Undoubtedly, the COVID pandemic has filled the community with fear and uncertainty and it has dominated community attention across the planet. When people are faced with difficult times, they react differently to the stresses and strains they experience. It’s not uncommon for people to turn to things that calm them down, things that relax them. Some people turn to arts and crafts, games and jigsaw puzzles, others meditate or exercise, and yet others seek out social support. Others turn to distractions that offer an opportunity to escape; such as drinking, medication, online gaming, binge TV watching or other habits that may be detrimental when taken to their extremes.

Yet others, turn to smoking. Evidence shows that some people use products like cigarettes and e-cigarettes to unwind, relax and to stay calm.

But at what cost?

It’s no secret that consuming tobacco is a high-risk behaviour. These are just some of the many evidenced risks of smoking:

  • It damages nearly all 79 major organs in our body
  • It places heavy burdens on economies and health systems
  • It shaves off an average 10 years of life
  • It greatly increases the incidences of chronic diseases and infections
  • Growing and producing tobacco damages the environment
  • And even the people around smokers suffer too (e.g. asthmatics)

Source: quit.org

There is no doubt nicotine is very addictive. Smoking can easily bury itself into a person’s daily habits, social circles and become part of one’s identity. Once smoking fuses with our identity, it becomes a very difficult behaviour to change, even for those who are motivated to quit. In fact, research tells us that most smokers have undertaken multiple quit attempts before they manage successful termination of the habit with many reporting relapse (see this study on predictors of successful quit attempts). 

So… What is being done to stop smoking?

Smoking has been around a long time. The burning of tobacco leaves is believed to have originated in the Americas as early as 5000 BC as an integral part of their religious and shamanistic tradition. When the Europeans brought it home around the 16th century, they quickly began mass production and commercialisation. In early promotion efforts the medical profession was recruited by the tobacco industry to promote smoking recommending cigarettes for people experiencing stress. This created clear associations between smoking tobacco and relaxation. In fact, all kinds of interesting associations were suggested by marketers ranging from losing weight, to making friends and helping you overcome sickness.

As early as 1604, doubts about smoking emerged.  For example, British King James I thought smoking was loathsome; and he described it as “harmful to the brain”, and “dangerous to the lung”. Later, renowned philosopher Francis Bacon pointed to the addictive qualities of tobacco use, observing that it “conquers men with a certain secret pleasure”.

Over time, scientific evidence identified correlations between tobacco consumption and lung cancer rates. The first public health efforts emerged demonstrating the costs of smoking to smokers themselves and the societies they live in.

Okay. But is tobacco still a problem today?

Well, as Virginia Slims would say, we’ve come a long way, baby. Thankfully, public health efforts have managed to change the wider attitudes and perceptions of smoking in many countries. What was once socially desirable; is now viewed negatively by most people. This dramatic shift has occurred in just over the last 30 years.

Information regarding the dangers of smoking built by the scientific and medical community, and now generally accepted by the greater public following public health and behavioural change efforts, allow the retrospective data to speak for itself (Figure 1). It’s clear something is working.

Cigarette consumption
Lung cancer death rate

Figure 1 – 20th Century cigarette consumption and lung cancer deaths
Source: eLifesciences.org

However, it is far from over. In 2019, the World Health Organization reported 8 million tobacco-related deaths. In fact, approximately 100 million tobacco-related deaths have occurred this century alone, with the expectation that deaths caused by tobacco will reach another 250 million before 2050 (eLifesciences.org).

Why then hasn’t smoking received the same urgent response globally that COVID-19 achieved?

Smoking is a global epidemic and it remains the leading cause of death worldwide. While COVID-19’s death toll continues to rise, it remains completely eclipsed by tobacco’s 8 million annual global deaths caused by tobacco.  

Why does this continue to be tolerated by our global community?

The incredible population booms occurring in developing nations have seen tremendous increases in smoking prevalence, and consequent deaths. Tobacco companies are fuelling this rise in developing countries with marketing tactics that are banned in most developed countries.

Meanwhile public health and social marketing efforts now control tobacco, with great success in the developed world.

Tobacco control efforts in Australia

1973Health warnings first mandated on all cigarette packs in Australia.
1976Bans on all cigarette advertising on radio and television in Australia.
1986 – 2006Phased in bans on smoking in workplaces and public places.
1992 – PresentGradual increases in excises on tobacco products.
2012Offence for advertising tobacco on the internet or other electronic media.
2012Introduction of tobacco plain packaging to replace industry branding.
Source: acosh.org

Let’s take a closer look at one component in the larger suite of tobacco control measures- health warnings on cigarette packs. Health warning labels in tobacco prevention have come a long way; from small text-only warnings, to large, graphic, and emotionally gripping labels. Countries such as Brazil have even incorporated additional themes in their formats such as risks to beauty and appearance (See figure below).

Plain packaging refers to the complete replacement of branding with graphic health warnings, and was first mandated in legislation by Australia in 2012. Post-implementation data reports significant declines in smoking prevalence seen several years after the implementation of plain packaging policy by governments.

Implementation of GHW’s has been observed across the world, and is considered as one positive initiative that governments can implement within a larger suite of tobacco control measures (e.g. the heavy tobacco excise, and public distancing for smokers). Unfortunately, some governments have hesitated to act. This is a lost opportunity given that all smokers see tobacco packaging, whether they are aware of it or not. 

Even in countries that have adopted strict tobacco control measures smoking prevalence rates of 0% are yet to be observed, which raises the question, what is missing?

The role of social marketing in smoking cessation

A recent social marketing literature review by Almestahiri and colleagues found that interventions in tobacco control use an average of 4 of the 7 major social marketing components. These components include:

  1. Behaviour change
  2. Audience research
  3. Segmentation
  4. Exchange
  5. Employing a marketing mix
  6. Competition
  7. Theory

The evidence review identified social marketers could be doing more and current smoking rates in Australia (12% of Australians are smokers) suggest policy and education measures aren’t enough to end smoking. You can read more about the different behavioural change approaches here.

One thing social marketers do well is understand people’s reasons why.

Recently, our team has been sifting through the tobacco control evidence base. A few things have come to our attention. As it currently stands, almost all of Australia’s current warnings (and many other nations) communicate the likelihood of long-term health risks. Interestingly, this means the communications on cigarette packs are heavily emphasising chance, proximities, and consequences of smoking to personal health.  

Evidence indicates that many or most of the people continuing to smoke in countries such as Australia, where strict control measures have been in place for decades, know that smoking kills. When asked about smoking risks, smokers are able to identify a range of risks. 

Overlooking the very fact that smokers are aware that smoking kills and they are already paying very high prices to smoke, professionals working in tobacco control feel that telling smokers about newly identified risks and continuing to increase the financial cost of smoking is the way to reach zero smoking rates. While these methods have been effective at reducing rates, they have also proven to be ineffective among those who continue to smoke today. The vast majority of adults who continue to smoke state that they want to quit now or in the near future, but they have failed at quitting before and are not sure they can. Rather than doubling down on telling people what to do or trying to make them give smoking up, we contend more efforts that show people other ways they can relax without the need to smoke cigarettes is needed.

Innovative strategies such as inserts within the packaging containing cessation tips, messaging that focusses on more immediate and tangible benefits arising from quitting are just some of the means needed to motivate new quitting attempts. In addition, we must understand why previous quit attempts failed and show smokers how their next attempt can be successful. These strategies and tips must be hyper-relevant to their behaviour change obstacles to convince them to try again and to be effective. By asking “what is keeping those who want to quit from doing so successfully?” we can save more lives.

Right. What does this mean for us?

While COVID-19 might have dominated the 2020 conversation we can’t lose sight of a war that has been waged over centuries. Can we, and should we all do more in relation to cigarette smoking?  Countries across the globe have shut borders, slowed down economies and redirected resources rapidly to slow the curve for COVID. Why hasn’t the same occurred for smoking? We can’t argue that there is an industry sustaining people’s livelihoods and contributing tax to countries to support products known to cause death. We can and should be doing more to stop global epidemics like tobacco. It is time to trial new and innovative approaches to end the tobacco game.

Authors: Alex Scodellaro, Prof. Sharyn Rundle-Thiele, Dr. Timo Dietrich, Jeffery Jordan