Challenging Dogma - Spring 2009

Thursday, May 7, 2009

The Flawed Approach of Teen Anti- Smoking Campaigns-April Violante

Every eight seconds someone dies from tobacco use. Smoking will kill one in five Americans (1). It is the single largest preventable cause of disease and premature death and has implications in heart disease, stroke and chronic lung disease (1). Each year cigarette smoking in the US causes an estimated 443,000 deaths and $193 billion in health care expenditures and productivity losses (2). The 1964 Surgeon’s General report on the deleterious health consequences of smoking played a major impact on public policy and health interventions. Despite declines in smoking prevalence from 1997 to 2007, cigarette smoking continues to increase among teens and cause large numbers of death across all US states (2). Previous public health approaches to prevent teen smoking have utilized media for anti-tobacco commercials that warn young teens of the health dangers and general unattractiveness to the opposite sex. These types of anti- smoking campaigns were failures as evidenced by statistical rises in smoking among teens (3). The problem with many anti-smoking campaigns displayed through media or implemented in school curriculums is the use of the commonly and widely used Health Belief Model (HBM). Using this framework to stop teen smoking is a flawed approach because of three major critiques that will be addressed in this paper. They are as follows 1) The choice of an individual level model 2) The faulty assumptions made by such a model and 3) The model’s implantation of fear in anti-smoking campaigns.

Critique 1: The choice of an individual level model
The HBM has been the oldest of the individual behavioral theories used in public health interventions (4). In this model decisions are made be weighing the perceived benefits of a behavior versus the perceived costs or barriers to performing this behavior (4). Two components that play a key role in this model and affect behavior are the individual’s perceived susceptibility and the perceived severity of the disease (4). All of these components contribute in determining the individual’s intention, which is thought to dictate the individual’s behavior. However, the first underlying critique of this model is that its primary focus is soley on the individual and the decisions of the individual. This model does not take into account social and environmental factors that influence those individual’s decisions. There is no inclusion of the social or environmental context and the way in which both interact with the individual. The model does not place much emphasis on external contexts that could affect the individual’s interpretation of information critical in the decision making process.

Applying an individual level model to prevent teen smoking is unlikely to achieve success. For this model to be effective the teen would have to assess their degree of risk and make a cost-benefit calculation about whether or not to engage in the preventive or health-oriented behavior of smoking cessation (4). This assessment does not include any environmental or social factors critical in influencing how teens perceive smoking. This model is largely ineffective because it is an individual level model and does not take into account the social dynamic of smoking and elements such as peer pressure among teens. Past studies primarily done in young people have documented the impact of social ties on the initiation and cessation of smoking (5). The social network in which the individual is embedded is an important aspect that needs to be accounted for along with other external factors that the HBM does not include. Research on the collective dynamics of smoking in large social networks concluded that network phenomena appears to be relevant in smoking cessation (5). Smoking behavior was observed to spread through close and distant social ties (5). Research showed that groups of interconnected people stop smoking in conjunction while those who smoked became increasingly marginalized socially (5).
The major public health implication from these findings is that a framework for anti-smoking campaigns aimed at teens need to be using a group level model. A group level model would target the social group of teens rather than just the individual teen. This data suggests that the decision to quit smoking is not solely made by an isolated individual, but rather the decision is a reflection of choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation (5). The study also found that the individual appeared to act under collective pressures from within niches in their social network (5). Therefore, it is quite obvious why an individual level model for smoking cessation among teens would be a failure when social ties and collective pressures from their social niche seem to be central to an individual’s decisions on health preventive behaviors. Additionally, this study stated that a change in smoking behavior of more than one contact may be required for a subject to quit and that there might be a threshold where the subject’s probability of smoking cessation depends on cessation by two or more contacts (5). Among teens smoking is a shared behavior and network phenomena is a critical way to spread positive health behaviors. A group level model that targets the social network of teens who smoke will yield more favorable results for group-level smoking cessation opposed to targeting just the individual through a model such as the HBM.

Critique 2: The faulty assumptions of the HBM

The first faulty assumption of using the HBM model for anti-smoking campaigns is that people make rational decisions and that it is simply enough to provide the public with information on why smoking is “bad.” This type of model assumes that everyone has equal access and an equivalent level of information from which rational decisions can be made (4). The problem with using a model like this for promoting anti-smoking amongst teens is that it provides information such as the perceived benefits and consequences of smoking but does not take into account disparities in knowledge that may influence one teen’s decisions but not another’s (4).

The second faulty assumption of using the HBM model is that intention lends itself to behavior. A teenage smoker may weigh the cost versus benefits of smoking and perceived severity of smoking as it relates to them and make the decision to quit. However, intention does not always dictate behavior. A model for anti-smoking campaigns is needed that provides more than information on the individual level to successfully identify with teens that smoke and make them want to quit but also enable them with the resources to do so. The problem with using the HBM model for smoking cessation is that it does not always lead to behavior change and that is why another conceptual framework is needed for successful interventions. This model does not take into account social or environmental barriers that influence the ability of the teenagers to socially and physically stop smoking despite intentions to do so.

An example of how these faulty assumptions of the HBM contribute to
ineffective smoking campaigns can be observed in school curriculums that implement programs such as Smoke Free America. In the Smoke Free America campaign, speaker Patrick Reynolds, the grandson of tobacco founder R.J. Reynolds, gives motivational speeches that advocate against teenage smoking (6). In his appearances Reynolds speaks of his father and eldest brother who died from smoking the family brands of Camel and Winston along with providing information and telling other touching stories of youth who died from tobacco related deaths (6). The faulty assumption of such campaigns are that providing information and giving the dire consequences a face by relaying real life horror stories is enough of a premise for teens to make the rational choice not to smoke. However, this approach is faulty to assume that people will make rational decisions if provided with information and even more flawed to assume that an intention will directly lead to behavior change.

Critique 3: The implantation of fear
A major critique of many of anti-smoking campaigns directed as teens is the use of fear. Many commercials portray the bleak consequences of smoking that will occur almost 50 years into the future. An example of one particularly disturbing commercial used to implement fear in teenage smokers displays an individual with a tracheal tube to the neck because of years of smoking that resulted in emphysema. The problem with these types of commercials is that the message is portraying consequences of the distant future and showing no immediate consequence or negative effects of smoking. This is an ineffective means to target teens not to smoke when this age group still tends to view themselves as invincible and that the chances of this happening to them is minimal. These types of commercials are based off the conceptual framework of the HBM because it is trying to show youth the costs of smoking and severity hoping that this image will cause behavior change in the youth. In the Smoke Free America campaign, the real life accounts given by Reynolds show more immediate consequences of teens that died sooner rather than later from smoking. However rare these accounts seem, they try to scare teens into believing that if you smoke now you will get sick and die. By telling such compelling stories of young teens that die from smoking the campaign implements fear and aims for adolescents to relate to the teens in the story and identify the perceived severity and cost of smoking. This fear-based approach is consistent with the conceptual framework of the HBM by attempting to use the perceived severity and costs to deter teens from smoking.

The use of fear in anti-smoking Public Service Announcements (PSAs) has inconsistent findings concerning effectiveness (7). A study defining the fear-appeals in anti smoking PSAs found that loss of control was perceived as more susceptible and severe than social threats among groups of college students (7). This finding suggests that commercials for anti-smoking campaigns and PSAs should focus on portraying loss of control rather than the tendency to use a fear-based appeal to prevent adolescent smoking.

Overall, the anti-smoking campaigns aimed at teenagers possess three major flaws that inhibit success and contribute to rises in teen smoking. These campaigns tend to use the HBM and assume that providing the information is enough for rational individuals to make a behavior change. Flawed in this conceptual framework is the assumption that an intention to change behavior will dictate behavior change. The HBM used for campaigns in school curriculums and PSAs is a conceptual framework tainted by faulty assumptions. Additionally, the HBM is an individual level model that does not take in account external factors that effect individual decision making. The social and environmental context and the way in which both interact with the individual are not taken into account. This is a major flaw because of the network phenomena of smoking as a shared behavior embedded within the social ties of the group. Campaigns utilizing the HMB are flawed in approach because the target is the individual for behavior change. The campaigns should target the social group because this has the potential to yield more favorable outcomes. The last major flaw in this approach is the use of fear to scare teens into seeing the severity and costs of smoking. The fear tactic is used in an attempt to manipulate teens from participating in the behavior of smoking. However, studies have shown that loss of control is a better indicator of preventing teens from smoking. While campaigns are out there to combat teenage smoking, better approaches are needed for more successful interventions otherwise money would be better spent elsewhere. These existing campaigns have good intentions and positive aspects in structure but need to address the major flaws that will hinder future success and not curve the rise in teenage smoking.

Implanting Social Sciences in Campaigns for Teenage Tobacco Prevention

Public health interventions aimed at smoking prevention in the teen-age population need to take novel approaches including more than a biological perspective but also a shared cultural identity. Current smoking campaigns to prevent teenage smoking can be seen as failures of public health from social science perspectives. The statistical rise in teen-age smoking from 1997 to 2007 has shown that current campaigns are not an effective means to prevent adolescents from smoking (2). According to the Centers for Disease Control and Prevention (CDC), approximately 23 percent of all high school students are regular smokers; each day, 4,000 kids under 18 try their first cigarette and another 1,140 become daily smokers (9).This is an important age group to target because almost 90 percent of adult smokers started before the age of 18 (9). On average smoking in the United States causes a man to lose 13.5 years of life and a woman 14.5 years of life (7). Despite an overall steady decline since the late 1990s smoking prevalence has continued to increase among teenagers. About half of all smokers will die because of their tobacco use, with half of these dying in middle age and losing an average of 22 years of life (8). Novel anti smoking campaigns need to utilize these statistics and the social sciences to incorporate a group level approach that takes into account flaws of the HBM and uses more effective PSAs (public service announcements).

Counter- Approach 1: A Group Level Model
One such campaign that has embraced the social sciences in their approach is The Campaign for Tobacco Free Kids (10). This campaign uses a group level model approach opposed to an individual approach. The campaign does provide information on the deleterious effects of smoking as it applies to the individual and population in statistics, but it also includes federal and state wide initiatives that are based on the group level approach (10.). Another unique feature of this campaign is “Kick Butts Day” which is a series of events supported by teachers, youth leaders and advocates for anti-smoking in adolescents. The implementation of such a campaign component (the kick butt event) encompasses youth and the adults who work closely with them to put a stop to smoking. This targets youth and their social group or social niche and takes into account the social and environmental context of the youth by including friends, peers, and teachers. Other interventions to prevent and stop teenage smoking would be improved by including aspects or components of campaigns that are based on group level models. Research has shown that the social network of the individual is an important aspect that needs to be addressed along with other external factors and an individual level model such as the HBM does not address this (5).

The use of an individual level model such as the HBM is not a problem for The Campaign for Tobacco Free Kids because this intervention targets the group of teens who smoke by taking into account the collective dynamics of smoking in the larger social network. By implementing state wide and federal initiatives and sponsoring events such as kick butts day this campaign is taking advantage of the conclusive research that network phenomena is relevant in smoking cessation and observed to spread through close social ties (5). It also takes advantage of research that has shown that groups of interconnected people stop smoking in conjunction (5). That is why a campaign such as this one is taking a counter approach to traditionally used individual level models such as the HBM that focused more on getting just the individual to stop by providing information on negative long term outcomes. This campaign counters that by providing the information but going farther to target the social group to stop together through national events and government initiatives (10).

Counter- Approach 2: Taking into account the flaws of the HBM

As aforementioned in Paper 3 in the critique of the HBM, this model possesses two major flaws. Those flaws being the faulty assumption that human behavior is rational and that if provided with correct information that humans will make rational decisions and the second flaw assuming that intention for behavior change leads to behavior change. This type of conceptual framework does not take into account social or environmental barriers that prevent smoking cessation among teens. This is not a problem in The Campaign for Tobacco Free Kids because this intervention does not solely rely on the HBM. The intervention does provide facts and statistics about smoking outcomes but it is not tailored to the individual to try to make a teenager weigh their perceived costs, benefits and severity to make an informed decision to quit smoking. Instead, the campaign relies on a group level approach that targets the social group and ties and cultural identity in which the teenager is embedded in a way that is more focused on the social network.
The campaign’s framework and promotion of this movement to quit smoking is encompassing the fact that human behavior is irrational. Human behavior has many facets, it can be learned or from some processes of higher brain function that we as humans do not understand nor can we predict. This campaign is not basing it’s framework on the assumption that humans will make rational decisions based on appropriate information. By adding components to the campaign such as an influential movement and resources for help, activities to join in and ways to stay involved it is acknowledging that human behavior is irrational and that information to quit is simply not enough. A rational person can know the facts and statistics of all the negative consequences of smoking but still choose not to stop. This campaign takes into account irrationality by including other components that will influence teens to make what we consider the rational decision, which is to stop smoking.
Additionally the HBM has the flawed assumption that intention leads to behavior change. This is not a problem in this campaign to stop teen smoking because advocates behind this campaign know how difficult it is to get adolescents to quit smoking, therefore the campaign includes resources for help and support of peers, and adults to make the behavior change. The fact that the campaign is a huge movement itself is in part a motivating factor for teens who intend to quit to actually do so with the support of smokers and non-smokers in the preparation of “kick butt day.”

Counter Approach 3: Effective Public Service Announcements (PSAs)
The use of fear in public service announcements (PSAs) was previously critiqued and criticized in paper 3 as an ineffective way to prevent and stop teenage smoking. Research has shown that loss of control is a more effective way to portray this message to young adults (7). Additionally the use of PSAs that follow the HBM need to be discontinued because of their tendency to show the negative long term effects of smoking which are deemed as ineffective in an age group of invincibility. These HBM based commercials tend to implant that use of fear to show susceptibility and severity, which have proved over the past decade to be unsuccessful in accomplishing the public health goal of deterring adolescents from smoke (7).

In The Campaign for Tobacco Free Kids, the use of the HBM in conjunction with fear is not a problem for the PSAs that this intervention uses (10). This intervention takes PSA’s made by real teens as if they are speaking to their peers in the creation of their own PSA’s with winners being chosen to be aired or posted on youtube (10.) This novel approach of having teenagers create the PSAs that others peers will see takes into account the cultural identity and incorporates the social and environmental context of the teenager into a message that is broadcast to be more effective in making a difference. Additionally a lot of these PSA’s target Big Tobacco and are similar to the Truth Campaign’s PSAs in the way they attack the big tobacco corporations (10). Studies have shown that US youth are 3 times more sensitive to tobacco advertising than adults (10). This is important for PSAs that are directed at teens showing the corruptive behavior of Big Tobacco firms in their pursuit to capture adolescents into a lifetime of smoking. These PSAs are countering the harmful messages in tobacco advertising that are targeting youth to smoker.

In 2008 616,395 kids became regular smokers (10). Of those kids 205,465 will die prematurely from their addiction (10). What will the toll of tobacco have to be before more effective and comprehensive campaigns and interventions are designed to hinder teenage smoking that successfully incorporate social science. The Campaign for Tobacco Free Kids is one such campaign that is headed in the right direction and leaving behind the traditionally used HBM of the past and looking to novel approaches to curb the rise of teenage smokers. This campaign has thought outside the box and implemented a group level approach to target the social network of adolescents while including support and resources that stray away from strategies previously seen and used in interventions framed by the HBM. Modern campaigns need to tailor their message to the target audience of teenagers and know that providing information on simply how bad smoking is will not cut it. This Campaign for Tobacco Free Kids has taken the messages in PSAs to a higher level by not using the typical HBM and implantation of fear, but instead by using real kids reaching out to other kids with PSAs that portray the deceitfulness of big tobacco companies. When more campaigns and interventions realize that you are not targeting one teen but the whole group of teens and that rationality does not apply along with fear tactics, is then and only then when the cloud of hovering smoke above US teenagers will begin to subside.

1. World Health Association. WHO/WPRO Smoking Statistics. WorldHealthAssociation.

2. Smoking statistics. The American Journal of Public Health. 1999;89:1106-1107.

3. Edberg M. Individual Health Behavior Theories . Essentials of Health Behavior Social and Behavior Theory in Public Health. Washington, DC. Jones and Bartlett Publishers.:2007.

4. Christakis N. et al. The collective dynamics of smoking in a large social network. New England Journal of Medicine.2008;358:2249-58.

5. Smoke Free America. The Foundation for a Smoke Free America.

6. Choi, Y. H., Cameron, G. T. and Leshner, G. M. "Defining Fear Appeals-Based Antismoking PSAs Using Izard’s Differential Emotions Scale" Paper presented at the annual meeting of the International Communication Association, Dresden International Congress Centre, Dresden, Germany Online 2009-02-04

7. Woolston, Chris. “Teen Smokers”. Httyp://

8. Cockerham, William C. Medical sociology. 11th ed. Upper Sadle, NJ: Prentice hall publishers:2007.

9. Weitz, Rose. The sociology of health, illness, and healthcare: a critical approach. 4th ed. Arizona: Arizona Sate University:2007.

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