The Family Smoking Prevention And Tobacco Control Act: Destined To Be Ineffectual

Introduction

Corpses, tracheotomies, screaming babies in incubators, oxygen masks, and visibly indisposed, presumably terminal stage cancer patients: these are just a few of the proposed warning images that will soon appear on cigarette packages and advertisements in an effort to deter Americans, specifically minors and young adults, from smoking. The unsettling graphics are a feature component of the Food and Drug Administration’s Family Smoking Prevention and Tobacco Control Act, which gives the FDA jurisdiction over tobacco product contents, labels, sales and marketing. New changes include manufacturer restrictions on placing terms such as “low,” “light” and “ultra-light” on cigarette packages, which may suggest decreased health risks; debarment of flavored tobacco sales, which are attractive to youths; and more prominent disclosure of harmful cigarette ingredients and health consequences, with warnings comprising 50% of package surfaces. Further, the FDA now has the authority to adjust nicotine levels in tobacco products (1).

Though certainly well intentioned, I feel that the Act will do very little, if anything, to change the habits of smokers. None of the provisions address the obstacles to smoking cessation, such as the presence of powerful social influences and an all-too-common lack of strong self-efficacy. The Act also assumes that people are able to think and behave rationally, when in fact, this is oftentimes not the case.

This paper seeks to explain why the Family Smoking Prevention and Tobacco Control Act will ultimately fail in its efforts to reduce tobacco use. After a thorough analysis of the policy’s shortcomings, alternative solutions addressing the fundamental challenges to smoking cessation will be explored. The solutions presented embody a greater understanding of human behavior and will therefore be much more effective in reducing tobacco consumption than those proposed by the Act.

Flaw #1: Assuming That People Think and Behave Rationally

Jacob Van Zanten, one of the world’s most experienced and accomplished pilots, made the decision to take off without clearance, resulting in the largest airline disaster in history (2). Black pearls, which were originally undesirable, became a coveted commodity after their prices were dramatically increased (3). Teenage girls who see that other teenagers are pregnant are more likely to become pregnant themselves (4). Despite a vast body of conclusive evidence that humans are prone to behaving irrationally, health policy makers, among others, often assume that people can and will make sensible decisions for themselves. The legislators who wrote the Family Smoking Prevention and Tobacco Control Act were of no exception; they, too, fell victim to this prevailing assumption.

The Family Smoking Prevention and Tobacco Control Act, in its efforts to change smokers’ behaviors, relies heavily on the Health Belief Model. The Health Belief Model is one of the oldest and most widely used theories in public health (5). The model presumes that people weigh out their options before making health-related decisions, taking perceived susceptibility of a disease or condition, severity of its outcomes, and the benefits and barriers associated with changing their behaviors (to avoid the condition) into consideration (6). The model therefore assumes a rational decision process.

In displaying gruesome health effect images on cigarette packages, removing “light” and “ultra-light” labels and making tobacco ingredients and health effects more prominent, legislators are trying to increase the perceived severity of the potential health implications of smoking. They believe that if the dangers of smoking are made more apparent, people will work this information into their decision and will be less likely to smoke in accordance with the Health Belief Model.

In reality, however, decisions are usually made on the spot without detailed, methodical consideration (7). If offered a cigarette, a person does not typically pause to reflect on the potential health issues that they may one day be faced with, nor do they think through any perceived benefits that come with the cigarette. This is especially true among minors and young adults, the main targets of the Family Smoking Prevention and Tobacco Control Act, who have a tendency to make decisions more impulsively (8). Recent studies have shown that teenagers’ prefrontal cortexes are not capable of the same reasoning that allows older adults to make rational decisions (9). Thus, if a teen is offered a cigarette by a friend, he or she may not be able to use the information they know about the negative effects of smoking to resist.

The graphic image approach is also flawed in that its persuasive efforts are fear-based. The sole purpose of the images is to scare smokers of the detrimental health effects of tobacco consumption, again, in an attempt to increase the perceived severity of the consequences of smoking and sway people to quit. This approach is problematic in several ways. First, minors and young adults often feel that they are invincible (10). They typically do not worry about the future, and believe that such extreme consequences are unlikely to happen to them. Use of fear in anti-smoking campaigns has also been shown to be inconsistently effective (11). In fact, some researchers believe that repeated use of fear tactics will result in desensitization to the message (12).

An even more compelling argument against the use of fear tactics in anti-smoking campaigns comes from a study from the University of Missouri. In the study, student smokers were given questionnaires that prompted them to think about either failing an exam or their own mortality. The participants were then offered cigarettes and the volume and duration of each puff taken was measured. The researchers found that heavy smokers responded with longer drags of their cigarettes when prodded to think about their own mortality than those prompted to think about failing an exam. Psychologist Jamie Ardnt suggests that the smokers may have been subconsciously attempting to purge their negative moods with an activity they enjoy, smoking (13). The study therefore implies that the startling cigarette package graphics may have a reverse effect on those who see them, actually prompting smokers to smoke more.

Another reason this Act is destined to be ineffective is that it fails to take into account that Nicotine is habit-forming. Nicotine is a highly addictive stimulant that enters the bloodstream upon the inhalation of cigarette smoke. The body becomes accustomed to nicotine over time and requires certain amounts of it to function normally. Nicotine is physically and psychologically challenging to give up (14). The Health Belief model does not take addictive substances into consideration, despite their potential to influence decisions. Since nicotine interferes with the nervous system, cravings inhibit the ability to think rationally (15). It is also very difficult for smokers to deal with smoking withdrawal effects long enough for them to actually quit, even if they have strong intentions to do so (16).

Finally, research has shown that persuasive health campaigns may be vulnerable to psychological reactance (17). Psychological reactance is an aversive reaction to perceived threats to freedom, and has been observed in humans from a very young age. Thus, a person may desire to smoke simply to exercise their legal right and freedom to do so in the face of a bombardment of anti-smoking messages.

Flaw #2: Failing to Address Social Influences to Smoking

There are powerful social reasons why people choose to smoke. The Family Smoking Prevention and Tobacco Control Act does not address – or even appear to recognize – any of these reasons.

One of the greatest causes for concern regarding youth tobacco use is the effect of peer influences. People, particularly adolescents, have a tendency to conform to the behaviors of their peers (18). If their peers are smoking, then adolescents will be more likely to smoke, especially if they are trying to be accepted into a circle of friends that smokes (19). This is a major risk factor to smoking among minors and young adults, regardless of whether or not they are aware of the dangers associated with the habit (20). Why, then, does the Act focus so much on scaring people of the effects of tobacco use but do virtually nothing to challenge its underlying social causes?

Peers are not the only ones to influence minors; family members have considerable impact on a child’s decision to smoke as well. Children are more likely to smoke if their family members smoke (21). They are also more likely to smoke if their parents are unsupportive or are uninvolved in the child’s life (22). These important social contexts appear to have been deemphasized by the Family Smoking Prevention and Tobacco Control Act, while disproportionate emphasis has been placed on dispositional factors. This is exemplary of the fundamental attribution error, a common misconception in judgment resulting in a gross misunderstanding of why people behave as they do (23). A more effective anti-tobacco campaign would also consider external, social causes of the problem, rather than proposing solutions that over-attribute the behavior of people to their character.

Another important social element to consider is that of belonging. According to public health researcher David Dubois, belonging is “one of the strongest human motivational needs” (24). For many, smoking provides a sense of belonging that anti-smoking policy makers do not consider. Smoking is a way for people to interact and bond with one another through social cigarette breaks. It is also an opportunity for striking up conversation and meeting new people in instances where one smoker is seeking a light or a spare cigarette from another. For those who have developed strong ties through smoking, the potential loss of these relationships may act as a deterrent to smoking cessation (25). Further, the creation of anti-smoking laws may be helping to strengthen the bond among the smoking community. As smoking is becoming more and more discouraged, smokers may find the need to band together to smoke outside of the realms mainstream society.

Some people, especially minors and young adults, chose to smoke simply because it is discouraged and against mainstream society. They believe that if they do so, they will come off as rebellious, edgy, sexy and cool (26). Tobacco advertisements frequently target insecure minors offering false promises of appearing more attractive and bold with a cigarette in hand. These advertisements have unfortunately been extremely effective among kids (27).

Lastly, some people smoke because they are smokers. They have been repeatedly labeled as so by society, and although they may very well recognize that smoking is detrimental to their health, they have accepted it as a part of who they are and have come to embrace it. Some smokers continue to smoke because of the self-fulfilling prophecy (28). They have developed a sense of ownership of that habit and it has thus gained more value than its worth. As a result of loss aversion, the habit of smoking subsequently becomes even more difficult to give up (29).

In short, there are a multitude of social factors that contribute to tobacco consumption. Smoking, for many, is a social phenomenon. Any anti-smoking measure that does not directly address these issues is bound to be inadequate.

Flaw #3: No Consideration for Self-Efficacy

Most people know that smoking is bad for their health (30). The majority of smokers would like to quit (31), but many do not possess the confidence that they can indeed do so (32). Therefore, anti-smoking endeavors should include efforts to boost self-efficacy, rather than trying to scare smokers, most of whom already want to quit, of the effects of smoking.

Alburt Bandura’s Theory of Self-Efficacy contends that a person’s health behavior is determined by two expectancies. The first is that the person must truly believe that engaging in a behavior will lead to better health outcomes. Second, the individual must believe that they are capable of successfully performing that behavior. Bandura believes that self-efficacy is predictive of a variety of attempted behavioral changes, including inhibition of behaviors, such as smoking cessation (32).

There is substantial research to back up Bandura’s claim. In 1995, Mudde, et. al demonstrated the predictive value of self-efficacy among smokers attempting to quit (33). A similar study conducted by Gritz et al. found the same results among a group of female smokers in forecasting long-term tobacco abstinence (34). Self-efficacy is a good predictor of success for other attempts at health behavior change as well, including weight loss, dieting, and coping with stress (35). The predictive ability of self-efficacy for smoking cessation, however, appears to be most impressive. In nearly every study examining self-efficacy and smoking cessation, self-efficacy has either been a strong indicator or the strongest of potential indicators examined (36).

Since self-efficacy is closely linked with successful quit attempts, anti-smoking measures should address efficacy issues. The Family Smoking Prevention and Tobacco Control Act does not do so. The cigarette boxes merely offer reasons why not to smoke, reasons that most smokers are already fully aware of. The packages do not provide any kind of encouragement or support. The majority of smokers want to quit and have tried to quit before, but have been unsuccessful (37). Why, then, is the Act still focusing on trying to convince people to quit? For many, the desire to quit is there; it is the efficacy that is lacking.

An Alternative Approach is Needed

The Family Smoking Prevention and Tobacco Control Act requires that cigarette ingredients and health effects be made more prominent. While it is important that smokers understand the dangers of tobacco use, studies suggest that most already do (38). Rather than trying to reinforce the dangers of tobacco use, anti-smoking campaigns should concentrate on the fundamental causes of smoking commencement and obstacles to smoking cessation. Additionally, strategies employed should not presume reasoned decision making. Some possible approaches to reducing tobacco consumption are as follows:

Solution #1: Assume that People Think and Behave Irrationally

The Health Belief Model is inappropriate for anti-smoking campaigns as it assumes that people think and behave rationally. A more effective strategy would instead assume that people behave irrationally. Research has shown that the Labeling Theory can be very influential. The theory, developed by Howard Becker, contends that peoples’ behaviors are a product of how they are labeled (39). Multiple studies have demonstrated the power of labeling, such as the Hypertension Labeling and Sense of Well-Being study conducted by J. Bloom and S. Monterossa. In this assessment, individuals were mislabeled as hypertensive and subsequently developed poorer health (40).

According to the labeling theory, those labeled as non-smokers will not smoke. I think that we need to develop a strong, comprehensive program that attempts to designate young Americans as non-smokers so that they will continue in this role throughout their lifetime. Such a program has already been implemented in Massachusetts called the84.org. The number “84” represents the percent of children in Massachusetts who are tobacco-free (41). The organization has a very straightforward and powerful slogan: “It’s not just a number, it’s who you are.” The number is plastered throughout the organization’s website, constantly reminding visitors that youth in Massachusetts do not smoke in a strong attempt to utilize labeling theory. The campaign also shows great potential for success in that it takes a much more positive, refreshing approach to addressing youth smoking than that of the Family Smoking Prevention and Tobacco Control Act. Rather than trying to scare children of the effects of tobacco, it celebrates and promotes non-smokers. Grewal, Gotlieb and Marmorstein have found that positive messages, like this one, tend to be more effectual than those which hone in on the negative (42) like the Act. Although it is too soon to determine whether or not the84.org has been able to reduce youth tobacco consumption in Massachusetts, the approach is a promising one as it is not based on the assumption of reasoned thinking.

Solution #2: Harness the Power of Social Influences

National anti-smoking campaigns should disseminate the fact that most kids in the United States are tobacco-free. By doing so, we can harness the power of the Theory of Herd Behavior, which suggests that people are inclined to “follow the herd” (43). According to the theory, just knowing that most kids do not smoke is apt to encourage others to behave the same way. Effective campaigns would devise means to communicate that most children do not use tobacco products, be it through advertisements, hosting public events for non-smokers, distributing anti-smoking pins and t-shirts or by allowing youth to connect and reach out to one another on websites. The state of Montana has developed an initiative like this to address drinking and driving among college students. Montana’s state-wide approach utilizes the Herd Theory by dispersing knowledge through billboards. The billboards read that the majority, or 70% of college students in the state, do not drink and drive. This strategy has helped to correct the social perception that drinking and driving is more common in Montana and has also resulted in a decrease in alcohol related car accidents (44).

Anti-smoking organizations should offer a way for kids to get involved and appeal to their innate desire to belong (45). Kids seek groups to associate with so that they can feel like they are a part of something (46). We need to make sure that healthy, attractive options are available, so that youth have an alternative choice to joining smoking cliques. Anti-smoking organizations such as the84.org, which host fun events and encourages non-smoking youth to connect with one another, should be established and advertised in communities.

It is also important that we consider who is delivering anti-smoking messages. As the Theory of Communication suggests, the message deliverer can have considerable power on whether or not the audience is impacted by the message. People are more likely to be influenced by those who they perceive as similar to themselves (47). They are less likely to be influenced by people they see as distant, commanding, or dissimilar to themselves, which is why the Family smoking Prevention and Tobacco Control Act will not be effective. Nobody likes being forced to listen to Big Government. The most influential people in getting a person to change his or her behavior are that person’s friends and family. A study conducted by Robert Murray et. al. demonstrated that social support is linked with successful quit attempts (48). Thus, an alternative anti-smoking program might instead provide advice and support for friends and family members of smokers to encourage them to quit. Hotlines, pamphlets and support groups could be used to help distribute information on how to talk to smokers and get them to quit. The focus of these approaches would thus not be of the effects of smoking, but rather of how to influence people to conquer their tobacco dependence.

Solution #3: Improve Self-Efficacy

Lastly, anti-smoking campaigns should address efficacy issues as perceived self-efficacy and quit attempts are strongly correlated (36). Rather than portraying images of detrimental health effects, perhaps we could take a more positive approach and show colorful, attractive images of cheerful non-smokers on cigarette packages. We could instead show non-smokers living happy, healthy long lives; something that smokers may not get to do if they continue with their habit. Cigarette packages could have profiles of real people who were able to quit. The profiles would include people of all ages, sexes and races. The cigarette boxes would have a picture of an ex-smoker on the front, some background information as to how much tobacco the ex-smoker once consumed, how they were able to quit, and how it affected their life for the better. The packages would end with the message “I could do it, and so can you” and a smoking cessation hotline and/or website would be listed. This solution would be likely to be effective for several reasons. First and foremost, it would help to improve smokers’ self-efficacy. Studies have shown that peoples’ self-efficacy can be improved by witnessing or hearing about others who have triumphed in similar situations (49). Additionally, the message conveyed by the cigarette boxes would now be a positive one and not a negative one, and thus would be more likely to be influential as discussed previously (42). This method would also employ the Herd Theory, which is demonstrably effectual (44), in that it would make successful quit attempts appear more common and encourage more smokers to follow suit. This approach, unlike the one proposed by the Act, would offer support and resources.

Conclusion

Although well intentioned, the Family Smoking Prevention and Tobacco Control Act attempts to reduce tobacco consumption among minors and young adults in all of the wrong ways. The Act relies on the ill-fated belief that people can make rational decisions for themselves. Further, self-efficacy and social influences play a huge role in determining an individual’s decisions regarding smoking, yet the Act does nothing to address either of these areas. In order to successfully reduce tobacco consumption, greater attention must be paid to external factors that contribute to smoking and to improving a person’s belief that he or she can, indeed, quit.

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