Challenging Dogma - Fall 2009

Thursday, December 16, 2010

Graphic Warning Labels For Cigarette Packs Using The Health Belief Model- Chris Sardon

Smoking has become one of the biggest health issues affecting the United States of America. Its devastation not only affects those who smoke, but also the people around smokers. According to the Centers for Disease Control and Prevention (CDC), tobacco use is responsible for 1 in 5 deaths with about 443,000 deaths due directly to tobacco use and 49,000 deaths due to second hand smoke (5). Smoking causes cancer, lung diseases, heart disease, and stroke and for every person who dies from a smoking related disease, twenty people suffer from a serious illness due to smoking (5). Clearly, cigarettes have catastrophic consequences thus making smoking a prime target for public health interventions.
Recently, a law was passed that gave the Food and Drug Administration (FDA) the power to regulate tobacco products through warning labels. Nine graphic warning labels will be chosen and they will take up half of the surface area of a carton or pack of cigarettes and a fifth of any advertisements. The graphic labels aim to get smokers to quit by vividly demonstrating the dangers of tobacco use. Amongst the potential labels are: a man blowing smoke through a hole in his neck, women blowing smoke into their baby’s faces, and people in coffins.

This public health intervention to combat smoking is based on the health belief model. The intervention assumes that people are weighing the perceived benefits with the perceived barriers to quitting smoking and making rational decisions based on that balance. It assumes that people plan their behavior and it aims at helping the individual, not a group of people. This model for a public health intervention is significantly flawed and will most likely fail to reach its intended purpose.
Critique Argument 1: Assumes Behavior is Rational
The main flaw of this intervention is that it assumes behavior is rational. The interventionists expect smokers to see these labels and weigh the perceived benefits and barriers of behavior change. After this balancing act, it assumes that the balance will shift to smokers intending to quit and eventually changing their behavior towards quitting smoking. But the intervention does not factor in that intention to do a behavior doesn’t always lead to the behavior. The health belief model relies on the individual taking in information and making an educated decision. This is not effective because it does not take into account the social factors that people encounter. This intervention, and the health belief model in general, does not answer the question: why do people smoke? Any intervention that does not factor in this essential question will not be successful.
Individual behavior is not rational because often times people follow a crowd. This is called the herd mentality. One person might be smart, but a group of people can be stupid. When individuals frame their behavior based on what a group of people are doing, it can often lead to irrational behavior. In this case, people see a group of others smoking and follow suit. The social network theory (6,7) demonstrates that the people they are connected to affect peoples’ behavior. In this theory, people won’t just quit smoking by seeing these labels; rather they will quit smoking if others are also doing it. They will quit in clusters instead of as individuals. Because the warning label intervention is based on the health belief model, it is aimed at affecting the individual and not a group, thus rendering the intervention likely to fail.
The health belief model is incapable of affecting the barriers to behavior change. Thus, this intervention does not make it easier for smokers to overcome the obstacles stopping them from quitting smoking. The model and intervention can only affect the perceived severity and susceptibility of the diseases caused by smoking. The label intervention aims to make smokers perceive that they are more susceptible to the diseases associated with smoking but this is a flawed assumption because the human perception of perceived risk is irrational. The optimistic bias theory states that people may have an accurate impression of getting an adverse health problem, but they believe that their personal risk is less (1,12). Therefore, smokers will underestimate their risk of developing lung cancers, heart disease, and strokes (1,10,11). The illusion of control theory also adds to this idea. It states that people tend to overestimate the degree to which they have control over events, which leads to an inaccurate perception of risk (9). Both of these theories lead to a lessened perceived susceptibility and severity of disease associated with smoking, consequently not shifting the balance between perceived benefits and barriers enough to theoretically alter behavior.
Critique Argument 2: Doesn’t Relate to Youths
Another major flaw of the label intervention is that it does not relate to youths. The intervention assumes that youths will be more affected by pictures than written warning labels and, as a result, be more likely to weigh the benefits and barriers to quitting smoking. This is an ignorant assumption. Any parent can tell you that their children’s’ behavior is often driven by rebellion. Rebellion is based on the theory of psychological reactants. The theory of psychological reactants makes the claim that people will rebel when they lose control or freedom (3). These labels are telling youths not to smoke. Youths will perceive being told not to smoke as a threat to their freedom to choose to smoke. These labels will not stop youths from smoking; they will rather increase the amount of smoking in youths because the youths will be trying to restore their control.
Once again, this intervention concentrates on the individual making an educated decision about behavior change. It does not take into account any social factors. Social factors are a big determinant driving the behavior of youths. The theory of social proof backs this assertion. It states that people will do an action if they see other people doing it. People will model their behavior after the norms of those around them. A terrific example of this is the “Bystander Effect.” The “Bystander Effect” is the phenomenon that people will not help a person in need because they see that other people aren’t doing it (2). They know that a person needs help but do not give it to them because it is against the norm of the people around them. This comes into play for teenagers. If they see their peers smoking, they are going to model their behavior after their peers in order to stay with the social norms around them.
The label intervention also does not approach the reason why youths smoke. Often, a person’s behavior will be attributed to their attributes and character. The fundamental attribution error theory shows that this is a poor way to approach this issue. The fundamental attribution error states that behavior is significantly affected by the context of the situation (8). Youths do not smoke because they have character flaws. They smoke because the environment they are in makes it “cool” to smoke. As demonstrated earlier, the context that contributes to a youth’s behavior is based on the social structure surrounding them.
Youths will also do dangerous behaviors even when they know the risks. They do this because they feel that they are invincible. This thought process is based on the theory of optimistic bias and the theory of illusion of control. As stated previously, the optimistic bias leads to people believing that they are at less risk than others. This is evident in the behavior of youths, as they believe their dangerous actions will not affect them. Youths also believe that they have complete control over their lives. This is consistent with the theory of illusion of control. Youths believe that they have more control over their events and accordingly perceive that they are at a smaller risk. Both of these theories demonstrate why youths believe that they are at a lower risk than others when it comes to the effects of smoking. Thus, this intervention is not going to work on youths because their perceived risk due to smoking is quite low. They know the consequences that come with smoking, but they believe that is for everyone else in the world but them. This is why this intervention is going to be useless on the youth of America.
Critique Argument 3: Does Not Deal With Addiction
A major limitation of the health belief model is that it does not deal with addiction. People who are addicted to smoking are affected by the stereotype or label they are given which leads to irrational behavior. This is based on labeling theory. People take on the characteristics of the label they are given (4). Smokers know what the risks of smoking are but choose to do actions based on the expectations of their label. People addicted to smoking are expected to smoke. Because they are expected to smoke they choose to behave in a way that meets these expectations. By knowing the consequences of smoking but choosing to meet the expectations placed on them, smokers are making the irrational decision to continue their unhealthy habit.
People also have the fundamental inability to control their actions. This lack of self-control leads to irrational behavior. Many smoking addicts have tried multiple times to quit but do not have the self-control to succeed. By seeing labels like these, it makes them feel defeated. This feeling decreases their self-efficacy to quit. It lessens their belief that they can quit their addiction. This is a fundamental problem to this intervention. People NEED to believe they can quit. Without that confidence, changing ones behavior is nearly an impossible task to accomplish. The other problem with this intervention pertaining to addicts is that it gets to them too late. These labels are hardly seen until someone is actually in the process of buying the cigarettes. People have already made the decision to smoke and at the point when they buy the cigarettes, it will be too late to change their behavior.
The theory of optimistic bias again factors in with addicts. These people have been smoking for a long time and have not seen the effects that the statistics claims are happening. If it has not happened to them over the years, they feel as if they are at a decreased risk. They do have an accurate perception of what could happen, but they believe that it won’t happen to them. They now perceive a much lower risk of illness due to smoking based on their own personal experience. The theory of illusion of control also factors in here. Many addicts believe that they have the control to stop whenever they want. Sadly this is not true. They have the belief that they can in fact control their actions, therefore leading to an inaccurate perception of risk. These two theories again demonstrate that smokers will believe that the risk to them is significantly less than the statistics show.
This smoking label intervention is simply not going to work. People who smoke already know what the risks associated with their actions are. This approach is too simplistic. It assumes that people are rational beings and are not affected by the people around them. This is a naïve belief. Initially, there is going to be a big shock to the public once the intervention is implemented. This will last a limited time, as people will become used to the new packaging. The same thing happened when the written labels were first placed on cigarette packs. People noticed them at first, but now people don’t even recognize they are there. I also believe that people will develop ways to block out these images. People use koozees on beer cans. Who is to say that the tobacco companies aren’t going to make a similar product for cigarette packs? As people naturally adapt to their environments, people will adapt to these new packages rendering the intervention useless. This intervention fails to acknowledge why people smoke. Without taking on that question, any intervention to get people to quit smoking will likely not succeed.

Proposed Intervention
As we observe society, we can conclude that people are not rational. A person can be given all of the statistics and data in world about smoking, but will still probably behave in an irrational manner. Previous interventions have relied on people’s reasoning skills and have proven to be unsuccessful. The optimal way to change a person’s behavior when it comes to smoking is to make it personal. If you can hit a person in the heart, they will be more likely to make behavior changes towards a healthier life.
I believe an effective intervention to get smokers to quit and to stop people from starting to smoke would be through a personalized commercial. In each region of the country, I would air a commercial starring a well-respected celebrity from that area with a personal story about how smoking has affected his or her own life. This approach is based on the law of small numbers. This law says that the perception of risk for people is related to the people they see around them or the stories that they hear, not through statistics. In this commercial, I would try to use a celebrity that can relate to young and old people. They will discuss how smoking personally affected their life and say that the tobacco companies have control over you when you smoke. This will hit people in the hearts as they can relate to this person as well as trigger the viewers desire to regain their freedom and control. At the end of the commercial, the celebrity would encourage people to talk about why they smoke and how they can quit with their family and friends while also providing the phone number and website for a smoking hotline. The closing of the commercial will be the celebrity making a promise to the viewer that cutting smoking out of your life will make you a happier person.
This approach is based on advertising theory, the health belief model, and the social network model. These different models and psychological theories allow the commercial intervention to influence a broad range of people. It will affect the common irrational person, youths, and smoking addicts. By taking into account multiple social psychology approaches, this intervention will be more successful than the current package labeling intervention. This approach factors in social aspects, personal stories, and the desire for control in order to appeal to a large audience.
Defense of Intervention: Plays to Predictably Irrational Behavior
This intervention does factor in that people do not make rational decisions. The health belief model portion of this intervention aims at the balance between perceived benefits and barriers. Normally smokers don’t believe that they are at much of a risk because they have a skewed perception about the risk they are at. They see the statistics of illnesses associated with smoking, but do not have personal affiliations with these diseases. This commercial will get the smokers and potential smokers to see a personal story, thus making the risks of smoking more close to “home.” This will make the perceived benefits of quitting seem larger, therefore shifting the balance towards healthier behavior. These personal stories will reduce the optimistic bias that a person feels. People will now have a more accurate perception of what their own personal risk is. This will also decrease the illusion of control. Viewers might see a former professional athlete who is suffering from smoking related illnesses. If a phenomenal athlete like that can’t have control of their own body, than how can a normal person have control. This will get the viewer to realize that they have less control over events than they previously thought. This commercial is taking advantage of this by selling control, not health.
This intervention also factors in that people are affected by society around them. People tend to follow groups and want to fit in with the crowd as stated by the social network theory. By getting smokers to talk to friends and family about why they smoke, they could potentially find support in others who don’t smoke and want to follow their lead. Also getting a smoker to come to the realization as to why they smoke is key to behavior change. If a person doesn’t understand their own reasoning for a behavior, it will be harder for them to change that behavior. The first step to changing the behavior of smoking is to identify the reason for smoking. Once the reasoning has been pinpointed, the smoker can concentrate on that point and try and correct it with the support of their family and friends.
Defense of Intervention Section 2: Relates to Youths
A strong point of this intervention is that it plays to youths. First off, by using a prominent celebrity from the local region, the youths will have a better time relating to that person. This is based on the principle of liking. If a youth likes or relates to a person giving a message, he or she is more likely to follow that message. Basically, the more similar a person is, the more likely they are to respond to the message.
As stated earlier, teenagers thrive on rebellion. This intervention, with its advertising theory basis, plays to this phenomenon. The key here is to convince kids not to trust the tobacco industry. When the celebrity that they are familiar with talks about how the tobacco industry controls you when you smoke, the youths will want to rebel to restore their control and freedom. Advertising theory has a foundation in promises and support. By promising the viewer that he or she will live a happier life without smoking, they are appealing to the core value of happiness. This will motivate people to think about changing their behavior regardless of if the promise is true. The way this works is by supporting it with a story, which the commercial does. The promise of the core value of happiness and control is the key to stopping and preventing children and teenagers from smoking.
As previously stated, this intervention factors in the societal environment that the people are in and the newly acquired perception of personal risk due to minimization of optimistic bias and the illusion of control.
Defense of Intervention Section 3: Approaches Addiction
Addiction to smoking is a tough dilemma to approach. Many people are set in their ways and are in denial of their addiction. The commercial intervention relies somewhat on the social network theory. It assumes that the people they are connected to influence people’s behavior. If the commercial does its job, it will convince smokers to talk to the people around them. This can help them realize that they have an addiction and come to a conclusion as to why they smoke. This is a big step for addicts because it gets them to admit that they have a problem. By hearing a celebrity’s story and talking amongst friends, an addict will see the support that he or she has. This realization of support, along with the minimization of optimistic bias and the illusion of control, will increase the addicts’ self-efficacy to quit smoking. This is a huge step for any addict. They need to believe that they have the power to quit. This newly found self- belief combined with a support system would help the addict change their behavior. Addicts are the toughest group to appeal to and I believe this intervention could help their progression to a healthier life.
There is not a single social psychological theory that can solve the smoking epidemic on its own. Every theory has its benefits and flaws. The commercial intervention attempts to take multiple theories and combine them in order to affect the most people possible. It acknowledges peoples’ predictably irrational behavior, youths desire to rebel, and addicts’ inability to recognize their problem. If implemented correctly, this intervention could have a dramatic effect on smoking simply because it confronts the reasons as to why people smoke. Finding the reason is the key to an interventions’ success and I firmly believe that this intervention is a step in a positive direction.


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