“The Real Cost” Campaign to Reduce Youth Smoking – Satvinder Kaur Dhaliwal

“The Real Cost” is the Food and Drug Administration’s (FDA) first tobacco prevention campaign targeting youth between 12 and 17 years of age who are open to smoking or are already experimenting with cigarettes (1). Through this campaign, the FDA aims to reduce smoking initiation rates among youth and reduce the number of youth experimenting with cigarettes (1). The campaign was launched on February 11, 2014 and will continue for at least one year (1). The FDA describes the campaign as consisting of messages that “educate at-risk youth about the harmful effects of tobacco use with the goal of reducing initiation rates among youth” (1). Campaign advertisements will be delivered through multiple media outlets, including radio, internet, and television. The campaign also includes digital games to attract youth to learn about the consequences of tobacco use.

            The main messages of the campaign are health consequences and loss of control leading to addiction. Multiple media sources to relay messages are expected to surround youth with campaign messages. “The Real Cost” is expected to reach 9 million youth, which is 90% of the target audience, 60 times per year (1). Campaign messages are based on research findings indicating that “The Real Cost” television advertisements are engaging and do not have unintended counterproductive messages (1). However, analyzing the campaign with social science theories reveals that several flaws could cause the campaign to be ineffective.

Critique 1: Hierarchy of Needs

            “The Real Cost” is trying to strike deeply held adolescent values of independence and youthfulness, but the man of the messages are based on health as a core value. For example, one of “The Real Cost” video ads shows a young person purchasing cigarettes at a roadside convenience store. When the teen attempts to pay for the cigarettes with money, the cashier replies, “You need a little more.” In order to fulfill the cost of the cigarettes, the young woman rips a piece of skin off of her face and pays the cashier (2). Thereby, the ad is based on the core value of health and sends the message that if you smoke, you will pay with your healthy, youthful skin.

            The FDA’s attempt to convince youth with a health argument contradicts Maslow’s hierarchy of needs, which suggests that human needs are arranged in a hierarchy of power. Higher level needs will only be realized if the most basic needs are realized. Physiological needs are at the lowest level of Maslow’s hierarchy, thus physiological needs have the greatest influence upon an individual’s choices. Health is not at the lowest level and is not among the most influential needs of a human. Therefore, messages that aim to change health behavior must strike a more important human need than health (3).

            Maslow’s hierarchy of needs should be an integral aspect in the FDA’s campaign because the campaign targets “at-risk” youth, who may have more important needs than health. The FDA indicates, “Campaign messages are intended to make the target audience acutely aware of the risk from every cigarette by highlighting consequences that youth are concerned about, such as loss of control due to addiction and health effects…” (1). Thus, the campaign assumes that young people care about self-control and health. Although self-control is important to youth, health may not be a top priority (4). Health is even less of a priority among the group identified by the FDA as “at-risk”. One aspect of “The Real Cost” campaign includes a fictional character, Pete, who is facing unstable social and economic situations in his home and at school. The campaign explains that Pete is living in suburban or rural areas with unmarried parents. Therefore, Pete’s primary concerns are regarding family insecurity and home insecurity. Based on Maslow’s hierarchy of needs, health is not a top priority for Pete, so awareness about health consequences will not dissuade Pete from smoking. Therefore, “The Real Cost” has created a fictional character who may not realistically be convinced by the campaign’s arguments.

            Additionally, many of the campaign posters, available on the FDA’s website are based on health as the core value. The themes of the four posters are chemicals, stunted lung growth, aging skin, and oral health (5). The most glaring message on these ads is about health, while smaller print strikes at youth independence. The following statement, “We give it to you straight. You can make your own decisions. Know the real cost of tobacco use.” appears at the bottom of each poster, in relatively small font. Therefore, youth are most likely to read the message about health consequences of smoking, which does not address an important core value.

            Although nicotine, which is found in cigarettes, is known to accelerate the aging process, one study found that smokers do not pay attention to the detrimental affects of smoking on the body (6). Furthermore, Urbańska et al also found that smokers’ decision to smoke is not influenced by knowledge of the fact that skin damaged by nicotine use can only be improved by cessation of nicotine use (6). Therefore, core value of health, and specifically wrinkle-free skin, does not hold great value for adolescents. Furthermore, an individual in the targeted age group is not very likely to have wrinkled skin. Therefore, the FDA’s effort to influence youth decisions around smoking is based on a value, health, which is relatively insignificant to the target audience.

Critique 2: Illusion of Control

            While some advertisements developed by the FDA use a stronger core value of independence, other flaws inhibit these ads from engaging youth. In an attempt to portray the negative lifestyle of addiction, two television ads created by the FDA use a four-inch tall bully as a metaphor for a cigarette. The bully speaks in an aggressive tone and the advertisement provides several examples of how cigarettes control adolescents’ actions – the cigarette bully literally drags a teenager out of a school hallway, forcing him to smoke on demand; the cigarette bully demands that a teenager “fork over” money upon demand, presumably to buy cigarettes; and the cigarette bully forces a group of teenagers to pause a movie and then drags one teenager outside to smoke (7). The core value in both cigarette bully advertisements is self-control and the message is that smoking cigarettes leads to an addiction that takes away adolescents’ ability to control how they spend their time.

            When comparing this advertisement to research studies on adolescent perceptions of smoking, it seems that the cigarette bully advertisement completely contradicts how youth perceive cigarette use. One study found that among low-income African American and European American 14 to 16 year olds, the primary reasons for smoking are that smoking is a coping mechanism, smoking is associated with social acceptance, and smoking is encouraged by environmental influences (8). Adolescents actually view smoking as a stress reliever, whereas “The Real Cost” cigarette bully portrays cigarette smoking as a source of stress and lack of self-control.

            The illusion of control theory can be used to explain why youth, who are considering smoking, prefer cigarette smoking compared to non-smoking. Illusion of control theory suggests that individuals are more likely to predict success for themselves when they feel like they are in control, compared to when they feel like they are not in control (9). Therefore, adolescents are likely to feel that smoking allows them to control their level of stress more than non-smokers. In comparison, “The Real Cost” cigarette bully ad shows individuals that the cigarette is in control of their behavior and stress. Based on the theory of illusion of control, successful campaigns give people a sense of ownership, whereas “The Real Cost” shows individuals losing control of their time. This portrayal in the advertisement challenges, rather than reinforces, deeply held adolescent values of control and ownership.

            Finally, psychological reactance theory explains that when an individual thinks he or she is losing control, he or she performs the forbidden action in order to restore lost or threatened control (10). Therefore, youth are more likely to smoke after watching the cigarette bully advertisement in order to reassure themselves of the self-control that appears to be threatened by smoking.

Critique 3: Flaws in Advertising

            It is useful to analyze “The Real Cost” campaign in comparison to the truth campaign because both campaigns are targeted to reduce smoking initiation rates and to reduce smoking among youth who are already experimenting with cigarettes. The “truth” campaign, which was a successful youth-targeted anti-smoking campaign in Florida, employed seven aspects of advertising – secure funding, youth involvement in campaign development, youth marketing, use of an acceptable tone, anti-manipulation strategy, branding, and focusing the campaign on a single problem (4). However, in comparison to the “truth” campaign, “The Real Cost” violates several aspects of advertising that were found to be beneficial in “truth”. For example, Hicks explains that “truth” was developed with respect to youth preferences and youth feedback on the creative process (4). Thus, developers of “truth” learned that a successful campaign would have to “surprise and lead” the target audience rather than present images that the audience is expecting to see (4). Additionally, youth have a strong distaste toward anti-tobacco campaigns that pass judgment on tobacco users, and youth prefer to receive the facts and make their own decisions rather than receive messages telling them what they should not do.

            Although “The Real Cost” was developed based on evidence-based practices and research that identified the most promising messages, it is too early in the campaign to analyze evaluation findings (1). Therefore, the advertising theory and findings from the “truth” campaign will be used to evaluate the potential of “The Real Cost” campaign. The FDA’s campaign presents images that youth expect to see and, much to youth distaste, the campaign tells youth what to do. “The Real Cost” essentially tells youth not try cigarettes and stop experimental smoking, but the campaign fails to provide a socially accepted alternative behavior. One of the valuable finding in the “truth” campaign research was that youth do not engage with messages that tell them what to do (4). Furthermore, “The Real Cost” is further disadvantaged by presenting images that youth are familiar with, such as wrinkled skin, tooth decay, gum disease, and consequences of damaged lungs. Youth are well aware of the consequences of smoking, so more information about health consequences will neither engage the target audience nor inspire change in behavior (4).

            In addition to lack of engagement, “The Real Cost” does not provide an equally valuable alternative to smoking. As reported by Hicks, youth perceive smoking as a form of rebellion, and because rebellion and independence are important youth values, these must be replaced when a form of rebellion or independence is taken away. “Truth” was successful in reducing youth smoking rates because it led youth in a rebellion against tobacco companies rather than repeat the harmful consequences of smoking as evidence to why youth should not smoke (4). Essentially, “truth” replaced rebellion expressed through smoking by creating a movement of rebellion against the control tobacco companies attempt to have on young peoples’ decisions to smoke.

            In contrast, “The Real Cost” tells youth not to smoke in every single advertisement. Thereby, removing youth rebellion and freedom to smoke, but the campaign fails to replace rebellion and freedom. Although, campaign posters and postcards use the tagline “We give it to you straight. You can make your own decisions. Know The Real Cost of tobacco use”, other messages by the campaign try to encourage teens to stop smoking. For example, radio ads about health consequences end with the following statement, “So even when you’re not paying… you’re paying.” This can be interpreted as a way of telling teens that they should stop smoking if they truly want to stop paying for cigarettes. However, “The Real Cost” campaign ads do not replace the rebellion that teens take part in when they smoke. Thus, the campaign doesn’t present an alternative behavior for teens to engage in.

            Finally, “The Real Cost” fails to present strong advertisements. Advertising theory suggests that strong advertisements should have three components – a strong promise, vivid support, and strong core values to support the promise (4). Most of “The Real Cost” campaign’s television ads lack a strong promise and strong support. One television ad, called Alison, shows a girl speaking about the negative addictive impacts of smoking. She speaks about smoking as if she is speaking about an ex-boyfriend, referring to the smoking addiction as ‘he’ and never using the words cigarette(s) or smoking. She describes smoking as a controlling and needy boyfriend by making statements like “everywhere I went, he had to follow”, “Outside, now!”, and “bossy, so bossy”. Alison also reminds teens that she initially overlooked the facts that she had learned about the addictive side effects of smoking by stating, “First I didn’t take him seriously. I had heard the stories, but I thought they were really overblown. But overtime, he became, like, really annoying.” The promise in this ad is that if teens smoke, their lives and decisions will be controlled by an addiction, and the support provided in this ad is a young girl talking about her addiction in comparison to a needy boyfriend in an attempt to relate to an unpleasant situation teens may have experienced. The support used in the Alison ad is very weak because it lacks vividness, such as images to visualize the unpleasant situation of living with an addiction or the desirable affects of living without an addiction. Although the core value freedom has potential to be strong, the promise and support used to advocate for freedom limit the core value’s potential. Finally, the advertisements fail to tell a story. Each campaign advertisement presents health or addictive consequences of smoking in relation to something that teens have witnessed, experienced, of heard about. Bullying and an unpleasant relationship are metaphors used in “The Real Cost” advertisements. Although teens may be able to relate to these metaphors, the ads are not executed in a way that will be accepted by teens.

Articulation of Proposed Intervention

            In order for a national campaign to be successful, it is important to remedy the flaws identified above so that the campaign will engage youth rather than turn them away. Some changes are needed in order for “The Real Cost” to be effective. In this section, I propose an intervention based on social science theories and research findings.

            “Break Free from the 3” will be an anti-smoking campaign that targets youth as a group rather than at the individual level. It will educate youth on the power that three tobacco companies have on young people’s decision to smoke (11). There will be emphasis on the idea that so few companies are able to control all of America’s youth. The campaign will deliver messages through television advertisements, posters, and educational rallies at sporting events and schools. Television advertisements will show youth coming together in large groups and breaking free of the barriers to freedom imposed on them by three tobacco companies. At the beginning of the advertisement, youth will appear helpless, unambitious, and living in a gloomy world with little potential. The world outside will be bright, colorful, and beaming with opportunity. The visual will include youth wrapped inside a cigarette roll, small groups will start spreading ideas about exploring the world outside, and finally youth will break through the cigarette skin preventing them from knowing their full potential in the world. Youth in the television ads will be diverse in all aspects of social life.

            Poster ads will show images of youth uniting to break free of the tobacco industry’s chains on their freedom and ability to choose a lifestyle. Rallies at high schools will serve as a place to excite youth about the campaign and educate youth on the strong influence that three tobacco companies have been able to achieve. Rallies will be different from classroom settings, with free gifts to remind students of their commitment to independence. A critical aspect of every rally will be participants’ chance to literally break through a giant cigarette butt. Each rally will feature a giant cigarette butt umbrella that hangs over the rally, labeled with facts about the three tobacco companies, ways the companies have managed to target specific groups of youth, and how companies continue to influence youth decisions over several years. At the end of each rally, youth will have a chance to unite, which will involve peer encouragement to increase the size of the group, and push through the umbrella. By doing so, youth will have joined a national pact to break free of the tobacco influence and remain independent.

Strong Core Values

            A strong anti-smoking intervention should be based on a core value that is important to youth. As explained by Hicks, youth value independence and rebellion (4). Therefore, an anti-smoking campaign needs to encourage youth to take control of their freedom and demand independence. “Break Free from the 3” will educate youth on the systematic method of control enforced on youth by just three tobacco companies. Although prevention of smoking will improve health status, the core values used in “Break Free” are independence and freedom, which are identified as most important values to youth (4). Additionally, “Break Free” television advertisements are based on the core value of freedom and satisfy Maslow’s hierarchy of needs theory. In these advertisements, youth will be depicted as unable to breath inside the cigarette world. Thus, there is need for a physiological need, which are the most important needs based on Maslow’s hierarchy of needs (3).

Youth Control and Social Expectations

            All “Break Free” advertisements and rallies will show young people uniting to achieve independence. Based on social expectations theory, an intervention must change social norms associated with a behavior in order to change the behavior itself (12). As explained by Hicks, one reason youth decide to smoke is social acceptance. Therefore, a large-scale campaign that encourages youth to join a group seeking independence can change the norms around social acceptance.

            Furthermore, the emphasis on three major tobacco companies is to empower youth. Showing youth that there are many more young people than there are powerful tobacco companies gives them ownership of the campaign. Thereby, illusion of control theory is successfully applied to give youth ownership of something positive and powerful. While the final goal of the campaign is to change youth attitudes about smoking so that smoking is not perceived as a positive or socially acceptable practice, the campaign never tells youth that they should not smoke. Instead, the campaign will creatively educate youth on tobacco companies’ tactics targeted to entrap youth while they are young. However, youth will be empowered throughout the entire campaign so not to portray that youth are losing ownership of the rebellion that encourages smoking, as suggested by Hicks (4). Although indirectly, youth are being encouraged not to smoke, the smoking rebellion is replaced with a rebellion against the three main tobacco companies. Therefore, Hicks’s explanation of replacing rebellion is also fulfilled, as it was during the “truth” campaign (4). Consequently, replacing rebellion is a way of replacing the freedom that youth lose when they are told not to smoke. Therefore, “Break Free from the 3” prevents psychological reactance in youth.

Effective Advertising

            Finally, “Break Free from the 3” will be executed with application of advertisement theory. Therefore, campaign advertisements are based on a strong core value with a strong promise that is presented with vivid support. For example, the television advertisement described above is based on the core value of freedom, which is highly valued by youth as described by Hicks and discussed above (4). “Break Free from the 3” campaign’s television advertisement promises youth that if youth unite against three major tobacco companies, they will be able to achieve the freedom to make decisions that allow them to achieve their full potential. Support for the promise is provided through vivid images. In the television advertisement, when youth are trapped inside the cigarette, the setting will be gloomy and individuals will be somber. Youth inside the cigarette world will look very similar to each other, showing that there is little freedom to dress or behave as one chooses. Youth will depict a sense of being trapped inside the cigarette. However, the world outside the cigarette will be lively, colorful, and filled with youth who choose how they dress and construct their personalities. Thus, the world outside the cigarette gives youth ownership of expression. Essentially, the support in television advertisements will tell a story of youth empowering themselves to achieve independence, and viewers will be able to follow the journey to independence. Thereby, “Break Free from the 3” television advertisements will successfully fulfill all three aspects of advertising theory in order to engage the target youth audience.

Conclusion

            Based on theories of social science and findings from successful anti-smoking campaigns, it is apparent that successful campaigns need to be conscious of youth needs. Campaigns to change youth behavior should also be framed in a manner that will engage youth and encourage participation. Therefore, “Break Free from the 3” presents a youth focused and youth targeted initiative that empowers youth through ownership of the campaign. “Break Free from the 3” is differs from “The Real Cost” by giving youth ownership of their own independence, which in itself is empowering. Finally, campaigns to change youth behavior must refrain from telling youth how to change behavior. Instead it is critical to frame messages in a way that leads youth to change behavior on their own will.

References

1. FDA. The Real Cost Campaign [Internet]. [cited 2014 Apr 23]. Available from: http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/AbouttheCenterforTobaccoProducts/PublicEducationCampaigns/TheRealCostCampaign/default.htm
2. The Real Cost Commercial: “Your Skin” [Internet]. 2014 [cited 2014 Apr 23]. Available from: http://www.youtube.com/watch?v=ixMEEI0Zq9g&feature=youtube_gdata_player
3. Maslow A. A theory of human motivation. Available from: http://psycnet.apa.org.ezproxy.bu.edu/journals/rev/50/4/370/
4. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tob Control. 2001;10(1):3–5.
5. FDA. The Real Cost Campaign - The Real Cost: Free Materials [Internet]. [cited 2014 Apr 28]. Available from: http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/AbouttheCenterforTobaccoProducts/PublicEducationCampaigns/TheRealCostCampaign/ucm384054.htm#1
6. Urbańska M, Ratajczak L, Witkowska-Nagiewicz A. [Analysis of knowledge about tobacco smoking influence on skin condition]. Przegla̧d Lek. 2012;69(10):1055–9.
7. The Real Cost Commercial: “Bully” [Internet]. 2014 [cited 2014 Apr 24]. Available from: http://www.youtube.com/watch?v=5G1Ma02K6Ys&feature=youtube_gdata_player
8. Scales MB, Monahan JL, Rhodes N, Roskos-Ewoldsen D, Johnson-Turbes A. Adolescents’ Perceptions of Smoking and Stress Reduction. Health Educ Behav. 2009 Aug 1;36(4):746–58.
9. Langer EJ. The illusion of control. J Pers Soc Psychol. 1975;32(2):311–28.
10. Brehm JW. A Theory of Psychological Reactance. Organization Change: A Comprehensive Reader [Internet]. Jossey-Bass; 1966. p. 377–90. Available from: http://books.google.com/books?hl=en&lr=&id=JZ0rkeNvVkcC&oi=fnd&pg=PA377&dq=psychological+reactance+theory&ots=nOsnNeSTzn&sig=_eLnbM6-DMGPeGHUCQi33vVjc6k#v=onepage&q=psychological%20reactance%20theory&f=false
11. CDC. Smoking and Tobacco Use; Fact Sheet; Economic Facts About U.S. Tobacco Production and Use [Internet]. Smoking and Tobacco Use. [cited 2014 May 1]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/
12. DeFleur M, Ball-Rokeach S. Socialization and Theories of Indirect Influence. Theories of Mass Communication. 5th Edition. White Plains, NY: Longman, Inc.; 1989. p. 202–27.