Social Marketing and Tobacco Control Policy

 “We don’t sell guns everywhere, we don’t sell alcohol everywhere and we don’t need to be selling tobacco everywhere. They’re all dangerous products, and they all require regulation.”

That is Barbara Ferrer, director of the Boston Public Health Commission, in a story by Katie Zazima in the Sunday NYT about a proposed ban on the sale of cigarettes in drugstores and on college campuses, as well as the closing of the city's cigar and hookah clubs. For me, it is reminder that when we talk about applying social marketing to social problems, and not just individual ones, we should be thinking broadly. And for the Boston Public Health Commission, they need to be thinking broadly as well.

One of the more neglected areas of social marketing is this intersection with public policy. Mike Rothschild, for example, has drawn a line between marketing and regulation, arguing that marketing stops where policy and regulation begin [pdf file]. Others like Stephen Dann, and at times myself, have decried the knee-jerk reaction to fashion regulation to govern individual behaviors before attempting to use other social marketing tools (and here is maybe where I diverge, and now digress).

In the evolution of tobacco control efforts, public health advocates began shifting their strategies from communications (or 1P marketing) - award-winning public service announcements, well-covered publicity events, evocative posters and culturally appropriate pamphlets  - to a broader consideration of the marketing mix. Few of them would have framed it as such at the time. This began with the realization that communications were not getting it done in the COMMIT study (at that time, many people wondered why the groups of investigators responsible for the large community-based CVD prevention studies did not become involved in that multi-community study. The answer was simple: we knew tackling smoking cessation among heavy smokers was going to take more than communication campaigns). As the COMMIT project went on, the idea of media advocacy came front and center - use the media not for education, but to set an agenda for large-scale change by calling attention to the social and environmental determinants of the initiation, maintenance and cessation of smoking behaviors (stop blaming the victim).

The COMMIT study led to the even larger ASSIST project, a 17 state initiative that focused on policy change to support tobacco control efforts. It was early in that project that Mike Pertschuk, a collaborator in the ASSIST Coordinating Center who led the efforts of the Advocacy Institute to support this project, and myself, were called in to the National Cancer Institute offices to reconcile the media advocacy approach (which he represented) and the social marketing approach (that was me) as the intervention model was being debated and developed. They literally had us sit at opposite ends of  a very long table and staff crowded into the room: the show down between opposite views of the world.

In fact, though Mike did try and throw the black hat on social marketing (we focus on individual level change and blame victims), by the end of the hour we had complete agreement on the basics. Tobacco control needed to focus on upstream issues (in one vernacular) or the other 4Ps in another. Product features, including on package labeling, the development of brands targeted at specific (and often vulnerable) groups of people, were fair game. Pricing, particularly increasing the price of cigarettes through increases in excise taxes was another. Enacting and enforcing laws to reduce the availability of cigarettes by not selling them to minors and reducing the opportunities to smoke through workplace smoking and health policies became core outcomes. And using communications to set the public agenda and develop support for policy initiatives at the local level, focus on policy-makers as a key audience and devote resources on prevention programs aimed at youth (not one OR the other, but all three) rounded out the model. Mike had his complete advocacy agenda met, and I had a complete social marketing program strategy set. Even before then, and this was 1992, the idea that advocacy and social marketing are mutually exclusive ways of looking at the world had eluded me, but then I grew up applying social marketing for large-scale change in communities, not individual behavior change. What media advocacy and social marketing do together is provide a broader framework for thinking about the context and determinants of behaviors among groups of people (a public health perspective), identify the leverage points through a marketing analysis focused on the 4Ps, and then focus on the audiences that are critical for success (public opinion leaders, media gatekeepers, elected officials).

ASSIST achieved startling successes in some states, and overall made a modest contribution to reducing tobacco use in those states and in the US in general. A great deal of attention throughout the project was also spent of dissemination and diffusion. With the Advocacy Institute's SCARCNet electronic communication system (a few readers may remember fondly), an email, list serve and bulletin board created a national and global community that could share ideas, brainstorm responses to tobacco industry attacks and new marketing strategies and learn from each other. This forerunner of our current social network sites, solidified what has become a paragon of public health (large scale) intervention models.

Returning to Boston, the old approach of regulation as a top-down model also has much to learn from ASSIST and similar projects. For any public policy initiative a marketing approach is a vauable ally. It can not only help identify the most important issues to focus on (products, services and behaviors; prices; distribution, opportunities and access) but it also puts on equal footing how the communication effort needs to drive and sustain public support for these initiatives while also focusing on narrower segments of the population (in this case, business owners) to create a win-win scenario for them as well. Social change, unike economics and game theory, does not have to be a zero-sum game. Social marketing is not the public relations function of public policy; when done well, it becomes the integrator and strategic driver of the entire process with a focus determined from the consumer-perspective and aimed at empowering them.

Comments

[LouisLaurent]

Good article. My company has been doing tobacco counter marketing in Iowa for the past nine years. In past two years, the state passed an increase in cigarette taxes and a smoke-free workplace law. Now we have a three legged stool which has proven very effective.