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, Dhaka 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. 4 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 Bangladesh Pratidin The National Tobacco Control Cell (NTCC) of the November The Daily Ittefaq Ministry of Health & Family Welfare published 2015 The Kaler Kantho 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 New Age 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 Jugantor 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 Amader Shomoy 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 Samakal 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 5 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.