Shock tactics to persuade smokers to butt out are familiar to West Australians. A graphic new campaign featuring WA doctors hopes to draw new attention to the message. Cathy O’Leary reports.

It is more than 40 years since an Australian marketing guru developed a novel anti-smoking television advertisement using kitchen sponges filled with tar to depict the deadly effects of cigarettes on the lungs.

The ‘yuk factor’ was enough to have the advertisement banned briefly in the 1980s – after fierce lobbying by the tobacco industry – while it was slightly altered to satisfy regulators.

It continued to be used on and off throughout Australia, including in WA, in 2014, and was credited for encouraging two-thirds of smokers under the age of 40 to consider quitting when it was rebooted in New South Wales in 2007.

Over the next decades, it was joined by other grim-looking advertisements, some showing the likes of sticky, fatty deposits being squeezed out of the aorta of a young smoker, or a gangrenous foot perched ominously on an operating table, destined for amputation.

In the swings and roundabouts of shock-tactic Quit campaigns, West Australians are now seeing the latest instalment, Voice Box, featuring some of the most graphic images since the early 2000s.

Coinciding with the 20th anniversary of the Make Smoking History program in WA, its reality-TV brief was to show the physical and emotional devastation of head and neck cancers caused by smoking.

The campaign was launched to coincide with the televised AFL finals series and the television, radio and print advertisements are expected to continue until at least the end of the year.

Its centrepiece is vision of a real-life laryngectomy – the surgical removal of a patient’s voice box – which was filmed at Fiona Stanley Hospital, with additional footage filmed at nearby St John of God Murdoch Hospital.

The leading ‘stars’ are consultant ear, nose and throat (ENT) surgeon Dr Rob Wormald and specialist anaesthetist Dr Hamish Mace, who both spend much of their professional lives trying to salvage bodies racked with smoking-related cancer.

While the male patient readily agreed to have his surgery filmed, the process still required careful planning, according to a FSH spokeswoman.

Permission was only granted because hospital administrators could see the significant potential of the campaign to persuade more smokers to quit.

Theatre time

“Allowing a film crew into an operating theatre during surgery, especially a procedure as complex and long as a laryngectomy, comes with a range of challenges and takes many hours of preparation,” she said.

“Foremost is always patient safety, which cannot be compromised.

“One of the key factors was managing the expectations of the film crew in terms of how much time we could give them to capture the images they required. While they would have preferred to have access to theatres for days and days of filming, the reality was could only allow them access for hours at a time.”

The focus of the Voice Box campaign is less on the deadly nature of smoking, and more on the everyday impact on smokers who can lose basic functions such as speech, with evidence this message can particularly resonate with young or middle-aged smokers.

In the campaign, Dr Mace describes some of the ways in which a person’s life is dramatically affected by having their voice box removed. After surgery, air passes through a stoma instead of the nose, which can affect the senses of smell and taste.

The patient needs to avoid getting water in the stoma, as it leads directly into the windpipe and down to the lungs.

Speech is also affected. Without the vocal cords the person cannot raise their voice, and that includes barracking for their football team – hence the opportunistic timing of the campaign launch in the lead-up to the AFL grand final.

Screening smokers

Dr Mace became involved in smoking cessation after helping to set up a small program at FSH which screens about 5-10 patients a week coming in for surgery for smoking status and offers them nicotine replacement therapy (NRT).

He told Medical Forum that being involved in the Voice Box advertisements was an eye-opener in terms of the work that goes into such campaigns.

“It was pretty challenging doing it all and very much outside my comfort zone,” he said.

Similarly, Dr Wormald said it was strange being filmed for an ad because being in the public eye was “not him at all”.

“I didn’t really enjoy seeing myself, but I’ve had fairly positive response from colleagues and friends, and I appreciate how much the Cancer Council WA and others have done over the years,” he said.

“That takes away that uncomfortable bit for me, because I can see the worth of it and that’s the most important thing.”

Dr Wormald’s public work is almost exclusively head and neck cancers, and more than half of patients are smokers.

“Statistically of all the patients with head and neck cancer – and while there are other causes it’s largely smoking and alcohol – the survival rates are about 50%,” he said.

Dr Wormald said that of the 50% who survive, few will escape without some sort of side effect or life-long issue that profoundly affects their quality of life, whether that be pain, swallowing, speech, or their social life.

It affects all ages, while the peak ages are 50s and 60s when people still have a good part of their life left.

Dr Mace agrees the impact of head and neck cancer treatment is devastating, and the campaign reflects that.

“Even the more sanitised version of the ads that can be shown before 9.30pm was that, when your voice box is removed, you’ll never be able to shout for your favourite footy team any more, and that plays on people’s fear of their lives being irrevocably changed,” he said.

Clear dangers

“People have heard so much that they might die of lung cancer, but they think that message is so passé. But the thought that you might have your voice taken away from you well before that – that seems to really hit home for a lot of people.”

Dr Mace said everyone knew about the links between smoking and lung cancer, heart disease and stroke, but few associated head and neck cancers with smoking.

“Apart from laryngectomy, we do other head and neck surgery such as tracheotomy, or glossectomy where we take the tongue out because of cancer, and those people have a bit of their leg taken off and put onto their face, and that’s overwhelmingly from smoking too.

“It can be a horrendously long recovery from these surgeries, not just the time you spend in hospital, because there’s the rehabilitation such as speech pathology, or people having to be fed through a nasal gastric tube for a long period of time.

“The feedback from my non-medical colleagues has been that the campaign is very confronting, particularly the images of the person having their neck stapled up. Certainly, the laryngectomy specimen is pretty gross, but having a guy’s neck stapled up even made me say, ‘whoa’.

Reality impact

“And this campaign is a bit more personal, because it’s a real person here in Perth people are seeing.”

Cancer Council WA chief executive Ashley Reid said the campaign was developed following concerns from WA health professionals and doctors about the low awareness of the causative link between smoking and head and neck cancers, and life-changing effects of the treatment for such cancers.

“We are so grateful to our anonymous patient for allowing the crew to film their deeply personal operation and to Dr Mace and Dr Wormald for speaking to camera about how much this type of operation changes a person’s life,” Mr Reid said.

He said research was clear that this type of hard-hitting campaign had the potential to save tens of thousands of lives.

Since the launch 20 years ago of Make Smoking History – which is funded by the WA Health Department, Healthway and Cancer Council WA – the adult smoking rate in WA has decreased significantly, from 22.5% in the early 2000s to 11.5% in 2018.

The current Voice Box campaign comes amid other developments in the tobacco control area, with Australian smokers recently hit with the annual increase in tobacco excise, which means an average pack of 30 cigarettes now costs about $40, while a pack of 40 can cost $50.

New State Government regulations have kicked in over recent months, including banning retail shop assistants under the age of 18 from selling tobacco products.

There has also been significant interest in the Senate Inquiry into Tobacco Harm Reduction which is addressing the contentious issue of nicotine vaping products and due to report to Parliament this month.

Public health experts continue to push the point that while smoking rates have declined significantly, even exceeding many expectations, the battle is far from over.

Professor Mike Daube, one of Australia’s most experienced tobacco control lobbyists, said it was critical that Make Smoking History continued with hard-hitting campaigns, even 70 years after clear evidence emerged that smoking kills.

Battle continues

“Smoking remains our largest preventable cause of death and disease,” he said. “The two major obstacles are complacency, and the activities of the global tobacco industry – now more aggressive, but also more subtle and strategic than ever before.

“This is the time to develop timelines for the phasing out of commercial tobacco sales in WA and nationally. If well planned, with proper cessation support and access for those few who will still by then be smokers, 2030 is a good target date.”

Meanwhile, at a more grassroots level, Dr Mace would like to see the NRT program used at FSH upscaled.

“There’s not a lot of money out there for smoking cessation for inpatients and it’s not as comprehensive as it could be at the frontline,” he said.

“Some people are still smoking even on the day they come in for surgery, and lots of people use the day they come into hospital as the day they quit smoking. But some still smoke afterwards.

“A lot of the literature shows that if you just tell a patient to stop smoking, they’re more likely than not to continue, but if you offer them assistance, one in 20 of those conversations will result in someone quitting for good.

“I’d really like to see more comprehensive funding for that sort of direct smoking support.”

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