A Critique of New Graphic Warning Labels for Cigarette Packages – Leah Casner
According to the Center for Disease Control (CDC), an estimated 46 million people, or 20.6% of all adults (aged 18 years and older) in the United States, currently smoke cigarettes. Cigarette smoking is the leading cause of preventable death in the United States, accounting for approximately 443,000 deaths or 1 of every 5 deaths in the United States each year (1). In recent years, numerous public health interventions have been focused on the prevention of youth and adolescent smoking, increased awareness of the risks of smoking and access to cessation programs. Though some have been successful, CDC data from the 2008 National Health Interview Survey (NHIS) indicated that from 1998-2008; the proportion of U.S. adults who were current cigarette smokers declined only 3.5% (from 24.1% to 20.6%) (2). The U.S. Department of Health and Human Services (HHS) also reported “every day 4000 youths try a cigarette for the first time, and 1000 become regular daily smokers”. Furthermore, the objective set out by Healthy People 2010, a set of health objectives for the nation detailed by the HHS in the Office of Disease Prevention and Health Promotion, of reducing the prevalence of cigarette smoking among adults to less than 12% nationally, has not been reached.
In response to the data, President Obama signed into law on June 22, 2009, The Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act), which required that cigarette packages and advertisements have larger, and more visible graphic health warnings. Under the law, cigarette manufacturers and retailers are required to produce the labels and display them in advertisements and on cigarette packaging by Oct. 22, 2012. The U.S. Food and Drug Administration (FDA) currently require cigarette manufacturers to include one of four small, text-only Surgeon General's warnings along the bottom of advertisements and on the sides of cigarette boxes. The new warning labels will take up approximately half of the front of each cigarette box, making them much more visible, and the graphic images they incorporate will be more eye-catching. On Nov. 10, 2010, the FDA released images of 36 warning labels that are designed to be wrapped around cigarette boxes. The warning labels each feature one of nine messages (i.e. "Cigarettes Cause Cancer," "Smoking during Pregnancy Can Harm Your Baby") superimposed over a related image (12). The images, most of which are in color and some of which are very graphic, include a cartoon of a crying baby, a photograph of a corpse, and a photograph of diseased lungs. Other recent tobacco control and prevention efforts announced recently included, the Affordable Care Act which gives Americans in private and public health plans access to recommended preventive care, like tobacco use cessation, at no additional cost; the American Recovery and Reinvestment Act (ARRA) which invested $225 million to support local, state and national efforts to promote comprehensive tobacco control and expand tobacco quit lines; the Prevent All Cigarette Trafficking Act (PACT) which aims to stop the illegal sale of tobacco products over the Internet and through mail order, including the illegal sale to youth; the Family Smoking Prevention and Tobacco Control Act (FSPTCA) which gives the FDA the authority to regulate the manufacture, marketing and distribution of tobacco products. Significant progress has already been made by restricting the use of the terms “light,” “low,” and “mild,” and banning fruit, candy, and spice, flavors from cigarettes, and putting in place restrictions on the sale and distribution of cigarettes and smokeless tobacco products to youth, and finally the Children’s Health Insurance Program Reauthorization Act (CHIPRA) which raised the federal cigarette tax by 62 cents per pack. Raising the price of tobacco products is a proven way to reduce tobacco use, especially among price-sensitive populations such as youth (3). The following critique will present an evidence-based criticism of the FDA’s new cigarette warning labels program and provide a proposal for an alternative intervention.
There is a plethora of conflicting evidence on whether graphic warning labels on cigarette packages prevent smoking and increase cessation. Most recent studies seem to suggest that based on smoker and non-smoker questionnaires, the warning labels are in fact more effective than previous text-only warnings. For example, White et al (4), found in a study conducted in 2008, that graphic warning labels on cigarette packs were noticed by the majority of adolescents, increase adolescents’ cognitive processing of these messages and had the potential to lower smoking intentions. The study ﬁndings suggested that the introduction of graphic warning labels helped to reduce smoking among adolescents. On the other end of the study spectrum was an investigation by Grandpre et al., (5) which demonstrated that grade level and message type had a significant impact on the processing of tobacco-related messages. In other words, while anti-smoking messages had succeeded with younger children, in adolescence despite understanding the harmful effects of cigarettes, anti-smoking campaigns produced more reactance. Studies also suggest that though the warning labels may increase knowledge of the health effects of smoking in smokers, there is little evidence to suggest that the warning labels actually decrease smoking. The failure of this public health intervention may be attributed to the social and behavioral science theories of Optimism Bias, Psychological Reactance Theory and Maslow’s Hierarchy of needs.
Optimism bias is the “demonstrated systematic tendency for people to be over-optimistic about the outcome of planned actions. This includes over-estimating the likelihood of positive events and under-estimating the likelihood of negative events”(6). The theory was described by Neil D. Weinstein in a 1980 study where it was reported that a majority of college students believed their chances of events such as divorce and having a drinking problem to be lower than that of other students, and their chances of events such as owning their own home and living past 80 years of age to be higher than that of other students (7). This theory can help explain why many people continue to smoke despite inescapable anti-smoking messages that warn of cigarettes harmful effects. Weinstein found in a study conducted in 1998 (8) that smokers consistently acknowledged that smoking increased health risks, however they judged the size of these increases to be smaller and less well established than non-smokers. Also, Weinstein found that smokers minimize the personal relevance of the risks: they did not believe that they were at much risk as other smokers of becoming addicted or suffering health effects. The effect of this unrealistic bias between personal risk and the risk faced by the rest of the population is not surprising. People do not want to believe that they are at risk, and they are quite clever at constructing arguments to explain why their risks are lower than others'. The unrealistic optimism that smokers tend to exhibit is one of the reasons why the new warning labels will not work. If smokers already have knowledge of smoking effects as well as the preconceived notion that these effects do not apply to them, the message of the labels will be lost.
The new FDA cigarette warning labels were an attempt to help tobacco users quit and prevent children from starting. At a news conference by HHS Secretary Kathleen Sebelius and FDA officials commented, “ Today marks an important milestone in protecting our children and the health of the American public” (3). The second argument for why the new warning labels may be a flawed public health approach has to do with the Theory of Psychological Reactance and the theory’s effect on adolescence. Reactance theory suggests that individuals become psychologically aroused when their perceived behavioral freedoms are threatened or reduced. The resulting reactance motivates attempts to restore the threatened freedoms (9). In other words, when individuals are told what to do or what not to do and given no choice in the matter, they see this as a threat to their freedom. To reclaim this freedom, most will do the opposite of what is expected. An example of such behavior “can be observed when an individual engages in a prohibited activity in order to deliberately taunt the authority that prohibits it, regardless of the utility or dis-utility that the activity confers” (6). It has long been recognized that desire for autonomy along with a disregard for authority are characteristic of adolescence. To this effect, messages restricting adolescent freedom conflict with needs for independence and compound perceptions of external control. In fact, PRT may explain why adolescences are so receptive to pro-tobacco messages (5). With this theory in mind, the new warning labels on cigarettes may in fact increase the rates of adolescent smoking. What the FDA has failed to consider is that the new warning labels though flawed, provide researchers with a framework for understanding and preventing adolescents’ negative reactions to anti-smoking messages using the psychological reactance theory.
MASLOW’S HIERARCHY OF NEEDS
The final criticism of the FDA warning label intervention is directed toward the intervention’s dismissal of Maslow’s Hierarchy of Needs. Maslow's hierarchy of needs is a theory proposed by Abraham Maslow in his 1943 paper A Theory of Human Motivation. Figure 1 displays Maslow’s pyramid of needs, where the most basic and fundamental physiologic needs at the very bottom. In order to reach “Self-Actualization”, which is the most desired level of need, one must first not only achieve the previous needs (physiological, safety, love, and esteem) but also master these needs. Maslow believed that the hierarchy of human needs motivated behavior. This may explain why not everybody responds to the obviously beneficial and well-meaning interventions. Health needs are often compromised for the sake of satisfaction of low-order needs. Only during emergencies, do safety needs such as health and security rise to the forefront. Furthermore, the consequences from smoking often occur later in life. It is hard for people to consider healthy choices when the results are 10, 20 or 30 years in the future. The warning labels do not consider that for some, smoking is a basic essential physiological need that will be put before health. In order to have a true effect a public health intervention needs to over come this.
In order to develop a public health program that would address the specific flaws of the FDA’s warning label intervention and be successful in the goals set out by the HHS, this critique proposes three steps. The first step would be to change optimistic bias and increase individuals risk perception, the second would be to minimize the reactance produced by the authoritative ads and the third would be to link health with a lower order need on Maslow’s pyramid. An intervention that accomplished these ideals would be more successful than the FDA’s warning label intervention.
It is clear that more research is needed on communicating risk magnitudes and on methods for overcoming unrealistic optimism. Perhaps if smokers understand the magnitude of their decisions to smoke and that their personal risk for harmful effects is very high, there will be more of a decrease in smoking and prevention of new smokers. At present, the smoking prevention community does not see risk perceptions as particularly important in smoking initiation (8). Furthermore, most of the recent studies on reactions to graphic warning labels have been misleading in that conclusions suggest that the new labels imagery are more likely than text-only warning labels to promote smoking-related knowledge and smoking cessation (10,4). This is not only false information but is also deterring public health organizations from developing new strategies to overcome optimistic bias. It is true that the new warning labels are more effective than the text-only labels, however a comparison to the text only labels is a moot point because that intervention was not effective. If we can develop communications that put smoking risks into proper perspective with other risks and that thwart prospective and beginning smokers' attempts to minimize personal risk, we will learn whether attention to risk can be more helpful in preventing and reducing smoking than has been demonstrated so far (8). These messages may include presentations in middle and high schools with not only those who have smoked for much if their lives, but those who have grown up in households with smokers and those who have suffered from health effects and only smoked for a minimal amount of time. Other interventions may be messages to increase the optimism bias that better things will happen if the individual does not smoke.
Minimizing psychological reactance is another effective way to correct the flaws of the FDA’s warning label intervention. This will allow public health programs to avoid making their audience feel as though their freedoms and choices are being taken away. The results of psychological reactance to previous anti-smoking campaigns suggest that it may be fruitful to allow adolescents more freedom to make their own choices regarding healthy behaviors. Such an approach would allow for the utilization of knowledge about harmful effects of tobacco use and positive attitudes toward being tobacco free. It may also be possible to make intriguing and attention-getting messages that stimulate thought about what it means to be healthy, attractive, accepted, and independent. By allowing adolescents the freedom to actively consider diverse health choices, decisions may be seen as being totally self-initiated. Furthermore, implicit messages may be more successful than explicit messages such as those on the new warning labels. A study by Shadel et al., investigated the message content in anti-smoking public service announcements (PSAs). They determined the message could be delivered explicitly (directly with concrete statements) or implicitly (indirectly via metaphor), and the method of delivery affected the efficacy of the PSAs. They found that tobacco industry manipulation PSAs that delivered their messages explicitly were associated with stronger levels of smoking resistance self-efficacy compared to tobacco industry manipulation PSAs that delivered their messages implicitly (11). Perhaps if the FDA focuses on implicit messages to reduce smoking behaviors and explicit messages of healthy, attractive, accepted, and independent individuals, they will achieve their desired effect.
The last step to develop a new public health intervention that would work better than the FDA’s warning labels, takes into account Maslow’s hierarchy of needs. Perhaps linking health with a lower order need will begin to make people view health as a basic physiological need and not one to be sacrificed for the sake of satisfaction. Another idea is to link health with other levels on Maslow’s hierarchy. For example, using imagery to promote behavior change; anti-smoking ads targeting women that tap into concerns about looking good and aging (self-esteem) to encourage them to stop smoking. For men, this may include imagery associated with sex, looking good and going out, to promote non-smoking behavior. Playing on people’s fears (linking to the security and esteem groups), as in the examples above, is one effective way of getting attention for a campaign. This is especially true for those groups who may be more likely to display negative behavior or be more easily influenced by what they see or by others’ behavior, rather than logical argument. Though this may sound manipulative, it seems to be the best way to have individuals take notice and make changes.
Taking the criticisms and proposals into account, new interventions will capitalize on the psychology of the consumer; just as the tobacco industry has done since its inception. What the public health field fails to believe is that individuals do not act rationally. Many industries have already caught on to this idea and have taken advantage of marketing strategies that influence the consumer to obey. The U.S. Department of Health and Human Services must act accordingly if they would like to change the current state of public health.
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