Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

Flawed Assumptions: the Success of Smoking Cessation Campaigns are Limited by their Reliance on the Health Belief Model– Jennifer Longacker

Smoking control and prevention is not a new concern in the field of public health. Cigarette smoking was linked to lung cancer as early as 1949, and by 1960 the Board of Directors of the American Cancer Society had concluded that, “the clinical, epidemiological, experimental, chemical and pathological evidence presented by the many studies reported in recent years indicates beyond reasonable doubt that cigarette smoking is the major cause of the unprecedented increase in lung cancer” (1). Individuals who stop smoking reduce their risk of early death, as well as their risk of developing several different types of cancers (2). Seventy percent of adult smokers in the United States report their desire to quit smoking and 44% have tried to quit at least once within the last year (2). Why then, nearly 50 years after the scientific and medical communities accepted the fact that cigarette smoking causes lung cancer, is smoking control and prevention still a major public health problem?

I will argue that smoking cessation interventions have not succeeded because public health professionals continue to rely on the Health Belief Model as the primary behavioral theory for the development of smoking cessation campaigns. Several assumptions central to the Health Belief Model (explained below) do not hold true when applied to this public health issue. Due to these flawed assumptions, public health interventions based on the Health Belief Model have had limited success in bringing about smoking cessation.

Since the 1950’s the Health Belief Model has been the primary behavioral theory used in the field of public health (3). This model states that individuals make health decisions first by taking into account their perceived susceptibility to, and the perceived severity of, the disease or health problem in question. They then weigh the perceived benefits of adopting the new behavior against the perceived costs of making this change. These four factors then lead the individual to form their intention to act, which then determines their actual behavior (3). To be valid, the Health Belief Model requires that we make several assumptions about the individual’s decision making process, primarily that: 1) individuals make rational decisions without outside influences, 2) intention determines behavior, and 3) the response to an intervention will be consistent across the population. I will argue that these assumptions do not hold true when this model is used in the context of smoking cessation, and this is the reason why public health campaigns have had limited success in controlling tobacco use.

Assumption #1: Individuals make Rational Decisions on their Own
The Health Belief Model assumes that individuals go through a methodical process when making health decisions. Often, though, decisions are made freely, without a systematic consideration of long-term health consequences (4). Also, the rational nature of the decision making process in the Health Belief Model does not allow for the concept of biochemical dependencies, such as the addiction to nicotine. According to the Centers for Disease Control, “Nicotine dependence is the most common form of chemical dependence in the United States. Research suggests that nicotine is as addictive as heroin, cocaine, or alcohol.” (2) This dependency is the reason why smoking cessation is an ongoing process, and may require several attempts to achieve lasting cessation. The addiction to nicotine makes rational decision making difficult in the process of smoking cessation.

In addition, the Health Belief Model focuses purely on the individual, and does not allow for the role of external influences, such as one’s social environment, in the decision making process (3). A primary example of an external factor in this setting is the influence of the media; the public is bombarded on a daily basis with conflicting messages about cigarette smoking. Big tobacco companies spent $8.2 billion in 1999 to promote smoking, while state public health agencies produced counter-advertising campaigns with budgets of less than 1% that amount (5). With limited resources public health campaigns must find creative ways to compete, like selectively running their ads to improve efficiency (choosing television channels, radio stations, and time slots frequented by smokers) (6,7). According to agenda setting theory, however, just by trying to compete with big corporations and calling attention to the public health message, these organizations are gaining recognition for the issue of smoking cessation (3). A cross-sectional research study by Spurlock demonstrated that every dollar (per capita) spent on counter-advertising resulted in an additional 26 smokers per 10,000 participants in cessation programs (8).

The process of quitting smoking is arduous. Since the decision to quit or to continue smoking is not often made rationally, nor without outside influence, the Health Belief Model is not the best theory to guide smoking cessation campaigns. As my next argument will illustrate, there are alternative theories which can be used to design more effective interventions.

Assumption #2: Intention Determines Behavior
The second assumption of the Health Belief Model is the belief that intention determines behavior. As mentioned in the introduction, most adult smokers in the United States want to quit smoking, and almost half have tried at some point within the last year, but the addictive nature of nicotine makes it extremely hard to quit (2). Clearly a disconnect exists between intention and behavior. Though individuals may intend to stop smoking, they may not possess the skills to do so. Even if an individual does possess these skills, it is often their lack of belief in their ability to perform the behavior that acts as the barrier between intention and action. Belief in the ability to perform a behavior, described by the Social Cognitive Theory as self-efficacy, can help individuals make the connection between intention and behavior (3).

Self-efficacy is an individual’s level of confidence that they can perform a behavior (3). The Health Belief Model does not take self-efficacy into account in the process of behavioral change. Instead of supporting self-efficacy by giving advice on how to quit smoking and providing successful examples, smoking cessation programs based on the Health Belief Model are primarily informational in nature, emphasizing the negative health effects of smoking. For example, the Massachusetts Tobacco Control Program’s (MTCP) 1993 to 1996 campaign entitled, “It’s Time We Make Smoking History” demonstrates how the application of the Health Belief Model to the issue of smoking cessation ignores the importance of self-efficacy (3, 9).

DeJong and Hoffman’s 2000 analysis of this campaign found that, “MTCP officials assumed that people must be scared into quitting when the research shows that the vast majority of smokers want to quit, have tried to quit before, but now wonder what to do next.” (9) Though the campaign included 8 smoking cessation advertisements, none mentioned: counseling, clinical treatments, coping skills and strategies, or nicotine replacement products. Two of the advertisements listed the number for the “Quitline”, but provided no further information about this resource (9).

An example of a smoking cessation campaign which uses the concept of self-efficacy can be found at GlaxoSmithKline’s “Nicorette” website (10). The advertisements found on this website use the Social Marketing principle known as targeting (3). This campaign has identified a core value that many smokers are searching for in their lives, control. The majority of U.S. smokers (70%) want to quit, and this campaign uses the promise of control (with statements such as, “You’re in charge with Nicorette gum”) to build self-efficacy (10).

Assumption #3: A One-Size Intervention Fits All
Since the Health Belief Model analyzes behavior at the level of the individual, it doesn’t take into account external factors that may influence an individual’s health decisions (3). This model, therefore, doesn’t allow for targeted interventions, customized for a particular group. The targeting of specific groups, known as audience segmentation, is an important principle of both Marketing and Communication Theory because it produces more effective campaigns. In DeJong and Hoffman’s analysis of the Massachusetts Tobacco Control Program, they criticized many of the advertisements for not targeting a specific audience. Uncertainty regarding the target audience also made it difficult for the authors to identify and analyze the intended destination (goal) of the advertisement’s message (9).

Audience segmentation can also identify fundamental causes of disease that my otherwise be overlooked. A recent (2008) study of smokers calling into a national helpline found that differences in smoking behavior when looking across sex and race cannot be explained by controlling for socioeconomic status (11). This means that, even when comparing the smoking behavior of individuals within the same socioeconomic group, we still find differences based on race and sex. Some of these differences may be explained using audience segmentation to identify the social norms, beliefs, and cultural experience of a particular group of people (3).

Yerger et al, for example, performed telephone interviews with African-Americans who did not use nicotine replacement products as cessation aids. The authors found that several subjects were concerned about using nicotine replacement products in regards to: the product’s status as a drug, the novel delivery method (absorption doesn’t allow the patient to control drug levels), and their potential for developing a dependency (12). These findings may be related to a fundamental cause of disease, such as a cultural distrust of the medical profession (and pharmaceuticals) stemming from a history of mistreatment by the medical community (3). Should these results be replicated on a larger scale, concerns regarding nicotine replacement products may help explain some of the race-related differences in smoking behaviors that would otherwise have been overlooked by an intervention using the Health Belief Model.

In conclusion, I have shown several limitations of the Health Belief Model. The assumptions of this model I have refuted include: 1) individuals make rational decisions without outside influences, 2) intention determines behavior, and 3) a one-size intervention fits all. These flawed assumptions have been used to design interventions which have limited success in bringing about smoking cessation. In its application to the problem of smoking control, the Health Belief Model oversimplifies a complex issue. I have suggested elements of several other models, including: Social Cognitive Theory, Social Marketing Theory, and Communication Theory, all of which are better equipped to deal with the complexities of smoking cessation campaigns.

1. American Cancer Society. Cigarette Smoking and Cancer: The evidence upon which the American Cancer Society’s position and programs are based. New York, NY: American Cancer Society, INC, 1963.
2. Centers for Disease Control and Prevention. Smoking and Tobacco Use, Cessation Fact Sheet. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2006.
3. Edberg M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Rust L. Prevention Advertising: Lessons from the Commercial World. Nicotine & Tobacco Research 1999; Suppl 1:S81-89.
5. Federal Trade Commission. Federal Trade Commission: Cigarette Report for 1999. Washington, DC: Federal Trade Commission, 2001.
6. Nelson DE, Gallogly M, Pederson LL, Barry M, McGoldrick D, Maibach EW. Use of Consumer Survey Data to Target Cessation Messages to Smokers through Mass Media. American Journal of Public Health 2008; 3:536-542.
7. Mosbaek CH, Austin DF, Stark MJ, Lambert LC. The Association between Advertising and Calls to a Tobacco Quitline. Tobacco Control 2007; Suppl 1:i24-29.
8. Spurlock AY. Policy Predictors of Participation in Adult Tobacco Cessation Programs. Policy, Politics, & Nursing Practice 2005; 4:296-304.
9. DeJong W, Hoffman K. A Content Analysis of Television Advertising for the Massachusetts Tobacco Control Program Media Campaign, 1993-1996. Journal of Public Health Management & Practice 2000; 3:27-39.
10. Nicorette Stop Smoking Gum. Quit with Nicorette. GlaxoSmithKline.
11. Andoh J, Verhulst S, Ganesh M, Hopkins-Price P, Edson B, Sood A. Sex- and Race-Related Differences Among Smokers Using a National Helpline are not Explained by Socioeconomic Status. Journal of the National Medical Association 2008; 2:200-207.
12. Yerger VB, Wertz M, McGruder C, Froelicher ES, Malone RE. Nicotine Replacement Therapy: Perceptions of African-American Smokers Seeking to Quit. Journal of the National Medical Association 2008; 2:230-236.

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