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I Quit Movement – Celebrating Quitters
Health Promotion Board, Singapore
Singapore

The Problem

Tobacco kills nearly six million people each year with one in ten of these deaths being caused by exposure to second hand-smoke. The World Health Organization (WHO) formed the Framework Convention on Tobacco Control in 2005, galvanising urgent action across countries to combat the tobacco scourge.

In Singapore, tobacco kills approximately 2,500 smokers and 250 non-smokers each year. Singapore also has one of lowest smoking rates in the world. This is a result of the National Smoking Control Campaign (NSCC) driven by the Singapore’s Health Promotion Board (HPB). The NSCC has proven to be highly cost-effective in averting lung cancer and chronic obstructive pulmonary disease with a cost savings of SGD12.20 million in the healthcare system during 2006.

However, smoking prevalence has risen in the past six years to the current prevalence of 14.3% (aged 18 – 69). More alarming is the rise in prevalence among young adults (aged 18 – 29) who was also the group surveyed to be knowledgeable about the harms of smoking. While traditional top-down policies, in tandem with awareness and cessation programmes have been successful in lowering smoking prevalence over the last two decades, more innovative and progressive initiatives are required to achieve the long-term goal of normalising smoke-free living and lowering the smoking prevalence.

Local studies have shown a large number of smokers to be contemplators (i.e. smokers with intention to start quitting within the next six months). This group of people can be influenced at this stage to change their behaviour. A large group of these quitters are also young working adults above the age of 18. As young adults were avid consumers of new media, HPB leverage this platform during the NSCC 2011 in the form of the “I Quit Movement” to support them in their journey to shift from an intention-to-quit to successfully quitting. The strategies deployed include:

1. Building knowledge of the right methods
2. Creating a supportive environment conducive to quitting
3. Starting a movement that is sustainable by itself

The movement took an innovative approach by bringing together a few initiatives which included the creation of pervasive quit services (i.e. delivering such services in the communities, workplaces, healthcare and virtual platforms where people live, work and play) and the celebration of ex-smokers or “quitters” as triumphant heroes.

This approach was undertaken as quitting was signified as an act that required tremendous effort and through this, smokers were not only encouraged to find their personal reason to quit, but also to start embarking on their quit journeys through the sharing of real-life testimonials.

Solution and Key Benefits

 What is the initiative about? (the solution)
The strategic objective of the I Quit Movement is to implement a comprehensive approach to smoking cessation: rather than simply provide smokers the knowledge of quitting methods and leave them to themselves, we aim to create a strong, supportive sense of community and provide accessibility and convenience for smokers to follow up or embark on their cessation journey. The target community was mobilised and brought together using social media to guide smokers to the right methods and resources. Roadshows and mobile studios were set up at shopping malls and community venues around Singapore to get ex-smokers to join as “I Quit Champions”, and smokers to come forward to take the pledge to quit. Ex-smokers were then trained to provide peer support to smokers, first online and then later face-to-face, as they could better relate to smokers and understand their struggles to quitting.

Besides the support provided by ex-smokers, the movement was complemented by a comprehensive network of more than 150 virtual and physical cessation touchpoints to create a self-sustaining environment conducive for quitting.

Virtual Touchpoints:
The nerve centre and anchor website of the I Quit Movement is the I Quit Club Facebook page (www.facebook.com/iquitclub) where smokers, non-smokers and ex-smokers were able to exchange tips and comments on quitting smoking on a daily basis. Ex-smokers were also invited to share their personal experiences on this page to motivate smokers to embark and persevere on their quit journeys. Smokers were also able to share their personal reasons to quit and further encourage other smokers to quit through the I Quit Facebook Pledge Application.

An I Quit iPhone application: (http://itunes.apple.com/sg/app/hpb-iquit/id477964258?mt=8) was developed for smokers to identify their profile type and the application is able to tailor the most effective approach for the user to quit smoking. The application also offers tips and coping strategies for smokers to manage cravings and is directly linked to QuitLine, physical I Quit Clubs, and cessation programmes to provide the support and advice when needed. In this way, smokers can move accessibly from the virtual touchpoints to the physical touchpoints to follow up on their journey to quit.

Physical Touchpoints:
Smokers are able to directly gain access healthcare professionals by contacting QuitLine (a free smoking cessation service) via phone, short messaging service, electronic mail, or Windows Live Messenger, or by visiting retail pharmacies that provided complimentary in-store smoking cessation counselling and subsidised Nicotine Replacement Therapy products. Through the engagement of workplaces, community clubs and residents’ committees, I Quit Clubs in workplaces and the communities were readily available for smokers to participate in smoking cessation programmes and workshops.

The I Quit Movement is monitored via the below methods:
• Post-campaign awareness survey on intention to quit post-campaign
• Uptake of smoking cessation counselling services (e.g. by healthcare professionals and calls to QuitLine)
• Online participation rate (e.g. number of likes on Facebook and number of downloads of I Quit application)

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Internally within HPB, the I Quit Movement was co-planned between the Adult Health Division, the Community & Partnership Division, and the Corporate Marketing & Communications Division.

The Substance Abuse Department of the Adult Health Division proposed the strategic objectives and action plans for the I Quit Movement. The team was responsible for coordinating and overseeing the direction of the initiative and for monitoring its progress.

The Community & Partnership Division and the Workplace Health Department of the Adult Health Division were tasked to expand the number of touchpoints for smokers to go to for guidance and support. Thus, these teams were responsible for reaching out to, and for forming cooperative relationships with, partners in the community and workplaces to plug them into the ecosystem for tobacco control, and creating a comprehensive network of positive support for smokers.

Finally, the Corporate Marketing and Communications Division led the integrated marketing plan, including Above-The-Line and Below-The-Line advertising, conceptualising and rolling out the campaign, pitching stories and ensuring positive coverage in the media, and new media engagement on the I Quit Club Facebook page.

Outside of HPB, we enlisted external partners and stakeholders who can help to implement this initiative by providing a pool of volunteers, providing logistical resources to form I Quit Clubs, offering locations for cessation programmes or community support, etc. The partners would include organisations from both the public and private sectors, so as to form a comprehensive network of touchpoints that smokers can go to and seek help and support.

Our partners and stakeholders thus include the following:
• Community Organisations
• Workplaces which offered the Workplace Smoking Control Programme
• Public agencies, including the National Environment Agency, Health Sciences Authority, Singapore Customs and Ministry of Finance
• Healthcare providers (e.g. pharmacies chains, such as Guardian Health and Beauty, Watsons and Unity)
• Voluntary Welfare Organisations (VWOs), including the Singapore Cancer Society, the Singapore Heart Foundation and the Chronic Obstructive Pulmonary Disease (COPD) Association

To briefly illustrate a role that our partners and stakeholders has for the Movement, partners from the community, VWOs and workplaces were involved and made aware of tobacco control measures in Singapore, including policies, legislations and smoking cessation programmes on the ground. We also empowered them with the knowledge and the accessibility to tap on available resources to help smokers within their respective spheres of influence.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The objectives of the project are as follows:
1. To encourage smokers to make a quit attempt by providing them with convenient and accessible touchpoints and services to quit smoking
2. To encourage non-smokers to support smokers who are trying to quit
3. To create a supportive environment where communities and businesses see the value in encouraging a smoke-free environment

To fulfil these objectives, HPB utilised three key strategies: first, not only do we engage smokers’ minds to build their knowledge, we also engage their hearts by creating the impetus for community and peer support that are undertaken by our volunteers and I Quit Champions, who themselves were once smokers, and whom smokers who wish to quit will be able to relate to. In this way this strategy aims to foster a supportive, positive environment that engages the totality of the smokers’ psyche and ensuring that they are thoroughly guided through their journey to quit. Furthermore, should these smokers relapse, their supporters will still be there to encourage them to strive on again.

A smoker’s journey to quit is not an occupation that has fixed hours, it is a 24/7 journey where the smoker struggles with both physical and psychological cravings daily. Thus, our second strategy was to provide an easy, convenient access to these knowledge tools and support communities, and we did this by leveraging on Information Technology (IT). The young adults of today are IT-savvy individuals who have ubiquitous access to the internet; thus, we chose Facebook as our anchor page and nerve centre of the initiative due to its popularity, its ease of use, and its plethora of tools that help smokers in their journey. The I Quit Club Facebook page is the main platform for knowledge resources and support, where smokers can interact with others and receive support, as well as easily access knowledge, cessation and counselling programmes from healthcare professionals. This creates a seamless delivery of service that is accessible and convenient to anyone, anytime, anywhere.

Our third strategy was to create multiple physical touchpoints for smokers to go to for further help or to follow up. Thus we partnered with organisations both in the public and in the private sectors, with the aim of achieving win-win situations where both parties, us and them, will mutually benefit. This means that we had to convince them from their own perspectives why they should be involved in the I Quit Movement. In the private sector, we convinced organisations that the initiative was an extension of their respective corporate identities. For example, our business proposition to pharmacies was the relevance of the initiative to them, which also aims to make people healthy. As for the public sector, we worked closely with the relevant community organisations, creating a mutual partnership in which both HPB and they become co-owners and co-drivers of the initiative. The details of such collaboration will be further discussed in the section below.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In addition to establishing the I Quit Club Facebook page as the nerve centre of the initiative, our first priority was to roll out our marketing strategy through the use of advertising to draw the target group’s attention to the Facebook page and evolve the I Quit Movement into the national consciousness.

Roadshows roamed the country, asking smokers to come forward and take the pledge to quit, while popular radio stations did additional publicity and encouraged smokers to quit as well. Smokers were also informed that the pledges can be taken on the Facebook page. After pledging online, they were contacted by our Quit consultants and are invited to join a cessation programme. We then invited these smokers who took the pledge to come forward to tell their stories and reasons for quitting. Coming from all ages, races, shapes, and sizes, these smokers share their stories through media such as television, print, radio, outdoor advertising, and our Facebook page, which in turn directed more people to the page, encouraging them to give their support and opinions, and thus inspiring more smokers to quit.

The Facebook page serves as the heart of the I Quit Movement This was complemented by working with the community organisations and leaders to provide a physical presence to reach out to the residents and heartland communities to catalyse a social, ground-up movement. To this end, we sought the support of these organisations and leaders through three phases in the Co-creation Plan:
1. In the first “Co-plan” phase, we identify and touched base with relevant community organisations to plan together a vision of smoke-free living. Here, a masterplan and timeline was thoroughly deliberated from its conceptual to its implementation stage according to a joint vision that we and our community partners have created.
2. In the second phase, the “Co-develop” phase, we work together with these organisations to “walk the ground” to recruit smokers and encourage them to join our cessation programmes. We also develop training materials and lesson plans to impart mentoring and counselling skills onto volunteers, so that they in turn can encourage residents to start their own I Quit Clubs.
3. Finally, in the “Co-implement” phase, we start to roll out the physical I Quit Clubs and activities, and induct smokers into the club. Here, we also consolidate and create a network of support so that smokers can easily access to it when they need help or advice, while we regularly monitor and evaluate the progress of the overall initiative.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Obtaining initial buy-in from community organisations and partners was challenging because they were either hesitant to change the status quo or they did not realise the need for a smoke-free living at first. Singapore is the first country in the region to adopt such a nation-wide smoke-free movement through the integrated use of social media and physical touchpoints for counselling and cessation programmes. Thus, one obstacle we faced was to change the mindsets of people to appreciate that a smoke-free environment should be a norm, and building a close, professional working relationship with our partners and stakeholders was necessary if the I Quit Movement was to be established within the community and the neighbourhoods.

To address this issue, the planning and implementation of the programme were carried out in a way that HPB worked side by side with our partners (as opposed to a top-down, commanding approach) and empowering the local community to have a sense of ownership of the initiative. Hence, we adopted a consultative approach with the community organisations and partners to plan for initiatives that effectively meet the needs of the local population, an approach that was eventually well-received. The process of co-creation has enabled creative solutioning (e.g. tapping on active citizenry to advance health promotion in the community through volunteers) to be championed by dedicated and passionate stakeholders.

Furthermore, it was through this process of co-creation that residents are able to recognise that an I Quit Club will, in the long term, create a more conducive and healthy environment for them. The prospect of achieving this goal far outweighs the additional effort required of them to kickstart and implement the project.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
About S$1 million was used on both marketing and education efforts in the initiative. HPB developed a marketing plan with the critical aim of amplifying our message and reaching out to as many of our target population as possible using a variety of channels. For example, television, radio, print, online, outdoor advertisements, and roadshows were utilised to make a big public statement and create a large scale public discourse among smokers and their friends and family. At the same time, our marketing plan reached out and recruited volunteers and ex-smokers. Education efforts involved educating the public on smoking-related issues and providing on-site advice to both smokers and non-smokers. Training was also conducted to equip volunteers and ex-smokers mentoring and counselling skills, so as to better engage and guide smokers.

In terms of technical resources, we leverage the social media platform, Facebook, to serve as a novel platform for the I Quit Club, as well as creating the I Quit mobile application for smart phones to complement the initiative and provide greater accessibility. The cost for the I Quit mobile application was minimal. While the I Quit Club Facebook page was free to set up and maintain, the cost came mainly from the manpower (pre-existing manpower within the Board) required to moderate and engage users. During the early phase after creating the page, HPB actively post status updates offering help and encouragement, as well as photos and videos of successful quitters, reiterating a message of hope and support with the aim of creating momentum of participations from users. Then, after our initial stage of active engagement has reached a peak of users’ activities, HPB maintained a minimal level of participation on the page. Over half of Facebook users continue to actively participate on a weekly basis.

The mobile application contains an integrated plethora of tools that helps smokers track their progress and the money they will save from smoking fewer cigarettes. It also provides advice and strategies to manage their craving, and lists the locations and contact details for QuitLine as well as participating pharmacies and cessation programmes. The application is also linked to the Facebook page, so smokers can seamlessly interact with other smokers who are on the same journey as they are.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Our initiative’s sustainability is achieved through the interaction of two other types of sustainability: The first type is social sustainability. The I Quit Movement is a mobilisation effort where we empower our volunteers to become a continuous pillar of support to smokers throughout their journey to quit. It is through such continued efforts of Quit Buddies and I Quit Champions who create impactful results and prolong longevity for the initiative.

The second type is technological sustainability, where users continue to actively participate in the I Quit Club Facebook page after we have generated the content and momentum for users to carry onward their conversations and content creations on the virtual platform. In this way, a reinforcing feedback loop is created to sustain the virtual platform:
1. The I Quit Club Facebook page provides an accessible, “anytime, anywhere” platform for interaction and motivation, and a variety of resources, information and inspiring stories.
2. Smokers, volunteers, and partners participate actively (e.g., form support communities, post comments, etc.) and use resources on the platform.
3. Active participation adds prominence to the platform.
4. As the platform becomes more well-known, it generates interest and inspiration for more individuals and communities to join in the cause.
5. Subsequently as more people join and participate, more content is created on the platform, thus sustaining it as well as the initiative itself.

In addition, the generation of interest and recruitment leads to more people joining the I Quit Movement, and this leads to more participation on the page and subsequently strengthening the reinforcing feedback loop. Thus, both technological and social sustainability work in tandem to strengthen the initiative’s sustainability.
The I Quit Movement can easily be replicated in other countries. To replicate the initiative, the lead agency must establish a strong, persistent foundation, where smokers, volunteers and partners who can conveniently seek advice, resources and motivation from these frameworks.

The virtual framework is in the form of an anchor website for convenient access. Constructing a Facebook page is the most prudent option, given its popularity and its range of tools to track users’ opinions, create communities that link like-minded individuals together, and provide online applications that help smokers in their journey to quit smoking. Important information such as contact details of support groups, cessation programmes, etc., should be clearly available on the website to make it easy for smokers to progress in their journey.
As for the physical framework, the lead agency should strategically identify and collaborate with community organisations, VWOs, public agencies, workplaces and healthcare partners to create a comprehensive network of accessible and convenient touchpoints for smokers to seek support from and to participate in cessation programmes. Here as well, the recruitment and retention of ex-smokers as passionate advocates and role models who have successfully quit will drastically help to further strengthen the physical framework, as smokers can relate to them much better. Another convenient touchpoint that should be considered is implementing a QuitLine.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
At least 74% of smokers are aware of at least one more quit method and one in five smokers has expressed an intention to quit within the next 12 months.
Uptake of cessation services has also increased: Healthcare professionals and partners have provided counselling to more than 9,000 smokers in 2011. Number of callers to QuitLine hit the 2,000 mark between June 2011 and March 2012, which is a 313% increase from the same period before the I Quit Movement was launched. Also, 30% of smokers followed-up by QuitLine have since quit smoking at six months.

The social movement gained momentum rapidly on Facebook. The I Quit Club Facebook page has garnered up to 30,000 ‘likes’ since it was launched in May 2011. A very positive and encouraging online environment was created where there are daily exchanges by ex-smokers sharing their own stories, smokers seeking advice on how to quit smoking and non-smokers penning a word of encouragement to those who are trying to quit.

Before the launch of the initiative, the dominant topics in the smoking narrative network online were legislation, costs of smoking and cigarettes themselves. In 2011 the conversation swayed towards the initiative efforts, diseases associated with smoking, and cessation programmes. This shift in the smoking narrative network suggested an increased in awareness on the effects of smoking, and the available cessation programmes among netizens.

The success of the I Quit Movement would not be possible without its critical hardware and heartware. In the past, taking the first step to cessation programmes was a barrier as the climate of isolation around smokers impounded their fears and halted their efforts. However, with the ubiquity of the internet and the popularity of new media, people today have become tech-savvy and avid consumers of new media. By recognising and leveraging on new media as a crucial channel for delivery of services and knowledge, smokers are able to connect with like-minded individuals and expedite their own efforts in quitting.

The second critical success factor was the heartware of the initiative in which we harness the energy and passion of the people. Our strategy was to instil within people from various backgrounds an impetus to take the lead in providing smokers both formal and informal support to guide and encourage them along their quit journey.

The likelihood of cessation increases as smokers find support within their own social network rather than try to quit by themselves, as revealed by the 31.5% success rate of our initiative, which is three times the success rate of any anti-smoking efforts in the world. We believe that our recruitment of ex-smokers as I Quit Champions greatly helped smokers to closely relate their challenges to them. The I Quit Champions also shared their journeys and encouraged smokers that to quit smoking, though difficult, is not impossible.
Therefore, while our volunteers and partners come from all walks of life, they are united in their efforts and passion to help their friends, family and even strangers to quit smoking.

Contact Information

Institution Name:   Health Promotion Board, Singapore
Institution Type:   Government Agency  
Contact Person:   Kah Liang, Gabriel Tang
Title:   Strategic Planning and Collaborations  
Telephone/ Fax:   +65-64352941
Institution's / Project's Website:   www.hpb.gov.sg
E-mail:   gabriel_tang@hpb.gov.sg  
Address:   3 Second Hospital Avenue
Postal Code:   168937
City:   Singapore
State/Province:  
Country:   Singapore

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