Making the Next Generation Tobacco Free: A Critique of The Real Cost Campaign for Teenagers – Stephanie Sanchez

Introduction

               One of the leading preventable causes of death is tobacco smoking (1). In the United States, 480,000 people die each year by causes related by the use of tobacco; and annually cost approximately $289 billion to the healthcare system (1). The Food and Drug Administration (FDA) launched their new anti-smoking campaign called The Real Cost, which is targeted to teens between 12 and 17 years old who are at risk of experimenting with cigarettes (2). On a daily basis more than 3,200 Americans younger than 18 years of age smoke their first cigarette (1). The FDA believes that early intervention is critical to reduce the population of habitual smokers (2).

                  The Real Cost campaign has the goal is to create awareness of the potential damage of tobacco smoking with an educational approach, emphasizing the consequences that teenagers care about (2). Most of the ads highlight how smoking affects physical appearance and that cigarettes can lead to addiction (2). The campaign has launched three commercials. The first one describes how smoking is harmful to teeth and contributes to overall mouth infections. The second one emphasizes how smoking can cause premature wrinkles and adverse effects on skin. The third one highlights how cigarettes can become “bullies” by leading to addiction.

                 Teenagers who smoke tend to live a chaotic life, struggling with social and economic situations (3). Research shows that most teenager that are smokers have poor academic achievement, poor coping skills, have trouble at home, and have a negative outlook on life (2). The anti smoking campaign will encourage these troubled teens to stop smoking by showing not only the financial cost of cigarettes but also how they are giving up so much more: their health. These new commercials dramatize the potential effects of smoking on teens’ physical appearance. Past campaigns have highlighted long-term tobacco-related diseases such as lung cancer and heart disease (4); this new campaign focuses on negative effects that teens are more susceptible to in the near future.

                The Health Belief Model (HBM) has been used widely for health intervention in order to understand and predict health behaviors (5). The theory explains that in order to change a health behavior there must be a negative condition that can be prevented followed by a positive outcome (5). Therefore, an individual must believe in the severity and susceptibility of a specific health behavior (5). The campaign follows this theory to reach to adolescent in order to reduce the rate of future smokers. The goal of the campaign is to reduce the number of youth cigarette smokers by approximately 300,000 within the near future (6).

Critique 1: The Health Belief Model Falls Short

                Based on the assumptions of the HBM, the main flaw is that this theory assumes that individuals follow a rational thinking process. However, people do not always act rationally, especially adolescents who make poor choices based on impulses, emotions or peer’s influences. The HBM does not take into account behaviors that are addictive or habitual (5), such as cigarette smoking. Other limitations, such as the lack of consideration of why teens smoke, non-health related reasons, and personal beliefs or environmental factors are issues that should be addressed for an effective intervention. Furthermore, self-efficacy is an important component of the HBM and refers to the individual’s ability to successfully change a specific health behavior (5); the intervention must show how benefits outweigh the consequences.             

              The Real Cost commercials successfully demonstrate the severity of smoking cigarettes. However, regarding the individual’s own susceptibility is questioned. Focusing on the skin and teeth commercials, they try to show the immediate consequences of tobacco smoking, however, how immediate are these negative outcomes? Teens who are currently smokers may see them as a long-term consequence since they might not see the consequences yet. In addition, it seems that the adverse effects are superficial for the audience, particularly to the low socioeconomic class. According to the Center for Disease Control and Prevention (CDC), factors that influence teens to smoke are low self-image, aggressive behavior and low socioeconomic status (7). Teens may carry other concerns that are far more important that just physical appearance, such as, food insecurity and lack of shelter (8).

               The component of self-efficacy of the HBM may not be as effectively portrayed in the commercials. The commercials assume that teens are confident in the ability to quit smoking, that by acknowledging a potential negative outcome they will have enough motivation and strength of will to change their behavior. Some teens might already have physical and emotional dependence on nicotine and may not be at the necessary stage for this educational ad to change their behavior. Evidence shows that young people may be more sensitive to nicotine and sooner become dependent (7).

Critique 2: The Realness of  “The Real Cost”

            The Real Cost campaign dramatizes the health consequences of smoking by showing teens pulling their teeth out or peeling their skin off. The campaign aims to show that smoking cigarettes comes with a cost and is not only financial (6).  Evidence shows that smokers believe in optimistic bias, thus, they tend to underestimate the odds of bad things happening to them (9). In addition, the reaction of some teen that were interviewed by local news reporters highlighted negative feedback after watching the ads, “I don’t think there is going to be an actual effect”, “nobody cares that much” and “the ads are weird to see” (10). Teenagers might question to what extent are the ads accurate, they might believe the ads are just trying to create fear towards smoking habits and that the real outcome is not as exposed in the commercials.

               According to Cathy Terwilliger, counselor at Wyoming Valley Alcohol and Drug Services in Wilkes-Barre, says, “the ads are more graphic than they are effective”, “it’s very difficult to look at”, (11). Also, smokers between 12 to 17 years old are not going to see the effects of premature wrinkles until after a couple of years. They might no even see any teeth consequences because they are still young. In addition, the commercials show consequences that will occur with aging, this can be an issue since some might believe that the health consequences will happen anyway, so why worry now.

Critique 3: The Campaign Lacks Tools to Relate to its Audience

               Teenagers are widely known for acting out and being rebellious (12). They are likely to oppose the rules and norms imposed by their parents as an act of independence (12). The FDA states that the campaign is targeted to at-risk teens who can smoke their first cigarette at any moment and to those who are already experimenting with it. However, the commercials struggle to relate to its audience and assume teens are willing to adopt a change because the consequences are severe.

           The commercials of The Real Cost do not show any sign of chaotic lives or financial problems. The commercial may not be suitable for a low socio economic audience since the price for cigarettes is stronger impact that getting premature wrinkles or damaging their physical appearance. Most teens contribute financially to help their families (13); therefore, the money spent is an important factor that is not emphasized in the commercials. In addition, the bullying commercial shows how smoking tends to alienate the individual away from the crowd, when in reality teen smoke to fit into certain group (7-14). The fact that the commercial takes out of context the main reason why teens smoke defeats the purpose of relating to teens. When the audience does not familiarize with the ad, it might lose effectiveness.

               Furthermore, the Psychological Reactance Theory might play a role, especially in troubled teens that tend to make less rational decisions. When an individual is forced to adopt a specific behavior, they may feel their freedom is taken away and then be motivated to resist compliance (15). This might be the case regarding the commercial about bullying, “Don’t let tobacco control you” is the slogan the campaign uses. The slogan attempts to focus on teen’s willpower to stop smoking. However, some teenagers might take the message the wrong way and see it as a challenge. Teens will want to prove they can smoke now and quit later.

Articulation of Proposed Intervention
           Health behavior patterns are influenced by social, cultural and economic factors. Understanding reasons why teenagers smoke is key to influencing individual’s decision-making process. According to the American Lung Association, 70% of smokers start smoking before they turn 18 for social acceptability, rebellion, independence, or due to the influence of parents who are smokers or the influence of cigarettes advertisement (16). The Real Cost campaign could have a more effective approach to change teen behavior if they emphasize the positive effects of smoking cessation instead of the negative effects of smoking. The goal will be to deflect reactance behavior in the audience, increase trustworthiness of the information provided and increase focus on relating to targeted audience.

             Combining different theories can lead to a more effective campaign. The Social Cognitive Theory (SCT) core premise is that people learn through observation and modeling, thus, the theory includes expectations of environmental cues, outcome expectation and efficacy expectation (16). This theory emphasizes on internal and external social reinforcements that encourages a health behavior change (16). The SCT will complement the HBM flaws making the approach more influential by dealing with cognitive and emotional aspects (16). Furthermore, the commercials should be more of a personal story telling of the immediate positive outcomes, adding familiarity and emotion may reduce the reactance behavior (15).

Taking out or lessening the effect of overdramatizing possible health consequences increases trustworthiness. The goal is to gain trust of the audience by being as accurate as possible. Since smokers believe they are less vulnerable to health consequences adding dramatic images may not be the solution (9). Shifting gears to the positive health outcomes can be more influential because it may motivate the targeted audience and create aspirations for a better future.

             In order to make the intervention more relatable, the audience is the key factor. Teenagers who tend to smoke are more likely to live stressful or chaotic events, struggling with social and economic factors (3). The proposed intervention should focus on commercials that emphasize on health and non-health benefits, such as saving money, teen’s breath and clothes smelling better, stained teeth getting whiter, food tasting better and increasing physical fitness. From teen’s perspective these examples are more realistic than “losing your teeth” and can outweigh the reason for smoking.       

Solution to Critique 1: The Health Belief Model Falls Short

              The HBM assumes that teenagers act rationally but using a more emotional approach such as a personal story rather than statistical facts can be more effective to change a behavior due to the Law of Small Numbers and the Optimistic Bias (9-17). Also, adding the SCT will influence individuals to adopt a modeled behavior if it results in a desired outcome or it is reinforced (18). The proposed intervention emphasizes the positive outcomes of smoking cessation, therefore, an improved ad would start with the immediate negative consequences of smoking such as bad breath, shortness of breath or altered taste of food and the actor should model its way through to the positive outcome in the commercials.

          The HBM and the SCT add the component of self-efficacy that is key to change a health behavior. The commercials assume that teens have the confidence to change their behavior. However, a more effective approach is to create the confidence through the commercial with positive reinforcements (component of the SCT). Teachers, sport coaches, family, friends in the commercials can reinforce smoking cessation within the commercials to successfully influence a change of behavior to those who are watching.

Solution to Critique 2: The Realness of  “The Real Cost”

             Reducing the exaggerated graphic health consequences featured in the commercial such as losing their teeth and damaging their skin to a more realistic outcome might be crucial. Adding real images as well as health and non-health benefits will increase the ad’s trustworthiness. In addition, showing immediate positive outcomes, for example, more leisure time, food tasting better, saving money and breath smelling better, just to name a few, can impact teen’s decision-making process since they know it is true. Furthermore, The Real Cost campaign should focus towards what reasons will make cigarettes less appealing to them. In the United States more than 30 million children and adolescents play a group or individual sport (19). For example, the fact that smoking decreases physical fitness by increasing shortness of breath will definitely influence the health behavior to the 30 million teens that practice sports.

Solution to Critique 3: The Campaign Lacks Tools to Relate to its Audience

             The FDA launched The Real Cost campaign for teens from 12 to 17 years old to educate them about the real health consequences they will face if they smoke. In order to make the campaign more effective, they should target specific groups within the age range. It is clear that 12-year-old kids think different than 17-year-old kids. In addition, the focus of at risk kids emphasizes on kids who are living chaotic lives, therefore, the campaign should narrow their targeted audience to make the commercials more relatable.

             Teens that are at-risk to become smokers usually are more rebellious and go by the motto “rules are meant to be broken”. Studies have shown that using stories, not statistics to convey our messages are more influential than using a rational approach for any kind of intervention (9-17). A commercial that relates to their situation and gives a positive outcome by leaving a bad habit might create hope for a better future. Aspirations and personal emotive stories that relate to teens can impact the decision making of teens and reduce the reactance behavior. For example, the commercials should emphasize how teens can practice a team sport without easily experience shortness of breath. Furthermore, exercising not only releases stress but also being part of a sport team or other clubs, if possible, can potentially open a possibility to go to college. This might be something to consider for those who cannot afford higher education. At the end of the commercials a positive reinforcement should be added in order for viewers to learn, following the SCT.

           Incorporating what really matters to low socioeconomic populations, such as financial stability, should be more emphasized. Another factor that should be addressed is in the bullying commercial the fact that cigarettes alienate teens is not always true. Social acceptability is a powerful component and one of the main reasons teens smoke; the new proposed intervention commercial incorporates how there are other ways to fit in. Being able to relate to the same situation as the teen in the commercial increases motivation and reassures the readiness of the audience. The intervention must show how benefits outweigh the consequences in order to influence a behavioral change.

Conclusion

          The Real Cost campaign has the potential to decrease the indices of smoking due to their early intervention. They use the HBM as their main approach where they focus on the severity and susceptibility as perceived threats. However, the theory should be reinforced to make it more effective. Combining different theories can lead to a more effective campaign. The health behavior intervention falls short by not highlighting important factors of the HBM such as susceptibility and self-efficacy. The tools used to relate to the targeted audience can be more successful if the intervention affects interpersonal, organizational, and environmental factors. Also, over dramatizing images may not be the most effective way to influence teens to change a behavior since some teens just do not care that much of the physical consequences. For many desirable health behaviors, the barriers are immediate and the benefits are long-range and this is something to consider.

          A solution to a more effective intervention could be to focus on positive immediate outcomes of smoking cessation. Individuals not always act rational and exposing them to commercials with emotional personal stories can make them think twice about their decision (9-17). The goal would be to lessen the reactance behavior in the audience, increase trustworthiness of the information provided and increase the focus to relate to the targeted audience.

REFERENCES:

1. Centers for Disease Control and Prevention. Smoking and Tobacco Use. Fast Facts. National Center for Chronic Disease Prevention and Health Promotion. (Accessed April 28, 2014)
http://www.cdc.gov/Tobacco/data_statistics/fact_sheets/fast_facts/index.htm

2. U.S. Food and Drug Administration. The Real Cost Campaign. The real cost: overview. U.S. Department of Health &Human Services (Accessed April 28, 2014)
http://www.fda.gov/downloads/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/AbouttheCenterforTobaccoProducts/PublicEducationCampaigns/TheRealCostCampaign/UCM384307.pdf
3.  Szabo L. FDA launches educational campaign to prevent at-risk kids from becoming life-long smokers. USA Today. February 4, 2014. (Accessed April 28, 2014)
http://www.usatoday.com/story/news/nation/2014/02/04/fda-anti-smoking-ads/5186731/
4. Leshner G., Vultee F., Bolis P., Moore J., When a Fear Appeal Isn't Just a Fear Appeal: The Effects of Graphic Anti-tobacco Messages. Journal Broadcasting and Electronic Media. Volume 54, Issue 3, 2010

5. Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2 No. 4.
6. U.S. Food and Drug Administration. The Real Cost Campaign. The real cost: research and evaluation. U.S. Department of Health &Human Services (Accessed April 28, 2014)
http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/AbouttheCenterforTobaccoProducts/PublicEducationCampaigns/TheRealCostCampaign/ucm383523.htm
7. Centers for Disease Control and Prevention. Smoking and Tobacco Use. Youth and Tobacco Use. National Center for Chronic Disease Prevention and Health Promotion. (Accessed April 28, 2014)
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/
8. Black, M. Household food insecurities: Threats to children’s well-being. American Psychological Association. June, 2012. (Accessed April 28, 2014)
http://www.apa.org/pi/ses/resources/indicator/2012/06/household-food-insecurities.aspx
9. Jensen Arnett J.  Optimistic Bias in Adolescent and Adult Smokers and Non-smokers. Addictive Behaviors. Volume 25, Issue 4, July–August 2000, Pages 625–632

(10) Newsy. FDA targets Teens in New “The Real Campaign” Anti Smoking Ads. Science Daily. February 4, 2014. (Accessed by April 29, 2014).

http://www.sciencedaily.com/videos/657587.htm

11. Greenberg L. New FDA Anti-smoking Ads: Will They Work? The News Station 16 WNEP. February 4, 2014. (Accesses by May 30, 2014)
http://wnep.com/2014/02/04/new-fda-anti-smoking-ads-will-they-work/

12. Pickhardt C. Surviving (Your Child’s) Adolescence. Psychology Today. December 6, 2009. (Accessed by April 26, 2014)
http://www.psychologytoday.com/blog/surviving-your-childs-adolescence/200912/rebel-cause-rebellion-in-adolescence

13. National Financial Educators Council. Financial Literacy Statistics, Research and Resources. (Accessed April 30, 2014)

http://www.financialeducatorscouncil.org/financial-literacy-statistics/

14. Mayo Clinic Staff. Teen Drug Abuse: You’re your teen avoid drugs. Mayo Clinic. (Accessed by April 30, 2014)

15. Brehm J."Psychological Reactance: Theory and Applications", in NA - Advances in Consumer Research Volume 16, eds. . (1989)  Thomas K. Srull, Provo, UT : Association for Consumer Research, Pages: 72-75.

16. American Lung Association. Why Kids Start. American Lung Association. (Accesses by April 30, 2014)
http://www.lung.org/stop-smoking/about-smoking/preventing-smoking/why-kids-start.html

17. Tversky K., Amos, D. Belief in The Law of Small Numbers. US: American Psychological Association. Vol 76(2), Aug, 1971. pp. 105-110

18. Bandura, A. Social Cognitive Theory: An Agentic Perspective. Annual Review of Psychology. Vol. 52: 1-26 (Volume publication date February 2001)

19. Engle M. Kids and Sports: Creating a Healthy Experience for Every Child. The Child study Center. October 2011. (Accessed April 30, 2014)
http://www.aboutourkids.org/articles/kids_sports_creating_healthy_experience_every_child