Challenging Dogma - Spring 2009

Tuesday, May 5, 2009

The Health Belief Model and Smoking Cessation: Making it Bigger and Stronger Doesn’t Make It Better - Catherine Snow

The Public Health Department of the city of New York recently began airing a commercial that has been receiving a lot publicity. It was featured on NBC’s Today Show on both April 2 and April 3, 2009, and has generated considerable controversy (1). The commercial features a boy, perhaps four years of age, who becomes separated from his mother at a crowded train station and begins to cry, quite convincingly. The tagline of the commercial is, “This is how your child feels after losing you for a minute. Just imagine if they lost you for life.” (2) The implication being that smoking can cause death, thereby leaving your children parentless. Unfortunately the controversy has nothing to do with smoking, or all of the children that are left without parents as a result of the habit, but whether the child actually shed some real tears during the commercial. The ad is doing a wonderful job of making people think about child actors and their protections (or lack thereof), but the ability of the commercial to fulfill its intended goal, getting current smokes to quit, is inherently flawed.
The commercial was taken from an Australian anti-smoking campaign called Quit (3). The campaign has been around for about 15 years and has made commercials increasingly graphic in an attempt to get people to quit smoking. What may have been effective fifteen, or even five years ago, will not continue to be effective. This campaign, which is now being adopted by New York state, is striking in that is identical to the majority of ad campaigns we have seen in the U.S. since anti-smoking initiatives began: If we just show people how bad smoking is for them, they will quit. If this were effective, then there would be far fewer smokers. It does not matter how graphic, or heart-wrenching we make the imagery, the ads do not address source of the problem. There are three main reasons this campaign will not be successful; 1) it continues to intervene at the individual level; 2) it continues to assume rational behavior; and 3) it maintains that behavior is planned.
The Importance of Social Considerations
Increasingly studies find that human behavior is influenced, not at the individual level, but at the group level. In fact, Social Network Theory posits that the individual influence on behavior is less important than that of the group within which the individual has social ties. Intuitively this seems to make sense. Smokers typically congregate with other smokers, and are often encouraged to find a quit partner. Smokers themselves define smoking as a social activity, and some people refer to themselves a “social smokers”. Studies show that factors such as race, education level, and socioeconomic status contribute to how likely someone is to be a smoker. All of this leads to the assumption that smoking behavior is affected significantly by forces beyond that of the individual.
The impact of social networks as it relates to smoking behavior was examined in a paper by Nicholas Christakis and James Fowler entitled “The Collective Dynamics of Smoking in a Large Social Network”. They looked at a network of over 12,000 people and found that “whole connected clusters within the social network stopped smoking roughly in concert.” Social connections influencing smoking behavior were present among all types of relationships, including spousal, sibling, friend, and colleague. Additionally, there is even some evidence on the larger scale that smoking behavior is subject to Diffusion of Innovation criteria. Those with higher education levels appeared to have more influence on the those with lesser education regarding smoking behavior, causing the behavior to diffuse through other social groups as a result of the adoption by the more educated (4).
All of these findings suggest that smoking behavior is far more complex than an individual seeing an advertisement that alerts them to the more dire consequences of smoking. Yet the most the Quit advertisement does is extend the decision to quit to encompass the effect it has on your children, while leaving the behavior as individually motivated and achieved. Children are certainly important determinants in many of the decisions that we make, but to assume that dramatizing a fairly well-known correlation will lead to behavior change underestimates the importance of how we use complex social networks to define ourselves and our behaviors.
The “Rationality” of Risk-Benefit Analysis
The Quit campaign contains many other commercials, many with graphic depictions of smoking related health problems, including mouth cancer, lung cancer, clogged arteries, and others, all of which can be viewed on their website (3). The implication is that if only we show people how severe the consequences can be, then they will quit. It assumes the decision is arrived at solely based on a rational risk-benefit analysis. This approach may be useful in circumstances where there is a lack of awareness, but given this is the same approach that has been used for decades, there is already awareness of the risks. In fact, Quit boasts on their website that they have been running ads like these since 1985 (3). Instead of being a marker of a successful campaign, one is more inclined to think a different approach should be taken if after 20 years there is still a substantial need for intervention.
In 2009 there are very few people in Australia or the United States, if any, who are not aware of at least some of the health risks of smoking, and most smokers even acknowledge these risks are legitimate. One of the newest commercials in the Quit campaign is entitled “Everybody Knows.” It shows a montage of previous campaign ads to the soundtrack of a deep voice singing “everybody knows”, implying that everybody already knows the health risks of smoking, particularly those already espoused by the campaign (5). Interesting that they would pour resources into a rerun of previous ads they feel everyone already knows about. Will images in montage form make viewers see the risks differently enough to decide to quit?
Smoking is a complex behavior, and cannot be easily packaged into a risk-benefit analysis. A distinction needs to be made between short term and long term risk benefit analyses. If looking at the short term, the analysis does not always work in favor of behavior change sought by the intervention we are discussing. The short term benefits of quitting are minimal when weighed against the difficulties. Not only are there the physical symptoms of withdrawal, but there are social adjustments which can be equally as difficult to deal with. To be the only person in a social circle who doesn’t go out for a cigarette break can be equally as difficult as being the only person who does. These are all factors that weigh against the benefit, and since they are all short term, they can be powerful counterweights.
Smoking in itself can be a benefit to a smoker, which is easy for non-smokers to trivialize. It is calming, familiar, reliable, and a powerful coping mechanism. It is also a self-defining characteristic for many smokers. The act of smoking provides instant gratification, and often that can be enough of a benefit to outweigh a risk. The “rationality” of weighing risks and benefits can be very subjective.
It is very difficult to translate long term health benefits, which may never be tangible, into compelling enough benefits. You will never know if you would have had lung cancer, you can only assume it is a benefit to quitting. For many of the remaining smokers this campaign is trying to reach, the risk-benefit analysis has not been as clear cut at the advertisements now running in New York would like to portray them. There needs to be a more direct and immediate incentive to compel the behavior alteration.
Even smokers for whom the heath risks have become so tangible that there is no risk-benefit analysis that cannot favor behavior change, the habit persists. In 2007 the Centers for Disease Control reported that more than 40% of those who suffered from emphysema and chronic bronchitis are current smokers (6). Even participants in public health campaigns continue to smoke despite the risks. In 2008, the Daily News reported that Skip LeGault, who was the main actor in some of New York’s anti-smoking commercials, continues to smoke, despite ads that show him warning others the habit has brought him “multiple heart attacks, surgeries, strokes, and an amputated right leg” (7).
It turns out many smokers actually want to quit. According to the Centers for Disease Control, 70% of current smokers report they want to quit, and in 2006, an estimated 44.2% had attempted to quit (8). If these large percentages already want to quit, why are resources being spent trying to convince people that they should? The issue would appear to be something other than convincing people that smoking cessation is in their best interest. The Quit campaign functions under the assumption that if people develop an intention to quit, then behavior will follow. There is very little that supports this assumption of human behavior. As illustrated above, human behavior is not rational. In basic matters there are a great many things that people intend to do that they never do. It is absurd to assume that a behavior will inherently follow an intention.
Planning Isn’t Everything
Many smoking cessation campaigns, including the Quit campaign, recommend that those who want to quit plan their efforts. Suggestions such as making lists, picking a quit date, weaning for a certain number of days, keeping journals, etc, are all common themes in quitting assistance programs. Yet the success rate for cessation is extremely low. The planning of behavior doesn’t seem to be advantageous.
An article from the British Journal of Medicine written by Robert West and Taj Sohal entitled “’Catastrophic’ Pathways to Smoking Cessation: Findings From National Survey” starkly illustrates this. They looked at the success rates of people who had quit smoking using both planned and unplanned attempts. They found that the unplanned attempts succeeded for longer. While only 42.3% of the planned attempts lasted at least 6 months, 65.4% of the unplanned attempts did. Even after controlling for age, sex, and socioeconomic group, the unplanned quit attempts remained more successful at 6 months. West and Sohal attribute this to Catastrophe Theory, which posits that “tensions develop in systems so that even small triggers can lead to sudden ‘catastrophic’ changes.” They go even further to say that when the trigger leads the smoker to plan for future action, that it “may signify a lower level of commitment.” (9)
These findings indicate that the Quit campaign (and many others like it) fails not only in their advertisements, but in their strategies to lead those who decide to quit to behavior change. There is even evidence to say that even if the campaigns are successful in getting people to plan to quit, they may not be as committed, and therefore not as likely to succeed.
Bigger and Stronger Isn’t Better
For New York to adopt the same campaign that they have used in Australia is folly. It is not a new or innovative approach to get people to stop smoking. It is the same approach that has been used since smoking cessation public health campaigns began. It is simply the Health-Belief Model, telling us that if only the perceived benefits outweigh the perceived barriers, people will decide to quit and actually follow through with it. The only novelty to these commercials is that they have an unprecedented degree of drama and graphic content. Even those of us with iron stomachs can’t help but wince at a close up of a gloved surgical hand squeezing fatty deposits out of an arterial segment (10). Despite their new found intensity the message is the same, and the message isn’t reaching any more people than it did the last time it was implemented in a public health campaign.
These advertisements are to the point where they are distracting from their purpose. Particularly in the case of the advertisement featuring the crying child described at the beginning of this paper. There have been all sorts of discussions about this commercial, but none of it has been to bring to the forefront the importance of getting smokers to quit. No one is discussing that ads have become this intense because smoking continues to be a significant issue despite years of efforts. There is only discussion of how terrible it is that this boy may have shed a few real tears. There are internet postings of people asking that it be pulled from the airwaves because it has “gone too far” (11). A commercial that is not being aired is not intervening with anything.
It is time to try another approach. The Health Belief model neglects the social aspects of behavior, and assumes that we act as rational beings who plan behaviors to achieve rationally weighed outcomes. Everyday the social sciences tell us that this not the case, yet public health departments continue with the old model thinking if only they make the message bigger and stronger it will somehow reach the demographic they keep missing. Unfortunately, none of this makes the Health Belief Model better. If anything it is causing the Health Belief Mode to make itself irrelevant as it draws the focus away from the public health issue it is trying to raise awareness of.

So What is Better? An Alternative Approach
Most public health interventions aimed at smoking cessation have been ineffective due to their reliance on the false premises of the Health Belief model. Just like the Quit campaign, most public health interventions assume that behavior is individually motivated, behavior is rational, and intention leads to behavior. The Health Belief Model can be useful, as in circumstances where the health effects of behavior are not well known. Surely when the ill effects of smoking were first conclusively identified such interventions did get large numbers of people to quit. At present, there are few if any people who are not aware of at least some of the myriad negative health effects of smoking, so it does not make sense to continue to use the same intervention.
It is unequivocal that smoking cessation is extraordinarily difficult. Using broad-based media campaigns, although reaching many, does not provide any real support or tools for individuals to successfully quit. Those who continue to smoke, likely are those who need a more direct, hands-on intervention in order for it to have any impact. Public health interventions should substantially narrow in scope and target much smaller populations, providing them with the support and resources necessary to have a significant effect.
Community Organization Theory and Social Network Theory are two social network theories that can achieve this. The most important aspect of this is appropriately choosing the community. If too large, the social connections will be too tenuous to influence behavior. A specific community(s) should be identified and evaluated at the local level and be based on some type of cost-benefit analysis.
As an example, the city of Boston could identify that within a specific neighborhood, low income residents have a very high incidence of child asthma related hospitalizations. Most of these children have parents who smoke, and a great deal of them live in public housing. The city could target a smoking cessation intervention focusing of public housing residents of a particular neighborhood. Not only will it be addressing the health problems of the smokers directly, but also those of everyone else living in those areas. Additionally, given these are low income residents likely on Medicaid, it will continue to provide returns to the city if successful.
Social Network Theory tells us that people exist in social networks, and people change as social networks. Looking at social networks involves looking at the characteristics of relationships within those networks, such as complexity, reciprocity, diversity, and subgroups. The intervention also needs to be designed so that the network is used as the facilitator of the intervention (12).
This is where Community Organization Theory is useful. It uses the community, in this case the public housing community, as the facilitator of the intervention. There are 3 types of community organization: Social Planning, Locality Development, and Social Action. Social Planning involves a group of outside experts with the help of community members, Locality Development involves experts and community members working together as equals, and Social Action is controlled by community members (13). Regardless of the type of community organization, all interventions should have community members participate in each phase, and supply training and knowledge where necessary to empower community members to actively participate in the intervention (13).
Developing a Social Network
For a smoking cessation intervention, Locality Development is the best approach. Quitting smoking is hard, and experts should be on hand to help increase success rates and provider resources. They can provide the participants with resources like how to run effective support groups and provide a supply of nicotine patches. However, the community needs to be equally vested. They need to have a personal stake in their own well-being and the health of their community for any intervention to be effective.
The best way to do this is to identify the community leaders within the public housing units, and enlist them as leaders in the public health initiative. This should be fairly easy since most public housing already have such figures planning social activities for residents. Getting these key figures can lead to diffusion of the behavior throughout the community (4).
Using the community addresses the problem of focusing on the individual that other interventions have had. Having this small network of connected community members with a concern not only for their own health, but those of the children in their community who have problems with asthma helps to provide an incentive that goes beyond the individual. Behaviors now have far more implications than individual ones.
Additionally, there now exists an immediate and accessible support network that is omnipresent. People who used to congregate outside the building at established times to smoke and socialize will now have to redefine that time and those rituals together. “Social smokers” no longer have a social catalyst to light up. The social component to smoking is very powerful, and changing that dynamic can be very powerful.
A Changed Risk Benefit Analysis
The Health Belief Model rests on the assumption that behavior decisions are based on a rational weighing of of perceived benefits and perceived barriers. With smoking cessation, the rationality of that weighing is anything but. Using an individual model, the short term benefits are non-existent. The short term brings withdrawal, social adjustments, identity re-evaluation, and stress. The rational decision to maintain long term survival through better health behaviors is unable to overtake the need for instant gratification.
Using a community intervention removes the need to make the risk benefit analysis about individual health benefits. Instead the risks and benefits shift to include all of the short term, less rational indicators discussed. Rational or not, there is a need to be an active participant of the social network that you are in. Whereas an individual trying to quit smoking has to deal with not having his/her morning break on the front stoop with the 6 other smokers he/she chats with, if an action is taken at the community level, continuing to go outside while everyone else is attempting to develop a new habit will become stigmatic. The short term social risk-benefit analysis has been reversed.
Although there will still be issues such as withdrawal and stress, having a framework within which to cope with them that allows you to maintain consistent social relationships, in itself becomes a benefit. You are strengthening your connection within the community and receive instant gratification whenever support is needed because you are immersed in a support network at all times.
Planning Still Isn’t Everything
Regardless of how well executed an intervention it cannot make people spontaneously decide to quit in order to increase their chances of success. However, having the intervention embedded within a small defined social network can increase the likelihood of a quit attempt. Again, people’s behaviors are heavily influenced by their social networks.
Having an entire housing project focused on a specific health goal, makes the said goal omnipresent in the environment. Having cues throughout your environment may prompt a spontaneous quit attempt. Also noting that we have tied childhood asthma as an additional incentive, perhaps the connection of suffering children within their own community can act as a trigger. The more potential cues present in the environment, the more likely that one will act as the trigger that West and Sophal claim can lead to a “catastrophic” change in behavior (9).
Even West and Sophal cede that their “findings do not necessarily imply that planning quit attempts is counterproductive, and use of behavioral support and nicotine replacement therapy are known to improve the chances of success even though they require planning ahead” (9). This tells us that even if quit attempts on behalf of the residents are planned, they are not necessarily doomed to failure. For those who do quit without prior planning, it follows that having proven resources readily available whenever that decision is made will only increase the likelihood of success.
Sometimes Smaller is Better
A new approach is needed in addressing the smoking habits of individuals who have thus far been unable to be reached by previous interventions. A broad-based approach no longer yields results, and resources would be far better allocated to a more intensive smaller scale approach. Using Community Organization Theory to implement the principles of Social Network Theory shifts the focus from the individual to the community, changes the risk benefit analysis away from simple health benefits to the more complex considerations of social identity, and provides the greatest opportunities for success for all community members willing to execute a behavior change.
1. “Today on NBC”. April 3, 2009.
2. ”Separation”. Quit Victoria: 2008.

3. Quit Victoria. 2005.

4. Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine 2008; 358:2249-2258.

5. “Everybody Knows”. Quit Victoria: 2009.

6. Centers for Disease Control and Prevention. Cigarette Smoking Among Adults-United States, 2006. Morbidity and Mortality Weekly Reports. Vol. 56. No.44. November 9, 2007.

7. Lite, Jordan. Man in Anti-Smoking Ad Still Lights Up. Daily News. January 11, 2008.

8. Centers for Disease Control and Prevention. Smoking and Tobacco Use. Atlanta, GA: 2008.

9. West R, Sohal T. “Catastrophic” Pathways to Smoking Cessation: Findings From National Survey. British Medical Journal 2006; 332:458-460.

10. “Artery”. Quit Victoria: 1997.

11. Emotional anti-smoking ad: Low blow or good campaign?.

12. Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers. 2007

13. The Health Communication Unit at the Centre for Health Promotion. Tipsheet: Summary of Social Science Theories. University of Toronto. 1992.

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