Gerard Hastings

Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey

Objective: To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke-free law, implemented in Ireland in March 2004. Design: Quasi-experimental prospective cohort survey: parallel cohort telephone surveys of national representative samples of adult smokers in Ireland (n  =  769) and the UK (n  =  416), surveyed before the law (December 2003 to January 2004) and 8–9 months after the law (December 2004 to January 2005). Main outcome measures: Respondents’ reports of smoking in key public venues, support for total bans in those key venues, and behavioural changes due to the law. Results: The Irish law led to dramatic declines in reported smoking in all venues, including workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). Support for total bans among Irish smokers increased in all venues, including workplaces (43% to 67%), restaurants (45% to 77%), and bars/pubs (13% to 46%). Overall, 83% of Irish smokers reported that the smoke-free law was a “good” or “very good” thing. The proportion of Irish homes with smoking bans also increased. Approximately 46% of Irish smokers reported that the law had made them more likely to quit. Among Irish smokers who had quit at post-legislation, 80% reported that the law had helped them quit and 88% reported that the law helped them stay quit. Conclusion: The Ireland smoke-free law stands as a positive example of how a population-level policy intervention can achieve its public health goals while achieving a high level of acceptance among smokers. These findings support initiatives in many countries toward implementing smoke-free legislation, particularly those who have ratified the Framework Convention on Tobacco Control, which calls for legislation to reduce tobacco smoke pollution.

The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project

This paper describes the conceptual model that underlies the International Tobacco Control Policy Evaluation Project (ITC Project), whose mission is to measure the psychosocial and behavioural impact of key policies of the Framework Convention on Tobacco Control (FCTC) among adult smokers, and in some countries, among adult non-smokers and among youth. The evaluation framework utilises multiple country controls, a longitudinal design, and a pre-specified, theory-driven conceptual model to test hypotheses about the anticipated effects of specific policies. The ITC Project consists of parallel prospective cohort surveys of representative samples of adult smokers currently in nine countries (inhabited by over 45% of the world’s smokers), with other countries being added in the future. Collectively, the ITC Surveys constitute the first-ever international cohort study of tobacco use. The conceptual model of the ITC Project draws on the psychosocial and health communication literature and assumes that tobacco control policies influence tobacco related behaviours through a causal chain of psychological events, with some variables more closely related to the policy itself (policy-specific variables) and other variables that are more downstream from the policy, which have been identified by health behaviour and social psychological theories as being important causal precursors of behaviour (psychosocial mediators). We discuss the objectives of the ITC Project and its potential for building the evidence base for the FCTC.

Methods of the International Tobacco Control (ITC) Four Country Survey

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and “quasi-experimental” designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Impact of Graphic and Text Warnings on Cigarette Packs: Findings from Four Countries over Five Years

Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out. Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n = 17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings. Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (text-only) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones. Conclusions: Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

The critical contribution of social marketing: Theory and application

This paper examines the symbiotic relationship between social, commercial, and critical marketing thought. Marketers seek to influence consumer behaviour. Much ill health and many social problems are caused by human behaviour. Social marketing puts these two phenomena together and uses marketing insights to address social behaviours. In the process both arms of the discipline can benefit, and this paper illustrates this using the examples of exchange theory and relational thinking. Social marketing also recognizes environmental influences on behaviour and that commercial marketing can be an important part of this influence. The case of tobacco is used to show that this influence can be malignant, and that as a result marketing has come under unprecedented scrutiny. Social marketing’s understanding of both the commercial and social sectors puts it in a unique position to provide realistic critiques of marketing and identify intelligent solutions. The paper concludes that socialmarketing will flourish by exploiting its twin understanding of the good and the bad that marketing can bring to society.

Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: findings from the International Tobacco Control (ITC) Four Country Survey

Objective: To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey. Design: Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia. Outcome measures: Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies. Results: Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban. Conclusions: Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Relational Paradigms in Social Marketing

It is fifty years since Wiebe suggested that generic marketing principles could tackle health and welfare problems and thirty since Kotler christened this “social marketing.” The future of social marketing depends on continuing this learning from commercial marketing and, in particular, its recent moves toward relational paradigms.

Promotion of electronic cigarettes: tobacco marketing reinvented?

Electronic cigarettes are not subject to the same marketing controls as tobacco products. Marisa de Andrade, Gerard Hastings, and Kathryn Angus argue that their advertising is likely to appeal to young people and undermine tobacco control policy

The meaning, effectiveness and future of social marketing.

The unique feature of social marketing is that it takeslearning from the commercial sector and applies it to theresolution of social and health problems. This idea datesback to 1951, when Wiebe asked the question ‘Can broth-erhood be sold like soap?’ For the first time, people beganto think seriously that methods used very successfully toinfluence behaviour in the commercial sector might transferto a non-profit arena. Wiebe evaluated four different socialchange campaigns, and concluded that the more similaritiesthey had with commercial marketing, the more successfulthey were.Over the next two to three decades, marketers and publichealth experts developed and refined this thinking, learningparticularly from international development efforts, wheresocial marketing was used to inform family planning anddisease control programmes (1). Social marketing thinkingand techniques spread to the developed world, and socialmarketing is now located at the centre of health improve-ment in several countries. In the USA, social marketing isincreasingly being advocated as a core public health strat-egy for influencing voluntary lifestyle behaviours such assmoking, drinking, drug use and diet (2).Last year in the UK, the potential of social marketingwas recognized in the White Paper on Public Health, whichtalks of the ‘power of social marketing’ and ‘marketingtools applied to social good’ being ‘used to build publicawareness and change behaviour’ (3). The National SocialMarketing Centre, led by the National Consumer Counciland the Department of Health, has been established to‘help realise the full potential of effective social marketingin contributing to national and local efforts to improvehealth and reduce health inequalities’ (4).Social marketing – like generic marketing – is not atheory in itself. Rather, it is a framework or structure thatdraws from many other bodies of knowledge such as psy-chology, sociology, anthropology and communicationstheory to help us understand how to influence people’sbehaviour (5). Several definitions of social marketing exist,but one of the most useful is Andreasen’s, which describessocial marketing as follows:Social marketing is the application of commercial mar-keting technologies to the analysis, planning, executionand evaluation of programs designed to influence thevoluntary behaviour of target audiences in order toimprove their personal welfare and that of society. (6)Four key features are illustrated in this definition. Thefirst is a focus on

Failure of self regulation of UK alcohol advertising

Although the content of alcohol advertisements is restricted, Gerard Hastings and colleagues find that advertisers are still managing to appeal to young people and promote drinking