Challenging Dogma - Spring 2009

Tuesday, May 5, 2009

Smoking Cessation Campaign “Every Cigarette is Doing You Damage”: A Health Belief Model Approach that Doesn’t Work- Ekaterina Solovieva

Introduction
Millions of dollars are spent each year in order to target smoking cessation campaigns at the smoking population, and yet only 2 to 3 percent of smokers quit each year in the United States (1). The question remains – are these dollars being spent wisely? “Every Cigarette is Doing You Damage” is a worldwide smoking cessation campaign that is currently being used in United States and Australia (2, 5). The campaign was previously run in a number of other countries such as Germany, Norway, and United Kingdom (16, 17). This campaign, which is based on the concepts of the Health Belief Model, fails to address some of the key issues associated with smoking behavior such as psychological, social, and environmental factors, and yet United States and Australia continue to use it (3, 4).
The Campaign
“Every Cigarette is Doing You Damage” campaign consists of print ads and commercials. The campaign aims to encourage smoking cessation among smokers by showing the various risks associated with smoking such as cancer, artery disease, blindness, stroke, etc. According to the Australian government, the initial creator of the “Every Cigarette is Doing You Damage” campaign, the campaign was developed to: “reduce the level of tobacco use … aimed directly at smokers, both youth and adults” (2).
For the purposes of this analysis, we are going to take a look at a specific commercial that is focused on informing smokers about the risk of getting lung cancer. The commercial begins with an image of a middle-aged man smoking a cigarette as he waits for the bus. As he inhales the cigarette smoke, we get a view of the smoke going into his mouth, and then into his lungs. As we go deeper, cancerous-growth formations can be seen on the interior walls of his lungs. Meanwhile there is a narration that goes as follows: “Every cigarette is doing you damage. New research shows how tobacco smoke attacks a vital gene which protects lung cells from cancer. One damaged cell is all it takes to start lung cancer growing. Every Cigarette is doing you damage… So the sooner you quit the better you’ll be." The commercial ends with a screen shot of the following message: “For Help Quitting Call: New York State Smokers’ Quitline…” (5).
This public health campaign is based on the concept of the Health Belief Model (HBM) which is the oldest and most widely used individual behavior theory in public health. In fact, this model is so popular for smoking cessation campaigns that the American Cancer Society (ACS) presents this theory as a way to analyze if an individual will quit smoking (6). On the ACS website you can find the following statement: “The Health Belief Model says that you will be more likely to stop smoking if you, 1) believe that you could get a smoking-related disease and this worries you, 2) believe that you can make an honest attempt at quitting smoking, 3)believe that the benefits of quitting outweigh the benefits of continuing to smoke, and 4)know of someone who has had health problems as a result of their smoking.” The statement is followed with the following words, “Do any of these apply to you?” (6).
Argument #1: People are well aware of the risks associated with smoking
As stated earlier, HBM is a very popular model for smoking cessation interventions, but as statistics of smoking cessation among adults show, this type of intervention hasn’t been very successful in the last decade (only 2 to 3 percent of smokers quit per year while 97 to 98 percent of smokers continue to engage in this risky behavior). Indeed, HBM is a very useful tool in the early stages of a public health campaign where it can be used to educate the public about a new disease, epidemic, etc. In fact, in the case of smoking cessation, HBM was very successful during the publication of the Surgeon General’s Report in 1964, which educated the population about the link between lung cancer and smoking for the first time, and as a result reduced smoking by as much as 30 percent (7). This report revolutionized the public’s perceived susceptibility, perceived severity, perceived benefits, and so forth about smoking and smoking cessation. However, with the help of the media, internet, and organized teen smoking prevention programs in schools today, people are significantly more aware of the side-effects associated with smoking than they were about fifty, sixty, twenty, and even ten years ago.
Such a campaign is unnecessary in the United States because people are already aware of the risks associated with smoking. “Every Cigarette is Doing You Damage” campaign is being targeted towards adults in relatively wealthy countries whilst recent research literature says that smokers in high-income countries are generally aware of their increased risks of disease when smoking tobacco (8). It makes you wonder: why is “Every Cigarette is Doing You Damage” campaign still predominantly focused on informing the public about the risks of smoking when they could be addressing social factors such as the current image that smoking is cool, and addressing psychosocial factors for smoking that are led on by stress and negative emotions (3). Instead of draining money into airing this campaign, public health practitioners behind this campaign should spend more money on researching the core values of smokers and trying to figure out what will sell to them because clearly education can’t achieve the goal of smoking cessation on its own.
Argument #2: People are not always rational (Long term health doesn’t sell)
With only 2 to 3 percent of smokers quitting per year, it shows that the HBM approach in “Every Cigarette is Doing You Damage” campaign, fails to successfully convey a public health message that encourages smoking cessation. This is largely due to the fact that HBM assumes people are rational individuals when in fact they are not - emotions, social norms, and expectations, are some of the forces that influence their behavior (9). The visual images of the cancerous growths inside the middle-aged man’s lungs, and the statement “just one cigarette is doing you damage… The sooner you quit, the better you’ll be”, attempts to target people’s perceived severity, perceived susceptibility, and perceived benefits. At the same time, by offering a number for a quit-line, the campaign attempts to address perceived barriers. However, just because a person has the perfect formula for smoking cessation according to HBM, it doesn’t necessarily mean that the person is going to take on the health-related action. This is primarily due to the fact that this campaign is based on an individual-level model that doesn’t take into account the fact that people’s behavior is influenced by their expectations of who they are and where they belong (9).
The “Every Cigarette is Doing You Damage” campaign coincides with public health practitioners’ historical reliance on selling long-term health. However, health is not the most effective product that a smoking cessation campaign can offer (10). According to Marketing Public Health: Strategies to Promote Social Change, “The most compelling product of the public health practitioner is the freedom, independence, autonomy, and control over life that come s with health… If public health practitioners fail to make this subtle, yet critical distinction in how they define and then market their product, they are unlikely to be successful” (10). Health is indeed important to people; however, the idea of long-term health is just too far away for people to care about. People have other values and priorities that are significantly more important to them than long-term health; likewise, addiction to nicotine overpowers smokers desire to quit. People’s decisions do not solely rely on individual level factors, but also on external factors such as their social context and environment (4, 10). For example, “women who are subject to discrimination or oppression (such as battered women, victims of sexual assault, immigrants, racial minorities, women with disabilities) may be more likely to be smokers” (3). For these groups of people, long term health is low on the list of priorities and is overpowered by nicotine addiction, grief, frustration, helplessness, the fear of gaining weight and becoming more marginalized in society, loneliness, etc (3, 18). “Every Cigarette is Doing You Damage” campaign is very informative, but it fails to address social and environmental issues that are important to smokers and people in general.
If people were always rational, then the most extreme cases where a person fulfils all of the components of HBM should quit smoking as a result of seeing the “Every Cigarette is Doing You Damage” campaign. However, smokers who are diagnosed with lung cancer are an example of the exception. By the time a person is diagnosed with a disease related to smoking, their perceived severity and perceived susceptibility is very high, and yet studies show that approximately half of the smokers who are diagnosed with early stages of lung cancer and have surgery, continue to smoke even though they could prolong the length of their life and speed up their recovery process (13, 14, 15). Patients are educated about the fact that smoking “diminishes treatment effectiveness, exacerbate side effects and interfere with wound healing,” and yet approximately half of these patients continue to smoke (13, 15). In fact studies have shown that in general “higher education was associated with a greater likelihood of smoking after surgery” (15). Perhaps educating smokers about the risks of smoking is not the key ingredient to smoking cessation because long-term health doesn’t sell to them (people have a difficult time thinking rationally) (9). Public health practitioners behind the “Every Cigarette is Doing You Damage” campaign need to stray away from the old fashioned Health Belief Model approach, and learn from their peers in the corporate market industry. Corporate organizations rely heavily on the latest research and techniques to market their product because they need to stay afloat in the industry and keep their market share. Corporate marketers that sell health products generally do not rely on the benefits of health and people’s rationality to buy their products (11). For example, “Health clubs are marketed to consumers not based on their ability to improve long-term health outcomes and prevent disease, but based on their ability to give people a feeling of control over how they look, how they feel, and how attractive they are to others” (11). Public health practitioners behind the “Every Cigarette is Doing You Damage” campaign need to learn from corporations who spend millions of dollars researching the core values that sell to people, use them to their advantage, and essentially avoid the cost of expensive research.
Argument #3: Negative messages do more harm than good
The concept of framing refers to the way a product or health behavior is packaged; framing is vital to creating a message that is successful at informing people about the health-related action they should take and how they would benefit from it (10). When it comes to framing a health related behavior, research has found the following: “In general, positive appeals are considered to be more effective. Based on interviews with 29 health communication practitioners, Baker and colleagues (1992) concluded that campaigns that emphasize positive behavior change and/or current rewards are more effective than those that emphasize negative consequences” (11). While commercials outside of the public health realm have been using this research to their advantage, public health practitioners behind the “Every Cigarette is Doing You Damage” campaign have failed to take advantage of this research (11). Not only is smoking cessation behavior in the “One Cigarette is Doing You Damage” commercial framed as a negative message, the frame implies that there is no point in quitting smoking because just “one” cigarette can do you damage and attack a vital gene that causes lung cancer. Instead of giving hope to smokers and giving them a desire to quit by pointing out that “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives,” this commercial leaves smokers helpless and encourages them to continue smoking because the “damage” has already been done (14, 19). Since success of tobacco companies is tremendous, perhaps public health practitioners should learn from their enemy about what “sells” to people because “there can be little question that cigarette ads attempt to create a positive image of the ‘smoker’” (19).
If the way a message is framed doesn’t make a difference on how people react to a public health campaign, people should always make the same decision when given the same information. A study by Tversky and Kahneman (1981) proved that this is not always true (12). They gave different students the same decision. For some students, the “decision was phrased in positive terms as a choice between a sure gain and an uncertain gamble”. The majority of these students chose the “sure gain” option. The rest of the students were given the same choices, but the choices were phrased in” negative terms as a choice between a sure-loss option and the risky gamble.” The majority of these students chose the risky gamble (12). Such an example provides further proof as to why public health practitioners behind the “Every Cigarette is Doing You Damage” campaign have to be very careful with the way they frame their message.
Conclusion
Public health practitioners behind “Every Cigarette is Doing You Damage” campaign need to re-evaluate the success of their campaign and recognize that an HBM approach might not be the best option for American smokers. These public health practitioners need to understand that a campaign that might have worked ten years ago, might not work anymore because of people’s changing environment, social norms, etc. Likewise, they need to take into consideration that a campaign that worked in Australia might not work in the United States because of the two country’s different social norms, culture, level of education about the risks of smoking, etc. Furthermore, these public health practitioners need to look at American corporations that sell health and learn from what works and doesn’t work for them- If corporate commercials/ads weren’t working, they wouldn’t still be in business today because they rely on making a profit. Likewise, they need think outside the box and focus on alternative theories to market smoking cessation such as marketing theory, branding theory, and framing theory, which are some of the leading theories the tobacco industry and other successful businesses uses today.






Response to the Smoking Cessation Campaign “Every Cigarette is Doing You Damage”: Alternative Campaign Based on Marketing, Branding, and Framing Theory - Ekaterina Solovieva

Introduction
In the previous critique, we showed reasons for why the smoking cessation campaign “Every Cigarette is Doing You Damage”, a Health Belief Model approach, is unsuccessful. Consequently, we suggested that public health practitioners should look at the selling techniques of successful corporations such as Nike, Abercrombie, L.A. Fitness, and alike, as guide to identifying what approach is currently hip, modern, and selling to Americans; given that these companies solely rely on profits, they have to be doing something right in order to be able to continue staying in business. It’s important to point out that although companies like Nike sell a product, they also sell an image associated with using that product such as success, the ability to do anything, attractiveness, likability, etc. Therefore, public health practitioner should not be concerned with selling “health” since long-term health doesn’t sell, and take advantage of the idea that a commercial that sells the image associated with being healthy, such as being attractive, could be a lot more successful. We recommend an alternative smoking cessation campaign that utilizes theories that are currently successful in some of the leading corporations in the United States; in particular, Marketing, Branding, and Framing theory.
Alternative Campaign: “Every Piece of Nicotine Gum is Getting You Closer to Joining the Group of Women Who Are Falling in Love”
Our alternative smoking cessation campaign utilizes Marketing, Branding, and Framing Theory. The campaign consists of commercials that address specific core values (shaped by social and environmental factors) that are important to our target audience: women between the ages of eighteen and thirty years old, who generally speaking tend to be unmarried. However, this commercial can be altered to address the male or older population as long as the commercial continues to follow the main principles of the theories we utilized.
At the heart of Marketing Theory is the task of identifying and understanding consumer needs and core values, and subsequently packaging and presenting the product/ health-related behavior in a way that addresses those consumer needs and core values (20). For smoking cessation campaigns, this approach requires more than just assuming that “long- term health” sells to consumers; it requires public health practitioners to understand other driving-factors for health such as the desire to look attractive, to be accepted in school, work, etc, or the desire to continue smoking because of addiction, the ability to relieve stress while smoking, and perhaps having an image that smoking is cool. The task of properly identifying and understanding consumer’s needs and core values makes research an integral part of marketing, and the major critique of this approach for selling health-related behavior because often times public health organization do not have funding for such research. However, as proposed earlier, the cost of research can be offset by utilizing the research of other successful corporations.
Since we do not have the financial means to conduct a study on the core values that sells to unmarried women, we relied on literature and used the Ralph Lauren Romance perfume commercial as a source to get us closer to understanding what sells to women in America. Romance perfume has been one of the most successful and lasting perfume lines for women, and this is why we felt comfortable relying on their marketing/branding technique. Branding theory is the concept of packaging that we briefly mentioned earlier; we use branding to influence people’s perceived costs and benefits of engaging in smoking cessation behavior (4). A branded message gives consumer a sense of value for engaging in smoking cessation behavior (21). “Brands, recognition of brands, and the relationship between brand and consumer are essential to marketing and largely explain the tremendous success of product advertising” (21). Consequently, we heavily rely on Marketing and Branding theory to sell our “product”.
According to the Ralph Lauren (RL) website, Romance is “the sensual fragrance for men and women that evokes the timeless essence of falling in love” (22). RL’s branded message gives consumers the idea that if you use Romance perfume, you will feel like you are/will fall in love. After analyzing the way RL presents their product to women (based on the commercial for women), we recognized that “romance” is a core value that sells to women. Likewise, we took a look at an Orbit Gum (for whiter teeth) commercial that is set in the context of a wedding reception where a bride is put on a pedestal and is praised by everyone; showing that marriage, falling in love, being praised and accepted is something that is important to women as well. Likewise, a Levi’s Jeans commercial that shows people walking for miles just to meet each other in “the name of love,” shows that finding the “right” and “perfect” man is another core value that sells. As a result of our research, we created a commercial implies that women who don’t smoke fall in love and end up with attractive, sexy, and romantic men.
The commercial begins with an image of a woman walking down a street chewing nicotine gum (making it clear that it is indeed nicotine gum). As she approaches a restaurant, she spits out her gum into a nearby garbage can, in slow motion that makes her look extremely attractive. She than walks in and greets an attractive and muscular man - he is waiting for her with flowers (a romantic quality). The following message appears: “This is Kelly’s first date with Jack”. Jack and Kelly proceed to have a lovely evening; at the end of the date, Jack leans in to kiss Kelly goodnight, his eyes light up, and he is in love because Kelly’s breath is so fresh. He thinks, “There is nothing like the bad taste of cigarette breath! Her breath is great. She is the ONE.” Then the commercial shows images of couples lovingly kissing while the girl’s are holding packs of nicotine gum. The narrator ends by saying the words, “Quit today and join the group of women falling in love” as the following message is written on the screen: “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives” (14, 19).
Addressing Argument 1: People are well aware of the risks associated with smoking
For the reasons presented in the original critique of “Every Cigarette is Doing You Damage”, an educational/informative smoking cessation campaign is unnecessary in the United States because people are already aware of the risks associated with smoking due to educational anti-smoking programs in schools, etc. American’s need a campaign that address’s the social and environmental issues that are important to smokers and society in general. “Although American’s certainly value health, they also hold other values that tend to be more important, more salient, and more influential on individual behavior” (20). Instead of preaching the health benefits of smoking cessation or the health risks associated with smoking, our alternative smoking cessation campaign utilizes Marketing and Branding theory to package smoking cessation in a way that addresses social and environmental factors that often times outweigh the desire to be healthy. The essence of our brand is that if you quit smoking/chew nicotine gum, you are going to become a part of a group of women that are falling in love; we do this not only because we recognize that people want to feel like they are a part of something (a group) that they can relate to, but also because of the concept of irrational/unplanned behavior that can hit groups of individuals almost like epidemic and cause them to all change their behavior at the same time (9,18). By addressing women’s desire to find “the perfect” and romantic man, we are targeting a core value that might be much stronger than health; indeed we are still addressing health, but in a context that the smoker can relate to. We feel that this is much a much more effective way to utilize financial resources than teaching about the health benefits of smoking cessation that American’s are already well aware of through other programs.
Addressing Argument 2: People are not always rational (Long term health doesn’t sell)

The Health Belief Model approach fails to successfully convey a public health message that encourages smoking cessation- this is mainly due to the reliance of the false idea that people are rational, that long-term health is on the top of their to do list, and that if a public health campaigns correctly addresses an individual’s formula for his/her perceived benefits and perceived barriers associated with a health-related behavior, than that individual will actually perform the behavior. “We[consumers] are really far less rational than standard economic theory assumes” (9). If people valued long term health, than people who are diagnosed with a disease related to smoking, should, if they were rational, quit smoking immediately because their perceived severity and perceived susceptibility is very high. However, studies have shown that approximately half of the smoker’s who are diagnosed with early stages of lung cancer and have surgery, continue to smoke even though they could prolong the length of their life and speed up their recovery process (13, 14, 15).
“The most compelling product of the public health practitioner is the freedom, independence, autonomy, and control over life that comes with health” (10). Instead of preaching the health benefits associated with smoking cessation and the negatives associated with continuing to smoke, in our commercial we are presenting the social and environmental benefits associated with smoking cessation (such as participating in the social norm of finding a husband and having a family). Similarly, we are presenting a way for smokers to “improve” their chance of falling in love and essentially giving them the ability to have control over this matter.
Addressing Argument 3: Negative messages do more harm than good
In the previous critique we proved that when it comes to framing a health related behavior, positive appeals are considered to be more effective; it is detrimental to the success of a smoking cessation campaign to frame smoking cessation in a way that is positive and encouraging (11). “Campaigns that emphasize positive behavior change and/or current rewards are more effective than those that emphasize negative consequences” (11). Not only is smoking cessation behavior in “One Cigarette is Doing You Damage” commercial framed as a negative message, the frame implies that there is no point in quitting smoking because just “one” cigarette can do you damage and attack a vital gene that causes lung cancer.
The ultimate competitor of smoking cessation campaigns are tobacco companies themselves, and since they too use this framing theory concept by creating a positive image of smoking, it is only natural that we utilize it as well for selling smoking cessation behavior (19). Accordingly, our campaign presents the positive aspects of quitting smoking, and does not try to reprimand people by showing the consequences associated with smoking or making them feel bad that they are slowly killing their body and the people around them. As opposed to offering a reward (long-term health) that is too far away for younger people to think about, our commercial offers a reward that can be realized today and can help the consumer feel like they fit into society: as a result of smoking cessation, they will be more attractive to the opposite sex.
Because we criticized “Every Cigarette is Doing You Damage” campaign for evoking a sense of helplessness among smokers, our campaign specifically includes these words in the commercial: “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives” (14, 19). We anticipate that this line will give people hope and the feeling that “the damage can be reversed” as opposed to “the damage has already been done.” Indeed the behavior we are selling is smoking cessation; however, smoking cessation behavior is linked to the use of nicotine gum to help consumers overcome the nicotine withdrawal associated with quitting smoking (11). Nicotine gum offers smoker the chance to slow down the effects of nicotine withdrawal that are feared by female smokers; not only does the fear include the chance of weight gain, but also the “impaired ability to concentrate, disruptive cognitive performance, mood changes, and impaired brain function” (3).
Conclusion
We present a smoking cessation campaign that we feel will successfully sell to female smokers between the ages of eighteen and thirty years old. As opposed to preaching the benefits of long-term health and relying on people’s rationality to quit smoking, we brand smoking cessation as benefit that female smokers can relate to, and provide a tool (nicotine gum) to help them in overcoming their addiction.
REFERENCES
1) Gordon, S. Promise of Cash Prompts Smokers to Quit: Financial incentives tripled rates of cessation, study found. HealthDay, 2009. http://www.nlm.nih.gov/medlineplus/news/fullstory_80237.html
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5) New York State. Every Cigarette is Doing You Damage. http://doingyoudamage.com/tumors.htm
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8) Curbing the Epidemic : Governments and the Economics of Tobacco Control. Do Smokers Know Their Risks and Bear Their Costs? Washington, D.C.: World Bank, 1999. http://www1.worldbank.org/tobacco/book/html/chapter3.htm
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12) California State University. Framing and Framing Theory. http://www.csun.edu/~rk33883/Framing%20Theory%20Lecture%20Ubertopic.htm
13) New-Medical. One-half of cancer patients continue to smoke after diagnosis. 2005 http://www.news-medical.net/?id=14720
14) A Report of the Surgeon General. The Health Benefits of Smoking Cessation. Rockville, MD: Center for Disease Control, 1990.
15) Fitness & Exercise for Senior Citizens. Exercise Provides Significant Reduction in Lung Cancer Risk for Women Smokers, 2006 http://seniorjournal.com/NEWS/Fitness/6-12-11-ExerciseProvides.htm
16) Public Health HSC Agency. Every Cigarette is Doing You Damage. 2009 http://www.healthpromotionagency.org.uk/Work/Tobacco/campaigns1.htm
17) Tobacco Control in Norway. Milestones in Norwegian Tobacco Control, 2006. http://www.helsedirektoratet.no/portal/page?_pageid=134,67665&_dad=portal&_schema=PORTAL&_piref134_76551_134_67665_67665.artSectionId=816&navigation1_parentItemId=996&_piref134_76551_134_67665_67665.articleId=50816
18) Christakis NA, Fowler JH. New England Journal of Medicine. The Collective Dynamics of Smoking in a Large Social Network, 2008; 358: 2249-2258.
19) Institute of Medicine. Growing Up Tobacco Free. Washington, D.C.: National Academy Press, 1994. 4:117- 118.
20) Kotler, P. Marketing Management: Analysis, planning and control (3rd Ed.) Englewood Cliffs, NJ: Prentice-Hall. 1976
21) Evans, D. and Hastings, G. Public Health Branding: Applying Marketing for Social Change. Oxford, UK: Oxford University Press. 2008.
22) RLTV: The world of Ralph Lauren in Motion Picture. Romance. http://www.entertainment.polo.com/rltv/

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1 Comments:

  • At July 1, 2010 at 11:47 PM , Blogger john said...

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