Report on Rapid Assessment of Usefulness of Graphic Health Warning based Anti-tobacco Advertisements in National Dailies

National Institute of Preventive and Social Medicine (NIPSOM) Mohakhali, 1212, Bangladesh

With support from

World Health Organization Bangladesh Country Office

September 2017

Table of Contents

Panel of Investigators 2

Summary 3

Introduction 4

Objectives 6

Methods 7

Findings of the study 12

Discussion 19

Conclusions and recommendations 21

References 22

1

Panel of Investigators

Principal Investigator Professor Dr. Md Shafiqul Islam Professor of Epidemiology, Department of Epidemiology, NIPSOM Co-principal Professor Dr. Baizid Khoorshid Riaz Investigator Director, NIPSOM and Head of the Department of Public Health and Hospital Administration, NIPSOM Investigators Dr. Khorshed Ali Miah Assistant Professor, Department of Public Health and Hospital Administration, NIPSOM Dr. Ummul Khair Alam Medical Officer, Department of Population Dynamics, NIPSOM Dr. K. M. Bayzid Amin Medical Officer, Department of Public Health and Hospital Administration, NIPSOM Dr. Md Noor Ashad-Uz-Zaman Medical Officer, Department of Public Health and Hospital Administration, NIPSOM

Technical support team from WHO

Dr M Mostafa Zaman Adviser, Research & Publication, WHO, Dhaka, Bangladesh Dr Tara Kessaram Medical Officer, Noncommunicable Diseases Dr S Mahfuzul Huq National Professional Officer (Tobacco Control) Mr Moniruzzaman National Consultant- Injury & Disability Prevention

2

Summary

This study was conducted to assess the usefulness of Graphic Health Warning (GHW) based anti-tobacco advertisements published in selected daily newspapers. It was a cross-sectional study using quantitative and qualitative methods and was conducted from 8 December to 31 December 2016. Data were collected from a total of 24 urban Primary Sampling Units (PSUs) from the division, district and upazila (sub-district) levels covering eight divisions of Bangladesh. Multi-stage geographical cluster sampling was used. A total of 3120 households were selected from the 24 PSUs (130 households from each PSU) for recruitment of participants. Face-to-face interviews were conducted to collect data from the household respondents. In addition, 16 key informants from the district level were separately interviewed using a key informant interview guideline.

In this study, a total of 2982 household respondents were interviewed. The response rate was 95.5%. Overall 34.5% of the respondents read newspapers. Of the total sample, irrespective of whether they read newspapers or not, 12.5% noticed a GHW-based advertisement. Among those who noticed a GHW-based advertisement, almost all (95%) said that the advertisement could clearly transmit the message that tobacco use is bad for health. Over four-fifths (82%) of those who noticed the advertisement considered GHW-based advertisements in newspapers to be an effective tobacco control tool; about three-quarters of respondents discussed the harms of tobacco and advised tobacco users to quit after seeing these advertisements. Around four-fifths of tobacco users thought of quitting after seeing the advertisements, and 85.5% of them attempted to quit tobacco. Nearly one-quarter of these tobacco users who had attempted to quit reported that they successfully did so (17 respondents).

Almost half of the key informants reported that the advertisements made tobacco users think about quitting tobacco. Most of the key informants reported that the newspaper was a good or partially good media through which anti-tobacco messages can be disseminated. Two-thirds of the key informants thought that the images used were strongly graphic. Three-quarters of the key informants thought that more such advertisements should appear in the local newspapers.

Based on these study findings, it is recommended that similar GHW-based anti-tobacco advertisements be published more frequently at regular intervals, and that such advertisements also be published in local well-circulated newspapers. Other platforms for advertising could be utilized as well, such as social media (Facebook, Twitter, YouTube, etc.) and electronic media.

3

Introduction

Communicating the health effects of tobacco use is part of a comprehensive tobacco control policy, and health warnings on tobacco packages are among the most widespread strategies to raise awareness of the health risks of tobacco.1 Evidence shows that health warning labels have been associated with increased awareness of smoking risks; reduced appeal of smoking and smoking initiation among youth; increased motivation and intention to quit among smokers; increased cessation behaviors; increased use of cessation resources; increased likelihood that ex-smokers will remain abstinent; and reduced consumption levels among smokers.2 3 4 5 Although the impact of all warnings has been shown to lessen over time, pictorial warnings are less impacted by this wear-out effect.6 7

By the end of 2014, a total of 77 countries or jurisdictions had implemented Graphic Health Warnings (GHWs)8 as per Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control.9 Recognizing the potential impact of GHWs, the government of Bangladesh mandated that GHWs be printed on tobacco product packaging effective from March 2016, and approved nine GHWs for this purpose. The government, with technical support from WHO, also carried out three rounds of GHW based anti-tobacco advertising in selected newspapers. The first two rounds of advertising occurred in the last quarter of 2015 and the third round in May 2016 in order to make the public aware of the detrimental health effects of tobacco use. Table 1 provides details about the publications.

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Table 1. Details of Graphic Health Warning (GHW) based anti-tobacco advertisements published in national dailies.

Round When In which newspapers Comments I October – The The National Tobacco Control Cell (NTCC) of the November Ministry of Health & Family Welfare published 2015 The nine different GHW based anti-tobacco The Bhorer Kagoj advertisements in nine consecutive weeks in six The Financial Express national dailies, with support from WHO. The Daily

II December The Bangladesh Protidin With support from WHO, the NTCC published 2015 The Kaler Kantho GHW ‘Smoking Causes Stroke’ based anti- The Daily Star tobacco advertisement in five national dailies The Daily Jugantar simultaneously in one day to supplement the The Amader Orthoneeti anti-tobacco TV campaign titled ‘Brain’. The ‘Brain’ campaign was undertaken by the NTCC in partnership with Vital Strategy.

III May 2016 The Bangladesh Pratidin Responding to a request received from the The Kaler Kantho NTCC, WHO supported the Bureau of Health The Daily Education of the Directorate General of Health The Ittefaq Services to publish one GHW based anti-tobacco The Bhorer Kagoj advertisement in eight national dailies on 31 The Financial Express May 2016 – the World No Tobacco Day. Dainik The New Age

IV November The Bangladesh Pratidin With support from WHO, the NTCC published 2016 The Ittefaq one GHW based anti-tobacco advertisement in The Financial Express five national dailies in November 2016. The Jugantor The

The advertisements were published in national dailies with high circulation in order to reach the maximum number of readers. (Copy of a page of newspaper with the published advertisement is annexed as an example – annex 1).

At this stage, the need was felt to conduct a rapid assessment of the usefulness of these GHW- based anti-tobacco advertisements in newspapers, where ‘usefulness’ means effectiveness, suitability or advantage of this campaign, and the study was designed accordingly. Findings of this assessment will be useful for improving planning and implementation of similar national interventions, in order to contribute to achieving the tobacco use target in the WHO Global action plan for the prevention and control of NCDs 2013-2020: a 30% relative reduction in the prevalence of current tobacco use by 2025.10

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Objectives

General objective: To assess the usefulness of GHW based anti-tobacco advertisements in national dailies/newspapers.

Specific objectives: 1. To ascertain the reach of the GHW based anti-tobacco advertisements to the general public residing in urban areas (percentage of respondents who noticed the advertisement). 2. To determine the percentage of respondents who discussed the health risks of tobacco use after seeing the advertisements. 3. To determine the percentage of tobacco users who thought about quitting tobacco after seeing the advertisements. 4. To assess the opinion of the respondents, who noticed the advertisement, on the effectiveness of GHW based anti-tobacco advertisement in newspapers as a tobacco control tool. 5. To explore the suggestions from the key informants for further improvement of GHW based anti-tobacco advertisements.

6

Methods

Sampling design

This was a cross-sectional study using a mixed (quantitative and qualitative) approach. Data were collected in December 2016. Persons (both tobacco users and non-users) aged 18 years and above who resided in urban areas were the target of the household survey.

The estimated sample size for this household survey was calculated using the formula11 n=z2p(1-p)/d2 assuming prevalence of noticeability of anti-tobacco information in newspapers in Bangladeshi adults as 0.09 (9.0%)12 and d= 0.045 (half of p if p is below 10%)11 in this case as per recommended evidence. The preliminary sample size was 155 which was then adjusted by number of reporting domains (12: male /female for six age groups), design effect (1.5) and individual response rate (0.90), resulting in the final sample size of 3,120.

For the household survey, a multi-stage geographical cluster sampling method was used. A total of 24 urban Primary Sampling Units (PSUs) were purposively selected – one PSU from each of three administrative levels (division, district and upazila) in the eight divisions of Bangladesh. The PSUs selected were from the mahallas (the smallest defined geographical unit in urban areas) where i) the City Corporation Office was located (at divisional headquarter level); ii) the Municipality Office was located (at district headquarter level); and iii) the Upazila Parishad Office was located (at sub- district headquarter level). The district headquarters nearest to the divisional headquarters, and the upazila headquarters (subdistricts) nearest to the selected district headquarters were selected. This study included urban areas only under the assumption that the reach and readership of newspapers are low in rural areas.

The field organizer listed the first 130 households from each PSU (130 x 24=3,120). From each household, only one respondent was selected randomly using the KISH table. To maintain an equal gender ratio, one household was selected for men and one was selected for women, alternately.

A household in this study was defined, based on the Bangladesh Bureau of Statistics (BBS) definition, as “a dwelling in which persons either related or unrelated are living together and taking food from the same kitchen.” The time of staying together was considered as most days of the 30 days prior to the interview day.

Qualitative data were collected by key informant interviews (KII). A total of 16 key informants were separately interviewed at the district level (two informants from one district in each division). Member secretaries of the District Tobacco Control Taskforce Committees and

7 representatives of civil society involved in tobacco control activities were purposively selected for the interviews, in consultation with the National Tobacco Control Cell (NTCC).

Data Collection Tools

Two separate data collection tools were used; the household survey questionnaire and a key informant interview (KII) guideline. The questions for the survey were adapted from the GATS questionnaire “media evaluation” and other relevant literature. A group of experts including WHO technical officers developed the questionnaire and the KII guideline, through a series of consultative meetings. The household questionnaire was translated into Bangla and pre-tested before data collection. The questionnaire and interview guideline for KII are attached in Annex 2 and 3, respectively. Example of GHW based advertisements shown to the respondents are attached in Annex 4.

Field Testing of Questionnaire Pre-testing of the household questionnaire was conducted with a similar population to the target sample (adults aged 18 years and older, living in urban areas). The questionnaire was pre- tested on 44 respondents by a team of nine public health experts of the National Institute of Preventive and Social Medicine (NIPSOM). This helped to improve the questionnaire through clarification of the wording, meaning, and understandability of the questions. The questionnaire was then finalized to be used in the field.

Questionnaire development and field testing of the questionnaire (at Mohakhali, Dhaka)

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Field team and training

Eight teams were formed in order to collect data from the field covering eight divisions. Each team was composed of one field organizer and two field enumerators (one male, one female). All of them had a minimum of a bachelor degree and previous experience of data collection in national level household surveys.

A day-long training of the field team (total 24 persons) was conducted before their deployment to the field, by the facilitators from NIPSOM and the WHO technical team. Participants were oriented to the study protocol, questionnaire, data collection procedure, interview technique, field operation procedures and other related issues.

Training of field workforce at NIPSOM, Dhaka

Data Collection Procedure

The day before the household visit, the field organizers went to the selected PSU, identified house number one based on the numbering done by the local government authority, and subsequent 129 households (mapping and listing of households). The next morning, field enumerators along with field organizers started face-to-face interviews from house number one and continued to interview people from consecutive households till the 130th house was reached.

The co-investigators of the study went to eight district headquarters and interviewed the key informants.

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Data collection from the field

Key informant interviews

Data Entry and Reporting

After completion of data collection, household data were entered in Microsoft Access. Data were cleaned at central level (NIPSOM IT Lab) and aggregated into a single file. Then the data were transposed to an analyzable raw data format. Data analyses were performed using SPSS (version 18.0). All categorical variables were calculated as frequency and percent. For continuous variables, mean, median, range, and inter-quartile range were calculated.

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Key informant interview data were summarized and presented in narrative fashion under appropriate thematic headings.

Ethical Approval and Consent

Ethical clearance was obtained from Institutional Review Board (IRB) of the National Institute of Preventive and Social Medicine (NIPSOM), Government of Bangladesh. Informed consent (either signature or thumb impression) was taken from each respondent.

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Findings

Household Survey

Overall, 2982 respondents were interviewed (response rate, 95.5%). Of all the respondents, 51.3% were women. The mean age of the respondents was 39.5 years (men, 39.5 years and women 39.6 years). The primary occupations among men were business (28.5%), service (27.9%) and self- employment (20.3%). The majority of the women were homemakers (80.2%). The median year of schooling was 8 years (9 years for men and 7 years for women) (Table 2).

Table 2: Socio-demographic characteristics of the respondents, (n=2982)

Variables Men Women Both (n = 1451) (n=1531) (n=2982) Age group in years n (%) n (%) n (%) 18-24 229 (15.8) 199 (13.0) 428 (14.4) 25-34 374 (25.8) 438 (28.7) 811 (27.2) 35-44 335 (23.1) 360 (23.6) 695 (23.3) 45-54 263 (18.0) 271 (17.8) 534 (17.9) 55-64 148 (9.9) 139 (9.1) 287 (9.6) 65+ 108 (7.4) 119 (7.8) 227 (7.6) Total 1451(48.7) 1531 (51.3) 2982 (100.0)

Mean age in years (range) 39.5 (18 –98) 39.6 (18 –100) 39.5 (18 –100)

Occupation n (%) n (%) n (%) Student 105 (7.2) 33 (2.2) 138 (4.6) Unemployed 41 (2.8) 45 (2.9) 86 (2.9) Homemaker 50 (3.4) 1228 (80.2) 1278 (42.9) Service 405 (27.9) 126 (8.2) 531 (17.8) Business 414 (28.5) 9 (0.6) 423 (14.2) Self employed 295 (20.3) 14 (0.9) 309 (10.4) Retired 87 (6.0) 19 (1.2) 106 (3.6) Others 53 (3.8) 57 (3.6) 110 (3.7) Refused 1 (0.1) 0 (0.0) 1 (0.1)

Years of Schooling median (IQR) 9 (4 ,12) 7 (2, 10) 8 (3, 12)

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Table 3 shows that out of all respondents, 34.5% were newspaper readers. A higher percentage of men (50.3%) reported that they read the newspaper, compared to women (19.5%).

Table 3: Distribution of the respondents by newspaper readership (n=2982)

Sex Age group Reads newspapers Year Number of respondents n (%) Men 18-24 229 119 (52.0) 25-34 374 198 (52.9) 35-44 335 160 (47.8) 45-54 261 142 (54.4) 55-64 144 73 (50.7) >65 108 38 (35.2) Total 1451 730 (50.3)

Women 18-24 199 31 (15.6) 25-34 437 102 (23.3) 35-44 360 81 (22.5) 45-54 273 56 (20.5) 55-64 143 23 (16.1) >65 119 6 (5.0) Total 1531 299 (19.5)

Both 18-24 428 150 (35.0) 25-34 811 300 (37.0) 35-44 695 241 (34.7) 45-54 534 198 (37.1) 55-64 287 96 (33.4) >65 227 44 (19.4) Total 2982 1029 (34.5 )

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The study revealed that 12.5% of all respondents, irrespective of being a newspaper reader or not, noticed GHW based anti-tobacco advertisements in newspapers (Figure 1).

12.5%

Yes No 87.5%

Figure 1: Distribution of the respondents, based on whether they have noticed GHW based anti- tobacco advertisements in national dailies or not (n = 2982)

Table 4 shows the distribution of the respondents who noticed any of the 9 GHW based anti-tobacco advertisement in the newspapers, and their thoughts on these. Of those who noticed GHW based anti-tobacco advertisements (n=373, 12.5% of total respondents), nearly all (95%) said that the advertisements transmitted the underlying message of health hazards of tobacco use clearly. More than 80% stated that it was an effective tobacco control tool. The respondents also reported that after noticing these advertisements, they discussed the health effects of tobacco use with others (76.9%) and advised other tobacco users to quit (78.0%).

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Table 4: Noticeability, impression and response to the GHW-based anti-tobacco advertisements in national dailies, n (row %)

Sex Age group Noticed any Noticed times Transmitted Considered Opinion on graphics used in the Responses Noticed same (years) GHW-based Message an effective advertisement graphics on advertisements clearly/ yes tobacco packs of 1 to 3 4 to 6 >7 times control tool Strongly graphic All right Too weak Discussed Advised tobacco times times health- tobacco products effects with users to quit others n Men 18-24 229 32 (14.0) 17 (53.1) 10 (31.2) 5 (15.6) 32 (100.0) 29 (90.6) 26 (81.2) 5 (15.6) 1 (3.1) 20 (62.5) 20 (62.5) 31 (96.9) 25-34 374 56 (15.0) 38 (67.9) 11 (19.6) 7 (12.5) 52 (92.9) 43 (76.8) 43 (76.8) 10 (17.9) 3 (5.4) 43 (76.8) 43 (76.8) 50 (89.3) 35-44 335 51 (15.2) 26 (51.0) 18 (35.3) 7 (13.7) 48 (94.1) 45 (88.2) 39 (76.5) 12 (23.5) 0.0 37 (72.5) 37 (72.5) 47 (92.2) 45-54 261 41 (15.7) 22 (53.7) 11 (26.8) 8 (19.5) 38 (92.7) 33 (80.5) 28 (68.3) 11 (26.8) 2 (4.9) 34 (82.9) 33 (80.5) 38 (92.7) 55-64 144 18 (12.5) 9 (50.0) 7 (38.9) 2 (11.1) 18 (100.0) 18 (100.0) 16 (88.9) 2 (11.1) 0.0 18 (100.0) 17 (94.4) 18 (100.0) >65 108 14 (13.0) 10 (71.4) 2 (14.3) 2 (14.3) 12 (85.7) 11 (78.6) 9 (64.3) 4 (28.6) 1 (7.1) 12 (85.7) 12 (85.7) 10 (71.4) Total 1451 212 (14.6) 122 (57.5) 59 (27.8) 31 (14.6) 200 (94.3) 178 (84.4) 161 (75.9) 44 (20.8) 7 (3.3) 164 (77.8) 162 (76.9) 194 (91.5)

Wom 18-24 199 28 (14.1) 23 (82.1) 2 (7.1) 3 (10.7) 25 (89.3) 22 (78.6) 24 (85.7) 4 (14.3) 0.0 23 (82.1) 24 (85.7) 25 (89.3) en 25-34 437 53 (12.1) 34 (64.2) 16 (30.2) 3 (5.7) 50 (94.3) 41 (77.4) 50 (94.3) 3 (5.7) 0.0 39 (73.6) 41 (77.4) 47 (88.7) 35-44 360 45 (12.5) 27 (60.0) 9 (20.0) 9 (20.0) 44 (97.8) 35 (77.8) 44 (97.8) 1 (2.2) 0.0 33 (73.3) 36 (80.0) 36 (80.0) 45-54 273 25 (9.2) 17 (68.0) 5 (20.0) 3 (12.0) 25 (100.0) 22 (88.0) 22 (88.0) 2 (8.0) 1 (4.0) 17 (68.0) 18 (72.0) 16 (64.0) 55-64 143 10 (7.0) 5 (50.0) 4 (40.0) 1 (10.0) 10 (100.0) 7 (70.0) 10 (100.0) 0 0.0 10 (100.0) 9 (90.0) 8 (80.0) >65 119 0 ------Total 1531 161 (10.5) 106 (65.8) 36 (22.4) 19 (11.8) 154 (95.7) 127 (78.9) 150 (93.2) 10 (6.2) 1 (0.6) 122 (75.8) 128 (79.5) 132 (82.0)

Both 18-24 428 60 (14.0) 40 (66.7) 12 (20.0) 8 (13.3) 57 (95.0) 51 (85.0) 50 (83.3) 9 (15.0) 1 (1.7) 43 (71.7) 44 (73.3) 56 (93.3) 25-34 811 109 (13.4) 72 (66.1) 27 (24.8) 10 (9.2) 102 (93.6) 84 (77.1) 93 (85.3) 13 (11.9) 3 (2.8) 82 (75.2) 84 (77.1) 97 (89.0) 35-44 695 96 (13.8) 53 (55.2) 27 (28.1) 16 (16.7) 92 (95.8) 80 (83.3) 83 (86.5) 13 (13.5) 0.0 70 (72.9) 73 (76.0) 83 (86.5) 45-54 534 66 (12.4) 39 (59.1) 16 (24.2) 11 (16.7) 63 (95.5) 55 (83.3) 50 (75.8) 13 (19.7) 3 (4.5) 51 (77.3) 51 (77.3) 54 (81.8) 55-64 287 28 (9.8) 14 (50.0) 11 (39.3) 3 (10.7) 28 (100.0) 25 (89.3) 26 (92.9) 2 (7.1) 0.0 28 (100.0) 26 (92.9) 26 (92.9) >65 227 14 (6.2) 10 (71.4) 2 (14.3) 2 (14.3) 12 (85.7) 11 (78.6) 9 (64.3) 4 (28.6) 1 (7.1) 12 (85.7) 12 (85.7) 10 (71.4) Total 2982 373 (12.5) 228 (61.1) 95 (25.5) 50 (13.4) 354 (94.9) 306 (82.0) 311 (83.4) 54 (14.5) 8 (2.1) 286 (76.9) 290 (78.0) 326 (87.4)

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Table 5 presents the data for current tobacco users who noticed the GHW-based anti-tobacco advertisements. Of the respondents who noticed GHW based anti-tobacco advertisements in the newspaper (n=373), 26.8% were current tobacco users (n=100)a.

Table 5: Distribution of tobacco users who noticed GHW-based anti-tobacco advertisements (n=100), by type of tobacco use.

Age group (years) Type of Tobacco Use (n=100) Current tobacco Sex Denominator Smoking Chewing Dual users (n) n (row %) n (row %) n (row %) n (row %) Men

18-24 32 6 (18.8) 5 (15.6) 1 (3.1) 0.0

25-34 56 15 (26.8) 12 (21.4) 2 (13.6) 1 (1.8)

35-44 51 20 (39.2) 13 (25.5) 4 (7.4) 3 (5.3)

45-54 41 20 (48.8) 14 (34.1) 2 (4.9) 4 (9.8)

55-64 18 5 (27.8) 3 (16.7) 1 (5.6) 1 (5.6)

>65 14 3 (21.4) 2 (14.3) 1 (7.1) 0.0

Total 212 69 (32.5) 49 (23.1) 11 (5.2) 9 (4.2)

Women

18-24 28 2 (7.1) 0.0 2 (7.1) 0.0

25-34 53 7 (13.2) 1 (1.9) 6 (11.3) 0.0

35-44 45 10 (22.2) 0.0 10 (22.2) 0.0

45-54 25 8 (32.0) 1 (4.0) 7 (28.0) 0.0

55-64 10 4 (40.0) 0.0 4 (40.0) 0.0

>65 0 0.0 0.0 0.0 0.0

Total 161 31 (19.3) 2 (1.2) 29 (18.1) 0.0

Both

18-24 60 8 (13.3) 5 (8.3) 3 (5.0) 0.0

25-34 109 22 (20.2) 13 (11.9) 8 (7.3) 1 (0.9)

35-44 96 30 (31.2) 13 (13.5) 14 (14.6) 3 (3.1)

45-54 66 28 (42.4) 15 (22.7) 9 (13.6) 4 (6.1)

55-64 28 9 (32.1) 3 (10.7) 5 (17.9) 1 (3.6)

>65 14 3 (21.4) 2 (14.3) 1 (7.1) 0.0

Total 373 100 (26.8) 51 (13.7) 40 (11.5) 9 (2.4)

a ‘Current Tobacco User’ was defined as ‘an adult who has smoked 100 cigarettes/ biris in his or her lifetime and who currently smokes / who currently use smokeless tobacco/ who uses both – either every day or some days.

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Of total current tobacco users (n=100), more than 80% (83) thought to quit after seeing the advertisement(s), and of those who thought to quit, 86% attempted to do so. Of those who attempted to quit, 23.9% reported successfully quitting (17 men, 0 women) as shown in Table 6.

Table 6: Distribution of current tobacco users (n=100) by stages of quitting after seeing the GHW- based anti-tobacco advertisements, n (row %)

Age group Successfully quit Attempted to quit (years) Thought to (out of those Sex (out of those who quit who attempted n thought to quit) to quit) Men

18-24 6 4 (66.7) 4 (100.0) 1 (25.0) 25-34 15 14 (93.3) 12 (85.7) 3 (25.0) 35-44 20 18 (90.0) 18 (100.0) 7 (38.9) 45-54 20 13 (65.0) 12 (92.3) 3 (25.0) 55-64 5 5 (100.0) 4 (80.0) 1 (25.0) >65 3 3 (100.0) 3 (100.0) 2 (66.7) Total 69 57 (82.6) 53 (93.0) 17 (32.1) Women

18-24 2 2 (100.0) 1 (50.0) 0.0 25-34 7 6 (85.7) 4 (66.7) 0.0 35-44 10 9 (90.0) 6 (66.7) 0.0 45-54 8 5 (62.5) 4 (80.0) 0.0 55-64 4 4 (100.0) 3 (75.0) 0.0 >65 0 0.0 0.0 Total 31 26 (83.9) 18 (69.2) 0.0 Both

18-24 8 6 (75.0) 5 (83.3) 1 (20.0) 25-34 22 20 (90.9) 16 (80.0) 3 (18.8) 35-44 30 27 (90.0) 24 (88.9) 7 (29.2) 45-54 28 18 (64.3) 16 (88.9) 3 (18.8) 55-64 9 9 (100.0) 7 (77.8) 1 (14.3) >65 3 3 (100.0) 3 (100.0) 2 (66.7) Total 100 83 (83.0) 71 (85.5) 17 (23.9)

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Key Informant Interviews

A total of 16 key informants were separately interviewed at the district level. Eight key informants were civil surgeons as they are the member secretaries of the District Tobacco Control Taskforce Committee, and eight informants were from NGOs involved in tobacco control activities. A pretested key informant guideline was used for key informant interviews (Annex 3). Data were analyzed in narrative fashion under following thematic headings.

Clarity of the advertisements

Half of the key informants thought that the advertisements carried the messages about health hazards of tobacco use successfully. One of the key informants said, “In our country, many people read newspaper. If after seeing the advertisement in a newspaper a mother realizes that the consequences of taking tobacco are so harmful then she would forbid her children to do so.”

Opinion on Introduction of Graphic Health Warnings

Most of the key informants reported that the newspaper was a good or partially good media through which anti-tobacco messages can be disseminated. More than half of the key informants mentioned that the advertisement had a role in preparing the general public to see GHWs on packages of tobacco products. Two-thirds of the key informants thought that the images used were strongly graphic in a sense that they had the potential to make people feel uneasy. Nearly half of the informants said that the advertisements were good enough to make tobacco users think about quitting tobacco. One key informant mentioned, “Tobacco cannot be controlled by act only. By only enacting laws, everything cannot be done effectively. So to control tobacco effectively, there should be strong enforcement of law, supplemented by awareness building, for example, through graphical health warning based advertisement in dailies.”

Recommendations about advertisements

Three-quarters of the key informants thought that such advertisements should appear in both national and local newspapers more frequently. Use of electronic media (television, radio) and social media (Facebook, Twitter, YouTube) were also recommended.

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Discussion

Mass media campaigns are among the most effective ways to warn about the dangers of tobacco use, to encourage smoking cessation, and to create support for tobacco control policies. For years, the tobacco industry used mass media to its advantage in order to present smoking as an attractive and socially-desirable behavior. Now governments and advocates are using this tool to reverse those perceptions and shift behavior.16

This study demonstrates the usefullness of GHW-based advertisements in national dailies, based on the urban public’s opinion that these advertisements transmit messages of the health hazards of tobacco use clearly, and prompt community discussion on the health effects of tobacco use and quitting. Furthermore, a small but direct impact on tobacco users has been noted. Of the tobacco users who saw the GHW based anti-tobacco advertisements in national dailies, more than four-fifths thought to quit. Among them, around 85% attempted to quit and of these nearly one- quarter reported success. These results are similar to the impact of health warnings on tobacco packaging in Bangladesh. According to the GATS Bangladesh 2009 report, overall, 74.4% of current smokers thought about quitting after noticing warning labels on cigarette packages.12 Evidence from a study by Fathelrahman AI et al. from Malaysia, shows that after seeing the GHW on cigarette packages, 55.5% smokers had the intention to quit smoking and 61.8% quit successfully.4 In Senegal and Norway, anti-tobacco campaign showing accumulation of tar in smoker’s lung (popularly known as the Sponge Campaign) motivated 22% and 59% of people to make quit attempts respectively17.

Two-thirds of the key informants thought that the images used were strongly graphic in a sense that they had the potential to make people feel uneasy. Of course, to be effective, graphics used in pictorial health warning and in anti-tobacco advertisements are to be strong. From that point of view this is a compliment. On TV, in print, and increasingly through innovative uses of internet- based social media platforms, mass media campaigns now use graphic, emotional images and messages that starkly present the health effects of tobacco use. Graphic advertisements convince people about the true dangers of tobacco use, cut through smokers’ defenses, and illustrate the urgent need for tobacco control policies. Unlike messages that rely on humor or irony, they translate easily and well across languages and cultures.

The study found that over one-third of the total respondents (34.5%) read newspapers. Of note, this is higher than the result from the Bangladesh Population and Houseing Census 2011 which showed that 25.8% of the urban population read newspapers.13 The current study revealed that

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12.5% of the total sample, irrespective of being a newspaper reader or not, noticed GHW based anti- tobacco advertisements in national dailies.

To the best of our knowledge, this assessment of the usefulness of a GHW based anti- tobacco media campaign is the first of its kind. This study demonstrates a different yet effective application of Graphic Health Warnings. An advantage of this study is that it explored and demonstrated the impact of GHW based advertisements in national dailies, beyond newspaper readers, and beyond tobacco users. To maximize the recall of participants, data were collected within 30 days of the last round of advertisements, published in the national dailies on 27 November 2016.

The study was conducted in eight divisions in urban areas. Therefore, information about rural areas was not included here. Further the PSUs of this study were selected purposively rather than randomly. For these reasons this study should not be considered as a nationally representative study but as a rapid assessment indicative study. This study focused on pictorial part of the GHW based advertisement only. Information about the written content of GHW-based advertisement was not investigated. Responses to the variables of this study were self-reported, in particular the quitting status, and not verified by another method. Therefore, the degree of underestimation or overestimation is not known.

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Conclusions and recommendations

This study indicates that GHW-based advertisements are perceived by the urban population to be an effective tobacco control intervention. Further, significant influence of the advertisements is noted on tobacco users to consider and attempt to quit. The reach of this media, however, as evidenced by this study, was limited to 12.5% of the urban population.

To increase reach, periodic, similar GHW-based anti-tobacco advertisements could be published more frequently both in national and local newspapers. Campaigns in electronic media (television, radio) could also be undertaken with greater intensity for an effective awareness building campaign, in synergy with a print media campaign. Use of other modes of communication can be employed such as advertisements on billboards and on vehicles. Social media may also be utilized (Facebook, Twitter, and YouTube). Methods like “Uthan Boithok,” “Shari Gaan” or any other popular and locally effective method can also be used for anti-tobacco advertisements.

Increasing awareness of the detrimental health effects of tobacco use is one of many evidence-based tobacco control strategies. Together, these collective measures will contribute to achieving a 30% relative reduction in prevalence of current tobacco use by 2025, and the Sustainable Development Goal target 3.4: a 30% reduction in premature mortality from noncommunicable diseases by 2030.

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References

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