Every year, 6 million people die from a tobacco-related cause worldwide. Smoking, which is a learned behavior resulting in physical dependence on nicotine, is the leading cause of tobacco related deaths. Despite numerous campaigns and interventions aimed at making smokers quit, only a small fraction succeeds. However, a bewildering number of smokers think and act upon quitting smoking, implying a high degree of awareness about both the consequences of smoking, and the benefits of quitting. Why is the success rate for quitting so low despite high awareness levels? Development organisations, especially in the health domain lay great emphasis on behavioral change communication in promoting positive behaviours in the target population. So how well does SBCC work in getting smokers to quit?
According to a survey conducted in across four countries, over 40% smokers attempt to quit in a given year. Moreover, each of these smokers attempt to quit twice a year on an average. Almost 90% of all smokers attempt quitting over a time span of 4 years, out of which 80% attempt to quit at the time of starting.[1] These numbers point to the fact that awareness of the consequences of smoking on health is widespread. In the development sector, WHO points to two primary models that are currently in use to promote discontinuation of tobacco use – namely, the 5A’s model and the 5R’s model.[2] Both of these models are aimed at addressing individual behaviors, enablers and motivators. The 5A’s (Ask, Advise, Assess, Assist, Arrange) model is usually deployed in a primary care setting, where the care providers advise the smoker on quitting smoking and then assist them through the quitting process on the basis of their readiness to quit. However, the 5A’s model proves effective only when the subjects attend 5A’s group counselling sessions. More on this later.
The 5R’s (Relevance, Risks, Rewards, Roadblocks, Repetition) model takes a person through a repetitive process in which personal stakes are identified around quitting, after which they are assisted on tackling the obstacles in achieving the target behavior. While no conclusive studies have been conducted on the effectiveness of the 5R’s model, there is a crucial point to be noted here. Identification of risks is one of the two components that leads them to making a quitting attempt. While health risks are well known to smokers through mandatory messaging on tobacco products, these messages do not fare well enough in getting smokers to quit, reiterating what we’ve always known – that information and knowledge by themselves are inadequate in facilitating behaviour change. However, messaging around risks that entail a social consequence like bad breath and/or losing virility proves more effective in ushering smokers across the quitting process.
SBCC campaigns usually rely on repetitive messaging to achieve higher incidence of positive behaviours. While this tends to be effective in most SBCC-based interventions, the actual impact of repetitive messaging to achieve positive behaviours amongst smokers remains an under-explored territory.
The objective of SBCC interventions is to trigger and stimulate the target population towards adoption of desired behaviors and practices. However, on the subject of tobacco use, where organisations are faced with high levels of awareness and messaging as the baseline or the starting points, SBCC must address weak links in the 5A’s and 5R’s model to usher smokers to quit. While current strategies address individual behavior and motivation, the 'S' of the SBCC finds presence in more or less fragmented slots of the process. While the ban on tobacco advertisement and paan and beedi shops around educational establishments (within 100 yards)* is a positive step towards addressing social enablers of tobacco use, the success rates towards deterrence have been dismal. Studies show that a 500-metre distance can increase odds of quitting by 20-60%. While anti-smoking social norms and physical distancing are positively associated with cessation behaviors, India’s high population density and tight urban and rural public spaces make it difficult to achieve a high degree of distancing. Moreover, laws have been enforced only to a questionable degree of effectiveness. Violations have been frequent, and passive availability is another barrier in enabling cessation through distancing.[3]
Behavioural group counselling, one-to-one communication, and even social mobilisation efforts, on the other hand have demonstrated higher success rates, which points to the potential of accounting for perceptions, practices and inert and dormant social dynamics that pertain to smoking. Organisations and governments must explore empathy-based messaging and introduce stimulants of social interaction in order to achieve a higher incidence of human interactions around tobacco use.
World no-tobacco day on May 31st, is a moment for us to reflect on the lessons we have learnt from SBCC interventions aimed at tobacco use and remodel programmatic strategies around techniques that actually work on field.
*100 yards = 91.4 metres
References
[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909986/#:~:text=Around%2040.1%25%20(95%25%20CI,of%200.82%20attempts%20per%20smoker
[5] R. E. Rice and C. K. Atkin,Public communication campaigns. Thousand Oaks, CA: Sage Publications, 2013.