We Scare because We Care- Using the Protection Motivation Theory to Empower Smokers to Make the Right Choice- Alayna Tress
Developing suitable interventions for smoking cessation is a great feat. Chemical, psychological, behavioral, and economic factors all play roles in forming a proper, effective intervention. Another challenge to tailoring interventions that are the most successful in helping people quit smoking is each individual person trying to quit has different levels of addiction and different personal perceptions of why and how they should quit, along with all of the various interventions they have knowledge of. Many anti smoking and smoking cessation campaigns try to use fear tactics to persuade the smoker to change their current smoking status. Focusing on three popular interventions, placing disturbing images in cigarette packs, the promotion of pharmacotherapy for smoking cessation, and anti smoking advertisements that highlight the risk and number of deaths from smoking, all do not encompass the proper methods to use fear tactics in persuasive, meaningful manner that leads to change in behavior.
The critiques of such public health interventions that use fear to promote a change in behavior will be evaluated in the framework of Protection Motivation Theory. This behavior theory outlines how people perceive and process different fear tactics based on the following four criteria; the perceived severity of an event, the perceived susceptibility of an event, the efficacy of the recommended behavioral change, and the perceived self efficacy (1). This framework was not chosen under the assumption that if an intervention employed all four factors that it is effective and flawless, but that if policy makers choose to use an intervention using fear tactics, it should encompass some of these factors to maximize effectiveness.
Always Keep in Mind What the Audience May Think
Beginning in 2012, the FDA will place graphic images on packs of cigarettes to deter potential and current smokers from smoking using the idea that if they see what smoking can do to them, they will refrain from smoking. Canada currently uses such images on their cigarette packs and reports 20% of smokers have smoked less because of these labels (2). As discussed in class and in numerous journal articles, one of the problems of inducing fear in order to change a health behavior is that “those who are at risk may act defensively to fear arousing information”(3). Inducing fear may also cause the recipient to completely reject the values of the message (3.) . Posting such images on cigarette packs also employs an incorrect assumption made by the Theory of Reasoned Action, that people will make well thought out decisions about how they should change that behavior, according to Dr. Siegel (Traditional Models of Individual Behavior Change: Are they Helping or Constraining Us?, September 30, 2010, Boston University School of Public Health). When policy makers choose to place graphic images on cigarette packs intended to induce fear, they failed to think about how smokers may act defensively against such images, therefore lessening the impact of the reduction in smoking that policy makers intended (4).
Posting graphic pictures on cigarette packs also fails to establish a proper connection between the smoker and potential health risks and outcomes the smoker is facing. When employing fear-inducing interventions, also including some sort of self-affirmation for the recipient can promote less defensive responses (4). If a smoker is not aware of their worth (the good qualities they possess as a human being), they may not see the need to change their behavior and therefore the graphic image may not have an impact on them. If a recipient does not have self-affirmation, they most likely will be more close-minded to the message (4).
Using graphic images on cigarette packs, for example an image of a tracheotomy, assumes that recipients understand the severity of this health outcome. Understanding the severity of a health outcome when inducing fear is crucial in order to make the message meaningful (5) and also part of Protection Motivation Theory. Viewers of such photos may think that a tracheotomy is a temporary ailment. Viewers may also wrongfully assume that the risk of needing to get a tracheotomy or other adverse health outcomes displayed in the images is very low, also making the message less powerful.
Another aspect of the Protection Motivation Theory that using graphic images on cigarettes fails to address is the efficacy of the recommendation. It may be clear to the viewer that smoking is dangerous to their health, but displaying the graphic image does not demonstrate that quitting smoking can reduce adverse health effects, or the chance and the extent that adverse health effects can be reduced. If someone has been smoking for decades and sees a picture of an oral tumor on their cigarette pack, they may figure they already missed their opportunity to reduce their risks of getting oral cancer since they have been smoking for so long.
Even if someone understands the efficacy of the recommendation to stop smoking to reduce or reverse adverse health effects, they may not have the self confidence that they can stop smoking. Self-efficacy is another aspect of the Protection Motivation Theory that should be present in delivering interventions as it allows the person to believe that they are capable of making the behavioral change (6). Showing a graphic image may indeed invoke fear, but could also make the viewer feel powerless, as they may have no idea how to begin to think about how they should quit. To reap the benefits of being smoke free, viewers of the graphic pictures need to initially have confidence that they can stop smoking.
Tailor to Your Needs
Healthcare professionals and patients alike are attracted to pharmaceutical therapies for smoking cessation. Hearing your doctor mention a pill you can take to stop smoking, or seeing an advertisement on TV about a prescription that will curb your cravings can be persuading to current smokers who wish to quit, but find the mere thought of attempting to quit daunting. The US Department of Health and Human Services recommends that no person who smokes more than ten cigarettes per day should attempt to quit without the use of pharmacotherapy (7). This statement demonstrates how many healthcare professionals view quitting smoking must be done conventionally with medication and/or some of the standardized support guidelines. It does not take into account what may work best for some of those people who meet the greater than ten cigarettes per day criterion, and that patients may have different levels of self efficacy and believes of efficacy of pharmacotherapies.
Doctors may be attracted to using pharmacotherapies as a vast body of evidence-based data is available comparing and contrasting the various medications available. From a doctor’s point of view, opting to offer a patient a pharmacotherapy may seem more promising that other behavioral therapies as the doctor may be more comfortable with researching pharmacotherapies instead of behavioral therapies as pharamcotherpies are closer in nature to his medical background. If a doctor chooses to advise a patient based on such evidence based findings, the patient may not clearly understand the efficacy of the findings. If a patient does not fully understand the efficacy of the findings, this may be a missed opportunity for the patient to feel self confident that the results of success in smoking cessation from such pharmacotherapies can be achieved.
An article (8) in the American Journal of Medicine outlines the different efficacies, risks, and success rates of different pharmacotherapies that would make it very easy to a prescriber to use on a patient who wished to quit smoking. Many similar articles exist, along with endless literature from pharmaceutical companies for doctors to make prescribing decisions and explain their reasoning to patients. Much of this literature does not outline how patients can stay smoke free using the given pharmacotherapy, or how counseling or the prospect of quitting cold turkey can be employed. If a patient does not receive information on coping mechanisms (besides taking the drug) to stay smoke free, such as stress relieving techniques or behavioral therapy, in the context of Protection Motivation Theory, the patient may not feel as confident as possible to begin the quitting process, or to remain successful during the quitting process.
The home page of the Chantix website, a commonly prescribed smoking cessation medication displays in a large font that 44% of Chantix users remained abstinent of smoking compared to only 18% on placebo, along with a moving slide show of user testimonials. Similar aspects of advertising around found in brochures and television advertisements for the drug. Displaying the different rates of abstinence and user testimonials do not allow the viewer to see how such information is relatable to them in order to start a quit attempt. Once again, lack of self confidence may be a factor if the viewer of the advertisements deems the people in the testimonials as “better off” causing the viewer to lack self efficacy if he/she thinks the other people had more will power to quit.
Pharmacotherapy combined with counseling and proper advice from the physician can be beneficial and yield higher smoking cessation successes than counseling alone (9). However incorporating information about various pharmacotherapies and how they are applicable to each patient on a personal level would increase the effectiveness of pharmacotherapies.
Another “fear” tactic that is common in print ads and commercials to get people to stop smoking is to give statistics about how smoking kills “this many more people per year than X”. Numbers on how many people die in one year from smoking, or how many people will die next year from smoking are also popular. A Truth campaign television ad displayed a pile of body bags equal to the amount of people that die from smoking each year around a tobacco company’s headquarters. These fear tactics ignore many of the principles of the Protection Motivation theory.
If an adolescent who smokes or potentially wants to try smoking sees such advertisements proclaiming the amount of deaths per year from smoking, most likely they will view the risk of this happening to them as very low, thus the ad does not demonstrate a strong susceptibility of the threatening event (death). Adolescents may figure because of their young age, that they are not at high risk as dying from smoking if they assume they won’t smoke their entire life. In the framework of the Protection Motivation Model, if the severity of the occurrence is low, then the message trying to change the health behavior will be weak.
When someone is bombarded with all kinds of anti smoking advertisements that specifically outline the amount of deaths per year from smoking, one can’t help to be jaded of such advertisements and the message they are trying to portray, especially if the advertisements all reiterate the same, concrete, message; in this case, the number of deaths from smoking. Adding a graphic image can help with the public being desensitized to such messages (10), however deciding on an image that is graphic enough to overcome the intrigue of the advertisements may not be deemed graphic to everyone in the audience. Targeting the messages and images of such advertisements that wish to outline the risk and magnitude of death resulting from smoking is not currently being done in the framework of properly using fear tactics via the Protection Motivation theory.
Recognize Your Strengths
Based on the three previous flawed interventions, an approach that I would like to augment and use is using the graphic images on the packs of cigarettes. However I would start a new campaign that would include a different set of information for each picture to maximize the appeals of the Protection Motivation Theory in order to give the viewer of the pack the most optimal tools to change their unhealthy behavior.
One of the key components needed for the Protection Motivation Theory to work is some sort of self-affirmation possessed by the recipient. Beside the graphic image is where I would place new facts and information (that will later be discussed in this paper). I could use some sort of self affirming headline such as “If you’re smart enough to read this package, then…”, as I would be communicating to the consumer that if they are thoughtful enough to stop and read the package, they may have the diligence to further put thought into their health choices. Some other self affirmation headlines that could be used could be targeted to different potential cigarette buyers such as those who are employed “If you’re a hard worker with a respectable job”, or buyers that are married or have children: “If you’re someone who deeply loves their spouse”, “If you’re someone that loves and cares for their children”. The benefits of self-affirmation previously described in this review (4) would help ensure that the self-efficacy criterion is filled for the Protection Motivation Theory to have a strong effect.
Recognize What’s At Stake
The graphic pictures on the cigarette packs should be accompanied by a small blurb or set of bullet points about the health outcome the picture is portraying that would focus on the severity of the health outcome. As with our tracheotomy example, bullet points could outline that a tracheotomy is permanent and the patient will need it for the rest of their life. Bullet points could also outline that tracheotomies are needed for when one someone’s mouth and nose cannot properly function anymore, resulting from complications of smoking. The tracheotomy picture would be a good picture to be paired with the “If you’re smart enough to read this…” headline as it is focusing on the perceived severity of the individual smoker.
Not only addressing the perceived severity to the smoker’s health could be done, but also addressing the perceived severity to the smoker’s significant other and children. A graphic image of man or woman who looks gravely ill (perhaps a pale cancer patient who lost their hair) could be placed with the spouse headline previously mentioned and include some bullet points about how second hand smoke can greatly put those who you love at risk for adverse health outcomes. Another idea would be a picture of a sick looking person being fed by a loved one with some facts about how if smoking debilitates you enough, your spouse will be forced to take care of you in a way that will most likely threaten your dignity. This threat to dignity could also help emphasize the severity of health outcomes from smoking.
Addressing the perceived severity to the smoker’s children could be done in a similar fashion of addressing the smoker’s spouse/ significant other. A common picture that the FDA is proposing to use on cigarette packs is a picture of a baby with cigarette smoke in the baby’s face. This picture could be paired with the “children” tagline and have some bullet points about the risks of second harm smoke on children and the increased chance that children of smokers will smoke when they come older (11). A similar approach could be done with a picture of a baby in utero with smoke in the face of the baby or surrounding the uterus. Bullet points could outline the risk and severity of smoking while pregnant. Bullet points could also outline the risks of smoking decreasing fertility in both men and women with a “If you want to start a family…” tagline. Describing the severity of a disease with the graphic image may instill fear on the recipient but will hopefully make it clear to the viewer that the perceived risks are severe enough to alter smoking behavior or at least the thought process the viewer uses regarding smoking.
Recognize Benefits are Tangible
Incorporating the treatment efficacy and self-efficacy components of the Protection Motivation Theory will pose a great challenge to overcome on a package of cigarettes with not that much room. To make the most direct message that addresses the efficacy of quitting smoking, statements to help promote such efficacy should be related to the graphic picture. For example, if there is a picture of a tracheotomy patient, a bullet point could outline how risks for oral cancer decline if one stops smoking, or the low risks of oral cancer if one does not smoke at all. Seeing this number may be powerful to the viewer as it shows them that they still have a second chance if they choose to make better health decisions.
Highlighting the efficacy of quitting smoking can also be paired with the images of a spouse. These highlights could emphasize health benefits like the reduction in risks that once were present from second hand smoke if the current smoker stops smoking. Other benefits like how it might be more pleasant for their spouse/ significant other to hug and kiss them, as they won’t smell like smoke. Similarly, if the cigarette pack had a picture of a baby or a baby in utero, statements about the reduced risks from quitting smoking could be outlined in regards to current parents and expecting parents. By outlining statements of efficacy that are directly related to the picture on the pack, this will hopefully provide a clear, believable message to the viewer that quitting smoking is indeed efficacious to reducing and reversing health risks. Incorporating this with our self-affirming headline, and a clear outline of the severity of risks is putting the viewer on the right track to processing fear in a way that will cause them to make a health behavior change in context of the Protection Motivation Theory.
Recognize You Are or will be Strong Enough
An even greater challenge than clearly outlining the efficacy of smoking cessation is outlining the fact that the viewer has the will power to stop smoking. For my intervention, I feel the best way to do this is to pinpoint statements that would increase self efficacy of the viewer in relation to the specific photo on the pack along with the specific tagline. For the “If you’re a hard worker…” tagline, statements about finding a support group at work to stop smoking could help increase self efficacy. Some social benefits to increase self-efficacy could also be used, like saying that the viewer has the choice and power to not be known as “the smoker” at work.
Self- efficacy for people with families may be easier to portray. Using statements about using their family for support in quitting could be employed that could remind the viewer that if they take the challenge to quit, they will have people there to help them. Facts could be presented like “X amount of parents quit smoking for their children per year, you can too”. I would choose to use information that is both encouraging and targets a specific audience in relation to the picture. My goal from such statements would be to ensure that the viewer feels like they have some sort of power in choosing to quit smoking, while being immediately reminded of how it can benefit their own personal life, and the lives of their loved ones. Another idea to raise self-efficacy in regards to smoking cessation is by presenting the viewer with the option to quit. Current smokers should be presented with an option to quit when they think they will be ready. Instead of telling smokers to quit because of XYZ, perhaps smokers could be advised to quit when the proper opportunity arises, such as “if you run out of cigarettes during a thunder storm, try to quit”. (12). The presentation of such option may increase self- efficacy as it reminds the viewer that they are in control, and if they decide to quit when they are ready, they may have more success as opposed to quitting when they are not ready for the challenge. Self efficacy is not only an important criterion of the Protection Motivation Theory, but should be present when trying to change health behaviors as it can help remind the person they are motivated and capable of changing their life.
Another component of the Protection Motivation Theory that previous interventions failed to address was perceived susceptibility. Already by some of the changes I’ve proposed such as pairing the images with specific facts of the health outcome/ health status in the image, we have addressed susceptibility. Our tracheotomy example would be paired with bullet points about how it is a permanent health status (severity) along with the risks of oral cancer leading to a tracheotomy (this somewhat addresses susceptibility). The cigarette packs with the significant other and family themes could also outline the chance of such defects. For outlining the risk of death, I still feel that it would be hard to convey susceptibility of this to smokers, especially adolescent smokers. I would put it sparingly on cigarette packs, but only in relation to the theme of the pack. For example, I would list a stillborn risk on some of the in utero picture packs, and some general cigarette death facts on the other packs. Perhaps for the “hard worker” pack, I could outline on average how many years of life are lost from smoking and how these years could have been spent enjoying retirement.
My other two flawed interventions, the advertisements of pharamcotherapies and print advertisements that specifically outline death rates, could also employ more aspects of the Protection Motivation Theory to create more motivation among audiences to decide to quit. I decided for the sake of this review to focus on cigarette packs as they provided a straight forward media to incorporate the aspects of the Protection Motivation Theory, although such aspects could also be incorporated in the literature/ advertisements about smoking cessation pharmacotherapies and other print advertisements.
Public Health professionals, health care providers policy makers, and patients alike all face challenges developing strategies to change health behaviors for the better. Finding a way to make such changes in a realistic, effective way is a constant learning process. Increased social- behavioral studies on what works and what doesn’t work shows to be one of the key ways that the realm of public health can work towards helping people make better health choices. Using the Protection Motivation Theory, along with other social-behavioral theories provides guiding framework. Instilling fear in audiences to get them to stop smoking may not be the absolute, best proven method, but if done right can yield some positive behavioral changes.
1. Orbell S, Lidierth P, Henderson CJ, et al. Social–cognitive beliefs, alcohol, and tobacco use: A prospective community study of change following a ban on smoking in public places. Health Psychology. 2009;28(6):753-761.
2. Hammond, D., Fong, G. T., McDonald, P. W., Cameron, R., & Brown K. S. (2004). Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Pub- lic Health, 94, 1442–1445
3. Croyle, R. T., Sun, Y. C., & Louie, D. H. (1993). Psychological minimi- zation of cholesterol test results: Moderators of appraisal in college students and community residents. Health Psychology, 12, 503–507
4. Harris PR, Mayle K, Mabbott L, Napper L. Self-affirmation reduces smokers' defensiveness to graphic on-pack cigarette warning labels. Health Psychology. 2007;26(4):437-446.
5. Bandura A. Social Learning Theory. Englewood Cliffs, N.J.: Prentice Hall, 1977
6. Kees J, Burton S, Andrews JC, Kozup J. Understanding How Graphic Pictorial Warnings Work on Cigarette Packaging. Journal of Public Policy & Marketing. 2010;29(2):265-276.
7. Nides M. Update on Pharmacologic Options for Smoking Cessation Treatment. The American Journal of Medicine. 2008;121(4, Supplement 1):S20-S31
8. Hays JT, Ebbert JO, Sood A. Efficacy and Safety of Varenicline for Smoking Cessation. The American Journal of Medicine. 2008;121(4, Supplement 1):S32-S42.
9. Black III JH. Evidence base and strategies for successful smoking cessation. Journal of Vascular Surgery. 2010;51(6):1529-1537.
10. Devlin E, Eadie D, Stead M, Evans K. Comparative study of young people's response to anti-smoking messages. International Journal of Advertising. 2007;26(1):99-128.
11.Green, G., Macintyre, S West, P. and Ecob, R. (1991), Like parent like child? Associations between drinking and smoking behaviour of parents and their children. British Journal of Addiction, 86: 745–758. doi: 10.1111/j.1360-0443.1991.tb03100.x
12. Larabie LC. To what extent do smokers plan quit attempts? Tobacco Control. 2005;14(6):425 -428.