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 (http://www.fda.gov/TobaccoProducts/Labeling/CigaretteWarningLabels/ucm259214.htm 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 (http://www.vapersforum.com/)(11). 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 (http://www.annualreviews.org.ezproxy.bu.edu/doi/full/10.1146/annurev.publhealth.28.021406.144132 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”.

Conclusion

“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.

REFERENCES
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Failures in Public Health Interventions to Minimize Marijuana Use among Adolescents in the United States-Nausheen Punjani

“Above the Influence” or “Under the Influence”

Introduction

In the United States, marijuana is the most commonly used illicit drug and in 1999 the average age for new users was approximately 16 years old for males and 17 years old for females (1). Surprisingly, marijuana use has increased at a much higher rate compared to cigarette smoking (2). Specifically, marijuana rates are relatively high among adolescents, who view the gateway drug as a form of experimentation that serves the teenage experience. For grades 8^th, 10^th, and 12^th, marijuana usage increased from 2009 to 2010 (2). Long term ingestion of marijuana is known to cause several health effects on multiple organ systems, particularly “mental, pulmonary, immune, and reproductive functioning” (3). In addition, evidence suggests that intoxication of marijuana has lead to many accidents and injuries (3). Therefore, there are numerous public health interventions geared toward minimizing marijuana use among adolescents. However, marijuana consumption rates among adolescents are constantly escalating. One of the most prominent public health campaigns is The National Youth Anti-Drug Media Campaign.

The National Youth Anti-Drug Media Campaign develops media campaigns such as, “Above the Influence” to prevent substance abuse among the youth, particularly adolescents. Above the Influence campaigns focus on advertisements that directly target adolescent drug abuse especially marijuana usage. As a public health advocates, they were successful in exposing their advertisements to the entire nation because most people are aware of Above the Influence media campaign. However, their public health campaign has failed to accomplish their main objective to reduce marijuana usage among. This is evinced by data that shows constantly increasing rates of marijuana use. In essence, although many adolescents are aware of the advertisements there is very little change to reducing marijuana usage. Perhaps, The National Youth Anti-Drug Media Campaign failed to address that most youths are aware of the health consequences but they have other reasons that influence them. In this paper, we will criticize the campaign, Above the Influence and illustrate the possible reasons for the unsuccessful campaign to minimize marijuana usage among youth. Specifically, we will focus on three psychological models that might explain why the campaign was not successful in reducing marijuana usage rates among adolescents: psychological reactance theory, theory of reasoned action, and optimistic theory.

“Withholding My Freedom”

The U.S. Congress has spent approximately 1 billion dollars for the National Youth Anti-Drug Media Campaign from 1998-2004 (4). Most of the investment is aimed toward short advertisements that target adolescents and demonstrate the negative consequences of illicit drugs especially marijuana. However, the campaign has not attracted many youths to avoid marijuana usage. One of the most important reasons that this campaign has been unsuccessful is because it focuses specifically on the negative consequences of marijuana use. Often, many youths rebel against the messages because they find the advertisement as a threat to their freedom of choice to experience and engage in certain behaviors (4). Many youths reacted against the Above the Influence advertisements by mocking the videos and illustrating the same video in a pro-drug approach. For example, one of the aired advertisements described a dog talking to a youth and telling her that he does not like her smoking. Soon after, a parody was created about the talking dog, ridiculing the anti-drug commercial. Essentially, this behavior originates from the theory of psychological reactance where individuals believe that control is taken away from them and they want to reclaim that freedom. In our example, youths who were exposed to these advertisements reacted against the original campaign to reestablish their freedom, which produced an effect that was opposite of what was intended (5). Based on psychological reactance theory, youths were in fact more attracted to marijuana after exposure of the anti-drug commercials (5). For example, one college student states, “…it’s like my little way of saying, ‘take that. I’m going to do it anyways.’ I’m being the bully, the rebel that I never was in high school or grade school” (6). Specifically, this suggests that the campaigns will have greater negative impact on high-risk adolescents such as those who have friends that use marijuana or are offered marijuana in comparison to low-risk adolescents (7). In addition, the ad campaigns attract those who are curious to learn about marijuana and to be accepted by their peers (7). Therefore, many youths find the anti-drug advertisements as a restriction to their freedom causing them to eliminate the restriction by experiencing marijuana. Ironically, the increasing presence of anti-drug commercials in the mainstream media has led to a stronger reactance for youths in support of marijuana use (4). Therefore, it is necessary to initiate a program that will not cause psychological reactance but ultimately be effective in deterring youths against toxic drug habits.

Social Norms: Our Youth Culture

Above the Influence advertisements generally focus on providing reasoned arguments against the use of cannabis. In addition, the campaign focuses on what the social norms are regarding drug use and also targets how to change the social norms for marijuana usage among adolescents. The campaign ultimately developed a framework that incorporates social norms using the theory of reasoned action by providing reasons to not smoke marijuana and what others think about marijuana on an individual level attitude (8). The anti-drug campaigns geared their ads to show what others think about their potential marijuana use. However, instead of attempting to show a family or friend’s opinion the advertisements often portrayed a pet’s opinion. Not many youths are concerned about their pet’s opinion thereby the campaign ineffectively used the theory of reasoned action. Therefore, many studies illustrate that this approach is “too indirect” to change social norms (9). Furthermore, these types of ads can negatively affect adolescents because many youths will assume that marijuana usage is popular among peers (10). Indeed, this reinforces the concept that many youths will want to experiment marijuana for social acceptance from their peers (9). Ultimately, this method could result in a boomerang effect where the target audience develops negative social comments in response to the campaign (11). For example, many adolescents developed youth groups via the internet and satirized the Above the Influence ads thereby developing a social norm rebelling against the ads. Generally, adolescents have a desire for peer approval and the critical dilemma is to develop an anti-drug campaign that is designed to attract peers to refuse experimentation with marijuana. However, Above the Influence campaigns develop advertisements that show youths using marijuana and the negative consequences of marijuana usage. Unfortunately, the more the campaign shows advertisements similar to these methods, the more adolescents will feel the urge to experiment marijuana to become socially accepted by their peers.

The theory of reasoned action is also an effective approach for the campaign because it is a static model which means that it does not account for dynamic changes that occur in an individual. The theory is criticized because it illustrates that individuals follow a linear decision making process when in fact most individuals have a dynamic decision making process (12). This is an important limitation in the model and perhaps one of the most significant limitations resulting in the campaign’s ineffectiveness because often drug-related beliefs and attitudes are dynamic (13). For example, many youths may have a reason to quit using marijuana but are unable to quit because of addiction or they might quit for a period of time and then start again. When many youths attempt to quit or reduce marijuana, they develop withdrawal symptoms such as anxiousness and restlessness. In essence, negative moods associated with marijuana withdrawal elicits more cravings for marijuana and thereby promote marijuana use amoung many youths(14). Indeed, those attempting to quit marijuana have reported significant experiences of craving marijuana and find it difficult to quit (14). In addition, numerous marijuana users who experience marijuana related health consequences and want to quit but are ambivalent about making changes to quit marijuana usage (15). Overall, these decision making processes do not follow a linear decision making process because many users develop an addiction to marijuana thereby reducing their ability quit. Of the youths who are able to quit marijuana, some might start using it again and go through the cycle constantly. Essentially, these behaviors are a dynamic decision making process and the campaigns are more focused on a linear model where youths will quit marijuana use and move to the next stage instead of regressing back to the initial stage. Therefore, this theory may not be the most beneficial model for minimizing marijuana usage among adolescents. In addition, anti-drug campaigns such as, Above the Influence, need to focus more on a dynamic decision making process instead of a linear model.

“It Won’t Happen To Me”

Adolescents are often optimistic and not concerned about their health because they do not perceive their health risks as severe in comparison to the population. Therefore, many youths believe that experimentation of marijuana is a rational and a positive choice because they believe that they will face no serious health consequences. One study explains that many youths believe that the health consequences will not affect them personally even though they are fully aware of the associated health risks (6). Hence, many youths are tempted to try marijuana because they consider themselves as an exception to the rule. This attitude is known as optimistic theory, where people do not believe that their personal risk is elevated as Dr. Siegel describes. In addition, optimistic theory varies with age and in general adolescents tend to be more optimistic in comparison to adults (16). Therefore, many youths feels impenetrable to the health risks associated with marijuana usage. For example, one college student states, “nothing bad will happen to me now so why bother?” (6). Many preventions programs such as The National Youth Anti-Drug Media Campaign try to only improve knowledge about the health risks associated with marijuana. However, these programs are not effective and often led to poor results in reduction of drug usage (16). Therefore, if Above the Influence advertisements constantly provide statistics of health risks, many youths will ignore the message assuming that they will not be part of the statistics. Even though most youths are aware of the negative health consequences they may be afraid of becoming just another number. Providing such statistics could lead to denial where youths will believe that the risks will not harm them in comparison to the entire population (17). For example, many youths have developed a belief of invulnerability when they view these campaigns and say, “it might happen to others but not to me” (18). In addition, one study observed that youths rated their risks to negative health consequences associated with marijuana use much less in comparison to others (19). Therefore, developing such advertisements can become counterproductive and force youths to experiment with marijuana.

A New Anti-Drug Campaign

Above the Influence Campaign has developed targeted efforts to prevent illicit drug abuse specifically marijuana among youths by illustrating the dangers and health risks. Although, this advertising campaign’s ultimate goal is to reduce and prevent the use of such drugs, it has not been a success by any means. Hence, we propose a new anti-drug campaign that maintains a similar goal to the previous campaign but incorporates innovative methods to achieve the goal. To develop a new public health intervention for the anti-drug campaign, we will focus on three modifications: positive messages, developing popularity among youths, and focusing only on one story/aspect instead of several statistics. Indeed, much more is required to develop a public health campaign but these three modifications could gradually evolve into a better and more resourceful program overtime in comparison to the previous campaigns. In addition, developing a public health campaign applying these methods may target more youths and reduce marijuana usage rates among youths in comparison to Above the Influence Campaign. Ultimately, we do not want to draw adolescents to the campaigns with fearful messages and instead we want to draw them with these three models.

Positive Messages

We can use positive messages in our public health campaign instead of graphic images or stories that arouse fear among youths. For example, one study portrays a happy young girl in the ad and under her picture it states, “She’s living proof that Treatment Works” (18). Instead of persuading youths with negative imagery, this advertisement provides hope by targeting those individual who desire to quit marijuana. In addition, this advertisement depicts an adolescent who quits marijuana and is happy with her life. This image illustrates a positive message by portraying the concept that it is possible to quit illicit drugs and still be able to maintain a normal and happy life. Therefore, our goal is to elicit positive messages such as warmth and happiness and eliminate facts that describe the negative health consequences of marijuana usage. By this method, we are trying to sell happiness to youths if they quit marijuana and trying to “unsell” a previous behavior (19). An example of a successful anti-drug campaign for youths is the Minnesota DARE Plus Project, which focuses on connecting youths through positive messages and preventing illicit drugs use such as marijuana. For example, their campaign provides positive peer role models that discourage drug use and instead encourages other extracurricular activities (20). Therefore, we can develop a program that emphasizes his or her success story of not using marijuana. For example, we can portray a story of a young happy girl named Sally, who is extremely popular among her friends circle. At the end of the advertisement we can say, “and she rejected drugs.” Using this method, we are trying to sell happiness by promoting messages of not using illicit drugs thereby eliminating negative or fearful messages associated with drug abuse. In addition, this method will motivate youths to take control over their lives by “rejecting” marijuana through peer pressure. Therefore, it is essential to encourage better decision making skills among adolescents and deliver positive messages by associating optimistic messages with non-use of marijuana. Indeed, this method will not only help to prevent drug abuse but also develop a negative image of drugs.

Building Popularity among Peers

Marijuana usage is prominent among adolescents and is increasingly developing popularity among youths. Many adolescents believe that marijuana use is a radical and a deviant behavior that can gain them peer acceptance. In addition, many anti-drug campaigns gear their advertisements toward negative statistics such as the percentage of marijuana users among youths or the percentages of risks associated with marijuana usage. Indeed, these percentages attract youths to experiment with marijuana so they can join their peers or those percentages. Thus, many marijuana users form a bond or a social group and often smoke with others thereby alienating other non-users (21). Many non-users become users to obtain popularity among their peers and join these groups to develop solidarity. The construction of the adolescent image is often contingent on group behavior and dynamics. Therefore, it is crucial to change the social norms among adolescents regarding marijuana usage. Not only do we have to eradicate the current social norm of marijuana among youths but also replace it with popularity to reject marijuana. For example, we can develop an advertisement that illustrates popular youths in a group together walking in the mall, taking random pictures, and having fun. Then at the end of the ad, we can say “they don’t need marijuana to have fun.” Another example of an effective ad could be of a group of popular adolescents in a band together and on stage showing off their catchy music followed by many fans. At the end of this advertisement, we can say, “they rejected marijuana.” Based on this advertisement, we are trying to “sell” popularity among youths and demonstrate that it is not necessary to gain popularity through drug use. In addition, the advertisement illustrates that instead of wasting time smoking marijuana, youths should participate in other activities such as band groups, sports, etc. Another method to reduce marijuana would be to create student groups where youths develop innovative techniques to reduce marijuana. For example, The Dare Plus Project developed student group activities where youths participated after school with other peers to address issues associated with drug use and the development of solutions to reduce drug use among their peers (20). This approach would allow youths to become involved in preventative campaigns against drug abuse. If youths are involved in such programs they can impact other youths to join the program and thereby developing popularity against marijuana usage. In addition, we can advertise positive statistics such as percentage of non-users or percentage of youths who quit marijuana thereby increasing youth groups against marijuana usage. This method can allow youths to form coalitions against marijuana and essentially decrease the popularity of marijuana users. Such methods can eliminate the alienation of non-users and perhaps reduce marijuana usage among regular users. Indeed, simple changes such as involving youths in the programs or advertisements that sell popularity without marijuana can drastically alter an ineffective campaign by establishing popularity among youths against marijuana usage and increase awareness.

Capturing the Story of One Person

Anti-drug campaigns often provide youths with numerous statistics to build awareness regarding the health consequences of illicit drugs such as marijuana. However, many youths ignore these messages and it sometimes leads to opposite effects because such messages do not offer youths what they want and instead threaten their freedom. Many advertisements target individuals by offering happiness or freedom through their products. For example, many people are willing to buy luxury brand products such as, Louis Vuitton, because the brand uses advertisements that associate their brand with a personal journey to freedom (22). Therefore, to attract youths against marijuana usage we have to offer them with such core values as health and happiness. In addition, we have to develop an advertisement that revolves around the story of one person and their journey to happiness instead of several statistics. For example, we can construct the story of one boy named, Jonathan, who is a typical adolescent and his life consumed with problems when he used to use marijuana. We can show brief glimpses of his past and how much he struggled until he decided to quit. Then, the story depicts his transition into a better and more joyful life after he quits smoking marijuana and breaks from his old habits. At the end of the story we can say, “join the journey, the discovery, to a new life.” In addition to this story, we can add a peaceful song in the background to increase emotional response and the attitude towards the advertisement. Overall, the advertisement illustrates the average youth gaining freedom by leaving marijuana. Essentially, using this method we are selling a journey to a new life that promises happiness and freedom. Therefore, we can attract youths not on the basis of spreading awareness through statistics but by promising successful stories of individuals who quit marijuana.

Conclusion

All in all, anti-drug campaigns such as Above the Influence have a critical task to prevent the use of illicit drugs such as marijuana among adolescents. Despite constant advertisements, such interventions have struggled to maintain adequate acceptance from adolescents. Often, youths ignore or mock the advertisements developed by Above the Influence because they believe these campaigns are targeting their freedom with fearful messages. The implications of marijuana use are profound. Although the health effects of marijuana use can be deleterious, it is known more importantly as a powerful gateway to other drugs such as cocaine. Therefore, there is a compelling need to alter these campaigns and develop effective interventions that encourage youths to refuse marijuana and stop the development of other toxic drug habits. In this paper we illustrate alternative methods to combat marijuana usage among youths through the use of positive messages aimed to promise better health and happiness. Perhaps the employment of these methods can shift the current paradigm and approach to marijuana cessation through adolescent-centric intervention that appeals to the identity-forming process that teenagers undergo during this critical period.

REFERENCES

Book:

1. J. Kennet et al., Evaluating and improving methods used in the National Survey on Drug Use and Health (Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2005).

Website:

2. National Institute on Drug Abuse – High School and Youth Trends (2011). Retrieved 11/27/2011, 2011, from http://www.nida.nih.gov/infofacts/hsyouthtrends.html

Journal Article:

3. M.R. Polen et al., “Health care use by frequent marijuana smokers who do not smoke tobacco.,” Western Journal of Medicine 158, no. 6 (1993): 596.
4. Hornik, Robert et al., “Effects of the National Youth Anti—Drug Media Campaign on Youths” American Journal of Public Health 98, no. 12 (2008): 2229-2236
5. L Henriksen, “Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect,” Tobacco Control 15, no. 1 (February 1, 2006): 13-18.
6. Wolburg, Joyce, “College Students’ Responses to Antismoking Messages: Denial, Defiance, and Other Boomerang Effects” The Journal of Consumer Affairs 40, no. 2 (2006): 294.
7. Yahui Kang, Joseph N. Cappella, and Martin Fishbein, “The Effect of Marijuana Scenes in Anti-Marijuana Public Service Announcements on Adolescents’ Evaluation of Ad Effectiveness,” Health Communication 24, no. 6 (August 31, 2009): 483-493.
8. Cohen, Elisia et al., “Anti-Smoking Media Campaign Messages: Theory and Practice,” Health Communications 22, no. 2 (2007): 91-102.
9. P. Palmgreen et al., “Effects of the Office of National Drug Control Policy’s Marijuana Initiative Campaign on high-sensation-seeking adolescents,” American Journal of Public Health 97, no. 9 (2007): 1644.
10. Yahui Kang, Joseph N. Cappella, and Martin Fishbein, “The Effect of Marijuana Scenes in Anti-Marijuana Public Service Announcements on Adolescents’ Evaluation of Ad Effectiveness,” Health Communication 24, no. 6 (August 31, 2009): 483-493.
11. David, Clarissa et al., “The Social Diffusion of Influence Among Adolescents: Group Interaction in a Chat Room Environment About Antidrug Advertisements,” Communication Theory 16 (2006): 118-140.

Book:

12. Mark Edberg, “Chapter 4: Individual Health Behavior Theories,” Essentials of Health Behavior: Social and Bheavioral Theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. pp. 146.

Journal Article:

13. Zhiqun Tang and Robert G. Orwin, “Marijuana Initiation Among American Youth and Its Risks as Dynamic Processes: Prospective Findings from a National Longitudinal Study,” Substance Use & Misuse 44, no. 2 (January 2009): 195-211.
14. S.J. Heishman, E.G. Singleton, and A. Liguori, “Marijuana craving questionnaire: development and initial validation of a self-report instrument,” Addiction 96, no. 7 (2001): 1023–1034.
15. Stephens, R. S., Roffman, R. A., Fearer, S. A., Williams, C., Picciano, J. F. and Burke, R. S. (2004), The Marijuana Check-up: reaching users who are ambivalent about change. Addiction, 99: 1323–1332.
16. E. R. Danseco, P. M. Kingery, and M. B. Coggeshall, “Perceived Risk of Harm from Marijuana Use among Youth in the USA,” School Psychology International 20, no. 1 (February 1, 1999): 39-56.
17. R. Hornik and I. Yanovitzky, “Using Theory to Design Evaluations of Communication Campaigns: The Case of the National Youth Anti-Drug Media Campaign,” Communication Theory 13, no. 2 (2003): 204–224.
18. Gerard Hastings, Martine Stead, and John Webb, “Fear appeals in social marketing: Strategic and ethical reasons for concern,” Psychology and Marketing 21, no. 11 (November 2004): 961-986.
19. P. TODESCO and B.H. STEPHEN, “Risk perception: Unrealistic optimism or realistic expectancy,” Psychological reports 84, no. 3 (1999): 731–738.
20. C.L. Perry et al., “The Minnesota DARE PLUS Project: Creating community partnerships to prevent drug use and violence,” Journal of School Health 70, no. 3 (2000): 84–88.
21. J.W. Clarke and E.L. Levine, “Marijuana use, social discontent and political alienation: A study of high school youth,” The American Political Science Review 65, no. 1 (1971): 120–130.
22. Wilcox, Keithe et al., “Why Do Consumers Buy Counterfeit Luxury Brands?” Journal of Marketing Research XLV (2008): 1-46.

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.

REFERENCES:

1. CDC - Fact Sheet - Fast Facts - Smoking & Tobacco Use. (2011, March).Center for Disease Control & Prevention. Retrieved December 14, 2011, from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/#cost

2. Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education: Theory, Research And Practice. Retrieved from http://books.google.com.ezproxy.bu.edu/books?hl=en&lr=&id=WsHxyj710UgC&oi=fnd&pg=PR5&dq=HEALTH+BEHAVIOR+AND+HEALTH+EDUCATION&ots=EVOZYeLl-M&sig=rq3nn5_iJHSkXso1oAaqi7KCHbk#v=onepage&q=HEALTH%20BEHAVIOR%20AND%20HEALTH%20EDUCATION&f=false

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