Anti-Smoking Campaign Ads On Cigarette Packages And The Health Belief Model – Jenna Barry
The US Food and Drug Administration have a new public health intervention in the works for combating smoking. The decline in smoking has been stalling since 2004 and there is still about 20% of Americans who smoke. It is a large public health issue and even though most people are aware of the dangers of smoking the habit continues. There have been many different interventions put into action over the years and some have been more effective than others. Public health officials have spent years studying why some interventions work better than others but there are still new interventions being made that rely on old theories that aren’t very effective. The new anti-smoking campaign being made by the Food and Drug Administration is an example of a new intervention being based on an old theory. This intervention will most likely be flawed due to the model it is based on and other countries that have tried similar programs are beginning to move away from it.
The new anti-smoking campaign that is being initiated is aimed at current smokers. The Food and Drug Administration has come up with 36 different graphic images, 9 of which will be chosen to be displayed on all cigarette packages. The images range from a man in a coffin, dirty teeth, bald cancer patient, to smoke damaged lungs. There is a large range of images that are meant to hit smokers with a strong impact of what their smoking is doing to them and to others. The hope is that these images will be a stronger message than the current warning labels and be harder for people to ignore. The images are going to be larger than current warning labels and take up half of the front side of the cigarette package. Starting in October of 2012 the images will be mandatory for all cigarette packages. The United States is behind other countries in regards to this program. Many other countries have already enacted such programs and some say they used even more graphic images than what the United States has planned.
This new anti-smoking ad campaign is a public health intervention that is based on the social science theory called the Health Belief Model. The health belief model was created in 1966 by Irwin Rosenstock and it dominates about 98% of all public health interventions. The model was initially created to find out what lead people to obtain chest x-rays for the detection of tuberculosis in the 1950s (1). The basis of the model is that it is used to predict the likelihood that people will perform preventive health behaviors. A person’s motivation to perform a preventive health behavior is based on three categories. The categories are susceptibility to disease and or health condition, their perceived severity, and the importance of health to the individual. The model also takes into account the perceived barriers that individuals include in their decision making, such as, cost, inconvenience, and discomfort.
The strengths of the health belief model are that it calls attention to the fact that people need to be educated about their behavior. The model is concise and efficient and it’s fairly easy to establish an intervention. There is good generalizability with this model and it is good when it comes to simple decisions and behavior that is constant.
There are many limitations of the health belief model. When dealing with complicated, complex and fickle behavior it is hard to use the health belief model. People have a hard time abstaining from some behaviors even when they intend to follow healthier behaviors. There is an inner struggle between an individual’s intentions and the behaviors they end up performing. There are many things that the health belief model doesn’t account for that are strong influences on people’s behavior. The model doesn’t take into account the forces from social and environmental factors, which play a large role in day to day decision making. The model is an individual level model that only predicts the behavior of an individual and doesn’t look at society as a whole and how group dynamics play a large role. People’s behavior is often irrational and unplanned and the health belief model relies on the opposite thinking that their behavior will be rational and planned. The model predicts an individual’s behavior by assuming they will calculate rationally between the benefits of the health behavior and the barriers of performing the health behavior. This calculation will only work if the individual thinks rationally but people are irrational. Due to this the model is poor at predicting addiction, which is behavior without intention and is irrational.
There are far more limitations to this model than there are strengths. This doesn’t mean that the model is completely useless but relying on it alone is not very beneficial. If it was to be combined with other models then it could work better. The new anti-smoking campaign is following the health belief model only and thus is not likely to wield very good results. The campaign is organized on the assumption that people only need to be told about the negative consequences of their smoking and they will want to quit. However, as a society we have known for a while now the dangers and risks of smoking and yet 20% of people in the US are still smoking and new people are continuing to pick up the habit. The campaign being based on the health belief model makes it a flawed one and the benefits will probably be few.
One reason that the new anti-smoking campaign is flawed is because it doesn’t take into account social factors like socioeconomic status and previous experiences (2). It relies only on the individual’s health beliefs and that if they are told about the dangers then their health beliefs will change and so will their behavior. The campaign hopes that using such graphic images will shock smokers into seeing the extreme dangers that they are putting themselves at risk for by smoking. If the individual has had previous experiences where they have known many people who have smoked and none of them experienced any major consequences then the individual may feel their susceptibility to disease is low. If there is a low susceptibility due to social factors not being taken into account then the health belief model is likely not going to work as well for that individual (3).
Another big reason that this new anti-smoking campaign is flawed is because the health belief model is poor at predicting addictive behaviors. Cigarette smoking is influenced by many factors that are not health related so it is hard for the model to predict these factors and behaviors (4). These factors are psychological and physiological and very complex in nature. The campaign is only targeting the severity and susceptibility of the disease and the barriers involved are more complex so that won’t be enough. Smokers are already aware of the dangers and just showing them graphic images isn’t going to target the more complicated reasons behind why they smoke. There is a strong addiction with smoking and this is a large barrier to try to tackle. The inconvenience and discomfort they would go through by trying to quit is a strong deterrent so individuals have a hard time between intention and behavior.
One of the largest flaws of the new anti-smoking campaign is that it is based on the idea that individuals behave rationally when weighing the perceived benefits of the health behavior with the perceived barriers. People do not behave rationally but rather they are irrational (5). There are 5 major ways why people behave irrationally. The first is due to expectation and stereotypes and when people are labeled a certain way they are going to live up to that label. Smokers are often labeled by society with negative connotations and if the individual feels they are part of this stereotype then they will try to live up to it. The second is due to ownership and loss aversion. This deals with prospect theory and how decision making is based on emotions and experiences. People are attached to things they own and human behaviors, such as, smoking are part of a person. When a person is doing something unhealthy (i.e. Smoking) they own it and it’s a part of them. If they smoke then it’s a part of their identity and they don’t want to give it up or lose it. The third reason for irrationality is framing. People are greatly affected by the way something is framed and the way the campaign is framed is more likely to incite a negative response from people due to rebellion. The fourth reason is fundamental attribution error, which deals with not taking into consideration the context where behavior takes place. Most likely people that smoke are doing it around other smokers and in that context they are not apt to think about the consequences when they see other people doing the same thing. The fifth reason involves self-control and those lacking self-control are not going to behave rationally.
An intervention that would be better at combatting smoking would tackle all of these flaws that the new anti-smoking campaign has not addressed. The intervention that would be better would focus on using multiple theories that are based on a group level. Group level models are more effective than individual level models like the health belief model. If an intervention was to combine multiple group level models it could put together the strengths of them into one intervention. A better intervention would be similar to the Truth campaign that used advertising theory and combine this with a marketing paradigm. The new proposed intervention would be to create a mass production advertisement that didn’t say anything about health consequences due to smoking. The focus of the advertisement would be to target people’s rebellion by using the theory of psychological reactance. Some people are worried that the new anti-smoking campaign will cause people to feel that their freedom is being threatened so in rebellion due to the theory of psychological reactance they will instead smoke more. As public health officials we need to use these theories that evoke stronger emotions and reactions from people to our advantage to influence people to choose healthy behaviors on their own. The mass advertisement would be targeted at smokers and inform them of how the tobacco industry is the one that is threatening their freedom. At the same time the campaign could create an image of sexy, strong, and independent individuals that are talking back to the tobacco industry. The promise made by the campaign could be that if you rebel against the tobacco industry like them then you will obtain a core value that the actors appear to possess.
This new intervention would address the first flaw of the new anti-smoking campaign that there are no social factors taken into account with the plan to display graphic images on the cigarette packages. This new intervention specifically targets social factors by using the marketing theory and targeting a core value of society (6). Core values are usually universal and many people can relate to them so it would target a large audience at a time and not just on an individual basis. People don’t value health until they don’t have it. Only when you’re not healthy do you start to lose other core values. So people that are healthy and smoking don’t feel like there is any incentive because they don’t feel that they’ve lost any core values. However, if there was this new intervention that made a large promise about how if you’re like the people in the advertisement then you can also have the core values that they possess. The intervention would start off by targeting the deepest aspiration that was believed to be held by the target audience and giving the image that the actors had obtained this core value by their anti-smoking behaviors. This would be more effective than the new anti-smoking campaign because it takes into account social factors like the target audience’s wants and needs. People spend their whole lives trying to obtain core values and if they think there is a behavior that can help them achieve these it will be a strong influence.
The new intervention would address the second flaw in the new anti-smoking campaign by using advertising theory. The new anti-smoking campaign will not be strong enough to address the addictive behaviors behind smoking. The new proposed intervention would be more complex and use stronger models that can have a greater impact on fighting addictive behaviors. Advertising theory can create a dramatic emotional impact that defies your brain. It would target strong human emotions and once these emotions are engaged then the mind will follow the emotion. The way to motivate people is to make them a promise. The promise is the basic premise of the advertising theory. The larger the promise the more effective it will be, which is the opposite of what you would think. The truth of the promise has nothing to do with whether or not the advertisements are effective. If we can develop this new public health intervention and make sure every message has a strong promise we can influence more people. Currently public health interventions are not taking advantage of this theory and that is a detriment to the cause. The promise would be backed up with support but not factual support. Instead it would be supported through stories, and images of people like the target audience. Advertisement theory is very universal and can be used for many products so it would work well for anti-smoking (7). For example, the promise that could be made in the new intervention could be that if you don’t smoke then you will be cool and attractive and powerful.
The third flaw of the new anti-smoking campaign would be addressed in the new intervention by appealing to the irrationality of people instead of assuming they are rational, like in the health belief model. This would be addressed by using the theory of psychological reactance to our advantage, rather than having it work against our public health initiatives. The plan for the graphic images on cigarette packages is going to have the theory of psychological reactance working against it. Instead this theory should be implemented in a new intervention to work to get people to smoke less. The mass advertisement could educate people about how the tobacco industry is targeting them and taking away their freedom. The most common thing to cause people to rebel is when people have lost control or loss of freedom. People then react to this perceived threat of their freedom when they feel that they are being told they have to do something or not do something and they have no choice in the decision. Right now every public health message tells people what to do and this evokes psychological reactance. As a result they must resolve this threat and do the opposite of what they are being told to do. Reactance has been found to be the most important risk factor for smoking (8). Before the new intervention is put into effect it should be measured and tested for how much reactance it creates. Reactance can be decreased through three different factors. The first factor is explicitness or the degree to which the language is clear; how plain is the intent of the source. Sometimes explicitness increases reactance and sometimes it decreases reactance but generally it reduces reactance. People are less likely to feel manipulated if the intent of the message is clear. The second factor is dominance or the extent to which the source believes they have control; the degree of the authoritativeness of the message. The more dominance there is the more reactance there will be. The third factor is reason or the degree of support for the claim in the message. The more support that there is for the message the less reactance there will be. The support doesn’t have to be scientific. Scientific support is actually the least effective kind of support. The intervention would be more effective if it uses stories and images to target the audiences emotions instead. The most important factor is how similar the source is to the target audience. The more similar the source is to the audience the less amount of reactance there will be. The intervention should thus use peers of the target audience to express the anti-smoking message rather than government officials or doctors. An example of an advertisement where peers have been used to increase the influence of a message was the ad campaign that was supporting gay marriage and the source of the message was straight couples to help appeal to their peers. Another option is to make it so there’s no perceived source of the message so the audience can’t discern that they are being told to do something by an identifiable source.
The new intervention will also address the reasons for people’s irrationality and will appeal to them rather than ignore them. It will address the expectation and stereotype irrationality by labeling people who are in the advertisement as active and cool and those who are non-smokers will begin to adapt this as part of their identity like in the 84.org campaign. The second reason for irrationality (ownership and loss aversion) would be addressed by creating a group of people in the advertisements that appear to have accomplished strong core values and people will want to be part of this group. Interventions can’t entice people to do healthy behaviors by offering them health so if they are offered these core values it will be something for them to aspire to. To be a part of the group they will have to quit smoking and establish the group as part of themselves and own it. The third reason of framing would be addressed in the new intervention by framing things in a more positive and appealing way. Fundamental attribution error and self-control would be addressed in the intervention by making sure the context of the message is taken into account and individuals will overcome their lack of self-control if there is a strong motivator like clear core values. Irrationality affects people’s behavior greatly and if an intervention could account for all of these things and use them to the advantage of public health then it would be a very strong message.
There are many newer more advanced models of social behavior that can be very influential for public health. The fact that so many public health interventions are relying on single models or ineffective models is a detriment to our society. There are many negative health behaviors that lead to extremely negative health outcomes. Prevention could be a huge step in combatting these diseases and illnesses that affect millions of people. An impact can only be made if the interventions start to be more innovative. Currently the interventions rely too much on the idea that if only people are informed about their poor health habits then they will stop. This is much how the health belief model is based and the fact that new interventions are coming out and still only relying on this one model is unfortunate. Companies that are damaging the health of people in the United States like the tobacco industry and fast food restaurants are using these new group level models that are effective and getting people to behave the way they want them to. Public health needs to fight back by using these same models that the big companies are using and are working. The tobacco industry has long known that appealing to people’s emotions will get them more loyal customers every day. They have tried to seem like they are on the side of supporting public health by giving money to our interventions. However, they know are interventions aren’t working and some are even helping them so they gladly support the ones that don’t work and are quick to fight back against the ones that do. New interventions need to be made and they need to use these stronger models and hopefully if this becomes more typical there would be too many good interventions for the tobacco industry to fight all at once.
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