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ShowCase │ Fight Back 1
Overview
As part of their PRIME programme to reduce
health inequalities in the area, NHS
Birmingham East and North (NHS BEN)
worked in partnership with healthcare
consultancy Dr Foster Intelligence to design
and deliver a social marketing campaign to
reduce smoking prevalence in male routine and
manual workers, aged 35 to 55 and living in
deprived wards of the NHS BEN area. The
campaign‟s hard-hitting approach directly
targeted this audience segment, who
experience the greatest health needs relating
to smoking-related conditions, by causing them
to re-evaluate their relationship with cigarettes
and to „Fight Back‟ against them.
The campaign used a variety of media
channels to deliver its message, including a
Fight Back film, advans at local football events
and an on-street delivery team who located a
branded trailer near events and locations
where the target audience were.
Results
The campaign achieved an 87 per cent
increase in the number of Quit Dates Set and a
65 per cent increase in successful quits, versus
the same 2-month period in 2008. The
campaign also resonated disproportionately
with the target audience, a group which
historically have accessed NHS BEN‟s smoking
cessation service in low numbers.
Fight Back
Topic:
Smoking
Organisation:
NHS Birmingham East and North
Location:
Birmingham (West Midlands, UK)
Dates:
Phase 1 – September to November 2009;
Phase 2 – May to June 2010
Budget:
Phase 1 – £367,000
Website:
www.benpct.nhs.uk/pharmacies-with-stop-
smoking-services
Contact:
Rebecca Clapson (Social Marketing
Manager)
Email:
Telephone:
0121 380 0643
ShowCase │ Fight Back 2
Smoking in England
In England in 2008 around 84,000 deaths were
estimated to be caused by smoking,
representing 18 per cent of all deaths in adults
aged 35 and over. With over 440,000 hospital
admissions attributed to smoking-related
conditions annually amongst the same age
group, it is clear that smoking represents a
considerable threat to the health of the
population. Furthermore, with the treatment of
smoking-related illness costing the NHS an
estimated £2.7 billion annually, the financial
burden smoking places on the NHS is
significant.
Smoking rates in England have declined over
the long-term, from 39 per cent in 1980 to 21
per cent in 2007. The impact of the smoking
ban in 2007 has also been well documented
with an estimated 400,000 people quitting
smoking as a result of its introduction. The
current government target, announced in
February 2010, is to reduce the adult smoking
rate to 10 per cent by 2020.
Despite this progress, serious inequalities exist
in smoking prevalence rates depending on
people‟s social status. In 2007, 28 per cent of
adult manual workers were estimated to
smoke, which compared unfavourably with 16
per cent in the non-manual population (The
Marmot Review). A National Institute for Health
and Clinical Excellence (NICE) report published
in 2008 stated that smoking is the primary
cause of health inequalities between the rich
and poor in England.
PRIME programme
Over 2009 the three Birmingham Primary Care
Trusts (PCTs) – Heart of Birmingham Teaching
PCT (HoBtPCT), NHS Birmingham East and
North (NHS BEN), and NHS South Birmingham
(NHS SB) – and the City Council all invested in
ways to improve engagement with their
services by targeting specific community
groups.
A number of projects across the PCTs are
increasingly utilising intelligence to support
effective decision making in commissioning and
communications. Among them NHS BEN has
created PRIME (Programme for Relationships,
Intelligence, Metrics and Equality), developed
in partnership with healthcare consultancy Dr
Foster Intelligence to address health
inequalities across the region.
The challenge
In 2009 within the NHS BEN region, overall
smoking prevalence stood at 28 per cent,
significantly above the national average and
equating to 84,000 smokers.
As part of the three-year PRIME partnership
programme, Dr Foster was tasked with
developing a social marketing campaign that
would reduce smoking prevalence among
those most at risk from smoking-related health
conditions. Its objectives were to:
Increase the number of Quit Dates Set
within the target audience by 40 per cent to
60 per cent during the campaign period
Increase the number of people within the
target audience recording a successful quit
following the campaign period
The budget was provided by the PCT and ring-
fenced for the PRIME programme. The project
was managed by a Dr Foster Account Manager
and the PCT Social Marketing Manager. The
core team consisted of a Stop Smoking
Manager, Stop Smoking Commissioner, PCT
Social Marketing Manager, PCT
ShowCase │ Fight Back 3
Communications Representative and the Dr
Foster Account Manager. The Director of
Public Health was also fully engaged and led
the process.
Secondary research
Desk research was undertaken and included:
A review of the information and evidence
that may be available at a national or global
level. This also identified any relevant
benchmarks or comparison
A review of previous social marketing
activity in the area
A review of the local services and how they
were promoted, including interviews with
key staff and health professionals, to
develop a picture of what was currently
happening
Primary research
Primary research was conducted to generate
insight on:
The barriers that were preventing the
audience from quitting smoking
Their motivations for continuing to smoke
What had prevented them from successfully
using the current smoking cessation
services
What would motivate them to stop smoking
Focus groups were undertaken with smokers
between the ages of 35 and 65 wanting to quit.
Smokers were recruited off the street and the
focus groups were run by dedicated
researchers. One-to-one interviews were also
held with pharmacists delivering the pharmacy
stop smoking service.
Exchange
Benefits for continuing to smoke:
Maintaining status quo – too hard to break
the habit
To cope with the stresses of daily life
To alleviate boredom
For relaxation or concentration
To be sociable with friends
To take a break from work
Benefits of quitting:
Financial
Health
For the family
Barriers to quitting:
Lack of motivation
Fear of the „pain‟ of quitting
Lack of confidence, having failed in the past
Resigned to always being a smoker
Friends smoke
Associate drinking alcohol with smoking
Belief that the damage to their health is
irreversible (particularly amongst those over
35)
Fear of gaining weight (particularly amongst
women)
Difficulty finding an alternative way of
coping with the stresses of life
Awareness of and attitudes towards stop
smoking services
Most were positive toward the NHS and
NHS stop smoking services, seeing them as
free and fairly equal
Most respondents were aware of the stop
smoking services provided by GPs, but
fewer respondents were aware of the stop
smoking services provided by pharmacists
and many said they would not think of
approaching them for help
A limited number of respondents were
aware of the PCT‟s drop-in sessions
ShowCase │ Fight Back 4
Many respondents were aware of the Call to
Quit telephone line having heard it
advertised on local radio or seen
advertisements in the local press and GP
practices
Target audience
As part of the PRIME programme, Dr Foster
and NHS BEN developed a population
segmentation tool called Typologies. This was
done by using a cluster analysis across a range
of health data sets available through the PCT
(such as local hospital admission and General
Practice data) and used geographical and
demographic information to supplement it.
These audience segments were described as
Red, Green and Blue typologies, with each
typology broken down into further subsections,
enabling the team to target their activity in a
precise manner. This enabled the team to
identify the typologies with the greatest health
needs in regards to smoking-related conditions.
This research was informed by the national
body of evidence that exists around smoking
cessation and tobacco control.
This process of creating unique „health
typology‟ audience segments grouped people
together based on the degree of association
that existed between them and provided insight
into people‟s health needs. The data showed
that British males, from the lower deprivation
quintiles between the ages of 35 to 55 were
most at risk from conditions such as cancer,
respiratory disorders and chronic obstructive
pulmonary disease. Additionally, this audience
were estimated to have a smoking prevalence
rate of over 30 per cent, making them the
target for campaign activity. This group
primarily came from the Red health typology.
“Our core purpose is to tackle health
inequalities and improve health and wellbeing.
The health typologies that Dr Foster created
have made a significant impact on our ability to
tackle these inequalities by enabling us to
focus on those that need our support the most.
The Fight Back campaign is an excellent
example of this approach in action.” Nicola
Benge (Director of Health Improvement and
Public Health, NHS BEN)
Actionable insight
The key piece of insight that the research
generated was that the target audience
strongly disliked the control that smoking held
over them and the feeling of being unable to
quit. This insight underpinned the development
of the campaign.
“I‟ll try anything because I want to give it up. I
want to break that habit. And that‟s what it is,
it‟s just habit.”
The team also found that almost all smokers
had smoked for many years and made
numerous unsuccessful quit attempts, which
left them unmotivated and unsure of how to
make another attempt to quit.
“I know that fags are going to kill me if I carry
on, so I‟ve got to stop. I will stop. How I‟m going
to do it, I don‟t know.”
The research highlighted that the target
audience were straight-talking and respected
that quality in others, an insight that provided
guidance for the tone of the campaign.
Smokers also reported some issues with the
existing smoking cessation services, ranging
from discomfort with discussing their battle to
quit in a group environment, to difficulty
accessing services at a time and a place that
suited them. This generated recommendations
for service redesign, which will help ensure
there is a longer-term and sustainable output
from the research.
Furthermore, it was agreed that the pharmacy
service would be the most effective smoking
cessation route for the audience, as it provides
one-to-one support and flexibility of access that
would better suit their lifestyle.
ShowCase │ Fight Back 5
“Dr Foster has been very proactive in engaging
with our population and their success in
generating insights into entrenched health
problems has been valuable. The research
conducted as part of the Fight Back campaign
helped us to identify the barriers affecting our
target audience and to promote a service that
would overcome them.” Nicola Benge (Director
of Health Improvement and Public Health, NHS
BEN)
Behavioural goal
To achieve the campaign‟s targets, the team
wanted their target audience to engage with
their stop smoking services through their local
pharmacist and ultimately set a quit date.
Building partnerships
A top priority was to ensure that effective
partnerships were built with pharmacists to gain
buy-in and ensure that they were aware of the
campaign, its core message and what would be
required of them. Building this cohesion was
paramount in ensuring that at the point
smokers entered the service there was
continuity of message to minimise the
likelihood of smokers dropping out of the
service.
This was achieved in three ways:
By taking advantage of the existing
communications channels that existed
between NHS BEN and the pharmacists,
plans for the campaign were shared through
the pharmacy representative and feedback
gathered to inform the development of the
finer details of the campaign
Information was provided to the NHS BEN
representative of the Local Pharmaceutical
Committee (LPC), enabling them to provide
a campaign debrief at their monthly meeting
All pharmacists were provided with a
debriefing pack, which outlined the aims of
the campaign, promoted the benefits the
campaign would bring to their business and
provided relevant materials such as posters,
leaflets and giveaways
Other key stakeholders were the stop smoking
team, who were key to the delivery and
development of the stop smoking service, and
the media. To manage stakeholder relations, a
public relations (PR) company were contracted
to develop a PR strategy.
Concept testing
Four campaign ideas, generated in response to
the insight, were tested with the target
audience. Each campaign idea focused on the
key insight that quitting smoking would enable
ShowCase │ Fight Back 6
the audience to regain control, although that
message was communicated in distinctly
different ways.
The four ideas were concept tested with 6
focus groups of 8 members of the target
audience (male routine and manual workers
aged 35 to 55).
One of these concepts – „Fight Back‟ – clearly
struck a chord with the audience and was the
most effective at engaging their interest.
Fight Back
The Fight Back concept confronted the target
audience with a graphic metaphor for the
damage that smoking does by enabling them to
„see it‟, but was also empathetic in
acknowledging that successful quitting is a real
fight.
The campaign challenged the audience to fight
back and beat cigarettes. The audience were
struck by its originality, clarity of message and
impact.
“Fight Back undeniably contains challenging
imagery, an approach that generated some
controversy. Importantly though, it resonates
with our target audience and the evidence
shows that it has made a difference to the
number of people quitting smoking.” Nicola
Benge (Director of Health Improvement and
Public Health, NHS BEN)
The marketing mix
Product
Accessing the stop smoking service via the
local pharmacies.
Price
While accessing the stop smoking service is
free, the target audience faced non-monetary
costs such as time and effort required to quit
smoking.
Place
The target audience would be encouraged to
use stop smoking services offered through the
local pharmacies in the areas of BEN with high
numbers of Red typologies. Promotional
activity was planned for areas where this target
audience were likely to be, plus areas as near
as possible to pharmacies that were offering
the stop smoking service. Thus if someone was
captured by the promotional activity he/she
would have the option to see a pharmacist
almost immediately. This would reduce any
likelihood that they would subsequently change
their mind or take no further action.
Promotion
The Fight Back campaign‟s imagery was very
effective in attracting attention and making
people stop and think. To capitalise on this
visual impact, six sheet posters carrying the
Fight Back message and a text number that
ShowCase │ Fight Back 7
signposted to local pharmacy services would
be displayed at over 50 sites.
A trailer, towed by a branded Land Rover
Discovery vehicle, was hired for the campaign.
This would be the focal point of activity and
contained experiential elements, such as the
lung age tester, as well as an LCD screen to
show the Fight Back film and a seating area for
the ambassadors to offer advice and guidance
to smokers. Mocked up police incident boards
would be displayed outside the trailer to grab
attention and attract people inside. A trained
team of paid sales personnel from a
merchandising company recruited by Dr Foster
would provide information, advice and
guidance, helping smokers understand the
hidden dangers of smoking and promote the
pharmacy service.
Timing
To ensure Fight Back was delivered at the
most effective time of the year, the team
analysed smoking cessation trends within NHS
BEN across a three-year period to investigate if
there were times during the year when people
were quitting in smaller numbers. This analysis
highlighted that the autumn months were
traditionally „quieter‟ and there was capacity in
the system to deal with additional quitters.
Capacity was a flagged as a valid concern as
the team did not want to flood the system and
have people keen to stop smoking waiting to be
seen, as this could ultimately be demotivating.
Additionally, they liaised with NHS BEN and the
regional tobacco control lead to understand
what local and regional social marketing activity
was planned, and considered national
campaign activity. Both these factors pointed to
an autumn campaign, launching in October and
running for eight weeks.
Beginning in October 2009 for two months, the
Fight Back campaign was delivered in two
waves. The strategy was designed to ensure
that smokers had the maximum number of
opportunities to see the message, understand it
and act on the message. In essence, the
message invited smokers to „fight back‟ against
cigarettes by setting a quit date at their local
pharmacy smoking cessation service.
Wave One – Sharing the message
The objective of the first wave was to share the
Fight Back message with the audience through
a communications campaign that utilised a
range of media channels. The campaign was
displayed and promoted in places where the
ShowCase │ Fight Back 8
target audience lived, worked and spent their
leisure time.
This activity was supplemented by the
distribution of smaller posters, campaign
leaflets and giveaways across 900 venues
frequented by the target typologies, including
cafes, public houses and trading estates.
Additionally, the team took advantage of large
gatherings of the target audience. Mobile
„advans‟ were deployed on match days at
Birmingham City and Aston Villa, patrolling the
approaches to the football grounds and sharing
the Fight Back message with thousands of
people.
This locally focused activity was supported by a
press and PR campaign focusing on local titles
such as the Birmingham Post that the audience
read.
The campaign was further promoted by a Fight
Back film, which was created by internationally
acclaimed filmmakers Rankin and Chris. This
hard-hitting representation of the Fight Back
message, showing a smoker felled by invisible
blows each time he inhales on his cigarette,
was released virally and recorded over 200,000
hits online during the campaign period.
Wave Two – Amplifying the message
through on-street activity
Previous experience in delivering smoking
cessation campaigns had shown that smokers
can benefit enormously from receiving face-to-
face advice and guidance. This personal
interaction enables a dialogue with smokers
and an opportunity to overcome barriers and
provide encouragement and reassurance.
ShowCase │ Fight Back 9
The overall objective of the face-to-face
interaction was to provide smokers who were
interested in quitting with the name, address
and phone number of their local pharmacist,
directing them straight into the smoking
cessation service. The benefits of stopping
smoking and of using the pharmacy service,
and its ease of access, flexibility and the
support provided were all promoted.
The team collected smokers‟ details to create a
contact database, which served two purposes.
First, the database was used to contact
smokers during the campaign by phone and
text to remind them of their local pharmacy
details and to offer further encouragement to
take the next step to make an appointment and
set a quit date at their local pharmacy. Second,
the database allowed NHS BEN to track the
progress of smokers and re-contact them
where necessary to provide further advice
about quitting. This ensured that support would
be ongoing, thereby improving smokers‟
chances of quitting.
To deliver this face-to-face activity a team of
trained on-street ambassadors were employed,
focusing on the areas where the audience
lived, worked and shopped by using internal
knowledge and the typology map. Experiential
elements such as carbon monoxide and lung
age testing were used, so that the target
audience could understand the damage that
smoking was doing to them, even if they could
not see it. To maximise the likelihood of
smokers engaging with the ambassadors an
eye-catching and engaging on-street
experience was created, making use of the
Fight Back film and mocked up police incident
boards to draw people to the trailer.
The on-street activity was very successful in
generating large numbers of referrals at
pharmacies close to the locations of the
activity. Some changes had to be made to the
initial implementation plans of street activity
due to some pharmacies becoming very busy
and capacity proving an issue. The teams
therefore adapted the dates and locations of
the on-street activity to maintain capacity and
respond to the needs of the local pharmacies.
The response from the press and media to the
violent and shocking imagery used in the
campaign was both positive and negative,
ShowCase │ Fight Back 10
though both ultimately served to raise the
profile of the campaign.
Evaluation planning
The project was evaluated by Dr Foster using
pre- and post-surveys administered to the local
pharmacists.
The Fight Back campaign‟s primary objectives
were to:
Increase the number of Quit Dates Set by
the target audience by 40 per cent to 60 per
cent during the campaign period
Increase the number of people within the
target audience recording a successful quit
following the campaign period
Results
During the campaign period there was an 87
per cent increase in the number of Quit Dates
Set at local pharmacies, versus the same 2-
month period in the previous year (2008).
A 65 per cent increase in the number of
successful quits was recorded over the
campaign period, versus the same 2-month
period in the previous year (2008).
The campaign was also shown to resonate
disproportionately with the target audience, a
group which historically have accessed NHS
BEN‟s smoking cessation service in low
numbers. This is of particular importance when
considering the impact on health inequalities,
where it is not enough to only increase
absolute numbers, but it is also necessary to
increase the number of people from the
audience with the greatest health needs.
As the chart above shows, all typologies
experienced a significant increase in the
number of people successfully quitting.
However, Fight Back had the greatest effect on
the Red typology audience.
“We‟re delighted with the results, which bucks
the trend of recent years and turns around a
decline in quit rates and begins to prove what
we believed – that investing in segmentation,
research and a well constructed campaign will
produce results when tackling health
inequalities.” Nicola Benge (Director of Health
Improvement and Public Health, NHS BEN)
There were also some unintended positive
outcomes, with the campaign resonating with a
wider audience, including the other typologies
and men and women alike, increasing referrals
outside the target audience.
Media exposure
75 per cent of the target audience had an
average of 6 opportunities to see the posters
over the campaign period. A tracker study
showed that 64 per cent of people questioned
were aware of the Fight Back campaign and 50
per cent of people recalled seeing the Fight
Back poster, which is 2.5 times the industry
average.
Return on investment (ROI)
ROI has been calculated and results will be
released soon.
ShowCase │ Fight Back 11
Findings and learning were shared with
regional tobacco control leads, pan-
Birmingham and internal PCT staff, and at core
cities events on smoking (where attendees
included directors of public health, smoking
leads and local authority tobacco control
leads).
Sustainability
The team were keen to ensure Fight Back
could be sustained beyond the life of the
campaign period. To achieve this, during the
face-to-face on-street activity they generated a
contact database of another 1,300 smokers,
whose progress towards quitting smoking has
subsequently been tracked.
Six months after the campaign‟s completion,
the entire database was contacted with a
response rate of 58 per cent. Of these:
27 per cent reported they had successfully
quit smoking
55 per cent reported that although they had
not quit smoking they were still interested in
doing so and were provided with further
encouragement, practical advice and
guidance
Phase Two
Given the high smoking prevalence rate in the
target audience, as well as NHS BEN‟s target
of reducing smoking prevalence to 18 per cent
by 2018, a second phase of activity was
delivered in May 2010 to build on the success
of Phase One.
The campaign‟s main focus remained on male
smokers aged 35 to 55 who fall into the Red
typology. However, data from Phase One
showed that smokers from all typologies
engaged with the campaign and that it also
resonated with female smokers, so quits
achieved from the broader audience will be
recognised in the evaluation.
“The Fight Back campaign made a big
difference to the number of people using our
stop smoking service. We were able to help
many more people quit smoking and it‟s great
news that the campaign has returned. I‟m
looking forward to welcoming many more
people and working with them to help them
quit.” Shazia Alam (Pharmacy Manager at the
Co-Operative Pharmacy in Acocks Green)
The delivery model from Phase One was
broadly replicated in the second phase of
activity, with some amendments made based
on learning from Phase One:
Local six sheet posters
The posting period was reduced from eight to
four weeks. During Phase One 75 per cent of
the target audience had an average of 6
opportunities to see the posters over the
campaign period. In Phase Two, over the 4-
week period 60 per cent of the audience will
have an average of 8 opportunities to see the
posters. In Phase One it was necessary to
achieve higher coverage over a longer posting
period to launch and establish the campaign.
However, given that 64 per cent campaign
awareness was achieved amongst the target
audience in Phase One, it was not necessary
to run Phase Two over as long a period.
ShowCase │ Fight Back 12
On-street activity
On-street activity was also reduced from 28
days to 21 days, as engagement with the public
was not from a „standing start‟ position. Phase
One provided solid evidence as to the most
effective locations to engage with the public,
and this information was used to plan highly
targeted on-street activity in Phase Two.
Relationships with pharmacies were also better
established and links made between the on-
street activity and those pharmacies with the
greatest capacity and willingness to engage
with the campaign.
Phase Two utilised all campaign elements
previously included, with the exception of the
48 sheet ad van and the viral seeding. Based
on anecdotal feedback from on-street teams,
these were not vital components for engaging
people, who were more interested in interacting
with other experiential elements.
“The success of the last campaign was really
inspiring. We were confident that the approach
would work but it was great to see such a huge
increase in people trying to quit. This second
phase is important to remind people about the
service and encourage more people to give it a
go and fight back.” Sally Brooks (previous
Social Marketing Manager, NHS BEN)
Lessons learned
Success of media coverage and on-street
activity
Extensive media coverage, both locally and
nationally, really helped drive the awareness
and success of the campaign, and the on-street
activity worked well to drive smokers to
pharmacies. This was due to a combination of
factors. First, the branded trailer, Land Rover
and incident sign grabbed people‟s attention.
Second, the trained ambassadors not only
encouraged smokers to try experiential
elements within the trailer, but they also
highlighted the ease and flexibility of using the
pharmacies‟ stop smoking service. In addition,
as they were located near to these pharmacies,
the team were able to direct those interested
straight to the service, removing the chance
that smokers would go home and change their
mind or not take the necessary steps to
quitting.
Engagement with pharmacists is essential
As a result of the success of the on-street
activity, some pharmacies were over-stretched
and unable to meet the demand for the stop
smoking service. To address this, the team
would have preferred to have briefed the
pharmacists better about the campaign and
prepare them for an increase in demand.
Engagement with stakeholders who are key to
delivery of a referred service is essential and
should be developed as early as possible. The
team would also recommend a different
booking mechanism to avoid inundating
pharmacists.
Learning from Phase One
In Phase One the advertising asked smokers to
text a number, which they then received an
automatic text from asking them to text back
their postcode for their local pharmacy. The
team found that very few people responded to
this text. This was altered in the second phase,
where a link was sent with the automatic text,
which took smokers to the campaign website
where they could find their local participating
pharmacy.