Tuesday, December 14, 2010

Recent Publicity Surrounding the 2009 Family Smoking Prevention and Tobacco Control Act: A Critique of Attempted Use of the Health Belief Model Center

Recent Publicity Surrounding the 2009 Family Smoking Prevention and Tobacco Control Act: A Critique of Attempted Use of the Health Belief Model Centered on Public Intervention via Graphic Warnings on Cigarette Labels – Dan Carroll
The Obama administration began working on legislation shortly after the election with a particular emphasis on the control and prevention of smoking at a young age and subsequent media influence on children related to the encouragement of future tobacco use. This legislation was passed around Capitol Hill after being negotiated with lobbyists, pundits, anti-smoking campaign organizers, and the nation’s leading cigarette seller, Phillip Morris. Eventually released in late June of 2009 under the name “2009 Family Smoking Prevention and Tobacco Control Act,” the bill dictated that the Food and Drug Administration would now have regulatory authority over tobacco products in the United States. This control came with additional changes to the original 1970 substitution of the previous disclaimer “Caution: Cigarette Smoking May Be Hazardous to Your Health” with the updated “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health.” The 2009 legislation enhanced the forty year old warning to one of nine statement options, all including the word “WARNING:” in all capital letters. Some of the examples include “Cigarettes are addictive” or “Tobacco smoke can harm your children/nonsmokers” along with more blunt statements like “Cigarettes cause fatal lung disease/cancer/strokes and heart disease” or just “Smoking can kill you.” Eight out of the nine warnings emphasize the danger and or damage risk represented by smoking cigarettes, but only one, “Quitting smoking now greatly reduces serious risks to your health,” had any positivity within its message to encourage the cessation of smoking cigarettes. The most recent publicity that the legislation has seen, after first receiving close scrutiny in a US District Court case in Western Kentucky (Commonwealth Brands Inc vs. the United States), was a November 2010 unveiling of the graphic images that will be used alongside the tobacco warnings starting as early as 2012. (1) In the next several pages, I am going to provide compelling evidence from past government backed anti-smoking attempts using similar tactics to warn consumers with graphic images on labels of cigarette packets, along with analysis of the established public health theories and empirical evidence supporting my argument that the approach, intervention, and expectations of the 2009 Family Smoking Prevention and Tobacco Control Act as it specifically relates to cigarette warning labels are flawed.
There are three dominant uses of public health theory that are detectable within the approach taken by the creators of the legislation that are significantly lacking in effectiveness as shown by both empirical data and publications written with regard to the success of using certain health models in a general fashion via mass media (i.e. cigarette warning labels). I am also prepared to present the argument that the chosen public health model, though not as productive as newer multi-level and multi-sectoral interventions (as suggested by the Balbach article in Tobacco Control, 2006), could have been made to generate more positive results had it been used more effectively. My primary observation with regard to the new cigarette warning labels was the overwhelming use of the health belief model as a nearly stand-alone approach to reaching current smokers with the message of danger and inherent risk in cigarette consumption. (2) Secondarily, the cue to action intended as a component of the health belief model is rendered ineffective over a short period of time due to an unvaried and bland set of messages that quickly blend in with the surroundings as modern mass media overloads the sensory systems of consumers. The third significant flaw that can be anticipated with initialization of the warning label legislation is simply the resistance of the public to hear the message due to the perceived sources generating the label content. The Social Reactance Theory is absolutely essential to consider when an entire nation of smokers are the target of a single intervention being forced upon a society that sees the authorities as a threat to their already infringed upon right to purchase and consume cigarettes freely.
As a counter-proposal to the current approach, I will carefully articulate changes that are supported by evidence explaining how each major flaw identified in the legislation could be reversed to improve the potential chances for effectiveness of the bill. I will define the new theory usage proposed to address the specific flaws that exist in each of the three cases outlined in this paper. I will provide details on how the Health Belief Model could have been used more correctly to achieve the desired goals of the intervention. I will propose an idea that incorporates the “Jolt” or “Catastrophic Theory” to improve upon the weak usage of the health belief model’s “cue to action” that was identified earlier in my argument. I will also lay out a declaration of change to the affect on the public by more appropriately using the Social Reactance Theory to create the environment of an opportunity to modify behaviors without the implication of threat or dictation from authorities.
Flaw in Usage of the Health Belief Model
As a primary and well known public health theory, the Health Belief Model has been widely used in public health for upwards of fifty years with some positive feedback relating to interventions involving individual behavior. Since its inception, many new outlooks on how to approach public health dilemmas have come about, much to the credit of Irwin Rosenstock, Godfrey Hochbaum, and Stephen Kegels’ original work under the U.S. Public Health Service. (3) It is also widely known that the original ideas behind the model were infantile with respect to the information and expertise available to the public health campaigns of modern day, and evidence is shown by the prompt clarifications or additions given to the Health Belief Model such as the sixth component of the model, self-efficacy. Many sources elaborate on the facts that point to the health belief model’s failure to account for the extreme complexity of human behavior. Rather than using the model as a resource with which to analyze the problem and proceed to further research the details of the behaviors and the optimal demographics that should be targeted with the approach of the campaign, too many significant U.S. public health interventions have relied on a loose and generalized structure inspired by the factors of the health belief model.
I would emphatically point to the first two components of the health belief model, which is the central focus and role played by the strongly worded WARNING labels and graphic visual images intended to carry the message of the intervention, as an established an inexcusably avoidable flaw that severely limits the impact of the legislation on smoking rates in the United States. The perceived susceptibility to falling victim to fatal lung disease, cancer, strokes, heart disease, or death is grossly underestimated by each individual smoker as evidenced by the work of Neil Weinstein almost thirty years ago in his studies investigating the tendency for people to be unrealistically optimistic about future life events. (4) Further studies, such as the work of Ayanian and Cleary investigating perceived susceptibility among cigarette smokers, even more clearly points to the fact that those specifically targeted individuals intended for realization and behavior modification as a result of the 2009 Act are far from experiencing the degree of impact assumed for a reasoned and logical decision maker.(5)
The second component of the health belief model, perceived severity of death or debilitating illness as a result of cigarette consumption is largely negated when the target of the message believe themselves to be far less likely to become involved in dealing with a severe health impact in the first place. (2,3) For those that are considering the likelihood of experiencing a real and negative outcome as a result of smoking, more often than not, have been consuming cigarettes for a substantial period of time during their lives and have not only heard each of the warning messages in other formats in the past, but also tend to internalize the risk as unavoidable given their long history of addiction to smoking tobacco products.
The net resulting impact of the combination of the perceived susceptibility and severity of risk from cigarette use is far less productive in this approach because the message is both over concentrated on the negative dangers of smoking and not an original idea in any way. The emphasis on horrific imagery and deeply damaging physical injury from tobacco use will turn the target of such intervention away as they seek avoidance of the issue and the internal feelings of depression and doom that await them post consumption. The attempt of the campaign is fighting the much stronger desire for immediate gratification of nicotine found in the tobacco smoke. (6) The nucleus of my critique lies in the both the decision to make use of the health belief model in the first place, especially considering the other options developed in the field of social sciences over the past few decades, and the poor attention to detail in constructing how to most effectively use the health belief model in this instance. I will proceed to further detail my suggested changes later in the section covering my counter-proposal.
Cue to Action Lacking Effectiveness and Longevity
While still a component of the health belief model, the second distinct oversight on the part of the writers of the 2009 Family Smoking Prevention and Tobacco Control Act is also the fifth component of the model, added to the existing four factors at a later time. The “cue to action” was designed to augment the model in order to meet the need for a motivation or “push” to act and make a change to the negative behavior. (3) The logical intention that one would conclude is desired by the use of alarming warning labels with graphic images depicting disturbing disease and health impacts that eventually lead to an early expiration is a clear direction to cease smoking cigarettes and preserve lifespan.
The first failure in the assumption that a “cue to action” would be effective in the 21st century is quite simply complete ignorance of similar past attempts to utilize this technique to generate results. (2) Not only have similar campaigns endorsed by the U.S. public health departments failed, but the exact same intervention was used in several other countries including Australia, Canada, and the United Kingdom. Very few publications show evidence of significant drops in smoking rates due solely to the exposure to graphic images and warnings on cigarette labels. Some of the only evidence to be found was taken out of context in a Financial Times article citing senior research fellow Lois Biener of the UMass Center for Survey Research for saying “graphic images are ‘very effective’ in anti-smoking campaigns” but failing to qualify that the publication was not analyzing cigarette labels. The campaigns Biener had cited were television and mass media ad campaigns, which interestingly were said to be eclipsed in effectiveness by personal stories with strong emotional arousal as opposed to the strong negative arousal found in ads with graphic and disturbing imagery. (7)
The latest news from the British and Canadian smoking campaigns are mixed, with Canada recently halting a move to expand upon the original idea with larger images in favor of concentrating on efforts to reduce levels of contraband cigarettes. (8) The move will leave citizens wondering how much of the influence to stop the program from proceeding forward is attributable to the three major tobacco companies with a significant financial stake in the game.
Recent changes in Russia have led to an attempted crack down on smoking by the Ministry of Health and Social Development in that country. New regulations require thirty percent of the front of packages to be covered by a warning label. Few details were available as to the variations in labels since the announcement was made this summer 2010. According to the World Health Organization, sixty percent of Russian men smoke and the numbers have been rising steadily since the collapse of the Soviet Union in 1991, particularly among young women. Russia, however, is still far behind the west in smoking prevention and control, largely due to the affordability of cigarettes in that country. The current price ranges just above one US dollar and previous attempts to raise excise taxes significantly enough to double the price of cigarettes were unsuccessful. (9)
The end result of the US legislation leaves the public with more of a brief novel interest in the new graphic images rather than substantial motivation to change their behaviors, particularly after the novelty wears off. (10) This attempt to produce action can end up generating more harm than good for the public as it provides an illusion of choice without properly informing the cigarette consumer of all their options. My biggest concern personally is the validation it may provide for a company like Phillip Morris given that they support such “lame duck” attempts at improving health. (2)
Failure to Consider the Public’s Reaction to Authority
The clear flaw of not considering the evidence given by the Social Reactance Theory, which explains the relationship between subordinates and authority, in this case the individual cigarette consumer and the Food and Drug Administration, prevents the effectiveness of the limited positive aspects found in the bill. The legislation makes special note to prevent the cigarette companies from referencing the FDA or placing a statement that might be construed as endorsement by the FDA, such as “in compliance with FDA regulations.” Regardless of which U.S. regulatory agency is producing the requirements for cigarette labels sold within U.S. borders, consumers of cigarettes will inevitably look at the warning as an infringement upon freedom originated by an authoritative body. The most significant potential downfall of the failure to properly recognize the social reactance theory in this particular campaign is the effect on how cigarette companies will be viewed by consumers. If the negative connotations of authority are passed even further from the producers of the deadly tobacco products to the very public health organizations that are hired by taxpayers to reduce tobacco consumption and save lives in the future, the opposite of the intended result will occur. Tobacco producers will become more powerful as blame is shifted from them to lawmakers who seek to take away freedoms in a country that was based on the very ideals of life, liberty, and the pursuit of happiness with the catalyst of freedom. It is no mystery then, as to why Phillip Morris, the makers of a symbol of freedom in cigarette choices, Marlboro brand, was a significant player in construction of the legislation and continues to claim full support and cooperation for the bill. (2)
The original intention of the legislation as indicated by the Obama administration was to assist in the reduction of smoking among adolescents and the prevention of smoking especially as it relates to the family unit. In a publication by James Sargent in the journal Preventive Medicine, evidence was found to indicate that receptivity to a cigarette promotional item was a significant player in whether a teen was more likely to become a smoker. (11) The study pointed to the fact that a reduction in cigarette promotional items would be a positive step towards the reduction of teen smoking as it is a symbol of rebellion that a susceptible teen would seek out or hold onto if available to them. My assessment of this paper led me to conclude that a cigarette label with graphic images, which is at the same time an item the teen should not be allowed to purchase given the age restrictions, would be somewhat of a trophy or bragging piece. I would also argue that an undesirable cigarette label in the hands of an adult may more frequently be improperly discarded earlier to relieve embarrassment, which would further increase availability to a teen as refuse.
As stated above, the government’s avoidance to confront the issues of rebellion and psychological reactance stems from the narrow scope used in the creation of the current intervention using the outdated health belief model. I can creatively produce an argument to validate the need for not only recognizing the impact of the campaign on teens and smokers, but also evidence how the social reactance literature gives several options to public health experts that may be combined with other techniques to successfully convince the public that they have the freedom to reject cigarette smoking as a habit. This tactic should be utilized to not only reduce the appearance of authority on the part of the public health departments but to return the natural rebellion in the direction of the true restrictions placed on cigarette consumers by the tobacco producers via the nicotine content inside the packages.

Proposed Revision to the Usage of the Health Belief Model
As generalized in my initial critique of the health belief model, I see the use of negative graphic imagery on cigarette labels as counterproductive to the goal of smoking cessation as evidenced by failed attempts in the past and publications such as the Balbach article arguing that the health belief model can actually help the tobacco industry. (2) This is further supported by the general interest Phillip Morris has shown in promoting this legislation. One could surmise that a profit-seeking manufacturer would not reasonably choose to promote any program that it had reason to believe would significantly impact its ability to sell its product and grow value for the shareholders.
A significant change that would vastly improve the labeling campaign currently proposed would be to reverse the general trend or theme in each warning. Providing information to consumers is potentially productive but that is not easy to do when the message carries with it such gloom and doom. I propose utilizing more positive messages with informative and useful tips on successful smoking cessation. Some examples would include changing the previous message of “WARNING: Cigarettes are addictive” to say “DID YOU KNOW: The addiction to nicotine in cigarettes can be overcome.” Though more impactful with the image of a happy sleeping baby, I would change the message of “smoke harming children/during pregnancy” to a more positive “SIGNIFICANT BENEFITS to children’s clean lungs are found in FRESH AIR.”
This idea can be replicated in each scenario to produce images with corresponding positive messages about enjoying life free of lung cancer, stroke and heart disease with the help of the FDA offered smoking cessation programs. Tactful inclusion of information about risks associated with tobacco consumption could be included so long as it does not shut the reader off with a message that is easier to avoid than to confront with the help and support of family members and the caring community.
Substitution of the “Cue to Action” With a “Catastrophic Jolt”
My critique of the designated usage of graphic imagery on cigarette labels focused on the tendency of a startling new sight, sound, or smell to increase adrenaline and provide a human response decreases significantly over time. A scary movie as viewed in a cinema is remembered or reflected upon as exciting and either disturbing or enjoyable based on the fact that it was usually only seen once or a handful of times at most. The most dramatic effect of a graphic image would be experienced by an individual the very first time he or she saw the label. As time goes on, the shock factor wanes and the imagery begins to blend in with the surroundings.
The publications of both L.C. Larabie and Robert West, in separate findings, indicate that a majority of successful smoking cessation attempts were as a result of an unplanned quit attempt. (12,13) The catalyst for the attempt may come in many forms, but the important fact is that success can be induced by a surprising or unexpected “cue to action.” The work on the “catastrophic” pathways that West attributed to success might also be found with the use of a cigarette label. My argument would be that, rather than a graphic image and warning on each and every cigarette label produced, a more infrequent “catastrophic” label should be put into the production mix to make the experience more unique and memorable. Additionally, the rarity of the event could invite a greater presentation of information such as a statistic consistent with the currently designed labels. If only one out of every 500 cigarette packs contain a warning related to the statistical probability of needing a tracheotomy before age 65, and that same statistical occurrence applies in the population of smokers (1 in 500) it would provide the consumer with a “catastrophic jolt” to take action to preserve their health and lifespan by calling the cessation information provided therein.
Consideration of and Potential Advantages of the Social Reactance Theory
As discussed significantly in the above sections, adherence to the effects of the social reactance theory should be combined with the use of other available public health models in order to generate a greater impact. I strongly suggest the enhancement of my “catastrophic” label proposed above by downplaying the novelty of the labeling on all other cigarette labels. Based on the published effect of cigarette promotional items in the article by James Sargent, the reduction in attractiveness of labels to prevent grabbing the attention of a child would counter the problem of social reactance and resulting value to an adolescent discussed in my critique of the public’s reaction to authority. (11) The teens interest would be mitigated if the majority of labels available to him or her were uninteresting. The significant benefit of this decision would further enhance the “jolt” felt when a consumer becomes accustomed to very plain or boring cigarette labels, only to find an exception to the rule in the form of a message that he or she is more likely to pay attention to. (14) The effectiveness of the message will be improved while making the burden on the individual’s freedom feel less overwhelming.
Though I have clearly provided three articulate reasons why the current 2009 Act is flawed with shortcomings, there are always ways to more creatively improve upon mass media campaigns in order to reach a target audience more effectively. Each of my counter-proposals contain room for improvement and public health officials must constantly be working to add value to their interventions and reconsider their approaches to achieve the desired expectations set forth in the project’s development.
1. Reuters. US judge upholds most limits on tobacco marketing. New York: Reuters. http://www.reuters.com/article/idUSN0510760820100105
2. Balbach, ED. How the health belief model helps the tobacco industry: individuals, choice, and "information". Tob Control. 2006 Dec;15 Suppl 4:iv37-43.
3. Rosenstock, Irwin. Historical origins of the Health Belief Model. Health Education Monographs, 2(4) Winter 1974. 328-335.
4. Weinstein, Neil. Unrealistic Optimism About Future Life Events. Journal of
Personality and Social Psychology. 39(5) 1980. 806-820.
5. Ayanian, J., Cleary, P. Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers. JAMA. 281(11) Mar. 1999. 1019-1021.
6. Leatherdale, S.T., McDonald, P.W., Cameron, R., et al., 2005. A multilevel analysis examining the relationship of social influences for smoking and smoking onset. Am. J. Health Behav. 29 (6), 520–530.
7. Biener, L. Effects of Different Types of Antismoking Ads on Reducing Disparities in smoking Cessation Among Socioeconomic Subgroups. Am J Public Health. 2009 December ; 99(12): 2217–2223.
8. Reuters. U.S. unveils graphic tobacco warnings. New York/Washington DC: Reuters. http://www.reuters.com/article/idUSTRE6A937020101110
9. Reuters. Russia adopts “smoking kills” cigarette warnings. Moscow, Russia: Reuters. http://www.reuters.com/article/idUSTRE65P1E720100626
10. Financial Times. Graphic images to help US smokers quit. Washington DC: FT.com. http://www.ft.com/cms/s/0/6294c828-ecf9-11df-9912-00144feab49a.html
11. Sargent, J.D., Dalton, M., Beach, M., et al., 2000. Effect of cigarette promotions on smoking uptake among adolescents. Prev. Med. 30 (4), 320–327.
12. West, Robert. Catastrophic Pathways to Smoking Cessation: Findings
from National Survey. BMJ. 332 Feb. 2006.
13. Larabie, LC. To What Extent do Smokers Plan Quit Attempts. Tob Control. 14, 2005. 425-28.
14. Reuters. Britain considers plain packaging for cigarettes. London, UK: Reuters. http://uk.reuters.com/article/idUKTRE6AT43Z20101130

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