“Think. Don’t Smoke”: Why the Health Belief Model Makes the Campaign Ineffective- Simona Shuster

"In order to motivate someone to quit, you have to provoke a strong emotional response," Jenna Mandel-Ricci, director of special projects for the Department of Health, told the Daily News. "If we run ads that people don't remember or that don't affect people, then people won't call for help (1).” This statement can be extrapolated to describe any situation, particularly anti-smoking. Many a campaign has been created to show the ravages of smoking on the psyche and body on youth and adults alike, but to no avail. About half of all smokers who keep smoking will end up dying from a smoking-related illness (2). If information and campaigns are so prevalent about the horrifying effects of smoking, why is youth still determined to smoke?
Most anti-smoking campaigns remain failures because their messages are unclear or weak. Millions of dollars have been wasted in efforts trying to make people quit, but much of the ads are only informational in nature. Ironically, it is more the colorful and fun pro-smoking campaigns and billboards that most people remember and not their antithesis. Philip Morris is notorious for making the Marlboro Man, the iconic rugged man on his horse, smoking his cigarette, because that is what real men do, and to which other men can only aspire. Thus, when Philip Morris set out the venture to dissuade youth from smoking, most were surprised, but admittedly pleased initially with the “Think. Don’t Smoke” campaign that resulted. However, what looks too good to be true often is and this campaign, with its official message of discouraging youth from smoking, brings out many subliminal messages, least of which is the adage that was intended.
As an anti-smoking campaign, “Think, Don’t Smoke” failed miserably because it based its advertisements on the Health Belief Model. Many facets of the Health Belief Model do not hold true when applied to this public health epidemic. Thus, the campaigns built upon them can only have limited success in their endeavor to keep adolescents off cigarettes. This essay will focus on the 3 most influential flaws of the “Think. Don’t Smoke” campaign committed by Philip Morris, based on the Health Belief Model.
The Health Belief Model is the oldest model and upon which much of public health campaigns still rely. Its main premise is that human beings are rational creatures and behave in predictable patterns. Therefore, once the intent is present, it will lead to behavior. However, several crucial components stem into the intention. Perceived susceptibility is the degree to which a person feels at risk for a health problem. If the susceptibility is high, the person will have increased chances of committing the behavior. Perceived severity focuses on the premise that the person may believe the consequences of the problem to be harsh. Perceived benefits are the positive outcomes a person believes will result from the action, whereas the perceived barriers are the exact opposite as the negative outcomes. Once a person has carefully accessed all of the pros and cons of the making that choice, and it is their intention to do it, they will go ahead and commence with that conclusion.
Flaw #1: Youth Act in a Predictable Manner
The first incorrect assumption is the most hindering to public health campaigns and entails the premise mentioned earlier that youth will act in a predictable manner. However, people are predictably irrational and youth make it their stance to be deliberately so. The research that Philip Morris used primarily failed to account for the rationale of youth and their rebellious nature and determination to seek full independence and maintain decision making authority. It is precisely their irrationality that makes the ads unrealistic and to which adolescents cannot relate. The children found the Philip Morris adverts to be the least effective of all in making them “stop and think” about not smoking. Some of the respondents said that the Philip Morris adverts sounded more like a parental lecture, and overall there was a feeling that they lacked substance and good reasons not to smoke (3). Studies have proven that the worst campaigns are those reflecting an authority figure telling the adolescents what to do. In one example, a young teen is going out with friends and upon leaving, her father reminds her not to drink or smoke. She replies that she knows and does not do so when someone tries to offer her a cigarette in her group. The ad is cleverly done because the girl is in a group of her peers and says no. However, if one pays attention to the subtleties of the advert, he will notice that she did not even glance at the person offering her a cigarette which means that she either does not know this person or does not hold him in high regard. If she did, she would have more likely accepted his offer of a cigarette.
The ads are also clever in that they only focus on teens as their current ages and do not extrapolate into the future. It is a well documented fact that young adults do not think about their health in the future. The focus is more short-term and during their teen years, adolescents have yet to acquire any diseases that could be attributed to smoking. Heart disease and lung cancer seems a long way away to a 16 year old girl starting to smoke because of peer pressure. Her attitude may be “anyway by the time I get to 40, they will have a cure(4).” There are also no perceived barriers to smoking during adolescence because the negative outcomes will be much later in life. The perceived severity is greatly reduced as teenagers feel, precisely as a result of their youth, that they will be able to quit whenever they want. That is very true in that they will quit and start up again. Nicotine, a drug found naturally in tobacco, is highly addictive -- as addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to (dependent on) nicotine. Studies have shown that smokers must deal with both the physical and psychological (mental) dependence to quit and stay quit (2).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The next flaw of the “Think. Don’t Smoke” campaign is that, because it is based on the Health Belief Model, it does not take into account external factors and social norms. A University of Georgia study found that youth will only respond to a campaign because of peer pressure; they assume that their friends are interested and will be listening. Otherwise, the ads appear to stimulate the rebellious and curious nature of youth, making them more interested in smoking (5). One advert that Philip Morris uses does have a group of teenagers sitting around the steps leading to a beach and discussing how different all of them are and that is what makes them unique (6). This is the reason they cite for not smoking. Some teenagers may react well to this ad, but if they think their friends will scoff at it or notice their peers making fun of it, then they will partake in this action. "Perception is sometimes more powerful than actual behavior, that it doesn't necessarily matter how your friends respond to the ads, but how you think your friends are responding (5).” While Phillip Morris tries to capture individuality or independence that adolescents crave during their teen years by showing all of the teenagers together, it still fails to make a big impact upon other teens in terms of anti-smoking, but does a great job of convincing them to pursue the bad behavior. Those who do not share the thoughts and feelings of the youths presented in the “Think. Don’t Smoke” campaign simply do not relate to the ad. This latter group, however, has greater potential to become future smokers and should therefore be the main focus of a tobacco counter-marketing campaign (7). The point is supposed to be to make the advertisements very pragmatic so that teens can realistically see themselves in those positions and being able to avoid succumbing to peer pressure.
Flaw #3: The Slogan Is a Failure
The final flaw in the “Think. Don’t Smoke” campaign is the actual failure of the slogan itself. Firstly, the slogan manifests itself in a derogatory and patronizing manner, which teenagers will immediately find offensive. When one is commanded to perform an action, it will immediately set off a rebellious attitude against the stated action, despite the perceived benefits of knowing that the consequences of performing that action would be positive. Furthermore, the authoritative and negative tone of the slogan draws teenagers to counteract out of spite. Philip Morris says it has spent more than $1 billion on its youth smoking prevention programs since 1998 and that it devised its current advertising campaign on the advice of experts who deem parental influence extremely important (8). Clearly their research is not very thorough because adolescents do not want to be told what to do, especially not by adults. Therefore, the slogan is stating if one thinks, then he is listening to what adults have to say, and he won’t smoke. Teenagers do not want to be associated with thinkers because they are the “not cool” crowd. The ad is counter-productive in the sense that it specifically draws out the disobedient nature of youth who will relish the thought of smoking just to avoid being mislabeled into the wrong crowd. This is again where societal norms take precedence over what the individual may think. Teenagers do not want to be different, and instead form cliques that then generate the label to all who “fit in.” The campaign has failed to take into account what adolescents hold in esteem and have created ads that are ridiculous in content and scope. Also, a very basic and obvious critique of the campaign is the tackiness of the ads. It gives one the impression that the Anti-Smoking campaign, albeit spending over $100 million dollars to create, couldn’t really care less about the anti-smoking message and that each campaign involved the most minimal of efforts on the part of the creators and writers. Youth seeing these adverts could disregard them based on these tenets alone, not even bothering to query about the message the campaign is trying to convey. The campaign did the least well among youths in greatest need of messages that discourage smoking (9).
The failure of the “Think. Don’t Smoke” campaign can be relegated to the fact that Philip Morris created these adverts. It would be prudent to remember that these people are in the market of promoting cigarette smoking and addiction because it keeps them in business. They would never create logical campaigns to promote anti-smoking because they would lose their revenue base. For each smoker who dies, the firm then taps into the youth markets and recruits more by using more of these campaigns. Oddly enough, the Philip Morris website itself indicates that they are actively promoting youth anti-smoking and that their product is intended for adults. These phrases will make the idea of the all mighty cigarette even more idealistic to young adults who see this as a toy that can only be played with once they are grown. They will do everything in their power to obtain this product to be able to brag that they are performing the action only meant for adults. This is a predictable behavior of human nature. One will always want what one “can’t have.” A new study by the American Legacy Foundation gives conclusive evidence that Philip Morris’ latest efforts to clean up its image by running advertisements purporting to discourage youth smoking are nothing more than a sham. Instead of reducing youth smoking, they insidiously encourage kids to use tobacco and become addicted Philip Morris customers (10).

Using Advertising and Marketing Theories in “Infect Truth” to Counteract the Health Belief Model and “Think. Don’t Smoke.”- Simona Shuster

Insofar as many anti-smoking campaigns have failed to live up to the promise of their campaigns, “Infect Truth” comes out with a stunning victory over other efforts as they base their campaigns on young adults’ and adolescents’ core values. The “Infect Truth” adverts are the exemplary counterpart to the “Think. Don’t Smoke” campaign launched by Philip Morris. The campaign features young adults revealing messages about tobacco companies- they are often campy and catchy, with sing-song phrases and musicals. It is the only national smoking prevention campaign not directed by the tobacco industry, which exposes the tactics of the tobacco industry, the truth about addiction, and the health effects and social consequences of smoking. It is a national peer-to-peer intervention that works (11). The messages are very cleverly designed because they criticize the tobacco slogans in a manner that is clearly understandable to the layman.
“Infect Truth” resulted from a victory of the state of Florida over the tobacco companies in 1998. The State took the $13 billion per year settlement and formed the Florida Tobacco Pilot Program in 1997. The program set out to drive a wedge between the tobacco industry's advertising and a youth audience. It not only assembled a team of advertising and public relations firms to develop the marketing portion of the campaign but also directly polled Florida's youth. From this, emerged “Infect the Truth” in 2000, the campaign concept of a youth movement against tobacco companies promoted through a youth-driven advertising campaign (12).
The campaign uses the social models of Advertising and Marketing Theories, based not on the individual but rather on society as a whole, to drive its point. Advertising and Marketing Theories are ubiquitous in the advertisements and show “Infect Truth” as a global brand that all young adults now recognize. Advertising theory posits that the way to have people behave is to make them a promise and provide support for that promise that will in turn help people behave in said manner. In this instance, the entire premise and promise of the “Infect Truth” campaign is if youth knows the truth about smoking and its effects and more importantly, can relate to the messages conveyed, they will be less likely to begin smoking or continue smoking if already started. Marketing Theory takes Advertising Theory one more level with the branding of the product- which in this case, is “infecting truth” about smoking. The campaign does an excellent job of correcting the three flaws that were prevalent in the “Think. Don’t Smoke” campaign.
Flaw #1: Youth Act in a Predictable Manner
The “Think. Don’t Smoke” advertisements focused on campaigns that had children listening to authority figures. “Infect Truth” advertisements feature edgy, and rebellious multi ethnic teens rejecting tobacco marketing efforts and revealing stark facts about the deadly nature of tobacco (13) “Truth” accounts for the rebelliousness of teenagers by showing them ridiculous adverts based on the real results of cigarette smoking. The adverts work because of their ludicrous nature- the whole scheme is that as the commercial is over, one shakes his head and says “wow, that was stupid” and that is exactly the point because it makes the person stop and focus exactly on the meaning and in turn grabs his attention to the inanity of smoking. The advert entitled the Sunny Side of Truth (14) shows two young males in front of a large corporate edifice, meant to portray the tobacco company, with a table filled with poisons outlining the chemicals found in cigarettes. One says to the other- “cigarette companies must really hate us.” To which the other replies, “or love us- it’s called tough love,” then they break into song and dance about how cigarette smoking maims and kills. The adage that comes to mind with this commercial is “tough love- whatever doesn’t kill you, will only make you stronger.” Ironically, cigarettes will kill, or make one significantly weaker. The adverts use both a white and black actor so as to not prejudice the commercial. Framing the adverts in such a manner encompasses and promotes the unity of all teenagers, indicating that youth smoking is a problem across ethnicities. There are no parental roles showcased in these adverts- solely teenagers making a mockery of the tobacco industry so that other teenagers can see this and relate.
Seventy-five percent of all teenagers between the ages of 12 and 17 state that they can accurately describe one or more of the Truth campaigns and that the adverts gave them good reasons not to smoke (15). The point is to have young children not smoke now so that they need not worry about their future health, as it relates to smoking. “The Truth” campaign provides a return on investment that would make the greediest corporate CEOs salivate and if the Truth campaign continues for another five years (2009-2014) with similar effectiveness, there will be up to 500,000 fewer youth smokers with savings of up to $9 billion in future medical costs (11).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The “Infect Truth” campaigns, as based on the Advertising and Marketing Theories, greatly focus on external factors and social norms. These adverts intentionally do not use the Health Belief Model because of its individual nature. The adverts’ foundation, the promise indicated in the commercials, is their ludicrous nature that amalgamates youths’ opinion. The commercials unify youth by exploiting the asininity of the messages. The very nature of the message is intended to have youth scoff at it, but simultaneously pay attention. Therefore, no alienation will occur amongst teenagers as they will think the same. The advert entitled Box of Poison (16) shows several teenagers walking into a shipment facility and asking if they can ship cyanide and poison. The workers are astounded and obviously say that these ingredients are hazardous material and therefore illegal to ship. The teenagers entirely agree, but also maintain their stance that they want to send the product, finally letting on that the product is a box of cigarettes. The commercial manifests itself in a sneaky, but witty manner, in that the contents are presented first, before the merchandise is revealed. Furthermore, the commercial imparts information without being obnoxious and alienating people. Teenagers find the commercial to be very relevant and significantly changed their attitudes towards tobacco. “The Truth” campaign is successful precisely because it takes into account [advertising theory] and develops its ads using the best scientific research about how young people make their decisions about whether to smoke and what is most likely to influence them not to smoke [which is social perceptions] (13).
Flaw #3: The Slogan is a Failure
“Infect Truth,” unlike “Think. Don’t Smoke.” is a very straightforward slogan. There is no mockery, no gimmicks being implied nor orders being inferred. It is the truth that the adverts are maintaining and therefore cannot be labeled anything else. There are no subliminal messages and the meaning, most importantly, is very clear. The slogans in every truth advert also feature “Knowledge is contagious.” This is a very pithy comment, and yet absolutely genius, because it resonates with people. It is human nature to share details of what one has learned or heard, regardless of whether groups are discussing gossip, local and national news or more trivial matters. People communicate constantly and will discuss these adverts. Therefore, knowledge really is contagious. Case in point is the advert featuring the crawling babies with orange shirts (17). It immediately grabs one’s attention because they are “crying babies,” but also because of the message written on the shirt, stating that babies avoid second hand smoking by learning to crawl away (17). One’s initial reaction is incredulity of the message and then the necessity to share it with others. Using the television medium empowers the efficacy of the commercial to reach millions of people. Once very small children are affected, the message is much more effective.
Infect Truth is written at the end of each advert and manifests the advertising theory very successfully in the way the phrase is actually written. The word infect is in white and truth in black dots that seem to diverge. The point is to infect, or spread the contagious truthful knowledge. The promise behind this campaign is again infecting truth and spreading knowledge such that the promise of keeping children from smoking is realized and executed. The fact that these scenes are filmed in public places where ordinary citizens are allowed, even subtly encouraged to participate is key to the slogan. These people are spreading the contagion of knowledge by reading the messages (in Baby Invasion) or listening to the teenagers (Box of Poison, Sunny Side of Truth) and their very reactions cause teenagers’ perceptions to shift even more so because they see on national television that others are appalled and/or disgusted by the newfound information. These adolescents would therefore be more inclined to pay attention to the adverts from these reactions as well.
“The Truth” adverts, as myriads of studies have attested, are the only ones that make a positive dramatic impact on the perceptions and attitudes of teenagers. It is imperative to keep the focus on decreasing the prevalence of youth smoking. Although the Truth campaign’s funding was officially cut in 2003 by the tobacco industry because the latter lost its 99.05% market share, new adverts have begun to play again. The Citizen’s Commission to “Protect the Truth”, the only independent national youth counter-marketing campaign with demonstrated results in keeping children and teens from smoking, is demanding that the tobacco firms resume payment because ending smoking by American children and teens is crucial to their health and cost of healthcare to our nation (11). Moreover, the adverts themselves, and the message implied, are very concise and factual. There is no attempt to mislead anyone, but only to “infect truth.”


REFERENCES:
1. New York Daily News. Australian Anti-Smoking Campaign draws howls as boy sobs for mommy. New York, New York. http://www.nydailynews.com/lifestyle/health/2009/04/04/2009-04 04_australian_antismoking_commercial_draws_-1.html.
2. American Cancer Society. Guide to Quitting Smoking. Oklahoma City, Oklahoma. Http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp
3. British Medical Journal. “Don’t Smoke,” Buy Marlboro. Washington DC: Public Medical Central. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1115680
4. Tate, Peter. The Health Belief Model Explained for Patients. EzineArticles.com.<http://ezinearticles.com/?The-Health-Belief-Model-Explained-for-Patients&id=411478>.
5. University of Georgia. Why Some Anti Smoking Ads Succeed and Others Backfire. ScienceDaily. 6. Phillip Morris. Think. Don’t Smoke Campaign. Http://www.youtube.com/watch?v=Bh8YMaO-wsQ.
7. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.22
8. New York Times. When Don’t Smoke Means Do. Washington DC: The New York Times. http://www.nytimes.com/2006/11/27/opinion/27mon1.html.
9. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.18
10. Spivak, Joel and Berman, Michael. “American Legacy Foundation Study shows Philip Morris Think. Don’t Smoke Campaign is a Sham.” Washington DC: Tobacco Free Kids. http:www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=499&zoom_highlight=duplicity
11. Citizens’ Commission to Protect the Truth. Truth Campaign Can Save Half a Million Lives and Billions of Dollars. New York, New York. http://www.jointogether.org/news/yourturn/announcements/2009/truth-campaign-can-save-half.html.
12. Wikipedia Encyclopedia. The Truth Campaign.
http://en.wikipedia.org/wiki/TheTruth.com
13. Counsel for Amicus Curaie, National Campaign for Tobacco Free Kids. Columbia Expert Panel and the Florida “Truth” Campaign. Washington DC. http://www.lungcanceralliance.org/news/documents/ALFAmicusBrief2.pdf
14. The Truth Advertisement. Sunny Side of Truth. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
15. The Truth Campaign. New York, New York
http://www.protectthetruth.org/truthcampaign.htm
16. The Truth Advertisement. Box of Poison. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
17. The Truth Advertisement. Baby Invasion. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/

The CDC’s Attempt to Reach out to Low Income Women Across America: A Critique of the WISEWOMEN Program – Erin Najuch

In 1993 the Centers for Disease Control and Prevention (CDC) established the Well-Integrated Screening and Evaluation for Women Across the Nation Program (WISEWOMEN). WISEWOMEN is a program that aims to help low income women gain access to screening and prevention of cardiovascular disease and other chronic illnesses (1). WISEWOMEN attempts to address risk factors such as high cholesterol, high blood pressure, diabetes, obesity, physical inactivity, unhealthy diet, smoking and other factors that significantly influence the health of women (1).  

Federal money is provided to the CDC, which then is distributed to state and territorial health departments and tribal agencies (2 -3). The state agencies are then responsible for the WISEWOMEN programs. Each of the fourteen state programs are unique and designed differently. All WISEWOMEN programs are required to screen for high blood pressure and high cholesterol levels. The WISEWOMEN program also provides funding for confirmation of screening results and annual follow-up examinations. The WISEWOMEN program does not provide any treatment (2). 

Cardiovascular Disease in US Women
Cardiovascular disease is the leading cause of death for white, black, Hispanic and American Indian/Alaskan Native women in the United States (5-6). Approximately half a million women die each year from cardiovascular disease and 2.5 million women are hospitalized each year from cardiovascular disease (6). One in three female adults has some form of cardiovascular disease (5). Since 1984, the number of cardiovascular disease deaths for females has exceeded the number of cardiovascular disease deaths for males (5).

Numerous research studies show a correlation between socioeconomic status and cardiovascular disease in women. Women of low-socioeconomic status have a greater risk of cardiovascular disease than women of higher socioeconomic status (8-12). Women of low socioeconomic status have lower education levels and less access to health care than women of higher socioeconomic status (8-12). It is apparent that a national program to reduce cardiovascular disease in women with low socioeconomic status is needed, however, WISEWOMEN is not adequately designed to achieve such a goal. Based on the WISEWOMEN eligibility criteria, national locations of the program and the assumption that intention leads to behavior, the WISEWOMEN program is not an effective way to screen and prevent cardiovascular disease and chronic illness to all of the low income women in the U.S.  

Criteria to joining a WISEWOMEN program
Criteria to join a WISEWOMEN program either exclude or deter many women who could potentially benefit from the program. The WISEWOMEN programs are restricted to females between the ages of 40 and 64. Participants must be enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and either uninsured or underinsured and eligible for Medicare, but are unable to pay the premium (monthly payment) to enroll in Medicare, Part B. (1)  

WISEWOMEN is advertised as a national program to help low income women across the nation. However, this program only helps certain women. Cardiovascular disease increases with age. (5). Women that are age 65 and older are at the greatest risk for cardiovascular disease (5). In 2004, women over the age of 65 were accountable for 401,784 deaths from cardiovascular disease (5). Although women that are 65 years and older would benefit from joining a WISEWOMEN program, the age requirement restricts them from joining. In order to help decrease the prevalence of cardiovascular disease in low income women, the age requirement to join a WISEWOMEN program should be altered to include all women over the age of 40.

The second criteria to join a WISEWOMEN program is enrollment in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDP is also funded by the CDC and provides low-income, uninsured women screening and diagnostic services for breast and cervical cancer (13). Guidelines to join the NBCCEDP include uninsured and underinsured women at or below federal poverty level; ages 18–64 for cervical screening; ages 40–64 for breast screening (13). Originally, WISEWOMEN was an expansion of the NBCCEDP. Congress only provided enough funding for one-fifth of the women who qualify for NBCCEDP. (14). This directly affects the women that could potentially join a WISEWOMEN program. If eligible women cannot join a NBCCEDP program because of the lack of funding then they are not able to join a WISEWOMEN program (14).

The last criteria to join a WISEWOMEN program is that women must be uninsured. According to the U.S. Census Bureau, 47 million American are uninsured (15-16). Approximately 46% of the uninsured population are women (15-16). Although WISEWOMEN does provide health screenings to some of the uninsured women it does not provide health screenings to all of them.  

The lack of health insurance has been associated with lower health screening rates, reduced access to care and lower quality hospital care (10, 12, 15). Women without insurance are less likely to seek preventative care and more likely to seek emergency care than women who have health insurance coverage (10, 12, 15). Failing to have annual physicals and cardiovascular screenings is associated with increased mortality in women (12). A study conducted by the Division of Nutrition and Physical Activity concluded that uninsured women have worse cardiovascular disease risk factors, predominantly factors related to lifestyle such as smoking and exercise than women who have health insurance coverage (12).  

The WISEWOMEN programs provide health screenings and annual follow-up examinations but they do not provide treatments. Since WISEWOMEN does not provide treatment, women enrolled in the program who need follow-up treatment are going to have to pay high out of pocket costs for procedures and prescription drugs. Many women will have to decide between food or medication. Both may be necessary. In addition to the high out of pocket health care costs, the uninsured population may face other barriers such as language and transportation. Approximately 12.5 million Americans without health insurance are foreign born and may face language barriers to health care (16). Women that do not speak English or do not have an interpreter are less likely to seek medical care. Without the proper screenings, these women may be at risk for cardiovascular disease (16). Transportation is another barrier to health care. Women with a low socioeconomic status may not have reliable transportation to bring them to and from the doctor’s office or pharmacy. Public transportation is an alternative option but some smaller towns may not have public transportation available. 

Locations of the WISEWOMEN Programs
In addition to the criteria to joining a WISEWOMEN program, the limited states in which WISEWOMEN is available also contributes to making the program ineffective. WISEWOMEN projects are only available in fourteen states. Unfortunately, geography is a barrier to joining the program. If a WISEWOMEN program is not available in your state you cannot travel to another state, it is advised to contact your congressman and express your interest in the program if you would like to start one in your state. There is an association between income level and education and education and health insurance coverage (17). Most uninsured women below poverty level have a low education level as well (6). They probably do not know who there congressman is and they most likely will not have the resources to find out.

The WISEWOMEN program started in three states, Massachusetts, North Carolina and Arizona (18-19). Since its beginning, WISEWOMEN has expanded to fourteen states and has fifteen programs in total. In order to receive funding for a WISEMWOMEN program each state that applied went through a competitive bidding process (14). At the end of the funding period each state has to reapply for continued funding. Although the goal of WISEWOMEN is to reduce the prevalence of cardiovascular disease in low income women; poverty level, uninsured rates and cardiovascular rates of each state were not determinants as to whether or not a state receives funding from the CDC (14).

The majority of the WISEWOMEN projects are in the Midwest where the poverty rate, uninsured rate and deaths from cardiovascular disease are low compared to other regions in the nation (5, 20). The south on the other hand, has two WISEWOMEN projects and has the highest poverty rate, uninsured rate and deaths from cardiovascular disease (5, 20). In fact, out of the ten states with the highest rate of cardiovascular disease, only two of them have WISEWOMEN programs. Currently, the WISEWOMEN programs are not aimed at the target audience.

The Health Belief Model – Intention does not always lead to Behavior
The WISEWOMEN program appears to be based on the Health Belief Model (HBM). The Health Belief Model assumes that intention leads to behavior. The primary objective of the Health Belief Model is to make someone understand that he or she is susceptible to certain illnesses and diseases (cardiovascular disease). Components of the HBM include perceived susceptibility, perceived benefits, perceived barriers, cues to action and self-efficacy (21-23). The HBM is based on the individual considering the extent of risk involved and making a decision about whether or not to partake in a health behavior (21-23). WISEWOMEN provides women with the tools and knowledge that they need in order to make healthy lifestyle decisions. The lifestyle changes include becoming more physically fit, adopting healthy eating habits and leading a smoke-free life (18-19). WISEWOMEN programs recommend that women exercise on a consistent basis. WISEWOMEN does not provide fitness memberships to all women who need to exercise. Instead, WISEWOMEN suggests that women purchase a fitness membership with their own money. Low-income women need to provide food, shelter and clothing for themselves and their families before they can even consider a fitness membership. WISEWOMEN may suggest daily walks. This will work for some women but not for all. Most low income women live in government subsidized or low rent housing. These areas may be unsafe and therefore women will not be utilizing “free exercise” (24).

The WISEWOMEN program may recommend that women decrease their caloric and fat intake each day. This would require women purchasing and eating fruits and vegetables. Eating healthier foods may be more expensive to purchase. Women that are below poverty level are going to buy the foods that they can afford which may be high in fat and calories. Women enrolled in the WISEWOMEN programs may rely on small neighborhood stores that do have fruit and vegetable options (2). Women enrolled in the WISEWOMEN program may have every intention of eating healthier and exercising more in order to reduce their risk of cardiovascular disease but their socioeconomic status may prevent them from doing so.

The second reason why the WISEWOMEN program should not be based on the HBM is because the HBM assumes that everyone has both access to care and knowledge to make rational decisions about a health behavior (21). Access to health care is not something that is feasible to all low income women. In addition, there is an association between socioeconomic status and education level (16). The women that the WISEWOMEN program is trying to target may not have the knowledge to make rational decisions about their health.  

Instead of basing the WISEWOMEN program on the Health Belief Model, it should be based on a model that takes into account the relationship between the individual and all the external factors that play a role in a low income woman’s life. Socioeconomic status, environment, culture and education level significantly influences the lives of the women enrolled in the WISEWOMEN program. It order to be a successful program, WISEWOMEN needs to be comprised of the external factors as well as the individual factors.

 
WISEWOMEN has the ability to be an effective cardiovascular disease screening and prevention program for low income women. By expanding the eligibility criteria and re-evaluating the program to include the states with the highest rates of uninsured and cardiovascular disease, WISEWOMEN could be a very influential program. Although WISEWOMEN projects have helped thousands of women, there are thousands of women still waiting for help. When the program is re-evaluated the critical barriers such as language, unsafe neighborhoods and the access to healthy foods must be considered significant factors. WISEWOMEN has the ability to become a program that could successfully help alter the cardiovascular and chronic illness rates of low income women in the United States.

References

1. Centers for Disease Control and Prevention. WISEWOMEN Program. Atlanta, GA: Centers for Chronic Disease Prevention and Health Promotion, 2007
2. Will J. et al Health Promotion Interventions for Disadvantages Women: Overview of the WISEWOMEN projects, Journal of Women’s Health 2004; 13: 484-500
3. Farris R. et al Expanding the Evidence for Health Promotion: Developing Best Practices for WISEWOMEN, Journal of Women’s Health 2004; 13: 634 -643
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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.

Conclusions

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.

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