Location targeted this audience segment, who · target audience and to promote a service that would...

ShowCase │ Fight Back 1

Overview

As part of their PRIME programme to reduce

health inequalities in the area, NHS

Birmingham East and North (NHS BEN)

worked in partnership with healthcare

consultancy Dr Foster Intelligence to design

and deliver a social marketing campaign to

reduce smoking prevalence in male routine and

manual workers, aged 35 to 55 and living in

deprived wards of the NHS BEN area. The

campaign‟s hard-hitting approach directly

targeted this audience segment, who

experience the greatest health needs relating

to smoking-related conditions, by causing them

to re-evaluate their relationship with cigarettes

and to „Fight Back‟ against them.

The campaign used a variety of media

channels to deliver its message, including a

Fight Back film, advans at local football events

and an on-street delivery team who located a

branded trailer near events and locations

where the target audience were.

Results

The campaign achieved an 87 per cent

increase in the number of Quit Dates Set and a

65 per cent increase in successful quits, versus

the same 2-month period in 2008. The

campaign also resonated disproportionately

with the target audience, a group which

historically have accessed NHS BEN‟s smoking

cessation service in low numbers.

Fight Back

Topic:

Smoking

Organisation:

NHS Birmingham East and North

Location:

Birmingham (West Midlands, UK)

Dates:

Phase 1 – September to November 2009;

Phase 2 – May to June 2010

Budget:

Phase 1 – £367,000

Website:

www.benpct.nhs.uk/pharmacies-with-stop-

smoking-services

Contact:

Rebecca Clapson (Social Marketing

Manager)

Email:

[email protected]

Telephone:

0121 380 0643


Smoking in England

In England in 2008 around 84,000 deaths were

estimated to be caused by smoking,

representing 18 per cent of all deaths in adults

aged 35 and over. With over 440,000 hospital

admissions attributed to smoking-related

conditions annually amongst the same age

group, it is clear that smoking represents a

considerable threat to the health of the

population. Furthermore, with the treatment of

smoking-related illness costing the NHS an

estimated £2.7 billion annually, the financial

burden smoking places on the NHS is

significant.

Smoking rates in England have declined over

the long-term, from 39 per cent in 1980 to 21

per cent in 2007. The impact of the smoking

ban in 2007 has also been well documented

with an estimated 400,000 people quitting

smoking as a result of its introduction. The

current government target, announced in

February 2010, is to reduce the adult smoking

rate to 10 per cent by 2020.

Despite this progress, serious inequalities exist

in smoking prevalence rates depending on

people‟s social status. In 2007, 28 per cent of

adult manual workers were estimated to

smoke, which compared unfavourably with 16

per cent in the non-manual population (The

Marmot Review). A National Institute for Health

and Clinical Excellence (NICE) report published

in 2008 stated that smoking is the primary

cause of health inequalities between the rich

and poor in England.

PRIME programme

Over 2009 the three Birmingham Primary Care

Trusts (PCTs) – Heart of Birmingham Teaching

PCT (HoBtPCT), NHS Birmingham East and

North (NHS BEN), and NHS South Birmingham

(NHS SB) – and the City Council all invested in

ways to improve engagement with their

services by targeting specific community

groups.

A number of projects across the PCTs are

increasingly utilising intelligence to support

effective decision making in commissioning and

communications. Among them NHS BEN has

created PRIME (Programme for Relationships,

Intelligence, Metrics and Equality), developed

in partnership with healthcare consultancy Dr

Foster Intelligence to address health

inequalities across the region.

The challenge

In 2009 within the NHS BEN region, overall

smoking prevalence stood at 28 per cent,

significantly above the national average and

equating to 84,000 smokers.

As part of the three-year PRIME partnership

programme, Dr Foster was tasked with

developing a social marketing campaign that

would reduce smoking prevalence among

those most at risk from smoking-related health

conditions. Its objectives were to:

Increase the number of Quit Dates Set

within the target audience by 40 per cent to

60 per cent during the campaign period

Increase the number of people within the

target audience recording a successful quit

following the campaign period

The budget was provided by the PCT and ring-

fenced for the PRIME programme. The project

was managed by a Dr Foster Account Manager

and the PCT Social Marketing Manager. The

core team consisted of a Stop Smoking

Manager, Stop Smoking Commissioner, PCT

Social Marketing Manager, PCT


Communications Representative and the Dr

Foster Account Manager. The Director of

Public Health was also fully engaged and led

the process.

Secondary research

Desk research was undertaken and included:

A review of the information and evidence

that may be available at a national or global

level. This also identified any relevant

benchmarks or comparison

A review of previous social marketing

activity in the area

A review of the local services and how they

were promoted, including interviews with

key staff and health professionals, to

develop a picture of what was currently

happening

Primary research

Primary research was conducted to generate

insight on:

The barriers that were preventing the

audience from quitting smoking

Their motivations for continuing to smoke

What had prevented them from successfully

using the current smoking cessation

services

What would motivate them to stop smoking

Focus groups were undertaken with smokers

between the ages of 35 and 65 wanting to quit.

Smokers were recruited off the street and the

focus groups were run by dedicated

researchers. One-to-one interviews were also

held with pharmacists delivering the pharmacy

stop smoking service.

Exchange

Benefits for continuing to smoke:

Maintaining status quo – too hard to break

the habit

To cope with the stresses of daily life

To alleviate boredom

For relaxation or concentration

To be sociable with friends

To take a break from work

Benefits of quitting:

Financial

Health

For the family

Barriers to quitting:

Lack of motivation

Fear of the „pain‟ of quitting

Lack of confidence, having failed in the past

Resigned to always being a smoker

Friends smoke

Associate drinking alcohol with smoking

Belief that the damage to their health is

irreversible (particularly amongst those over

35)

Fear of gaining weight (particularly amongst

women)

Difficulty finding an alternative way of

coping with the stresses of life

Awareness of and attitudes towards stop

smoking services

Most were positive toward the NHS and

NHS stop smoking services, seeing them as

free and fairly equal

Most respondents were aware of the stop

smoking services provided by GPs, but

fewer respondents were aware of the stop

smoking services provided by pharmacists

and many said they would not think of

approaching them for help

A limited number of respondents were

aware of the PCT‟s drop-in sessions


Many respondents were aware of the Call to

Quit telephone line having heard it

advertised on local radio or seen

advertisements in the local press and GP

practices

Target audience

As part of the PRIME programme, Dr Foster

and NHS BEN developed a population

segmentation tool called Typologies. This was

done by using a cluster analysis across a range

of health data sets available through the PCT

(such as local hospital admission and General

Practice data) and used geographical and

demographic information to supplement it.

These audience segments were described as

Red, Green and Blue typologies, with each

typology broken down into further subsections,

enabling the team to target their activity in a

precise manner. This enabled the team to

identify the typologies with the greatest health

needs in regards to smoking-related conditions.

This research was informed by the national

body of evidence that exists around smoking

cessation and tobacco control.

This process of creating unique „health

typology‟ audience segments grouped people

together based on the degree of association

that existed between them and provided insight

into people‟s health needs. The data showed

that British males, from the lower deprivation

quintiles between the ages of 35 to 55 were

most at risk from conditions such as cancer,

respiratory disorders and chronic obstructive

pulmonary disease. Additionally, this audience

were estimated to have a smoking prevalence

rate of over 30 per cent, making them the

target for campaign activity. This group

primarily came from the Red health typology.

“Our core purpose is to tackle health

inequalities and improve health and wellbeing.

The health typologies that Dr Foster created

have made a significant impact on our ability to

tackle these inequalities by enabling us to

focus on those that need our support the most.

The Fight Back campaign is an excellent

example of this approach in action.” Nicola

Benge (Director of Health Improvement and

Public Health, NHS BEN)

Actionable insight

The key piece of insight that the research

generated was that the target audience

strongly disliked the control that smoking held

over them and the feeling of being unable to

quit. This insight underpinned the development

of the campaign.

“I‟ll try anything because I want to give it up. I

want to break that habit. And that‟s what it is,

it‟s just habit.”

The team also found that almost all smokers

had smoked for many years and made

numerous unsuccessful quit attempts, which

left them unmotivated and unsure of how to

make another attempt to quit.

“I know that fags are going to kill me if I carry

on, so I‟ve got to stop. I will stop. How I‟m going

to do it, I don‟t know.”

The research highlighted that the target

audience were straight-talking and respected

that quality in others, an insight that provided

guidance for the tone of the campaign.

Smokers also reported some issues with the

existing smoking cessation services, ranging

from discomfort with discussing their battle to

quit in a group environment, to difficulty

accessing services at a time and a place that

suited them. This generated recommendations

for service redesign, which will help ensure

there is a longer-term and sustainable output

from the research.

Furthermore, it was agreed that the pharmacy

service would be the most effective smoking

cessation route for the audience, as it provides

one-to-one support and flexibility of access that

would better suit their lifestyle.


“Dr Foster has been very proactive in engaging

with our population and their success in

generating insights into entrenched health

problems has been valuable. The research

conducted as part of the Fight Back campaign

helped us to identify the barriers affecting our

target audience and to promote a service that

would overcome them.” Nicola Benge (Director

of Health Improvement and Public Health, NHS

BEN)

Behavioural goal

To achieve the campaign‟s targets, the team

wanted their target audience to engage with

their stop smoking services through their local

pharmacist and ultimately set a quit date.

Building partnerships

A top priority was to ensure that effective

partnerships were built with pharmacists to gain

buy-in and ensure that they were aware of the

campaign, its core message and what would be

required of them. Building this cohesion was

paramount in ensuring that at the point

smokers entered the service there was

continuity of message to minimise the

likelihood of smokers dropping out of the

service.

This was achieved in three ways:

By taking advantage of the existing

communications channels that existed

between NHS BEN and the pharmacists,

plans for the campaign were shared through

the pharmacy representative and feedback

gathered to inform the development of the

finer details of the campaign

Information was provided to the NHS BEN

representative of the Local Pharmaceutical

Committee (LPC), enabling them to provide

a campaign debrief at their monthly meeting

All pharmacists were provided with a

debriefing pack, which outlined the aims of

the campaign, promoted the benefits the

campaign would bring to their business and

provided relevant materials such as posters,

leaflets and giveaways

Other key stakeholders were the stop smoking

team, who were key to the delivery and

development of the stop smoking service, and

the media. To manage stakeholder relations, a

public relations (PR) company were contracted

to develop a PR strategy.

Concept testing

Four campaign ideas, generated in response to

the insight, were tested with the target

audience. Each campaign idea focused on the

key insight that quitting smoking would enable


the audience to regain control, although that

message was communicated in distinctly

different ways.

The four ideas were concept tested with 6

focus groups of 8 members of the target

audience (male routine and manual workers

aged 35 to 55).

One of these concepts – „Fight Back‟ – clearly

struck a chord with the audience and was the

most effective at engaging their interest.

Fight Back

The Fight Back concept confronted the target

audience with a graphic metaphor for the

damage that smoking does by enabling them to

„see it‟, but was also empathetic in

acknowledging that successful quitting is a real

fight.

The campaign challenged the audience to fight

back and beat cigarettes. The audience were

struck by its originality, clarity of message and

impact.

“Fight Back undeniably contains challenging

imagery, an approach that generated some

controversy. Importantly though, it resonates

with our target audience and the evidence

shows that it has made a difference to the

number of people quitting smoking.” Nicola

Benge (Director of Health Improvement and

Public Health, NHS BEN)

The marketing mix

Product

Accessing the stop smoking service via the

local pharmacies.

Price

While accessing the stop smoking service is

free, the target audience faced non-monetary

costs such as time and effort required to quit

smoking.

Place

The target audience would be encouraged to

use stop smoking services offered through the

local pharmacies in the areas of BEN with high

numbers of Red typologies. Promotional

activity was planned for areas where this target

audience were likely to be, plus areas as near

as possible to pharmacies that were offering

the stop smoking service. Thus if someone was

captured by the promotional activity he/she

would have the option to see a pharmacist

almost immediately. This would reduce any

likelihood that they would subsequently change

their mind or take no further action.

Promotion

The Fight Back campaign‟s imagery was very

effective in attracting attention and making

people stop and think. To capitalise on this

visual impact, six sheet posters carrying the

Fight Back message and a text number that


signposted to local pharmacy services would

be displayed at over 50 sites.

A trailer, towed by a branded Land Rover

Discovery vehicle, was hired for the campaign.

This would be the focal point of activity and

contained experiential elements, such as the

lung age tester, as well as an LCD screen to

show the Fight Back film and a seating area for

the ambassadors to offer advice and guidance

to smokers. Mocked up police incident boards

would be displayed outside the trailer to grab

attention and attract people inside. A trained

team of paid sales personnel from a

merchandising company recruited by Dr Foster

would provide information, advice and

guidance, helping smokers understand the

hidden dangers of smoking and promote the

pharmacy service.

Timing

To ensure Fight Back was delivered at the

most effective time of the year, the team

analysed smoking cessation trends within NHS

BEN across a three-year period to investigate if

there were times during the year when people

were quitting in smaller numbers. This analysis

highlighted that the autumn months were

traditionally „quieter‟ and there was capacity in

the system to deal with additional quitters.

Capacity was a flagged as a valid concern as

the team did not want to flood the system and

have people keen to stop smoking waiting to be

seen, as this could ultimately be demotivating.

Additionally, they liaised with NHS BEN and the

regional tobacco control lead to understand

what local and regional social marketing activity

was planned, and considered national

campaign activity. Both these factors pointed to

an autumn campaign, launching in October and

running for eight weeks.

Beginning in October 2009 for two months, the

Fight Back campaign was delivered in two

waves. The strategy was designed to ensure

that smokers had the maximum number of

opportunities to see the message, understand it

and act on the message. In essence, the

message invited smokers to „fight back‟ against

cigarettes by setting a quit date at their local

pharmacy smoking cessation service.

Wave One – Sharing the message

The objective of the first wave was to share the

Fight Back message with the audience through

a communications campaign that utilised a

range of media channels. The campaign was

displayed and promoted in places where the


target audience lived, worked and spent their

leisure time.

This activity was supplemented by the

distribution of smaller posters, campaign

leaflets and giveaways across 900 venues

frequented by the target typologies, including

cafes, public houses and trading estates.

Additionally, the team took advantage of large

gatherings of the target audience. Mobile

„advans‟ were deployed on match days at

Birmingham City and Aston Villa, patrolling the

approaches to the football grounds and sharing

the Fight Back message with thousands of

people.

This locally focused activity was supported by a

press and PR campaign focusing on local titles

such as the Birmingham Post that the audience

read.

The campaign was further promoted by a Fight

Back film, which was created by internationally

acclaimed filmmakers Rankin and Chris. This

hard-hitting representation of the Fight Back

message, showing a smoker felled by invisible

blows each time he inhales on his cigarette,

was released virally and recorded over 200,000

hits online during the campaign period.

Wave Two – Amplifying the message

through on-street activity

Previous experience in delivering smoking

cessation campaigns had shown that smokers

can benefit enormously from receiving face-to-

face advice and guidance. This personal

interaction enables a dialogue with smokers

and an opportunity to overcome barriers and

provide encouragement and reassurance.


The overall objective of the face-to-face

interaction was to provide smokers who were

interested in quitting with the name, address

and phone number of their local pharmacist,

directing them straight into the smoking

cessation service. The benefits of stopping

smoking and of using the pharmacy service,

and its ease of access, flexibility and the

support provided were all promoted.

The team collected smokers‟ details to create a

contact database, which served two purposes.

First, the database was used to contact

smokers during the campaign by phone and

text to remind them of their local pharmacy

details and to offer further encouragement to

take the next step to make an appointment and

set a quit date at their local pharmacy. Second,

the database allowed NHS BEN to track the

progress of smokers and re-contact them

where necessary to provide further advice

about quitting. This ensured that support would

be ongoing, thereby improving smokers‟

chances of quitting.

To deliver this face-to-face activity a team of

trained on-street ambassadors were employed,

focusing on the areas where the audience

lived, worked and shopped by using internal

knowledge and the typology map. Experiential

elements such as carbon monoxide and lung

age testing were used, so that the target

audience could understand the damage that

smoking was doing to them, even if they could

not see it. To maximise the likelihood of

smokers engaging with the ambassadors an

eye-catching and engaging on-street

experience was created, making use of the

Fight Back film and mocked up police incident

boards to draw people to the trailer.

The on-street activity was very successful in

generating large numbers of referrals at

pharmacies close to the locations of the

activity. Some changes had to be made to the

initial implementation plans of street activity

due to some pharmacies becoming very busy

and capacity proving an issue. The teams

therefore adapted the dates and locations of

the on-street activity to maintain capacity and

respond to the needs of the local pharmacies.

The response from the press and media to the

violent and shocking imagery used in the

campaign was both positive and negative,


though both ultimately served to raise the

profile of the campaign.

Evaluation planning

The project was evaluated by Dr Foster using

pre- and post-surveys administered to the local

pharmacists.

The Fight Back campaign‟s primary objectives

were to:

Increase the number of Quit Dates Set by

the target audience by 40 per cent to 60 per

cent during the campaign period

Increase the number of people within the

target audience recording a successful quit

following the campaign period

Results

During the campaign period there was an 87

per cent increase in the number of Quit Dates

Set at local pharmacies, versus the same 2-

month period in the previous year (2008).

A 65 per cent increase in the number of

successful quits was recorded over the

campaign period, versus the same 2-month

period in the previous year (2008).

The campaign was also shown to resonate

disproportionately with the target audience, a

group which historically have accessed NHS

BEN‟s smoking cessation service in low

numbers. This is of particular importance when

considering the impact on health inequalities,

where it is not enough to only increase

absolute numbers, but it is also necessary to

increase the number of people from the

audience with the greatest health needs.

As the chart above shows, all typologies

experienced a significant increase in the

number of people successfully quitting.

However, Fight Back had the greatest effect on

the Red typology audience.

“We‟re delighted with the results, which bucks

the trend of recent years and turns around a

decline in quit rates and begins to prove what

we believed – that investing in segmentation,

research and a well constructed campaign will

produce results when tackling health

inequalities.” Nicola Benge (Director of Health

Improvement and Public Health, NHS BEN)

There were also some unintended positive

outcomes, with the campaign resonating with a

wider audience, including the other typologies

and men and women alike, increasing referrals

outside the target audience.

Media exposure

75 per cent of the target audience had an

average of 6 opportunities to see the posters

over the campaign period. A tracker study

showed that 64 per cent of people questioned

were aware of the Fight Back campaign and 50

per cent of people recalled seeing the Fight

Back poster, which is 2.5 times the industry

average.

Return on investment (ROI)

ROI has been calculated and results will be

released soon.


Findings and learning were shared with

regional tobacco control leads, pan-

Birmingham and internal PCT staff, and at core

cities events on smoking (where attendees

included directors of public health, smoking

leads and local authority tobacco control

leads).

Sustainability

The team were keen to ensure Fight Back

could be sustained beyond the life of the

campaign period. To achieve this, during the

face-to-face on-street activity they generated a

contact database of another 1,300 smokers,

whose progress towards quitting smoking has

subsequently been tracked.

Six months after the campaign‟s completion,

the entire database was contacted with a

response rate of 58 per cent. Of these:

27 per cent reported they had successfully

quit smoking

55 per cent reported that although they had

not quit smoking they were still interested in

doing so and were provided with further

encouragement, practical advice and

guidance

Phase Two

Given the high smoking prevalence rate in the

target audience, as well as NHS BEN‟s target

of reducing smoking prevalence to 18 per cent

by 2018, a second phase of activity was

delivered in May 2010 to build on the success

of Phase One.

The campaign‟s main focus remained on male

smokers aged 35 to 55 who fall into the Red

typology. However, data from Phase One

showed that smokers from all typologies

engaged with the campaign and that it also

resonated with female smokers, so quits

achieved from the broader audience will be

recognised in the evaluation.

“The Fight Back campaign made a big

difference to the number of people using our

stop smoking service. We were able to help

many more people quit smoking and it‟s great

news that the campaign has returned. I‟m

looking forward to welcoming many more

people and working with them to help them

quit.” Shazia Alam (Pharmacy Manager at the

Co-Operative Pharmacy in Acocks Green)

The delivery model from Phase One was

broadly replicated in the second phase of

activity, with some amendments made based

on learning from Phase One:

Local six sheet posters

The posting period was reduced from eight to

four weeks. During Phase One 75 per cent of

the target audience had an average of 6

opportunities to see the posters over the

campaign period. In Phase Two, over the 4-

week period 60 per cent of the audience will

have an average of 8 opportunities to see the

posters. In Phase One it was necessary to

achieve higher coverage over a longer posting

period to launch and establish the campaign.

However, given that 64 per cent campaign

awareness was achieved amongst the target

audience in Phase One, it was not necessary

to run Phase Two over as long a period.


On-street activity

On-street activity was also reduced from 28

days to 21 days, as engagement with the public

was not from a „standing start‟ position. Phase

One provided solid evidence as to the most

effective locations to engage with the public,

and this information was used to plan highly

targeted on-street activity in Phase Two.

Relationships with pharmacies were also better

established and links made between the on-

street activity and those pharmacies with the

greatest capacity and willingness to engage

with the campaign.

Phase Two utilised all campaign elements

previously included, with the exception of the

48 sheet ad van and the viral seeding. Based

on anecdotal feedback from on-street teams,

these were not vital components for engaging

people, who were more interested in interacting

with other experiential elements.

“The success of the last campaign was really

inspiring. We were confident that the approach

would work but it was great to see such a huge

increase in people trying to quit. This second

phase is important to remind people about the

service and encourage more people to give it a

go and fight back.” Sally Brooks (previous

Social Marketing Manager, NHS BEN)

Lessons learned

Success of media coverage and on-street

activity

Extensive media coverage, both locally and

nationally, really helped drive the awareness

and success of the campaign, and the on-street

activity worked well to drive smokers to

pharmacies. This was due to a combination of

factors. First, the branded trailer, Land Rover

and incident sign grabbed people‟s attention.

Second, the trained ambassadors not only

encouraged smokers to try experiential

elements within the trailer, but they also

highlighted the ease and flexibility of using the

pharmacies‟ stop smoking service. In addition,

as they were located near to these pharmacies,

the team were able to direct those interested

straight to the service, removing the chance

that smokers would go home and change their

mind or not take the necessary steps to

quitting.

Engagement with pharmacists is essential

As a result of the success of the on-street

activity, some pharmacies were over-stretched

and unable to meet the demand for the stop

smoking service. To address this, the team

would have preferred to have briefed the

pharmacists better about the campaign and

prepare them for an increase in demand.

Engagement with stakeholders who are key to

delivery of a referred service is essential and

should be developed as early as possible. The

team would also recommend a different

booking mechanism to avoid inundating

pharmacists.

Learning from Phase One

In Phase One the advertising asked smokers to

text a number, which they then received an

automatic text from asking them to text back

their postcode for their local pharmacy. The

team found that very few people responded to

this text. This was altered in the second phase,

where a link was sent with the automatic text,

which took smokers to the campaign website

where they could find their local participating

pharmacy.

Location targeted this audience segment, who · target audience and to promote a service that would...

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