Reasons behind the Failure of the New York City Soda Tax Campaign – Joy Chinazom Anyanwu

Increasing rates of obesity in the United States and efforts to stem the ‘epidemic’ has become a buzz word. Everyone from politicians to public health professions is pushing people to become more physically active and to eat more nutritious foods. In the past few years, there has been a lot of talk especially with policy makers about a tax on sugar-sweetened beverages (ssb’s) to generate revenue, to reduce consumption of unhealthy beverages and ultimately to put a dent on the rising rates of obesity (14). Obesity is defined as having a bmi greater than 30 and overweight is having a bmi between 25 and 29.9 (19). In the case of New York city, sugar sweetened beverages are defined as those containing more than 10 calories per 8 ounces except fruit juices without added sugar, milk products and milk substitutes (20). However, the big debates surround the taxation of soda, where oftentimes, diet sodas are excluded from the category of sugar sweetened beverages.
Such taxation proposals have been backed up by the huge success of tobacco excise taxes in reducing tobacco consumption (23, 27). Although the scientific data is largely inconclusive, some studies have found that soda consumption may be price sensitive where a 10 percent increase in price could lead to about an 8 percent decrease in consumption (2). Other studies have found that consumer demand for soda is mildly price inelastic, meaning that price changes may not lead to significant changes in consumption (3). In the public sphere, the argument has been that once price increases, people will reduce their soda consumption and switch to something like 100% fruit juice, milk or water, which would help people lose weight (6). This is known as cross-price elasticity of demand (2). However, there is very little scientific information to support this. Additionally, there is currently little to no empirical research demonstrating that an increase in the price of soda as reflected by a soda tax will translate into reduced weight. Although the scientific data delineating the health benefits of such a tax is very unclear, the amount of revenue that states can generate from a soda tax is quite clear especially at this time when many state budgets are faced with huge deficits and the possibility of more budget cuts in the future. For New York City, it is estimated that the tax would raise $465 million in 2010-11 and $1 billion in 2011-12 (9).
Based on all this information, in February 2010, for the executive budget for 2010-2011, New York’s Governor David Paterson, proposed an excise tax on sugar-sweetened beverages that would increase the price of such products by one cent an ounce or by 17 percent from their current rate (9). This 17 percent increase in price is much higher than that present in other states, where the national tax average is 5.2%. New York City is supported in this large increase from current rates of soda taxation because most researchers have shown that the current national rate of taxation on SSB’s is not enough to make an impact on consumption (3). To gain public approval for this tax, the city of New York launched an advertisement campaign that mainly consisted of a radio ad and a YouTube video (1). The advertisement campaign clearly failed in its goals because by the end of June 2010, legislators had failed to pass this proposal and the public were generally opposed to this tax, calling it a “fat” tax (21). The flaws in the advertisement campaign clearly plays a key role in the failure of this proposal especially when polls conducted in 2008 show that 52% of New Yorkers support a soda tax and 72% support the tax if the revenue is used to support programs that work towards the prevention of obesity in children and adults (6). If there was such strong public support for the tax before the governor’s proposal, then the question of why the Governor’s proposal failed arises.
The failure of the soda tax proposed by Governor Paterson is related to the many flaws in the advertisement campaign which instead of decreasing opposition to the proposal increased reactance, followed the tenets of the Health Belief Model which should not be used with an issue that is as complex as this one, and failed to use many of the techniques associated with successful advertising and marketing.
A principal flaw of the advertisement campaign supporting the soda tax is that it is mainly based on the health belief model. The advertisement by the Alliance for a Healthier New York which supports the tax on sugary beverages begins with a message that states “there is a growing health crisis affecting nearly one third of our children” (1). This message is followed by several health authorities and professionals including nutritionists, a notable pediatrician and a pediatric psychologist amongst others, all with the same message, that obesity and its associated morbidities e.g. diabetes and heart disease, is on the rise in children nationally and locally. This presentation is in accord with the main tenets of the health belief model which are that perceived susceptibility, perceived severity, perceived benefits and perceived barriers, all play a major role in an individual’s intention and ability to change behaviour. This means that for a person to take action about a health condition, they have to believe that they are personally susceptible to it, that the disease will have a severe effect on their lives, that they can take action but that the costs of taking action are not inconvenient, expensive, unpleasant, painful or upsetting (24). In the advert, susceptibility was shown with the use of statistics stating that obesity is the most common health problem seen in young people by pediatricians and that 10 million New Yorkers are dangerously overweight (1). This plethora of statistical information is supposed to show viewers that they and especially, their children are susceptible to being overweight or obese. To show severity, many of the authority figures in the video called the current rate of obesity an epidemic, mentioned that being obese is correlated with an increase in one’s risk of developing diabetes and cancer and the last person, called the issue a life and death matter. If the previous statement had not convinced people of the severity, the hope was possibly that by calling the issue a ‘life and death’ matter, the severity would hit home. The benefits of the soda tax as advocated by the video included the statistic that reducing one’s consumption of soda by 1 can a day could lead to a 60% decrease in the risk of becoming overweight. Other benefits of the tax advocated by the advert were that the tax would help to reduce the consumption of sugar sweetened beverages and so, reduce obesity rates and that the money from the tax would be used to stop health care cuts in the Albany area. No barriers to the tax are mentioned in the advert, apart from the implicit message that it may be difficult to convince legislators to support the soda tax.
While all these ideas sound nice, the use of the health belief problem is very problematic for such a complex issue. Firstly, it focuses mainly on individual decisions without addressing the social and environmental factors that lead to obesity (11). The financial and access difficulties that push parents to buy unhealthy foods is never discussed nor is there any mention as to how a soda tax will deal with such issues. The beverage industry which opposes this task takes advantage of this fact in its counter adverts where it shows community members who have to bring calculators with them to the store. This is a successful attempt to show that finances are limited for those who will be affected by the tax and that adding this tax will increase the financial burden on many families. Another problem with using this model is that the health belief model assumes that health is highly valued by people and that once they have knowledge and cues to action, people are likely to act in a manner that is favourable to their health (25). It ignores the fact that with the current focus on nutritious education by almost everyone, the general public is probably aware that high consumption of soda and other sugar sweetened beverages is unhealthy. This attitude is reminiscent of efforts to educate youth about the dangers of smoking but when youth were surveyed, it was found that a 100% of youth knew about the dangers of smoking (13). The approach advocated by the health belief model also ignores other factors including but not limited to social norms that play a role in an individual’s decision to act in a manner favourable to their health (25). Additionally, such an individual approach can lead to the tendency to blame the victim especially with regards to obesity, where the obese person is seen as not having the willpower or the desire to make healthy choices (18, 10). It also ignores the circumstances in which people live and how this affects their food choices (18). As a result, for some of the audience, the advert may come across as being insensitive to their plight or worse, it may portray the campaign organizers as disconnected from the realities facing the average resident of New York City. Either of these responses to the advert is undesirable and would be associated with not supporting the tax. All of this show that reliance on the health belief model as the basis of the advertising campaign for such a complex topic is one reason for the failure of this campaign.
Another limitation of the advertising portion of this campaign is that it does not follow many of the tenets of advertising theory that make for successful advertisement campaigns. Firstly, this advert mentions a lot of studies and statistical facts. According to advertising theory, providing a lot of statistical information is not very helpful in getting people to support one’s message. A key component of advertising theory is to appeal to the viewers’ emotions using visually appealing images and stories. While this advert contains nice pictures, there is no clear story line to which people can relate or which effectively draws the target’s attention. As advocated by advertising experts like Ogilvy, you cannot bore the consumer into watching your advert (22). Many public health messages are filled with statistics and dire warnings and this is no different. There is therefore no reason why the viewer at home will pay more attention to this advert when there are many other adverts competing for his or her attention.
Additionally, marketing theory posits that some form of formative research is conducted before a campaign is launched (28). This involves testing out ideas for the right promise on the target audience to see what works. As stated by a prominent advertiser, “promise, a large promise is the soul of an advertisement” (22). The right promise cannot be based on guesswork or conjecture but must be based on conducting some research through focus groups, using advertisers connected to your desired demographic or any other research method to learn about the core values of the target audience and to test out ideas on what the audience classifies as the right promise. This kind of research was conducted in Florida’s truth campaign where youth summits were held to find out about the likes and dislikes of youth and to provide feedback on the creative process (13). The only detectable promises in the advert supporting the soda tax is that the money from taxing sugar sweetened beverages will be used to stem “devastating health care cuts in Albany” (1) and that the taxes will reduce obesity rates. Both of these promises are unsuccessful. The first promise of using the money to bolster health care budgets is not specific enough to appeal the needs of viewers. Conversely, opposing advertisements by the beverage industry appeal to the economic security of many viewers. One of their adverts consists of a grocery cart with beverages being added one by one, where the current price of the beverage plus the amount that the tax would add, gives a total price that increases very quickly with the addition of a new beverage into the cart (21). This vivid imagery combats the idea put forth by the governor’s office that the tax would be only pennies (9). This advert also shows that the tax could further tighten viewer’s budgets, which with the economic recession is an issue that resonates with many members of the target audience. The advert supporting the soda tax, mentioned none of this, instead, choosing to focus on the promise that supporting the tax would be beneficial to maintaining good health.
Health while important is not an immediate concern for most people. The advert supporting the tax mentions the consequences of obesity such as diabetes which will likely not occur for years to come and so, can be easily ignored when faced with more pressing priorities such as the ability to feed one’s family on a daily basis. According to Maslow’s hierarchy of needs, long term health is at the top of the pyramid and only becomes an issue after people are able to fulfill lower level needs including safety in terms of security of resources and physiological needs like the need for food and accordingly, the ability to feed one’s children (16). Therefore, the failure of the advertising campaign in support of the tax to connect with New York City residents stems from its inability to take advantage of some of the tenets of advertising theory.
Another key reason for the failure of the soda tax campaign is simply because it proposes that the public support a new tax. By nature, especially in the United States, where individual ability and achievement is often lauded and government is usually seen as an intruder, taxes are often seen as a government imposition and as restricting one’s freedom (15). This is one reason why politicians are often very reluctant to talk about increasing taxes especially during campaign periods because their constituents often react to this threat to their freedom by voting such politicians out of office. In social psychology, this reaction is embodied in the theory of psychological reactance. Reactance is a motivational (and emotional) state that is aimed at restoring the threatened freedom (4). Reactance occurs in response to regulations or impositions that individuals view as threatening their freedom and autonomy (5). The threat of increased taxes is especially pertinent in this case where a soda tax not only generates reactance by virtue of its being a government imposed tax but also because by nature, taxation restricts the individual’s freedom to make autonomous decisions on how to spend his or her money (15). People attempt to reassert their independence by resisting attempts to limit their freedom of decision (4). This can occur through a variety of ways including choosing the opposite behavior than that desired by the source of the threat. This may be part of the reason why the data on the effect of taxation on soda consumption is inconclusive. Reactance can also manifest itself as motivation to reestablish one’s freedom by developing negative attitudes toward taxes and the government in general. It can also result in a decrease in tax morale where other people’s antitax behavior is seen as more acceptable (15). This may be one of the reasons behind the success of counter ads by the beverage industry where the soda tax is criticized as having a bogus health claim behind it and some ads called for the government to stop ‘overspending’ instead of implementing a new tax (21). The strong reactance created by taxation and the inability of the advertising campaign associated with the proponents of the soda tax to reduce this reactance is a key factor in why this tax did not receive much public support.
Lastly, although the idea of taxation has been proposed and used many times, it is ethically wrong and is part of a regressive system where those who feel the effects of the tax are often those from a lower socioeconomic background (6). Accordingly, while taxing sugar sweetened beverages may appear to be a quick and potentially easy way to deal with the obesity epidemic, it is fraught with error as it amounts to taxing foods that the poor can afford without giving them other options. Another flaw is the idea that money from taxation will be used to fund health care projects which have suffered from budget cuts. While this is helpful in the short term, this approach is dangerous and very short sighted. This is because if public health officials hope to reduce consumption of sugar sweetened beverages with this tax, the tax money used to run these health programs will eventually run out if taxation is successful. The result will be that essential health programs will again, be short of funding. So the current emphasis on taxation, while attractive, will ultimately fail to resolve some of the deeper causes of both obesity and the lack of public health funding. Instead of trying to sell or coerce the public into practicing positive health behaviours, public health officials should strive to create an environment where healthy choices are accessible and affordable (17).
A campaign that seriously seeks to reduce the rate of obesity in the population would tackle some of the root causes of obesity. A key reason why many people are obese is that they do not have access to nutritious foods either because of the location of food stores and restaurants, and the availability & access of public transportation to locations where nutritious foods are available (26). A study showed that the BMI of children living below the federal poverty level was about 50 percent more sensitive to fruit and vegetable pricing than was the BMI of higher-income children (31). Also, New York City has 137 fewer supermarkets providing affordable and nutritious foods compared to the national number of supermarkets per capita (32). Even with a growing population, there are one-third less supermarkets in the five boroughs of New York City compared to six years ago (30).
Accordingly, a better proposal would be for the New York department of health or another concerned public health authority to propose that New York City legislators pass a bill dedicating a certain percentage of the state’s budget to subsidizing fruits and vegetables and to increasing the number of supermarkets selling nutritious foods in New York City. This approach was implemented in Philadelphia with a different financing plan and has been successful in not only improving the nutritious content of diets but has also had a positive economic effect, where it has helped revitalize the economy of some inner cities (12). So if we are interested in reducing obesity, especially among the poor, instead of implementing a tax that is regressive and overly burdens the poor, there should be public investment into increasing the number of supermarkets across the board both in low income and high income neighbourhoods. Although this campaign will be multifaceted, the advertising portion of this campaign that seeks to garner public support for this idea would require that it is framed in a positive way that appeals to members of the general public, that uses some of the tenets of advertising theory and that seeks to reduce psychological reactance to this as a government program.
The way in which this proposal is framed is essential to its success. Framing is a conceptual structure that governs the way we think and view the world around us. It is principally about changing perceptions. George Lakoff in his writing on framing delineates three levels of analysis to use when speaking about frames. The first focuses on principles and universal values that we all share such as equality, fairness, justice, protection, reward for work, family, community and many others. The second level deals with the categories into which we classify issues e.g. as an environmental, human rights or moral issues amongst others. The third level deals with programs and policies that deal with problems e.g. housing programs and health care programs (7-8, 34).
While this proposal is on the third level, to garner public support for it, we have to appeal to the core values and principles in level one. The only issue is that though we all have similar core values, we all interpret these things differently. So, a campaign to garner public support for this proposal should focus on the core values of freedom, control and security (28). The message linked to the core value of freedom would be that voting for this proposal is a way to assert freedom from the fast food industry, including the beverage industry. Having access to supermarkets gives people the freedom to choose whether they want to buy available fruits and vegetables or spend their money on unhealthy food. Not voting for this proposal would be to play into the hands of the beverage industry and allow oneself to be easily manipulated by this industry, which provides and supports a disproportionately high number of adverts for fast foods in low income neighbourhoods (37). Supporting this proposal can also be framed as appealing to the core value of control where supporting this proposal gives individuals the ability to have a say in how their government spends public funds. Many of those affected by obesity are those in the lower socio-economic category, who often feel powerless and voiceless, so, such a proposal could be a way for them to make their voices heard.
There is the danger that this proposal can be framed as welfare or as providing for the poor or the socially maligned. This frame may appeal to those who hold the value of empathy and shared responsibility but for most of the population, for whom welfare is often associated with bad government, a campaign based on this argument may be unsuccessful (7-8). This is where the core value of security is important. This component should focus on the fact that increasing the number of supermarkets and therefore businesses will ensure economic security for all New York City residents. In Philadelphia, increasing the number of supermarkets and providing them where there was previously none has been a booster for the economies of those areas of the city (12). This will especially appeal to business owners who may be finding it difficult to make ends meet in the economic recession. If a principal message is that this proposal will help to revitalize the economy and that the government allocation will help businesses to expand, this touches on the core value of economic security that everyone desires. Appealing to these core values while not explicitly mentioning health, still serves the end goal of getting people to reduce consumption of sugar sweetened beverages and other unhealthy foods.
However, regardless of how an issue is framed, there will be people who still will not like the idea of allocating government funds to subsidizing nutritious foods and increasing supermarket access and who think the available money should be used in different ways or who fear that such a proposal will lead to cuts in other public services. For such individuals, a key way to reduce reactance and to increase compliance is with the use of interpersonal similarity (29). Similarity works to increase the persuasive force by increasing liking and decreases reactance by making the message seem less threatening. This technique was used effectively by the beverage industry who “recruited over 10,000 citizens and 158 businesses to join New Yorkers Against Unfair Taxes” (21). This group was by no means homogeneous and likely represented people from all walks of life who participated in anti-tax rallies and were showcased in advertisements against the tax. For this proposal, a similar approach should be taken where people from all walks of life are showcased at public events in support of the proposal and are used in advertisements. Using people from all walks of life and not just health care professionals for advertisements is good because it increases the likelihood that there will be similarity with the members of the audience. This is also a good strategy because it provides not just one source for the message but a lot of different sources, so that although people may display some reactance to some sources of information e.g. authority figures, they will feel more similar to other sources e.g. people in their own age group, and so, will be more likely to agree with the proposal. So for advertisements gauged towards parents, other parents should be used in advertisements, and for those gauged towards young people, young people and their icons should be used in advertisements. Doing so, not only increases liking but reduces the degree of threat that such a proposal will have an adverse effect on them. Therefore, all aspects of the campaign should work to diffuse opposition to this campaign by taking advantage of interpersonal similarity.
Lastly, the advertising portion for this campaign is very essential for its success in its ability to garner public support. To begin, formative research should be conducted about the voting population and about parents. Formative research is essential in identifying and prioritizing the basic needs, desires and values of the target audience (28). The voting population will ultimately be the population with the political power to push their legislators into supporting this proposal. Parents are a subset of this population who care deeply about the social and health effects of obesity on themselves but especially on their children, so it is important to know about they value. After finding out the needs and values of the target audience, the next step is to find out what promise works for them. As the experienced and successful advertiser, David Ogilvy states, “your most important job is to decide what you are going to say about your product, what benefit you are going to promise” (22). Dr. Johnson, another successfully advertiser states, “promise, a large promise is the soul of an advertisement” (22). After formative research has shown what promise works, then advertisers have to support the promise by convincing the audience that the product, in this case, the proposal, will fulfill their specific needs and desires (28). So, conducting formative research e.g. through the use of focus groups or other methods, will be essential in finding out what the most appealing promise and message of the advertisement is for this portion of the population (22, 28). Without the knowledge gained from such research, any message towards the general population is a stab in the dark and may not lead to a successful advertising campaign.
The manner in which the message of the advertisement is delivered is also important. As discussed earlier, the advertisement campaign in support of the soda tax focuses mainly on providing statistics about the rising obesity epidemic and the dangers of this trend. While statistics definitely have their place, the provision of a large amount of statistical information does not make for very successful advertisements. One reason for this is that as humans, we have a distorted view of probability, where although we may see numerous statistics showing that the obesity epidemic is real and affects a lot of people around us, we often do not believe that either obesity or its side effects will have an effect on us or our families. This attitude is related to two theories. The first is the belief in the law of small numbers where people look at a random sample from the population as being highly representative of the actual population (33). In this case, people may look at the few people they know who consume soda regularly but seem to have little to no ill effects as representative of the effect on the whole population regardless of what statistics show. The second is optimistic bias where as humans we always believe that positive events will happen to us more than it will to others (36). These two laws highlight the fact that although statistics are a useful tool for supporting our claims, they are not necessarily useful as a tool for convincing people that the information in the statistics also applies to them. So, a successful advertisement would be one that may display a statistic to show credibility but that focuses on a story that appeals to the emotions of viewers (22).
However, knowledge of these two laws can be used advantageously in an advert where with the law of small numbers, an advert could depict a family whose neighbourhood stores do not sell fruits and vegetables, and so, the adults in that family are forced to travel far out their neighbourhood to get the food they need. The advert could emphasize the difficulties that having to travel so far presents and show the effects of this lack of access by telling a story of how members of the family became obese and the resulting health issues that arose from this. This advertisement not only appeals to one’s emotions but also takes advantage of the law of small numbers by using the story of one family and telling of their difficulties with finding nutritious foods. A story like this is memorable and can sway viewers’ emotions to support the proposal advocated by the advert.
In conclusion, policy makers and public health practitioners are constantly coming up with possible policy changes and interventions in an attempt to stem the current obesity epidemic in the United States. The contribution of liquid calories to obesity and the need for increased revenue for states facing budget cuts have caused many to call for taxation on soda and other sugar sweetened beverages. In New York City, this proposal failed for many reasons including the fact that the advertisement campaign for this proposal failed to incorporate some of the qualities needed for a successful advertisement campaign, followed the tenets of the health belief model which is ill suited when dealing with such a multi-faceted issue and for the pure reason, that it involved advocating for yet another tax in a political atmosphere that often shies away from advocating for increased taxes, thereby invoking psychological reactance among residents of New York city. A better intervention that is both evidence based and ethical is a proposal calling for the city of New York to allocate a portion of its budget to financing the building of supermarkets offering fresh fruits, vegetables and other nutritious foods to areas of New York that were previously lacking this and to subsidize the prices of fruits and vegetables in the city. This proposal is an indication that policy makers are aware that some decisions including those surrounding food goes beyond individual choice. For this proposal to succeed, it requires that the idea be framed in a manner that appeals to the core values of the target population, that campaign organizers take advantage of the reduction in reactance by using interpersonal similarity and that the advertising campaign take into consideration lessons from previous successful advertising campaigns both from the public health world and from the world of mainstream marketing and advertising. This intervention if successful will not only factor into the reduction of consumption sugar sweetened beverages but more importantly, will reduce obesity rates and encourage healthy eating habits among members of the general population.

 
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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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