Challenging Dogma - Spring 2008

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

Thursday, April 17, 2008

Limitations of Two Public Health Campaigns for the Promotion of Chronic Obstructive Pulmonary Disease Awareness – Ting-hsu Chen

Chronic obstructive pulmonary disease (COPD) affects over 11 million individuals in the US, primarily former and current smokers (1) and is the 4th leading cause of death in the US (2). The diagnosis of COPD, characterized by irreversible airflow obstruction, the inability to easily exhale inspired air, is made using pulmonary (lung) function testing known as spirometry in a physician’s office. There are two types of COPD: emphysema and chronic bronchitis. Limited public awareness and under-diagnosis of COPD have become of growing public health concern given the insidious nature of the disease and the percentage of the population affected in the 1990s (3).

Drawing upon the experience of public health campaigns in the field of cardiovascular medicine which had effectively raised awareness of risk factors in patients and altered treatment patterns of physicians (4), the National Lung Health Education Program (NLHEP) was established in 1997 with the goal of promoting awareness of COPD in a national campaign titled “Test your lungs; know your numbers.” (5) The campaign established a collaborative model amongst many professional organizations promoting early diagnosis and monitoring of COPD through the widely disseminated use of office-based spirometry and advocacy for smoking cessation.

In January 2007, with support from the NLHEP, the National Institutes of Health’s (NIH) Heart, Lung and Blood Institute developed the “Learn More Breathe Better” campaign which, in similar fashion, sought to promote awareness of COPD in individuals over age 45. Its three key objectives, as outlined on the campaign website are: (6)

1. Increase awareness of COPD as a serious lung disease—the 4th leading cause of death in the U.S.
2. Increase understanding that COPD is treatable.
3. Encourage people at risk to get a simple breathing test and talk to their doctors about treatment options.

The multi-part campaign targets both the public and healthcare providers to raise awareness of COPD. It uses a number of approaches in gaining a wide audience, but similar to the NLHEP’s campaign does not utilize potentially more effective behavioral change models to convey its message, repeating mistakes of the prior campaign.

Both campaigns fail to effectively utilize advertising theory to promote COPD awareness

Both campaigns fail to adhere to the principles of advertising theory by misidentifying their target audiences. This represents one of the key failures of both campaigns. While both programs developed separate materials for lay and professional audiences, many of these materials miss their intended target.

In a presentation to healthcare professionals (7), the NLHEP identifies primary care physicians, followed by the public, as their intended audiences. To that end, the NLHEP produced a series of posters (8) beginning with the words “To my patients…” and recommending medical follow-up for COPD that are intended to be placed in physicians’ offices and other healthcare settings. Yet in those settings it would reach only those individuals who already had access to the healthcare system. It would miss the population segment that either lacked access to the healthcare system or had chosen not to seek it out, for example, otherwise healthy smokers who have mild obstructive lung disease. Placement of these posters in a newspaper, magazine, or on public transportation would reach a broader public audience.

While partially addressed in the NIH campaign, the weighting of the NLHEP campaign’s target audience between healthcare professionals and the public is inappropriate. For example, one can compare the resources provided via the NLHEP website. There are six links in the “Resources for Patients” section with one outside web link while the section for healthcare providers features 17 documents on COPD alone plus an additional 20 external resource websites. A public awareness campaign driven primarily by busy healthcare providers is likely doomed to relative obscurity in comparison to a campaign effectively utilizing advertising theory within mainstream media and geared towards the public.

The NIH campaign features only a single type of print advertisement (9) featuring the letters “COPD” printed in large black, block type over a background of numerous, lightly printed descriptive phrases for difficulty in breathing, both in lay and professional language. The densely packed nature of the light print with its repetitive nature makes the advertisement difficult to read and may prompt some to simply skip reading it.

While the NIH campaign identifies current and former smokers over age 45, individuals already diagnosed with COPD and healthcare providers as separate audiences, the single print advertisement lumps the first two groups together. In combining non-diagnosed smokers with individuals carrying a diagnosis of COPD, the campaign does not consider that these two subgroups may have different barriers in accessing the healthcare system. Further, the group already diagnosed with COPD should be engaged by their healthcare provider for COPD management without placing the onus on the patient to initiate the discussion. A similar disregard for who should initiate the discussion is shown in the NLHEP’s poster campaign.

Evaluating the advertising campaign in the scope of a hierarchical McGuire’s communication-persuasion matrix (10), we can see improvement in the quality of the message source from the NLHEP, which was specifically created for COPD awareness, to the NIH which enjoys greater common name recognition. However, while the NLHEP program utilized the target audience to communicate its message through its multi-ethnic, multi-aged poster campaign, the NIH campaign took a step back through the creation of a generic advertisement that does not employ a human face to deliver its message.

In fact, the overall tone of the NIH message could be perceived as grim from the color scheme utilized, to the contents of the message which do not convey a lasting, empowering message. This delivery fails to consider the generally more effective impact of positive advertising from a marketing perspective.

Both the NLHEP and NIH materials aimed towards healthcare providers focus on primary care providers who are not routinely involved in administering and interpreting spirometry for the diagnosis of COPD. As such, both campaigns provide extensive resources for the diagnosis, classification and treatment of COPD. While such efforts may spread awareness of COPD as a separate clinical diagnosis in the professional community, they do not effectively address the target audience’s need for a means to incorporate these screening measures into the daily routine of a busy office practice. By merely supplying information on COPD, without presenting methodologies for efficiently incorporating screening into an office visit, the campaigns fail to facilitate self-efficacy to healthcare providers for executing the campaign goals. For example, a validated questionnaire for identifying COPD exist from the Confronting COPD Survey (11) which could be used as part of a screening questionnaire completed prior to seeing the healthcare provider.

Both campaigns inaccurately targeted their audiences and failed to utilize basic advertising methodology to deliver an effective message. This has resulted in continued need for improved public awareness of COPD perceived by both the public and healthcare providers (12).

Both campaigns focus too narrowly on the health belief model in courting behavioral change in addressing the pivotal issue of smoking cessation

Smoking cessation has been demonstrated to halt the progression of early smoking-related airflow obstruction and has been established to be of fundamental importance in the management of lung disease (13;14). However, a population-based screening program as envisioned in the NLHEP and NIH campaigns has met with skeptical opinions in the professional community with the American Thoracic Society and European Respiratory Society supporting such programs and the American College of Physicians and most recently the U.S. Preventive Services Task Force dissenting (15).

Spirometry, as a biomarker measuring the extent of smoking-related lung disease, has been shown to be a potentially useful counseling tool to elicit a greater desire for smoking cessation (16). However spirometry’s effect on actual cessation rates remains inconclusive (17). A more recent randomized, controlled trial demonstrated that a brief counseling intervention in combination with knowledge of spirometric values had a significant effect on smoking cessation rates (18). The study was underpowered to assess whether a differential effect by trans-theoretical stages of change was present, where individuals in the active stage were more apt to quit versus those in the pre-contemplative stage. It did conclude that individuals with abnormal lung function were no more likely to quit than those with normal lung function. This raises the question whether spirometry itself or the additional time and effort spent discussing abnormal results with the participants was responsible for the differential cessation rates.

There are clear discrepancies between intent for and actual smoking cessation and only a minority of individuals who intend to quit smoking actually proceed to do so. An estimated 70% of US adult smokers, responding to a CDC survey on smoking behavior in 2000, stated they wanted to quit smoking (19). Yet secular smoking trends in the US demonstrate that while smoking had declined between 1997 and 2004, between 2004 and 2006 the number of current smokers had not changed further with 20.8% of US adults reporting they were current smokers (20). While it is impossible to attribute the decline between 1997 and 2004 to any specific intervention such as the NLHEP campaign, the steady smoking rates between 2004 and 2006 suggest that present interventions including the NLHEP campaign are failing.

In this context, the focus of the NLHEP and NIH campaigns promoting spirometry as part of a health belief model intention-behavior pathway is misguided. Both campaigns have firmly entrenched themselves in this model beginning with their respective slogans: “Test your lungs; know your numbers” by the NLHEP and “Learn More Breathe Better” by the NIH.

The limitations of the health belief model pathway in smoking cessation have been abundantly demonstrated with a clear need to focus on additional behavior modification pathways to address a complex behavior with both societal influences and individual-level pharmacologic dependence (21). Training healthcare providers to not provide a “one-size fits all” approach but rather utilizing a personalized, trans-theoretical stages of change framework may produce better results when combined with pharmacological adjuncts such as nicotine replacement therapy. With the evolving understanding of the psychology of addiction (22), an over-reliance on the health belief model by the NLHEP and NIH campaigns fails to take advantage of progress made in the understanding of human behavior change.

Both campaigns fail to utilize social and group theory to make community advocacy a fundamental focus

A key component of public awareness for other serious diseases has been the creation of community support groups to raise local awareness of the impact of the disease. Breast cancer walks, substance abuse peer counseling groups and heart disease survivor groups all form the framework of community-based interventions around which behavior change can be encouraged and maintained. These types of participatory exercises empower individuals from a social-cognitive standpoint to recognize that they possess self-efficacy for behavioral change, be it abstinence from drugs, a heart-healthy lifestyle or lung function testing and smoking cessation.

Smoking has strong social contexts in its marketing and glamorous advertising (23). In these contexts, a campaign solely predicated on individual-level smoking cessation efforts is likely to fail. In framing COPD and smoking cessation as community-level problems, rather than an isolated, individualistic issue, it enables a combination of an individual trans-theoretical stages of change approach with a group social-learning approach to effect behavioral change in such support structures as group smoking cessation therapy (24;25).

Garnering community-level support for smoking cessation efforts must take into account secular changes in smoking prevalence in the US and an increased prohibition on public smoking with ensuing stigmatization of smokers. This becomes especially important in regard to smoking-related diseases such as COPD and lung cancer (26;27). Further, simply carrying the label of an incurable disease such as COPD, which brings with it strong association of self-inflicted injury through smoking, produces strong stigma. This can emanate both from self-blame or may be projected from others such as family, friends or even a healthcare provider. Addressing these barriers must be an important focal point of community-level interventions and can be accomplished with social-marketing theory to make it as acceptable to carry a label of COPD, as it is to be labeled with having breast cancer.

Regrettably, neither campaign makes strong in-roads in the development of community-level organizations, relying instead on partnerships with other national organizations such as the American Lung Association and American Thoracic Society. While these partners have pre-existing local chapters for the promotion of lung health, the national COPD awareness campaigns provide no significant new support to these chapters beyond a minimal outline on possible community activities (28) and a website on which to list local events which at present features only five community events in the entire nation (29).

Branding could be utilized as an effective national umbrella under which these local organizations could operate to promote COPD awareness and acceptance. The red ribbon for HIV/AIDS activism and the pink ribbon for breast cancer have generated significant public awareness of those diseases (30). A simple yellow bracelet is strongly tied to Lance Armstrong’s Live Strong foundation promoting cancer awareness. All of these symbols have been used as branding for public events, community organizations, support groups and fund raisers to raise awareness of the underlying diseases. Yet neither COPD campaign has opted to utilize such branding to find a single powerful image to rally around.


Despite efforts over the past ten years by the National Lung Health Education Program and now the National Institutes of Health to bring chronic obstructive pulmonary disease to the public forefront as an important and serious public health hazard, public perception has been limited. This has been in part due to ineffective messages delivered to an inappropriate audience and in part due to a lack of branding to make COPD easily recognizable in similar fashion to other chronic diseases.

Lock-step with COPD awareness is the importance of smoking cessation. In mirroring the NLHEP efforts, the NIH campaign’s focus on a health belief model does not capitalize on improved understanding of behavioral change models in furthering smoking cessation. By not emphasizing social and group dynamics to effect behavior change, both campaigns fail to utilize a powerful behavior change mechanism by not engaging the individual in a manner to counter-balance stigmatization, fear of labeling and glamorization of smoking.

However, through the input of public health professionals versed in behavioral and social sciences both campaigns may begin to adopt more effective techniques to promote COPD awareness and smoking cessation.


(1) National Center for Health Statistics NHISSS. American Lung Association, Epidemiology and Statistics Unit, Trends in Chronic Bronchitis and Emphysema: Morbidity and Mortality. 2004.

(2) National Vital Statistics Reports. Deaths: Final Data for 2004. CDC . 8-21-2007.
Ref Type: Generic

(3) Strategies in preserving lung health and preventing COPD and associated diseases. The National Lung Health Education Program (NLHEP). Chest 1998 February;113(2 Suppl):123S-63S.

(4) Voelkel NFM. Raising Awareness of COPD in Primary Care. Chest 2000 May;117(5):Supplement-375S.

(5) Petty TL, Weinmann GG. Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease. National Heart, Lung, and Blood Institute Workshop Summary. Bethesda, Maryland, August 29-31, 1995. JAMA 1997 January 15;277(3):246-53.

(6) Learn More Breathe Better Campaign. National Heart Lung and Blood Institute 2008;Available from: URL:

(7) Early Diagnosis of COPD. National Lung Health Education Program 2008;Available from: URL:

(8) The COPD Awareness Poster Project. National Lung Health Education Program 2008;Available from: URL:

(9) COPD: It Has a Name. National Institutes of Health 2008;Available from: URL:

(10) McGuire W. The nature of attitudes and attitude changes. In: Lindzey G, Aronson E, editors. Handbook of Social Psychology.New York, NY: Random House; 1985. p. 233-346.

(11) Mullerova H, Wedzicha J, Soriano JB, Vestbo J. Validation of a chronic obstructive pulmonary disease screening questionnaire for population surveys. Respir Med 2004 January;98(1):78-83.

(12) Halpern MT, Stanford RH, Borker R. The burden of COPD in the U.S.A.: results from the Confronting COPD survey. Respir Med 2003 March;97 Suppl C:S81-S89.

(13) Hasan SU. ATS statement--cigarette smoking and health. Am J Respir Crit Care Med 1996 November;154(5):1579-80.

(14) Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994 November 16;272(19):1497-505.

(15) U.S.Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008 April 1;148(7):529-34.

(16) McClure JB. Are biomarkers useful treatment aids for promoting health behavior change? An empirical review. Am J Prev Med 2002 April;22(3):200-7.

(17) Bize R, Burnand B, Mueller Y, Cornuz J. Effectiveness of biomedical risk assessment as an aid for smoking cessation: a systematic review. Tob Control 2007 June;16(3):151-6.

(18) Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008 March 15;336(7644):598-600.

(19) Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults--United States, 2000. MMWR Morb Mortal Wkly Rep 2002 July 26;51(29):642-5.

(20) Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults--United States, 2006. MMWR Morb Mortal Wkly Rep 2007 November 9;56(44):1157-61.

(21) Zimmerman GL, Olsen CG, Bosworth MF. A 'stages of change' approach to helping patients change behavior. Am Fam Physician 2000 March 1;61(5):1409-16.

(22) DiClemente CC, Schlundt D, Gemmell L. Readiness and stages of change in addiction treatment. Am J Addict 2004 March;13(2):103-19.

(23) Evans WD, Price S, Blahut S et al. Social imagery, tobacco independence, and the truthsm campaign. J Health Commun 2004 September;9(5):425-41.

(24) Wagner J, Burg M, Sirois B. Social support and the transtheoretical model: Relationship of social support to smoking cessation stage, decisional balance, process use, and temptation. Addict Behav 2004 July;29(5):1039-43.

(25) Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2005;(2):CD001007.

(26) Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ 2004 June;328(7454):1470.

(27) Johnson JL, Campbell AC, Bowers M, Nichol AM. Understanding the social consequences of chronic obstructive pulmonary disease: the effects of stigma and gender. Proc 2007 December;4(8):680-2.

(28) Event Planning Tips. National Institutes of Health 2008 April 3;Available from: URL:

(29) COPD Event Listing. National Institutes of Health 2008 April 3;Available from: URL:

(30) Vineburgh NT. The power of the pink ribbon: Raising awareness of the mental health implications of terrorism. Psychiatry 2004;67(2):137-46.

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  • At April 17, 2008 at 3:19 PM , Anonymous Ting said...

    I'd like to point out that "asthma" is the only lung disease related category in this blog while there's an umbrella "cardiovascular disease" category. This just goes to prove my point further.


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