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New evidence, new practicesUsing social media to change smoking behaviorsStephen HamillDirector of Policy, Advocacy and Communication

Privilege to be here,Worked at NYC 10 years

Goals:Talk about our work in a way that informs your workThree sections, after each time for a few questions1) Theory2) A lighting fast review of two case studies that contributed to current learnings3) A more in depth reviewFollowed by an activity

With just an hour, Im going to move really fast

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Vital Strategies envisions a world where every person is protected by a strong public health system. We bring leading global expertise to complex and intractable health problems.

We partner with governments to make progress possible and create lasting change.Strategic HealthCommunicationResearchand EvaluationProjectManagementWorkforceDevelopmentPolicy AdvocacySurveillance andEpidemiology

Vital Strategies develops large scale public health programsDifficult health problems are multi-factoral require complex responsesWe partner multi-disciplinary teams with government to implement world-standard solutions2

Strategic Health CommunicationOur Strategic Health Communication practice uses marketing strategies to move large populations from awareness to action on issues like smoking, drink driving or obesity.

One of these disciplines is strategic health communicationTodays work funded by Bloomberg PhilanthropiesOne of five partners in Bloomberg InititiaveOur remit communication3

More than 2 billion people in 53 countries have seen one of our campaigns.

Launched mass media campaigns in 53 countries

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Media influences behavior, social norms and policy uptake

NCI Monographcancercontrol.cancer.gov/tcrb/monographs/19/m19_complete.pdf

Evidence is that media works across specturmNot only changing individual behaviorBut changing the context of health decision makingBoth social norms and Support for policies, environment where poicy change is possible

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Tobacco is OKTobacco is deadlyHard-hitting messages transmit knowledgeLow knowledgeHigh knowledge

Whats the mechanism for these behavior changes?Knowledge drives changeAs people or society we first see knowledge change, then attitudes, then intentions and than behavior Emotionally-driven messages the key to driving changeHard-hitting messages can change the perception of risk6

Process of Behavior Change frameworkPreknowledgeunaware of the problem or of the riskKnowledgableaware of the problem and the desired behavior changeApprovingin favor of the desired behaviorIntendingpeople express the desire to take the desired actionPracticingpeople are actively undertaking desired behaviorAdvocatingpeople are practicing and asking others to do the samePiotrow, PT, Kincaid, DL,Rimon, JG & Rinehart, W/ (1997). Health communication: Lessons from family planning and reproductive health. Westport, CT: Praeger PublishersLow knowledgeHigh knowledge

The Process of Behavior Change framework, which is based on the states of change/ transtheoretical model, provides a mental map of where audiences (like smokers) might be.

Our goal is to use media to bring people from the bottom to the top.7

Low knowledgeHigh knowledgeSmokesRecognizesdangerMotivatedto quitQuitsUrges othersto quitTolerates SHSMoves away from SHSSupports SF lawSocial SFEnforcement

Tobacco is OKTobacco is deadlyTobacco Control nota prioritySupports theissueUrges othersto supportDemandslegislation

advocacypersonal behaviorpolicy

And its worth noting that a single campaign, a single message, works on all levels at once personal behavior but also generates increased interest in policy and advocacy behaviors.8

New populationsNew channelsNew behaviors

Digital is rapidly changing the media landscape

So where does social media fit in?

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#CountryUsersPenetration1 United States166,029,24052.9%2 India62,713,6805.2%3 Brazil58,565,70030.2%4 Indonesia51,096,86020.5%5 Mexico38,463,86033.5%6 United Kingdom32,950,40052.3%7 Turkey32,131,26040.3%8 Philippines29,890,90028.8%

http://en.wikipedia.org/wiki/Facebook_statistics#ReferencesSina WeiboUsersPenetrationChina503,000,000+30%+

Our work has changed with the media landscapeTop social network by country, 2012

Even for my work in low- and middle-income countries social media has become a critical piece of the mix.

Even though social media has very limited reach fro a per capita basis, we still see very large populations on line, and social media is becoming increasingly important.

In some markets, like the US and UK, Facebook alone has achieved almost 50% penetration in adults. In the U.S. we spend more than 7 hours a months on Facebook. While less than 4% of Indians use Facebook, there are still more than 43 million Indian users. 6 of the top 10 largest Facebook populations are in LMICs. Each of these countries also has a terrible tobacco problem.

Ill note that even in these old figures, from 2012, each of these is larger than the entire population of Australia.

So as communication consumption is increasing globally, and incerasingly social media is a part of that mix we have to understand how to make this work for implementation of tobacco control policies.

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http://en.wikipedia.org/wiki/Facebook_statistics#ReferencesSocial Networks: Canada

In Canada, just under seven in 10 internet users in the country, or 56.7% of the total population, were projected to use social networks in 2015

I took a quick google of Canadas numbers.

About 50% of people use Facebook alone. So clearly theres promise here as well.11

TextPictoralHow does social media operate?Not all media vehicles are the sameMultimedia

Why does media work?In short, images and sound convince. Marketing messages need to create emotional impact that stays with the target audience in order to motivate action.

Every time an audience sees a message thats called an impression. Thats a technical term. To take hold, audiences need multiple impressions of the same message up to a point.

Impressions can happen on TV, in print, or on social media

But all impressions are not equal. In tobacco, weve got some unique parallels to consider.

The text-only pack warnings on the left are informative but studies show that they have very little impact on smokers habits. Graphic picture warnings being introduced in many countries are much more effective. Even better, hard hitting television campaigns, like this one on mouth cancer, may only need to be seen once to convince a smoker to try to quit.

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Id say the mobile euqivalent is an SMS message on the left, receiving multimedia SMS or seeing a photo on a social network in the middle, and a broadband-empowered smart phone or app on the right.

In general the big social media vehicles like Facebook and Twitter are not as persuasive as traditional mass media, which forces people to watch ads.

Effective messages and multimedia messages willneed less frequency.

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Integrated campaigning working at population levelhjhlkjhxxxx

Wakefield et al (2010)1. We rely on mass mediato persuade smokers tochange risky behavior in apersonal, direct route

2-4. Social media playsan additional role inactivating audiences whoare primed for action: indirect network effects and peer influencing strategies can also change smoking behaviors

Thats how behavior change happens on the individual level, and some of the potential limitations of social media.

When you look at a strategic approach for a population, how does social media fit in?

If we accept that it is not as efficient, as persuasive, how do we utilize the power of social media.

Up to now, weve been talking about #1 here in this behavior change model how media directly drives changes in perceptions and intentions to change behavior.

But media campaigns have a proven indirect impact as well. They are generating discussion among people that influence smokers, thats #2,3, and 4 above. These discussions.14

Low knowledgeHigh knowledgeMotivatedto quitQuitsUrges othersto quitSupports SF lawSocial SFEnforcement

Tobacco is OKTobacco is deadlyDemandslegislation

advocacypersonal behaviorpolicy

Social media can target and empower those who will take action, build sustainable communities, and react to day-to-day events.Strategy: Use mass media to change levels of knowledge, creating population level change and more people at the top of the pyramid.Supports theissueUrges othersto support

So, wrapping this all together this is the Vital Strategies approach to using social media

Use mass media, which is very persuasive, to drive people from the bottom of the knowledge pyramid to the top and create potential for change.

Use social media, which is less persuasive, to create actionable and prompting moments, to make action on tobacco a priority today.

We can also use it to target these people.15

Low knowledgeHigh knowledgeMotivatedto quitQuitsUrges othersto quitSupports SF lawSocial SFEnforcement

Tobacco is OKTobacco is deadlyDemandslegislation

advocacypersonal behaviorpolicy

Supports theissueUrges othersto support

Likes are not enough. Our campaigns must translate online actions intoreal-world impact.

Slacktivism / ClicktivismFeel-good measures that have little effect other than to make the user feel they have contributed.

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Questions?End part 1 of 3: Theory

Case study in failure: Packhead

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2009: World No Tobacco Day

For my first campaign Id like to share WLFs 2009 campaign in support of World No Tobacco Day. You may remember that the theme was graphic pack warnings.WLF wanted to mount a small budget campaign that would allow tobacco control advocates to grow awareness about pack warnings and their effectiveness and also communicate the harms of smoking.19

+=What if you could personalize the damage of tobacco?

We came up with a big idea to drive our campaign what if you could make your own graphic pack warning, with pictures of you or your friends as the basis? It would personalize the health harms of tobacco in an in-your-face way, showing the negative consequences and convincing people not to use tobacco. It would also allow people to envision what a powerful disincentive to smoke pack warnings can be.

Develop an app that would allow people to apply in paper doll fashion effects of smoking onto their facebook photos.20

Goal 10,000 installs in the first monthBudget US $15,000 on application development

We thought Facebook would be an ideal medium each person already has pictures of themselves and their friends online that they could modify. With every picture they made and shared the application could grow virally.

As with every communication campaign we try to identify a target audience, our resources and some measurable goals to measure our impact. In this case, we aere trying to reach global tobacco control advocates, and we had about $15,000 to spend on developing the application and set a goal of 10,000 installs.

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2000+ emailsYou can help fight tobacco with Facebook!

200+ Portraits

About a week into the campaign we looked like we were well on our way to global domination we had a successful press announcement that got us a story in new media age, we sent out more than 2000 emails to tobacco control activists, and a more than 200 custom pack photos had been made online. Also, we were encouraged that people were spending several minutes in the app every session so we knew it was being used.22

FLATLINE!

2000+ emailsYou can help fight tobacco with Facebook!

200+ Portraits

About a week into the campaign we looked like we were well on our way to global domination we had a successful press announcement that got us a story in new media age, we sent out more than 2000 emails to tobacco control activists, and a more than 200 custom pack photos had been made online. Also, we were encouraged that people were spending several minutes in the app every session so we knew it was being used.23

Packhead: Lessons learnedDepending on viral growth is a lottery ticket!Social media growth is all about numbershow big can you make your baseGo for a bounce, not an explosionUse provocative content for PRFor online sharing, message is key Emotionally arousing content is more likely to be shared positive/humorous more likely than negative (perhaps missing behavior goals)

In our first campaign, we learned that depending on viral growth is a lottery ticket. Lotteries work because almost everyone loses. Videos like the recent Kony 2012 video are the exception that proves the rule.

Social mediais all about the numbers build as big of a launch base as possible. Use social media to provide a bounce but dont expect an explosion.

And, just as with broadcast communications, messaging is key. In this case, we should test and look for messages that also include sharing as a testing factor. But in my opinion, even though we know that positive and humorous messages are more likely to be shared online, we should avoid them. We know that behavior change communication policy communications can also build audience support for policy change, and that policy change communications can prompt behavior changes. With limited resources, we should concetrate our efforts online and off on finding messages that can do both, which means avoiding humor.

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Case study in integration: Vietnam

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Vietnam: Adding digital platforms to engage audiences

National mass media campaign on TV and radio Goals: Influence public knowledge and risk perception around smoking and SHS, drive quit attemptsBuild support for VINACOSH legislative draft

In vietnam aboutLike manhy of the places my organization works tobacco use is public health distaster.

two out of three men smoke, but interestingly only around 3% of women.

In response, Vital Strategies teamed up with the Ministry of Health and Vinacosh, an umbrella public health organization, to air a mass media campaign on the dangers of smoking.

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91.5M population134M mobile subscriptions31M internet users10.6M Facebook users

We used mobile SMS,Facebook ads, mobileshortcodes in TV adsand a web site to engage viewers.Vietnam: Adding digital platforms to engage audiences

Looking at Vietnams profile ot seemed like a good place to incorporate some of the social media learning.

Instead of relying on viral strategies, we used paid mobile and social media advertising to capture the attention of people who were primed for action.

Our advertising drove people to a site where they can take action a petition web site where they could like our facebook page and submit their name and email in support of new legislation.

This Facebook community and email became the basis for a community of advocates, of message ambassadors that we can easily and cheaply mobilize to share out campaign messages to their own networks, which will include smokers and others.

WE developed a goal of 5000 signatures on the email petition, based on advice from PR experts at what would be newsworthy.27

Facebook ads: 6,743 clicks, US$1.012

ReachFrequencyClick RateCost per click258.0676.1.031%$0.12493.8845.4.044%$0.11678.2166.3.059%$0.09

Message Evaluation: Emotional imagery outperformed

One of the great things about social media, paricularly advertising, is that you can do message evaluation in real time.

We launched more than ten different mini-ads using just that little side space in Facebook.

Imagery is critically important for engagement.

The top performing ad was 90% more effective in generating clicks, and 30% more cost effective.

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Digital allows us to track progress in real-time

Integrated campaigning was one key to success

Also, because we are tracking our progress in real time, we can look back and start to tease out what the impact of different communication interventions were on our desired goal of getting people to sign up for our community.

1) You can see that the well integrated launch created our initial spike2) Social media created a nice background buzz3) TV ads with a moile shortcode created a big spike (although at a high cost)4) A final, urgent appeal to our web community to sign up their friends made a big difference.29

2012 survey results - advocacyadvocacyFemale 64.73% Young adults 56.21% 21-29 years Live in a city 91.93% Highly educated 53.10% graduate/post-graduate, 37.59% graduated SSC/HSCLifetime non-smokers 90.31% have not smoked 100+ cigarettes in their lifetime- Succeeded in recruiting mostly new advocates (67%)- Gave voice to the silent sufferers women?

So a web survey of people who took part in the campaign had some results that confirmed our theory that social media is attractive people who are prediscposed.

Its not persuasive but it is an impactful and efficient mobilizier and we built a community of people we can mobilize for the next campaign.

Demographics show .30

High MiddleLowIs online engagement leading to offline action?Engagement level

And we found that we arent just recruiting slacktivists

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Questions?End part 2 of 3: Case studies

Case study in success: Indonesia

IndonesiaTobacco use in Indonesia is epidemicPrevalence: 67.4% men 4.5% women overall1/5 male deaths due to smokingVery weak tobacco control & influential industryHighly affordable; No marketing restrictions; no national smoke free; No counter-marketingYouth as young as 10 starting85%+ exposed to SHS

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Panjaitan

October 2014 launch with MOH Indonesia

First national campaign, coordinated with pack warnings

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Social listening demonstrated potential#30HaritanParokok

YouTube

A lot of these little links happen in public now, online. We take them as a representative of offline conversations too.36

Empowering people and creating network effects

Since I became a smoker, my red lips suddenly turn to brown :3 I dont wanna smoke again when I saw scary perforated neck commercial at TV Do you guys know about the health commercial last night at TV? Cancer caused by smoking is really true. Larynx Cancer. Perforated throat.

My son Pauls advice to his Uncle Boris: Uncle, please dont smoke too much, otherwise your neck will have a hole

Are we changing the conversation?

Robby Indra WahyudaA vocalist and photographer who survived from Larynx Cancer stadium 3He first know cigarette on 2nd grade at Junior high, then started to smoke on 1st grade at senior highHe kept on smoking until one day he felt something uncomfortable in his throat and came to the hospital Doctor made a hole and put tracheostomy on his throat. The cancer is detected to be stadium 4A

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2015 strategic plan: 6 month timelineUse social media to create visible public counter-norm around tobacco use.

Build a community of supporters online who will carry our message

Identify spokespeople for future tesimonial campaigns

Bridge to an offline event test our community eventually bridging to overt advocacy

Needs:

Tech capacity: Recruited a social media/ online agency

Ownership recruit partners

Content pipeline: Social media agency

Measurable outcomes, tracking metrics

So for our campaign in 2015 we knew we wanted to use social media proactively alongside our planned mass media campaign.

We developed some specific campaign goals based on previous experiences and identified the needs.39

2015: #SuaraTanpa Rokok: Voices Against TobaccoGrow the networkActivate our supporters to tell their storiesPick the best torebroadcast to create scale; Hold a real-world event.Publish content that will create emotional reactions; set up platforms like Facebook, Twitter,web siteUse online platformsto urge people topublish their own stories and share thestories of othersCurate the bestof the bestA campaign in three phases

We developed a campaign framework in three braod buckets.

As you know in social media you have to feed the beast, to be putting out content all the time.

So instead of trying to create in advance all of the content we developed some broad principles around what we were trying to do during each phase, which informed what types of messages we would generate and amplify. 40

Create engagement opportunities at different levelsLikes or RetweetsCommentsSharesJoinsContributesTake action offlineAdvocates online100,0001010010,000For every person takingaction offline, 10,000 times as many may have beenengagedIf we want 50 people atour event, we may have to get500,000 likes

One way of thinking about campaign is a ladder of engagement, with highly engaged people investing more time and energy and making tobacco use a priority at the top. We want as many people all of society at the top!

Looking at how social media engagement works you looking at maybe a .01 or .001% of a return, in other words may need to expose hundreds of thousands of people at the bottom of the ladder liking your content to get 50 people attend the event.

This understanding helps us guage what level of investment we might need, and prompts us to create opportunities for people to participate all along the ladder.

We make specific call outs like this Share this

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Phase 1:Grow Concern, motivate participationIke

Nonsmoker, victim of SHS workplace exposure

March 2015 Launch

In March 2015 we started the campaign with this powerful ad spot, featuring Ike, a nonsmoking victim of workplance exposure to SHS.42

Phase 1: Grow Concern, motivate participation

Health harms messages connected to the mass media campaign

For social media, in the first phase we undertook our plan to generate messages that would raise concern about harms and generate outrage, motivating people to take action during this stage and the next stage.43

Phase 1: Grow Concern, motivate participation Messaging platforms

Include a specificcall to action:

Like our Facebook pageFollow us on TwitterVisit our web site andsign up for emailShare this post

Our messages had a clear call to action, join our community through Facebook or twitter, visit our web site and sign up for email.44

The web site became a Gallery of Voices to collect and showcase personal testimonialsfrom aroundthe web.

The web site became a place where we showcased the best of the best stories, showed Ikes videos and some more behind the scenes videos.

By the end of the first stage we have more than 20,000 Facebook followers and several thousand email subscribers.45

Phase 2: Community engagement Share and submit your own stories

#IchallengeFAILPhoto messageFAIL

IN the second stage, we tried a number of things to try to get our growing community to tell their own communities.

Everything in social media requires lots of measuring, because you fail often. But you want to fail well and fail fast, so you can move on to a new idea and invest more time and energy into those ideas that are working.

Here are a couple of ice bucket challenge type things that failed largely because I think they reuired a lot of investment and public exposure on the nehalf of users.46

Phase 2: Community engagement Share and submit your own stories EmailSuccess

BuzzersFAIL

Similarly we tried paying for buzzers or people with a large number of followers, and tracked the number of signups and visitors they generated through a unique link. It worked very poorly.

Our best method was email newsletters, asking our followers to share their story or help us identify stories of people that matter,

We used Ikes image again to orient people as to what we were looking for.47

Robby Wahyudas faily and friends were one of the dozens of powerful stories that were volunteered to be featured. Phase 3:Rebroadcast

One of the dozens of stories that was submitted was of Robb Wahyuda the young man we saw from the Pnjaitan campaign, who tragically died over the course of our campaign. Heres the ad we created with his family.48

Phase 3: Rebroadcast the best stories. Get together IRL

With the other stories, we were inspired by Humans of New York

We teamed up journalism students from our list of supporters with victims to create social- media ready, poignant profiles.

We gave them a training and help them coordinate to tell the stories of these victims.

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Phase 3: Rebroadcast the best stories. Get together IRL

12,877 people like this63 shares238 commentsAt first, my throat was sore, I was coughing continuously and suffocating. I went to a specialist The doctor told me I have a tumor in my respiratory tract. I asked the doctor what caused this, and he asked me back, 'Does anyone smoke in your family?' 'I'm a smoker,' said my fatherI learned the hard way that being a passive smoker is harmful."Tobacco victim Zainudin

We used small dollar boosting of between $50 and $100 to get widepsread reach numbering in hundreds of thousands for each of these posts.

We had tremendous uptake of these messages.

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We wanted to end the campaign with something that would allow our community to feel a real accomplishment.

Again we looked to bridge our online activity into offline unpaid media coverage. To create message impact offline and outside of our community.

Held press event and photo exhibition ceremony featuring tobacco victims and the student journalists we recruited.

Promoted the event to our online followers and others more than 200 participants from NGOs, press, followers.

Generated 25 earned media stories.51

Results: Social reach and engagement by the numbersWeb site150,000 unique visitors4,011 email sign ups

YouTube750,000+ youTube viewsat $.01 a view

IRL: In Real Life200 attendees at gallery event

Campaign budget: US $80,000

Twitter19.1 M impressions9.2 M reach3,333 users

FacebookPage reach of 21.6 MAd reach of 4.7 M990,950 users engaged*559,054 talking about this*34,1433 likes

*Daily totals

10 million people

Grow the networkActivate supportersRebroadcast storiesNumber of tweets: #SuaraTanpaRokok124,567,8,91) Launch event/ website and FB launch2) Social media ads3) Volunteer buzzers

4) Training students, connecting with victims5) Emailing our list for victims6) Coordinating with Robby campaign and youTube7) Buzzer campaign8) Releasing the Gallery of Voices9) Final Event3

FRAMINGA picture is worth 1000 words54

In summaryFor success you must identify and understand your audience: What do they know? What are their attitudes? Who influences them?Develop a theory and use metrics to prove itIntegrate with other messages they are receivingEmotional content drives social media funny, tragic, outragePowerful, personal stories are universalHow do you create scale? Or integrate with something happening at scale?

Questions?End part 3 of 3: Final case study

Take one idea or principle from this presentation and think about how you can apply it to your work?

Some examples:Social listeningMessage evaluationTestimonial campaignsPeer influence strategiesIntegrated campaignsCommunity Engagement/ Community forumsTargeting Opinion Leaders

Thank you!

Stephen HamillDirector of Policy, Advocacy and CommunicationVital Strategies shamill@vitalstrategies.org @stvhamill LinkedIn.com/in/stephenhamill

VitalStrategies.org@VitalStratVital-Strategies