Challenging Dogma - Fall 2011

Friday, December 23, 2011

Do Anti-Smoking Ads Lead To Avoidance Of Smoking Or Avoidance Of The Ads? – Neha Jha

The Impact of Tobacco on Society:

Tobacco has a huge global disease burden with significant detrimental effects on health related quality of life. According to the Center for Disease Control & Prevention, “20.6% of all adults or 46.6 million people were current smokers in the year 2009” (1). In the United States, “tobacco use causes one in five deaths annually or about 443,000 deaths per year, and an estimated 49,000 of these tobacco-related deaths are the result of secondhand smoke exposure” (1). Smoking causes cancer, heart disease, stroke, and lung diseases such as emphysema, bronchitis, and chronic airway obstruction (1). Smoking is estimated to cost $193 billion in lost productivity and health care expenditures (1). It is the bane of society since it drains valuable dollars that could be spent in other health care costs.

As of 2008, “Smoking prevalence in the United States has dropped by half since the first Surgeon General’s Report on Smoking and Health was published in 1964, but tobacco use still causes over 400,000 premature deaths each year” (2). The World Health Organization estimates that the smoking epidemic could claim one billion lives by the end of this century, worldwide (2).

What We Are Doing About It:

Millions of dollars have been spent on anti-smoking advertising and millions will continue to be spent over the years to reduce the number of people affected by the often deadly consequences of smoking. The New York City (NYC) Department of Health is the sponsor of several anti-smoking ads as part of their larger “NYC Quits” anti-tobacco campaign. The content of these ads are meant to inform people of the serious health consequences of smoking and encourage them to attend the free nicotine replacement patches and gum giveaway events held regularly. But their approach in designing the televised ads is questionable. Even as a non-smoker viewing these ads, one wonders how to avoid the uncomfortable feeling evoked by watching the ad.

Why Advertising Might Be A Great Tool:

Statistics from 2006 reveal that up to 30% of individuals who recently quit smoking attributed their attempt to quit due to anti-tobacco advertising (3). In fact, anti-smoking advertisements were found to be the single most effective smoking cessation aid (3). There are several reasons why mass media and television advertisements are appropriate tools to tackle the huge task of curbing smoking and reduce it to the lowest achievable proportions. Televised advertisements combine both visual and auditory cues that provide a multisensory experience. These ads are watched by millions of people giving us a direct mode to reach large numbers of people with a simple yet sensitively and effectively created message. There is research to show that media portrayal of events has a large impact of the expectations of society (4). There is also research indicating that anti-smoking counter-advertising impacts youth’s tobacco related beliefs (3).

Unfortunately, much of the research on anti-smoking advertising and its influence is based on feedback from younger, college-going students who are not representative of the entire population of smokers. The 2003 article by Agostinelli, mentions that the research up until now has focused disproportionately on non-smokers compared to smokers (5). Most anti-tobacco counter-advertising research focused on the efficacy of preventing smoking initiation among young nonsmokers, with less attention given to studying smokers. We must interpret the results of these studies with non-smokers carefully because “…anti-smoking communications can backfire and strengthen initial pro-smoking attitudes when viewed by smokers” (5).

Many of the recommendations on principles to follow in anti-tobacco advertising are based on observations and data obtained through interviews with focus groups. Consequently, investigators could only obtain self-reported attitudes and not real behavior. Another reason to be cautious in using the principles following from this research is that predisposition has an effect on how anti-smoking messages are received, processed and viewed (6). And so the same messages that evoke a reaction and long term health behavior change in some will be insufficient or inappropriate to initiate a behavior change in others.

Components of the Ads That Do Not Work:

It is important for smokers to be informed about the reality of the adverse consequences of tobacco on their health and quality of life. Smoking impacts both the smoker directly by leading to or speeding up the process of development of heart disease, cancer, COPD, emphysema, bronchitis, etc. A smoker’s health deterioration also affects their partner, children, parents and friends who care about them and depend on them. Additionally, people around them risk facing adverse health effects due to second hand smoke. Smokers should be encouraged to realize that their decision to smoke affects the quality of their life while also impinging on the emotional and physical well being of people who they care for and who care for them.

We need to use advertisements as a mode in which we incorporate those principles that are most likely to produce a lasting change in a viewer’s smoking behavior. The NYC Quits anti-smoking advertising tries to do just that. But some elements of their ads indicate a subtle oversight of what might be more effective; other elements are downright disturbing.

An example is the “Reverse The Damage” Ad that states, “20 minutes after you quit smoking, your blood pressure decreases. After 2 days, your chance of heart attack drops. And 1 year after you quit, your risk of heart disease drops in half, but right now…” (7). This is when the visuals include gory images of open chests with diseased, live and beating hearts, chilling images of sharp surgical tools inside bloody chests gushing blood and the use of defibrillators are depicted. The voice behind the ad continues, “…but right now, you’re a heart attack waiting to happen. Every cigarette makes you sick. More than 1 million Americans are living with the misery of a stroke caused by smoking” (7). This is just one advertisement out of dozens sponsored by NYC’s Department of Health that has the potential to shock and upset a viewer.

The questionable elements are the framing of the advertisement to be gain or loss framed (i.e. indicating health benefits to be gained or quality of life to be lost), the use of fear through graphic images or videos and the use of statistics instead of personal narratives to initiate health seeking behavior in smokers. This paper systematically evaluates these three elements and seeks to offer alternative ways to reach the goal of decreasing the prevalence of smoking in the population.

I. Message Framing In The NYC QUITS Ads:

The NYC Quits campaign involves television advertisements that frame the health promoting message in a negative manner. Comments such as, “Dying from smoking is rarely quick…and never painless” or “When smoking leads to stroke, you can suffer every minute of everyday” or phrases that sound something like, “If you smoke, you are a stroke waiting to happen or one cigarette closer to cancer” are all examples of negative framing of the consequences of smoking (8,9).

In the context of what influences smokers to take positive action to quit smoking, the delivery of messages in a “gain frame” as opposed to a “loss frame” is of great interest. “Health communications can be framed in terms of the benefits of engaging in a particular behavior (a gain frame), or in terms of the costs of failing to engage in the behavior (a loss frame)” (10). Framing of messages can be thought of as providing a context in which to evaluate a problem. “The way in which a message is framed affects the amount of persuasion it elicits” (11).

Most smokers are aware of the negative outcomes but they continue the addictive behavior. Some young smokers might be more likely to continue smoking because it shows a sense of rebellion, independence and risk taking which they may feel makes them more attractive to others and therefore popular among them (12). They may also be overly optimistic about judging their risk for the negative consequences and feel that they will not be affected by the outcomes. According to Witte, people may feel that the risk is not significant or relevant (13). So negative framing might actually have very little impact to those people who are risk takers or those who feel that they will not be the ones to get sick.

Relative to younger people, older people reported positive messages more informative than negative ones and tended to have a better memory for positive messages (14). So for both young and older adults, we see benefits of using positive framing.

An interesting theory that can be used as a framework to understand the effect of framing on smoking behavior is the Prospect Theory. This theory was developed by Kahneman and Tversky who postulated that “people underweight outcomes that are merely probable in comparison with outcomes that are obtained with certainty” (15). The theory suggests that choices with relatively certain outcomes are more likely to be considered when people are faced with the potential positive consequences that might follow, but risky choices with uncertain outcomes are motivated when people focus on potential negative consequences.

Utilizing this model to understand the appropriateness of negative and positive frames in different contexts, since behaviors such as smoking avoidance or cessation are associated with certain outcomes such as better health and reduced illness risk, a gain-framed outcome is a better approach. “Although most messages about tobacco use are loss framed in that they focus on the costs associated with smoking, a potentially more effective approach might be to emphasize the benefits or gains that can result from smoking avoidance and cessation” (16). Schneider et. al also reported that “in general then, gain-framed messages led to greater acceptance of the idea that there are benefits of avoiding smoking and to viewing different temptations as less likely to lead to smoking” (16). The Prospect Theory along with the research by Schneider indicates that using a gain frame for anti-smoking ads will have a better outcome. “…for smokers, any type of gain frame, visual or auditory, decreased temptations to smoke when stressed” (16).

A gain frame perspective such as that put forth by phrases such as “Reverse the damage - 20 minutes after you quit smoking, your blood pressure decreases. After 2 days, your chance of heart attack drops. And 1 year after you quit, your risk of heart disease drops to half of that of a non-smoker” are helpful in showing viewers the positive effects that quitting cigarettes could have on their health (7). But such an approach should be used independently instead of in combination with negative framing and threatening images such as those used in the NYC Quits Ads.

By focusing on the positive outcomes smokers can look forward to after they quit, we give them the incentive to work towards a positive outcome rather than avoid a negative outcome. In this context, the concept of “self-efficacy” is a theoretical construct postulated by Bandura in 1977. He suggested the idea of self-efficacy as a cognitive mechanism that supports behavioral change. Bandura stated that “expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences” (17). The gain frame messages should incorporate positive messages that increase self-efficacy of the viewer making them more confident in their ability to achieve the challenging task of quitting smoking and maintaining the behavior over their lifetime.

II. Use of Fear Appeals and Threatening Themes:

An endoscope being thrust down someone’s trachea and lungs to show a tumor in the lung completely blocking the airway and the person gasping for breath with a actor dressed like a doctor saying, “By the time most lung cancers are found, it’s already too late”; depicting newborns, infants and toddlers attached to naso-gastric tubes and respirators with accompanying narrative that states “Cigarettes are eating you and your kids alive”; explicit and graphic images of diseased lungs, hearts and oral cavities, surgeries in progress, surgical tools covered in blood, etc - are all scenes meant to inspire fear (18).

These ads incorporate elements of fear and shock to spur the audience to take action. They are known as “fear appeals”. “Fear appeals are persuasive messages that are designed to scare people by describing the terrible things that will happen to them if they do not do what the message recommends” (13). Fear appeals contain explicit or gruesome content such as vivid language, personalized language, or gory images. The fact that they grab the audiences’ attention initially is quite obvious. The disturbing images or stories are hard to ignore. But are they having the desired effect?

Health promotion messages with threatening themes are meant to make viewers perceive a threat. “Perceived severity is an individual’s belief about the seriousness of a threat” and “perceived susceptibility is an individual’s beliefs about his or her chances of experiencing the threat” (13). These components of perceived threat - perceived severity and perceived susceptibility relate directly to two factors outlined in the Health Belief Model.

This current Health Belief Model states that a person’s health seeking behavior and other health behavior is motivated by six factors: a) perceived severity, b) perceived susceptibility, c) perceived benefits of an action, d) perceived barriers to taking that action, e) cues to action and f) self-efficacy (19). The Health Belief Model falls short in many respects such as ignoring the influence of social and environmental factors such as community and cultural factors, not differentiating between attitudes and their translation into behaviors and assuming that providing information will change behavior.

The Health Belief Model alone is an incomplete model to utilize in a public service announcement. Moreover, the fear appeals approach, through the use of disturbing themes underutilizes the model. It reminds the viewer about perceived severity and susceptibility through intimidating images. By throwing in some facts about positive health outcomes along with powerful and intimidating images that inspire fear, it downplays the perceived benefits of an action and neglects to increase the self-efficacy of individuals. So the smoker watching the ad is not encouraged or made to feel capable of taking the recommended action to succeed in implementing and maintaining it.

Tobacco ads that show disturbing images of diseased lungs are meant to have a dramatic and powerful impact on smokers so that they inspire immediate action. But these grotesque images have been shown to trigger a defensive reaction in smokers which causes them to stop processing the images and tune them out. So “…the smoker avoids the disturbing images rather than avoid smoking” (20).

The Psychological Research on Information and Media Effects Lab claims that health promotion messages that included threatening or graphic images resulted in “greater attention, better memory and a heightened emotional response” (20). There is no doubt that fear is accompanied by anxiety and a high level of physiological arousal (13). But other research suggests that smokers who showed a defensive response and stopped processing the threatening images exhibited lower memories and emotions response towards the images. A study by Hammond et al. (21) finds that “1% of smokers reported smoking more when seeing threatening visual warnings: 36% reported making some efforts to avoid the labels and 13% felt that the warnings were not credible” (21). Since people deal with fear by denying that there is an impending threat and risk of illness, they avoid the threat thereby leading to message rejection.

The defensive reaction phenomenon can be supported by the Extended Parallel Process Model. The model was proposed by Kim Witte, who suggested that when perceived efficacy or self-efficacy is less than a perceived threat, people feel that they are unable to escape the threat (13). They look for a way to decrease the level of anxiety and reduce the emotion of fear through “defensive avoidance”. As we might imagine, such images and the resulting defensive reactions lower the level of message acceptance therefore cannot be used to change attitudes and behaviors especially in a long term process such a quitting smoking.

The Protection Motivation Model developed by R.W. Rogers in 1975 is another model to address the fear control process. It suggests that fear appeals must be combined with messages that focus on efficacy of the recommended intervention, in our case, smoking cessation (22). According to Witte, who builds upon the Protection Motivation Model, fear appeals must be supplemented with messages that increase self-efficacy of the individual (13). This will increase the chances that the recommended intervention will be adopted and maintained. But according to the article by Gallopel-Morvan, the right combination of self-efficacy and fear appeals has not been researched enough (23). The alternative might be to rely on positive framed advertisements and supplement them with messages that increase self-efficacy. In order to make anti-smoking ads more effective, visual or auditory cues that increase self-efficacy should be incorporated. Messages that promote higher self-efficacy would sound like “You are able to easily and effectively lower your chances of chronic lung diseases and certain cancers if you quit smoking”. Besides support from the model, it seems even instinctively that given a choice between visualizing gasping for air due to emphysema and imagining a dazzling, white smile, a viewer would choose to think about the nicer picture.

III.Using Statistics To Call Attention To The Devastating Effects Of Smoking On Health:

In their dramatic anti-tobacco advertisements, the NYC Quits program provides statistics of how many people are affected by smoking related diseases every year. It assumes that the viewer is not aware of the magnitude of problems that smoking can cause. It also assumes that knowing about the numbers will increase a smoker’s perception of perceived risk. But statistics don’t do much other than prolong the length of an ad. Examples from the NYC Quits campaign are: “4 million Americans live with the misery of emphysema caused by smoking” or “More than 1 million Americans are living with the misery of a stroke caused by smoking” (8,24). Facts alone are not relatable and do not draw the viewer in.

A powerful tool for reaching people and touching their hearts when it comes to promoting change of a certain behavior in them is personal narratives. In their article, Meisel & Karlawish state that narratives have been shown to improve individual health behaviors in multiple settings (25). Although the scientific and public health community considers statistical evidence the most reliable evidence, using facts and figures to translate data and bring attention to the multiple health effects of smoking and the multitudes of people affected may not be effective. Meisel & Karlawish state that stories are an essential part of how individuals understand and use evidence (25). Collecting concrete evidence is the first step to understanding the negative outcomes of addictive behaviors such as smoking but providing smokers this information as a tool to convince them underestimates the complexity of the problem and the grip that the addictive behavior has on them. “…Evidence from social psychology research suggests that narratives, when compared with reporting statistical evidence alone, can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases” (25). Messages that primarily use statistics to inform people assume that if we give people the information, they will be rational and will use it to change their current behavior and adopt a new one. This is another example of the idea presented in the Health Belief Model which does not differentiate between attitudes and actual behavior.

Why are public service announcements or advertisements that use a narrative approach more successful in their goal? To address this question, Dunlop et. al explain the role of an intrapersonal process in the level of engagement in a health message. They suggest that the extent to which an individual becomes involved with the narrative depends on a phenomenon known as transportation (26).

The Transportation Theory was developed by Melanie Green and Timothy Brock during their research on public narratives to which numerous people are exposed to during different occasions or at the same time. They describe transportation into a narrative world as “as a distinct mental process, an integrative melding of attention, imagery, and feelings” (27). It is accompanied by a psychological distancing from reality. Green and Brock explain that the major elements of the transportation experience are cognitive attention to the narrative, emotional involvement, lack of awareness of the surroundings, and formation of mental imagery (27).

Transportation leads to three consequences that are important in how we design and implement anti-tobacco advertisements. “The first consequence is that parts of the world of origin become inaccessible” (27). The reader, viewer or listener loses touch with real-world facts while accepting the narrative world and in fact “may be less aware of real-world facts that contradict assertions made in the narrative” (27). Another consequence is that transported viewers may experience strong emotions and motivation in spite of the knowledge that the events in the story may not be real. Thirdly, people return from being transported changed by the experience. These consequences are predicted to occur regardless of whether the narrative is based on true events. This implies that the phenomenon of transportation through narratives may be an important method to produce anti-smoking messages that the audience will take to heart.

Smoking is a problem that requires a long term solution, not just an initial “cue for action”. As public health experts, we must evaluate what types of ads are most believable and relatable to the viewer thereby providing the most appropriate cue for change and increasing the chances of creating a lasting impression. “…narratives have been shown to be most helpful for boosting clarity and believability of a health message if recipients identify with characters from the stories” (25). In this article, the authors relate evidence that suggests that those who provide only evidence without narratives about real people are unable to have the desired impact.

A Look at the Future of Anti-Tobacco Advertising: Advertising is a large field in itself but advertising of health related messages is a specialized field that requires in-depth understanding not only about the principles of advertising but also how public health messages are received and processed. Although over the decades, anti-tobacco counter advertising has become more sophisticated in its approach, several deficiencies in understanding the principles of social and behavioral psychology are undermining their effectiveness. Fear tactics and negative framing, while they do initially catch the viewer’s attention do not produce any significant long term change and in fact evoke defensive avoidance. No human being wants to be bullied by the government, public health officials, health care providers or anyone else for that matter. By giving smokers a positive picture to look forward to and work towards, and increasing their self-efficacy, we give them a better set of tools to work with. Narratives that people can relate to make creative messages that are easily accepted and can move people to take action. It is in the best interest of researchers, public health officials and citizens and tax payers to maximize the influence of the advertisements while reaching the greatest number of people. We should aim to target these appropriate elements in an individual’s psyche that produce the greatest change in their addictive behavior.


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