Challenging Dogma


...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Scared to Action: Do scare tactics elicit behavior change? – Erin Taylor

Over the last several decades, study after study has shown that tobacco use of any kind is very detrimental to one’s health. Warnings against tobacco use are everywhere: schools, TV, news, your doctor and the list continues. There have been countless public health initiatives and policies that have been put into place to try to encourage cessation or prevention of tobacco use. Many of these efforts have been targeted at adolescents. Prevention of tobacco use in this age group is crucial, but can be extremely difficult to design an appropriate program for various reasons. Adolescents are very complex due to many factors that contribute to their health behavior decisions. In an effort to make a large impact on teens, some public health initiatives have resorted to using scare tactics to promote their message. The use of scare tactics assumes that knowledge alone is enough to encourage a change or at least intent to change behavior. This reasoning is flawed thinking. Scare tactics are an ineffective means of promoting public health, especially in adolescents.

A very popular campaign known as the truth® campaign has tried to tackle tobacco prevention in adolescents.(8) The campaign began in Florida around 2000 and relies heavily on scare tactics and sensational images to promote its agenda of tobacco prevention and cessation in teens.(8) The campaign is comprised of TV ads and an interactive website with “scary” tobacco facts and graphic images such as hundreds of body bags to drive home the fact that tobacco is harmful. The truth® also encourages teens to spread the facts presented in their ads.(8) This campaign uses social marketing techniques to package their message but relies heavily on the Health Belief Model and the Theory of Reasoned Action to predict health behavior change.

Public health initiatives that rely on both of these theories as a means of promotion assume that knowledge is enough to encourage a change or at least intent to change health behavior. Both of these models also assume that a rational thought process is used to make health decisions.(2,5) However, not all health decisions are made through a rational thought process. Scare tactics also do not address the reason the harmful health action is begun.

It is first important to understand why the truth® campaign would go as far as using scare tactics to promote its agenda. Looking through the literature discussing adolescent use of tobacco, it is clear that there was increasing dialogue about prevention and cessation efforts for tobacco use among teens throughout the 1990s. Teens were the focus of public health research because during the teen years is when many lifetime smokers typically begin their habit.(6) Teens were also the target audience for the tobacco industry for the same reason. According to the CDC YRBSS survey in 2001, 28.5% of teens reported that they smoked one or more cigarettes in the past 30 days. In 2003 the percent dropped to 21.9 but there was a small rise in 2005 to 23.0%.(7) 2005 is the most recent data but the survey suggests that experimental smoking is slowly on the rise in the US.

Along with all of the dialogue and public health planning, Big Tobacco finally had its day in court in 1998.(4) Plastered all over the media, the tobacco industry was finally made accountable for the addictiveness and harmful effects of its product. The trial proceedings became a part of evening news and conversation around the dinner table. As part of the court findings, the major players in the tobacco industry were required to pay a large sum of money to fund anti-tobacco efforts targeted at teens. Some of this money was used to fund the truth® campaign.(4) With this money, it was time to make a difference in the lives of adolescents.

The use of scare tactics is actually not anything new to the anti-tobacco effort. Many remember seeing the black lungs in science class to demonstrate what tobacco can do to our bodies. Many countries such as the UK plaster huge warnings on the front and back of cigarette packs with various graphic messages and images. These warnings actually make the US warning labels look quite benign.(10) While these messages are all sent with good intentions and based on very popular health theories, they somehow miss the mark. Both the Health Belief Model and the Theory of Reasoned Action can support the use of scare tactics, but there are some critical assumptions that these theories make that might explain why scare tactics are not always successful in creating a behavior change.

The Health Belief Model relies on two key facts: the perception of the seriousness of a disease or action and the perception of one’s own susceptibility to the adverse outcome. According to this theory, if people acknowledge the seriousness and their own susceptibility then they will be motivated to change their health behavior.(2) The model makes a large assumption that all health decisions are made with a rational thought process. People do not always make rational decisions. Due to the many influences on adolescent decision making, rational decisions might occur even less frequently.(9)

Many teens seem to think they are invincible.(9) The concept of time and consequences is a skewed idea. Teens think that someone 30 years old is ancient and it will be forever until they are that age, let alone 50 or 60 years old.(9) They are unable to process the realistic harmful effects of many of their risky health choices. Many feel that all of the potentially harmful effects of tobacco simply will not happen to them or the adverse effects are simply not a big deal. To clearly depict a common attitude, a quote from one teen smoker on the potential harmful effects,

“Nothing bad will happen to me now so why bother? Cigarettes serve a purpose by giving pleasure. No one wants to live forever.”(6)

According to the Health Belief Model, if people never see themselves as susceptible they will not change their health behavior.

The truth® campaign bombards viewers with “scary” facts about tobacco and the tobacco industry to try to encourage a change in behavior. With these facts, the campaign is also trying to drive home the seriousness of tobacco use. However, these messages have had very different responses with different groups of teens. In one study, students were shown ads, some from the truth® campaign, depicting clear adverse health effects from tobacco use. In this group of adolescents, the ads did not affect perceived health risk or belief of the seriousness of health outcomes for tobacco use. The students did however empathize with the victims of tobacco related illnesses.(3) Unfortunately, empathy is not a strong motivator that will lead to a behavior change.

Many teens who are smokers do not perceive their own tobacco use as serious. They see that their smoking is under their own control and they are not really addicted. These attitudes were noted in a study done among teens in Scotland.(1) This attitude translated into a reduction in intent to change behavior. This contradicts the use of the Theory of Reasoned Action as the basis of anti-tobacco initiatives. The Theory of Reasoned Action states that “a person’s voluntary behavior is predicted by his/her attitude toward that behavior and how he/she thinks other people would view them if they performed the behavior. A person’s attitude, combined with subjective norms, forms behavioral intention.”(5) It is clear to see that if those that smoke do not even see their actions as serious or problematic, they will have no intent to change their behavior. Scare tactics will not make teen smokers acknowledge that they have a habit or are addicted.

One study was done among college students using an ad from the truth® campaign and an ad from another anti-tobacco campaign.(6) The participants were both smokers and non-smokers. Both groups were asked to watch the ads and explain the response that they had to the images that they saw. Both groups had fairly strong responses but they were very different. Among the smokers, a few responses were:

“All the ‘truth’ campaign does is convince me that I should go outside and light up another cigarette.”(6)

“The first time I saw the ads, I was impressed. Now the campaigns are too heavy. It’s just annoying now. It’s less effective on me because whenever it comes on TV, I just zone out or change the channel. It’s on all the time, and I don’t want to hear that smoking is killing me every second.”(6)

This type of response was quite opposite the truth® campaign’s goal. From the actual mouths of the target audience, teen smokers are not impressed with the scare tactics.
The ads did receive much more favorable response among non-smokers. One non-smoker said:

“After I see ads like this, I thank God that I wasn’t stupid enough to start smoking.”(6)

The study did note that many nonsmokers overestimated the effectiveness of the ads.(6) One such response follows:

“If I smoked, it would really make me think twice. I would be so disgusted by this fact that I would try to stop smoking right away.”(6)

This response completely contradicts the feelings smokers reported. Some non-smokers were able to identify the problems that smokers had with the ads. One person said:

“… ’truth’ ads insult smokers. That just makes matters worse. I think that would just make them want to smoke more.”(6)

According to the Health Belief Model(2), the smokers will never achieve the perception of susceptibility or seriousness and, therefore, never make a health behavior change. Even with the positive response among the non-smokers, there is not a guarantee that the information presented in the ads is enough to maintain their intent not to smoke. The scare tactics appear to have backfired among these smokers and among some of the non-smokers.

It is also important to remember that just because people have the intent to begin or stop a certain action, they might not always change their behavior. Teenagers have so many competing factors that knowledge and intention might not always be enough to change their health behavior. Many people can have the intent not to smoke but somehow they still pick up a cigarette. Especially for those that already smoke, many have the intent to quit but just never seem to make the effort. The truth® campaign relies heavily on the intent of a person to lead to action. On the “Protect the Truth” website the group claims that 85% of youths (12 to 17 year olds) said that the ads gave them good reasons not to smoke and 90% of youths said that the ad they saw was convincing.(4) These statistics do not always translate into rational health decision making.

One article noted that a study was done among US high school smokers. The study found that while most had thought about quitting, and some had tried to quit, they did not intend to quit in the foreseeable future.(1) With these underlying attitudes, it is very difficult to have scare tactics elicit a strong enough response to move intention into real action. Also, for many teens, smoking will allow them to enter a social group or would exclude them if they quit smoking. These feelings of belonging would be enough to override any intention that teens had to avoid starting or quitting smoking.(1)

Scare tactics also do not address the reason teens start smoking in the first place. Researchers have spent countless hours and dollars to try to understand all that is involved for teens to begin smoking or any risky behavior for that matter, which may include peer pressure, modeling, and sensation seeking among many other factors. Throwing sensational facts and images at these reasons does not address the issue. The use of scare tactics assumes that lack of knowledge is the reason why a risky behavior will begin.

The truth® campaign also assumes that a lack of knowledge about the harmful effects of tobacco is the main reason for contemplating or initiating tobacco use. The tag line for the campaign is “Knowledge is contagious. Infect truth.”(8) Teens in today’s society do not have a lack of knowledge of the harmful effects of cigarettes. They are inundated with information at school and various other sources through the media. Using these scary facts to spread information is not the most efficient means of sharing the information. Many actually find the information insulting. In one study, a respondent to the truth® campaign said:

“You would have to be a moron to not know that it kills.”(6)

One has to ask: Is the truth® campaign wasting its time and money?

As stated previously, the Theory of Reasoned Action states that people’s behaviors are influenced by their attitude along with the subjective norms around the action. During the adolescent years, people are desperately trying to find acceptance and a place to fit in. They are also testing boundaries and in search of their own independence. If teens are in a social group that smokes or if they live in a home where smoking is okay, it will be very difficult for scare tactics to combat these competing influences. The truth® campaign has to be persuasive enough to change the attitudes toward smoking among the majority of teens to change the subjective norms. Teens are constantly bombarded by images from Hollywood, ads, TV, and pop culture that reinforce the idea that smoking is cool. All of these factors work together to make it difficult for almost any public health initiative for adolescents. Scary facts and sensational images are unlikely to overcome all of these barriers to health behavior change.
There has been a lot of research on the truth® campaign to see if the campaign really works. After looking through the literature, there is much debate on the true merit of this ad campaign. Although the campaign appeared to be very successful at first in Florida, its effectiveness seems to be waning.(3) The novelty of the ads is wearing off, and, in states with already well established anti-tobacco industry campaigns, the truth® campaign appears to have little effect.(3) Although the truth® campaign has done a very nice job packaging its message using social marketing techniques, the campaign has relied on the Health Belief Model and the Theory of Reasoned Action by employing scare tactics to carry their important message. While there has been some benefit of the truth® campaign, it is important to realize that the campaign message is not appropriate for all teen audiences. Every public health initiative has positive and negative attributes. As public health professionals, we can learn from the truth® campaign’s efforts in order to create stronger health initiatives in the future.

References

1. Amos A, Wiltshire S, Haw S, & McNeil A. Ambivalence and uncertainty: experiences of and attitudes towards addiction and smoking cessation in the mid-to-late teens. Health Education Research, 17 August 2005, Vol 21, no. 2, pgs 181-191.
2. Health Belief Model, Wikipedia, available from http://en.wikipedia.org/wiki/Health_Belief_Model, retrieved on April 3, 2007.
3. Pechmann C, Reibling ET. Antismoking advertisements for youths: an independent evaluation of health, counter-industry, and industry approaches. American Journal of Public Health. May 2006, Vol 96, No 5, pgs 906-913.
4. Protect the Truth. truth® Campaign, available from www.protectthetruth.org/truthcampaign.htm, retrieved on April 1, 2007.
5. Theory of Reasoned Action, Wikipedia, available from http://en.wikipedia.org/wiki/Theory_of_reasoned_action, retrieved on April 3, 2007.
6. Wolburg JM. College Students’ Responses to Antismoking Messages: Denial, Defiance, and Other Boomerang Effects. Journal of Consumer Affairs, Winter 2006, Volume 40 Issue 2.
7. YRBSS survey – Tobacco Use, CDC, available from http://apps.nccd.cdc.gov/yrbss/CategoryQuestions.asp?Cat=2&desc=Tobacco%20Use, retrieved on April 3, 2007.
8. The truth® campaign, available from www.thetruth.com, retrieved on April 1, 2007.
9. Lightfoot, C. (1997). The Culture of Adolescent Risk Taking. Guilford Press.
10. Hitti, Miranda. Supersize Cigarette Warning Label? Study: Larger Labels With Pictures-As in Other Countries-May Make Smokers Think Twice. WebMD Medical News, February 6, 2007, available from http://www.webmd.com/Article/131/118153.htm, retrieved on April 1, 2007.

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