Smoking and Teenagers: A Public Health Failure - Bozena Malyszko

Introduction
One out of 5 adults in the US (45 million people) and nearly 1 out of 3 adults in the world (1.3 billion people) are estimated to smoke.(1) Cigarette smoking has been linked to 443,000 deaths in the United States annually (nearly 20% of all deaths) including death caused by heart disease, cancer, chronic lung disease, and vascular disease including stroke.(2) For every person who dies from tobacco related disease, 20 more will suffer at least one serious illness.(3) Smokers die on average 13-14 years sooner than non-smokers.(4) In the US, tobacco smoke accounts for an estimated health cost burden of more than $193 billion annually ($97 billion in lost productivity plus $96 billion in health care expenditures).(1) Cigarette smoking has been linked to at least 10 cancer sites and approximately 30% of all cancer deaths in the United States.(5)
Despite aggressive advertising to protect the American public from harms of smoking, 20.6% of Americans continued to smoke in 2009, down from 20.9% on 2005.(6) The decline in smoking rates has decreased over the past decade. Smoking rates also vary in certain populations. According to the CDC report in August 2010, more men (nearly 24%) than women (about 18%) smoke. Nearly 30% of multiracial adults and 23% of American Indian/Alaska Native adults smoke. Smoking rates are also higher among people with a lower education level. For example, nearly 1 in 2 of all US adults who have a GED smoke; only around 6% of people with a graduate degree smoke. Also alarming is that about 31% of people who live below the poverty level smoke.
Perhaps the most concerning are the statistics regarding teenagers and smoking listed below.(6) In 1997, about 36% of high school students smoked cigarettes. Between 1997–2003, the rates of smoking among high school students dropped from 36% to about 22%. However, from 2003 to 2009, declines slowed from 22% to 20%. The slowing decline in teen cigarette use suggests that smoking and all the health problems related to smoking will continue as teens become adults. In 2009, nearly 1 in 5 high school students (20%) still smoked cigarettes. Monitoring teen smoking is important because most adult smokers (about 80%) began smoking before the age of 18.

Graphic Images of Tobacco Dangers, Help or Hinder?
Much of today’s anti-smoking campaign focuses on blunt descriptions and graphics of the diseases associated with smoking and emphasize that smoking can shorten your life span. Most recently the size of these graphic images was enlarged on cigarette packages to induce a stronger message. A new set of 36 ads was proposed in November 2010.(7) Of these 9 final ones will be chosen. They represent the following 9 warnings: “Cigarettes are addictive.”, “Tobacco smoke can harm your children.”, “Cigarettes cause fatal lung disease.”, “Cigarettes cause cancer.”, “Cigarettes cause stroke and heart disease.”, “Smoking during pregnancy can harm your baby.”, “Smoking can kill you.”, “Cigarettes cause fatal lung disease in nonsmokers.”, and “Quitting smoking now reduces serious risks to your health.”. One of the 9 will be required to appear on the front of all cigarette packages as seen above. The proposed changes are scheduled to occur in October 2012.
There has been much controversy as to whether these warnings are too gruesome, but more importantly there were questions raised to the effectiveness of these warnings. At least 30 other countries already require graphic warnings, including some, like Brazil, that often go even further than the proposed U.S. messages. Canada, which became the first country to require more graphic warnings in 2000, has seen a significant drop in smoking.(8) Other studies do however show that these images actually promote smoking.
Martin Lindstrom, a former ad agency executive and expert on the science of marketing describes a study he conducted on cigarette advertising in his bestseller - Buyology: Truth and Lies About Why We Buy . He found that increasingly vivid anti-smoking warnings actually increase a smoker’s cigarette craving. His possible explanation for this in a concept called Terror Management Theory, which supports the idea that a threat to one’s life increases the need for self-esteem and suggests that a warning label such as “Smoking makes you unattractive.” may be more harmful to one’s self esteem than “Smoking leads to deadly lung cancer.”

Optimistic Bias and Illusion of Control Theories
There are many reasons why the ultra graphic type of anti-smoking campaign does not work, particularly in teenagers. Teenagers often see themselves as indestructible and considering many of the ill effects of smoking do not occur for 20-40 years after a person begins to smoke, they feel that that they will not be affected. This is part of the Optimistic Bias Theory described in a study by Weinstein, which holds particularly true in young adults.(9) A college cohort of 258 college students was interviewed regarding their chances for 42 future events occurring. Overall, they rated their chances of above average for positive events and below average for negative events. In another paper by Kirsch et al. reported that judgments of disease susceptibility correlated with disease severity, mainly that the more serious the illness, the lower people perceived their chances of falling ill.(10)
The Illusion of Control Theory, defined as “expectancy of a personal success probability inappropriately higher than the objective probability would warrant.” by Langer can also be applied to the graphic marketing of cigarettes.(11) Individuals, especially of the younger generation, tend to believe that they have great control over chance events. In the case of cigarette smoking and disease, youth feel both that they can beat the odds and not get the disease and that even if they start smoking, they have control over whether they will get addicted or not. Therefore, the graphic images of the dangers of smoking do not impact young adults heavily as they often feel “It will not happen to me.”

The Health Belief Model
Another reason that the graphic depictions of illness and death are unlikely to work among the younger populations is that the younger generation generally feels healthy and do not feel that smoking is a risk. Even if they have multiple family members who suffer the effects of smoking, their perception is that any negative outcome associated with smoking is too remote for them to truly consider it a threat, and therefore do not feel that not smoking will have any effect on future illness. According to the Health Belief Model (HBM), behavior is an outcome of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self efficacy.(12)
Teenagers who begin to smoke do not perceive themselves as susceptible to the harms of tobacco smoke, nor do they recognize the severity of the illnesses associated with smoking - such as lung and other cancers, largely because it is not people their age who get sick. The only perceived benefits they see with not smoking are that maybe if they feel an internal guilt for smoking, that guilt will go away. The perceived barriers they have to not smoking may be social pressures associated with the coolness of smoking and the increased self esteem they have with smoking. Cues to action may be limited, as the anti-smoking ads do not target them directly and there are few cessation programs set up just for teens. In adults, the main concern with having self efficacy to quit smoking is the physical addiction to nicotine. In teens, they are less addicted as generally they have been smoking much lower amounts and for much less time than their older adult counterparts. For the smoking youth, the lack of self efficacy to not smoke is more a matter of not looking cool around their friends who smoke.
HBM is also considered a value expectancy model suggesting that people will be more likely to participate in healthy behavior if they believe that the outcome is valuable (being healthy) and they feel the behavior is related to the outcome. As stated above, young people do not necessarily feel that smoking provides an immediate threat, therefore, they do not feel that the removal of the non-perceived threat will provide any real benefit for them. They do not feel that not smoking will make them healthier and live longer lives if they do not feel smoking will make them sick and die sooner in the first place.

Psychological Reactance Theory
Perhaps one of the main reasons that it is difficult for the FDA, CDC and the Tobacco Control Act to find effective means to appeal to teenagers and young adults is that as a general rule what is prohibited, is “cool”, regardless of whether it is harmful or not. Parents often struggle with successful communication with teenagers, because of the teens own struggle for independence and self identity. Any suggestion of taking a teenager’s freedom away by not allowing to them certain behaviors, will usually result in an action on their end of reinforcing their sense of self and acting against the prohibition, whether real or perceived. An example of this was seen in a study by Hornik et al., where the effects of a national youth anti-drug media campaign aimed at decreasing marijuana use in youths 12.5 to 18 yrs showed no effect of the campaign in decreasing use over a 5 year period and may have had a statistically significant pro-marijuana effect in some cases. (13) This is the basis of the Psychological Reactance Theory. Smoking ads that state “Do not smoke because it will kill you.” present a perceived threat to a young person’s independence to choose to smoke. The natural reaction is to smoke and show that “I can do what I want and smoking won’t kill me.”
An Alternative Proposition for Promoting Smoking Cessation in Teens
Given the above arguments that graphic smoking ads do not help in decreasing smoking among teenagers and the statistics which show that smoking declines among young people has leveled off, it is necessary to find a useful and effective mechanism to inform young people of the harmful health effects of smoking, and get them to quit smoking or not even start smoking, without the intervention resulting in the opposite action.
A plausible approach would be to use media campaigns that are not so drastic and change the focus from the long term effects of smoking, such as lung cancer, other cancers, emphysema and premature death, to the immediate effects of smoking - including how tobacco smoke alters a person’s appearance or physical condition. This is a similar suggestion to the one made above by Martin Lindstrom above in making an ad stating “Smoking makes you unattractive.” More subtle, but more real messages to teenagers about smoking would be “Smoking makes your teeth yellow.” “No one likes boys who cough.”, “Nobody digs girls who smoke.”, “Smoking doesn’t make you beautiful (sexy, a diva, a stud etc.).”, “Smoking makes you smell bad.”,” Yuck! Yellow fingers.”, “Smoking makes you ugly.”, “Smoking makes you look old.” and “Smoking gives you bad skin.”
Although some of these suggestions seem immature, even childish, they would likely have a stronger impact on today’s youth than an anti-smoking ad showing lung cancer, because they would affect a teenager’s everyday life, not something that may or may not occur in 20-40 years. No young adult wants to think that they are ugly, have yellow teeth, smell bad or have an undesirable physical appearance. A similar approach would be to emphasize the physiological effects that smoking has on a young person’s physical condition. Ads showcasing a smoker vs. a non-smoker in physical competition also affects a young person’s perception of self and self esteem. Advertisements such as: “I can run faster than you.”, “I can bike farther than you.”, “I can swim better than you.”, “I can lift more weights than you.”, “Can’t believe you missed that shot… want a smoke?”, “I caught the train that you missed and got the job that you wanted.” and “Catch me if you can.” may make a young person think twice about lighting up, especially if they have a track meet in the morning. Despite the popular notion that athletes do not smoke or smoke less, many students involved in high school level athletics do smoke at similar levels to non-athletes and for many of them, sports are a confidence booster. This was shown in a study of male high school students, but similar results have been seen in female athletes.(14-15)
Posting these advertisements in locations which are highly visible to teenagers and young adults such as schools, playing fields, gyms, libraries, malls, on public transportation and even on social media websites such as Facebook, would provide continuous and unavoidable exposure that will make a teenager feel inferior for smoking.

Why the Increased Effectiveness of Subtle, Direct Advertisements
We have described why drastic and graphic anti-smoking ads do not work against teenagers using Optimistic Bias and Illusion of Control Theories, the Health Belief Model (HBM), and Psychological Reactance Theory. The reasons why more subtle, direct ads would be more effective under these same theories are reviewed below.
Under Optimistic Bias Theory, even if teenagers feel that they are immune to the health effects of smoking and that the chances that they will suffer from smoking are less than by chance, most young people question their appearance every time they look in the mirror. They question their attractiveness, compared to their peers. They also question how good they are on the sports field and always want to be stronger and better. Therefore, the more subtle ads target what is most vulnerable in teenagers, resulting in a lower likelihood of lighting up that cigarette. Since the negative threat associated with smoking in these ads is more based on physical appearance and condition, teenagers will have less of an optimistic bias, as the threat is not as severe. As described above, the more severe an outcome is, the more of an optimistic bias young people tend to have and the less likely they feel that they will fall victim to it.
Similarly, for the Illusion of Control Theory, young people may believe they are in control of whether they get addicted or get sick, but will feel less in control of whether their appearance is less than what it should be. They may wonder every time they smoke if others are observing them and looking at their teeth or fingers for discoloration or whether their peers think they have bad skin or look old. Making a teenager more self conscious about themselves is usually not a positive effect, but in this case it may prevent the harmful behavior of smoking.
Under HBM, behavior is an outcome of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self efficacy. With the new proposed ads, the perceived susceptibility is greater than with the more graphic ads, as teenagers themselves may notice a skin or teeth discoloration and decreased athletic ability with smoking. The perceived severity is overall less, but in the case of teenagers, a direct hit to their appearance today, may seem more severe than a potential for cancer in the future. The perceived immediate benefits would be that every time they see a poster that states “Smoking makes you ugly.”, they will not wonder if that’s how others view them. The perceived barriers would be the same as above, in that the main obstacles to not smoking would be the social circle whose members smoke and if this is an individual’s main social circle, it may be difficult to walk away or to stand up against them. Cues to action would be a teen consistently seeing the advertisements and finally believing that he or she would be a better person for not smoking. Self efficacy in teenagers is more of a social concern than fighting a physical addiction, but making smoking less popular through these ads, would overall make a teenager feel more empowered to not smoke.
The less extreme ads are also less likely to induce a rebellious response as described by the Psychological Reactance Theory because these ads do have such an authoritative message to them. In the new proposed ads, the feel is more of one’s peers mocking a teenager for smoking and making that person feel like less of a person than the adults or health authorities saying “Do not to smoke because it is bad for you.”

Theory of Reasoned Action/Theory of Planned Behavior
According to the Theory of Reasoned Action (TRA) a person’s behavior intention is based on a person’s attitude towards that behavior, as well as the perception of the subjective norms associated with that behavior.(12) The Theory of Planned Behavior (TPB) was added as a supplement to the TRA in recognition that even if a person has the right attitude towards taking an action, it may be difficult to actually perform the behavior. Regarding the newer, milder anti-smoking ads targeted at teens, the main benefit through the TRA/TPB model would come from changing a teenager’s attitude towards smoking, identifying the subjective norm as not smoking, and having a high level of perceived behavioral control, which in turn would lead to the behavioral intention of not smoking.

Social Expectations and Social Network Theories
Empowering the individual young adult to not smoke largely requires an adjustment or perceived adjustment in social norms as described previously. Although true for all individuals this appears to be more true for teenagers, whose sense of self is largely based on the society around them. They are heavily influenced by their peers. This is described by the Social Expectations Theory.(16) Mass media plays a large role in shaping what is considered normal in society and what is expected by society. By including anti-smoking advertisements in a mass media campaign that affects what is expected of teenagers, not only by the adult society, but by the critical society of their peers, can influence an individual’s behavior in not smoking.
In a related analysis of how society impacts an individual’s decision to act in a positive manner, the Social Network Theory further suggests that many public health interventions aimed at groups of peers and which provide peer support tend to be more successful than ones aimed solely at individuals. According to a study by Christatkis et al., individuals were much more likely to quit if their social network quit as a whole. (17) The study followed a social network of 12, 067 individuals from 1971 to 2003 as part of the Framingham Heart Study. There was an overall decrease in smoking in the population, but the clusters of smokers remained similar over time, suggesting that groups were quitting together. Smoking cessation by a spouse, sibling, friend and co-worker decreased one’s chances of smoking by 67%, 25%, 37% and 34% respectively. Friends with more education tended to influence each other more than friends with less education. Although this is an older population than the teenage population we are targeting, the results and social network theories can be extrapolated. If a friend or team mate in a social circle stops smoking, the likelihood of quitting will be much higher than if the friend or team mate continues to smoke. This can promote a domino effect, if just one person in the social circle decides to quit or not smoke.

Advertising and Public Health Branding
Perhaps the most compelling reason why the new more subtle advertisements would be more successful than the previous more graphic ones, is that overall they promote an image of a better lifestyle. This is the premise of public health branding, which differs from commercial branding, in that rather than promoting a product, it promotes a set of healthy behaviors.(18) Public health branding often encompasses multiple health behaviors as part of a healthy lifestyle choice. The teenage anti-smoking campaign is just one example of promotion of a health behavior. The challenges associated with public health branding include limited funding as compared to commercial products and the difficulty with maintenance of the healthy behaviors, once the message is no longer advertised. With a commercial product it is easier to sell as the advertiser only needs to grab the consumer’s attention for a brief moment to sell the product, whereas in public health, it is the brand of a healthy lifestyle that the advertiser is trying to sell and this requires persistent commitment on the consumer’s end. The more subtle messages of the anti-smoking campaign described above suggest that smoking makes you have yellow teeth, bad skin, or appear old in turn promotes not smoking as making you have a whiter smile, nicer skin and a younger appearance. This, combined with a promise of better athletic performance promotes a healthy lifestyle. If young people are constantly exposed to these images and messages for a period of time, and if they feel and look better when they do not smoke, that in itself should promote longevity of the public health brand.

Conclusion
In recent years, mass media has been one of the main forums for the delivery of anti-smoking messages. However, many of these messages focus on tobacco related health effects that occur decades after beginning to smoke, include lung cancer, mouth and throat cancers, emphysema and heart disease. These images may have some effect in older adults, as they are nearing the age where they will begin to be affected, however for teenagers and young adults the threat of disease decades from now is too remote to have a strong influence on their current smoking habits. America’s youth is more concerned with their physical appearance, and how they are viewed by their peers in society. A proposition for an anti-smoking campaign which targets the vulnerabilities that affect a teen’s everyday life is more likely to be successful in decreasing the desire to light a cigarette, than campaigns aimed at presenting potential future risks. Incorporating the more subtle, yet direct anti-smoking messages into a social network norm would further aid in decreasing smoking rates among teens.

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