Social Cognitive Theory: An Effective Method to Deter Teen Smoking– Mobolaji Odewole

A more effective intervention would utilize the Social Cognitive Theory (SCT) methods and could potentially result in successful outcomes.  Social Cognitive Theory posits that human behavior outcomes are motivated by several components of individual characteristics, such as cognitive and biological events, as well as environmental factors (19).  This theory focuses on the continuous interaction between the individual, their social, and physical environment (20).    This paper will show an effective intervention than that of Philip Morris’s “Think, Don’t Smoke” anti-smoking campaign ad, and explains how this particular intervention would work and address the specific flaws that were articulated in previous assignment.  

Intervention

According to the Social Cognitive Model, an effective method to deter teen from smoking would address the basic idea of self-efficacy, positive influence through observation/modeling, and environmental support from the community.  An intervention based on this model would be a television “Anti-Smoking” campaign ad with a tagline that reads “Be Cool, Don’t Smoke.”  This television commercial highlights two different scene settings. One of the scenes shows parents providing emotional support, encouragement, and providing their children tools necessary to overcome peer pressure such as making friends with right group teens (nonsmokers). The other scene shows school teachers educating their students on the importance of not smoking.

There is a shift in scene as we now see them hanging out and playing together at the school basketball court.  Three upper classmates (bullies) approach one of the teen (guy) and ask him for a lighter. The guy responds by telling them that he does not smoke, at this time the boy starts getting teased, pushed and smacked around by the three bullies.  The teasing goes on for about ten seconds with the bullies saying “what’s wrong, mommy would not let you smoke”.  The guy never gives in and continues to tell them “I don’t smoke and I don’t want to smoke”.  Soon enough, every other classmates walking by to class stand right next to the guy and say “I don’t smoke, my friends don’t smoke and I’m cool”.   Finally, the three upper classmates (bullies) left the teen (guy) alone and walked away.  The ad ends by providing a toll-free number for more information on ways to quit smoking.

Self-Efficacy

“Be Cool, Don’t Smoke” anti-smoking campaign ad effectively fulfilled one of the main principles of Social Cognitive Theory by introducing the importance of self efficacy.   The Theory of Self-Efficacy by Albert Bandura suggests that behavior is best predicted by an individual's confidence in their ability to accomplish a given task (6).  Self-efficacy may impact health by influencing the adoption of health promoting behaviors, cessation of unhealthy behaviors, and/or the maintenance of behavioral changes when faced with difficult situations.  In 2002, Kear found that self-efficacy to resist cigarette smoking was a significant determinant of smoking behavior (7). 

“Be Cool, Don’t Smoke” intervention addresses one of Philip Morris “Think, Don’t Smoke” advert flaws by providing teens the necessary tools to enhance their self-efficacy.  This was shown in the ad when parents were providing emotional support, encouragement, and educating their children on the importance of not smoking.  Teenagers are less likely to smoke when parents are involved in their children's activities (8) and are supportive (9).  Similarly, parental emotional support was inversely related to tobacco, alcohol, and marijuana use among adolescents.  Lack of family support, on the other hand, was a significant barrier to smoking cessation among teenagers (10).  These findings suggest that family social support has a positive influence on health promoting behaviors.  Students with a negative social support network are especially at risk to develop poor health behaviors. 

            Additionally, the influence of variables, such as social support, adjustment, and positive climate are also important in protecting youth from participating in smoking.  This was captured in the ad when school teachers were educating the students on the importance of not smoking.  This would promote self-efficacy by providing the opportunity for modeling from other students and encouragement from teachers and students.  Self-efficacy is further influenced by the person’s mastery experience (success in performance), vicarious experience (modeling from others), social persuasions (encouragement or discouragement from others) and physiological factors (response to stress) (21-22).  By providing both children and parents the tools necessary to promote self-efficacy and environment supports at school, “Be Cool, Don’t Smoke” advert would be effective in decreasing teens smoking.

Peer-Influences

“Be Cool, Don’t Smoke” addresses another flaw of Philip Morris anti-smoking advert of failing to recognize the peer influence by providing teens the necessary tools to combat peer-pressure.  This was shown in the intervention when parents were talking to their children about potential scenarios, making friends with the right group (nonsmokers) and thinking through strategies together on how to deal with those scenarios if they arise “Be Cool, Don’t Smoke” campaign ad shows how effective and helpful it’s for both parents and teens to think about peer-pressure ahead of time rather than dealing with situations as they occur or trying to recover after they happen.  An example of this specific situation was capture in the intervention when one teen (guy) was faced with peer-pressure and was able to deal with it without giving in into peer-pressure despite been smack around and tease by three upper classmates (bullies).  Teens watching the television advert would probably be able to relate themselves to the situation the guy “Right, I wish it was that easy as ABC” and turn off the television.  Adolescence is clearly a sensitive time period in the onset of cigarette smoking. Peers and peer relationships have been cited frequently as major factors involved in cigarette use 12).  In addition, youth are viewed as being most likely to imitate the smoking or non-smoking behavior of those with whom they have the greatest amount of contact, both in frequency and duration.  This was illustrated in the intervention when the guy was adamant on his words to the bullies that he does not smoke and neither do his friends. They guy was later on supported by his friends and fellow classmates.  Transitions to increased levels of smoking have been linked to friends’ encouragement and approval and the message conveyed that smoking is an enjoyable activity that promotes popularity 13). Studies have also shown that non-smokers who affiliate with smokers have been found to be at greater risk for transitioning to tobacco use than youth without smoking friends 14).  By addressing the problem of peer influences in the target population, anti-smoking ad campaign to combat teens smoking would be successful. 

Irrational Behavior

“Be Cool, Don’t Smoke” anti-smoking campaign ad addresses the flaw of Philip Morris “Think, Don’t Smoke” advert by recognizing that teens’ behavior might be irrational. This was shown in the ad by providing a toll-free number for more additional information and the availability of nicotine gum at local stores when they have the urge to smoke.  One’s decision is affected by mood, past experiences, thought processes, individual perception of desirable and undesirable outcomes (17), social pressure, time constraints, information and skills (18).  To fully understand teen’s irrational behavior, one must consider the full picture, the context in which teen decision-making takes place behind such behavior.  According to Ariely’s Predictably Irrational, understanding how we are predictably irrational provides a starting point for improving our decision making and changing the way we live for the better (16).  Social Cognitive Theory “Be Cool, Don’t Smoke” advert offered an alternatives behavior with an equal value to that in which they are giving up (cigarette) because teens tend to value option and potential behavior differently than do adults, further decreasing irrational behavior in the target population.  By addressing the problem of irrational behavior in this target population, intervention to combat teens smoking would be effective and successful.  

Conclusion

            Social Cognitive Theory seems like an ideal and more effective technique for an intervention to reduce teen’s smoking and promoting healthy behaviors in the target population.  This intervention provides teens the tools necessary to enhance their self-efficacy and deal with peer-pressure. Finally, this intervention recognizes irrational behavior.

Philip Morris True Motives behind “Think, Don’t Smoke” Anti-Smoking Ad Campaign:   A Critique Based on Theory of Planned Behavior ----Mobolaji Odewole

In 1998, the United States tobacco giant Philip Morris decided to spend 100 million dollars a year on a campaign to reduce teenage smoking (1).  The anti-smoking ad campaign presents the idea that all teens have to say is “No” when they are being ask by their friends or peers if they want a cigarette.   According to a study released by the Wall Street Journal, children found the Philip Morris antismoking ad campaign to be the least effective of all in making them “stop and think” about not smoking.  A focus group of 12-16 year olds from the state of California, Florida, Massachusetts, and Arizona claimed that Philip Morris adverts sounded like a parental lecture, and overall there was a feeling that they lacked substance and good reasons not to smoke (2).  Teen smoking is a growing major public health problem in the United States with teen’s facing increased risk of health problems later in life.  Teen smokers are more likely to use alcohol, illegal drugs, and die early from a smoking related disease than non-smokers.  They are also more likely to have panic attack, anxiety disorders and depression than non-smokers (3).  Supplying millions of dollars for a program that is based on ineffectual methods seems fruitless, and the campaign adverts attempt seems equally ineffective.  In reality, Philip Morris is getting maximum public relations value out of its teenage antismoking campaign while achieving little results. This is not so surprising because the tobacco company has a long history of diverting attention away from its true motives.  In the United States Marlboro, one of Philip Morris tobacco product is preferred by sixty percent of 8^th, 10^th, and 12^th grade boys and girls (14-18 year olds) who smoke and ninety percent of new smokers are under age (4). 

            Given the severity and consequences of teens smoking, an effective public health intervention is necessary to address this growing problem in the United States.  Philip Morris anti-smoking campaign advert “Think, Don’t Smoke” was unsuccessful in decreasing teen’s smoking among children because most of its TV advertisement inappropriately apply Theory of Planned Behavior (TPB).  Theory of Planned Behavior is based on the relationship between people’s attitudes towards a specific behavior and their perceived social norms (5).  TPB stresses the importance of “perceived behavioral control” which originates from self-efficacy.  Theory of Planned Behavior seems like an ideal technique for Philip Morris’ anti-smoking intervention to reduce teen’s smoking; however, the “Think, Don’t Smoke” campaign falls short to connect with teen’s due to three key factors: failure to recognized self-efficacy; negative peer influences; and irrational behavior.

Failure to Recognized Self-Efficacy

            One television commercial employed in the campaign shows that when parents talk to their children about not smoking, they actually listen.  Analyzing this ad will help explain and understand how this campaign falls short.  The television ad shows four children that are friends (three boys and one girl) riding their bikes to school, playing all together at the park.  While this entire event is taking place, there is a voice in the background describing the scenes at the same time.  There is a shift in scene to when the children are older (teens) and we now see them eating together at a fast food restaurant.  Later into the night when they are all going back home, one of the guys takes out a cigarette and asks the girl if she want one.  At this time, there is a pause in the scene with the background voice saying “when you are being ask to smoke, think and say No”. The scene resumes with the girl saying “No”.

            “Think, Don’t Smoke”, in an attempt to employed Theory of Planned Behavior, presents the idea that all teens have to say is “No” when they are being ask by their friends or peers if they want a cigarette. While this commercial makes an honest attempt to fulfilled one of the main principle of Theory of Planned Behavior by introducing the importance of individual attitudes toward a particular behavior, the portrayal of the children just saying “No” seems unrealistic.  The Theory of Self-Efficacy is the belief that one is capable of performing in a certain manner to attain certain goals. Basically, self-efficacy posits a person confidence to perform a certain behavior which is also known as “perceived behavioral control”.  This refers to the degree to which someone believes they have control over a particular action (control beliefs) and the strength of their belief of the action (perceived power).   Control beliefs could also be a person’s belief about factors that will make it easier or difficult to perform the behavior (5).  The Theory of Self-Efficacy by Albert Bandura suggests that behavior is best predicted by an individual's confidence in their ability to accomplish a given task (6).  Self-efficacy may impact health by influencing the adoption of health promoting behaviors, cessation of unhealthy behaviors, and/or the maintenance of behavioral changes when faced with difficult situations.  The role of self-efficacy on smoking, however, needs to be further examined along with other personality and cognitive factors among teens.  In 2002, Kear found that self-efficacy to resist cigarette smoking was a significant determinant of smoking behavior (7).

            Philip Morris “Think, Don’t Smoke” advert simply tells children that they have a choice of saying “No” when asked to smoke a cigarette.  This does not provide teens the tools necessary to enhance their self-efficacy.  This campaign will not succeed unless the parents provide their children with emotional supports, encouragement and ways to overcome peer pressure.  Teenagers are less likely to smoke when parents are involved in their children's activities (8) and are supportive (9).  Similarly, parental emotional support was inversely related to tobacco, alcohol, and marijuana use among adolescents.  Lack of family support, on the other hand, was a significant barrier to smoking cessation among teenagers (10).  These findings suggest that family social support has a positive influence on health promoting behaviors.  Students with a negative social support network are especially at risk to develop poor health behaviors.  The influence of variables, such as social support, adjustment, and positive climate are also important in protecting youth from participating in smoking and drinking.  Without providing both children and parents the tools necessary to promote self-efficacy, just saying “No” will not decrease teen’s smoking.

Failure to Recognized Negative Peer-Influences

            Philip Morris anti-smoking advert also fail to recognize the key role peer-pressure plays when it comes into behavior.  The television advert assumes teens will have positive attitudes toward not smoking, which leads to the intention of them not smoking and they can therefore resist peer-pressure and “just say no” when they being ask to smoke.  I’m amazed that the writers of a multi-million dollars campaign could actually convinced Philip Morris that the anti-smoking advert will be effective, my guess is that Philip Morris knew all along that the campaign writers did not pass their child adolescents class.  Teens watching the television advert will actually say to themselves “Right, I wish it was that easy as ABC” and turn off the television.  Adolescents’ susceptibility to peer influence was examined as a marker of difficulties in the general process of autonomy development. Although peer relationships provide an essential context for adolescent social development, adolescents’ conformity to negative peer norms appears as a major risk factor linked to negative outcomes ranging from delinquency and smoking to risky sexual behavior (11). Adolescence is clearly a sensitive time period in the onset of cigarette smoking. Peers and peer relationships have been cited frequently as major factors involved in cigarette use 12).  In addition, transitions to increased levels of smoking have been linked to friends’ encouragement and approval and the message conveyed that smoking is an enjoyable activity that promotes popularity 13). Studies have also shown that non-smokers who affiliate with smokers have been found to be at greater risk for transitioning to tobacco use than youth without smoking friends 14). Youth are viewed as being most likely to imitate the smoking or non-smoking behavior of those with whom they have the greatest amount of contact, both in frequency and duration.  The Social Network Theory assumes that the individuals in a social system interact with each other and serve as significant reference points in each other’s decision making 15).  Thus, an individual’s location in the network and his/her pattern of relations with others affects his/her behaviors.  Without addressing the problem of negative peer influences in the target population, anti-smoking ad campaign to combat teens smoking will not be successful. 

 

 

Failure to Recognized Irrational Behavior

            The Philip Morris anti-smoking ad campaign fails to recognize that children do not actually go through the process of thinking in the same way that is implied by the Theory of Planned Behavior.  As described by Ariely, “we fail to understand the profound effects of our emotions on what we want, and how expectations, emotions, social norms, and other invisible, seemingly illogical forces skew our reasoning abilities” (16).  One’s decision is affected by mood, past experiences, thought processes, individual perception of desirable and undesirable outcomes (17), social pressure, time constraints, information and skills (18).  To fully understand teen’s irrational behavior, one must consider the full picture, the context in which teen decision-making takes place behind such behavior.  According to Ariely’s Predictably Irrational, understanding how we are predictably irrational provides a starting point for improving our decision making and changing the way we live for the better (16).  Teens tend to value option and potential behavior differently than do adults, so what may look to an adult like an irrational decision may look to a teen like a well-put rational decision.  For example, getting in trouble with the principal for smoking in school may not be big deal to a teen while avoiding being teased at school for not smoking may be a huge deal to a teen.   Philip Morris “Think, Don’t Smoke” advert could  promote teen being teased in school, further increasing irrational behavior in the target population.  Without addressing the problem of irrational behavior in this target population, intervention to combat teens smoking will be unsuccessful.  

Conclusion

            Theory of Planned Behavior seems like an ideal technique for Philip Morris’ anti-smoking intervention to reduce teen’s smoking; however, the “Think, Don’t Smoke” campaign is unlikely to be effective and could have unintended negative consequences due to the inappropriate implementation of the theory.  This intervention does not provide teens the tools necessary to enhance their self-efficacy, leaving teen vulnerable to unhealthy behavior such as smoking.  “Think, Don’t Smoke” campaign fail to recognize the key role peer-pressure plays when it comes into behavior.  Finally, this intervention fails to recognize that children do not actually go through the process of thinking in the same way that is implied by the Theory of Planned Behavior.  A more effective and successful intervention would focus on promoting self-efficacy among teens to improve healthy behavior.

REFERENCES

1.     Novelli. “Don’t Smoke,” buy Marlboro”. British Medical Journal 2008; 318(7193):1296

2.     National Institutes of Health. Medline Plus (National Institutes of Health, 2009) http://www.nlm.nih.gov/medlineplus/smokingandyouth.html

3.     McLeish AC, Zvonlesky MJ, Marshall EC, Leyro TM.  The Negative Affectivity as a Moderator of the Association between Smoking. PudMed 2009; 197(2): 111-6

4.     McLeish AC, Zvonlesky MJ, Marshall EC, Leyro TM.  The Negative Affectivity as a Moderator of the Association between Smoking. PudMed 2009; 197(2): 90-6

5.     Edberg M. Individual Health Behavior Theories. Essentials of Health Behavioral Social and Behavioral Theory in Public Health. 2007:38-42.

6.     Maddux JE, Brawley L, Boykin A. Self-efficacy and health behavior. Prevention, promotion, & detection. In: Maddux JE, editor. Self-efficacy, adaptation, and adjustment: Theory, research, and application. Plenum Press: New York; 1995. pp. 173–202.

7.     Maddux JE, Brawley L, Boykin A. Self-efficacy and health behavior. Prevention, promotion, & detection. In: Maddux JE, editor. Self-efficacy, adaptation, and adjustment: Theory, research, and application. Plenum Press: New York; 1995. pp. 173–202.

8.     Krohn MD, Massey JL, Zielinski MA. Role overlap, network multiplexity, and adolescent deviant behavior. Social Psychology Quarterly. 1988;51:346–356. doi: 10.2307/2786761.

9.     Chassin L, et al. Changes in peer and parent influence during adolescent: longitudinal versus cross-sectional perspectives on smoking initiation. Developmental Psychology. 1986;22:327–334. doi: 10.1037/0012-1649.22.3.327.

10.  Milligan RAK, Burke V, Beilin LJ, Richards J, Dunbar D, Spencer M, Balde E, Gracey MP. Health-related behaviours and psycho-social characteristics of 18 year-old Australians. Social Science & Medicine. 1997;45(10):1549–1562. doi: 10.1016/S0277-9536(97)00092-0.

11.  DiIorio C, Dudley WN, Kelly M, Soet JE, Mb-wara J, Potter JS. Social cognitive correlates of sexual experience and condom use among 13- through 15-year-old adolescents. Journal of Adolescent Health. 2001;29:208–216.

12.  Friedman, L. S., Lichtenstein, E. 15:41 PM Biglan, A. 1985) Smoking onset among teens: an empirical analysis of initial situations. Addictive Behaviors, 10, 1–13.

13.  McAlister, A. L., Krosnick, J. A. & Milburn, M. A. (1984) Causes of adolescent cigarette smoking: tests of a structured equation model. Social Psychology Quarterly, 47, 24–36.

14.  Urberg, K. A., Degirmencioglu, S. M. & Pilgrim, C. (1997) Close friend and group influnce on adolescent cigarette smoking and alcohol use. Developmental Psychology, 33, 834–844.

15.   Knoke, D. & Kuklinski, J. H. (1982) Network analysis. In: Sullivan, J. L. & Niemi, R. G., eds. Series: Quantitative Applications in the Social Sciences. Beverly Hills, CA: Sage.Dan Ariely. Predictably Irrational. The Hidden Forces That Shape Our Decisions. 2008

16.  Neumann, P. J., & Politser, P. E. (1992). Risk and optimality. In J. F. Yates (Ed.), Risk-taking behavior (pp. 27-47). Chichester, England: John Wiley & Sons.

17.  Fischhoff, B., Crowell, N. A., & Kipke, M. (Eds.). (1999). Adolescent decision making: Implications for prevention programs: Summary of a workshop. Commission on Behavioral and Social Sciences and Education, National Research Council, Institute of Medicine. Washington, DC: National Academy Press.

18.  Bandura, A. (1989). Human Agency in Social Cognitive Theory. American Psychologist, 44, 1175-1184.

19.  Edberg M. Individual Health Behavior Theories. Essentials of Health Behavioral Social and Behavioral Theory in Public Health. 2007:51-56.

20.  Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.

21.  Wikipedia. Self-efficacy. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Self_efficacy.

 

 

 

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

Introduction
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.


References
1. World Health Association. WHO/WPRO Smoking Statistics. WorldHealthAssociation.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a1.htm

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. http://www.anti-smoking.org/

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 http://www.allacademic.com/meta/p90143_index.htmlMla

7. Woolston, Chris. “Teen Smokers”. Httyp://www.ahealthyme.com/topic/teensmokers.

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.

A Intervention for Smoking Prevention and Cessation Among Adolescents-Brita Reed

Introduction
Although the prevalence of cigarette smoking has decreased substantially in the U.S. over the past thirty years, less impact has been made on the incidence of the initiation, or the prevalence of the continuation, of smoking among adolescents. The current inability among public health researchers to not only fully understand adolescent smoking cessation, but also to find effective intervention methods is unfortunate since implementation of smoking cessation interventions in adolescents is well justified in light of the devastating consequences of smoking on health. For example, in 2000, smoking-related illnesses claimed more American lives than alcohol, motor vehicle accidents, suicide, homicide, AIDS, and illegal drugs combined. (http://cancer.org/smoking/adoslescents).

Among adult populations, numerous studies employing the Trans-Theoretical Model (TTM) have shown that the behavioral and cognitive processes of change, as well as an understanding of decisional balance (i.e., how individuals weigh the pros and cons of their behavior change) and temptations (i.e., individual’s beliefs about their behavior change), can aid in public health interventions regarding smoking cessation (Prochaska & DiClemente, 1983). Employing TTM as the basis for Motivational Interviewing (MI) in adults, for example, allows the interviewer to address behavior change in smokers that enhance readiness to change, increase smokers perception of the negative consequences of smoking, decrease smokers perception of the positive benefits of smoking, and assess the obstacles to moving forward to a higher stage (Sommers-Flanagan, & Sommers-Flanagan, 2003).
The use of TTM in public health interventions concerning smoking initiation and continuation among adolescents, however, has produced disappointing results. This is disconcerting in that, for both males and females, smoking initiation is primarily an adolescent behavior and relatively few people begin smoking after age 21(Lewis, 2002). Many adolescents who begin to smoke are unaware of how difficult it often is to stop smoking.

Foundation of the Proposed Intervention: Erik Erikson’s Psychosocial Stag of Adolescent Development
Erik Erikson’s epigenetic formulation of the stage-theory of psychosocial development in the 1950s and 1960s was loosely based on Freud’s psychosexual stages of development which had been published decades earlier. Freud, a psychoanalyst, thought that personality was essentially completed by the end of early childhood. Erikson was a developmental psychologist; as such, he was convinced that personality continued to develop across the life span.

According to Erikson, there are eight stages of psychosocial development beginning with infancy’s stage of trust versus mistrust and ending in old age’s stage of integrity versus despair. Completion of each stage helps to ensure mental well-being. Erikson’s stage of identity-versus-role-diffusion, which begins at puberty and extends through adolescence (Erikson, 1950), readily lends itself to the creation of a novel intervention to mitigate both the incidence of initiation and the prevalence of continuation of smoking among U.S. adolescents.
Eriksonian theory states that the formation of identity is the vital task of the late adolescent years and is unique to the adolescent stage of development. Failure to successfully work through identity issues may inhibit further healthy personality growth (Erikson). Erikson has a rich sense of the complex relationships between the adolescent and the surrounding culture; indeed, he is certain that culture molds an adolescent’s identity as the individual psyche is generated and shaped with the requirements, values, and sensibilities of a particular cultural context (Mitchell & Black, 1995).

For Erikson, adolescent identity occurs at a time of transition between childhood and adulthood, at the point of intersection between the individual and the social world. According to Erikson, adolescents in the stage of identity-verses-role-diffusion are primarily concerned with how they are seen by others and how that view compares to their own self-conception (Erikson, 1950). To this end, they temporarily over-identify, to the point of complete loss of their own identity, with “the heroes of cliques and crowds (228).” This over-identification serves an important purpose: It aids the adolescent in his/her attempt to arrive at a definition of his/her identity by projecting his/her diffused ego images on one another and, by seeing these ego images thus reflected, gradually clarified.

Proposed Intervention Informed by Eriksonian Theory: Peer-Led Group Therapy
Eriksonian theory suggests that an intervention that is socially-based, rather than individual interventions such as TTM, may be more effective in reducing smoking among adolescents. I propose an intervention of peer-led group therapy which focuses on the meaning of smoking to the group participants. The group will be comprised of adolescent smokers, some of whom are contemplating smoking cessation. In addition, adolescents who are contemplating initiating smoking will also be in the group.
This intervention will explore the psychosocial aspects of adolescents through an understanding of their need to explore identities, including the identity of being a smoker or a non-smoker. As such, it will addresses adolescents’ feelings, attitudes, and experiences concerning using tobacco, as well as not using tobacco. Who do they think they are in the eyes of their friends, parents, and teachers if they smoke or do not smoke? What statement does their decision to smoke or not to smoke make to the world about who they are? Is smoking or not smoking congruous with the identity they are developing as young adults? In sum, these sessions attempt to aid the adolescent who is smoking, as well as the adolescent who is considering the initiation of smoking, to strive to fully understand the meaning of smoking in his/her life.

The Value Added of the Proposed Intervention over TTM: Understanding Risk-Taking in the Development of Identity in the Adolescent
These therapy sessions will help the adolescent to understand his/her own risk-taking tendencies. According to Erikson, adolescence is a time of experimentation: As young people seek to define and solidify their identity, they often try on many identities (Erikson, 1950). Experimentation, therefore, serves the purpose of testing whether particular behaviors are congruent with the adolescent’s self-image (Lewis, 2002). Some behaviors are engaged in to represents to others the way the adolescent wants to be identified. Seigel reminded us that, in certain populations, it is the potentially destructive nature of high-risk behaviors that may motivates and supports the behavior (Seigel & Doner, 2004).

These therapy sessions will aid the adolescent to understand what the risky nature of smoking, which is known to them, adds to their inchoate identity. Many researchers believe that risk-taking behaviors may be normative for this adolescent period of identity formation as the adolescent explores identity options (Lewis, 2002). In fact, research suggests that some experimentation with smoking may actually characterize the psychologically health adolescent (Lewis). This may help explain why interventions which focus on educating adolescents on the short and long-term health risks of smoking have not made significant impact on adolescent smoking initiation or cessation. The problem, of course, is that many adolescents are making the decision to begin smoking or to continue smoking without fully comprehending the power of the addiction involved.

Value Added of the Proposed Intervention Over TTM: Understanding Differences Between Adolescent Smokers and Adult Smokers
This intervention is based on the Eriksonian premise that the period of adolescence is a specific and unique stage of psychosocial development in the life of the individual. It helps to explain the folly of taking an intervention, such as TTM which has been shown to work for adults, and assume that it works for adolescents. Although Eriksonian theory predated neuroanatonical research employing technology such as fMRI, he seemed to know intuitively that the adolescent brain functioning was different from that of the adult. Thus, he postulated a specific stage of development unique to the adolescent brain which resolved in young adulthood. We now know that adolescents have less frontal lobe conductivity than adults; consequently, they have less executive functioning, and more difficulty in goal setting, controlling impulsive behavior and imagining the future. My intervention will specifically target these nascent abilities in adolescents and allow them to improve these skill sets at their own pace with the help of their peers.

Value Added of the Proposed Intervention Over TTM: Understanding the Adolescent’s Social World
Because Christakis has shown us that smoking is a network phenomenon (Christakis, 2008), my proposed intervention involves groups that not only comprise peers, but also are peer led. Erikson understood the importance of peers to the identity development of adolescents. My intervention uses the Eriksonian notion that adolescents overinvest themselves in their peers during this stage of development.
The importance of the nested social contexts of the adolescent, which include an individual’s family, peers, school, neighborhood, and wider social culture, needs to be addressed in any intervention that concerns adolescent smoking. My proposed intervention aids adolescents in exploring the influences of these constituents on their decisions concerning smoking. It also regards the media’s attempts to influence the developing identity of adolescents as it develops market niches for tobacco companies.

A Critique of the Current Anti-Smoking Efforts in Egypt – Gilan Abdelmegeed

Introduction:

In August 2007 the Egyptian government established the Smoking Control Department (SCD). The objective of the SCD is to create successful public health anti-smoking campaigns. After numerous unsuccessful anti-smoking laws, the SCD was established. Since 1977, a ban on all tobacco radio and television advertisements has been put into affect. A 1981 legislation required tobacco companies to print health warning labels on cigarette packs. It also banned smoking in enclosed public areas and on public transportation, including the subways and buses. The 1981 legislation was amended in 1994 to include a fine for smoking violations. In spite of the tobacco legislation implemented by the Egyptian government thus far, there has not been a decrease in smoking prevalence amongst Egyptians (3, 7).

Smoking in the Arab Republic of Egypt has evolved within the past 30 years to become a socially integrated behavior. Egypt has the highest rate of tobacco consumption in the Arab world, with a current prevalence of 40%, increasing at a rate of 8% per year. This percentage rises among certain professions with 45% of teachers and 43% of physicians smoking. There are 25 new smokers in Egypt per hour. According to the WHO, 1/3 of Egyptian smokers start before the age of 10, with the majority of adult smokers’ beginning before the age of 18. Smoking is responsible for over 150,000 deaths in Egypt annually. The direct annual cost of treating diseases caused by tobacco use is estimated at US$ 545.5 million. Smoking has become a way of life in Egypt, where children and adults alike are socially accepted to practice it (3, 6).

On August 1, 2008 the SCD launched an anti-smoking campaign. The strategy of the campaign is to reduce smoking prevalence through educating the public on the health affects of smoking on the smoker and on women and children through second hand smoke. The campaign requires tobacco companies to print graphic labels on cigarette packs depicting the health effects of smoking. The use of women and children targets the importance of family and children in the Egyptian community. It does not indicate that only males smoke, but instead, that the affect of second hand smoking on women affect children and family life consequently. This campaign fails in reducing smoking rates in Egypt because education does not result in action, it does not address smoker’s self-efficacy to quit smoking, and it does not acknowledge the social factors which are in fact the root of the smoking crisis in Egypt (3, 7).

Argument 1: Education does not Result in Action

The SCD fails to reduce smoking prevalence because education does not lead to action. The information written on the cigarette packs convey the negative health affects on the smoker and on smoker’s family life. These health effects include the health risks on spouses, children and developing fetuses. The graphic labels on the cigarette packs also illustrate the negative affect smoking has on personal and sexual relationships. Research has been conducted which supports the claim that education does not have a direct causal relationship with behavior change. The SCD campaign, which lacks an official title, is a classic example of the Health Belief Model (HBM). The HBM is a Behavior Change model which states individuals judge a behavior change by comparing the perceived severity and perceived susceptibility of the outcome of their current behavior. Individuals then compare the perceived benefits and the perceived barriers of the new behavior and from there, create an intention to act, which entails either changing the behavior or not. The intention is the only factor affecting the decision to act (2, 4).

The HBM, as well as the SCD campaign, are both too simplistic in their approach. The assumption that education will naturally lead to a change in behavior is naïve and flawed. There have been other Behavior Change models which demonstrate the flaws in the argument that solely education can cause action. The Theory of Reasoned Action (TRA) is a behavior model that builds on the HBM and states that the attitudes towards, and the perceived social norms of, the behavior change play a vital role in adopting an action. TRA also introduces the concepts of belief, attitudes and irrational behavior. The Theory of Planned Behavior (TPB) builds on the HBM even more to add a vital concept of behavior change: Self-efficacy. Self-efficacy is an individual’s belief in whether he/she can carry out the behavior change. The TRA and TPB demonstrate that intention is only a small part of executing an action (1, 2).

The current data on the demographics of smokers in Egypt illustrate that education is not sufficient for this campaign. First, with the prevalence of smoking being higher among the most medically educated proportion of society, education clearly does not have a negative affect on smoking. Second, in a study by the WHO in 2001, 82.1% of smokers said they had the intention to stop smoking. 60.9% of these people wanted to quit due to known health reasons (3). The majority of the population is already aware of the health affects, have the intention of quitting but are unable. Again, education alone is clearly insufficient. Third, the campaign is based exclusively on written health information, and at a 30% national illiteracy rate, the campaign is unable to reach a large proportion of the society (3).

Argument # 2: The Campaign Doest not Address Self-Efficacy.

The SCD campaign fails to provide the self-efficacy smokers need in order to quit smoking. Self-efficacy is an essential factor in promoting health behavior change. Three Behavior Change models support this: The Theory of Planned Behavior, The Social Learning Theory and The Social Cognitive Theory. All three theories state that self-efficacy is a vital part of behavior change. The Theory of Reasoned Action goes further to say that without self-efficacy one does not even have the intention to act (1, 2). The campaign ignores three important factors for smoker’s self-efficacy: the addictive nature of nicotine, the pleasures derived from smoking, and the habitual nature of smoking in Egypt.

The campaign falls short on addressing the addictiveness of nicotine. It does not provide alternatives to smoking, like the patch, nicotine gum or a social support network. The existence of such alternative measures is overall scarce in Egypt and are not well advertised nor understood. The campaign needs to acknowledge the need for biological and psychological nicotine rehabilitation. 45.4% of Egyptian smokers perceive smoking as an addiction. This campaign provides no means to show smokers that they have the ability to stop smoking. In fact, it shows that smoking is a circle of unhealthy, uncontrollable behavior (3).

The SCD campaign does not provide the self-efficacy needed for smokers to give up their personal gains from smoking. Smokers in Egypt identified the personal gains from smoking to be self-confidence, being fashionable and social acceptance. 26.3% of Egyptians say smoking increases their self-confidence and 24.6% say they find it fashionable (3). The campaign does not illustrate how one can quit smoking yet still maintain the perceived benefits.

The SCD does not acknowledge the habitual nature of smoking. Smoking is a daily or even hourly habit, easily accessible and affordable in Egypt. 46.6% of Egyptians perceive smoking to be a habit, resulting in 71.2% of smokers smoking at least once a day (3). The message is not given by smokers, instead by a government whom the average public has a hostile attitude towards. 88% of Egyptians believe that advertisement countering smoking is not enough (3). The campaign provides no successful examples of individuals who have been able to quit. Especially in Egypt where the default health role models, doctors and teachers, heavily smoke, the need for good examples to imitate is essential. Behavior Change Theories support the need for positive role models and outcomes. The Marketing Theory and Branding Theory both establish that you need to have a set of associations with what you are selling (1). In theory the SCD campaign is selling “stop smoking”; however it is not advertising it well. The SCD needs to represent the positive outcomes of the behavior change. It needs to represent the ability to make that change and to provide the self-efficacy.

Argument # 3: To change a social behavior you need to address the social norms

The campaign fails to address the fundamental social influence on smoking. It regards smoking as an individual problem, not as a group-level one. The campaign does not account for the pervasive nature of smoking, the cultural aspects which embed it into daily routine, or an alternate to, reduce the incidence of smoking.

Tobacco advertising on television and radio stations has been illegal since 1977 (7). However, tobacco companies simply do not need to promote cigarettes because social norms and networks have become the promoters. The popularity of smoking has been embedded into the culture and become socially acceptable. There is no stigma against it, and no encouragement for people to stop smoking. The SCD’s campaign is directing its efforts towards individuals to stop smoke. Instead, SCD needs to target the social networks. The Social Networking Theory (SNT) states that people exist in social networks not as individuals and people change as networks and not as individuals (1, 2). As smoking has become such a vast practice in Egypt, targeting each of the 35 million smokers as individuals, rather than as social networks, to quit is a resource-wasteful method.

The SCD ignores the traditional and cultural aspects of smoking in Egypt. Smoking in Egypt is socially acceptable where many smokers start early in their youth. Smoking is placed as a priority in social households and it builds on traditional Egyptian customs such as the Egyptian tobacco water-pipe, also known as the “shisha”. A number of Behavior Change theories state that social agendas need to be incorporated into campaigns. These theories include the SNT, The Agenda Setting Theory and The Framing Theory. All three focus on changing behavior at a social level that includes factors that influence the social, rather than the personal attitudes towards smoking. Smoking in Egypt is a cultural phenomenon; therefore, it needs to be addressed as a social problem. Most smokers start while they are still minors, with a 1/3 of smokers starting before the age of 10 (3). Youth are commonly sent to buy cigarettes, are given cigarettes by adults and often work in stores, markets and cafes which either sell cigarettes or serve “Shisha”. Their childhood involves cigarettes and smoking on a daily basis. By the time they reach adulthood, smoking has become a part of the norm.

The priority of smoking in the household is further evidence that smoking in Egypt is an acquired social practice. On average, 6% of the total Egyptian household expenditure is spent on tobacco (3, 7). This rate reflects a slight increase in total tobacco expenditure despite inflation in prices. Tobacco is considered an inelastic commodity in Egypt. Hence, even with the increase in tobacco taxation, the sales of cigarettes did not significantly decrease. Heads of family were simply increasing the percentage of income spent on cigarettes, where they have spent more on cigarettes than on activities and sports for their children combined. Smoking takes precedence over the activities and development of children which reflects the primacy of smoking in Egyptian households and hence Egyptian culture (3).

Smoking builds on traditional Egyptian customs and hence should be approached using social behavioral change theories. Cigarette smoking is similar to the “Shisha” or tobacco water pipe, which is consumed on a daily basis in social settings such as traditional Egyptian cafés, bars and restaurants. Smoking shisha has been a tradition for centuries. 92% of Egyptians who smoke cigarettes also smoke Shisha (3). This strong correlation suggests their influence on each other. Cigarette smoking mirrors the cultural practices, has become a tradition like the Shisha, and has been practiced everywhere. Interventions and campaigns will not be influential enough to stop this habit if they do not approach smoking as a tradition (3).

The SCD campaign ignores the social pressures to start smoking by not promoting smoking prevention methods. With such a large portion of smokers starting at a young age, smoking is socially embedded. The Branding Theory and The Framing Theory support a reframing of how people think of the behavior, reinforcing the core values of society. By ignoring the social factors of smoking in Egypt, the SCD is overseeing possible important points of intervention that are more influential. The objective of the SCD should be to reduce the prevalence of smoking and to reduce its incidence of smoking in Egypt as well (1, 5).

Conclusion:

The SCD campaign builds on the assumption that human behavior is rational, intentional and controllable. However, smoking counters these three fundamental behavior assumptions. Tobacco education is an important step towards reducing tobacco usage, but it is not enough. The SCD did not create a campaign built to target the Egyptian smoker specifically. The SCD is trying to promote quitting; yet it ignores the need to create preventative campaigns, the addictive nature of smoking and the social pressures pertaining to smoking in Egypt. It is far easier to prevent one from smoking, than to try to have them overcome an addictive behavior. Maintaining the SCD campaign will lead to minute results. To build a campaign based on educating individuals on the harms of a culturally integrated practice in Egypt is ignoring the fundamental problems and reasoning behind the harmful behavior.

References

¹Ball-Rokeach, Sandra. Defleur, Melvin. Theories of Mass Communication. White Plains, NY. Longman Inc. 1989

²Edberg, Mark. Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett. 2007

³Nasser, Heba. The Economics of Tobacco in Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

⁴Rosenstock IM. Historical origins of the Health Belief Model. Health Educ Monogr. 1974;2:328-335.

⁵Salazar, Mary Kathryn. Comparison of Four Behavioral Theories. AAOHN Jounral. 1991;39 128-135

⁶Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.

⁷World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.

Role Models as a Means to Alter Smoking Behavior Patterns - Gilan AbdelMegeed

Introduction

Tahader is a novel anti-smoking campaign aimed at addressing the ubiquity of smoking in Egypt. Tahader roughly translates from Arabic to mean development. In fact, Tahader means more than the development of infrastructure, health, and housing; it extends to the social and economical growth required for progress to occur. It is the concept that building personal traits, such as education, is needed for development. Tahader is a national goal. This campaign title links the concept of national and personal development to a smoke-free environment. It reframes the effects of smoking from an individual-level health problem to an issue of national development. The campaign utilizes Egyptian role models as a key means of improvement and change. The campaign creates role models, based on exalted personalities in Egypt. These role models are the major players in changing the social attitude towards smoking. The campaign is launched using the radio, television and billboards and well as other non-media methods. The role models are displayed through the media to increase the self-efficacy of smokers to quit, to reduce the accessibility of cigarettes and to bring about social change.

Section 1: Smoker’s Self-efficacy to Quit.

Tahader addresses self-efficacy of smokers by establishing support groups and by promoting the use of smoker alternatives such as nicotine gum and nicotine patches. The structure of the support groups are group meetings similar to the concept of Alcoholics Anonymous. These groups are complete with trained rehab doctors, rehab and medical facilities, and anonymity of members. Individuals can recruit themselves, or friends and family can call to recommend someone to join. Friends smoke together, but rarely quite together or support quitting. The support groups will provide an additional source of encouragement and support.

The alternatives to smoking, such as the nicotine patch and gum, will be advertised to the public through the media advertisements using the role models. This will allow for both a promotion of alternatives and a visual confirmation of their success and feasibility. Successfully promoting these alternatives is important as the public is not generally aware of them. Promoting alternatives will increase their self-efficacy as a majority of Egyptians perceive smoking to be an insurmountable biological addiction. The media advertisements will display the role models actively and effectively using these alternatives. Providing both social support groups and medical assistance will provide Egyptians smokers with the self-efficacy needed to stop smoking.

Section 2: Decreasing the Accessibility of Cigarettes

The second part of the campaign is to decrease the accessibility of cigarettes to children, youth, and adults alike. Enacting and enforcing laws prohibiting minors’ possession of tobacco have been ineffective (4, 5). Tahader is proposed to the Egyptian government for implementation. This campaign therefore proposes enacting laws to increase the taxes on tobacco products. Tahader decreases the accessibility of cigarettes by increasing the taxes on tobacco products. From the tobacco tax increases in 1995 and 2000, data show a decrease in cigarette consumption (4). The data also show a correlation between price and consumption. By increasing the price, the consumption of tobacco products decreased. Following this pattern, enacting an additional tobacco tax will result in a decrease in accessibility of cigarettes and a decrease in tobacco consumption.

Tahader tackles why youth start smoking, and provides the much needed role models that set the example for a smoking-free life. Youth start smoking due to boredom, expectancies, and social pressure (3). There are documentaries and films produced in Egypt which portray the common life of the Egyptian adolescent. These documentaries reflect on Egyptian adolescent’s relationship with smoking, it being a habitual behavior to fill the void of daily activities (1, 3, 5).

This campaign furthermore decreases accessibility by encouraging a more responsible adult-child relationship. Many Egyptian smokers begin at a young age (4, 5). Children obtain a large proportion of their cigarettes from adults, parents, and superiors at work and school (3, 4). The media advertisements include the role models displaying a more responsible approach to the adult-child relationship with respect to cigarettes. This includes refusing children tobacco, removing tobacco from easily accessible areas, and encouraging a smoke-free child environment. It redefines responsible adult behavior, encouraging adults to deal with tobacco in a manner that protects the youth from it. Increasing the tobacco taxes and promoting a responsible adult-child relationship concerning tobacco products will lead to an overall decrease in Egyptian smoker’s accessibility of tobacco.

Section 3: Stimulating a Social Change

Egyptian adolescents have a lack of local role models and this hinders changing smoking behavior patterns (1). Tahader creates role models who are reflective of the Egyptian culture and are representatives of Egyptians. The purpose of the role models is to help every youth in Egypt believe that they can become a role model as well. The role models are from four age groups: children, teenage adolescents, young adults and adults. These four categories are designated in order for the campaign to address each Egyptian with a representative of their age group. It will be more effective to have an adolescent address an adolescent as opposed to having an adult address an adolescent (2,3). Among each age group four different characters are demonstrated: the Rebel, the Family man, the Patriot, and the Successful Entrepreneur. These four characters were chosen because they represent four highly exalted personalities in Egypt (1, 3, 5). These four characters were also chosen because they play a role in Egyptian’s perception of Tahader. Development in Egypt goes hand in hand with education, success, patriotism, and family/friend commitment (1, 3).

In the media advertisements, the role models will each depict one of the four characters. In the advertisement, the role models will also demonstrate an active refusal to smoke by discarding of a cigarette or a cigarette pack. The role models will depict the characters by cliché actions. For example, the Successful Entrepreneur will be depicted by attaining a promotion at work or achieving high grades in school. The role models will be transparent and will have achievements within reach to the average Egyptian. These attainable goals send the positive message that Egyptians can become their role models. The visual affirmation of role models and of role model behavior will induce a social change in the attitude of smoking, not because of health risks, but because of a responsibility towards acting like the role models.

Conclusion

Tahader reframes smoking because it does not exclusively address the health affects. The campaign addresses how smoking affects an individual and national goal in Egypt. Tahader personalizes the problems arising from smoking. An increasing number of Egyptian youth and adults are suffering from a lack of role models (1). The role models provide a compass for behavior change, and are messengers and representations of commended personalities in Egypt. They add to the self-efficacy of smoking behavior change, and promote a responsible adult-child relationship regarding tobacco products. This campaign triggers a change in the attitude towards smoking. Tahader provides a different perspective on the types of damage smoking causes. Targeting matters of the heart induce the most response. The success of Tahader lies in encouraging Egyptians to become their own role model, and in doing so, alters their smoking behavior patterns.

¹Raweh Rageh, Egypt’s Youth Lack Local Role Models. Al Jazeera Network. 2009

²Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett. 2007

³Moustafa, Mohammed. Awqat Faragh, The Movie. Kalla, Hussein. 2006

⁴Nasser, Heba. The Economics of Tobacco in Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

⁵Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.

⁶World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.