Project Ex-4: The Failure to Utilize Effective Social and Behavioral Approaches to Prevent Smoking Among Adolescents-Kathleen Leahy

Tobacco use among adolescents is a major issue facing public health practitioners today. The majority of young people who begin smoking during adolescence will be addicted by age 20 (1). Although there was a significant decrease in tobacco use among youth between 1997 and 2003, rates have since stabilized and studies indicate that approximately 4,000 young people in the U.S. smoke their first cigarette every day (2,3). According to 2007 YRBS data, 50% of U.S. high school students have tried cigarettes and 20% are daily smokers. These numbers have major implications for the health of U.S. adolescents and effective interventions are needed to reduce rates of smoking in this population. Project EX-4 is a school-based smoking prevention and cessation program adopted from Project EX, a clinic-based smoking cessation program for adolescents. The goal of Project EX-4 was to utilize the classroom setting to reach large numbers of high school students and to implement a program that would prevent smoking in non-smokers, while encouraging current smokers to quit (4,5). The program consists of eights sessions delivered by teachers over a six week period. The sessions provide information regarding the harmful effects of tobacco on the body and the nature of addiction. Discussions about lifestyle and coping mechanisms for stress are also a major component of these sessions. Finally, students are given assertiveness training and anger management, so that they are not tempted to turn to cigarettes or other substances to deal with their problems (4,5). While this program was shown to have short-term effects on smoking related knowledge and decreases in daily smoking, long-term studies showed that Project EX-4 had no effect on smoking initiation rates or daily smoking rates among 12th graders (5-8). This program is largely information based and fails to use many of the social and behavioral approaches that have been shown to be effective in adolescents. The following are three principle critiques of the preventative efforts of Project EX-4.

Critique 1: Assumes Rational Decision Making
Project EX-4 is a lecture-based intervention that draws from the Health Belief Model, providing students with information about the harmful effects of smoking on the body, the biological basis of addition, and alternative methods for coping with problems and daily stress(4). The goal is to increase students’ perceived risk of smoking-related health problems while stressing the benefits of remaining a non-smoker. This approach, which has been criticized by many social scientists, assumes that adolescents will engage in a rational weighing of the risks and benefits of cigarette smoking and fails to take into account the many factors that influence adolescent behavior (9,10).
The adolescent brain is growing and changing, and full maturation of the frontal lobe, the part of the brain responsible for judgement and decision making, does not occur until the mid-twenties (11). The majority of adolescent decision making, particularly in emotionally heightened situations, takes place in the amygdala, the emotional center of the brain (11,12). As a result, adolescents rely primarily on their ‘gut’ for deciding whether to engage in risky behavior and are virtually incapable of fully considering the consequences of their decisions. Furthermore, as adolescents’ bodies change and they acquire new cognitive abilities, they develop a sense of invulnerability that makes them prone to risk-taking and feelings of immunity to the consequences of such behavior(13). The Project EX-4 sessions focus on scare tactics and statistics, information that students are unlikely to consider when offered a cigarette by one of their peers. The intervention inaccurately assumes that avoiding diseases such as lung cancer and emphysema are at the forefront of students' minds and that they will consider these consequences when faced with the opportunity to smoke. In reality, adolescents are influenced by the opinions of their peers and their environment, factors that further impede rational decision making. A survey of adolescents in California indicated that students who smoke or have tried smoking weigh the chance of experiencing a smoking-related social benefit, such as looking cool or gaining popularity much more heavily than the chance that they would experience smoking-related health problems (14), In order to be more effective, smoking prevention programs must appeal to students' desires and provide them with negotiation and refusal skills, thus removing the need for rational decision making(15). An intervention which presumes that simply informing students of the risk of cigarette smoking will discourage them from engaging in this behavior is developmentally inappropriate and bound to fail.

Critique 2: Failure to Consider Environmental Influences
In addition to it's focus on rational decision making, the failure of Project EX-4 to account for environmental influences is a second reason this intervention fails to be successful in preventing adolescent smoking. Many studies have indicated that factors such as socioeconomic status, gender, developmental status, and race have an effect on smoking initiation rates and this intervention neither identifies a target population among high-risk groups nor does it tailor its approach to vulnerable students (16,17). There is no indication in the literature that Project EX-4 is designed to be implemented in urban vs rural schools or with minority vs. non-hispanic white students;this generalized approach rarely works, especially with adolescents. Perhaps the most important environmental influence that Project EX-4 fails to address is the social norms regarding smoking in the adolescents populations targeted by this intervention. Adolescents are highly concerned with the approval of their peers and often gage how 'normal' they are by the actions or presumed actions of their classmates and friends (13). There have been numerous studies that have investigated the effect of perceived social norms on the prevalence of drinking, drug use, and smoking in different adolescent populations and the results are extremely convincing. Young people almost universally overestimate the degree to which their peers are engaging in risky behaviors and this perception has a profound affect on their behavior (18-20). With regards to smoking specifically, studies suggest that students are influence by how 'normal' is is to smoke in their community. For example, one paper showed that students who attended schools that strictly enforced anti-smoking policies were less likely to begin smoking than their counterparts at schools where these policies were not heavily enforced (21). In addition, there have been several studies that have suggested that students are more likely to smoke when they perceive it to be an acceptable or common behavior among their peers (22,23). The Social Norms and Social Expectations Theories, as well as the Social Ecological Theory take these environmental factors into account when considering behavior (24-26). Project EX-4, however, failed to utilize any of these theories in their prevention efforts. The classroom sessions do not include any discussion of school norms around smoking or students' perceptions regarding the acceptability of this behavior among their peers. In addition, there is no discussion of a school anti-smoking policy, s0 there is no aspect of this intervention that attempts to portray smoking as a socially unacceptable behavior among educators or peers. Once again, in order to be effective, an intervention that aims to prevent smoking among adolescents must take into account all of the influences that affect their decision to engage in this behavior. By focusing solely on the harmful and addictive effects of smoking and disregarding the strong environmental and social pressures that influence behavior, Project EX-4 falls short in its efforts to prevent smoking among students.

Critique 3: Failure to Consult Adolescents in the Design and Implementation of Intervention
Adolescence is a time of truth-seeking and of searching for a sense of belonging (13). These developmental aspects of adolescents can prove extremely useful when planning successful interventions aimed at this population. The most successful campaigns to prevent smoking in young people have been mindful of these developmental traits and involved students in the formulation of an intervention. Campaigns such as the 'Truth' Campaign to prevent smoking formed focus groups of students and surveyed youth in order to understand their values and aspirations (27, 28). Project EX-4 did not use any of these approaches in their smoking prevention intervention. Project EX-4 did not involve any of the students at test schools in the planning of this intervention. In addition, there were no focus groups in which to test the efficacy of the message or delivery before school-wide implementation. In failing to utilize student input, the Project EX-4 initiative did not successfully 'brand' the anti-smoking message or market this message to adolescents. This school-based intervention assumed that adolescents aspire to health and a long life above all else, and therefore focused on the harmful effects smoking have on the body and smokers' increased risk for disease. However, had they taken the time to survey students, they would have found that most young people most strongly desire freedom and independence above all else. If Project EX-4 had tied non-smoking to these ideals, this intervention could have been more successful. In addition to promoting the wrong values, Project EX-4 failed to effectively market the anti-smoking message to students. The sessions provided to students focused on informational lectures in which students were provided with facts and statistics. The students were not exposed to any slogans or images and there was no use of media, which is a highly effective way to reach adolescents today (27). Had students been consulted, organizers of Project EX-4 could have found more appropriate ways to deliver the anti-smoking message.
Branding and marketing are aspects of Social Marketing Theory, an approach to interventions that is gaining popularity among public health practitioners. These concepts are highly dependent on the involvement of the population targeted for intervention(28-30). By determining the values and aspirations of adolescents, for example, an intervention can create an ideal or group that young people will long to be a part of. Project EX-4 did not empower students or make them feel like they belonged to something special by not smoking. It also failed to appeal to the hopes and dreams of adolescents, instead relying on a catch-all approach to smoking prevention. This final critique is one the most important reasons why Project EX-4, and other programs based solely on the Health Belief Model are largely ineffective in preventing smoking among adolescents.

Alternative Program

I propose an alternative intervention to Project EX-4, one that is comprehensive rather than school-based, and is based primarily on the principles of three theories: Social Marketing Theory, Social Networking Theory, and Social Cognitive Theory. The intervention also includes components from Maslow's Hierarchy of Neeeds and Labeling Theory.
Studies have shown that comprehensive programs to prevent smoking in adolescents are the most effective (31,32). By involving the community, local media stations, and other local organizations, students are able to receive the anti-smoking message frequently and consistently. My program would begin with a task force that is comprised of members from the community, including teachers, students, local business owners, law enforcement, and local journalists. Together they would produce effective and feasible ways to make the entire community 'smoke-free'. In addition, several focus groups of students from middle school and high school would be heavily involved in the formulation of an anti-smoking message that will 'speak' to adolescents and in the design of posters, ad campaigns, and slogans. The school component of the intervention would also be very different, consisting of six sessions per school year, starting in seventh grade and continuing throughout ninth grade, since data suggests that there is a greater effect with interventions that are continuous and have several sessions (16). The sessions will be interactive and include a variety of approaches to educate and empower students. While much of the information included in Project EX-4 will still be included in the intervention, this information will be coupled with negotiation skills, education about social norms, and a comprehensive anti-smoking media campaign. The following is a detailed explanation of how this alternative campaign addresses the three main problems with the Project EX-4 campaign. Answer to Critique 1:Recognizes Connection between Behavior, Self Efficacy, and Environment

This alternative intervention does not rely on the rational decision making of adolescents to prevent smoking. While information regarding the health risks of cigarettes will be included in the intervention, this is not the focus of the program. Taking a social learning approach, this intervention will seek to empower students and promote self esteem and then surround them with a community, both inside and outside the school, that models anti-smoking behavior (33).
The first step in building self efficacy is promoting self-esteem and a sense of belonging, and providing students with negotiation skills. Part of the school-based aspect of this intervention will involve choosing a community service program that students will participate in throughout the three year intervention. Community service builds self esteem and by choosing the program, students can take ownership of this project and develop a sense of social belonging within this small group(34). In addition to community service, intervention sessions will include role-playing to build refusal and negotiation skills that students can use when faced with any risky behavior, such as smoking, drugs, or alcohol. These role-playing activities have been shown to increase self-efficacy and have a positive effect on students' ability to refuse tobacco (35).
Finally, the commitment of both the school and the larger community to be 'smoke-free' will provide an environment that promotes anti-smoking behavior. Teachers and students will not be able to smoke outside the school and local businesses will ban smoking on their premises. Even parks and playgrounds will be declared smoke-free zones. In every aspect of students' lives, smoking will be viewed as socially unacceptable, which leads into the answer to the second critique. Answer to Critique 2: Takes a Social Networking Approach to Smoking Prevention
Project EX-4 relies heavily on the principles of the Health Belief Model, which assumes that once individuals are provided with the information regarding the risks of a certain behavior, they will weigh those risks versus the benefits of not doing the behavior and make the right decision. However, this model is not appropriate to prevent smoking among adolescents, as they are highly susceptible to environmental influences, particularly the behaviors of their peers(13). This alternative intervention takes into account the importance of social influences and uses social networking theory to correct inaccurate perceptions about the prevalence of smoking in the school community and to create a new, anti-smoking social norm. As part of the planning stages of this intervention, the students in the focus group will help survey peers regarding their tobacco use and their perceived notions about tobacco use among their peers. As with most risky behaviors, it is likely that perceived norms will be greater than actual norms (18-21). A major part of the media and advertising aspect of this campaign will be devoted to promoting actual norms in the school and community. This approach was highly successful in a Montana campaign aimed at teens, entitled 'MOST of US (70%) Are Tobacco Free'. This campaign, like our intervention, involved students in the media campaign that promoted the actual norms and resulted in a 41% difference in teen smoking rates between test and comparison counties (36,37).
In addition to this social norms campaign, each school will encourage students leaders, such as team captains, student council members, and other well-likes members of the student body to promote the new social norm of not smoking. These students can perpetuate this anti-smoking norm within their networks and before long, not smoking will become engrained in the culture of the school. Throughout the discussion of this alternative intervention there has been an emphasis on student involvement, which leads to the third and final critique of Project EX-4. Answer to Critique 3: Using Student Input to Brand Anti-Smoking Behavior and Effectively Market to Adolescents Project EX-4 did not involve students in the formulation of the intervention and thus the message and delivery of the program did not resonate with the target population. This alternative intervention relies heavily on input from students and is modeled in part after the 'Truth' Campaign to prevent smoking in adolescents. The 'Truth' Campaign involved students in every aspect of planning and implementation and appealed to many of the fundamental developmental aspects of adolescents (38). In our intervention, classroom sessions will include a dissection of the tobacco industry and activities where students find and criticize tobacco advertisements aimed at adolescents. By exposing the manipulation displayed by tobacco companies, students will feel empowered and display reactance that will lead them to reject tobacco. In addition, students will have the opportunity to pledge to remain part of the smoke-free group, thereby labeling themselves as non-smokers. This feeling of ownership over their status as smoke-free will help promote the anti-smoking 'brand'. Finally, students will be involved in the design and implementation of a slogan and media campaign, involving posters, a Facebook page, and possibly even local television PSA's. The slogan and images will all be designed to empower students and appeal to their desire to be free and independent, as opposed to being puppets for the tobacco industry. This social marketing approach has been very successful, not only as part of the 'Truth' campaign, but in many other public health interventions as well (39,40).

Conclusion
Smoking is a serious threat to the health of adolescents and there is a great need for effective interventions to prevent tobacco use in this population. Many current school-based interventions, such as Project EX-4, are based on theories that are developmentally inappropriate for adolescents and the effects of such programs do not extend outside the classroom. Schools and communities must work together to provide comprehensive anti-smoking interventions to adolescents that are based in more contemporary and appropriate social and behavioral theories. By appealing to the core values and aspirations of adolescents, while also taking into account developmental and environmental influences, it is possible that we will someday be able to celebrate a generation of young people that are truly smoke-free.

References
1)Lewis PC, Harrell JS, Bradley C, Deng S. Cigarette Use in Adolescents: The Cardiovascular Health in Children and Youth Study. Research in Nursing & Health 2001;24:27-37 2)Center For Disease Control. Tobacco Statistics: Highlights HYPERLINK "http://www.cdc.gov/tobacco" http://www.cdc.gov/tobacco 3)Massachusetts Youth Risk and Behavior Survey 4)Sun P, Miyano J, Rohrbach LA, Dent CW, Sussman S. Short-term effects of Project Ex-4: A classroom-based smoking prevention and cessation intervention program. Addictive Behaviors 2007; 32:342-350 5)Sussman S, Miyano J, Rohrbach LA, Dent CW, Sun P. Six-month and one-year effects of Project EX-4: A classroom-based smoking prevention and cessation intervention program. Addictive Behaviors 2007;32:3005-3014. 6)Wiehe SE, Garrison MM, Christakis DA, Ebel BE, Rivara FP. A systematic review of school-based smoking prevention trials with long-term follow-up. Journal of Adolescent Health 2005;36:162-169. 7)Flay BR. The Promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews. Tobacco Induced Diseases 2009;5:1-12. 8)Thomas RE, Perrera R. School-based programs for preventing smoking (Review). The Cochrane Collaboration 2008;4:1-185. 9)Poss JE. Developing a New Model for Cross Cultural Research: Synthesizing the Health Belief Model and the Theory of Reasoned Action. Advances in Nursing 2001;23:1-15. 10)Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995;11:246-252 11)Steinberg L. Cognitive and affective development in adolescence. TRENDS in Cognitive Sciences 2005;9:69-74. 12)Giedd JN. The Teen Brain: Insights from Neuroimaging. Journal of Adolescent Health 2008;42:335-343. 13)Catalano RF, Hawkins, JD, Berglund ML, et al. Prevention science and positive youth development: competitive or cooperative frameworks? Journal of Adolescent Health 2002; 31(6 Suppl): 230-239. 14)Halpern-Felsher BL, Biehl M, Rubenstein ML. Perceived Risks and Benefits of Smoking: Differences Between Adolescents Who Have and Have Not Smoked. Journal of Adolescent Health 2008;32:147-148. 15)Dobbins M, DeCorby K, Manske S, Goldblatt E. Effective Practices for school-based tobacco use prevention. Preventive Medicine 2008;46:289-297. 16)Harrell JS, Bangdiwala SI, Deng S, Webb JP, Bradley C. Smoking Initiation in Youth: The Roles of Gender, Race, Socioeconomics, and Developmental Status. Journal of Adolescent Health 1998;23:271-279. 17)Anderson C, Burns DM. Patterns of Adolescent Smoking Inititation Rates by Ethnicity and Sex. Tobacco Control 2009;9:4-8. 18) Perkins, H. W. & Berkowitz, A. D. (1986). "Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming." International Journal of the Addictions, 21, 961-976. 19)Martens M, Page J, Mowry E, Damann K, Taylor K, Cimini MD. Differences between Actual and Perceived Student Norms: An Examination of Alcohol Use, Drug Use, and Sexual Behavior. Journal of American College Health, 54(5), 295-300. 20)Albarracin D, Kumkale GT, Johnson BT. Influences of social power and normative support on condom use decisions: a research synthesis. AIDS Care, 2004. 16(6); 700-723 21)Lipperman-Kreda S, Grube JW. Students' perception of community disapproval, perceived enforcement of school antismoking policies, personal beliefs, and their cigarette smoking behaviors: Results from a structural equation modeling analysis. Nicotine and Tobacco Research 2009;11:531-539. 22)Glantz SA, Jamieson P. Attitudes Toward Secondhand Smoke, Smoking, and Quitting Among Young People. Pediatrics 2000;106:1-3. 23)Brown AK, Moodie C, Hastings G, Mackintosh AM, Hassan L, Thrasher J. The Association of Normative Perceptions with Adolescent Smoking Intentions. Journal of Adolescence 2010:1-12. 24)Berkowitz, A. D. The Social Norms Approach: Theory, Research and
Annotated Bibliography. Available at http://www.edc.org/hec/socialnorms/theory.html
25)Berkowitz, A. D. Applications of Social Norms Theory to Other Health and Social Justice Issues. In H. Wesley Perkins, (Ed.), The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco: Jossey Bass. 26).McArthur, Leslie Z.; Baron, Reuben M.Psychological Review. Toward an ecological theory of social perception. (1993);90:215-238. 27) Brown, J. (Ed). (2008). Managing the Media Monster: The Influence of Media (From Television to Text Messages) on Teen Sexual Behavior and Attitudes. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy. 28)Evans DW, Hastings G. Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (pp.1-24). In: Evans DW, Hastings G. Public Health Branding, Oxford 2008. 29)Blistein JL, Evans WD, Driscoll DL. What is a Public Health Brand? In:Evans DW, Hastings G. Public Health Branding, Oxford 2008. 30) Marketing Social Change-An Opportunity for the Public Health Practitioner (pp. 45-71). In:Evans DW, Hastings G. Public Health Branding, Oxford 2008. 31) Wakefield, M, Chaloupka F. Effectiveness of comprehensive tobacco control programs in reducing teenage smoking in the USA. Tobacco Control 2009;9:177-186. 32)Glantz SA, Mandel LL. Since School-based tobacco prevention programs do not work, what should we do? Journal of Adolescent Health 2005;36:157-159. 33) Redding CA, Rossi JS, Rossi SR, Vellicer WF, Prochaska JO. Health Behavior Models. The International Journal of Health Education 2000;3:180-193. 34)Conrad D, Hedin D. School-based Community Service: What We Know From Research and Theory. Journal of Adolescent Health 1999;10:743-749 35)Nichols TR, Graber JA, Brooks-Gunn J, Botvin GJ. Ways to Say No: Refusal Skill Strategies Among Urban Adolescents. American Journal of Health Behaviors 2006;30:227-236 36) MOST of Us Are Tobacco Free "http://www.mostofus.org/projectdetail.php?id=4" http://www.mostofus.org/projectdetail.php?id=4 37)Martino-McAllister J, Wessel MT. An Evaluation of a social norms marketing project for tobavvo prevention with middle, high, and college students; use of funds from the Tobacco Master Settlement. J Drug Educ., 2005, 35(3): 185-200. 38) Niederdeppe J, Farrelly MC, Havilnd L. Confirming 'Truth':More Evidence of a Successful Tobacco Countermarketing Campaign in Florida. American Journal of Public Health 2004;94:255-257. 39) Friend K, Levy DT. Reductions in smoking prevalence and cigarette consumption associated with mass-media campaigns. Health Education Research 2002;17:85-98. 40)Evans DW, McCormack L. Applying Social Marketing in Health Care: Communicating Evidence to Change Consumer Behavior. Medical Decision Making 2008;28:781-792.

A CRITIQUE OF THE INDUSTRY-SPONSORED YOUTH ANTI-SMOKING CAMPAIGNS- Adeola Akinlonu

INTRODUCTION
Smoking among youths in the United States has been a significant public health issue for decades. Studies have shown that most adults who smoke began experimenting with cigarettes in middle school and became regular smokers before completing high school.1 Therefore, the continued onset of smoking among adolescents is the primary barrier to long-term reduction in the smoking prevalence in the U.S population.
Each day in the U.S, approximately 3,900 young people between 12 and 17 years of age smoke their first cigarette, and an estimated 1,000 youths become daily cigarette smokers.2 In 2007, 20% of high school students were current cigarette smokers: 18.7% of female and 21.3% of male high school students were known to be smokers.1
Research has revealed that the factors that determine whether a young person starts smoking are complex and interrelated. These factors include peer pressure, family influence, and a perception that smoking is the norm.1This relationship has been explained by social scientists through the Social Learning Theory, which posits that people learn and acquire behavior by observing other people and adopting their behavior. Other factors that determine a smoking habit include low socio-economic status, accessibility, availability and price of tobacco products.2 In addition, it’s been proven that adolescents who have low academic achievements, low self-image or self-esteem, and aggressive behaviors are more likely to adopt a smoking habit.2
In the past years, the tobacco industry began programs worldwide to promote youth smoking education and prevention.3 Companies like Phillip Morris, Lovillards, and R.J Reynolds in the U.S have produced campaigns to discourage youth from smoking. Phillip Morris was known for the slogan “Think, Don’t Smoke” (TDS), a $100million anti-smoking campaign that focused on teens. This campaign was aired nationally between 1998 and 2002.3 The TDS featured role model youths who stated that their minds and bodies were committed to not smoking, and tried to discourage others from smoking.4
During the same period, the industry also distributed book covers in schools around the U.S with slogans “Think, Don’t Smoke” to remind teens to consider the health effects of smoking. In addition to this, the company also sponsored a “Talk, They’ll Listen” (TTL) television ad which admonishes parents to discourage their kids from smoking.4 The industry claimed that it devised its ad campaigns on the advice of experts who deem parental influence extremely important.5
However, these campaigns by Phillip Morris, and many other from the tobacco industry have been met with much criticism since their inception. A school-based study of U.S youths found that exposure to campaigns such as the youth-focused TDS and the parent-focused TTL were actually associated with lower perceived harm of smoking, stronger approval of smoking, and stronger intentions to smoke.6 The tobacco industry failed to understand the dynamics of human behavior, especially among youths.
The Phillip Morris anti-smoking campaigns have been portraying not smoking as a behavior that flaunts rationality, by asking the youths to think, and with the assumption of health as a universal and superseding core value and life goal. The TDS campaign tells teens, in a lecturing manner, to do something no free-spirited emotional teen wants to do – “think”. It cried out for rational thought, but young teenagers have not yet mastered self-analysis.7
Studies showed that programs were less appealing and convincing to youth, and that industry programs subtly promoted smoking.3 Moreover, due to their ulterior motives, it seemed that the tobacco company never wanted the campaigns to be effective.
Despite all the various anti-smoking campaigns sponsored by the tobacco industries, as exemplified by Phillip Morris, the rate of smoking among youths in the U.S continues to rise over the years. The following arguments explain, in detail, why the industry-sponsored campaigns failed to make an impact.
Argument 1
The Campaigns did not consider individual social and environmental factors that influence behavior.
The theory of Social Learning proposes that direct and vicarious experience with rewards and punishments in one’s environment lead to the acquisition of specific beliefs about the consequences of behaviors.8Events in one’s environment affect personality. The TDS campaign did not put into consideration the events in the environment of these youths before asking them to think not to smoke. Human beings make irrational decisions based on social context, economic and environmental factors. Seventy five percent of youth smokers have parents, older siblings, or friends who smoke. Parents’ smoking affects health beliefs such that the more one’s parents smoke, the less one is likely to believe that smoking has health consequences. The TLL campaign reached out to the youth through their parents, but the company forgot to tell the parents, as role models, to stop smoking themselves. Likewise, among their peers, youth believe that smoking gives them enjoyment, makes them popular, and reduces tension.8The more of one’s friends who smoke, the more likely one is to adopt the behavior based on the perceived beliefs.8
In addition, socio-economic status determines one’s behavior. A study showed that, 43% of 17-18 year olds who drop out of school smoke, and other studies have shown that smokers most often come from low socio-economic backgrounds.2These kids might require different and more intensive interventions than just asking them not to smoke.
In general, the TDS and TTL campaign are flawed because they expect youths to “just say no” without considering each person’s cultural, social, economic, and environmental backgrounds that compel them to smoke.
Argument 2
Phillip Morris Campaign Messages are Persuasive and they Challenge Youths’ Autonomy
The Phillip Morris campaigns are authoritative. TDS directly commands teens not to smoke, and TTL indirectly instructs youths not to take up smoking. Campaign creators failed to realize that youths desire to gain control of their lives. Scientists have studied the seemingly infinite number of interdependence variables that affect persuasive messaging.7 According to developmental psychologists, teenagers tend to reject authoritative messages because they believe they are independent,9 hence any message that attempt to challenge their freedom will be rejected.
In addition, the theory of psychological reactance posits that people become motivationally aroused by a threat to or elimination of a behavioral freedom. This motivational state is what is called psychological reactance.10Psychological reactance is an aversive affective reaction in response to regulations or impositions that impinge on freedom and autonomy.11 Phillip Morris TDS campaign, which told American youth- “Don’t Smoke”, was perceived by the recipient to reduce or threaten personal freedom, arouse a motivational state and reactance. The entire process directs the individual towards re-establishing the lost or threatened freedom, hence encouraging them to initiate or continue the habit of smoking.12
Moreover, American society constantly limits the autonomy of its youth: e.g. compulsory education, age limits in many activities, control and monitoring of their sexual and other health-related behaviors.13Some social analysts have proposed that smoking itself is a form of resistance by the youths to authority in general.13Therefore, simply telling the youths not to smoke through TDS campaign, violates their social independence.
Furthermore, some believe that nothing makes tobacco more alluring to adolescents than hysterical grown-ups admonishing them not to smoke.14 The TTL campaign also failed because teens are known to spurn their parents’ advice.
In addition, the TDS television campaign added a slogan that describes the Surgeon General’s warning that smoking is not good for a person’s health. However, the theory of psychological reactance also explains that attributing a message to a highly authoritative source, in an attempt to increase the effect of the warning in the message, could produce reactance in youth, making the message ineffective.12
Considering a young teenager from broken home, socially, economically, and educationally disadvantaged, and who has adopted a smoking habit as a social norm to boost self-esteem, gain control of his/her life, would see such ads like TDS or TTL as a big threat to his/her existence. According to the theory of illusion of control, people feel if they choose a habit or behavior, they own it. Therefore, simply telling youths not to smoke is both useless and ineffective.
Argument 3
Corporate Practices Undermines Effectiveness of Campaigns
Research has revealed that corporate practices play a substantial role in shaping health and health behavior.15 The tobacco company marketing strategy has been described as the most bizarre and extra-ordinary mixed messages in commercial history.12 The same Phillip Morris that encourages adults to continue smoking wants to prevent youths from smoking through TDS and TTL campaigns. This means that they never intended to stop the habit of smoking, but rather delay the onset until adulthood. The campaign, however, failed to realize that youths always want to live for today and prefer not to delay smoking till adulthood.
Corporate practices must be considered as an important social determinant of health. There is clear evidence that the purpose of the industry’s youth smoking prevention program is not to reduce smoking but rather to serve the industry’s political needs by preventing effective tobacco control legislature; preserving the industry’s access to youths; creating allies within policy making and regulatory bodies; defusing opposition from parents and educators; and bolstering industry’s credibility.3
A randomized controlled study was carried out to test whether adolescents’ exposure to anti-smoking ads promotes intentions to smoke, curiosity about smoking, and positive attitude towards the tobacco industry.12 Exposure to Phillip Morris anti-smoking ads was found to have engendered favorable attitudes towards the tobacco company. Ads were noticed to do more to promote corporate image than to prevent youths from smoking.12
Phillip Morris campaigns are considered “warm and fuzzy”, which could actually generate favorable feelings for the tobacco industry, and by extension, its product.5The campaigns were minimally financed, understaffed and run by people with no expertise.5 This reduced the possibility of creating impact in the lives of the youths. Some believe that the big tobacco anti-smoking ads have actually become a new way of getting young people addicted to cigarettes.9
With ulterior motives of tobacco industry at the background, anti-smoking campaigns by tobacco industries like Phillip Morris are ineffective in controlling youth smoking habits, and possibly counterproductive.6
INTERVENTIONS
The anti-smoking campaigns to youths in the U.S can still be made effective. Firstly, campaigns must be presented in ways that put individual socio-economic and environmental factors into consideration. In addition, because adults who smoke could influence the kids, public health awareness programs must also focus on reducing smoking habits in adults.
Secondly, instead of just instructing youth not to smoke, campaigns should present a new lifestyle to them as alternatives. Behaviors that interest teens and which they can easily identify with must be created as alternatives for them.
Thirdly, youth anti-smoking campaigns must be taken away from the tobacco industry because they have been proven counterproductive. There is evidence that the tobacco industry purposely promotes and funds ineffective youth anti-smoking campaigns.16In addition, the government should impose heavy tax on the tobacco industry.
1. Campaigns must address soci0-economic, and environmental factors.
Presenting a campaign that considers individual characteristics is an important approach. Public health professionals need to differentiate between “targeting” large groups and “tailoring” to specific individuals. Targeting messages involves segmenting people into homogenous groups and then developing a message that speaks to that group, just like the TDS campaign to the youth. Tailoring, on the other hand requires an assessment of an individual characteristics and then creating a specific message solely suited to that person.7
Public health experts should conduct research to find out what the core values of these youth smokers are individually, the social and environmental factors affecting their existence, and then empower them by giving support to the disadvantaged, creating jobs, sponsoring education, and giving them a sense of ownership. This will appeal more to the youth to prevent them from smoking, rather than sham ads persuading them not to smoke.
In addition, it’s been suggested that tobacco control program should emphasize strategies that encourage cessation among adults. Scientists believe that this approach also impacts on adolescent smoking thus achieving the dual aims of tobacco control programs.17 Campaigns directed at adults, grounded in both health believe model and theories on the process of persuasion, can be aimed to change both attitudes towards smoking and smoking behaviors among adults, who can later influence the young positively.17
Adult campaigns that encourages quitting may influence adolescent smoking by reducing smoking among parents with subsequent reduction in the number of teenagers exposed to a major risk factor for smoking uptake. In addition, making smoking a less desirable adult behavior, can reduce adolescents’ motivation to use tobacco as a signifier of adulthood. Furthermore, as adolescents identify with adults and want to be treated as adults, they are highly likely to attend to the message contained in adult focused anti-smoking campaigns.
Teens want to be like adults, therefore the public health community should realize that the best way to keep kids from smoking is to reduce tobacco consumption among everyone. This sends a strong message to the youths about social norms.18

2. Change message to promote new lifestyle instead of just telling kids what to do
Campaigns aimed at preventing youth from smoking should focus more on giving them options of new lifestyles other than smoking. In Europe, one of the largest public health awareness campaign called “HELP: for a life without tobacco”, has been proven to be effective among youths of the 27 European Union member countries.19 This campaign speaks directly to youth smokers and non-smokers, offering help to quit, not to start, or avoid passive smoking. It provides a comprehensive communication concept that combines television spots (including MTV), e-coaching, YouTube and a website, using state-of-the-art marketing techniques to build a transnational brand that bolsters a positive image of nonsmoking.20 The website is interactive and engages youths in various activities that promote life without tobacco. In addition, they obtain information on various activities that get youth together to promote healthy lifestyles.19 Public health experts in the U.S should adopt this concept and produce anti-smoking campaigns that promote new lifestyles to youths instead of just telling them not to smoke.
An awareness of this approach must be created through multi-media campaigns using youths and high profile artists they can emulate. It can also be introduced to them during various after-school activities in the U.S. Youths can find support through this avenue, and engage in various life promoting activities that take their attention away from bad habits like smoking.
3. Law Enforcement against Tobacco Industry
The tobacco industry must be restricted from getting involved in youth smoking prevention. This is because its ads, such as TDS and TTL by Phillip Morris, and many others have been found to promote corporate image than to prevent youth smoking.12Studies have revealed that one of the ways tobacco industry influences policy and thwarts effective regulations is by promoting and funding ineffective “youth smoking prevention” programs.16 The government must stop this act.
A better way to involve tobacco money in youth smoking prevention would involve taxation. The government should impose a large tax increase on the tobacco industry in order to reduce the sale of its products. Like most goods, the quantity of cigarettes demanded is inversely related to price. So, increasing the price of cigarette with excise taxes will reduce the amount sold. Studies revealed that every 10% increase in the price of a pack of cigarette would produce up to a 7% reduction in the number of children who smoke. This drop would occur because children are far more sensitive to price increase than adults.21 Moreover, W.H.O, in its guidelines on tobacco products revealed that price and tax measures are effective and important means of reducing tobacco consumption particularly in young persons.22
In accordance with the W.H.O Framework Convention on Tobacco Control (FCTC) issued in 2003, the government should act to protect public health policies on smoking from other vested interests of the tobacco industry.22Koop Everett, a former Surgeon General of the United State, once called for a smoke-free society stating that smoking need not be a part of American life.18Studies revealed that this campaign was attacked by tobacco industry and later changed to a less potent and counterproductive one – “We don’t want kids to smoke”. In Massachusetts, the tobacco industry raised a huge fuss when the health department mounted an aggressive and effective media campaign, as well as co-ordinated local programs concentrating on secondhand smoke and de-normalization of tobacco use.18 The U.S government must therefore act in the interest of youths and other citizens by maintain policies that promote health.


CONCLUSION
Factors contributing to the formation of an enduring health belief or behavior are extremely varied, especially among youths. The theories of human behaviors have been able to prove why the myriads of youth anti-smoking campaigns, especially by the tobacco industry, have failed in curbing the rising prevalence of smoking among youths. The campaigns ignored the effect of smoking parents, friends, and socio-economic factors that prompt youths to smoke. It also did not realize that youths react negatively to authoritative messages that underlie the campaigns. In addition, corporate practices by the tobacco industry have been proven to affect the health of the youths.
In order to make an effective impact, interventions aimed at correcting such enduring habits must put into consideration the social context, psychological needs, and environmental circumstances around which such behavior was formed in each of the teens. The government legislatives must be strict at promoting health of the youths, and public health campaigns aimed at reducing teen smoking should sell to the youths a new lifestyle they can comfortably identify with, and take ownership of.











REFERENCES
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11. Psychological Reactance Theory. Psychlopedia. Available from: http://www.psych-it.com.au/Psychlopedia/article.asp?id=65. Accessed on 04/10/10
12. Henriksen L, Dauphinee A, Wang Y, Fortmann S. Tobacco companies anti-smoking ads and adolescent reactance: Test of a boomerang effect. Paper presented at the annual meeting of the International Communication Association. 2004. Available from: http://www.allacademic.com/meta/p112761_index.html. Accessed on 04/03/10
13. Eakin J, Robertson A, Poland B, Coburn D, Edwards R. Towards a critical social science perspective on health promotion research. Health Promotion International. 1996; vol 11(2): pg157-165.
14. Jacoby J. Teen Smoking Campaign flops. The Boston Globe. 1998; p.A19
15. Frendenberg N, Galea S. The impact of corporate practices in Health: Implications for health policy. J. Pub. Health Policy. 2008; vol 29: pg 86-104.
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17. White V, Tam N, Wakefield M. Do adult focused anti-smoking campaigns have an impact on adolescents? The case of the Australian national tobacco campaign. Available from: http://www.tobaccocontrol.bmj.com/content/12/suppl_2/ii23.full.html. Accessed on 04/03/10
18. Editorial: Preventing tobacco use – The youth access trap. Available from: http://www.ajph.aphapublications.org/cgi/reprint/86/2/156.pdf. Accessed on 04/10/10
19. The HELP Campaign 2009-2010. Moving towards a smoke-free Europe. Homepage. Available from: http://uk-en.help-eu.com/pages/images/share/HELP_210x297_HELPERS_2010.pdf Accessed on 04/25/10
20. HELP campaign: tobacco-free lifestyle. World Heart Federation webpage. Available from: http://www.world-heart-federation.org/publications/heart-beat-e-newsletter/heart-beat-december-2008january-2009/in-this-issue/help-campaign-tobacco-free-lifestyle/ Accessed on 04/25/10
21. Barry M. Politics of youth smoking fueled by unproven data: Legislation’s desired effects dress up as facts. The New York Times National. 1998.
22. World Health Organisation. W.H.O Framework Convention on Tobacco Control (FCTC). 2003. Available from: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf Accessed on 04/25/10.

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.
Conclusion
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.






REFERENCES
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
2. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995;11:246-252.
3. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Institutes of Health publication 2005.
4. Marks DF. Health Psychology in Context. Journal of Health Psychology 1996;1:179-193.
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6. Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. MEJM 2008;358:2249-2258.
7. Weinstein ND. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980;39:806-820.
8. Ayanian J, Cleary P. Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers. JAMA 1999;281:1019-1021.
9. Siegel M. Marketing Public Health – An Opportunity for the Public Health Practitioner (pp 127-152). In Siegel M. Marketing Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
10. Evans WD, Hastings G. Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (pp 3-24). In Evans WD, Hastings G. Public Health Branding: Applying Marketing for Social Change. New York, NY: Oxford University Press, 2008.
11. West R. Time for a Change: Putting the Transtheoretical (Stages of Change) Model to Rest. Addiction 2005;100:1036-1039.
12. Larabie LC. To what extent to smokers plan quit attempts? Tobacco Control 2005;14:425-428.
13. West R, Sohal T. “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ 2006;332:458-60.

A Horse Of The Same Color: Why The Family Smoking Prevention And Control Act Fails To Curb Tobacco Use – Tyler Collins

Smoking is the leading cause of preventable death in the United States (US) (1). It is responsible for approximately one in five deaths annually, with smokers dying on average 13 to 14 years earlier than none smokers (2). Nearly 20% of all US adults are current smokers and 1800 Americans over the age of 18 are added to their ranks daily (2). This is in part due to the fact that the tobacco industry spends $13 billion annually on advertisements and promotions (2). This staggering number can be looked as a partial explanation to why the 70% of smokers, who wish to quit, often fail (2). Not only has the tobacco industry engrained itself into the fabric of society, through its constant barrage of advertisements, but also through the 1998 Master Settlement Agreement (MSA). This arrangement requires the industry to pay 46 states, over the next 25 years, to combat smoking related disease and disability (3). States have come to depend on this settlement money, though, to fill budget deficits. This usage of funds, straying from its original purpose, has allowed big tobacco to influence government agendas (4). As a result, most interventions bent on targeting the industry will fail because of state government ties to tobacco’s success.
Fast forward 11 years and you will find one such intervention that has failed since its inception. This intervention is the Family Smoking Prevention and Tobacco Control Act and was signed by President Barack Obama in 2009. It has been heralded by the media as a “sweeping anti-smoking bill” and praises it for providing critically needed protection to future generations (5). Unfortunately, it falls short of providing the critical care so desperately needed. In a country influenced from the top down, the entanglement of tobacco into the finances of state government sours any chance to change social norms. What has transpired instead is a restoration of previously ineffective plans that completely disregards certain groups. Although many pages of legislation create seemingly groundbreaking advancements, it is merely a charlatan attempting to hoodwink the American public. A true intervention must take place not only to save the government from big tobacco, but also its citizenry.

New Interventions Will Fail Because Government Has Failed

To understand where the United States went wrong requires a look at the historical underpinnings of how the tobacco industry wrapped its tentacles around state budgets. Then a clear distinction can be made between an intervention aimed at the root cause of tobacco’s success and one cast aimlessly out. The research thus starts with the 1998 Master Settlement Agreement between big tobacco and 46 states. The MSA was originally a settlement with these states where the 4 big tobacco companies would pay $206 billion over 25 years to help cover the cost of tobacco related disease and disability (3). But, with few stipulations in the plan as to how the money was to be spent, states have elected to veer the money from its original purpose to more pressing budget deficits (4). In 2007, only 3% of the $24.9 billion available was used in tobacco control programs, with the rest going to fill budget shortfalls (2). As a result, programs have remained underfunded, government has come to rely on tobacco money as a lifeline, and successful programs have been cut so as not to threaten tobacco’s profits too greatly (4). This was seen when the wildly successful “truth” campaign in Florida was cut because it threatened to actually work at curbing tobacco use (6). This campaign was able to retract youth smoking rates from 18.5% to 11.1% among middle school students and from 27.4% to 22.6% among high school students in Florida (7). Sadly, this success became the programs downfall and it was discontinued because it threatened market profitability for the tobacco industry, which threatened MSA settlement payouts to the state of Florida. This clear conflict of interest silences any attempt at government taking meaningful steps to ensure stringent regulation of cigarettes and shows a failure of the system as a whole.
This conflict can be seen through social science models. As shown in the Social Ecological Model, the most overarching determinant of human behavior is the social structure, policy and systems in which one lives (8). If an intervention wants to have a sweeping effect in producing change, a policy or law promoting that change is the surest way to compliance. This understanding is further echoed through the guise of the Social Expectations Model, which dictates that if a social behavior wants to be changed, social norms must be changed (9-10). One way to ensure that change is through government action. This is often in the form of a change in regulations, laws, or policies that affect social behavior (10).
One such example of successful curbing of socially undesirable practices is the implementation of mandated seat belt use in automobiles. Prior to the enactment of seat belt laws, less than 20% of motorists voluntarily buckled up (10). This was in the face of “extensive advertising campaigns and buzzer systems” that attempted to promote buckling up for safety (10). In the first months after the law was enforced in New York State, the first state to require seat belt usage, compliance jumped to between 45% and 60% (10). As is seen in the case of the seat belt, social norms changed only once laws changed. Unfortunately, this will not be the case with the Family Smoking Prevention and Tobacco Control Act.
Through this legislation the Food and Drug Administration (FDA) is going to work closely with the Centers for Disease Control and Prevention (CDC) to “establish contracts with states to support the public health goals of the Tobacco Control Act” (11). This sounds just on the surface, but when states are spending only 3% of their MSA funds on tobacco related issues, collaboration between federal departments and states will only produce minimal benefits (2). The CDC recommends that adequate control of tobacco require 15% of MSA funds to be used for that purpose (2). So, unless more funding is given to tobacco control, no sweeping changes will occur as the law has been heralded to produce (5).

Tobacco Legislation Threatens To Fail To Market Change Properly

The Family Smoking Prevention and Tobacco Control Act plans to increase marketing that informs individuals of the harm posed by smoking cigarettes (11). Sadly, this marketing follows the same mantra of so many failed public health initiatives before it. With this new legislation, “the FDA…intends to propose new graphic health-warning labels to cover 50% of the front and back of each cigarette pack” (11). Furthermore, the FDA believes that many Americans do not truly know the risks of smoking cigarettes and feel that they are often duped into believing that “light” and “low tar” cigarettes are safe to use (11). To combat these misunderstandings, the FDA plans to educate consumers about the true danger of these cigarettes, with the assumption that such understanding will curb usage (11). This belief is bolstered by a 1999 study, which found that the majority of smokers do not believe they are at greater risk of heart disease and cancer than their non-smoking counterparts (12). But, as outlined in Advertising and Marketing Theory, educating consumers and telling them what they should desire is like placing the cart before the horse (13).
The first step in creating a successful marketing campaign is to research what the consumer desires (13). Then, the marketer packages their product to meet those needs (13). Contrary to this theory, the prevailing assumption in public health interventions is to rely on the practitioner’s intuition to judge what society should want and then package their product accordingly (13). This only appeals to those who are conscious of the importance of good health. Regrettably, health is not always a core value in society and is frequently overshadowed by other desires. This is understood by advertisers and marketers, but not by public health practitioners. To illustrate this concept, a study was conducted in 1993 on the rates of smoking cessation after the diagnosis of lung cancer (14). The study found that 21% of smokers diagnosed with lung cancer continued to smoke even after diagnosis (14). These findings are clearly divergent from long held public health assumptions.
According to the FDA and the Family Smoking Prevention and Tobacco Control Act, most smokers do not know the true risk of their habit and if educated, would likely discontinue such habits (11). If this is true, then why would smokers diagnosed with lung cancer, resulting from their cigarette smoking, continue to smoke? The answer can only be that health is not a core value for many individuals and those interventions designed to promote health, through education on the problem, are ineffective. Given this knowledge, interventions like the one proposed in the latest tobacco control legislation continue to follow old, ineffective habits, rather than looking to newer, and more successful ways of producing societal adherence to healthy practices.

The Family Smoking Prevention And Tobacco Control Act Ignores Minority Groups

The Family Smoking Prevention and Tobacco Control Act has established guidelines on how tobacco may market their products and which products may be sold (15). This marketing and removal of certain products may unconsciously allow certain minorities to be targeted by tobacco firms and to an extent borders on institutionalized racism. The group targeted by such racism is primarily black smokers. Currently, nearly 20% of African American adults smoke on a daily basis (2). White and Native American adults are the only two groups to surpass African Americans in smoking percentages (2). Black smokers also tend to prefer a particular type of flavored cigarette; a preference not shared widely by other consumers (16). Luckily, the new legislation mandates the removal of all candy-flavored cigarettes; except for one (11-15). The one flavored cigarette that is not removed from the market is menthol-flavored cigarettes (15). Coincidently, this type of cigarette is the most popular flavor among African American smokers (16). This trend has been noted in numerous studies. One such study conducted a year before the Family Smoking Prevention and Tobacco Control Act found not only that black smokers consume the greatest proportion of menthol cigarettes, but also that menthol cigarette smoking resulted in a higher rate of cigarette consumption overall (16). The study went on to state that any legislation on tobacco control should take into account menthol cigarette usage by blacks and the high consumption such products encourage (16).
As such, it can be inferred that cigarette sales in large part are dependent on the product needs of African American smokers. To this end, menthol cigarettes also comprise a large proportion of cigarette sales in the US. Unlike other candy-flavored cigarettes, which clearly accounts for nearly no sales of cigarettes, menthol is a highly desired flavor. Yet, no restrictions have been placed on their distribution. So, a cigarette that clearly is at the forefront of contributing to major health problems for one particular group, African Americans, has no regulation stemming from this new bill (15).
This is a clear example of one of Camara Jones’ Levels of Racism, which she calls Institutionalized racism. She defines it as the “differential access to the goods, services, and opportunities of society by race” (17). This is undoubtedly what the sale of menthol cigarettes poses to black individuals. Rather than being an inaccessibility of such goods and services, it is an over accessibility to a certain harmful product. Now, this may or may not be a conscious act of racism on the government’s part, but it certainly can be framed as such. It can also be said that some ignoring of scientific findings took place in the drafting of the new tobacco control legislation. Prior to the enactment of this legislation, studies noted the high consumption of menthol flavored cigarettes by black smokers and suggested that legislation curtail this trend (16). The reasoning behind the lack of regulations controlling menthol cigarettes has as much to do with institutionalized racism as it does with the prior criticisms in this paper. This includes the financial ties tobacco firms have to state government budgets (3-4).

Tobacco Control Must Come In The Form Of Effective Legislation

Before any headway can be made on tobacco control, state governments need to get out of the pockets of tobacco firms. Tobacco has state governments right where it wants them by tying settlement payouts to the sale of cigarettes (3-4). Now, state governments have a vested interest in the profitability of tobacco. This is further exacerbated by the current economic downturn and the increasing budget deficits among states. This has allowed money that was intended to curb tobacco related cost and usage to be used to fill gaps (2). Government has since become dependent on these payouts to fulfill the shortcomings in their budgets. Until this trend changes, government will have a stake in how profitable tobacco is. State tobacco control programs could be fully funded to CDC recommended levels if the percent of MSA settlement money used to fund such programs was raised by 12% (2). This would still leave $21.2 billion in settlement funds that states could use for other purposes. This increase from the $747 million currently put toward tobacco control would have a substantial impact on initiation and continuance of smoking by individuals.

Marketing Strategies To Curb Tobacco Usage Should Follow Standard Advertising Practices

Attempts made to market the harms incurred to individuals by smoking must be carefully constructed. It is no easy task to try and stop individuals from partaking in a habit-forming practice. Some basic rules that are commonly followed by advertising agencies can ensure a greater success in interventions aimed at decreasing cigarette consumption. The specific issues with the current legislation is the proposed placement of “graphic health warning” labels on cigarettes (11). Trying to disgust people into giving up cigarettes is not an effective way and would not be recommended by any advertising firm. As described above, smokers know smoking is harmful to their health and even after the effects of the habit have manifested into smoking related disease and disability, many still continue the habit. In order to see meaningful change in the consumption of cigarettes, marketing strategies must be taken to discover what is important to smokers and then market the intervention around those needs and wants. If the current public health practice of using intuition to make an assumption of what average individuals should want, warning labels will be ignored just as other interventions have been.

Greater Emphasis Must Be Taken To Ensure Equality Of Interventions

Interventions regarding tobacco use must encompass all users of tobacco products. Only banning substances that are already not used by individuals helps no one. Considerations must be made to face the full spectrum of the problem, not just pieces. If the objective is to appear as though headway is being made in the fight against the tobacco industry, then a continuation of the status quo is an effective approach. But, if the objective is to truly limit tobacco use, then the proper steps must be taken to limit the use in all groups.
It is clear through multiple studies that menthol cigarettes are used disproportionately by black smokers compared to other smokers (16). It has also been shown that menthol cigarettes lead to a higher consumption of cigarettes in general (16). So not only are African American the highest proportion of menthol cigarette smokers, but they also consume a greater quantity of cigarettes in relation to other groups. This issue must be addressed for the future safety and well being of the black community. Any future legislation should ban the sale of menthol cigarettes just as the current legislation has banned the sale of other candy-flavored cigarettes. Only then will a reduction in the usage of tobacco be evident in the United States.

Conclusion

Tobacco related disease and disability is a worldwide issue. Even so, some aspects of the problem are uniquely American and some problems span the entire spectrum. The newest legislation, the Family Smoking Prevention and Tobacco Control Act does have some merit and may in fact prove effective in some parts. It does have its flaws though, many of which are historical in nature. In order to understand why this legislation is so limited in its scope, one must look the 1998 Master Settlement Agreement for how government finances got so entwined in tobacco sales. Furthermore, a general overhaul in the way public health professionals think and act when implementing interventions should take place. New research shows what is effective in changing behaviors if the profession only looks to them. These new tactics of how to frame issues alone could increase the effectiveness of interventions drastically. This being said, if something does not happen to change the historical tendencies in this country to exclude some groups from the advances of policy and social standards, no intervention will truly be all encompassing. In the case of the newest tobacco legislation, black smokers are passed over in protection from deadly menthol cigarettes. This is not to say that this overlook was intentional, but as Camara Jones illustrates in her analogy of the gardener with the two gardens, the gardener must realize that the problem with some flower’s stunted growth is in its roots (17). Society needs to take all of these tools to cultivate a more prosperous garden for all.

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