J Canc Educ (2010) 25:637–642 DOI 10.


Quit Smoking for Life—Social Marketing Strategy for Youth: A Case for Pakistan
Liaquat Ali Khowaja & Ali Khan Khuwaja & Parvez Nayani & Saleem Jessani & Malika Parveen Khowaja & Saima Khowaja

Published online: 18 March 2010 # Springer 2010

Abstract Smoking is the single most avoidable risk factor for cancers. Majority of smokers know about this fact but it is difficult for them to give it up mainly in the face of widespread smoking advertisements by the tobacco industries. To reduce the prevalence of smoking and its associated cancers, immediate actions are required by public health authorities. Social marketing is an effective strategy to promote healthy attitudes and influence people to make real, sustained health behavior change by transiting through different stages which include precontemplation, contemplation, preparation, action, and maintenance. Social marketing can influence smokers to voluntarily accept, reject, modify, or abandon their smoking behavior. In Pakistan, the smoking prevalence has been increasing,
L. A. Khowaja Quality of Life Project, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan A. K. Khuwaja (*) Department of Family Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan e-mail: ali.khuwaja@aku.edu URL: http://www.aku.edu/chs/dralikhankhowaja P. Nayani : S. Jessani Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan M. P. Khowaja Coronary Care Unit, Aga Khan University, Karachi, Pakistan S. Khowaja School of Nursing, Aga Khan University, Karachi, Pakistan

necessitating effective measures. The trend of its usage has been going upwards and, according to the World Health Organization, in Pakistan, the usage of cigarette smoking is increased by 30% compared to 1998 figures. The Pakistan Pediatrics Association has estimated 1,000 to 1,200 schoolgoing children between the ages of 6 and 16 years take up smoking every day. In Pakistan, ex-smokers in the low socioeconomic group reported spending 25% of the total household income on this habit. This paper focuses on the antismoking social marketing strategy in Pakistan with an aim to reduce smoking prevalence, especially among the youth. Keywords Cancer . Smoking . Social marketing . Health behavior change . Youth

Introduction Smoking is a major public health concern, especially in developing countries. Current trends show that, by the year 2020, tobacco is likely to be the world’s leading cause of death and disability, killing more than 10 million people annually, of which 70% will occur in developing countries [1], and smoking is most common mode of tobacco use. About 15 billion cigarettes are sold daily (10 million per minute) and every cigarette smoked cuts at least 5 min of life on average [2]. It is reported that there are approximately 1.1 billion smokers in the world, about one third of the global population aged 15 years and over [1]. According to the World Health Organization (WHO), between 80,000 and 100,000 children start smoking every day worldwide, approximately half of whom live in Asia [2]. Cancer is a leading cause of death worldwide which accounted for 7.4 million deaths (about 13% of all deaths) in the year

Population Services International. In addition. Social Marketing as a Tool for Health Education and Promotion The term “social marketing” was first introduced in 1971 to describe the use of marketing principles and techniques to advance a social cause. tobacco kills people at the height of their productivity. people are not persuaded to spend money. Pakistan’s tobacco industry has traditionally been a dependable source of government’s income. and evaluative research. and the Government of Pakistan have successfully used the social marketing techniques to attack the problem of iodine deficiency and. The synergistic combination of media campaigns and social change effectively stimulates positive attitudinal and behavioral changes [16]. Several social and health problems have behavioral causes. Despite heavy health and economic costs. Smoking is the single largest preventable risk of cancers and its related premature deaths. cigarette smoking was introduced by the court of Akbar the Great as early as 300 years ago [8]. fake images of body fitness. In addition to the high public health costs of treating tobacco-caused diseases. Literature revealed that teenagers are heavily influenced by tobacco advertising [2. During last few years. relief from stress. The ultimate purpose of social marketing is to change people’s behavior. smoked more than 10 cigarettes a day. beauty. Smoking causes substantially increased risk of mortality and morbidity from several cancers mainly including lung and upper aerodigestive tract and a range of other cancers [1. Social marketing is used to influence a target audience to voluntarily accept. Smoking also puts extra financial burden to smokers.200 school-going children between the ages of 6 and 16 years take up smoking every day [11]. United Nations Children’s Fund.638 J Canc Educ (2010) 25:637–642 2004. process.4% of the national gross domestic product [11]. 10]. only 10% of advertising expenditure goes to print and outdoor . In China [6]. Lung and other cancers resulting from rising tobacco consumption pose enormous problems on the already existing fragile health infrastructure in Pakistan [8]. and offering costly prizes. In Pakistan. and being slim are used by the tobacco companies for their brands to attract the general public. and education combined. health.and middle-income countries [3]. millions of Pakistanis now Smoking Situation in Pakistan On the Indo-Pak subcontinent. male cigarette smoker spent more than twice as much on cigarettes as per capita expenditure on clothing. or abandon a behavior for the benefit of individuals. The social marketer seeks to build a relationship with target consumers over time and their input is sought at all stages in the development of a program through formative. In a community-based survey in Karachi. with over 70% of the population estimated to be at risk. Pakistan’s tobacco revenue constitutes 0. Social marketing is a tool rather than a solution for health education and health promotion problems. but to change their behavior to stop smoking. This paper describes the social marketing approach for addressing the smoking menace in Pakistan and pleads for the case for application of social marketing approach to reduce smoking prevalence. the usage of cigarette smoking is increased by 30% compared to 1998 figures. however. especially among the youth. especially the youth population [10]. or behavior. The Pakistan Pediatrics Association has estimated 1. advertisements [2]. smokers in the Minhang district spent 17% of household income on cigarettes. reject. the tobacco industry has changed the way it advertises its products. modify. depriving families of breadwinners and nations of a healthy workforce [5].000 to 1. their families. and according to the WHO. items. and their country as a whole. In a recently published study from Pakistan. it is evident that over 40% of tobacco users imitated this habit by inspiring from media advertisement [17]. more than 70% of these deaths occurred in low. Social marketing techniques have been used successfully in Pakistan for multiple health and social issues. approximately the same percentage allocated for health [11]. or society as whole [13]. and smoked in public places. contributing some $458 million as taxes per year—equivalent to 4. such as jewelry and air tickets for overseas tours. ex-smokers from the low socioeconomic group reported spending 25% of the total household income on this habit [12]. Pakistan [10]. in Pakistan. Khuwaja and Kadir reported 34% prevalence of current smokers. Social marketing provides means for dealing with such problems by encouraging people to adopt healthier lifestyles. 4]. no clear policy on tobacco control exists in the country. The government of Pakistan had identified smoking as one of the leading causes of morbidity and mortality in its health policy of 1997 [9]. Now. Pakistan has been one of the most severely affected countries for iodine deficiency. making it a high cigarette consumption country [9]. The trend of its usage has been increasing. housing. the consumption of cigarettes continues to rise in Pakistan. With social marketing for reduction of smoking. group. and in Bangladesh [7]. idea. The social marketing theory is based on “marketing philosophy” that people will adopt new behaviors if they feel that something of value is exchanged between them and the social marketer [15]. while more than half goes to promotional allowances.7% of the gross national product. as a result. majority of them began smoking when younger than 25 years.

In social marketing. Social advertising has been the linchpin of Canada’s antitobacco social marketing programs [21]. augmented. the “truth” social marketing campaign has been a dramatic success where. In the antismoking campaign. Monthly antismoking walks in different public places and regular television advertisement at primetime like before the news at 9:00 p. The long-term downward trend in smoking prevalence in most high-income countries over the past three decades has coincided with a long-term upward trend in people’s levels of knowledge about the harmful effects of smoking [25]. Smokers would be discouraged to smoke by promoting healthy behaviors. the augmented product is the stepwise guide to quit smoking. In the case of the antismoking campaign.m. Marketing Mix for Antismoking Advertisement The basic structure of a marketing campaign consists of the four Ps (product. adult male smoking prevalence has been decreased from 58% to 53% and teenage male smoking has dropped from 22% to 16% in less than a year with the social marketing approaches [24].and college-aged students who are smokers or are at risk for smoking in the near future. In the United States. since the introduction of hormonal contraceptive social marketing in 1997. These include the cost of giving up the old behavior and taking up a new behavior. The primary target audience is all school. In the Republic of Korea. the price of the product will be the cost of giving up smoking or not starting to smoke. augmented product is tangible objects/services offered to support behavior change. In the Philippines. and promotion) and is called . Also. and core product [13]. such as the discomfort of withdrawing smoking and the feeling of no longer belonging to smokers groups. while the percentage of high school students fell from 27% to 21% [23]. the actual product is the behavior of quitting smoking. and financial benefits such as savings in terms of costs per month and per year. and implementing comprehensive smoke-free policies [24]. the social marketing product is what is being promoted to the target audience. and core product is the benefits target audience will experience as they execute new behavior. the percentage of Florida middle school students who smoked cigarettes in past 30 days fell from 19% to 9%. It is important that the entire product range being marketed should be made easily accessible to the target population at most frequently visited places and through potential outlets of distribution [26]. the four Ps are as follows: Product Like commercial marketing. In the antismoking campaign. The secondary audience is the parents of those students and the general public to show them the benefits of quitting smoking. Place Place is where and when the target market will perform the desired behavior and access products and services [13]. place. replacement alternatives. oral and injectable contraceptive use has risen consistently in Pakistan [19]. only in 2 years. The marketer’s task is to ensure that the benefits offered to the target audience are equal to or greater than the costs of adopting new behavior. placing before them social benefits such as respect and status enhancement. Price The price of a social marketing product is the (monetary or nonmonetary) cost that individuals associate with adopting the new behavior [13]. Actual product is the specific behavior that is being promoted. smoking prevalence among adolescent males declined steadily by nearly one full percentage point per year [22] by using social marketing strategy. the product place can be schools to address the youth and public places to address the rest of the population. The strategy would focus on a clear-cut picture to the smokers about higher benefits compared to the loss in case of quitting smoking.J Canc Educ (2010) 25:637–642 639 consume iodized salt and are thus no longer at risk of iodine deficiency [18]. and the core product is the health with financial and social benefit after quitting smoking. Public health education programs through mass media can help devise strategies to prevent people from smoking. the percentage of youth smokers declined by a third from 2000 to 2003 through evidence-based tobacco control strategies. such as bans on tobacco advertising. The Canadian government data indicate that. Target Audience The key of social marketing is audience. Effect of Social Marketing on Smoking Control Social marketing campaigns using mass media techniques were successful in preventing cigarette smoking in highrisk youth [20]. marketing mix. from 1970 to 1991. price. Information on benefits of not smoking can be distributed in schools/colleges and public places. can be other best options for placing the antismoking campaign. there are three types of products: actual. The social marketer’s task is to make the place as easily accessible as possible for the target audience to get the product range they need to make behavior changes. For antismoking social marketing. increasing tobacco taxes and prices.

contemplation. These are Steps for Adopting New Behavior People move through different stages before adopting a new behavior. regular announcements. Attitude. and behaviors and motivation behind these. group discussions. action. Some key messages for the antismoking campaign include “Quit smoking for your own life. as mentioned in the following cycle (Fig. When they acknowledge that there is a problem behavior but they are not yet ready to change. model. signs and displays.640 J Canc Educ (2010) 25:637–642 Promotion Promotion is persuasive communication designed and delivered to highlight the product benefits [13]. a belief into an attitude. Besides these four Ps.). necessarily go through all the stages.).” they use their will power and change their behavior.” and “Put cigarettes away for LIFE!” The social marketer for the antismoking campaign can use some tactics to educate the target audience regarding the health hazards of smoking. Value: the smoker finally believes that smoking is hazardous to everyone’s health and all smokers must quit smoking. It ensures that the target group knows about the offer. “Strategy development” prepares a marketing plan which includes the goals and objectives of the project.” “Smoking is self made enemy. and an attitude into a value. The plan is organized on the four Ps discussed earlier. Change stages include precontemplation. etc. Pricing strategy focuses on costs. People do not Social Marketing Process Initial Planning Tracking and Evaluation Formation Research Program Implementation Strategy Development Campaign Development Fig. transport shelter posters. Belief. and strategies to address factors associated with such behaviors. The same is described for the antismoking campaign: Belief: smokers believe that smoking is hazardous to health. Facilitation of change such as legislation. Attitude: the smoker then feels that smoking is hazardous to his/her health and he/she would like to quit smoking. description of the audience. and potential behavioral determinants. specific behaviors to be promoted. the program planner positions the product in order to maximize the perceived benefits and minimize the perceived costs. handouts. and often recycle [29]. preparation. fairs. It is important to note that this is a circular. Five distinct stages are identified in the stages-ofchange model. arranging events (walks. and maintenance [29]. Positioning a product correctly helps the message to be heard in today’s culture that has been saturated with a variety of communications [28]. positioning as the fifth P is used by many authors in the marketing mix. Messages and strategies are designed separately for different stages. essay-writing competitions in school/college children against smoking. and is inspired to act. It also includes what prices they are willing to pay. and Value for Antismoking The task of the social marketer is to convert a nonbelief into belief. etc. Positioning refers to the psychological “image” of the product [27–29] by the target population. In the next stage of “preparation. Promotion has two components. Some tactics may be personal meetings. not a linear. audience. people can benefit from different interventions that matched to their stage. values. distribution of antismoking material (pamphlets. Having understood the target audience’s beliefs related to it. regular media advertisements. During the process of change. etc. distribution of material. 1 Social marketing process . that stage is considered as the “contemplation” stage. brochures. 1): “Initial planning” identifies behavioral objectives. “Precontemplation” is the stage where people do not realize that there is a problem behavior that needs to be changed. Social Marketing Process There are six major steps in the process.” they get ready to change the behavior and then. policy formulation. and interaction with renowned personalities such as national heroes. This is followed by the “maintenance” stage when they maintain their new behavior and do not return to the old behaviors. believes that they will experience the stated benefits. the messages and the tactics to convey the messages.” “Smoking is dangerous—stop it NOW!.” “I don’t smoke. “Campaign development” involves development of campaign material. “Formative research” deals with the understanding of consumers and includes analysis of their beliefs. or curriculum development is also included. they can enter and exit at any point. The plan also includes activities such as trainings. at the stage of “action.

policy formulation trainings. Outcome evaluation is conducted after a sufficient time to bring desirable change. “Program implementation” requires proper sequencing of different activities and carrying out these activities. A social marketing and antismoking process planners’ group is described in the Table 1. and training Campaign development Development of campaign material and strategies Professional are hired to develop new material. and activities New plans are made and the cycle continues . That may identify successes and failures. curriculum. and material distribution Timely decisions are taken for any change in implementation of different activities. medial advocacy. an evaluation of the entire program is done The results are used to begin the new cycle identification of objectives. and campaign messages Public relations activities are planned All materials are pretested and revised Program implementation All activities are timed and implemented All the actors are coordinated for their activities Sequencing is ensured for legislative advocacy. promote healthy attitudes. This may be possible using the social marketing approach which has the potential to address health behavior at a larger scale. Education to increase awareness and changing behaviors is essential particularly in developing countries like Pakistan where poor knowledge about cancers has been reported [31]. curriculum development. and data collection instruments are prepared Formative research Investigate the factors identified earlier Factors motivate to adopt recommended behavior Factors deter from change Which factors have the greatest impact on behavior What benefits would be found most attractive What price they are willing to pay Where to impart information for better effect Who are most influential to be targeted Which promotional activities will be more effective How can the program fit in their norms and beliefs Which group is more likely to change behavior Strategy development Marketing plan is prepared with: Statement of overall mission or goals Measurable objectives and work plan Description of audience Specific behavior to be promoted Strategies for addressing critical factors Plan uses conceptual framework of four Ps Pricing strategy focuses the costs associated Placement strategy deals with information distribution and material development and training Promotional strategy includes activities for legislative change and policy development. Most people know that smoking is harmful to health but it is difficult for them to give it up in the face of inducements by the tobacco industry. sustained health behavior change. “Monitoring and evaluation” includes documentation of the progress for ongoing modifications. Table 1 Proposed social marketing strategy and antismoking process suggested for the youth Initial planning Planners’ group is formed to discuss Potential target population Desired health behavior Factors influencing adopted behavior List of affected subgroups is prepared List of factors influencing behaviors is prepared Research objective.J Canc Educ (2010) 25:637–642 641 pretested before their utilization. Social marketing is an effective tool to educate audiences. target audience. and influence people to make real. sampling frame. To conclude. if required Monitoring and evaluation The progress of different components is documented Baseline is used to measure the changes The program performance assists in managers to decide what to continue or refine After a specific time. which are useful for future program planning [30]. current smoking statistics indicate that it is difficult to reduce smoking-related cancer deaths unless extra efforts are put in to cut its use.

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