In Cambodia, a tobacco control campaign helped. But now what?

MANILA — “When you smoke around kids, you expose them to thousands of chemicals that are killing them alive …” begins a public service announcement by Cambodia’s National Center for Health Promotion and NGO Cambodia Movement for Health.

Over the next 20 seconds, the video shows infants hooked up to tubes, a child struggling to breathe, a stillborn baby.

The harrowing visuals were broadcast on Cambodia’s national television as the country began a smoking ban in public places and introduced pictorial health warnings on tobacco products. Sin Sovann, deputy director of NCHP, said it actually worked. To an extent.

“We found out it was very effective in [preventing] secondhand smoke,” he told Devex at last week’s Innovations and Actions Against NCDs Conference, co-convened by the Asian Development Bank.

But “the campaign is short term. We don’t expect that it will impact on prevalence of smoking. But we expect that it will reduce some in terms of secondhand smoke exposure. Now, people feel when they smoke in front of others, they feel guilty,” he said.

He was confident it would have had an impact on reducing prevalence of smoking in the country, if only it were allowed to continue for at least 3 years, allowing for modifications in the message as they went along. But public health campaigns, especially ones involving mass media, can cost millions of dollars. The campaign, funded by Bloomberg Philanthropies and implemented through the World Lung Foundation — now Vital Strategies — lasted for only 3 months.

“We sent the report, our study, to them, but I think the project they have also has a budget limit,” he explained.

The campaign was in 2015. No other donor has since stepped in or showed interest to fund a similar one, he said. The health official is under the impression that when it comes to tobacco control, it seems most donors are interested in supporting the development of legislation.

Yet enforcing the law, which will require the aid of public health campaigns such as the one they had, is costly.

Public health messaging, a core intervention, but where’s the financing?

Article 12 of the World Health Organization's Framework Convention on Tobacco Control specifically speaks to the responsibility of parties to the convention to educate their citizens and raise awareness about the health, economic, and environmental consequences of tobacco production, consumption, and exposure.

Mary Assunta, senior policy adviser at the Southeast Asia Tobacco Control Alliance, told Devex that public health messaging is a means by which the health community and government can “persuasively convey the truth about the harms of smoking to the public.”

“The message has to cut through all the noise and reach the heart of the individual and help him/her make the right health choices,” she said, but emphasized the importance of policy coherence. Countries should include antismoking messages as part of a comprehensive national tobacco control policy, she argued.

“Antismoking messages will be ignored if the smoker is bombarded with positive messages of tobacco advertising every time he walks into the shop, or [when] cigarettes are really cheap,” she said.

“Public education on the harms of tobacco use is Article 12 of the WHO FCTC, and it is the government’s responsibility to enforce it along with all the other measures.”

But funding for antismoking campaigns doesn’t come easily, neither by domestic investment nor via external donor support.

Media campaigns are “effective, cost-efficient measures” for countries to achieve tobacco control goals, and countries should be delivering such “high-reach” campaigns “most months of the year over many years,” according to a 2016 position paper by Vital Strategies.

But it admits few countries are able to achieve this for two main reasons: Government commitment and difficulties in “procuring and sustaining funds.” In fact, only 1 in 5 countries is allocating resources to media campaigns on tobacco control, according to the paper. And only few of them are doing it “with the frequency, intensity and duration required to drive rapid progress against tobacco use.”

Some governments are able to overcome the funding barrier. Turkey, for example, requires all broadcasters to dedicate at least 90 minutes of free air time for content that explains the hazards of tobacco use, including during primetime, which runs from 5 p.m. to 10 p.m. The requirement is part of the country’s national tobacco control law.

In India, the government has mandated broadcasters to screen preapproved, antitobacco PSAs, as well as disclaimers at the beginning of all Indian and foreign films and television programs where tobacco use is depicted, as well as when tobacco usage is shown.

Others dedicate portions of tobacco tax revenues to mass media campaigns, while some governments provide multiyear funding commitments enshrined in legislation.

Each of these initiatives does raise some issues, but they provide alternatives in the midst of limited government budgets and still limited donor appetite for noncommunicable diseases.

NCDs continue to draw just a small fraction of global health aid. In 2017, it was only 2 percent of total global development assistance for health, according to the Financing Global Health report by the Institute for Health Metrics and Evaluation. Antitobacco programs received 8.5 percent of that amount, or $70 million.

Those working in the NCD space and advocating for more financing to address its growing burden, have long argued against the funding misalignment. NCDs are now the leading cause of death globally, accounting for more than 70 percent of deaths annually.

Some argue the dearth of funding for media campaigns in the NCD space, such as the one on tobacco control, is a reflection of this mismatched investment. And while the issue is getting more attention — with meetings, such as the one ADB had in the lead up to the third high-level meeting on NCDs in September — it’s too early to tell whether funding will follow.

“Long term, we hope governments will see the potential and ultimate cost savings of strong and proven media strategies to protect people’s health,” said Sandra Mullin, senior vice president of policy, advocacy, and communication at Vital Strategies, which provides technical assistance to governments, including in the development of effective media campaigns in areas concerning NCDs, such as tobacco control.

“While the initial outlay to place messages on traditional media channels like television can be significant, the sheer numbers of people media can reach — sometimes tens of millions for pennies — is why the return on investment can be significant and why they are often included in the arsenal of a comprehensive public health campaign strategy,” she said.

Had he the money, Sovann said he would certainly put it in public health campaigns.

“Because campaign is not only [about] raising awareness [against] tobacco use, [or] secondhand smoke, but also about raising awareness of the existing law to the public, like understanding the law on the ban on smoking in public spaces, or [the] law on [the] ban on [tobacco] advertising to industry,” he said.

For more coverage of NCDs, visit the Taking the Pulse series here.