Challenging Dogma - Fall 2011

Wednesday, December 28, 2011

Why Graphic Health Warnings on Cigarette Packages Backfire: A Public Health Intervention That Will Increase Smoking –Rachel Yorlets Bryte

Introduction to Cigarette Use

Tobacco addiction has been identified by the Food and Drug Administration (FDA) as the predominant cause of early and preventable mortality in the United States. According to the Center for Disease Control and Prevention (CDC), cigarette smoking is responsible for 443,000, or 1 in 5 deaths annually in America. Of 312.8 million Americans (13), 44.6 million are cigarette smokers, and about 88 million nonsmokers are affected by secondhand smoke (2). Each year, the American economy suffers a loss of almost $200 million in healthcare costs and productivity loss caused by tobacco use (22).

Tobacco contains nicotine, an addictive drug that is absorbed into the bloodstream when smoke is inhaled. Nicotine stimulates adrenal glands, releasing epinephrine, which stimulates the central nervous system. This process elevates heart rate, blood pressure, glucose levels, and respiration rate. In addition, nicotine increases dopamine, which is the neurotransmitter associated with pleasure and satisfaction. Someone addicted to tobacco will experience a variety of withdrawal symptoms when they attempt to quit, including cravings, difficulty focusing and sleeping, and mood and appetite changes (15).

Cigarette smoking increases the risk of developing a number of health problems, affecting nearly every organ in the body. Cigarette smokers have an increased risk for cancers, including that of the lung, pharynx, esophagus, larynx, kidney, uterine cervix, urinary bladder, lip, pancreas, mouth and lip. Male and female smokers have 23 and 13 times the risk, respectively, of developing lung cancer in contrast to those who have never smoked. Smokers are 2 to 4 times more likely to have coronary heart disease, 10 times as likely to die from chronic obstructive lung disease, and 2times as likely to have a stroke (3). More than 80% of smokers develop the habit before age 18, and each day approximately 3,450 people under age 18 try a cigarette for the first time. Of these youth each day, about 850 become daily smokers. According to the CDC’s analysis of the 2010 National Health Interview Survey Data, about 70% of smokers want to quit, about 52% tried to quit during 2010, and of them, about 6% successfully quit during 2010 (4).

Introduction to Graphic Health Warnings on Cigarette Packages

In June of 2009, the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) was passed, requiring the development of 9 new, bigger warnings to be placed on cigarette packages and advertisements. This portion of the law was prompted by the research that showed the existing warnings were not very noticeable to customers. This idea was encouraged by the Institute of Medicine’s report in 2007that said that bigger warnings would communicate risks effectively, thereby prompting smokers to quit. International experiments have provided research supporting this theory. As a result, the FDA was directed by the Tobacco Control Act to use color graphic warnings that showed the health risks of smoking with the 9 text warnings. In addition, a resource must also be provided for a smoking cessation hotline (22).

In 2010, the FDA chose these 9 graphic images through a research study, consulting communications, graphic design, and marketing experts. Within the study, the FDA provided 36 tentative pictures to 18,000 subjects in a survey. The subjects were representative of 3 categories: adult smokers 25 years and older, young adult smokers aged 18 to 24, and youth aged 13 to 17 who were smokers or susceptible to starting to smoke. The FDA then determined the subjects’ ability to remember the pictures a few days after they viewed them (22). Researchers also considered the subjects’ emotional reaction to the pictures, but it did not, by any means seek to consider whether people would quit after seeing the images (18). As FDA spokesman, Jeffrey Ventura commented, the study only looked to agree with literature sources that graphic warning labels are effective, and that they are in line with the FDA’s interest in promoting education about smoking risks. “These warnings haven’t been updated since 1985, and anecdotal logic says that these warnings have become white noise,” justified Ventura. “The new generation of youth at risk are a very visually stimulated group of folks” (18).

The FDA posted its study results in December of 2010, and then considered them, along with literature resources, and public feedback on the study before selecting the final 9 graphic warnings. The FDA made this decision hoping that the new warnings would increase knowledge, promote smoking cessation, and discourage non-smokers from initiating smoking, and, by doing so, save lives, increase life expectancy, and reduce healthcare costs. The FDA even projected that, annually, they could prevent 16,544 to 19,687 people from smoking, and save 1,749 to 5,802 quality-adjusted life-years (22).

The graphic warning labels will be put into effect on September 22, 2011, after which no tobacco companies will be allowed to manufacture cigarettes without graphic warning labels (22). The new warning labels must occupy the left half of the front and the back surfaces of each cigarette package, replacing the existing Surgeon General’s warning. In addition, the FDA will continually monitor and evaluate the efficacy of the graphic warning labels, and consider the need for changes (22). However, an abundance of evidence already exists to demonstrate why these labels will not only fail to prevent smoking, but will serve to increase it. Public health professionals will then be forced to develop a new intervention that utilizes current research.

Critique I: Why the Health Belief Model Fails – Optimistic Smokers & Cognitive Dissonance

The Health Belief Model (HBM) is a social science theory that was used in the development of graphic warning labels for cigarette packages. The Health Belief Model postulates that there are three necessary criteria that must be fulfilled in order for someone to make a health-conscious decision. The first of these criteria is that there must be a health concern, or a sufficient source of motivation, in order for that particular health problem to matter to someone. Second, the person must believe that there is a “perceived threat”, meaning that they believe they are vulnerable to that health problem. Finally, one has to believe that making a particular, advised, health-related choice will result in a significant reduction of the perceived threat, and that this reduction will be beneficial. There is a condition on this final criterion: it must be satisfied at a “subjectively-acceptable cost.” In these terms, the cost describes the obstacles that must be surmounted by the individual for that person to make the advisable health-related choice. It must be noted that these obstacles may include financial problems (19).

In short, the HBM states that people will make the correct decision if they just have all the knowledge and ability necessary to do so (19). By placing the graphic health warnings on cigarette packages, the FDA assumes that people would quit smoking (and never start) if they just knew the dangerous health risks of smoking. However, social scientists know from extensive research that non-health-related factors play a substantial role in health behavior, including the choice to smoke. Specifically, smoking, as source of nicotine, is addictive, and involves psychological and physiological factors (8). Since HBM does not account for these elements, it is not an appropriate model for cigarette smoking.
The social science theory of cognitive dissonance further explains why HBM fails to prevent smoking. Cognitive dissonance results from an imbalance, or disequilibrium among one’s cognitions. This presence of “nonfitting relations” is essentially an “antecedent condition” that results in someone acting in a manner that will reduce that disequilibrium, or dissonance. Dissonance will not only prompt someone to reduce that imbalance, or clashing of different ideas, but it will also motivate that person to avoid and ignore any source of knowledge or any situation in which that clashing of ideas would be increased (7).

Cognitive dissonance occurs as smokers, who are well aware of the health risks of their behavior, continue to smoke for a number of reasons. First, the smoker thinks of the pleasure that smoking affords, and justifies smoking to achieve it. Second, the smoker does not really believe that he is vulnerable to the health risks of smoking, even though he may acknowledge that other people suffer from them. Third, the smoker continues to rationalize the act of smoking by thinking that he cannot possibly avoid every dangerous behavior in his life. Finally, the smoker rationalizes this exposure to a health risk by asserting that s/he would probably gain weight (another health problem) if s/he were to quit smoking (7).

Smokers will rationalize their decision to continue smoking when faced with graphic warning labels because of cognitive dissonance. “Consider this: a pack-a-day smoker will see these labels more than 7,000 times a year,” said Margaret A. Hamburg, the Commissioner of the FDA in a press statement ( to view the statement) (23). Considering what is known about cognitive dissonance, one might readily agree that a pack-a-day smoker will see the labels more than 7,000 times yearly because that smoker will not have quit. Each time the smoker sees the label, or at least initially, the rationalizing arguments previously mentioned will enable that person to continue smoking. Beyond this, it seems unintelligent to attempt an intervention after the cigarettes are already being purchased, especially, since, after the new cigarette packages are in circulation, smokers will expect to see them, and still continue to buy them. Graphic warning labels seem to be, put simply, “too little, too late”. Carol Tavris, a behavioral psychologist interviewed by Science on this subject, even thinks that smokers that want to stop, but have not yet successfully, are especially likely to be unaffected by the new warnings. “Dissonance is a pretty powerful phenomenon,” says Tavris, that explains “why people continue to do things they know are harmful, but still see themselves as smart” (18).

Optimistic bias, another behavioral theory, explains why smokers continue to smoke after seeing these gruesome warnings. Optimistic bias is a simple concept: a person continues to believe that, while negative consequences may affect someone else, those consequences will not affect them personally. This optimistic bias is increased by an individual’s belief that they have control over their destiny (12). Essentially, the smoker believes that none of those health problems will happen to him/her.

Critique II: How Graphic Warnings Misuse Framing & Ignore Psychological Reactance Theory

Framing is the means by which a source depicts an issue of concern to the public. Framing is a powerful art that has the ability to affect change in the public’s opinion, and to convince people to see some health problems a certain way. This is critical because the public’s view of the problem, and consequently the problem’s causation, plays a considerable role in how they will respond to it (17).

Graphic health warning labels on cigarette packages frame smoking as a risky, dangerous behavior with serious, life-threatening consequences. Through negatively framing smoking, the labels are perceived as taking a freedom from smokers or people who are considering smoking. Instead, the same theory, while not denying the negativity of smoking, can choose to instead frame the issue in terms of liberating a smoker. For example, instead of reminding a smoker that tobacco kills, the label could remind people that quitting smoking restores a number of liberties, including financial ones. Telling a pack-a-day smoker about what he could purchase with the money he would save by not smoking may be more effective than threatening messages.

Psychological reactance, a social science theory, describes this phenomenon that explains why smokers will resist the graphic warning labels, perceiving them as a threat to their right to smoke. Psychological reactance postulates that when someone’s behavioral freedom is threatened, they will do what is in their power to prevent any further deprivation of liberty, and they will try to restore their freedom. When a person is told to not smoke through means of graphic warning labels, that person may perceive it as a threat to their freedom, and resist the label, while continuing to smoke as an attempt to regain or protect that threatened freedom. The amount of resistance and reactance expressed by an individual is directly related to the perceived importance of the freedom is threatened. This is why smokers will continue to smoke after they see the warnings, and why graphic warning labels will actually provoke those considering starting to smoke to do so as an assertion of their liberty (1).

Critique III: Scare Tactics Just Encourage Smoking

Terror management theory, an idea of social psychology, asserts that behavior mostly prompted and affected by the powerful human fear of death. The anthropologist Ernest Becker, made the argument that everything humans do is done in order to avoid and reject our own mortality. One might think that graphic health warnings would motivate smokers to quit for this reason, but in reality, it forces smokers to push aside that anxiety. According to the theory, self-esteem alleviates the stress caused by this reminder of mortality (21). Smokers may find some self-esteem, some belonging, and stress-relief in their smoking; this just reinforces their positive attitudes about tobacco. Several research studies show that warnings addressing mortality just encourage smokers to keep smoking (9).

Martin Lindstrom, author of Buyology, conducted a brain-imaging study in 2006, illustrating why graphic warning labels actually tend to encourage smokers to continue smoking. There were 32 subjects in the study, including residents of the United States, Japan, China, Germany, and Great Britain, some of whom were 2 pack-a-day smokers. The majority of them reported that graphic warning labels actually decreased their cigarette cravings, but Lindstrom’s research proved the exact opposite. Each subject was required to lay in a functional magnetic resonance imaging (fMRI) scanner for approximately 1 hour. During this time, the subject viewed a small screen, onto which several graphic warning labels were projected. These labels included textual warnings as well, indicating health risks of smoking. The scanning technique is able to detect oxygen and glucose levels within the brain, showing its activity. When each person saw the warning, there was no blood flow to the area of the brain that shows alarm and fear (the amygdale), or to the area of the cortex that indicates disapproval. Ironically, when subjects viewed the warnings, the nucleus accumbens, also known as the “craving spot” showed activity; this activity occurs when someone has a strong desire for drugs, tobacco, alcohol, or gambling (14). While more research is justified, it is surprising that the warning labels caused the subjects to want to smoke more. “We couldn’t help but conclude that these same cigarette warning labels intended to reduce smoking, curb cancer, and save lives had instead become a killer marketing tool for the tobacco industry,” said Lindstrom (14).

Another study, done at the University of Missouri by psychologist Jamie Arndt, supports the idea that reminding smokers of their mortality only increases their smoking. Arndt asked student smokers to fill out surveys that were designed to make them think of 1 of 2 situations: their mortality, or failing a test. After the questionnaire was completed, researchers offered cigarettes to students, and then analyzed the student’s smoking in terms of the length of time, flow, and volume of each puff they took. Those who were light smokers generally smoked with little intensity, but heavy smokers smoked with a lot of intensity after reading about their own mortality. Arndt explains this by saying that smokers use smoking (a source of pleasure) to deal with the negativity of thinking about death (20).
Proposed New Intervention: Using Labeling, Social Expectations, and Social Networking Theories to Utilize Social Networking Sites

Hundreds of millions of people around the world use social networking sites, such as Facebook, Twitter, and MySpace, but what are the implications of this network for public health professionals? Can these social networking sites be used for public health interventions, including smoking cessation? A new intervention might use labels for members of these sites, indicating that they are “Smoke-free since…” or “Trying to Quit”, or simply unstated. This part of information could be provided with equal simplicity as someone’s relationship status, place of employment, or education, is given. In addition, and most importantly, social networking sites can provide a forum for discussion, much like the Vapers Forum, which facilitates discussion of smoking alternatives ( This would provide a supportive outlet through which smokers could discuss trying to quit, and those who recently quit could discuss improvements to their life and help each other stay smoke-free. Cessation resources could be provided through the forum, message board, or group. The forum would provide a form of accountability for those trying to quit, while the labels would give a constant reminder of pride to non-smokers, and additional motivation to those trying to quit.

Research suggests that, not only can complex relationship-based networks be utilized for a meaningful public health intervention, but that such an attempt would be likely to be effective. The network itself (which is made of many different groups) is all about relationships. The social network is usually composed of relationships among close friends, and family – people who have the power to influence an individual on important decisions like quitting smoking. Social networking theory, a group-level theory, says that social scientists can actually explain human behavior by looking at the social network, and not at the individual (5).

Social networking theory is particularly promising because there is an effect that occurs in the network, known as the “tipping point”. In other words, smoking cessation can flow within and throughout the networking site to a certain point (the tipping point), after which it will overflow, and everyone within the network will quit. This is also tied to the idea of what is referred to as “crowd behavior”, which is behavior change that is apparent to the entire network (5).

Why is this phenomenon so important to public health? Research shows that information is distributed throughout the social network, spreading a behavior (15). This phenomenon has been shown to be very applicable to promoting smoking cessation. “Smoking behavior spreads through close and distant social ties, groups of interconnected people stop smoking in concert, and smokers are increasingly marginalized socially,” says Nicholas Christakis, a researcher for the subject.
Once social networking is applied in a public health intervention for smoking cessation, it can be evaluated through network analysis, which describes graphically the relational nature of health behaviors ( to see how social networks are analyzed graphically) (15). Network analysis can describe the influence that social networks have on smoking cessation; this provides a method of evaluating the effectiveness of the intervention (15).
This proposed new intervention also takes advantages of social expectations theory, another group-level model, which is based on the fundamental social nature of humans. The theory postulates that everything in the human experience, from birth to death, is related to the social nature of humanity. Simply put, social expectations theory focuses on the behaviors or events that transpire between people, tying it closely to social networking theory. This theory describes how certain patterns within society define how individuals are expected to behave when they relate to those most important in their life. As being smoke-free becomes the norm, and smoking is marginalized, the social expectation changes, and essentially pressures smokers to quit (6).

Furthermore, research shows that labeling a person (as a nonsmoker, or one trying to quit would label them) actually institutes a type of self-fulfilling prophesy, in which the person will modify their behavior to meet their label (10). Once a person labeled as “trying to quit” is perceived by others, and treated by others, as such, and that person is reminded often of that label, that person eventually will fulfill it. Labeling would also have the impact of helping those who quit to remain smoke-free by their desire to fulfill the proud label of “nonsmoker”.


“Social psychologists have decades of research showing that fear communications generally backfire, that people tune them out, and therefore that these tactics are generally not effective,” says Tavris (20). In summary, although there are good intentions behind them, research strongly suggests that graphic health warnings will actually have the opposite effect, causing smokers to smoke more, and vulnerable non-smokers to consider starting to smoke. Instead, public health professionals would be wise to send positive messages about the benefits of being smoke-free, and to do so through the powerful social networking sites that millions of people use regularly. Through this intervention, the freedom of smoke-free can spread, marginalizing smokers, and providing positive outlets from which quitting smokers can gain support.

1. Burke W, Lake D, Paine J. Organization Change: A Comprehensive Reader. Marblehead, MA: John Wiley and Sons, 2008.

2. Center for Disease Control and Prevention. Chronic disease prevention and health promotion: tobacco use, targeting the nation’s leading killer at a glance 2011. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2011a.

3. Center for Disease Control and Prevention. Smoking and Tobacco Use: Basic Information. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2011b.

4. Center for Disease Control and Prevention. Smoking and Tobacco Use: Quitting Smoking Among Adults – United States, 2001, 2010. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2011c.

5. Christakis N, and Fowler J. The Collective Dynamics of Smoking in a Large Social Network. The New England Journal of Medicine, 2008. 358: 2249-2258.

6. DeFleur M, and Ball-Rokeach S. Theories of Mass Communication. White Plains, NY: Longman, 1989.

7. Festinger, L. A Theory of Cognitive Dissonance. Standard University Press, 1957.

8. Galvin K. A critical review of the health belief model in relation to cigarette smoking behavior. Journal of Clinical Nursing, 1992. 1: 13-18.

9. Hansen J, Winzeler S, and Topolinski S. When the death makes you smoke: A terror management perspective on the effectiveness of cigarette on-pack warnings. Journal of Experimental Social Psychology, 2010. 46(1): 226-228.

10. Harold, Kelley H. The Warm-Cold Variable in First-Impressions of Persons. Journal of Personality. 18(4): 431.

11. Jelsoft Enterprises Ltd. Vapers Forum. 2000-2011.

12. Klein C, and Helweg-Larger M. Perceived Control and the Optimistic Bias: A Meta-Analytic Review. Psychology and Health, 2002. 17(4): 437-446.

13. Limit on Population. U.S. Census Bureau. U.S. & World Population Clocks, 2011.

14. Lindstrom, Martin. Buyology: Truth and Lies About Why We Buy [Book]. New York, New York: Doubleday, 2010.

15. Luke D. and Harris J. Network Analysis in Public Health: History, Methods, and Applications. Annual Review of Public Health, 2007. 28: 69-93.

16. National Institute on Drug Abuse. NIDA InfoFacts: Cigarettes and Other Tobacco Products. Bethesda, MD: National Institutes of Health, 2010.

17. Nelson T, Oxley Z, and Clawson R. Toward a Psychology of Framing Effects. Political Behavior, 1997. 19 (3).

18. Reardon S. Scary New Cigarette Labels Not Based in Psychology. ScienceInsider, 2011. American Association for the Advancement of Science.

19. Rosentock I, Strecher V, and Becker, M. Social Learning Theory and the Health Belief Model. Health Education Quarterly, 1988. 15(2):175-183.

20. Schrock, Karen. How Smokers Think About Death: Do Graphic Warning Labels on Cigarette Packages Really Deter People from Lighting Up? Scientific American, 2010.

21. Solomon S. Terror Management Theory. Oxford University Press, 2011.

22. U.S. Food and Drug Administration. Tobacco Products: Frequently Asked Questions: Final Rule “Required Warnings for Cigarette Packages and Advertisements”. Silver Spring, MD: U.S. FDA, 2011.

23. U.S. Food and Drug Administration. Tobacco Products: Overview: Cigarette Health Warnings. Silver Spring, MD: U.S. FDA, 2011.

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