England’s Maternal Prenatal Smoking Cessation-Robbie Frank

There are a number of successful smoking cessation interventions based on behavioral theories. Even though many smoking cessation interventions are deemed successful, none of the interventions are without flaws (12). In England, there is a smoking cessation intervention targeting pregnant women. This intervention is based on the theory of planned behavior (TPB). An intervention based on the TPB model is a fundamentally flawed approach to maternal prenatal smoking cessation because it is an individual level based intervention, it asserts that perceived behavioral control is a predictor of actual behavioral control, and assumes that human behavior is the output of rational, linear decision making process.
Intervention
The England Department of Health launched a smoking cessation ad campaign based on the TPB model targeting pregnant women (20). The ad shows an obviously pregnant woman smoking a cigarette. The campaign then goes on to provide information on how cigarette smoke “restricts the essential oxygen supply to an unborn baby, so that their tiny heart has to beat harder every time a pregnant woman smokes.” The campaign reinforces the message that cigarette smoking harms unborn babies, and that stopping smoking is the right thing to do (social norms say smoking when pregnant is bad). The ad also goes on to inform the reader that smoking cessation –no matter how far long the pregnancy is−will immediately benefit the woman and her baby (control belief—the belief in the ability to control the improvement of the health of mother and child will make it easier for the mother to participate in smoking cessation). It then offers information on how pregnant women can take the situation into their own hands and receive professional support to assist them in smoking cessation (perceived power). The offer of assistance in smoking cessation is meant to turn intentions into the desired behavior. This ad presents smoking cessation as a positive, desirable behavior that one can control.
Theoretical Framework of Intervention
To contextualize the flaws of the England smoking cessation intervention, it is important to understand the health behavior model upon which the intervention is fashioned. The TPB model was proposed by Icek Ajzen in 1985 as an extension of the theory of reasoned action (TRA). TRA is an individual level theory based on the concept that individuals go through complex cognitive assessments before making decisions on behavioral intentions. This is then followed by the rational movement from assessment to behavior (15). A person’s intent to perform (or to not perform) a behavior is viewed as the instant determinant of the action (13). TRA includes two determinants to intention: personal (attitude) and social (subjective norm). An attitude is described as a negative or positive evaluation of performing or not performing a desired behavior. Subjective norm indicates a person’s perception of the social pressure exerted by others who think that a given behavior should or should not be performed. This theory lacked because a person can go through the process of assessment and have a behavioral intention, but still not be able to do the behavior (13). To address this issue, a new element called perceived behavioral control was added to TRA. Perceived behavioral control refers to the degree to which someone believes they have control over whether they can take the action (control belief) and the strength of that belief (perceived power). This new element reformulated TRA to TPB. It attempts to explain the relationship between people’s attitudes and their behaviors, based on people’s perceived behavioral control and perceived power (13).
Flaws of Intervention
Individual Level Intervention

The ultimate goal of the ad intervention is to reach a broad target audience of maternal prenatal smokers and convince them to change to the desired health behavior of smoking cessation. This smoking cessation intervention is based on the TPB model. Due to such, this intervention has inherit flaws of the TPB model, one of which being that this intervention functions on the individual level. The ultimate goal of an individual level intervention is to change the knowledge, awareness, and skills of an individual. These types of campaigns focus on changing a specific aspect of an individual’s attitude, belief, and/ or cognition (27). This is a drawback in an attempting to change the health related behavior of a target audience because the enactment or non-enactment of the target audience’s behavior is likely a result of personal individual-level processes that precede the behavior. Because maternal prenatal smokers are not a homogenous group, different women will have different reasons for participating or not participating in the desired health behavior of smoking cessation. England’s individual level smoking cessation interventions does not take into account that being healthy and giving birth to a healthy baby is not a core value for all women. Due to such, a smoking cessation intervention must be able to find a common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation.
The individual level approach to maternal prenatal smoking cessation is unable to address the social factors that may influence the behavior of continued smoking. Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics) (22). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy. Some women have cited a socio-economic burden as a barrier to smoking cessation. These women are unable to fund smoking cessation aids such as cigarette modification products, thought changing products, and stop smoking educational products (22). In a study conducted by Greaves, research found that some women use cigarettes to “organize” their social interactions in order to build and bond pleasant social and work relationships (24). In other studies, pregnant women cited smoking as a tool of self definition. Continued smoking projected a personal image perceived by the smoker as cool, tough, defiant, adventurous, sexy, young, and slim. Smoking was also cited as a means through which pregnant women are able to suppress emotions or dissipate feelings of fear or pain in preference to expressing negative emotions openly. The behavior of continued maternal prenatal smoking was also influenced by the smoking habits of husbands, partners, family members, and friends. These factors can contribute to the difficulty of smoking cessation (2). An individual-level model is inappropriate in shaping a smoking cessation intervention for pregnant women because it neglects to acknowledge that the decision of smoking cessation is not necessarily made on and individual level and that there are a number of social factors that impact decisions related to health behaviors.
Perceived Behavioral Control is a predictor of Actual Behavioral Control
A fundamental defect of a maternal prenatal smoking cessation intervention based on the TPB is the assumption that perceived behavioral control is a predictor of actual behavioral control. It is postulated that perceived behavioral control serves as a proxy for actual behavioral control, therefore having a direct influence on both intention and the actual behavior (1). On the contrary, perceived behavioral control is fundamentally different from actual behavioral control. Perceived behavioral control is a strong predictor of the strength of a person’s intention to participate in a certain behavior (25), not a substitute or predictor for the actual behavioral control that a person possesses. Actual behavioral control refers to the extent to which a person has the skills, resources, and other prerequisites needed to perform a given behavior (19). Due to the conceptual difference between perceived behavioral control and actual behavioral control, it is inaccurate to assume that perceived behavioral control can predict or impact a person’s actual behavioral control. Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). The TPB model does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control.
In a study conducted on the influence of perceived behavioral control, research revealed that perceived behavioral control impacts behavior only through the prediction of a person’s behavioral intentions (8). Perceived behavioral control is a strong predictor of the intent to do a behavior, but not a predictor of the actual behavioral control a person possesses (25). The fulfillment of many health behaviors do not coincide with attitudes towards, or intentions regarding a specific behavior. The England’s maternal prenatal smoking cessation intervention possesses the ability to convince a pregnant woman to develop a strong belief that she has control and power over her ability to stop smoking. However, strong perceived power and control beliefs do not lead to actual behavioral control, which is necessary to act on the desired behavior intention. Strong perceived power and control beliefs lead to strong intentions to do the desired behavior. Strong intentions is not sufficient enough to illicit the execution of a desired behavior. Pregnant women must possess actual behavioral control in order to perform the intended behavior (19). The assertion that the belief of perceived behavioral control is linked to pregnant women’s ability to act on the intention to participate in smoking cessation is inaccurate. Actual behavioral control must be present in order for a person to act upon his/her perceived behavioral control. Without actual behavioral control, the pregnant woman does not possess the skills and resources necessary to enable her to exercise the intended behavior of maternal prenatal smoking cessation. It is therefore difficult to assess how the construct of perceived behavioral control impacts behavior modification without first understanding the role that actual behavioral control plays in the human decision making process.
Human Behavior is Rational and Linear
Due to the fact that this intervention is rooted in the TPB model, its design oversight assumes that behavior is the output of rational, linear cognitive decision making processes (15). Many behavioral theorists and social scientists argue that human behavior is complex and irrational, therefore difficult to predict (18). Irrationality is defined as the tendency that humans possess to behave, express emotions, and think in ways that are inflexible, unrealistic, absolutist and self- and social-defeating and destructive (16). In light of the irrational nature of human behavior, it cannot feasibly be asserted that decision making is a linear, planned process. Human behavior is affected by the broad social or cultural environment surrounding the behavior, the immediate social situation or context in which the behavior occurs, the characteristics or disposition of the person performing the behavior, the behavior itself and closely related behaviors, and the interaction of all these conditions (22). There are a number of factors that can cause a person not to carry out their planned behavior. In smoking cessation, the decision to use or not to use tobacco is linked with a range of factors, some of which have little or not relation with actual tobacco usage (22). The human decision making process is the result of a complex interplay between cognitive, emotional, social, personal, and environmental influences (16) that can often time lead to irrational, self defeating unplanned behavior.
Today, most pregnant women seem to be aware of the health risks associated with maternal prenatal smoking, however, awareness alone is not sufficient enough to prompt women to stop smoking (9.). Studies show that maternal prenatal smoking is not solely the result of a lack of knowledge of health risks associated with the behavior. It is instead the result of the human decision making process which is shaped by external factors that can persuade women to deviate from the planned, desired behavior of smoking cessation (7). The assumption that decision making is a linear process neglects to consider the extraneous factors that might influence the target audience’s behavior. In a study of women’s attitudes toward smoking, it was found that although most of the women in a focus group considered themselves addicted and dislike smoking itself, they liked the social, psycho-logic, and physical effects of the cigarettes (23). Some reasons given by women for maternal prenatal smoking included those related to an inability to cope with psychological issues (i.e., depression, anxiety, irritability, etc.) and their physical addiction to nicotine (the appearance of characteristic withdrawal symptoms when the use of nicotine is suddenly discontinued) (3). Other factors associated with smoking cessation for pregnant women are their level of education and their race. Research reveals that smoking cessation among pregnant women increases as their level of education increases (5.). In 1991, 45.4 percent (±10.5) of women with 16 or more years of education quit smoking during pregnancy. This finding is consistent with previously published studies (6, 11.). Studies also showed that the percentage of smokers who reported having quit smoking for at least one week during their pregnancy was higher among American Indian mothers (64 percent) than among white mothers (57 percent) or black mothers (49 percent) (26). The factors that impact the decision to participate in maternal prenatal smoking cessation are not all rational, nor are they part of a linear decision making process. The previously stated research helps to illustrate the fundamental flaw of a maternal prenatal smoking cessation intervention based on the TPB model because it demonstrates that the human decision making process is irrational and unplanned (10), thus completely contradicts the functioning of the TPB model.
Conclusion
Due to the inherent flaws and shortcomings of all health behavioral theories, there is no one theory able to adequately and accurately predict human behavior. Human behavior is complex and influenced by a number of intrinsic and extrinsic factors (12). When attempting to predict human behavior, it is important to examine behavior decisions in the context of the target audience’s needs, preferences, social and environmental networks, and core values. In regards to such, public health practitioners must design and utilize health behavior modification interventions based on appropriate health behavior models in order to continue to advocate for healthier behavior.
Introduction
In assignment #3, the fundamental flaws of a maternal prenatal smoking cessation intervention based on the theory of planned behavior (TPB) approach was highlighted. This paper addresses the fundamental flaws highlighted in assignment #3 by offering an alternative approach to the maternal prenatal smoking cessation intervention. To address the fundamental flaws of the TPB approach, the new approach is based on the framing theory. Framing theory asserts that an issue can be viewed from a number of different perspectives . These different vantage points can be interpreted as having implications for multiple deeply ingrained core values of a population. Framing refers to the process by which people develop a particular conceptualization of an issue or organize their opinions about an issue (30). Thus, framing theory redefines, repackages, repositions, and reframes behavior modification interventions in a way that addresses the fundamental core values and needs among the target audience (33). The framing theory approach improves upon the flaws of the TPB approach in assignment #3 because it functions on a community level, takes advantage of the fact that human behavior is irrational and decision making can be non-linear, and it understands that perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact whether or not a person performs a desired behavior.
Functions on Community Level
Unlike the TPB approach, the framing theory functions on a community level by addressing the wide-spread core values of the target audience. This theory does so by speaking to the packaging and positioning of a public health intervention to appeal to deeply ingrained, widely shared core values held by the target audience (33). A community level smoking cessation intervention must be able to address the common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation. Literature shows that health is generally important to individuals because it impacts their core values by garnering the fundamental need and desire to have a certain degree of personal freedom, independence, autonomy, and control over their lives (33). To market changes in health behavior, public health must redefine, repackage, reposition, and reframe the health behavior intervention in a way that satisfies an existing demand among the target audience (33). By redefining the problem, framing also suggest a new solution to the problem (35). Framing theory moves the maternal prenatal smoking cessation intervention from the individual level to the community level because this approach equips the intervention with the capacity to appeal to the core values of the general public (34).
While the underlying model in assignment #3 tries to change current health behaviors to fit with the suggested health behaviors, the framing theory recognizes that the target audience will only take action when they believe that the suggested behavior aligns with the core values of their community. Thus, the framing theory focuses on appealing to its audience’s widely accepted core values and not the health value of the public health practice (33). For example, if public health practitioners were trying to market a framing theory approach of smoking cessation to pregnant teenaged girls, the intervention should address the core values of this target audience. Research shows that continued smoking during pregnancy projects a personal image perceived by the smoker as cool, tough, defiant, adventurous, and sexy (29). The framing theory approach could use these core values to create an intervention that sends the message that not smoking during pregnancy is cool, tough, defiant, adventurous, and sexy. This repackaging and repositioning of teenaged maternal prenatal smoking cessation speaks to the core values of a large community of people, thus having appeal beyond the individual level.
Takes Advantage of Irrational Human Behavior and Non-Linear Decision Making

The framing theory takes advantage of the fact that human behavior is irrational and that decision making can be non-linear. This theory addresses the flaws from assignment #3 by using irrational human behavior and spontaneous decision making as means through which it can change the perception of a suggested behavior while ultimately changing the audience’s perception of self interest. It does so by altering the relationship between the perception of the behavior and the audience’s self interest. Framing theory does not assume the need to change its audience’s health behaviors to conform to the suggest health behavior. This model redefines the suggested behavior so that it is perceived as being in the audience’s self interest and addresses the audience’s core values (33). This will encourage the audience to participate in the suggested behavior. This is achieved by demonstrating that the intervention will help the audiences to fulfill its fundamental needs and desires.
For example, a maternal prenatal smoking cessation campaign based on the framing theory can use a group of core values; such as freedom, independence, and control, to frame an intervention. Instead of defining a smoking cessation intervention as a behavior that will improve a person’s health, it can be redefined to be perceived as a behavior that will offer smokers freedom from the tobacco industry’s manipulation, independence from the addiction of nicotine, and control over the fate of their lives. In this smoking cessation campaign, the solution to the problem of loss of freedom, independence, and personal control is smoking cessation. The irrational behavior and non-linear nature of human decision making enables the relationship between the perception of the audience’s behavior and the perception of the audience’s self interest to be altered by repackaging and repositioning a smoking cessation campaign to be about empowerment within the target community.
Perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact a person’s ability to perform a desired behavior

The framing theory accounts for the fact that perception of control over one’s ability to complete a behavior (perceived behavioral control) does not necessarily lead to actually having the power or control to practice that behavior (actual behavioral control). Perceived behavioral control does not lead to actual behavioral control because there are external factors that can limit a person’s ability to perform a behavior in which he/she might have perceived control over (13). Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy (22).
The TPB approach does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control. It does not consider the impact of external factors in a person’s ability to have actual behavioral control. The framing theory addresses this flaw by redefining, repackaging, repositioning, and reframing the health behavior intervention in a way that satisfies an existing demand or need within the lives of the target audience, thus, addressing the external needs and desires of the audience to enable them to participate in the desired behavior (33). For example, a group of pregnant women have the desire to stop smoking are offered an opportunity to participate in a free program that will assist them with smoking cessation (perceived behavioral control). Unfortunately, many of the women are unable to attend the weekly program due to transportation issues, lack of appropriate child care, work, etc. This means that these women do not possess actual behavior control to carry out their desired behavior of smoking cessation. A framing theory approach would restructure the health behavior intervention in ways that would satisfy the demands and needs within these women’s lives in order to give them actual behavior control to participate in smoking cessation.
Conclusion
Maternal prenatal smoking is a complex behavior that is influenced by a number of factors. The framing theory is able to addresses the different ways in which situational and personal factors influence a woman’s decision to participate in smoking cessation. The framing theory provides public health practitioners with a means through which they can define, position, and package a smoking cessation intervention in ways that address pregnant women’s core values and help to them to quit smoking.





Works Cited

References
1.) Ajzen, I. The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 1991: 50, 179-211.
2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
5.) Fingerhut, L.; Kleinman, J.; and Kendrick, J. Smoking before, during, and after
pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
6.) Floyd, R et al. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review of Public Health 1993; 14:379–411.
7.) Gillies, P., Madeley, R., and Power, F. Why do pregnant women smoke? Public
Health Sept. 1989; 103 (5): 337-43.
8.) Godin, G; Lepage, L.; and Valois, P. The pattern of Influence of perceived behavioral control upon exercising behavior: An application of Ajzen’s theory of planned behavior. Journal of Behavioral Medicine 1993; Vol. 16, No. 1. Springer Netherlands.
9.) Hymowitz, N. et al. Postpartum relapse to cigarette smoking in inner city women. Journal of The National Medical Association 2003; 95, 461−474.
10.) Morasco, B. et al. Spontaneous smoking cessation during pregnancy among ethnic minority women: A preliminary investigation Feb. 2006; Addictive Behaviors, Vol. 31, Issue 2: 203-210.
11.) O’Campo, P. et al. The impact of pregnancy on women’s prenatal and postpartum smoking behavior. American Journal of Preventive Medicine 1992;8 (1):8–13.
12.) Salazar, M. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Nurses Journal Mar. 1991; 128-135. Vol. 39, No. 3.
13.) Ajzen, L. and Fishbein, M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ., Prentice-Hall, 1980.
14.) Brown, L. Sex slaves: The trafficking of Women in Asia. London: Virago Press, 2000.
15.) Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett, 2007.
16.) Ellis, A. Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy. Promotheus Books, 2001.
17.) Rourke, J. International Politics on the World Stage. Fifth Edition International
on the World Stage, 10/. McGraw-Hill Higher Education, 2004.
1.) Ajzen, I. The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 1991: 50, 179-211.
2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
5.) Fingerhut, L.; Kleinman, J.; and Kendrick, J. Smoking before, during, and after
pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
6.) Floyd, R et al. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review of Public Health 1993; 14:379–411.
7.) Gillies, P., Madeley, R., and Power, F. Why do pregnant women smoke? Public
Health Sept. 1989; 103 (5): 337-43.
8.) Godin, G; Lepage, L.; and Valois, P. The pattern of Influence of perceived behavioral control upon exercising behavior: An application of Ajzen’s theory of planned behavior. Journal of Behavioral Medicine 1993; Vol. 16, No. 1. Springer Netherlands.
9.) Hymowitz, N. et al. Postpartum relapse to cigarette smoking in inner city women. Journal of The National Medical Association 2003; 95, 461−474.
10.) Morasco, B. et al. Spontaneous smoking cessation during pregnancy among ethnic minority women: A preliminary investigation Feb. 2006; Addictive Behaviors, Vol. 31, Issue 2: 203-210.
11.) O’Campo, P. et al. The impact of pregnancy on women’s prenatal and postpartum smoking behavior. American Journal of Preventive Medicine 1992;8 (1):8–13.
12.) Salazar, M. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Nurses Journal Mar. 1991; 128-135. Vol. 39, No. 3.
13.) Ajzen, L. and Fishbein, M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ., Prentice-Hall, 1980.
14.) Brown, L. Sex slaves: The trafficking of Women in Asia. London: Virago Press, 2000.
15.) Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett, 2007.
16.) Ellis, A. Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy. Promotheus Books, 2001.
17.) Rourke, J. International Politics on the World Stage. Fifth Edition International
on the World Stage, 10/. McGraw-Hill Higher Education, 2004.
18.) Skinner, B. Science and human behavior. Simon and Schuster, 1965.
19.) Actual Behavioral Control. Apr. 2, 2009. http://www.people.umass.edu/aizen/abc.html.
20.) Department of Health. New smokefree campaign aimed at pregnant women. Feb. 5, 2009. http://www.dh.gov.uk/en/News/Recentstories/DH_094115.
21.) Sharma, M. and Kanekar, A. 2008 Diffusion of innovations theory for alcohol, tobacco, and drugs The Free Library (April, 1), http://www.thefreelibrary.com/Diffusion of innovations theory for alcohol, tobacco, and drugs.-a0179277678 (accessed April 03 2009).
22.) “2001 Surgeon General’s Report-Women and Smoking.” U.S. Department of Health and Human Services: 2001. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001/sgr_women_chapters.htm.
23.) Greaves, L. “Background Paper on Women and Tobacco (1987) and Update (1990)” Health Canada, Ottawa: Health and Welfare Canada, Minister of Supply and Services, 1987 and Update 1990.
24.) Greaves, L. “The meaning of smoking to women. Proceedings of the Seventh World Congress on Smoking and Health.” Perth, Australia, 905-907, 1990.
25.) Gross, J. The perceived behavioral control of breastfeeding among pregnant
adolescents and its relation to postpartum breastfeeding difficulties. BSN
Honors Research. University of Kansas School of Nursing, 1:1, 2008.
26.) Sugarman, J. et al. The urban American Indian oversample in the 1988 National
Maternal and Infant Health Survey. Public Health Reports, 109 (2):243–50, 1994.
27.) Wallack, L. Mass communication and health promotion: A critical perspective. Mass Communication and Public Health: Complexities and conflicts, Newbury Park, CA: Sage, 1989.
28.) Ajzen, L. and Fishbein, M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ., Prentice-Hall, 1980.
29.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal. Jan. 15, 1995; 152(2): 163–166.
30.) Chong, D. and Druckman, J. Framing Theory. Annual Review of Political Science 2007; 10, 103-126.
31.) Fetchenhauer, D., Flache, A., Buunk, A. and Lindenberg, S. Solidarity and Prosocial Behavior: An Integraion of Sociological and Psychological Perspectives. Springer, 2006.
32.) Gross, J. The perceived behavioral control of breastfeeding among pregnant
adolescents and its relation to postpartum breastfeeding difficulties. BSN Honors Research: University of Kansas School of Nursing. 2008. http://www.kumc.edu/archie/bitstream/2271/412/3/Gross-2008 PerceivedBehavioral Control.pdf.
33.) Lotenberg, L. and Siegel, M. Marketing Public Health: Strategies to Promote Social Change. Jones and Bartlett Publishers. 2007: 45-71,127-152.
34.) Overview of agenda setting research: Symposium agenda setting revisited. Journal of Communication. 1993:43(2), 58-127.
35.) Wallack, A., Dorfman, L., Jernigan, D., and Thomba, M. Media advocacy and public health: power for prevention. Newbury Park, CA: Saga Publications, 1993.

“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 American Dental Association’s Oral Cancer Campaign: Raising Awareness And Positive Behavioral Changes, But to What Effect? - Amulya Jayanty

Introduction

The American Dental Association (ADA) in collaboration with Oral CDx Laboratories, Inc. Oral CDx, a vendor for oral cancer detection, conducted a three-year nationwide public service campaign in late 2001 to raise awareness of oral cancer (1). The campaign focused on increasing awareness of oral cancer as a means of inspiring people to take action and lead healthier lives.

Oral cancer involves abnormal, malignant tissue growth in the mouth.(2) Oral or mouth cancer involves lips, tongue, floor of mouth, cheek lining or palate.(2) The vast majority of oral cancer is attributed to the use of tobacco products (70-80% of oral cancer cases) that are smoked or chewed, with cigarettes being the major culprit (3-13). Men are affected twice as often as women, particularly men older than 40 (3). “Oral cancer strikes an estimated 34,360 Americans each year. An estimated 7,550 people (5,180 men and 2,370 women) will die of these cancers in 2007, according to the Centers for Disease Control and Prevention” (4-24) More than 25% of the 30,000 Americans who get oral cancer will die of the disease (3-4). According to a study African Americans are especially vulnerable, the incidence rate is 1/3 higher than Whites and mortality rate is almost twice as high (4).

The ADA campaign uses large billboards and posters to deliver the awareness message to people in 11 cities. One of the ads shows an attractive young woman with a spot on her tongue circled beside the slogan, “It’s tiny now. Don’t let it grow up to be oral cancer” Below those slogans are two more: “See your dentist,” and “Testing is now painless” (5-22). “We want people to realize that oral cancer is out there, that it's a big problem, and that if they have a suspicious condition in the mouth, they should see a dentist,” said Clayton Mickel, director of the division of communications for the ADA (6).

This paper aims to critique the current public health approach of the American Dental Association’s oral cancer campaign to raise awareness and positive behavioral changes towards early detection of oral cancer. The ADA oral cancer campaign fails to account for psychological, social and socioeconomic factors that determine a certain behavior, thus it fails to inspire people to quit smoking and alcohol consumption, and visit a dentist for the early detection of oral cancer. Self efficacy and attitudes towards certain behavior reveal an important driver to health behavior and should be used as a motivator and as a means of helping people address many of the barriers they face (such as socioeconomic status, access to care and distrust of health care system). Unfortunately, the ADA oral cancer campaign has ignored these data points because they are inhibited by the rigid, illogical structure of the Health Belief Model.

Flaw in basic design of campaign

The ADA oral cancer campaign was developed with the assumption that all health behaviors are rational, such that basic awareness of oral cancer risk will inspire people to visit their dentists and get screened. Coupling this postulation, seemingly derived from the Health Belief Model (HBM), which dictates people rationally weigh the benefits and costs of engaging in a specific behavior (7), the campaign assumes that intention to visit a dentist will lead to behavior.

The ADA oral cancer campaign appears to have been built on the HBM, as its primary aim is to make people understand that they are highly susceptible to oral cancer and that contracting it will cause considerable harm. According to the HBM, internalizing this susceptibility and potential severity should cause people to see the benefit of visiting a dentist and, therefore, cause them to intend to adopt this behavior. The theoretical basis on which the campaign is designed assumes that intention leads to action.

The campaign’s disregard for sociocultural and economic variables would further render the intervention ineffective. It assumes that once a person identifies oral cancer that he/she would visit a dentist. It does not consider the fact that those with oral cancer might not be able to afford going to a dentist in the very first place. Persons of low socioeconomic status are more likely to engage in high-risk behaviors, such as tobacco or alcohol use, a fact that may explain some of their poor performance on oral cancer indicators. (10)

The ADA oral cancer campaign fails to address important causes of oral cancer because it overlooks the psychological and emotional hardships that lead to the consumption of tobacco/alcohol which are the primary causes of oral cancer. The campaign featured two advertisements which stated the facts of oral cancer and how smoking leads to oral cancer. Emphasis is placed on the statistics of oral cancer and the association of it with smoking. The social and psychological factors that lead one to smoking are ignored. The campaign fails to address the basic driving force that makes people smoke or consume alcohol (such as when under stress or pressure, in order to be more sociable or just because it is cool to smoke or consume alcohol). (8)

The ADA oral cancer campaign sends out the wrong message

The campaign merely uses billboards that advise people to visit a dentist in case they happen to find a growth in the mouth. Emphasis is placed on visiting a dentist to test for oral cancer rather than the actual cause of oral cancer and the means of preventing it.

In the campaign conducted in 2001, Oral CDx gave ADA 2.5 million dollars to run the billboard campaign. (10) The words oral cancer and early detection are getting out there in the same sentence to an American populace that hasn’t even heard of the disease for the most part, let alone the need for early detection of it. But oral cancers are NOT like colon cancer that requires a polyp to exist before it can become full-blown cancer. (10) Or cervical cancer that requires an HPV infection prior to the development of a malignancy. There is no “mandatory” oral precancerous lesion that always appears before manifestation of this disease. (10)Many times even the primary disease itself can be occult and not visible, only detectable early through the palpation and touching of the tissues - feeling for indurations or hard spots, or in some cases the primary lesion is completely occult right up until a metastasis of the disease is discovered as an enlarged lymph node in the neck, and the primary is never found. (10)

The Oral CDx Brush Test is a method that dentists use to detect oral cancer. (9) This screening method helps sort out those who likely have the disease from those who do not. It cannot be equated to diagnosis of oral cancer. When Oral CDx does find abnormality, it usually means that the spot is dysplastic (with abnormal cells), not cancerous. (9)The reliability and validity of the test is also questionable. The gold standard for diagnosis of oral cancer is a conventional punch or incisional biopsy, and not the test suggested by Oral CDx.(10) Thus, people are given the wrong message that the painless testing method would suffice to determine whether oral cancer is present or not.

Whether the right audience is being targeted is questionable

The campaign featured two advertisements on billboards, bus shelters and taxi tops in 11 cities that read- “See your dentist. Testing is now painless”. (5) The ADA oral cancer campaign is restricted because the primary means of disseminating information to the people is through the use of billboards. It is highly correlated to income-level and geographic region, rendering the health information less accessible to a large proportion of the population.

The ADA oral cancer campaign strongly suggests people to develop a healthy relationship with their dentist to determine their risk of oral cancer. Yet in the general US population, distrust of the health care system is high. (11) This distrust in the health care system also varies considerably by race and culture. Significant racial differences in the level of trust (mostly amongst African Americans) in medical care have also been found to exist. (11)

The ad depicts a woman with a tiny little cold-sore dot highlighted on her tongue, and bludgeon the reader with these words of caution: “It’s tiny now. Don’t let it grow up to be oral cancer.” They also advise: “See your dentist. Testing is painless.” (5) So, the ads are ostensibly trying to stop cancer. You can’t possibly object to that. The scourge of cancer and importance of early detection is undeniable. The advertisements recommend going to your dentist, where – and this is just implicit – you are probably going to get a check up as long as you are in, and maybe wind up spending a bunch of money on fillings and other things.

The ads feature an attractive young woman (or just her tongue or mouth, by themselves) as the victim.The advertisement depicts a young attractive woman, which does not in the real sense depict a person with oral cancer. According to the patterns of oral cancer, the image of a young woman is highly deceptive. It may no doubt grab attention of the youngsters; however whether it really targets the population at high risk is questionable. In fact, when you look at the odds for a young city like Boston, it seems like a weird thing to try to inform every single Bostonian that they're at risk for oral cancer. Look at it this way: There are 589,141 people in the city of Boston. The US population as a whole is 477.68 times bigger than Boston itself, according to the US Census Bureau. Therefore, Boston probably suffers about 17 of the 8,000 annual deaths from oral cancer in the US. Does this warrant a campaign that most Bostonians will come in contact with every week, if not every day? (12) No. The ADA campaign is admirable in a way- it will probably save lives. But it will also needlessly panic a legion of cold-sore sufferers, and it squanders its money addressing the audience that is least at risk for this terrible disease. Properly targeted, the enormous sums of money the ADA is no doubt spending on this campaign could make an enormous difference against a terrible disease. Instead, dentists across the US will be making a large some of money from high-strung hypochondriacs of all ages stampeding in for their check up.

Conclusion

Through the oral cancer campaign, the ADA has the opportunity to bring about awareness of oral cancer by expanding its use of communication channels and rethinking its advertisement placement. Adjusting the content of promotional materials to take social and cultural as well as environmental and economic factors into account would make the messages and behavior modifications more realistic. Acknowledging that obstacles to adopting a given health behavior do exist, would serve to make the intervention a powerful resource and means of affecting health behavior change. With approximately 30,000 newly diagnosed oral cancer cases and 8,000 deaths annually, a vigorous agenda that includes education, policy and research initiatives, and taking into account social and behavioral sciences is needed to enhance oral cancer prevention and early detection.(5-19)

The ADA oral cancer campaign is built on the Health Belief Model, which does not take into account how attitudes and beliefs may affect a particular behavior. Thus, the reach of the campaign is restrained. This could be rectified by incorporating components of other health behavior models (Bandura’s notion of self-efficacy or the Theory of reasoned action that takes into account perceived attitudes, social factors and the belief that one can actually do the behavior) to address the obstacles people face in adopting behavior beneficial to their well being.(15) Also, if the ADA oral cancer campaign makes use of the Advertising Theory and promises to offer strong core values, support them with effective images would make the intervention far more effective in bringing about a positive behaviour(in this case to quit smoking and visit a dentist).(16)If these modifications can be made, the ADA oral cancer campaign still has a chance to make a true impact in not only bringing about awareness but also positive behavioral changes amongst the population.

References

1. http://www.ada.org/prof/resources/topics/cancer.asp

2. Medical Health Encyclopedia :Heath Care 2008

3. http://www.healthcentral.com/ency/408/001035.html

4. http://www.woodlandhillsdentist.org/adaoralcancer.php

5.http://jada.ada.org/cgi/content/full/135/9/1261

6.http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Dental_Group_Campaigns_for_Oral_Cancer_Awareness.asp

7. Rosenstock I.M Historical Origin of the Health Belief Model. Journal Health Education Monogr.1974 Volume 2 pages 328-335

8. http://ezinearticles.com/?Why-Do-People-Smoke-Cigarettes?&id=688804

9.http://www.oralcdxindia.com/

10. http://www.oral-cancer.info/?p=4

11.http://www.kff.org/minorityhealth/upload/Key-Facts-Racial-and-Ethnic-Differences-in-Medical-Care-Chartbook.pdf

12. http://www.flakmag.com/misc/adaads.html

13. Journal Cancer Causes and Control-Volume 15, Number 2/ March 2004

14. 2001 Journal of the California Dental Association

15 Journal: Cognitive Therapy and Research Volume 8, Number 3/ June 1984

16.The Quarterly Journal of Economics, Vol. 108,No. 4( Nov 1993) pp. 941-964- A Simple Theory of Advertising as a Good or Bad

17. Baden E. Prevention of cancer of the oral cavity and pharynx. Cancer 1987;37:49.

18. National Cancer Institute. Cancer statistics review 1973-1987. Washington , DC : US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1989. NIH publication no. (NIH) 88-2789.

19. American Cancer Society webpage.

20. National Institute of Dental and Craniofacial Research, National Institutes of Health, website 2007.

21. Funk GF, Karnell LH, Robinson RA, Zhen WK, Trask DK, Hoffman HT. Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24(2):165–80.[Medline]

22. Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA. The need for health promotion in oral cancer prevention and early detection. J Public Health Dent 1996;56(6):319–30.[Medline]

23. Ries LA, Miller AB, Hankey FB, Kosary CL, Harras A, Edwards BK, eds. SEER cancer statistics review, 1973–1991: tables and graphs. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1994. NIH publication 94-2789.

24. CDC and the National Institutes of Health. Cancers of the oral cavity and pharynx: a statistics review monograph, 1973-1987. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1991.