Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 25, 2008

Anti-Smoking Campaign Amongst Youth in Nigeria: A critique of the Social Marketing Theory – ASHAYE AJIBADE OPEOLUWA

Over the last decade there has been a significant increase of youth smoking in Nigeria. According to the World Health Organization (WHO), there was a ten fold increase in smoking among young women between 1990 and 2001.1 A survey conducted by the WHO in the southern part of Nigeria revealed a smoking prevalence of 23.9 % among male youths, 17.0 % among female youth and an overall prevalence of 18.1%. 2 Smoking is harmful to nearly every organ of the body; causing many diseases and reducing the health of smokers in general.3 The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States.4, 5 More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murder combined.4,6

Active smoking causes most leading causes of death worldwide: cancers, cardiovascular diseases, chronic respiratory diseases, and respiratory infections. Not surprisingly, smokers have a substantially reduced lifespan in comparison with never smokers. Tobacco smoking causes diminished health and several problems such as cataract and gingival disease. Smoking by women adversely affects nearly all aspects of reproduction. Even though the health effects of active smoking have been under investigation for decades, new adverse health effects are still being identified. As recently as 2002, the list of cancers caused by smoking was expanded to include cancers of the liver, stomach, and cervix, along with acute leukemia.7 Tighter controls need to be instituted in the control of tobacco so that the growing epidemic does not wipe out the working population of developing countries like Nigeria.

The issue of smoking and health is complicated by the fact that Governments of developing countries have been slow to arrest tobacco smoking because of the large government revenues derived from the manufacture and sale of tobacco products. Tobacco is grown commercially and is relied upon to bring in foreign exchange through export, or revenue for the government if sold on the home market. Consequently, in some nations the ministries of health and of agriculture are working at crossroads. Transnational tobacco companies take full advantage of the present lack of legislation in most African countries on the promotion and use of tobacco.

While countries in the western world are making attempts at reducing the levels of cigarette smoking, not much is being done in the developing countries. Thus, while there is a significant decline in smoking rate in the United States and Europe, in the developing world such as Nigeria, the smoking rate increases by at least 20% each year. There are social factors that help contribute to the increase in smoking in Nigeria.

The Federal Governments fight against Tobacco has largely been on the basis of the Social marketing theory which is a combination of theoretical perspectives and a set of marketing techniques. It is defined as the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group. While not trying to discredit its effort, the Nigerian Government needs to employ additional behavioral model changes in its Anti-tobacco control campaign in ways that will be acceptable to the youth.

The Federal Ministry of Health in Nigeria adopts the Social marketing theory in its anti smoking campaigns. These campaign involves the use of Billboards are erected in several locations throughout the country bearing warning signs about the harmful effects of tobacco smoking. Most of these bills boards are not attractive and are not located in places where they can be easily seen by the youth. They are on major highways and in the health care centers, clinics and other health care delivery centers. It has however not been effective as evidenced by the growing prevalence of tobacco smoking amongst the youth population. The present billboards need to be overhauled and their content adjusted to messages that will appeal to the youth population. The messages appear coercive and judgmental thereby limiting its effectiveness. Also, youth do not like to be told what to do, they want to be able to make their own decisions and be responsible for it.

More appealing billboards and TV adverts need to be employed in the fight against tobacco smoking. Information is being given without the necessary skills to change behavior. It also assumes that behavioral change, is largely a result of changes in beliefs, and that people will perform behavior if they think they should perform it. However, according to Prochaska and DiClemente (1986), behavioral change occurs in five distinct stages, Pre-contemplation, contemplation, preparation, action and maintenance. The later (maintenance) is lacking in the anti-smoking campaign. They should be given skills necessary to effect changes in behavior and to maintain such changes.

The issue of acceptance is paramount amongst youth; they want to be among, do not want to be the odd one amidst their group. Tobacco industries make the youth believe that smoking makes them look mature, independent and courageous. Most youths who want liberation quickly buy the entire ideas of tobacco companies. So as soon as thy get into their teenage years, they want to pick up habits that are seen to be for adults. With this declaration is made however subtly, that they have now become of age and can take decisions of their own as deemed appropriate. Instead of bunging correct information on relationship between cancer and tobacco smoking, the big tobacco companies buy over some reputed scientists to refute correct research about tobacco smoking and health. In most of the French-speaking West African countries, you see three of four youths sharing a stick of cigarette. They use it to express their love for each other. In mall, youths inter-viewed claim that cigarette makes them strong and gives them courage. Unfortunately it is a false courage.

The present antismoking campaign in Nigeria does little or nothing in portraying smoking as a harmful habit other than the billboards it erects and the health warnings it requires some cigarette companies to place on their packages. Youth learn more by modeling and not by being ordered or given rules. Rules may play a role but advertisements that depict acceptable social behavior by modeling will be more efficient. This can be in the form of peer modeling or modeling by adults or icons in the society. Youth tend to identify with this role models and their influence can be positively harnessed. Behavioral change in the youth could be maintained by ensuring that they belong to the right peer group, one that supports the promoted behavior (not smoking). In the past two decades social marketing campaigns have been conducted in developed countries as well, to bring about other kinds of behavior change: smoking cessation, diet, condom use, helmet use and other preventive health behaviors. There is a great deal of literature on some very successful programs in developing countries.8

Even though smoking is not socially acceptable in Nigeria, tobacco companies have made tremendous efforts in increasing the social acceptability of tobacco smoking in the youth population and in the country at large. They have employed Cultural sponsorship as a marketing strategy. They have done this by sponsoring youth programs like Sport competitions, Movie shows and talent hunts all to increase access to the youth. A good example is Benson and Hedges who now sponsors some festivals as a way of projecting and expanding its product and market. Their products are clearly displayed in such festival. In Schools, they sponsor inter-school cultural activities and inter-house sports competitions, giving the youth the impression that cigarette smoking gives them courage, equality with adults, and makes them feel like adults. An example is the British American Tobacco (BAT) which commands about 78% of the cigarette market in Nigeria. The tobacco firm took a number of blockbuster films, including the Matrix and Ocean's Eleven, around the country in a domed travelling theatre with 500 seats and a wide screen and called it the "Rothmans Experience It Cinema Tour". Posters for the films were overlaid with pictures of packets of Rothmans and free cigarettes were handed out to people buying tickets.

The anti-tobacco campaign has not demystified the various myths and legends associated with smoking. Smoking is widely thought to offer a number of benefits, as in other African markets, it is believed to aid/speed digestion and to prevent vomiting after eating. Smoking is also said to aid/speed excretion hence it is a common practice for smokers to have a stick when they go to the toilet. It is also believed to be a stimulant especially in cases of depression. This and many more beliefs that individuals hold drive their demand for tobacco smoking. The FGN and the Ministry of Health (MOH) will need to intensify its effort in disseminating appropriate health education messages. Wrong beliefs needs to be dispelled with appropriate health information as pertaining to tobacco smoking.

With annual cigarette import of the increase (20 million sticks in 1970 to 2.966 billion sticks in 2000) 9, it is imperative to create anti-tobacco campaigns that are effective in reducing the initiation of tobacco smoking especially amongst the youth and also to reduce tobacco consumption in the nation as a whole. Other control measures have been introduced without much effect. Such include the cigarette taxes and duties, enforcing anti- tobacco laws. This can be done by encouraging private companies’ participation in the fight against tobacco smoking encouraging them to sponsor anti-tobacco programs and also encouraging the numerous antismoking Non Governmental Organizations that are springing up in the country.

As seen with the Florida Youth Tobacco campaign, The Florida TRUTH anti-smoking campaign built a new product and branded it. The product/action was being cool by attacking adults who want to manipulate teens to smoke. The campaign reduced the price of the behavior (attacking adults) by selecting adults everyone agreed had been manipulating them. They created places where kids were found by means of a statewide train caravan and the founding of local "Truth chapters." And, of course, they used promotion - but promotion that went beyond the traditional media ads to having kids directly confront the tobacco industry and publicize this teen "terrorism" in the popular media. The Campaign routinely carried out surveys of its target audience that allowed the campaign to discover important micro-market segments (South Florida Hispanics) where impacts were lagging. The Truth campaign has been a dramatic success; it is now the model for the Legacy Foundation's national anti-smoking campaign. In just two years, from 1998 to 2000, the percent of Florida middle schoolers who smoked cigarettes in the past 30 days fell from 18.5 to 8.6 percent while the percentage for high schoolers went from 27.4 to 20.9. 10

The Present Anti- Tobacco campaign in Nigeria needs to employ the strategies used in the Florida Youth Tobacco Campaign (FYTC), merchandise like t-shirts, key holders, baseball caps, and other branded materials can be distributed via an official campaign van at teen functions; youth advocacy groups should be encouraged as they will serve as a peer groups that will positively reinforce the acceptable behavior of ‘not smoking’ and increase youth empowerment through community involvement. Facilities need to be put in place to reduce the availability of and youth access to tobacco products and reduce youth exposure to second- hand smoke. Unlike in South Africa, for instance, it is still legal and common in Nigeria for cigarettes to be sold individually which makes it easier for children to afford them. Stricter control measures need to be in place like it’s done in other parts of the world where one requires an ID to purchase tobacco products.
The antismoking campaign adopted by the Nigerian government will work effectively if other social marketing methods are used in the campaign. Community-based participatory research should be encouraged as this provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. Ads asked youth to directly confront the tobacco industry and publicize this teen activism in the popular media. There is still an opportunity to change the situation that exists in Africa especially NIGERIA by learning from the experiences of other public health interventions, such as those for the HIV epidemic. The interventions appear to have reduced the risk behaviors by utilizing the existing infrastructure such as antenatal clinic. Applying this model to the current situation, it may be possible to provide public health information on the risk of smoking and exposure to environmental tobacco smoke.

In many modern societies, smoking has been an acceptable norm. It used to be socially acceptable in Europe and the United States but is less so now. This is because large-scale tobacco control programs have been instituted in such countries with increasing effectiveness. The mass media provide effective tools for convincing youth not to smoke; because they can communicate prevention messages directly to young people and influence their knowledge, attitudes and behaviors (Hopkins et al, 2001). Mass media campaigns usually achieve long- term success but they must be framed in ways that are attractive to the target population especially the youth. Research has also shown consistently that tobacco counter – marketing campaigns are most successful when they are part of a broader, comprehensive tobacco control activity.

1. Nigeria takes on big tobacco over campaigns that target the young
2. Smoking Prevalence. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000).
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [cited 2006 Dec 5]. Available from:
4. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 1997–2001. Morbidity and Mortality Weekly Report [serial online]. 2002;51(14):300–303 [cited 2006 Dec 5]. Available from:
5. Centers for Disease Control and Prevention. Health United States, 2003, With Chartbook on Trends in the Health of Americans. (PDF–225KB) Hyattsville, MD: CDC, National Center for Health Statistics; 2003 [cited 2006 Dec 5]. Available from:
6. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of the American Medical Association 1993;270: 2207–2212.
7. Tobacco Free Japan: Recommendations for Tobacco Control Policy, 2005. Health Risks of Smoking.
8. DeJong, W. Condom promotion: The need for a social marketing program in America's inner cities. Am J Health Promotion, 1989;3(4):5-10.

9. SMOKING PREVALENCE. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000).
10. Social Marketing Institute; Success Stories – Florida Youth Campaign.

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