Social marketing, smoking cessation and inequalities

‘Social marketing’ is gaining currency. It was identified as a key tool in the UK's recent public health White Paper (Choosing Health 2004) and the Canadian, New Zealand, Australian and US governments are all exploring its potential. We examine what social marketing might contribute to the field of addiction using the example of smoking cessation services, focusing on inequalities. Modern marketing practice is based on the idea of putting the consumer—rather than production—at the heart of the business process. Whereas Henry Ford purportedly sold what he could produce, offering his customers ‘any color you want as long as it's black’; modern marketers invert this rubric and produce what they can sell. This deceptively simple change has revolutionized commerce over the last 50 years. It has succeeded because putting the consumer first makes it easier to influence his or her behaviour. Social marketers simply apply this approach to social and health behaviour, rather than consumer behaviour. Smoking cessation treatment is now offered widely across the globe and can be considered reasonably as a product worthy of marketing. The UK National Health Service offers free face-to-face smoking cessation support (SCS) to smokers. The 12-month abstinence rates are approximately 15% (Ferguson et al. 2005), compared with an unassisted quit rate of about 4% (Hughes et al. 2004). The SCS is highly cost-effective (Godfrey et al. 2005), and can have impressive reach—some half a million English smokers signed up last year alone. Yet, despite this success, as currently devised the UK SCS is fated to make only a marginal impact at a population level. Even if 40% of smokers were to sign up (currently approximately 7%) prevalence would drop by only 1% (R. West, personal communication). Social marketing suggests that the way to move beyond this limited role is to become more ‘consumer orientated’; but what does this mean in practice? First we need to remember that all smokers are not the same. Some smokers want to stop abruptly, while others lack the confidence to do so; some have used the service before, others are first-timers; some prefer groups, others individual support. Given this diversity of needs, we have to question the current policy of offering a standard, one-size-fits-all service. Furthermore, there is a perplexing mismatch between this service—which lasts typically 6 weeks—and the outcome, cessation at 12 months: what Robert West (2004) calls ‘latency’. Compare the SCS for a moment with another service provider—the driving school. You would not expect to be told that you had six lessons to learn to drive, then you would sit your test whether you felt ready or not, and pass or fail the driving school would wash their hands of you. Rather, you would expect them to customize their offering to meet your particular needs—which ultimately is not for driving lessons, but a driving licence. Closer to home, the tobacco industry certainly customizes its offerings, producing trendy Marlboro’ Lights for young aspirants or cheap-and-cheerful Royals for low-income jobbing smokers (see http://www.tobaccopapers.com). If the SCS is to move to a more bespoke service, we need to know far more about why people do or do not use cessation services; and for those who do, what is the experience like? How does it make them feel? Would they do it again? This moves us towards the idea of ‘consumer-defined quality’. It is not that technical expertise has become devalued by business; just that focusing on technical performance alone is dangerous—as the demise of the British motor cycle industry famously shows (The Times, 1 December 1992). The Norton Commando was technically superb, but it did not respond to consumer demand for cleaner, smaller and more reliable motorbikes. Recognizing the consumer's role in defining quality increases in turn the importance of customer satisfaction as a measure of success. Sales—or their SCS equivalents of throughput and quit rates—are a potentially dangerous marker because they put the focus on yesterday rather than tomorrow. The fact that you bought a brand X washing machine once is no guarantee you will do so again; that decision will be much more dependent on your satisfaction with the shop’s, and of course, the machine’s, performance. Sales targets also encourage unscrupulous selling practices; if you have to sell 10 washing machines a week to gain promotion you are more inclined to twist the customer's arm or fabricate returns. Such targets can create ‘perverse incentives’ that contaminate the evidence base and ultimately drive down quality. Consistent satisfaction enables a company not just to generate more transactions with their customers, but to build relationships with them. The plethora of loyalty cards and invitations to ‘register’ with suppliers bear witness to business interest in this more strategic focus. The motives are, of course, pecuniary: it is easier and cheaper to keep existing customers than win new ones. One study found that a 5% increase in customer retention could generate a 20–80% increase in profits (Reichheld 1996). What do smoking cessation services do with customers who come to the end of their course? Some offer ‘relapse prevention’ or longer-term follow-up, but mainly they simply say ‘goodbye’. Business, with its emphasis on relationship-building, would not be so profligate. For the large majority of smokers who do not ‘succeed’, it would want to minimize the dissatisfaction and attempt to re-engage with them at an appropriate point in the future. It would want to create a perception of success, of progress, of empowerment and build on that—rather than leaving with a sense of failure. With those who succeed, business sees an even greater opportunity. They are likely to comprise what Reichheld's (2003) subsequent research revealed to be ‘delighted customers’. On average, delighted customers will tell four other people of their pleasure, effectively becoming the company's marketing department (interestingly, customers who are merely ‘satisfied’ tell nobody) and his research was on car hire; how delighted are our customers, where the service provides a benefit as life-changing as quitting tobacco? So social marketing would adapt the SCS around customer needs: simple, common-sense ideas, laced with evidence from the commercial sector, but none the less powerful for that. Let us apply the thinking to health inequalities. Low-income groups are notoriously enthusiastic smokers in the United Kingdom; prevalence rates are almost double the national average. Health promotion initiatives of all types and sizes have been tried and found wanting. However, the SCS is getting through and being welcomed; last year, it helped 4000 of the UK's poorest smokers quit (Chesterman et al. 2005). These will be Reichfield's delighted customers, already telling others of their success, and (hopefully) that of the SCS. They are embedded in the communities we most want to reach and have unbeatable source credibility. Suppose we did not sever links with these people, but built relationships with them, encouraged and supported them, recruited them as volunteers—or even paid—helpers. They could boost attendance at the SCS, increase empowerment (they are living, breathing testimonials) and even set up additional services such as self-help groups; and why stop at smoking? A little joined-up thinking and a whole raft of health improvement issues could be put onto the agenda using our new, ideally positioned and highly motivated sales force. Derek Wanless (2004), in a major review of the UK health scene, talked about ‘full engagement’ and how this could bring about a ‘step change’ in health improvement; the White Paper (op. cit.) advocated social marketing. The Smoking Cessation Service provides an opportunity to bring both lines of thought together and, perhaps for the first time, get a real grip on health inequalities. It is an opportunity we have to take. The Centre for Tobacco Control Research is funded by CRUK.

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