The the elimination of tobacco product consumption

The state of Kuwait is a country in the
Middle East, whose affluence began following the discovery of crude petroleum
in 1938, which led to a boom in the country as a whole. Kuwait currently has a
population of 3.9 million and a per capita GDP of $63,863
(Health Data, 2018). As of 2016, the WHO Framework
Convention on Tobacco Control (FCTC) report estimates that the total prevalence
of smokers in Kuwait is approximately twenty percent
(WHO FCTC, 2006). Only three years after the Environmental
Protection Agency in the United States issued a report identifying second hand
smoking as a carcinogen in 1992, the Kuwaiti government initiated progressive
steps in the control of tobacco consumption by placing a smoking ban in public
(WHO FCTC, 2016).  However due to the lack of appropriate law
enforcement of the stated policies, the tobacco industry in Kuwait was not
(WHO FCTC, 2016).


The problem is further illustrated when physicians inside the
hospital grounds perpetuate the social norm of indoor tobacco use, despite the
knowledge of the harmful effects of smoking. A
literature review revealed that 18.4% of physicians in Kuwait are current
(Behbehani, Hamadeh, & Macklai, 2004), with more
historical questionnaires revealing that up to 45% of male physicians were
(Bener, Gomes, & Anderson, 1993).  The #HealthyKuwait Campaign is
focused on addressing the elimination of tobacco product consumption on
hospital grounds among physicians working in Mubarak Al-Kabir Hospital (MKH), one
of the five Kuwait University affiliated government hospitals. A literature
review for this campaign reveals the target audience is comprised of male physicians,
with the mean age of 44.6 ±
9.1 years
(Behbehani et al., 2004), of Middle Eastern ethnicity, and
middle to high socioeconomic status.

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The intention of the campaign is to
utilize social norms and the diffusion of innovation theories to target the audience
through persuasive measures and alter current social norms. The utilization of opinion
leaders to alter the prevailing social norms will be the desired outcome of the
campaign. Key informants will be interviewed from the medical community to gain
in-depth qualitative insight to characterize the habits of the tobacco using
physician prototype and identify opinion leaders within this subculture.
Formative research will be utilized to further identify the shared beliefs
amongst the group. The research reveals that 18% of physicians currently smoke,
and 31% are Kuwaiti nationals (Behbehani
et al., 2004). Questions regarding Knowledge and
attitude towards tobacco control showed that smokers were less knowledgeable
about the harmful effects of smoking and have less favorable attitudes towards tobacco
(Behbehani et al., 2004). Thus, those who identify with this
prototype are more inclined to engage in behaviors associated with this group
(Hogg & Reid, 2006), further reinforcing the social norms
theory which posits that the individual will seek external factors from the
reference group, which the individual identifies with, in order to ascertain
how to behave in an ambiguous situation.


Kuwait as a collectivist culture (Hofstede
Insights, 2018) is susceptible to trends and the heightened interest in
social media can be adopted to target the subculture of smoking physicians. One
study demonstrated via survey that approximately 94% of medical
students, 79% of medical residents, and 42% of practicing physicians use social
(Bosslet, Torke, Hickman, Terry, & Helft, 2011). Targeting materials to a specific
audience segment increases likelihood of exposure, liking, and behavior change (McGuire,
2001; Slater, 1996). McGuire et al. emphasize that the audience must tune in to
the message, attend to the message and like and maintain interest in the
message in order for behavioral change to occur (McGuire,
2001). Employing social norms and diffusion of innovation
theories will be the mode by which behavioral change will be achieved.


Social norms are “set of expectations
concerning the attitudes, beliefs and behavior of a particular group of people”

(Abrams & Hogg, 2006; Moran, Walker, Alexander, Jordan, & Wagner, 2017) and “the stereotypic perceptions,
beliefs and modes of conduct associated with a group”
(Abrams & Hogg, 2006). Social norms are socially negotiated
and context dependent
(Moran et al., 2017; Rimal & Real, 2005; Rimal & Lapinski, 2015). There are two types of norms;
descriptive norms, which are perceptions of the prevailing behavior in a
community, and injunctive norms which are perceived notions of what the community
approves or disapproves of
(Lapinski, Anderson, Shugart, & Todd, 2014; Rimal & Real, 2005; Rimal
& Lapinski, 2015). Norms are dictated by informational and
normative influences, the former being the understanding that a behavior is
performed or preferred due to a belief that the majority have a deeper level of
understanding of said behavior, while the latter is a conformation of behaviors
in order to achieve a sense of acceptance and belonging
(Lapinski et al., 2014; Rimal & Lapinski, 2015). Social norms are effective cues in
situations that are difficult to interpret, so while there are no-smoking signs
in the hospital, physicians look to the majority behavior as a heuristic to
determine what is socially acceptable. This behavior is illustrated when
physicians smoke in-doors due to the prevailing norm within the medical
community identifying this as an acceptable code of conduct. Real et al.
explored this in a study that illustrated a positive correlation between peer
communication regarding alcohol consumption and perceived estimates of the prevalence
of alcohol consumption
(Real & Rimal, 2007). The aim with the campaign is to utilize
social norms interventions to alter the misperceptions regarding tobacco
consumption in the hospital grounds and ultimately encourage the adoption of a
tobacco free lifestyle.

The diffusion of
innovation “is the process by which an innovation is communicated through
certain channels over time among the members of a social system” (Rogers, 2010), which highlights the four elements of this process. The
first element is the innovation, which is influenced by its relative advantage,
compatibility, complexity, trialability and observability (Rogers, 2010). The innovation in the campaign will be the adoption of a
tobacco free environment. The advantage of the innovation is the concept of a healthier
tobacco free lifestyle relative to the prevailing idea of smoking in the
hospital. The idea is compatible with the physicians’ values and will be
further reinforced with opinion leaders. The complexity and trialability of the
idea will be congruent with the policies that are already set in place. The
physicians will be asked not to smoke on the hospital grounds and alternative
means of smoking outdoors will be provided for the physicians who wish to
continue to smoke. Those who do not comply will be subject to the already
stated fines. Observability is the degree to which others can observe the
results of the idea being introduced, with the notion being that the more
visible the results of the innovation can be seen the more likely it will be
adopted (Rogers, 2010).

The second element is
the communication channel, the means by which “the innovation is communicated
between one individual to the next” (Rogers, 2010). In this strategy, the idea will be communicated through
social media, and supplemented by campaign posters. “Most innovations are not
evaluated based on the scientific studies of its consequences but depend mainly
on the object evaluation of an innovation that is conveyed to them from another
individual like themselves who have previously adopted the innovation” (Rogers, 2010). Time and the social system make up the third and fourth
elements with the latter being defined “as a set of interrelated units that are
engaged in joint problem-solving to accomplish a common goal” (Rogers, 2010). The diffusion of innovation theory categorizes individuals
based on their adoption traits in a Gaussian distribution, with innovators
being the initial promoters of the idea. These are generally wealthier individuals
who make a smaller percentage of the population, followed by early adopters,
who are well-integrated opinion leaders within the community. The early
majority, late majority and the laggards follow this group. Innovators are
considered suspicious, thus opinion leaders within a social system influence
the majority on attitudes towards innovations (Rogers, 2010). The goal of the campaign is to incorporate opinion leaders
to help guide the new social norm.

In order to develop the #HealthyKuwait: A
campaign to create a tobacco free zone, the campaign will be using the social
norms and diffusion of innovation theory as the foundation of behavioral
change. Logistically, the hospital will have modifications to its no-smoking
policies with alteration of the current no-smoking signs as well as utilization
of campaign posters emphasizing that the hospital is a tobacco free zone.  The application of heuristics, with the
replacement of red no-smoking signs with green signs, will aim to create
positive attitudes towards the campaign.


Incorporating the diffusion of innovation
theory the campaign will involve the creation of an online social media
presence through the use of instagram and snapchat. This online presence will
utilize early adopters and opinion leaders in the medical field within the
hospital community. The tobacco free campaign is expected to work due to target
segmentation of a population in Kuwait of physicians who identify by
collectivism, valuing and prioritizing the group over the self, making the
campaign technique effective, as the audience will be more likely comply with
the new social norm. Social media and the healthcare system is a new trend that
has been utilized over the past five years at an increasing rate in Kuwait.
Physicians engage in an influencer type status in the Kuwaiti community through
the use of social media with posts that are updated on a regular basis ranging
from discussions about personal feelings, daily activities, and endorsement of
products as well as the occasional discussion about health. The early adopters recruited
for the campaign will be highly respected members of the medical community who
will use their social media accounts to talk about their success professionally
and how they achieved their success by maintaining a healthy life style and
specifically by remaining tobacco free. The aim here is for the early adopters
to engage the early majority in adopting a tobacco free lifestyle in the work
environment until the norm becomes that smoking in the hospital is socially


The #HealthyKuwait Campaign is built on
the concept of altering the social norm by utilizing the knowledge that the
target culture identifies by collectivism within the Kuwaiti community and
applying theories of diffusion of innovation to promote and create positive
attitudes towards a tobacco free environment and associating the campaign with
a healthy lifestyle by utilizing the growing interest in social media.