1. Promoting Behaviour Change
By Dr Nik Nor Ronaidi bin Nik Mahdi

2. Objectives
2. Describe different theories of health behavior and
behavior change
3. Understand why people engage in health compromising
or health promoting behavior
4. Identify the barriers to promote behavior change
5. Briefly describe different intervention techniques to
change behavior at both community and individual
level
6. State the generic principles that can be used as the
basis for planning, delivering and evaluating public
health activities in changing health behaviors
7. Aware of the national and international policies
implemented in order to change health behaviors
8. Appraise the existing policies i.e. evaluate the
outcomes, suggest for improvement

3. Question:
• In reference to different theories and guidelines
to promote behavioral change, critically evaluate
the existing national health strategies and policies
in changing health behavior and recommend for
further improvement.

4. Content
• Introduction
• Principle of planning, delivery, evaluation of
behavior change programs
• Framework Convention on Tobacco Control
(FCTC)
• National health tobacco control program
• Evaluation of measures taken for tobacco
control in Malaysia
• Recommendations for tobacco control

5. Introduction
• The major causes of death in the US and other developed
countries are now chronic diseases, such as heart disease,
cancer, and stroke.
• Behavioural factors, particularly tobacco use, diet and
activity patterns, alcohol consumption, sexual behaviour,
and avoidable injuries are among the most prominent
contributors to mortality.
• The resurgence of infectious diseases, including food borne
illness and tuberculosis, and the emergence of new
infectious diseases such as antibiotic resistant infections,
HIV/AIDS, Hepatitis C, and human papillomavirus (HPV) are
also largely affected by human behaviours

8. NHMS (1986, 1996, 2006)
Current Adult Smokers in Malaysia
% 50
45 49.2
46.4
40
40.9
35
1986
30
25
24.8 1996
20 21.5 21.5
15
10 2006
5
4.1 3.5 1.6
0
Current Smokers Male Female
~ 4 mil smokers in Malaysia; consume average 14 cigarettes/day

9. Principle of planning, delivery,
evaluation of behavior change
programs

10. Planning
• Any intervention that aims to change behaviour should:
1. be as specific as possible about its content
2. spell out what is done, to whom, in what social and economic
context, and in what way
3. Clarify with underlying theories will help make explicit the key
causal links between actions and outcomes
• Important factors:
– the behavior that is about to be changed
– target population
– The level of the intervention (individual, community or
population)
– the barriers and opportunities for change
– intended outcomes and outcome measures

11. The 5 basic ways to help smokers quit
Schroeder AS. JAMA 2005;294:482-7
1. Increase the price of cigarettes
2. Prohibit smoking in public places
Population
measures 3. Create and disseminate effective counter
(Government marketing messages about smoking
initiatives) (media, pack displays)
4. Ban tobacco advertising and promotion
• Provide cessation aids
Individual – Counselling / Behavioural therapy
measures – Pharmacotherapy
(Stop Smoking
• NRT
Services)
• Bupropion
• Varenicline
• Nortriptyline, Clonidine

12. Examples of theories used
• People need to recognise that their health is
threatened, and that the benefits of giving up
outweigh the benefits they obtain from smoking
(Health Belief Model)
• Intention to change behaviour is influenced by
personal attitudes and by the behaviour and
attitudes of people around them (Theory of
Reasoned Action and Planned Behaviour)
• Smokers go through a series of distinct phases in
their attitudes towards smoking cessation
(“Stages of Change” model)

15. Planning
• Time and resources should be set aside for evaluation.
• Attempts to change behaviour have not always led to
universal improvements in the population’s health.
– E.g: different age groups react differently to incentives and
disincentives, or ‘fear’ messages.
– No single method can be universally applied to influence all
behaviour and all people.
• The cultural acceptability and value of different forms of
behaviour varies according to age, ethnicity, gender and
socioeconomic position.
• Changing behaviour may not be a priority for the
individuals being targeted. People do not necessarily make
their own long-term health a priority and may want to
focus on other, more immediate needs and goals.

16. Planning
• An intervention aimed at changing one behaviour
may inadvertently lead to other changes.
• Motivated individuals actively seeking to make
changes in their behaviour require a different
approach from those who are unmotivated.
• Enabling individuals and communities to develop
more control (or enhancing their perception of
control) over their lives can act as a buffer against
the effects of disadvantage, facilitating positive
behaviour change.

17. Delivery
• As well as focusing on individual factors, it is
important to address the social, environmental,
economic and legislative factors that affect people’s
ability to change their behaviour.
• The following mechanisms were successful in some
circumstances:
– legislation and taxation
– mass media campaigns
– social marketing
– community programmes
– point of sale promotions.

18. Evaluation
• Evaluation is the formal assessment of the process
and impact of a programme or intervention.
• An effective evaluation is based on clearly defined
outcome measures – at individual, community and
population levels, as appropriate.
• Methods and outcome measures are identified
during the planning phase.
• Effective interventions specify their ‘programme
theory’ (or reason why particular actions are
expected to have particular outcomes).

19. Framework Convention on Tobacco
Control (FCTC)

20. Framework Convention on Tobacco Control
(FCTC)
• It is the first treaty negotiated under WHO
• It was developed in response to the globalization of the
tobacco epidemic
• The objective is to protect present and future
generations from the devastating health, social,
environmental and economic consequences of tobacco
consumption and exposure to tobacco smoke by
providing a framework for tobacco control measures
• 150 nations have already ratified the FCTC
• First Conference of the Parties—Feb 2006
• Second Conference of the Parties—June 2007

21. • Recommended strategies:
1. Demand reduction
• Price & tax measures
• Protection from exposure to tobacco smoke
• Regulation of the contents of tobacco products
• Regulation of tobacco product disclosures
• Packaging and labelling of tobacco products
• Education, communication, training and public awareness
• Tobacco advertising, promotion and sponsorship
• Demand reduction measures concerning tobacco dependence and
cessation.
2. Supply reduction
• Illicit trade in tobacco products
• Sales to & by minors
• Provision of support for economically viable alternative activities

22. 1. Demand reduction
• Price & tax measures
– tax policies and price policies
• Protection from exposure to tobacco smoke
– measures for protection from exposure to tobacco smoke in public
places.
• Regulation of the contents of tobacco products
– measures for testing and measuring the contents and emissions of
tobacco products, and for the regulation of these contents and
emissions.
• Regulation of tobacco product disclosures
– measures requiring manufacturers to disclose to governmental
authorities information about the contents and emissions of tobacco
products.
• Packaging and labelling of tobacco products
– Avoid false and misleading impressions
– Contain health warnings and information on relevant constituents and
emissions of tobacco products.

23. • Education, communication, training and public
awareness
– promote and strengthen public awareness of tobacco
control issues, using all available communication tools
• Tobacco advertising, promotion and sponsorship
– comprehensive ban of all tobacco advertising, promotion
and sponsorship or at least prohibit false and misleading
advertisements
• Demand reduction measures concerning tobacco
dependence and cessation
– design and implement effective programmes aimed at
promoting the cessation of tobacco use
– establish in health care facilities and rehabilitation centres
programmes for diagnosing, counselling, preventing and
treating tobacco dependence

24. 2. Supply reduction
• Illicit trade in tobacco products
– eliminate all forms of illicit trade in tobacco
products, including smuggling, illicit manufacturing
and counterfeiting
• Sales to & by minors
– prohibit the sales of tobacco products to persons
under the age set by domestic law, national law or
eighteen.
• Provision of support for economically viable
alternative activities
– Promote economically viable alternatives for
tobacco workers, growers and individual sellers.

25. National Tobacco Control
Programme

26. National Tobacco Control Programme
Vision:
It is envisaged that by the year 2020,
tobacco will no longer be a major public
health concern in Malaysia, where
decreasing national prevalence of tobacco
use is halved and tobacco attributed
diseases and mortality will continuously
decline.

27. Mission:
Considerations for achieving the above
vision will be realised when there is
widespread general public awareness
concerning tobacco, its hazards and
wastefulness. This appropriate knowledge
then becomes the basis for established
right societal attitude that translates to
behavioural norm of not using tobacco

28. Objectives:
• Decrease the prevalence of tobacco consumption
amongst Malaysians
• Reduce the uptake of smoking by young people
• Increase the number of smokers giving up smoking
• Minimize and eventually eliminate exposure to
environmental tobacco smoke among non-smoking
populations in all public and work places
• Reduce the burden of tobacco related deaths and
diseases in the country
• Do away with economic and social dependence on
tobacco and tobacco products for sustainable
livelihood

29. Strategies:
• Legislative control
• Health promotion & public advocacy
• Tobacco tax policy
• Smoking cessation services
• Research, monitoring and evaluation
• Multisectoral collaboration & capacity
building

31. Barriers in tobacco control
• Economic Dependence on Tobacco
– The extent to which tobacco industry contribute to a
state’s economy may play a role in its political will to
undertake tobacco control action.
– If a significant proportion of the workforce is engaged in
tobacco industry, people may not support tobacco
control for fear of job loss. Also, the state government
would want to protect its revenue and workers.
– Research suggests that states that have economies that
are highly dependent on tobacco are less likely to adopt
strong tobacco control measures.

32. Barriers in tobacco control
• Genetic and environments
– There is evidence that genetic characteristics may play a
role in determining which individuals become dependent
smokers (Pomerleau and O. F., 1995)(Li et al, 2003).
– It may also contribute to increased difficulty in quitting
for some smokers (Heath et al, 1993)(Madden et al, 1999) or may modify the
potential effectiveness of pharmaceutical aids for
smoking cessation (David et al, 2003).
– Culture within the family plays a role in smoking
behavior.
• Parental smoking is an important determinant of adolescent
smoking uptake (Flay et al, 1994)(Distefan et al, 1989).

33. Barriers in tobacco control
• Interferences by tobacco companies and their
business allies
• Addiction
• Limited budget
– Research fund
– Campaigns
• Limited manpower
– Legislative enforcement

34. Evaluation of measures taken for
tobacco control

35. UNDERSTANDING THE INFLUENCE OF THE MALAYSIA-WIDE
MEDIA CAMPAIGN "TAK NAK" ON INTENTIONS TO QUIT AND
PERCEIVED RISK OF SMOKING: FINDINGS FROM THE ITC
SOUTHEAST ASIA SURVEY
• TAK NAK – Malaysia’s first nationwide anti-smoking campaign.
• Launched in February 2004 by the PM of Malaysia in order to reduce the
prevalence of smoking and smoking related morbidity and mortality.
• It was a 5-year project with an annual cost of approximately RM 17 million
for the first phase of 2004/2005, RM 9 million for the second phase of
2006/2007 and the last phase was RM 9.2 million for 2008/2009.
• The campaign’s slogan “Every puff you take damages your body” was aimed
at discouraging teenagers and women from starting to smoke, smokers from
continuing and, friends and families to support activities to curb tobacco
smoking.
• The information and attitude/belief-change efforts were communicated
through multiple media channels (tv, newspapers, magazines, radio, cinema
billboards, and through collateral items such as t-shirts).

37. • The ITC Project is an international collaboration of
tobacco control researchers whose mission is to
evaluate the psychosocial and behavioural effects of
national-level tobacco control policies throughout the
world.
• This study attempted to understand what psychological
processes Malaysians underwent after being exposed
to aspects of the media campaign.
• Face-to-face survey
• Baseline year (Jan-Mar 2005) included a cohort of
N=2006 adult male and female smokers randomly
selected from six states throughout Malaysia
including Kedah, Selangor, Johore, Terengganu,
Sabah, and Sarawak.

38. Mediational model
(p<.001) Fear (p=.012)
TAK NAK Intention to
Exposure (p=.106) / (p=.187) Quit
(p=.042) Perceived (p<.001)
Risk

39. • Result:
– Malaysian smokers who reported being more exposed to
the TAK NAK campaign had higher levels of perceived
risk of the health harms of smoking and more likely to
worry (feel fear) of smoking, and perceived risk and
worry, in turn, were associated with having intentions to
quit.
• Conclusions:
– TAK NAK campaign was associated with greater quit
intentions through both enhancing perceived risk and
increasing fear/worry about the health consequences of
smoking.

41. • Every cigarette pack sold in Malaysia is required to
be printed with pictorial health warning effective 1
January 2009.
• The pictorial health warnings on all cigarette packs
must not be obstructed from view by any object
and by any means, when displayed or offered for
sale. A penalty will be imposed on any person who
violate the law and be liable to a fine not exceeding
RM10,000 (US$3,000) or to imprisonment for a
term not exceeding two years or both.
• Malaysia ranked the fourth country in the ASEAN
region to implement pictorial health warnings after
Singapore (2004); Thailand (2005) and Brunei
(2008).

43. Tobacco Industry: Circumventing the Law
• No specification of size of the pack, thus allowing
the tobacco industry to introduce cigarette packs in
the shape of small ‘lipstick’ boxes or ‘button’ pack.
– Distortion of the picture warning as the cigarette
packaging is smaller in size and reduces the impact of
pictorial health warnings significantly

45. Tobacco Industry: Circumventing the
Law
• Specification of the printing of outer packaging has
been exploited by tobacco industry where
innovative designs were printed at the bottom on a
transparent sleeve to be placed on the cigarette
pack.
• Smokers can switch the position of the sleeve with
the design to the top of the pack to obscure the
surface of pictorial health warning.

47. Tobacco Industry: Circumventing the Law
• No specification of banning the use of colour and
design to add a graphical component at the bottom
half of the packs.
• This has led to direct exploitation by tobacco
industry through utilizing colours and graphic design
to distract viewers from looking at the health
warnings and therefore diluting the effect of
pictorial health warnings.

49. Tobacco Industry: Circumventing the Law
• No specification on the thickness of the black
border width where the words “AMARAN” and
“WARNING” and the health message text shall be
printed on each unit packet and unit carton.
• The tobacco industry has capitalized on this
weakness by increasing the border width with the
aim to reduce the size of the pictorial health
warning.

51. Recommendations for tobacco control

52. Recommendations
• Anti-smoking media campaigns should be
continued.
• The tax on all tobacco products should be increased
to 75% of retail price as recommended by the World
Bank to make them unaffordable to youth. It is also
recommended that the government introduce a 2%
dedicated tax on tobacco products to support
health promotion and increase anti-smoking
campaigns to reduce smoking among young people.

53. (Southeast Asia Tobacco Control Alliance, 2009)

54. Recommendations
• Ban duty-free sales on tobacco products
• To protect the Malaysian populace from the harms
of exposure to secondhand smoke, the government
should legislate and implement 100% smoke-free
environments (all private workplaces and
entertainment outlets such as pubs, nightclubs,
discos, karaoke lounges, casinos and nonair-
conditioned eating outlets).
• Establish permanent government units with staff
working full-time on tobacco control

55. (Southeast Asia Tobacco Control Alliance, 2008)

56. Recommendations
• The government should ban the display of cigarette
packs at all retail outlets.

57. Recommendations
• New technology:
– Electronic cigarettes

58. Recommendations
• Total ban of tobacco sales
– Is it possible?

61. Thank YOu