I Keep Looking at What I’m Doing to My Organs: Samoans’ Responses to Adapted Anti-Tobacco Television Advertisements

There has been an increase of adapted tobacco control media campaigns in low- and middle-income countries. Adapting existing material offers many benefits especially to countries with limited resources. We adapted 3 television advertisements for the Tu’u Nei Loa Le Ulaula Tapa’a (Stop Smoking Now) campaign in Samoa. Adaption included rigorous efforts to ensure advertisements were culturally appropriate. To determine audiences’ perception of anti-tobacco television advertisements to promote smoking cessation, we conducted 8 talanoa, a Pacific Islands research methodology, among 54 smokers and nonsmokers in Apia, Samoa. The talanoa were transcribed, translated, and thematically coded. Results suggest that the advertisements raised awareness on the negative health impacts of tobacco use, especially to the internal organs. Graphic and emotionally evocative advertisements, especially those that have an impact on the family, have greater potential to motivate Samoans to quit.


Introduction
Do antismoking campaigns increase awareness of the harms of smoking in a Pacific context? Our research examined public responses to a tobacco control advertising campaign adapted from high-income countries for Samoa. Among the five "best buys" for cost-effective intervention, mass media campaigns that educate the public about the harms of smoking/tobacco use and secondhand smoke 1 has been proven to be one of the most effective. 2,3 Although investment in tobacco control has increased across the Pacific region, there are still high rates of tobacco use. 4 To address this, tobacco control media campaigns implemented in low-and middle-income countries have increased. Most advertisements adapted the concept of successful antitobacco campaigns in high-income countries, and in most cases, comprehensive formative research was undertaken to adapt these advertisements to the local context. 5 Adaptation ranges from high-level adaptation, where the concept is retained but reproduced to suit local settings, to low-level adaptation, where only the voiceover (i.e., voice narration) and end-frame credits (i.e., closing still graphics) is changed. 6 Potentially, such adaptations are efficient ways of using funds to free up financial resources for media placement. 6,7 It is also an equitable approach to tobacco control, with the benefits of educational information being available to a mass audience.
Several "adapted" campaigns have been implemented with the assistance of Vital Strategies (formerly World Lung Foundation). 8 These campaigns were designed to be "racially and culturally agnostic," ready for adaptation for use in any country, especially those with limited resources. 8 Cognizant of the potential benefits of adopting anti-tobacco advertisements, 9 we obtained permission from the World Lung Foundation to use these advertisements, to provide population-wide information on the health effects of smoking, including secondhand smoking, and to promote a text message-based smoking cessation program (mCessation) in Samoa. 10

The Tobacco Control Advertisements
Three 30-second advertisements were aired on national and local television and radio stations across Samoa in 2017 as part of the Tu'u Nei Loa Le Ulaula Tapa'a (Stop Smoking Now) campaign. Two of the adapted advertisements were based on a campaign called "Cigarettes Are Eating You Alive" developed by the New York City Department of Health and Mental Hygiene; the third advertisement was based on an original concept developed by the California Department of Health Services (Table 1). The advertisements used existing graphic animation that shows the damage inside the body when someone inhales the cigarette smoke, interspersed with scenes dramatized by local actors and locally shot footage ( Figure 1).
The research team worked with a communications consultant and Vital Strategies to license and produce the advertisements for use in Samoa. To ensure that adaptation was culturally appropriate, the team conducted multiple consultations among stakeholders (eg, Samoa Ministry of Health, local nongovernment organizations, etc) to ensure script translations were correct, video images mirrored local scenarios, voiceovers were clear, and translated medical terms were accurate. Approval from the New York City Department of Health and Mental Hygiene and California Department of Health Services was obtained to adapt these advertisements through a licensing agreement. Key guidelines suggested by Cotter and colleagues 6 in adapting media campaigns were considered, including conducting pretests, assessing budget limitations to determine the level of adaptation, ensuring copyright and intellectual property being acknowledged, and maintaining key messages of the original advertisements.
This research project aimed to determine Samoan audiences' perception and the perceived efficacy of anti-tobacco television advertisements to promote smoking cessation. The evidence generated in this study can inform decisions about the potential rollout of a multifaceted tobacco cessation initiative in Samoa with consideration for other Pacific Island Countries and Territories (PICTs).

Methods
The talanoa research methodology was utilized in this study to explore participants' views on the advertisements. Talanoa is a widely used Pacific Island research methodology described as "a personal encounter where people story their issue, their realities and aspirations." 11 The process privileges Pacific voices, and provides participants a facilitating "space" to have an open dialogue, while developing relationships. 11 The "storying" was critical for understanding the factors that affected recall (the details that were recalled from viewing the advertisements in retrospect), receptivity (views about the advertisements), and potential effect on motivation to quit. The talanoa were advertised via flyers and posters that contained a mobile number that participants could contact if they wanted to participate. A sign-up table was also set up at high-people-traffic areas (eg, university, workplaces, market). Interested participants were contacted over the phone to confirm eligibility and go through the information sheet about the study. Eligible participants were invited to join one of the eight age-and gender-specific talanoa. Written consent was obtained from all participants.
Eight talanoa were conducted with smokers and nonsmokers from different age groups (16- Our in-country research team member facilitated the talanoa. Discussions were recorded, transcribed, and translated to English by a Samoan translator. To ensure accuracy, one of the authors reviewed the transcriptions and translations. The primary analysis was conducted by the lead author and discussed with the team to reach interrater agreement on the primary themes that were dominant throughout the talanoa. The transcriptions were analyzed to identify themes using an inductive process that included a review of the transcriptions, generating codes, identification of recurring themes, and organization of initial codes to main themes.

Results
Three main themes that reflect participants' thoughts and perceptions were derived from the talanoa. Seeing how the internal organs are affected by smoking is a motivator to change smoking behavior. The advertisements also highlighted the potential health risks of secondhand smoke, and seeing its effects to family, especially children is perceived as a prime motivator to quit.
We conducted eight talanoa composed of 54 individuals ( Table 2). The majority of the sample were male (n=28), younger (16-24 years), and was equally split with smokers and non-smokers. Qualitative, inductive analysis of the textual data identified the following primary (dominant) themes.

Seeing Is Believing
This theme emphasizes the significance of visual imagery in demonstrating the effects of smoking on internal (unseen) organs. All participants reported being generally aware of the negative effects of smoking on the body. However, for most participants, the mechanisms by which smoking damages the organs were unclear. One participant shared: "I didn't go to school and learn about science things, but I have learnt things about smoking and how my body is affected by smoking" (male nonsmoker, aged 25+). Pervasive misconceptions about the effects of chemicals constituents in cigarettes ranged from providing a pleasurable experience that stopping smoking may cause sudden death, and smoking promotes sleeping. One participant shared that he knew many smokers who were unwell but had never associated their poor health with their smoking.
The graphic images that depicted the effects of inhaling tobacco smoke on internal organs were unnerving for many of the participants: "I have no idea how deep the effect of smoking is. . . . I didn't know that your insides are badly affected" (female nonsmoker, aged 16+). There was an immediate understanding of the seriousness of the effects of smoking inside the body. Participants noted the use of medical terms from the advertisements (e.g., blood vessels, arteries, blood circulation), and used them when describing their feedback. In particular, the effect of tobacco use on blood vessels, arteries, and the heart was the most likely to elicit a strong, often emotive, reaction. Beliefs about the effects of smoking as presented in the advertisements were also anchored in the lived experiences of participants. Seeing family, friends, or someone from the village who has experienced health effects such as those depicted in the campaign, resulting in a stronger acceptance of the message.
I believe it because we have this girl out back in the village who does not want to eat but only wants to smoke. Now, she has cancer all over her body. (Female nonsmoker, aged 16+) However, there was some uncertainty expressed around the negative effects of smoking when participants have friends or family who despite being smokers have not developed any diseases associated with smoking. My grandma is 100 or more years old, and she started smoking when she was young so I figure, she was smoking for such a long time but she is still well and yet these ads are saying that we will be affected. ( Some participants also mentioned feeling angry after seeing the ads. A few smokers reported to have turned the TV off when the ads came on. One participant explained: "As Samoans, they [smokers] do not want to be told what to do, when we are told what to do, we get angry" (male nonsmoker, aged 25+). On the other hand, nonsmokers' anger was projected toward smokers: "We don't smoke but if we sit near smokers . . . we are breathing in smoke" (female nonsmoker, aged 25+ years).

Advertisements Reveal the Impact of Secondhand Smoke
The Baby Alive and Heart ads, which focused on the effects of secondhand smoke exposure, resonated with participants. Graphic depictions of smoke entering the body of a bystander (in particular, a baby or young child) were especially provocative for most participants. Several participants acknowledged being unaware that inhaling secondhand smoke was damaging. One participant explained: "I didn't know how deeply it would affect another person's body" (female nonsmoker, aged 16+). Some participants associated their own or others' recent illnesses with the possible relationship to secondhand smoke.
For smokers, most of the reaction was to "protect" nonsmokers from inhaling the smoke coming from their cigarettes. One smoker said, "I need to think about other's health that are being affected" (male smoker, aged 25+). Some felt "uncomfortable," and "mindful of their actions"; some reported wanting to hide when they smoke. I would rather tell my friends to move away from me, go, or I go somewhere else. Even though they wanted to accept me for who I am, I tell them to go somewhere else . . . secondhand smoking is worst then first-hand smoking. (Female smoker, aged 16+) However, the advertisements brought out some antismoker sentiments among non-smokers. Some commented that they will be more careful when around smokers-telling them to smoke somewhere else. One participant shared that when a friend smokes: "I will tell her straight that she needs to stop smoking because her smoking is affecting my heart" (female nonsmoker, aged 16+). Several nonsmokers told stories of how they tried to stop family members from smoking when children or the elderly are around. This was born out of their concern for others-to protect those who cannot protect themselves from secondhand smoke. The advertisements also accentuated existing emotions about feeling guilty when smoking; several reported avoiding family or public places when they smoke. Other smokers resorted to secrecy or hiding when smoking. A smoker explained, "I smoke secretly, even my boyfriend doesn't know anything about it . . . (laughs) so it's more like have a smoking then brush your teeth and have about 2-3 PK [chewing gum] and you're alright" (female smoking, aged 16+). A few smokers disclosed that their smoking has become a source of judgment and conflict at home, and within their church and community. Yet, these responses were deemed appropriate given the harm inflicted on others.
When I smoke, my wife chases me outside the house so it's like she is chasing me onto the road. This is because of the kids, so this ad is really important for me because now I understand that the smoking has many effects on kids. (Male smoker, aged 25+) Both smokers and nonsmokers commented that the advertisements explained how smoking poses risks to the unborn baby and may help pregnant women stop smoking. Some participants felt emotional when describing how they felt seeing the harmful effects to babies and children; some stated it was inappropriate for pregnant women to smoke. However, there were also a few who said that they were not clear how smoking increases the risk of health problems for a fetus.

Motivations to Quit
Younger smokers (16-24 years old) reported being more motivated to quit (than older adults) after watching the advertisements. Seeing how smoking affects the internal organs and knowing how in a few years the negative effects will start to manifest was alarming. Since most have only been smoking for a few years, younger smokers believed that they could easily stop smoking because they are "not addicted yet" to smoking. One participant said: "Since I just started smoking, and it made me scared I'm thinking of quitting" (female smoker, aged 16+). It was also a common view among participants that older smokers are already "addicts" so it will be hard for them to quit smoking: "The youth, that is who should be the target; the older ones are addicts now" (male nonsmoker, aged 25+).
All participants placed on us on children as the prime motivation to quit smoking. Awareness and knowledge of the potential risks of secondhand smoke to children were deemed key to quitting.
The approach of the ad was good too, and especially how it was talking about kids because I know for some, a weak spot is their children or their small relatives. I think that if people understood this then they would probably quit. (Male smoker, aged 16+) Many smokers commented that they were "worried" (popole [worry]), and "scared" for their children, and how their smoking is affecting their health. Some smokers shared that they did not care much about themselves and were far more concerned that their smoking is harming children and therefore making them think about quitting.
Participants perceived quitting smoking as beneficial to children, not only to minimize exposure to risks but also to improve overall health and well-being. Being able to provide for children's (and the family's) needs is paramount and is believed to take precedence over spending on tobacco. Some smokers also expressed concern and anxiety for the family if they get sick or die because of their smoking: If I keep smoking then I might die and I am the only worker, my family will be greatly affected. If the breadwinner dies, then his family will suffer because there will be no one able to earn money for them. (Male smoker, aged 25+)

Discussion
Our research demonstrates the perceived value of graphic, locally adapted advertisements to support efforts to reduce tobacco use in Samoa. Adapted advertisements, which required minimal investment in terms of resourcing, offered a cost-effective means to reframe the risks associated with tobacco use using realistic, locally relevant imagery. Leveraging the role of the youth is vital, as they are more receptive to antismoking messages, and serve as motivation to their families to stop smoking. Based on our study, the adapted advertisements raised awareness of the health impacts of tobacco use and are also effective in translating abstract concepts about the impact of smoke inhalation on internal organs.
It is also important to highlight that the talanoa methodology was useful as it enabled the researcher and participants to have a free dialogue. According to Vaioleti, 12 talanoa "allows more mo'oni (pure, real, and authentic) information to be available for Pacific research than data derived from other research methods." The participatory nature of the talanoa allowed participants to "story" their experiences, perceptions, and thoughts in a safe space. The sharing of personal stories was fluid, and participants were able to offer a rich and complex contour of their beliefs and perceptions. For instance, their belief of the negative effects of smoking is anchored not only on what they saw in the advertisements but on their personal experience of having known someone who was affected by smoking. We offer the argument that "adaptation" does not end in the reproduction of advertisements to suit local culture, but culturally relevant and appropriate qualitative pretesting and evaluation methods are also critical to construct quality research evidence. Furthermore, the discussion and description of the talanoa is an important contribution of this study in Pacific Islands research literature.
This study provides evidence of the efficacy of the use of media campaigns to reduce tobacco use in the PICTs. More than ever, there is a need to continually expose the public to the effects of smoking and offer options to support smoking cessation. Using graphic imagery to health messaging has been controversial, 11,13 yet the anecdotal evidence suggests it may be effective an approach for Samoan smokers. It may also be useful in realigning misconceptions about the effect of tobacco use on smokers' and nonsmokers' health.
Arguments against hardline messages about the effects of tobacco use recognize that stigmatizing smokers may not be conducive to behavior change. 14,15 It is not clear whether the depiction of graphic health images is more effective than campaigns focused on other drivers to smoking, such as social norms. Often a combination of strategies is most effective, for example, including warning people of the risk via graphic images and supporting people to quit through supportive messages, services, and normalizing quitting. Other factors such as extent of reach and frequency are also associated with campaign effectiveness. 16 A limitation to the study is that we did not include quantitative measures of exposure, nor did we measure, objectively, changes before and after exposure to the campaign. We believe that in this case, quantitative methods might present data too narrowly, and miss opportunities to delve into the nuances that hinder people to quit smoking. Our study sought a "consumerist" perspective on the value of the campaign, finding support for its continued contribution to Samoa's tobacco control plans.

Conclusion
Mass media campaigns are key components of tobacco control programs. The evidence from both high-income and low-and middle-income countries suggests that mass media campaigns are effective in raising awareness and changing attitudes toward tobacco use. The number of anti-tobacco mass media campaigns in low-and middle-income countries has grown over the years, but evaluations of these initiatives are still lacking. Understanding what works and sharing lessons learnt in the implementation of anti-tobacco mass media campaigns are critical to save on vital resources to support efforts to reduce the harms from tobacco.