Tuesday, May 4, 2010

A Critique of Fight 4 Your Life, a Massachusetts Tobacco Cessation Campaign – Andrea Lenco

Fight 4 Your Life is a tobacco cessation public health campaign created in 2008 by the Massachusetts Tobacco Cessation and Prevention Program at the Massachusetts Department of Public Health. The campaign involves television commercials, subway posters, and a website that feature vignettes of real people who successfully battled to quit smoking (1). The vignettes focus on how difficult it is to quit smoking, and the rewards to quitting, such as health, a longer life, and being able to take care of one’s family. Despite pre- and post-campaign telephone survey evaluations that found a 9.4% increase in quit attempts among the target audience, I argue that the Fight 4 Your Life campaign is flawed for three main reasons (1). First, as an individual level approach, the campaign seeks to change risk behaviors of one person at a time, framing smoking as an individual failure. This is inefficient and unrealistic. Second, the campaign focuses on avoiding negative health outcomes rather than gaining positive outcomes through smoking cessation. Third, the Fight 4 Your Life campaign is based on a model that assumes people engage in planned, rational behavior.
A Critique of Individual Level Interventions
The Fight 4 Your Life smoking cessation campaign is an individual level intervention; it seeks to alter tobacco-related risk behaviors of the population, one person at a time. Campaigns focused on individual behavior change rely on unrealistic notions of the impact of personal behavior on health, and fail to address the environmental factors associated with the risk behavior. The disease or unhealthy behavior is framed as a failure of the individual and the wider social context in which the individual’s behaviors and beliefs exist, such as family and social influences, and community acceptance or promotion of risk behaviors, are ignored. Individual level interventions also fail to identify the political barriers to behavior change, and who constructs and benefits from these barriers – such as the excess advertising by the tobacco industry in lower-income neighborhoods (2).
Smedley and Syme’s discussion of the ecological perspective tells us that there are multiple levels of influence affecting the health behaviors of individuals, such as social relationships, neighborhoods and communities, and social and economic policies (3). In the case of smoking, individuals often smoke in a social context, and are heavily influenced by the behaviors and attitudes of their peers. Neighborhoods and communities can promote or deter smoking by, for instance, strictly upholding laws that prohibit tobacco sales to minors. Social and economic policies affect smoking behaviors in the population with smoking bans in restaurants and other public places, and heavy taxes on tobacco products. Dhalgren and Whitehead’s general framework for the determinants of health depict these layers of influences as an onion-like structure, with the individual at the center, surrounded by the larger context of social and community influences, living and working conditions, and general socioeconomic or environmental conditions (4).
Social Cognitive Theory introduces the concept of reciprocal determinism, which describes “interactions between behavior, personal factors, and environment, where each influences the others” (3). This theory explains some drivers of individual behavior change such as positive or negative reinforcement. Examples of negative reinforcement for smoking might include smoking outside in the cold while patronizing a bar that no longer allows smoking indoors, and doing so alone while all of one’s friends (perhaps former smokers who have successfully quit) remain inside to socialize.
The Diffusion of Innovations is a useful group level model that describes the way in which behavior change moves through populations of people through geographic proximity and the pressure of social networks (5). As opposed to individual level models that predict each person choosing and executing behavior change in isolation, this group level model identifies direct interactions between individuals as the precursor to adoption of a new behavior. The behavior adoption progresses through the network in an exponential fashion, until only individuals who are strongly opposed to the new behavior have not adopted the behavior change. Because of this exponential spread of behavior change, the Diffusion of Innovations model describes adoption of a new behavior as a network-based decision. Behavior change has a cumulatively increasing influence on a network of peers. As the pressure to conform builds and perceived risks decrease as more peers adopt the behavior (5). Studies show that smoking cessation programs that modify a person’s social network by providing peer support groups are more successful than those that rely on isolated individual behavior change (6). The Fight 4 Your Life campaign does not appear to provide any type of support – particularly peer support – to the target population.
A Critique of the Fight 4 Your Life Frame
The Massachusetts Department of Health’s Fight 4 Your Life campaign focuses on avoidance of possible future negative health outcomes related to smoking, some – such as lung cancer – which may not materialize for decades. Studies in the Journal of Personality and Social Psychology show us that people are unrealistically optimistic about future life events, and believe that experiencing future negative events is unlikely. These studies ascertain that educating individuals about the attributes, actions, and outcomes of others, as in the Fight 4 Your Life campaign vignettes, works to reduce optimistic bias but does not eliminate it (7). Further nationally representative studies show that even heavy smokers and those with other cardiac risk factors have unjustifiable optimism in regard to the possibility of future heart attacks or lung cancer (8).
If individuals commonly deny their own personal risks from unhealthy behaviors, this means that smokers are not likely to worry that they could be affected by tobacco-related illness in the future when viewing a public health advertisement that warns about the risks of disease caused by smoking. A more effective public health intervention would approach behavior change in a way that offers something desirable to the individual in exchange for behavior change, rather than simply rewarding the behavior change with an avoidance of future negative health outcomes.
Marketing Theory tells us that to successfully sell a healthy behavior change to the population, we must appeal to their core values, such as freedom or free enterprise, independence or economic opportunity, control, fairness or equality, and community or a sense of belonging, among others (9). Fight 4 Your Life does not invoke a promise of fulfillment of these core values in the campaign’s attempt to convince the population to buy into smoking cessation. Theories of social branding indicate that public health campaigns like Fight 4 Your Life fail to establish trust with the target audience because they do not take into consideration the perceived benefits of the risk behavior. This type of campaign also has a negative tone and does not appeal to emotion or offer any realistic behavioral alternative (10).
Framing Theory describes the ways in which we position an issue to the public (9). The Fight 4 Your Life campaign attributes the responsibility for smoking, and smoking cessation, to the individual. This does not set up smokers for success, as the frame used isolates the individual and blames them for their failure. A more strategic use of framing would frame the behavior change, or the identity of “non-smoker” as aligning with some core value of the public, such as independence or economic freedom.
The Fight 4 Your Life campaign was intended to reach people in lower-educated and lower-income groups, where smoking rates have remained high despite a steady decline in other demographics over the past twenty years (1). The only apparent way the campaign reaches out to this demographic in particular is by using the stories of real lower-educated and lower-income people in the vignettes. The campaign seems to ignore the fact that those working and living in disadvantaged communities inherently exhibit more health risk behaviors as a means of coping with stressful circumstances, and have fewer resources (such as time and money) with which to manage behavior change (4). A more effective public health intervention would directly address the environmental and social factors that disproportionately affect the health behaviors of socio-economically disadvantaged groups, by reshaping social policies and cultural norms that, for instance, target lower-income areas for heavy tobacco advertising.
A Critique of Planned Behavior
The Fight 4 Your Life campaign is based on a model that assumes individuals are engaging in a rational cost/benefit analysis and planning out their quit attempts. The individual is defined outside of any context in which there may be emotional rewards for continuing to smoke. In reality, human behavior is usually unplanned and driven by visceral influences that crowd out all logic and self-efficacy. Critiques of the Transtheoretical (Stages of Change) Model, in which individuals plan to change a behavior and take steps toward that change, claim that human behavior reflects the moment-to-moment balance of motives, is often irrational, and entrenched in context (11).
Several studies on smoking cessation have shown that more than half of reported quit attempts involve no planning or preparation – not even as far as finishing the current pack of cigarettes (12,13). These unplanned quit attempts were also more likely to be successful. The results of these studies indicate that a “catastrophe theory” or “chaos theory” is a more accurate description of the complex and ultimately unstable motivational forces behind individual behavior change. As it is unknown what factors will ultimately tip the balance and lead an individual to quit smoking, public health can encourage smokers to recognize and act on opportunities to quit spontaneously (such as running out of cigarettes while in an inconvenient position to pick up more), rather than planning a date to quit (12).
The findings of studies on unplanned smoking cessation attempts also raise the possibility that a quit attempt is more likely to be successful if the decision to quit is acted on immediately. In motivating smokers to quit, this time scale should be described explicitly as a key in the quitting process for many (12). The Fight 4 Your Life campaign does not give such details on how one might be most successful at quitting smoking.
An Alternative Smoking Cessation Intervention
An alternative intervention to the Massachusetts Tobacco Cessation and Prevention Program’s Fight 4 Your Life smoking cessation campaign might involve the following components.
1. Implement a smoking ban within 100 feet of any building that serves as a place of employment. This state or citywide policy would be passed under the legal premise of creating a safe work environment for employees, and would address the obtrusive cloud of second hand smoke often found directly outside workplace doors. The law would also create an inconvenience for smokers wishing to take cigarette breaks during work, as they would have to travel not only 100 feet away from their own place of employment, but just as far from every place of employment for a cigarette break. Reducing the opportunities for people to smoke would necessarily decrease the amount of cigarettes they consume, and in turn decrease their nicotine dependence.
2. Broadcasting television commercials that sell the idea of being a non-smoker. Alternative television spots to those utilized by Fight 4 Your Life would sell positive images and core values, such as financial independence, worldliness, and romance. They would not even necessarily be linked to the promise of future good health. A commercial would feature no dialog, only music and a video montage: An attractive young woman runs out of cigarettes in her city apartment. She looks out the window to see heavy rain and a dark thunderstorm. Smiling, she tosses her empty pack of cigarettes and a pack of matches into the trashcan. She grabs an empty jar and puts her cigarette money in it. We see a series of shots of her happily adding her cigarette money to the savings jar each day. She researches tropical vacations online, and buys a plane ticket. We see her reclining in a first class seat, smiling and looking up as the “No Smoking” sign lights up above her. In the last scene she is lounging on a beach in a tropical location, and a handsome man approaches to offer her a cocktail. She smiles at him, and we see that a romantic connection will ensue. Several different commercials would show a similar type of scenario for each specific demographic we are targeting with the campaign.
Altering the Environment for Health Promotion
As discussed earlier, the ecological perspective of health behavior describes that individuals exist within a larger social and economic context, with multiple layers of influence affecting their decisions around health behavior (3,4). While the Fight 4 Your Life campaign focuses solely on convincing individuals to tackle behavior change, the alternative approach outlined above broadens the focus of the intervention to create an environment where smoking cessation is supported, and continuing to smoke regularly becomes inconvenient.
This alternative intervention is in line with critical feminist perspectives of the individual level Health Belief Model of behavior change calls for a more holistic examination of the motivators and barriers to healthy behaviors (2). The intervention is supported by studies show that lasting behavior change requires consistent a balance of motivators that favors an alternative whenever the opportunity to engage in the risky behavior arises (11). A smoking ban within 100 feet of all places of employment provides consistent reinforcement for opting not to take a cigarette break, as finding a location for a cigarette break becomes very inconvenient and more time is necessary to accommodate smoking a cigarette.
Networking Theory and the Social Acceptance of Smoking
Networking theory indicates that behavior change, such as smoking cessation, moves through a population via social ties. Groups of interconnected people appear to quit smoking in concert, and smokers become increasingly socially marginalized, until few connections remain between smoking and non-smoking groups. (6). Part 1 of our alternative campaign, a smoking ban within 100 feet of all places of employment, is an intervention that decreases the social acceptability of smoking. By affecting what appears to be socially acceptable in regard to smoking behaviors, public health can plant the seed of behavior change in some people in the community, who will in turn spread their new ideas of what is socially acceptable to their peers. The new ideas of socially acceptable smoking behavior will in turn spread exponentially throughout the community as fewer and fewer people see smoking in public as acceptable. Since smoking is a social behavior, more people will quit when they run out of easily available contacts to smoke with (6).
Selling Core Values in Public Health
Research shows that effective social marketing begins with recognizing the desires and values of our target population and promising these benefits in exchange for healthy behavior changes, rather than asking the population to change their values (9). The alternative commercial described above sells universal core values to our target population: financial independence, exotic travel or worldliness, and romance or love.
The commercial also advertises a desirable lifestyle: the luxurious, young “jet-set” with freedom, independence, and disposable income. Evans and Hastings’ discussion of public health branding describes the benefits of selling a lifestyle choice to consumers (10). Public health can compete with the tobacco industry’s corporate interests by offering the benefits of a desirable alternative lifestyle to consumers who choose to quit smoking. The consumer earns the benefits of the core values in the advertisement – financial independence, exotic travel or worldliness, and romance – by choosing to be a non-smoker and therefore the lifestyle that comes with it. Branding constructs are persuasive as a marketing tool because they speak to the population’s aspiration to appealing external ideals (10).
The commercial described as part of this alternative intervention showcases the story of a woman who successfully quits smoking spontaneously. This lines up with West and Sohal’s version of “catastrophe theory,” which suggests that public health should focus on creating or identifying these spontaneous opportunities for people to change their behavior (13). Studies show that many quit attempts are spontaneous and that unplanned quit attempts are much more likely to be successful (12,13). Public health can aim to trigger these spontaneous quit attempts in smokers who are on the cusp of behavior change by advertising the idea that individuals should look for opportunities to quit, rather than planning a quit attempt in advance.
The Massachusetts Tobacco Cessation and Prevention Program’s Fight 4 Your Life smoking cessation campaign is flawed in several major aspects. The program is an individual level approach to behavior change, which leaves out necessary discussion of the social and environmental factors supporting the risk behavior. The program frames the main benefit of quitting smoking as avoiding future negative health outcomes, which is less effective than offering the promise of a positive reward to those trying to quit. Fight 4 Your Life also takes for granted the assumption that people are making rational cost/benefit analyses and planning out their quit attempts, an assumption about human nature which is known to be flawed. The alternative approach outlined here would better serve our target population. This approach creates a workplace environment that is unfavorable to smoking, altering the public perception of smoking as socially acceptable. The alternative approach also uses television commercials and marketing theory to make healthy behavior change look alluring and positive by promising core values such as economic freedom.

1. Massachusetts Tobacco Cessation and Prevention Program. Fight 4 Your Life campaign. Massachusetts Department of Public Health. http://www.makesmokinghistory.org/en_US/about-mtcp/Fight-4-Your-Life.html
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