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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Why Charging Smokers Higher Premiums Doesn’t Pay – Kathleen King

During the recent Congressional debates leading up to the passage of the 2010 Patient Protection and Affordable Care Act, a multitude of strategies were identified to help address two serious and related health care challenges facing the United States. First, how do we improve health outcomes through prevention and wellness initiatives that promote healthy behaviors? Second, how do we reduce or stabilize health care costs? One such strategy identified was to charge people who use tobacco products a higher health insurance premium than people who do not use tobacco. Under the Affordable Care Act, premiums can vary for tobacco users by up to 1.5 to 1. In other words, smokers can be charged up to 50% higher premiums than non-smokers (1). In 2010, the average annual premium for employer-sponsored insurance was $5,049 for an individual plan and $13,770 for a family plan (2). If these rates varied by smoking status, tobacco users could pay an additional $2,525 for a total premium of $7,574 for an individual plan and $6,885 more for family coverage costing $20,655. The rationale behind this policy is two-fold. Smokers incur more direct health care costs than non-smokers so they should pay more into the system. Also, having to pay a higher premium should motivate those who smoke to quit, in order to save money. If smokers quit, they would get the benefit of reduced premiums and improved health, while the system overall would see cost reductions because the ex-smoker is healthier.

The idea of charging tobacco users more for health insurance than their non-smoking counterparts is not new. When the Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996, it mandated that all beneficiaries of employer-sponsored health insurance pay the same premium regardless of health status. However in 2008, when HIPAA rules were finalized, an exception was created for certain wellness programs. These exemptions allowed employers to offer a financial reward or penalty for up to 20% of the total cost of covering an employee, to encourage healthy behavior changes (3). Employers implemented “smoker surcharges” with the goal of decreasing and shifting health care costs for the company, especially for self-insured entities, and improving worker productivity via a healthier workforce (4).

However, this misguided policy implemented by the government, insurance companies, and employers is ineffective at best and counterproductive at worst. First, charging tobacco users higher premiums stigmatizes and marginalizes this group, which not only undermines smoking cessation efforts but can increase the likelihood that a person will continue to smoke. Second, by focusing on the idea that smokers choose to engage in unhealthy behaviors ignores all social factors that contribute to an individual beginning to smoke and make it difficult to quit. Lastly, this policy issues an ultimatum to smokers to “quit smoking or pay”. This framing will threaten a smoker’s freedom and will likely lead to psychological reactance, where the smoker becomes more intent on smoking to regain control. Ultimately, charging smokers higher health insurance premiums oversimplifies a very complicated behavior (5). This approach will not motivate smokers to quit and will fail to improve health outcomes and reduce health care costs.

Stigmatizing Smokers

The idea of varying health insurance rates based on “voluntary health behaviors” invokes a merit-based system that implies someone is paying what they “deserve or have earned” to pay. While this may work for automobile insurance and driving records, unhealthy behaviors are much more complex (3). Charging higher premiums for people who smoke stigmatizes this group, marginalizing tobacco users and decreasing their motivation to quit smoking.

Stigma Theory was postulated in 1963 by Erving Goffman in Stigma: Notes on the Management of a Spoiled Identity. He defined stigma as “an attribute that links a person to an undesirable stereotype which leads to that person being cut off from society and from himself” (6). The five main components of stigma are as follows: people identify and label human differences, stereotyping follows by linking the labeled person to an undesirable characteristic, the group doing the labeling separates “us” from “them”, the “them” group is now stigmatized and experiences discrimination and loss of status, and this stigma has occurred due to an exercise of power by the “us” group (7,8). Following this model, charging smokers higher insurance premiums can be found to: label smokers as different, stereotype smokers as risk-takers who are responsible for their poor health, lack willpower, choose not to quit, and contribute to everyone’s increased health care costs, divide non-smokers and smokers into two groups within a workplace, and increase the financial burden placed on smokers with additional premiums, which is forced on them by their employer (9).

Internalizing stigma encourages secrecy and discourages seeking cessation support. One study has shown that 8% of smokers concealed their true smoking status to their health care provider. While this is a low percentage, there was a strong association between concealment and perceived stigma. Those who felt that smoking was less socially acceptable were more likely to conceal their behavior (10). Smokers who do not feel comfortable having an honest discussion with their health care provider about their tobacco use would receive no cessation resources, medications, or support to help quit.

Labeling theorists argue that stigma traps people into deviant roles, which deepens and stabilizes their deviant behavior. People begin to withdraw socially and isolate themselves from non-deviants, meaning smokers would predominantly socialize with other smokers. Decreased social networks increases depression, decreases quality of life, and decreases self-esteem. One study has shown that an increase in social withdrawal increases the number of cigarettes smoked per day (9). After being marginalized, smokers also internalize the negative label put on them and begin to identify themselves as a deviant, increasing their ownership over the unhealthy behavior. This can have a large impact on self-esteem and self-efficacy, or the belief that you can successfully quit if you try. All of these consequences of stigmatizing people who use tobacco increases stress and decreases the likelihood that smokers will be motivated to quit (9).

Ignoring Social Context

Policies to charge smokers higher insurance premiums focus on an individual’s personal responsibility for their health. This argument largely ignores all social factors that contribute to a person starting and continuing to smoke. For most, starting and continuing to smoke is not a rational choice based on analyzing the costs and benefits of the unhealthy behavior. The majority of smokers want to quit, but it is difficult to do so (11). Quitting smoking is determined by many mental, physical, and social determinants. Placing the blame entirely on an individual smoker negates the role of tobacco industry tactics, physical addiction, and social factors such as poverty and education levels.

Prevalence of tobacco use is strongly associated with education level and socioeconomic status. According to the Centers for Disease Control and Prevention, in 2009 the smoking rate of adults with a GED diploma was 49.1 percent compared to adults with an undergraduate degree, whose smoking rate was 11.1 percent. For adults living below the poverty level, the population’s smoking rate was 31.1 percent compared to 19.4 percent of adults living above the poverty level who smoke (12). These disparities cannot be attributed solely to individual choice. People of low socioeconomic status experience multiple health threats, such as poor access to healthy foods, increased violence, and unsafe housing. They are more likely to have other chronic diseases, but have fewer resources for health care or to improve their living conditions. The multiple burdens that face people living in poverty in addition to using tobacco can have an additive affect, each increasing the harm of the other, causing and exacerbating poor health (13).

There is a unique relationship between using tobacco and a smoker’s finances. The inability to afford food and clothing has been found to significantly increase the odds an individual uses tobacco and decreases the odds that they will be able to quit smoking. When faced with a limited budget, many people eliminate non-essential spending, but tobacco tends to be an exception because it is an addiction and a stress reliever. Studies have also shown the reverse, that smoking is a predictor of financial hardship and stress (14). The cyclical relationship between a limited income, stress, and smoking would only be made worse by increasing health insurance premiums. Smokers, particularly low income smokers, would face an additional financial pressure and would turn to smoking to help alleviate the related stress.

Social conditions, including race, income, education, gender, stress, and social support can be fundamental causes of disease. An intervention that focuses on changing unhealthy behaviors will not be effective if it does not also address the fundamental underlying causes of disease (15). If a person smokes because they are under severe stress from financial pressure or an unsafe living environment, implementing a “smoker surcharge” to address their unhealthy behavior will do nothing to alleviate the reasons why a person is smoking. Unless these fundamental causes are the target of a public health intervention, health status will not improve.

Inducing Psychological Reactance

The policy at hand assumes that everyone thinks rationally and that smokers have analyzed their unhealthy behavior and decided the benefits of using tobacco outweigh the costs (8). The employer believes that by offering a financial savings for quitting smoking, this will increase the overall benefits (which now include health and fiscal improvement) and the smoker will quit. However, human behavior is not strictly analytical and includes many emotions that make many of our choices irrational (16). Depending on how an intervention is framed, different emotions could influence and determine an individual’s reaction and subsequent behavior.

Making smokers pay higher insurance premiums compared to non-smokers gives them an ultimatum to “quit smoking or pay a penalty”. The framing of this message would likely elicit psychological reactance from tobacco users. The Theory of Psychological Reactance was put forward by John Brehm in 1966, who argued that psychological reactance is a response to a threat to one’s freedom. If an influencer pressures someone to change a behavior, the responder will try to reassert their freedom by ignoring the influencer and will feel an increased ownership over the behavior that was threatened (17). According to this model, if an employee’s choice to use tobacco is threatened with a financial penalty they will experience reactance and not only will they not be motivated to quit, but will actually feel a stronger ownership over smoking and recommit themselves to continuing the behavior.

Three factors that can determine the level of reactance are the strength or extent of the threat, the current presence or perception of freedom regarding the behavior, and the importance of that freedom to the person (18). Reactance has also been found to be greater if the restriction was directed at an individual as opposed to an impersonal pressure towards change (19). For example, an employer pressuring an employee to quit smoking would elicit much stronger psychological reactance compared to a convenience store that sold out of cigarettes, preventing the person from smoking.

Once reactance has been induced, a smoker will likely increase their “ownership” of this behavior. As ownership increases over time, the object or behavior increases in value (20). As value and attachment grow, people become more “loss averse”. This means losses and disadvantages are viewed as greater than potential gains and advantages. Smokers who have ownership over their behavior and are loss averse would put more weight on the consequences of giving up tobacco use than on any benefits derived from quitting. Even if they do not want to be smoking, they put a high value on “losing” that behavior (21). Penalizing smokers financially to motivate quit attempts is built on the assumption that individuals think rationally. Understanding the concepts of psychological reactance, ownership, and loss aversion highlights that this assumption is incorrect and the intervention will be ineffective.

Rethinking Employer Cessation Policies

Setting higher health insurance premium rates for tobacco users to encourage smoking cessation is a fundamentally flawed public health intervention. At best, this policy will not motivate smokers to quit and at worst, may deter tobacco users away from resources and support to help them quit. Instituting “smoker surcharges” places blame on smokers. Tobacco users who are stigmatized and marginalized by this policy will socially withdraw from non-smokers and internalize the deviant label, increasing the likelihood that they will continue the unhealthy behavior. Focusing solely on personal responsibility for an individual’s health defines smoking entirely as a voluntary behavior and ignores the influence of social determinants on the behavior, including poverty and stress. Lastly, by issuing an authoritative policy demanding that smokers quit or face a financial penalty, the intervention will induce psychological reactance, causing smokers to ignore the employer’s demand and continue smoking to reassert their freedom.

Smoking is a physical addiction and quitting can take multiple attempts to be successful. An effective intervention must support and encourage smokers’ efforts to quit and bring people who use tobacco into the health care system, not create barriers to good health as higher premiums would do. As noted by Steven Pearson and Sarah Lieber, “All employees should have equal access to services for behavior change and improved health” (22). One possible alternative intervention would consist of two parts. First, the employer would implement a “wellness program” open to all employees regardless of tobacco use, featuring a workshops series and social support. The program would embrace a broad understanding of what factors would help smokers quit and help all employees engage in healthier behaviors. Second, all employer-sponsored health insurance policies would cover a comprehensive smoking cessation benefit free of any barriers. The benefit would cover all FDA-approved cessation medications and phone and in-person counseling, with no out-of-pocket- costs (e.g. co-pays and deductibles) for employees and no annual caps or limits.

Support Instead of Stigma

The new wellness program would be inclusive and supportive with the goal of increasing self-esteem and self-efficacy in individuals and fostering social support between employees. Self-efficacy is an individual’s own belief in their effectiveness, competence, and ability to accomplish what they set out to do (23). Wellness workshops could be offered to all employees including topics on leadership, communication skills, project management, and how to set personal goals and identify strategies to achieve those goals. As employees discuss these topics as a group, co-workers could begin to view one person’s goal of quitting tobacco use similar to another person’s goal of achieving a better balance between work and their personal life or akin to their own goal of losing 15 pounds. This interaction between smokers and non-smokers would reduce the marginalization of tobacco users, prevent social withdrawal, and foster an understanding of the challenges that face a smoker who is trying to quit, instead of blaming them for the unhealthy behavior.

Studies have shown that social support is a significant predictor of successfully quitting smoking (24,25). As part of the wellness program, an organization could provide group cessation counseling sessions to those who choose to participate and are looking for that kind of interaction with others trying to quit. As Mermelstein concludes, “Most smokers consider quitting to be a difficult and stressful process. Having confidants to whom one could turn to help reappraise stressful situations as nonthreatening or to provide adequate coping resources aided cessation” (25). Group counseling sessions would also be open to spouses and children of employees who are trying to quit, as this would benefit the health of the entire family unit and increase the support of the employer for the entire well-being of its employees.

Lastly, the company could openly promote all the tools it was offering to help people quit smoking. A voluntary “Ex-Smokers Hall of Fame” in the break room could be created, highlighting employees who successfully quit smoking recently or ten years ago to create a supportive and encouraging environment. A wellness newsletter could frame all health-improvement activities in a positive light. The smoking cessation benefit covered under insurance should be highlighted as much as Weight Watchers and gym membership reimbursement benefits are, to encourage employees and their families to take advantage of the resources available to them.

Looking Beyond Tobacco

Understanding that employees face a variety of challenges in life, the employer must focus on addressing the fundamental social causes underlying unhealthy behaviors. Employers must take concrete steps to reduce barriers and increase an individual’s ability to access the resources and support made available to them. Focusing on the broader relationship between the social context each individual lives in and their health can lead to “a realization that actions taken have a marked and positive impact on one’s health while also radiating good effects on other dimensions of life and on other people” (26). As part of the wellness workshop series, the employer should offer financial and debt reduction counseling, stress management and coping skills, time management, and sessions on work/life balance. Time during the workday should be set aside for these programs to make them available to all employees regardless of their commitments outside of work. The company could also offer programs aimed at the employee’s family, like tutoring for children, in addition to a mentorship program to increase professional development opportunities for employees, improving their potential for a promotion or salary increase.

Insurance coverage should be designed to eliminate all employee cost-sharing for the smoking cessation benefit and all preventive/wellness visits to their health care provider. This will encourage use of the benefit by all tobacco users, regardless of their financial situation, and will also help bring people of low socioeconomic status into the health care system and into their doctor’s office where they can address any other health concerns that they might have. In Massachusetts, offering this type of barrier-free, affordable, and comprehensive cessation benefit to Medicaid subscribers was found to drastically reduce smoking rates within this population, which had previously not seen the reductions in smoking prevalence that the state’s higher income population had experienced (27). In addition, the company could offer a free Nicotine Replacement Therapy (or patch) give-away to employees trying to quit. As argued in Helping Smokers Quit: Understanding the Barriers to Utilization of Smoking Cessation Services, “Making cessation services more affordable and widely available would increase access for the subpopulations with the highest current smoking rates, especially people of lower socioeconomic status, Native Americans, and those with psychiatric illnesses” (28).

Eliminate the Ultimatum

Psychological reactance is likely when there are punishments, like “smoker surcharges”, in place as consequences for not changing a behavior. To avoid psychological reactance, employees should be involved in all aspects of the organization’s wellness program design, implementation, and evaluation. There should be an initial survey taken by all employees where they can identify their health needs, but also their highest life-concerns more broadly and support or resources they need. Programs, insurance benefits, and workshops should be shaped by what employees voiced would be most helpful to them (22). As wellness initiatives are implemented, there should be a feedback and evaluation mechanism to allow the program to adapt over time to fit employees’ needs. One study has shown that a strong sense of control is associated with self-initiated preventive care, an increased effort to avoid the harms of smoking, and overall higher self-ratings on individual health status (29). By including employees in the design of the interventions, they are more likely to feel in control of their efforts to lead a healthier life and may decrease ownership of their identity as someone who uses tobacco.

Higher Premiums Do Not Pay, Find a Better Way

Charging tobacco users higher health insurance premiums will not achieve the intended goals of motivating cessation, improving employee health, nor reducing health care costs. It is a flawed public health intervention that blames smokers, assumes that tobacco use is solely a volitional behavior, and demands personal responsibility of an individual to quit. This policy stigmatizes smokers and marginalizes them from non-smokers, increases stress, decreases social support, and ignores all social factors that led the person to use tobacco. By demanding smokers quit and charging them a penalty, companies are ensuring that current smokers will experience psychological reactance, not be motivated to quit and may even strengthen their ownership of this unhealthy behavior.

John Braithwaite writes, “Long-term internalization of values like altruism and resistance to temptation are inhibited when people view their action as caused by a reward or punishment” (30). Thus, employers who empower employees to achieve healthier lifestyles, instead of penalizing them, may see greater long-term health improvements in their workforce. Any alternative intervention must focus on providing social support, defining the causes of unhealthy behaviors like smoking more broadly and addressing these underlying factors, and reducing barriers to access resources. Providing barrier-free smoking cessation coverage of medications and counseling and offering diverse topics through a wellness workshop series provides employees with multiple pathways to successfully quit smoking and improve their health. These two alternative approaches will avoid the three flaws discussed above that make charging tobacco users an increased health insurance premium an ineffective, and possibly counterproductive, intervention.

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