Predictors of Quitting Attempts Among Tobacco Users in Bangladesh After a Communication Campaign to Launch Graphic Warning Labels on Packaging

"That quit attempts are more likely among those discussing PBTP campaign messages with others and recalling more PBTP campaign messages highlights the importance of ensuring message content is both memorable and engaging."

Tobacco use contributes to an estimated 14.6% of male and 5.7% of female deaths in Bangladesh. This study examines the determinants of tobacco-related quit attempts among Bangladeshis with and without awareness of the synergised "People Behind the Packs" (PBTP) social and behaviour change communication (SBCC) campaign implemented by the government to support the introduction of pack-based graphic warning labels (GWLs) in 2016.

The introduction of the GWLs covering 50% of tobacco product packaging (to replace existing written text warnings covering 30% of packaging) was accompanied by a 6-week national communication campaign (PBTP) aimed at (i) increasing public awareness of, and engagement with, the message that tobacco use is associated with significant health conditions and (ii) encouraging quit attempts. Using a social marketing value exchange approach, the four synergised PBTP messages drew on "raw and real" messaging techniques involving graphic and emotional testimonials from Bangladeshi patients experiencing the tobacco-related diseases depicted in the GWLs. Two PBTP campaign messages aired on 13 national television stations, and all four appeared on billboards and community health center posters across Bangladesh. An integrated social media website (no longer in operation) provided quit advice, resources, and links to PBTP campaign materials.

Data from 1,796 adults were collected using multistage sampling and a cross-sectional face-to-face survey. Analyses used a normalied design weight to ensure representativeness to the national population of smokers within Bangladesh.

Quitting attempts were reported by 38.1% of the overall study sample. This figure rose to 66.5% among those aware of one or more PBTP communication message. For the overall sample, the multivariable logistic regression model revealed that quit attempts were associated with having seen the pack-based GWLs, recalling one or more PBTP campaign message, higher levels of self-efficacy to quit, and recognising more potential side-effects associated with using tobacco products. Conversely, the likelihood of quitting attempts was lower among dual tobacco users (relative to smokers) and those using tobacco at least daily (vs. less than daily).

The strongest association between PBTP campaign-related variables and quitting attempts identified in the hierarchical multivariable logistic regression was in relation to discussion of the PBTP campaign messages with others. One explanation for this positive association is that discussion provides individuals with a way to elicit views that align with their own, thus tapping into social approval/norms and bolstering existing inclinations to embark on a cessation attempt. The researchers call for further study to explore this and other potential mediation pathways.

The researchers calculated the actual number of quit attempts resulting from PBTP based on the Bangla population age groups for the survey and extrapolated that around 27 million quit attempts were made during the campaign intervention period. When they costed this figure out based on the media spend, it amounted to 0.003 cents per quit attempt.

Thus, the "finding that being aware of at least one PBTP campaign message is independently associated with the likelihood of making a quit attempt supports the efficacy of using such national communication campaigns in tandem with the launch of new GWLs on tobacco packaging." Furthermore, "given that self-reported quit attempts were associated with increased knowledge of potential tobacco related side-effects and self-efficacy to quit, there may be efficacy in future public health campaigns focusing on building capacity in these areas within the general population." Given the high uptake of mobile phones in Bangladesh, one option could involve trialing mobile phone cessation tools, which can be tailored to specific audiences.

In conclusion, "[t]his national evaluation of pack-based GWLs and accompanying PBTP campaign within Bangladesh supports the efficacy of using synergized communication messages when introducing such labels."