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

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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.
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pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
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Health Sept. 1989; 103 (5): 337-43.
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“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/

Anti-Smoking Campaign Amongst Youth in Nigeria: A critique of the Social Marketing Theory – ASHAYE AJIBADE OPEOLUWA

INTRODUCTION
Over the last decade there has been a significant increase of youth smoking in Nigeria. According to the World Health Organization (WHO), there was a ten fold increase in smoking among young women between 1990 and 2001.1 A survey conducted by the WHO in the southern part of Nigeria revealed a smoking prevalence of 23.9 % among male youths, 17.0 % among female youth and an overall prevalence of 18.1%. 2 Smoking is harmful to nearly every organ of the body; causing many diseases and reducing the health of smokers in general.3 The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States.4, 5 More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murder combined.4,6

Active smoking causes most leading causes of death worldwide: cancers, cardiovascular diseases, chronic respiratory diseases, and respiratory infections. Not surprisingly, smokers have a substantially reduced lifespan in comparison with never smokers. Tobacco smoking causes diminished health and several problems such as cataract and gingival disease. Smoking by women adversely affects nearly all aspects of reproduction. Even though the health effects of active smoking have been under investigation for decades, new adverse health effects are still being identified. As recently as 2002, the list of cancers caused by smoking was expanded to include cancers of the liver, stomach, and cervix, along with acute leukemia.7 Tighter controls need to be instituted in the control of tobacco so that the growing epidemic does not wipe out the working population of developing countries like Nigeria.

The issue of smoking and health is complicated by the fact that Governments of developing countries have been slow to arrest tobacco smoking because of the large government revenues derived from the manufacture and sale of tobacco products. Tobacco is grown commercially and is relied upon to bring in foreign exchange through export, or revenue for the government if sold on the home market. Consequently, in some nations the ministries of health and of agriculture are working at crossroads. Transnational tobacco companies take full advantage of the present lack of legislation in most African countries on the promotion and use of tobacco.

While countries in the western world are making attempts at reducing the levels of cigarette smoking, not much is being done in the developing countries. Thus, while there is a significant decline in smoking rate in the United States and Europe, in the developing world such as Nigeria, the smoking rate increases by at least 20% each year. There are social factors that help contribute to the increase in smoking in Nigeria.

The Federal Governments fight against Tobacco has largely been on the basis of the Social marketing theory which is a combination of theoretical perspectives and a set of marketing techniques. It is defined as the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group. While not trying to discredit its effort, the Nigerian Government needs to employ additional behavioral model changes in its Anti-tobacco control campaign in ways that will be acceptable to the youth.

SOCIAL MARKETING THEORY AND SMOKING

The Federal Ministry of Health in Nigeria adopts the Social marketing theory in its anti smoking campaigns. These campaign involves the use of Billboards are erected in several locations throughout the country bearing warning signs about the harmful effects of tobacco smoking. Most of these bills boards are not attractive and are not located in places where they can be easily seen by the youth. They are on major highways and in the health care centers, clinics and other health care delivery centers. It has however not been effective as evidenced by the growing prevalence of tobacco smoking amongst the youth population. The present billboards need to be overhauled and their content adjusted to messages that will appeal to the youth population. The messages appear coercive and judgmental thereby limiting its effectiveness. Also, youth do not like to be told what to do, they want to be able to make their own decisions and be responsible for it.

More appealing billboards and TV adverts need to be employed in the fight against tobacco smoking. Information is being given without the necessary skills to change behavior. It also assumes that behavioral change, is largely a result of changes in beliefs, and that people will perform behavior if they think they should perform it. However, according to Prochaska and DiClemente (1986), behavioral change occurs in five distinct stages, Pre-contemplation, contemplation, preparation, action and maintenance. The later (maintenance) is lacking in the anti-smoking campaign. They should be given skills necessary to effect changes in behavior and to maintain such changes.

SMOKING AS A GLAMOROUS HABIT
The issue of acceptance is paramount amongst youth; they want to be among, do not want to be the odd one amidst their group. Tobacco industries make the youth believe that smoking makes them look mature, independent and courageous. Most youths who want liberation quickly buy the entire ideas of tobacco companies. So as soon as thy get into their teenage years, they want to pick up habits that are seen to be for adults. With this declaration is made however subtly, that they have now become of age and can take decisions of their own as deemed appropriate. Instead of bunging correct information on relationship between cancer and tobacco smoking, the big tobacco companies buy over some reputed scientists to refute correct research about tobacco smoking and health. In most of the French-speaking West African countries, you see three of four youths sharing a stick of cigarette. They use it to express their love for each other. In mall, youths inter-viewed claim that cigarette makes them strong and gives them courage. Unfortunately it is a false courage.

The present antismoking campaign in Nigeria does little or nothing in portraying smoking as a harmful habit other than the billboards it erects and the health warnings it requires some cigarette companies to place on their packages. Youth learn more by modeling and not by being ordered or given rules. Rules may play a role but advertisements that depict acceptable social behavior by modeling will be more efficient. This can be in the form of peer modeling or modeling by adults or icons in the society. Youth tend to identify with this role models and their influence can be positively harnessed. Behavioral change in the youth could be maintained by ensuring that they belong to the right peer group, one that supports the promoted behavior (not smoking). In the past two decades social marketing campaigns have been conducted in developed countries as well, to bring about other kinds of behavior change: smoking cessation, diet, condom use, helmet use and other preventive health behaviors. There is a great deal of literature on some very successful programs in developing countries.8

SOCIAL ACCEPTABILITY AND SMOKING
Even though smoking is not socially acceptable in Nigeria, tobacco companies have made tremendous efforts in increasing the social acceptability of tobacco smoking in the youth population and in the country at large. They have employed Cultural sponsorship as a marketing strategy. They have done this by sponsoring youth programs like Sport competitions, Movie shows and talent hunts all to increase access to the youth. A good example is Benson and Hedges who now sponsors some festivals as a way of projecting and expanding its product and market. Their products are clearly displayed in such festival. In Schools, they sponsor inter-school cultural activities and inter-house sports competitions, giving the youth the impression that cigarette smoking gives them courage, equality with adults, and makes them feel like adults. An example is the British American Tobacco (BAT) which commands about 78% of the cigarette market in Nigeria. The tobacco firm took a number of blockbuster films, including the Matrix and Ocean's Eleven, around the country in a domed travelling theatre with 500 seats and a wide screen and called it the "Rothmans Experience It Cinema Tour". Posters for the films were overlaid with pictures of packets of Rothmans and free cigarettes were handed out to people buying tickets.

The anti-tobacco campaign has not demystified the various myths and legends associated with smoking. Smoking is widely thought to offer a number of benefits, as in other African markets, it is believed to aid/speed digestion and to prevent vomiting after eating. Smoking is also said to aid/speed excretion hence it is a common practice for smokers to have a stick when they go to the toilet. It is also believed to be a stimulant especially in cases of depression. This and many more beliefs that individuals hold drive their demand for tobacco smoking. The FGN and the Ministry of Health (MOH) will need to intensify its effort in disseminating appropriate health education messages. Wrong beliefs needs to be dispelled with appropriate health information as pertaining to tobacco smoking.

IMPLICATIONS OF SMOKING AMONGST NIGERIAN YOUTH
With annual cigarette import of the increase (20 million sticks in 1970 to 2.966 billion sticks in 2000) 9, it is imperative to create anti-tobacco campaigns that are effective in reducing the initiation of tobacco smoking especially amongst the youth and also to reduce tobacco consumption in the nation as a whole. Other control measures have been introduced without much effect. Such include the cigarette taxes and duties, enforcing anti- tobacco laws. This can be done by encouraging private companies’ participation in the fight against tobacco smoking encouraging them to sponsor anti-tobacco programs and also encouraging the numerous antismoking Non Governmental Organizations that are springing up in the country.

As seen with the Florida Youth Tobacco campaign, The Florida TRUTH anti-smoking campaign built a new product and branded it. The product/action was being cool by attacking adults who want to manipulate teens to smoke. The campaign reduced the price of the behavior (attacking adults) by selecting adults everyone agreed had been manipulating them. They created places where kids were found by means of a statewide train caravan and the founding of local "Truth chapters." And, of course, they used promotion - but promotion that went beyond the traditional media ads to having kids directly confront the tobacco industry and publicize this teen "terrorism" in the popular media. The Campaign routinely carried out surveys of its target audience that allowed the campaign to discover important micro-market segments (South Florida Hispanics) where impacts were lagging. The Truth campaign has been a dramatic success; it is now the model for the Legacy Foundation's national anti-smoking campaign. In just two years, from 1998 to 2000, the percent of Florida middle schoolers who smoked cigarettes in the past 30 days fell from 18.5 to 8.6 percent while the percentage for high schoolers went from 27.4 to 20.9. 10

The Present Anti- Tobacco campaign in Nigeria needs to employ the strategies used in the Florida Youth Tobacco Campaign (FYTC), merchandise like t-shirts, key holders, baseball caps, and other branded materials can be distributed via an official campaign van at teen functions; youth advocacy groups should be encouraged as they will serve as a peer groups that will positively reinforce the acceptable behavior of ‘not smoking’ and increase youth empowerment through community involvement. Facilities need to be put in place to reduce the availability of and youth access to tobacco products and reduce youth exposure to second- hand smoke. Unlike in South Africa, for instance, it is still legal and common in Nigeria for cigarettes to be sold individually which makes it easier for children to afford them. Stricter control measures need to be in place like it’s done in other parts of the world where one requires an ID to purchase tobacco products.

CONCLUSION
The antismoking campaign adopted by the Nigerian government will work effectively if other social marketing methods are used in the campaign. Community-based participatory research should be encouraged as this provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. Ads asked youth to directly confront the tobacco industry and publicize this teen activism in the popular media. There is still an opportunity to change the situation that exists in Africa especially NIGERIA by learning from the experiences of other public health interventions, such as those for the HIV epidemic. The interventions appear to have reduced the risk behaviors by utilizing the existing infrastructure such as antenatal clinic. Applying this model to the current situation, it may be possible to provide public health information on the risk of smoking and exposure to environmental tobacco smoke.

In many modern societies, smoking has been an acceptable norm. It used to be socially acceptable in Europe and the United States but is less so now. This is because large-scale tobacco control programs have been instituted in such countries with increasing effectiveness. The mass media provide effective tools for convincing youth not to smoke; because they can communicate prevention messages directly to young people and influence their knowledge, attitudes and behaviors (Hopkins et al, 2001). Mass media campaigns usually achieve long- term success but they must be framed in ways that are attractive to the target population especially the youth. Research has also shown consistently that tobacco counter – marketing campaigns are most successful when they are part of a broader, comprehensive tobacco control activity.

REFERENCES
1. Nigeria takes on big tobacco over campaigns that target the young
http://www.guardian.co.uk/world/2008/jan/15/smoking.britishamericantobaccobusiness
2. Smoking Prevalence. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
4. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 1997–2001. Morbidity and Mortality Weekly Report [serial online]. 2002;51(14):300–303 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm.
5. Centers for Disease Control and Prevention. Health United States, 2003, With Chartbook on Trends in the Health of Americans. (PDF–225KB) Hyattsville, MD: CDC, National Center for Health Statistics; 2003 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus031.pdf.
6. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of the American Medical Association 1993;270: 2207–2212.
7. Tobacco Free Japan: Recommendations for Tobacco Control Policy, 2005. Health Risks of Smoking.
8. DeJong, W. Condom promotion: The need for a social marketing program in America's inner cities. Am J Health Promotion, 1989;3(4):5-10.

9. SMOKING PREVALENCE. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
10. Social Marketing Institute; Success Stories – Florida Youth Campaign. http://www.socialmarketing.org/success/cs-floridatruth.html

Losing the Fight 4 Cessation – Dan Dao

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

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

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

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

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

References
[1] Doll R. Lung cancer and other causes of death in relation to smoking. British Journal of Medicine 1956; 2(5001): 1071–1081.
2 McAlister A, Morrison TC, Hu S, et al. Media and community campaign effects on adult tobacco use in Texas. J Health Comm 2004; 9(2):95-109.
3 Massachussetts Department of Public Health. Make Smoking History: Fight4YourLife. Make Smoking History .
4 Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr 1974; 2:Entire Issue.
5 Baghavra, Rohit. Influential Marketing Blog: Fear Marketing. Influential Marketing Blog .
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7 Weinreich N. Spare Change: Making Fear Based Campaigns Work. Spare Change .
8 Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice Halls, 1986.
9 Solomon LJ. Free Nicotine Patches plus Proactive Telephone Peer Support to Help Low-Income Women Stop Smoking. Preventive Medicine 2000; 31:68-74.
10 Stanton WR. Adolescents' experiences of smoking cessation. Drug and Alcohol Dependence 1996; 43:63-70.
11 Gronroos C. On definining marketing: finding a new roadmap for marketing. Marketing Theory 2006; 6:395-417.
12 Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall,1980
13 Thompson KA. Women's perceptions of support from partners, family members and close friends for smoking cessation during pregnancy- combining quantitative and qualatative data. Health Education Research 2004; 19.1:29-39.
14 Flay BR. Mass Media and Smoking Cessation: A Critical Review. American Journal of Public Health 1987 77(2):153-160.
15 Fehr E. Social norms and human cooperation. Trends in Cognitive Sciences 2004; 8(4): 185-190.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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