Response to an indigenous smoking cessation media campaign – It's about whānau
Michele Grigg, The Quit Group, PO Box 12-605, Wellington, New Zealand. Fax: 64 4 472 7632; e-mail: firstname.lastname@example.org
Objective: To assess any effects among Māori (the indigenous people of New Zealand) smokers and their whānau (the traditional Māori family unit) of a campaign designed to support Māori smokers to quit smoking.
Method: New Zealand-wide cross sectional population surveys between 2000 and 2002 of smokers and whānau pre- and post-airing of the campaign. Measures included recall and awareness of the campaign; perceptions of the campaign; and campaign-attributed changes in quitting-related attitudes and behaviours.
Results: Seventy-eight per cent of smokers and 73% of whānau were able to recall the campaign one year following its launch. The television commercials (TVCs) were consistently rated very believable or very relevant by over half of the smokers who had seen them. More than half of smokers (54%) stated that the campaign had made them more likely to quit.
Conclusion: This nationwide mass media cessation campaign developed to deliver a cessation message to indigenous people was received positively by Māori smokers and their whānau and played a role in prompting quit attempts.
Implications: Social marketing campaigns have an important role as part of a tobacco control program to reduce high smoking prevalence among Māori and inequalities in health outcomes between Māori and other New Zealanders.
Prior to European contact, Māori, the indigenous people of New Zealand, had a tobacco-free culture.1–3 Colonisation of New Zealand during the 19th century had a devastating effect on Māori health and the introduction of tobacco has been a major contributor to their ill-health.4
Today, Māori comprise 15% of New Zealand's population and smoking is the leading cause of preventable death among this group. At least one in five Māori die from smoking-related disease.5,6 Lung cancer mortality and incidence rates among Māori are three times those of non-Māori and Māori women's rates are among the highest in the world.7–9
Forty-two per cent of Māori smoke (2006/07), compared to 19% of Europeans/ others and 27% of Pacific people. Smoking rates are particularly high among Māori women (45%).10 After two decades of no change, recent data shows a significant decline in Māori smoking prevalence.10
There is a strong link between smoking and deprivation.11,12 Smoking is a key contributor to health inequalities between Māori and non-Māori. Evidence suggests that a key mechanism through which this inequality occurs is through Māori being over-represented in lower socio-economic groups.13
The New Zealand Quit/ Me Mutu Campaign
The New Zealand Quit/Me Mutu campaign was launched in 1999. Modeled on the Quit campaign delivered in Victoria, Australia, the New Zealand campaign included delivery of a Quitline service and a mass communications campaign to prompt quitting behaviour and calls to the Quitline.
The mass communications campaign included use of ‘Every cigarette is doing you damage’(EC) TVCs (televisioncommercials) originally developed in Australia14 but modified with a New Zealand voice over and amended 'smoker moment’ segments at the start of the TVCs. These TVCs use a ‘threat appeal’ approach and have been found to be effective in prompting quitting.14–17
In recognition of the inequalities in smoking prevalence and health outcomes between Māori and other New Zealanders, a core objective of the Quit/Me Mutu campaign was to ensure that Māori receive at least equitable benefit from the intervention compared to other population groups. While the proportion of Māori smokers calling the Quitline was comparable to the proportion of Māori smokers in the New Zealand smoking population,18 it was decided to develop a Māori-specific campaign to further increase Māori quit attempts and Māori engagement with the Quit campaign.
Specific objectives of the campaign were to increase motivation to quit and to encourage calls to the Quitline among Māori smokers. The campaign also aimed to denormalise smoking and create a supportive quitting environment for Māori smokers.
A collaborative working group was established to develop the campaign. The group included representatives from Māori organisations and Māori experts in public health, research, tobacco control and communications.
A first stage in developing the campaign was identifying a theory of action that would underpin it. ‘Te whare tapa wha’, a Māori framework for health, was used as a basis for developing the theory of action.19 This framework highlights the central role of whānau (the traditional Māori family unit) in health as well as promoting physical health, psychological health and spiritual well being, grounded in a Māori world view. It was important to recognise traditional and contemporary perspectives on being Māori so as not to prescribe what it is to be Māori for key audiences. For example, the concept of whānau was interpreted broadly and included traditional extended family relationships as well as nuclear arrangements and relationships between people not defined by birth or marriage.
A number of research projects were commissioned to further develop the theory of action for the campaign. These included a literature review, qualitative interviews, pre-testing of campaign concepts, and baseline studies.20–22 This research found that many of the principles underlying the existing EC campaign were also relevant for the new campaign. In particular, motivating smokers to put quitting high on their personal agenda15 and ensuring that the campaign was relevant, credible and thought provoking.16
Focus group findings suggested that many Māori smokers were distrustful of government-driven anti-tobacco programs, especially those that were seen to create negative stereotypes of smokers. Particular concern was expressed in relation to creating negative stereotypes of Māori as smokers.22 A solution to this was to not use overt threat appeal advertisements targeted at Māori smokers. Instead a strategy was used that built upon Māori identity through the use of empowering positive messages. The concept of maintaining whānau was identified as a key motivator for Māori smokers to quit.22 Highlighting the risk of smoking to whānau:
“…gives the smoker a choice; a choice to be around for their tamariki/mokopuna (children/grandchildren) … a choice to be around on the marae (Māori community meeting place) and to experience the continuation of their whakapapa (genealogy/family history); or the choice of missing out.”22
For Māori society, whānau, or extended family, is often seen as a primary social unit. Its structure consists of three to four generations of family members that may be spread across a number of households.23 Whānau plays a dualistic role for its members. Firstly, whānau can be seen as providing supportive and nurturing environments. Secondly, it creates reciprocal obligations where members have a responsibility to contribute to maintenance and support of other whānau members.24 Focus group research suggested that the importance of smokers contributing to whānau well being, including supporting and being around for its younger members as they grow, was a significant motivator for quitting smoking. In addition, support from whānau members for smokers to quit was seen as an important catalyst for prompting and maintaining quit attempts.22
The final campaign TVCs depicted Māori smokers and whānau of Māori ex-smokers delivering testimonial messages of what it was like to quit smoking. Māori females aged 25–44 years were a target group for the campaign as this group has the highest smoking rate in New Zealand. The ‘It's about whānau’(IAW) campaign was launched nationally in August 2001. Its main focus was use of TVCs, however, these were supported by print and radio advertisements. At the time of writing, the campaign had aired on all New Zealand free-to-air television channels each year since 2001. It was internationally unique, as, to the best of our knowledge, it was the first indigenous mass media cessation campaign to be aired nationally. A total of 15 TVCs were produced. The TVCs utilise interviews with real Māori smokers and their whānau talking about quitting smoking and how this has affected them.21 The TVCs are primarily communicated in English, however, Māori language is included when it is a natural part of the story. The end of each ad shows the Quitline number with a voiceover giving the call to action, “It's about whānau, call the Quitline on 0800 778 778.”
The purpose of this study was to assess any impacts of the campaign following its first year of airing. The specific aims were to assess awareness of the campaign, how key audiences perceived the campaign and any self-reported changes in behaviour associated with the campaign's objectives.
Two samples were collected for this study: current smokers (smoked at least weekly) along with recent quitters (those who quit in the four months prior to the survey) and whānau. Table 1 shows the sample sizes of the two main surveys used in this study.
Table 1. Sample sizes of second baseline and second follow-up surveys
|All survey respondents 18+ years||473||655|
|Smokers and recent quitters||254||404|
For the purposes of this study, whānau was broadly defined as ‘anyone close to a Māori smoker’ and included family, friends and workmates of Māori smokers who were not smokers themselves. The purpose of the whānau sample was to identify some of the broader impacts of the campaign, including identifying who had been affected by exposure to the campaign and how this may have contributed to a more supportive cessation environment for Māori. The whānau group comprised more females and people aged 45+ years than the smokers group.
A structured closed ended interviewer administered questionnaire was used to collect information from research participants. The questionnaire included question items previously used in New Zealand and Australian Quit campaign surveys.14
Questionnaires were administered via a computer aided telephone interviewing (CATI) system. Māori interviewers were used as a means of encouraging Māori to participate in the survey and to ensure that interviews were conducted in a culturally appropriate manner.25
Campaign awareness was measured via a series of questions determining unprompted and prompted recall. In the follow-up surveys, unprompted recall of IAW was assessed by asking: “During the past three months have you seen, heard or read any advertisement about smoking, quitting smoking, second hand smoke or being a non-smoker?” If prompting was needed, the respondent was given a short description of the campaign and the question re-asked. Prompted awareness questions followed the smoking behaviour questions so as not to influence answers to these questions.
Smokers and recent quitters who recalled the IAW campaign were asked if it had made them more or less likely to quit smoking or had made no difference. They were asked if they had talked to anyone, such as whānau, friends or workmates about their or others’ smoking in the previous few months. If they had, they were asked what they discussed and what prompted the discussions. Smokers and recent quitters were also asked how much influence the TVCs had in prompting any attempts to quit smoking.
Repeated cross sectional surveys were used to collect information for this study. Two baseline surveys were conducted before the campaign was launched – the first in January 2001 and the second in July 2001. The first follow-up survey was carried out in December 2001, four months following the launch and the second in September 2002, one year after the launch.
The samples for this study were derived from randomly selected Māori registered on the national electoral rolls. Details of selected Māori were electronically telematched to phone numbers. This provided phone numbers for residential households where it was likely that a Māori person resided. Within each randomly selected household, one participant 18 years or older was randomly selected using the next birthday method. In the event that the selected participant was not immediately available, eight call back attempts were made before the household was counted as a non-response.
This study reports on findings from the second baseline and the second follow-up surveys. Comparisons are made between the two follow-up surveys where appropriate. More detailed results are reported elsewhere.26
Statistical methods and analysis
Smoker respondent survey data was weighted to reflect the age and sex distribution of Māori smokers from the 1996 New Zealand Census of Population and Dwellings and the 1996/97 New Zealand Health Survey27 No similar data was available for the whānau sample, so each individual that participated in the whānau survey was weighted to the age and sex proportions of the combined sample from the second baseline survey and the first follow-up survey. The average response rate for both surveys was 57%. The design effect for the smoker, whānau and combined groups in the follow-up survey was de=1.06.
Data was analysed using SAS Version 13.0 to identify significant changes across survey years. Unless otherwise stated, the 'smokers’ group includes the recent quitters. Reference to the ‘combined sample’ refers to the samples of both smokers/quitters and whānau together.
Results are reported if they were significant at the 95% level (p<0.05) after adjustment for the design effect. Demographic characteristics for each of the two survey samples are shown in Table 2.
Table 2. Demographic characteristics of smoker and recent quitter respondents and wh¯nau respondents (weighted).
|< 25 years||22%||20%||9%||9%|
Quitline monitoring data indicated that the number of Māori and other Quitline callers increased following launch of the campaign and the percentage of Māori callers among all callers increased from 20% prior to launch to 25% in the two months following launch.
Unprompted recall of any smoking related advertising increased significantly among smokers between baseline and follow-up from 82% to 89%. Prompted and unprompted (total) recall of the IAW campaign, a measure of exposure to campaign advertising, was 78% among smokers and 73% among whānau one year following the campaign's launch (Table 3). There were no gender differences in awareness.
Table 3. Unprompted and prompted recall of IAW among smokers and whānau.
|Unprompted recall of IAW||23%|
|Prompted recall of IAW||55%|
|Total recall IAW||78%|
|Unprompted recall of IAW||24%|
|Prompted recall of IAW||49%|
|Total recall IAW||73%|
Reactions from smokers and whānau to the IAW campaign were positive overall and were largely similar. Among smokers, the campaign received high ratings for being very believable and very relevant and these increased significantly between the first and second follow-up surveys (Table 4). The proportion of smokers stating that the TVCs were very thought provoking was slightly lower and there was no significant increase in ratings between the two time periods.
Table 4. Reactions to the IAW campaign.
|Thought provoking (% very)||45%||48%|
|Believable (% very)||62%||73%a|
|Relevant (% very)||57%||67%a|
|Ads influence quitting (% more likely)||51%||54%|
|Thought provoking (% very)||43%||54%a|
|Believable (% very)||65%||75%a|
|Relevant (% very)||69%||64%|
|Ads influence quitting (% more likely)||40%||51%a|
Many whānau participants thought that the TVCs were very believable and very relevant at second follow-up. Ratings for believability and whether the advertisements were thought provoking increased significantly over the 10 months among whānau participants, especially females.
At the time of the second follow-up, just over half of smokers and whānau who recalled the IAW campaign reported that it had made themselves (in the case of smokers) or would make smokers (in the view of whānau) more likely to quit (Table 4). There was no variation between the first and second follow-ups in the proportion of smokers who thought the IAW advertisements would make smokers more likely to quit. However, there was a significant increase in the proportion of whānau who thought this, from 40% to 51%.
Influence on smoking and quitting behaviour
Motivation to quit smoking across the surveys was measured according to stage of change indicators as defined by Prochaska et al.28 Results suggest there was no change in motivation to quit among Māori smokers across the study period.
Associations between perceptions of the IAW campaign and readiness to quit show that smokers who were more motivated to quit smoking in the shorter term were more likely to believe IAW would make a smoker more likely to quit. For example, two-thirds (67%) of smokers in the second follow-up who thought the IAW campaign would more likely make a smoker quit, planned to quit themselves within the next six months (Table 5). This compares to 40% of smokers who thought the IAW campaign would make a smoker less likely to quit and 40% who thought the campaign would make no difference. It should be noted that as the analysis is based on cross-sectional data it is difficult to establish any causal relationships between the IAW campaign and motivation to quit.
Table 5. Relationship between intention to quit and campaign influence on smokers to quit, second follow-up.
|Plan to quit in next six months||(n=168) 67%||(n=145) 40%||(n=18) 40%|| |
| || || || ||0.28(p<.001)|
|No plan to quit in next six months||33%||60%||60%|| |
Discussing smoking and quitting
Just over half of smokers (53%) had talked to someone about their own smoking in the four months prior to the first follow-up survey (Table 6). This was similar for the second follow-up (48%). Whānau members were more likely to have talked to a smoker about smoking (64% and 62% in each follow-up survey) than a smoker was to have talked to someone about their own smoking. Smokers mentioned whānau as the main prompt for their discussions about smoking.
Table 6. Held discussions with whānau, friends or workmates about your/their smoking in the previous four months.
Self-reported data indicated that the IAW campaign played a significant role in prompting discussions about smoking (Table 7). This was especially the case among smokers. At first follow-up 75% and at second follow-up 79% said that the IAW TVCs had either ‘a lot’ or 'some’ influence in prompting discussions about smoking. The proportion of whānau saying IAW had some or a lot of influence in prompting discussions increased from 65% to 70%.
Table 7. Influence of IAWTVCs in prompting discussions about smoking in the previous four months.
|Don't know||1 %||0%||1%||0%|
These results indicate that the IAW campaign TVCs were seen and recalled by a substantial proportion of both Māori smokers and their whānau. In addition, the campaign was seen as being highly believable and relevant by those who had seen the TVCs. Just over half of smokers felt that the IAW campaign had an influence in making them more likely to quit smoking and this level was maintained in both follow-up surveys. Results also indicate that whānau is an important motivator to quit smoking.
Additional analysis shows that this and other cessation media campaigns aired in New Zealand are successful in generating calls from Māori to the Quitline.18 A supportive, empathetic campaign such as IAW provides a balance to the EC campaign. Both are effective at generating calls to the Quitline (including from Māori smokers) and encouraging people to think about quitting29 without portraying a negative image of Māori as smokers. Such campaigns are commonly seen as an important addition to the mix of tobacco control interventions that aim to increase quit attempts. They complement other ‘non-voluntary’ interventions such as increased tobacco taxes and workplace smoking bans.
These findings support the intention of article four of the World Health Organization Framework Convention of Tobacco Control which articulates the need for indigenous individuals and communities to participate in the development, implementation and evaluation of tobacco control programs that are socially and culturally appropriate to their needs and perspectives.30
Māori smokers have stated that a supportive smokefree environment is an important component in making the decision to give up smoking and to remain quit.20 The information from the whānau group in the baseline and follow-up surveys for this study provides useful additional insight into the role of the whānau in supporting Māori to quit. It also highlights the importance of campaign support from a group of primarily non-smokers.
Overall, the IAW campaign has been effective for Māori. It plays an important role in providing both smokers and their whānau with information about the benefits of quitting smoking and also where to obtain cessation support. While the campaign targeted a priority group for reducing smoking prevalence (Māori) it also appealed and resonated with the general population as evidenced through survey responses from whānau (some of whom were not Māori). This combination of responses suggests that the campaign has had a positive effect on the smoking and cessation attitudes and behaviours of both Māori and others. It underlines the importance of developing campaigns for Māori smokers to ensure that they have ownership over the campaign and that key messages are relevant and resonate. This ensures that the impacts of the campaign are maximised among a group where almost one in every two adults smokes.
This study was funded by the New Zealand Ministry of Health and The Quit Group. The design of the study was the responsibility of Andrew Waa and The Quit Group. We thank the Health Sponsorship Council for providing resource and support for the development and evaluation of the campaign, and Forsyte Research and the Whariki Research Group for contributing to survey development, undertaking the interviews and analysing the results. We thank Helen Glasgow for review comments and the smokers and whānau interviewed in each of the surveys. Hard copies of the five unpublished references are available from the first author.