Challenging Dogma - Spring 2008

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

Tuesday, April 22, 2008

Losing the Fight 4 Cessation – Dan Dao

One of the biggest issues that faces public health has been the battle against smoking. The complex connection between smoking and health was discovered with epidemiological testing (1) but now the battle that faces public health is to get individuals to quit smoking. Public health departments have used advertising as a way to publicize the message that smoking is bad (2). A new set of ads by the Massachusetts Department of Public Health demonstrates the failures and shortcomings of trying to scare people to change. The ad starts with Ronaldo Martinez talking about how he has lost his voice through throat cancer caused by smoking. The ad quietly ends with the phrase “fight for your life, quit now”(3).

Public health officials rely on fear as a motivator and believe that will make people change. The Ronaldo ad is based on the health belief model, which is a model that was developed to try to explain health behavior (4). The model has 4 main factors it bases health behavior on: perceived susceptibility, perceived severity, perceived benefit of an action, and perceived barriers to that action (4). The advertising developers believe in this model and that increasing perceived severity (through the use of fear) will promote behavior change (4). According to Rohit Baghavra the goal of fear marketers is to make some dangerous outcomes seem immediate and real which drives people into purchasing their products to avoid this outcome (5). In these ads they try to make smoking seem like condition that will kill you sooner rather than later. This is in essence what the health belief model states, but the main failure with this approach is that it has been used too frequently. What the health belief model fails to take into account is that this message has been repeated so much that most of the public is desensitized to it (6), other advertisers constantly revise their slogans and campaigns to make their products seem fresh and new. When people become desensitized to a message they do not take the threat seriously and view it more as a annoyance than warning (boy who cried wolf analogy) (6). One interesting view is that people do realize the dangers of smoking but this has rarely caused change and, therefore, these ads rarely cause change (6).
Although the fight for your life campaign still blindly follows by the health belief model they donot realize that most Americans cannot connect with the message. According to Nadra Weinrich these messages have to be semi-realistic so that the consumer will feel that the message is relevant to them (7). By having ads displaying situations that do not affect the average individual, the message is weakened; people do not fear the consequences of smoking because they feel that the outcome is unlikely to happen to them. This is counterproductive to the health belief model by decreasing perceived severity. When a message no longer can invoke fear in a population that message must be revised so that it can increase perceived severity, if it does not it is much less effective at creating change.

If quitting smoking was as easy as watching the F4YL commercial there would be no problem, the major mistake these ads make is that they fail to increase self-efficacy. The F4YL campaign focuses heavily on asking people simply to quit, but fail to give individuals any tools to increase their self-efficacy. These ads show what will happen if individuals do not quit smoking, but if you are smoking they do not give you many options and tools to quit. According to the social cognitive theory, two main factors determine change (8). Individual characteristics, that is a person’s self-efficacy about behavior, and environmental factors that are the social/physical environment they live in (8). According to this theory, if people do not feel as if they can change it is difficult for them to succeed, change then is not something people can accomplish on their own (8). A supportive environment with resources such as free nicotine patches and telephone support has been shown to increase the likelihood of cessation (9). F4YL fails in that their ads do not provide any way to increase self efficacy like giving tools and support, and by not doing this they do not increase self-efficacy, making people feel like they can not change.
In the ad featuring Kendyl Davis, she explains it as the hardest battle of her life to overcome her 33 year addiction (3). This ad, though, does nothing to increase efficacy or motivation. This type of advertising paints a bleak and dark struggle in change in the looming future. People who are dependent on smoking have huge obstacles, chemical dependence, withdrawal symptoms, and probably have the least experience in quitting (10). No where else in advertising do companies take an approach like this. Most advertisers want to make it seem easy and attainable to get to your outcome, i.e. (harder abs, better hair, endurance, cleaner carpet), they increase efficacy by showing before and after images and using testimonials. Advertisers have perfected this approach, by relying on the promise concept of marketing, they sell the goal that customers want and promise their customers their product can get them there (11). The advertising F4YL uses does not make us feel better about self-efficacy of cessation either, if anything it is disheartening. Compare this with a ad for the Ab Rockerâ which simply shows a product and people talking about how they got “rock hard abs”, they are focusing mainly on outcome and change in everday people. F4YL is not increasing efficacy at all in this way, if anything they are making the task seem harder which decreases self-efficacy and makes people less likely to change.

Social Norms
Social norms are important factors that impact behaviors and traditions. F4YL does not take into account these major considerations in their ads. These commercials portray smoking using individual horror stories but, in fact, smoking can be associated with how a person feels about smoking and, more importantly, how their social group feels about it. According to the theory of planned behavior, which bases changes in action on three criteria: a persons attitude towards an action, their perception of the subjective norms associated with that action, and the perceived power they believe they have over that action (12). The social norms are tied into the theory by being customary codes of behavior in groups and culture that have huge impacts on the actions people in those groups make (12). These ads never address that in some cases smoking is used as a way to interact with other individuals and family members, in these groups smoking is not only viewed as acceptable but as a way to connect (13). These are social norms defined by the group and by quitting they may feel they are not only judging their families/friends but also alienating themselves by not smoking anymore. These ads take no step in changing social norms or even dealing with them, people then have the very difficult task of trying to change in an environment that probably does not support them doing so. It would be very simple if these ads just had to change the mindsets of individuals but it many cases it needs to change the mindset of a group.
As long as there will be advertising from other smoking campaigns it will be very difficult to influence change, there must be a steady flow of self help and education in the public and on a community level (14). It has been shown that social norms are extremely difficult to quantify and measure; but one observation that has been described is that people need to buy into the message for it to become a social norm (15). Advertising like F4YL must then choose a different message that not only people but also groups can buy into and follow if it is to be effective. The problem recently in advertising has not been its presence but its substance, ads should reflect ideas and promises people can buy into and not just rehashing of scare tactics like F4YL.

The main issue here is that the complexity of smoking really cannot be addressed by a smoking campaign based on fear to cause change. New ads need to address the relevance of efficacy. Ads need to take into some account the idea of group dynamics and most importantly social norms. Public health is largely playing in an arena it fails to understand, by creating ads that are disconnected, gloomy, and worn-out. Advertising of this kind will never work, the public health school of thought would do well to understand how advertising and consumer culture works and to use those lessons when designing advertising.

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