Some BAT employees are energetically promoting BAT and BAT brands on Facebook through joining and administrating groups, joining pages as fans and posting photographs of BAT events, products and promotional items. BAT employees undertaking these actions are from countries that have ratified the WHO FCTC, which requires signatories to ban all forms of tobacco advertising, including online and crossborder exposure from countries that are not enforcing advertising restrictions. The results of the present research could be used to test the comprehensiveness of the advertising ban by requesting that governments mandate the removal of this promotional material from Facebook.

Gone viral? Heard the buzz? A guide for public health practitioners and researchers on how Web 2.0 can subvert advertising restrictions and spread health information.

Many nations have banned or curtailed advertising of potentially harmful products to protect public health, particularly in the area of chronic disease control. The growth in Internet-based marketing techniques is subverting these advertising regulations. Explosive rises in use of social networking and user-generated content websites is further fuelling product promotion through electronic media. In contrast, there is a very limited body of public health research on these ”new media„ advertising methods. This paper provides an overview of these advertising methods and details examples relevant to chronic disease control. There is a vast untapped potential for health practitioners and researchers to exploit these same media for health promotion.

Can Mobile Phone Apps Influence People’s Health Behavior Change? An Evidence Review

Background Globally, mobile phones have achieved wide reach at an unprecedented rate, and mobile phone apps have become increasingly prevalent among users. The number of health-related apps that were published on the two leading platforms (iOS and Android) reached more than 100,000 in 2014. However, there is a lack of synthesized evidence regarding the effectiveness of mobile phone apps in changing people’s health-related behaviors. Objective The aim was to examine the effectiveness of mobile phone apps in achieving health-related behavior change in a broader range of interventions and the quality of the reported studies. Methods We conducted a comprehensive bibliographic search of articles on health behavior change using mobile phone apps in peer-reviewed journals published between January 1, 2010 and June 1, 2015. Databases searched included Medline, PreMedline, PsycINFO, Embase, Health Technology Assessment, Education Resource Information Center (ERIC), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles published in the Journal of Medical Internet Research during that same period were hand-searched on the journal’s website. Behavior change mechanisms were coded and analyzed. The quality of each included study was assessed by the Cochrane Risk of Bias Assessment Tool. Results A total of 23 articles met the inclusion criteria, arranged under 11 themes according to their target behaviors. All studies were conducted in high-income countries. Of these, 17 studies reported statistically significant effects in the direction of targeted behavior change; 19 studies included in this analysis had a 65% or greater retention rate in the intervention group (range 60%-100%); 6 studies reported using behavior change theories with the theory of planned behavior being the most commonly used (in 3 studies). Self-monitoring was the most common behavior change technique applied (in 12 studies). The studies suggest that some features improve the effectiveness of apps, such as less time consumption, user-friendly design, real-time feedback, individualized elements, detailed information, and health professional involvement. All studies were assessed as having some risk of bias. Conclusions Our results provide a snapshot of the current evidence of effectiveness for a range of health-related apps. Large sample, high-quality, adequately powered, randomized controlled trials are required. In light of the bias evident in the included studies, better reporting of health-related app interventions is also required. The widespread adoption of mobile phones highlights a significant opportunity to impact health behaviors globally, particularly in low- and middle-income countries.

Regulating the tobacco retail environment: beyond reducing sales to minors

The World Health Organization Framework Convention on Tobacco Control (FCTC) has little to say about the regulation of tobacco retailing, with most research and policy debate having been restricted to confining sales to adults and removing advertising displays, including packs. Tobacco retailing is largely unregulated, reflecting the historical regulatory trivialisation of tobacco products, now demonstrably anachronistic with the advent of near global support for the FCTC. This situation contrasts markedly with the regulation of pharmaceuticals, and many other goods and services subject to a wide variety of restrictions. This review proposes that the international tobacco control community should open up debate on retail regulation to examine the suitability of principles long accepted in pharmaceutical regulation. These include: restrictions on the number and location of tobacco retail outlets, the banning of tobacco retail displays, floor (minimum) price controls, restricting the amount of tobacco smokers could purchase over a given time and loss of retail licensure following breaches of any of the conditions of license. It proposes that retail licenses should be heavily restricted and tradable, becoming valuable commercial assets, where the threat of loss or revocation would act as an incentive for strict adherence to the measures proposed.

Open source marketing: Camel cigarette brand marketing in the “Web 2.0” world

Background: The international trend towards comprehensive bans on tobacco advertising has seen the tobacco industry become increasingly innovative in its approach to marketing. Further fuelling this innovation is the rapid evolution and accessibility of web-based technology. The internet, as a relatively unregulated marketing environment, provides many opportunities for tobacco companies to pursue their promotional ambitions. Methods: In this paper, “open source marketing” is considered as a vehicle that has been appropriated by the tobacco industry, through a case study of efforts to design the packaging for the Camel Signature Blends range of cigarettes. Four sources are used to explore this case study including a marketing literature search, a web-based content search via the Google search engine, interviews with advertising trade informants and an analysis of the Camel brand website. Results: RJ Reynolds (RJR) has proven to be particularly innovative in designing cigarette packaging. RJR engaged with thousands of consumers through their Camel brand website to design four new cigarette flavours and packages. While the Camel Signature Blends packaging designs were subsequently modified for the retail market due to problems arising with their cartoon-like imagery, important lessons arise on how the internet blurs the line between marketing and market research. Conclusions: Open source marketing has the potential to exploit advertising ban loopholes and stretch legal definitions in order to generate positive word of mouth about tobacco products. There are also lessons in the open source marketing movement for more effective tobacco control measures including interactive social marketing campaigns and requiring plain packaging of tobacco products.

Banning smoking in cars carrying children: an analytical history of a public health advocacy campaign

Objective: Framing public health policy reform in ways that attract public and political support is a core skill of advocacy. In this paper we summarise the 12‐year Australian history of advocacy for banning smoking in cars carrying children, culminating in the governments of the Australian States of South Australia and Tasmania enacting legislation.