Developing Antitobacco Mass Media Campaign Messages in a Low-Resource Setting: Experience from the Kingdom of Tonga

"The Tongan experience underscores the importance of an adaptation process that draws from evidence-based best-practice models and engages local and regional stakeholders to ensure that campaign materials are tailored to the local context and are embedded within a mix of antitobacco strategies."

This paper presents some of the practical steps involved in adapting antitobacco campaign materials for local audiences with minimal resources and a limited budget and without the need for an external production team. It is argued that the adaptation approach can result in considerable savings of cost and time in low-resource and low-population settings and may be considered a viable option in countries facing challenges similar to those in Tonga. In this small South Pacific island nation, tobacco use is a major cause of preventable death and a leading contributor to the nation's rise in non-communicable diseases (NCDs). In fact, approximately 46% of males and 13% of females smoke in the Kingdom, with about 90% of this population smoking daily. Furthermore, over a third of Tongans reporting that they have been exposed to secondhand smoke at least once during the previous week at home (39%) and at work (32%). Yet low- and middle-income countries (LMICs) with low populations, like Tonga, face a number of challenges when creating evidence-based, high-impact antitobacco campaign materials.

A number of considerations, informed by the literature base, proved vital in adapting a series of antitobacco ads in Tonga despite limited resources, a production team of just 2 individuals, and a budget of $A5,000. The team was guided by the following questions when looking for campaigns to adapt: Is the campaign based on the latest and best evidence? Has it demonstrated effectiveness in promoting changes in knowledge, attitudes, and behaviours among intended audiences? Can it be adapted on a small budget and with few resources? How easily can it be tailored to the Tongan context and made suitable for Tongan audiences? Can permission to adapt the original material be granted by those who own the copyrights? Will the campaign complement and support other antitobacco strategies? On the basis of the answers to these questions, the team selected 6 TV ads for adaptation in Tonga (see table 1). "In short, these six advertisements were evidence-based, effective, technically feasible, affordable, locally adaptable and could be embedded within an integrated strategy, making them a highly suitable option for a Tongan adaptation." (For one example, see the video, below.)

The paper explores the practical steps that followed in the process of adapting the ads, including stakeholder engagement: Regular face-to-face discussions and feedback sessions were conducted with a range of doctors, nurses, health promotion workers, members of the National Tobacco Control Subcommittee, and heads of relevant health organisations throughout the pre-production and planning phases. Foreign actors appearing in the original ads were replaced with Tongans, and the ads were adapted to include a call to action that made smokers aware of community cessation support services that were to be developed by the Ministry of Health with the support of Quit Victoria. Translating the English voice-over and text into Tongan proved the most challenging and time-consuming aspect of the project. Consumer field pretesting of the ads was conducted by the Tongan team with technical advice provided by a research group from Cancer Council Victoria, an independent non-profit organisation that advises various Australian and international groups on cancer-related issues. Among other feedback, pretest data indicated that secondhand smoke ads may be more effective than individual health-threat ads in Tonga, perhaps due to the fact that Tongans typically live in extended family environments. "These findings suggested that broadcasting the secondhand smoke ads (Baby Alive and Heart) might have the greatest potential in motivating quit attempts among Tongans and in reducing smoking behaviours that result in harmful passive exposure."

Some aspects of the adaptation process could have been improved; lessons learned are outlined. For example, "[t]he project would have benefited from developing deeper insight into local audiences and local circumstances prior to ad production." Looking ahead, the authors note that Tonga had planned to launch a National NCD Strategy in May 2016. The Australian Government funded a series of 6-week mass media bursts to complement the airing of the antitobacco TV ads with billboards, posters, bus signs, radio spots, and social media across the Kingdom over the 5-year initiative. This is appropriate, considering that "[r]esearch shows that antitobacco mass media campaigns are more effective when delivered as part of a mix of integrated strategies, including cessation support services, school education programmes, community workshops, bans on tobacco advertising, smoke-free areas, tobacco taxes and prominent health warnings on cigarette packaging..." A longitudinal pre–post study will evaluate the impact of the campaign in reaching intended audiences, raising awareness, shifting attitudes, and changing smoking behaviours.