Challenging Dogma

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

Sunday, April 22, 2007

TRUTH: Promoting Prevention by Infecting Knowledge versus the Inability to Effectively Intervene – Ana Morales

Smoking among teenagers in the United States continues to be a major public health concern. Smoking cigarettes has also been associated with increasing one’s risk of developing smoking-related diseases such as cancer (lung, pharynx, pancreas, lip, uterine, and kidney), coronary heart disease, stroke, respiratory problems (shortness of breath, asthma, etc) and can eventually lead to a decreased quality of life and premature death (1, 2). Almost 90% of adult smokers began smoking at or before the age of 18 (3). Every day approximately 3,900 youth try a cigarette and about 1,500 will become daily smokers (4). This means that roughly 40% of those who decide to experiment by taking a few “innocent” puffs are actually creating the foundation for what could be a life long addiction. It is imperative to focus on not only preventing youth from smoking but to also intervene and change the behavior of current smokers.

TRUTH was launched in February of 2000 by the American Legacy Foundation as a national initiative to prevent smoking among youth aged 12 -17. The campaign’s goal is to target teens and prevent them from smoking and/or change their behaviors by making them aware of the true facts about cigarettes, smoking, and “Big Tobacco’s” marketing tactics and deceptions (5). The campaign utilizes promotional items, street marketing, television ads, and an interactive website to infect youth with the truth (6). Television ads are used to grab the attention of teens who can then visit the interactive website ( and be entertained for hours. The website has different sections where teens can view their favorite tv ads, download facts, buddy icons, and wallpaper, play some video games, even send “hairy mail” to their friends (7).

The TRUTH campaign has been successful at making people more aware of the facts and effects of smoking cigarettes. However, knowing about the health related issues and the trickery of Big Tobacco does little to address the fundamental causes of why teens begin to smoke and therefore does little to change the behavior of those who continue to smoke.

TRUTH does not address the fundamental causes of smoking
“Grooming not a strong priority,” “Not into ideas,” “Low self-esteem,” and “emotionally insecure” are all terms that Big Tobacco has used to identify some of their potential costumers (8). Big Tobacco has correctly identified two of the most important fundamental causes of smoking – low self-esteem and emotional insecurity. Big Tobacco’s ability to identify these fundamental causes and then target those individuals through marketing is probably the reason they are able to convince almost 4,000 teens each day to take a puff of a cigarette for the first time. TRUTH has effectively provided teens with this information about tobacco companies by including it in one of their television ads, but they have not effectively targeted these most vulnerable teens or provided them with the means to raise their self-esteem or feel emotionally secure. Unless this is addressed they will continue to be victims to Big Tobacco’s marketing schemes.

In order to fully understand the reasons why teens smoke, one must look at the socio-cultural environment that these teens are a part of. The decision-making process is not isolated from the environment, in actuality; one’s environment plays a crucial role in the decisions being made. Teens are at a very vulnerable stage in their life, in which many of them, at one point or another, suffer from low self-esteem or emotionally insecurity. At these moments of vulnerability teens are looking for social acceptance or approval from their peers and can be more easily peer pressured into smoking. “A teen’s peer group plays a major role in the development of its member’s self-identities and may impart values that encourage experimentation with tobacco products (9).” Teens that can successfully counteract the peer pressure are those who not only have the information and knowledge, but who also have strong support systems, are who are confident with themselves and their decisions.

The strategy behind the TRUTH campaign is to appeal to a teen’s “natural desire” to rebel, challenge authority, take risks, assert control, and independence. According to the American Legacy Foundation, the old approach of just telling a teen not to smoke by solely focusing on the detrimental health effects enhances the “forbidden fruit” status of cigarettes (10). The campaign hopes to appeal to the same “rebellious nature” of teens, but by shifting it and having them rebel against tobacco companies by revealing all the deadly and addictive chemicals in cigarettes. However, this strategy does not help teens who have a low self-esteem or who do not have enough self-confidence to assert themselves and rebel against tobacco or even against their own peers.

TRUTH’s campaign is based on the assumption that with the facts and knowledge, teens will be able to then make an informed decision and not smoke. However, many teens are often in situations where their decisions are not rational, especially for those with low self-esteem. For example, a teen that is not in the “cool” crowd is at a party when someone from the “cool” crowd offers them a puff from a cigarette. That teen is now faced with two options: either take an innocent puff of the cigarette despite all the information learned and have a shot of being “cool”, or decline the cancer stick and risk being that person who is not accepted. Someone with a low self-esteem may decide to take a puff to be socially accepted among their peers; unfortunately, now they have a 40% chance of becoming a contributor to Big Tobacco’s bank account. Teens who do not have the confidence in themselves will not be likely to rebel against their peers, especially among those who they want to be accepted by. TRUTH does not address this irrationality or even the vulnerability of some teens.

TRUTH does not provide the tools to raise self-efficacy
TRUTH seeks to empower teens by providing them with the facts of smoking and cigarettes and sheds light on the dishonesty of Big Tobacco. The campaign seeks to grab the attention of teens through the ads and then directs them to their websites where teens will learn while having fun. According to a telephone survey administered, just 10 months after the launch of the TRUTH campaign, there was a 21 point percentage increase in the proportion of teens who were aware of any anti smoking campaign (5). On MySpace, a very popular social network, especially among youth, TRUTH has over 21,000 friends and these friends can then “infect” others by sending bulletins or posting a “hairy mail” message (11). This is a great network, providing information, however it does little to help current smokers who want to quit. Smokers with the intention to stop smoking cannot find any hope to actually change their behavior because the campaign only addresses the effects of cigarettes or their adverse effects on health.

In the United States, approximately 50% of middle school and 62% of high school smokers reported that they wanted to stop smoking. Of the middle school smokers 55.4% and 53.1% of high school smokers have tried to quit sometime within the past 12 months (12). A high percentage of students have the intention to quit and a large portion of them have attempted to change their behavior, unfortunately they failed.

One of the major barriers to changing the current behavior from smoking to quitting is one’s perception of one’s ability to reach a goal, in this case quitting smoking. This is known as self-efficacy and it plays a central role in the cognitive regulation of motivation (13). People will be more inclined to change their behavior if they believe they can succeed. Those with high self-efficacy will be more likely to attempt and engage in behavior changing decisions more than people with low self-efficacy. According to Bandura, there are four main sources of influence that affect self-efficacy – mastery experience, modeling, social persuasion, and physiological factors (14). The first relates to the number of successes, which raise self-efficacy. Therefore, more failed attempts at smoking will lower one’s perception of one’s ability to quit. Modeling relates to seeing people who look like you also quit smoking successfully and social persuasion is encouragement or discouragement that the person gets from the society in which they interact with. Physiological factors includes any physical effects that a decision may have, in this instance nicotine withdrawal symptoms which include irritability, headaches, cravings, drowsiness or trouble sleeping, tension, increased appetite and weight gain (15). If these sources of influence do not work to increase a teen’s self-efficacy, they will likely be unsuccessful in their attempt to quit smoking, even if the intention is there.

The TRUTH campaign does not address any of the sources that influence self-efficacy. In one ad, Singing Cowboy, a middle-aged man is sitting at an intersection of a crowded street in Manhattan, dressed as a cowboy. His friend is playing the guitar and the cowboy is singing a song about tobacco. He is singing “you don’t always die from tobacco, sometimes you just lose a lung… sometimes they just snip out your tongue” with a voice machine pressed up against the hole in his throat (16). This ad is supposed to be shocking, while also making people aware of some of the consequences of smoking. Singing Cowboy is used as a mechanism to prevent teens from smoking and to change the behavior of current smokers, by using scare tactics. However, this ad does not address any of the sources of influence needed to increase self-efficacy. The cowboy is not setting an example as a role model, because he is not a person that teens can relate to.

Singing Cowboy may actually spark a small number of teens to look for information on the website that appears at the end of the commercial. Despite this interest, teens will not be able to find any help on the campaign’s website. The website does not include any links to any smoking cessation programs or support groups. There are no personal testimonies about the benefits of quitting or how some have overcome the addiction and nicotine withdrawal symptoms. TRUTH does not provide teens with any of the tools needed to raise self-efficacy and teens will not be able to quit successfully. They will be on a continuous cycle of failed attempts and lowered self-efficacy, while continuing to smoke.

In Conclusion
TRUTH as a national movement to prevent smoking among teens has successfully integrated into the youth scene through their tv ads and social networks. However, the campaign has not used their resources to 1) address the fundamental causes of smoking and 2) to provide the tools necessary to increase self-efficacy. Due to these factors the campaign has not been able to successfully intervene and prevent teens from smoking and/or successfully provide teens with the tools needed to change their behavior. One’s intentions do not always correlate to action, but if the tools were in place to help increase one’s self- efficacy, the challenge may be just a little easier.

1. Department of Health and Human Services Center for Disease Control and Prevention YRBSS National Youth Risk Behavior Survey 1991-2005 Trends in the Prevalence of Cigarette Use
2. Center for Disease Control. Youth Risk Behavior Surveillance – United States, 2005. Morbidity and Mortality Weekly Report Surveillance Summaries 2006 Jun 9; 55(SS-5)
3. Gallogly M. The Path to Smoking Addiction Starts at Very Young Ages. Campaign for Tobacco-Free Kids 2007 March 2
4. Youth Exposure –Legacy American Legacy Foundation Fact Sheet
5. Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting the Truth: Evaluating National Tobacco Counter marketing Campaigns. American Journal of Public Health 2002 Jun; 92(6): 901-07
6. TRUTH Factsheet. American Legacy Foundation. 2005 June 17
7. TRUTH website
8. New truth Campaign Uses Giant Arrows to Get Straight to the Point about Tobacco. American Legacy Foundation 12/05/05 press release
9. Ennett ST, Bauman KE. Peer Group Structure and Adolescent Cigarette Smoking: A Social Network Analysis. Journal of Health and Social Behavior 1993 Sept; 24:226-236
10. Healton C, Speaking truth to Youth: How the American Legacy Foundation is Helping Teens Reject Tobacco. NCMJ. 2002 May/June; 63(3):162-4
11. TRUTH MySpace page.
12. Center for Disease Control. Youth Risk Behavior Surveillance – United States, 2005. Morbidity and Mortality Weekly Report Surveillance Summaries 2006 May 19; 55(SS-03)
13. Wikipedia. Self-Efficacy. Wikimedia Foundation Incorporated
14. Bandura A. Self-Efficacy. In V.S. Ramachaudran (Ed), Encyclopedia of human behavior. 1994; 4:71-81
15. Ballas P. Nicotine Withdrawal symptoms. Medline Plus. Last Updated 5/17/06
16. Singing Cowboy. TRUTH ad campaign. Video can be accessed on or

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