Tuesday, January 1, 2013

When Less is More: A Critique of Cigarette Health Warning Labels – Vania Lin

Background Information
            The U.S. Food and Drug Administration (FDA) sought to replace in September 2012 the current text-only health warning labels on cigarette packaging with larger warnings and graphic images.  The new labels consisted of messages such as “WARNING: Cigarettes cause fatal lung disease.” and “WARNING: Smoking can kill you.” that are accompanied by images including diseased lungs and corpses.  One of the stated goals of this change was to “empower youth to say no to tobacco” (1).  Court proceedings in the case of R.J. Reynolds Tobacco Co. v. U.S. Food and Drug Administration, the lawsuit tobacco companies brought forth against the FDA, have delayed the implementation of the new warnings (1).  With the U.S. Court of Appeals in Washington, D.C., denying to rehear the case as of December 5, 2012, the final say on implementation may be left up to the U.S. Supreme Court should the government decide to appeal (2).
Overview of the Critique
            The effectiveness of the new graphic labels in preventing smoking initiation in adolescents is questionable.  In particular, the warnings neglect to address the effects of branding on adolescent smoking and the formation of social identity.  The labels also overvalue the importance of health to adolescents.  In their failure to take into account the values that adolescents hold in high regard, such as independence and reputation, the warnings have weak impact on adolescent smoking prevention and may even encourage adolescents to start smoking.  Lastly, the labels will likely trigger psychological reactance, which would incite rebellion against the warnings and may even provoke smoking initiation.
The Implications of Branding
            The graphic warning labels fail to address the importance of branding in adolescent smoking and social identity.  The new labels may be more prominent, but they do nothing to eradicate the associations that tobacco companies have designed cigarette packaging to convey.  Adolescence is characterized by experimentation and the formation of identity; it is the time in life when people are most likely to start smoking.  Escobedo, Anda, Smith, Remington, and Mast (1990) found that smoking initiation sharply increases after eleven years of age and reaches its peak between seventeen to nineteen years of age before rapidly declining through 25 years of age and gradually declining in older age groups (3).  Tobacco companies, armed with this knowledge, aim to attract people to smoking at a young age.  In a revealing study conducted in Tracy, California, Henriksen, Feighery, Schleicher, Haladjian, and Fortmann (2004) found that stores where youths shopped at more frequently had almost three times the amount of tobacco marketing materials and considerably more shelf space for the major cigarette brands Marlboro, Camel, and Newport than other stores (4).  This finding highlights the connection between marketing of cigarettes by tobacco companies and adolescent smoking.
Branding plays a large role in the marketing scheme: the cigarette brand name, the visual logo, the pack design, and the color scheme all come together to create branding signals that represent the brand’s core values (5).  Scheffels (2008), in a series of interviews conducted with young smokers in Norway, found that young smokers formed social identities and established social status based on their choice of cigarette brand.  For example, the Scandinavian brand Prince, which contained a picture of a cigarette on its red packaging, was seen as strong, harsh, and of low social status, while Marlboro Light, with its gold-lettered white packaging and foreign origin, was associated with femininity and higher social class status.  What is striking is that Norway has banned advertising for tobacco since 1975; despite the ban on advertising, tobacco companies have and continue to succeed in branding their cigarette products to attract different populations of young people.  The actions of the Scandinavian Tobacco Company, which manufactures Prince cigarettes, support the assumption that tobacco companies extensively research the effects of branding themselves—soon after Scheffels conducted the interviews, the company replaced the blunt image of the cigarette with that of subtle floating smoke on Prince packs (6).  Without curbing the advertising effect of the cigarette packing itself and severing the link between smoking and social identity, the new warning labels are unlikely to have a large effect on the prevention of adolescent smoking.
Overvaluation of the Importance of Health
            The graphic warning labels centered on the harmful health effects of smoking overestimate the importance of health to youths.  The effectiveness of the warnings is based on the assumptions that adolescent smokers value health highly and that knowledge of the health risks of smoking will deter youths from smoking.  In contrast to these assumptions, Virgili, Owen, and Severson (1991) found that adolescent smokers, compared to ex-smokers and nonsmokers, had a harder time imagining the harmful health effects of smoking in themselves and tended to downplay the severity of the health risks.  Smokers also perceived greater benefits of smoking relative to the risks of smoking (7).
Lee, Buchanan-Oliver, and Johnstone (2003) further explored the relationships between adolescent characteristics and values and smoking.  They found that the sense of being invulnerable persisted in adolescents despite their knowledge of the health effects of smoking.  The authors characterized this aspect of adolescence as the “personal fable”: adolescents have a hard time separating personal beliefs from universal principles.  In the case of smoking, adolescents may rationalize that, although smoking does cause harmful health effects, these conditions would occur in other people but not in themselves because of their inherent uniqueness and difference from others.  This denial mechanism contributed to the study participants’ heavy focus on the benefits of smoking, such as being perceived as cool or sophisticated, and their relatively light focus on the negative aspects of smoking.  The authors also found that adolescents were motivated to smoke by the belief that smoking was an act of rebellion; risk-taking was a declaration of independence and a way to build reputation and establish social identity.  As one participant succinctly put it, “You do things because they are bad for you.  ‘Cause you do things to take a risk” (8).  In overvaluing the importance of health and failing to take into account qualities that adolescents value highly, cigarette labels emphasizing health risks are unlikely to be effective in preventing adolescent smoking and may even have the opposite undesirable effect of encouraging smoking among adolescents.
The Effects of Psychological Reactance
            The graphic labels will likely trigger psychological reactance in adolescents and exacerbate the problem of adolescent smoking.  The theory of psychological reactance asserts that people believe that they are free to make their own choices and shape their own behavior.  When they are faced with a force, such as a persuasive message, that is seemingly trying to dictate their choice or behavior, they will act to restore their freedom.  One way to do so is to rebel against the force (9).
Dillard and Shen (2005) described the three aspects of a message that contribute to psychological reactance: dominance, explicitness, and reason.  Dominance is the degree to which the message imparts the belief that the source can control its audience.  Explicitness is the extent to which the message conveys the source’s purpose.  Reason is the justification the message provides to convince the audience to adopt the source’s view.  In general, dominance in a message incites anger and psychological reactance, while reason decreases psychological reactance.  The effect of explicitness varies and depends on context, but usually works in favor of persuasion and generates positive emotions (10).
            The elements of the new graphic warnings will likely incite psychological reactance in adolescents.  The messages are highly dominant: the capital letters of “WARNING,” along with the severe messages and extreme images, combine to make the labels take on an authoritative and almost condemning tone.  The labels are explicit in delivering their message, which is likely not a positive factor here in convincing adolescents not to smoke but rather an instigator of anger and psychological reactance.  Their explicitness makes clear that the government is trying to influence the adolescents’ behavior through the warnings.  The reason provided in the messages is tenuous: smoking certainly causes the conditions described by the messages and depicted by the images in some people, but their extreme nature may cause youths to dismiss these warnings as scare tactics.
Erceg-Hurn and Steed (2011) showed that graphic labels triggered heightened psychological reactance.  They measured the level of psychological reactance in smokers after the smokers were exposed to text-only or graphic labels, both of which were in use in Australia at the time of the study.  The tested labels contained messages such as “Smoking Kills.” and “Smoking Causes Mouth and Throat Cancer”; photographs accompanied the graphic labels.  Erceg-Hurn and Steed found that 51.2% of smokers experienced no psychological reactance after viewing text-only labels; only 8% of the smokers who did experience reactance experienced it at a moderate to high degree.  In contrast, over 80% of smokers experienced psychological reactance after viewing graphic labels, and 30.4% of these smokers experienced a moderate to high level of reactance (9).  These results can reasonably be generalized to adolescents—adolescents, with their tendency to rebel, may experience even greater levels of psychological reactance than adults.
Furthermore, Miller, Burgoon, Grandpre, and Alvaro (2006) determined that psychological reactance was a major risk factor for smoking behavior.  They surveyed students in grades six through twelve (ten to twenty years of age) to examine the significance of variables that may contribute to smoking behavior.  They found that increased psychological reactance, decreased age, poor school performance, previous experimentation with smoking, and having friends who smoke were the major predictors of smoking behavior.  Poor communication with parents was also a predictor of smoking behavior, though to a lesser extent.  In addition, psychological reactance was a significant risk factor even among adolescents who did not smoke and had not previously experimented with smoking (11).  The findings of these studies demonstrate that the new graphic labels have a high likelihood of triggering psychological reactance in adolescents and, contrary to their goal, may prompt some adolescents to begin smoking.
Proposed Alternative Intervention
            An effective alternative approach may be to utilize plain packaging and warning messages focused on independence and self-affirmation rather than on health.  In plain packaging, the color, size, material, and the opening method of cigarette packs are standardized.  Packs are distinguished by their brand names only, which appear in the same color, size, and font and at the same location on all packs.  No other writing, excluding health warnings, or visual images are allowed (12).  Plain packaging would thus effectively eliminate the associations created through branding.
The warnings would focus on the aspects of independence and control rather than on health and would draw upon the theory of self-affirmation.  The messages would be phrased in the form of questions.  The goal is to prompt adolescents to question the effect that smoking has on their freedom and control without triggering psychological reactance.
The Power of Plain Packaging
            Replacing the current multitude of cigarette packaging designs with a single, standardized plain design eliminates the venue for branding.  Branding relies on the coordination of elements including the brand name, the color scheme, and visual logos to create distinct characteristics for each cigarette brand; branding can only be accomplished if tobacco companies are able to differentiate the cigarette brands with unique traits.  Plain packaging blocks this route by standardizing all pack designs.  The only aspect that would be different between each brand would be the brand name—and even that would appear in standardized font and at the same location on each pack.  Wakefield, Germain, and Durkin (2008) demonstrated that plain packaging successfully removed brand associations.  In the study, smokers rated the attractiveness of cigarette packs that are shown both in their original packaging and in progressively plainer packaging.  Participants also rated the smokers of these cigarettes on various qualities, including stylishness, class, and confidence.  Lastly, participants rated how satisfying smoking the cigarettes from each pack would be.  Wakefield et al. found that smokers rated original packaging as most attractive, with the ratings dropping as the packaging became progressively plainer.  Participants gave smokers of plain packs lower ratings on positive qualities (e.g., less stylish, less sociable, less mature) than smokers of original packs.  They also responded that smoking cigarettes from plain packs would be less satisfying and that the tobacco would be of poorer quality (13).  These findings show that plain packaging reduces the attractiveness of cigarette packs and removes much of the positive associations (e.g., trendiness, youth, class) that tobacco companies seek to brand their products with.
A Shift in the Focus of Warnings
            Warnings on the cigarette packs focusing on independence and control would likely have a greater impact on youths than those focusing on health.  Adolescents value independence and autonomy highly, while health is not as valued in part because of the sense of infallibility.  Messages that focus on health would likely trigger the adolescents’ cognitive “personal fable” defense.  For example, when asked about cigarette health warnings, one adolescent responded, “No, I don’t think that I am going to die younger, I don’t believe that” (8).  In contrast, messages that frame smoking as threats to their independence and control bring the warnings much closer to the adolescents’ lives.  Take for example the following message: “You are independent and in control: why let nicotine addiction change this?”  The message centers the issue on independence and control, importance aspects of adolescence; this increases the likelihood that adolescents would pay attention to the message.  The message also alerts them to the fact that they are no longer infallible—the very act of smoking, what they thought was a way to rebel against authorities, may now take away their freedom.  As such, warnings on cigarette packs that focus on the effects that smoking has on freedom and control would be more effective in gaining the attention of adolescents than those that focus on health.
The Usage of Self-Affirmation and Questions
            Incorporating self-affirmation into the warnings on the cigarette packs and phrasing the warnings in the form of questions would help reduce psychological reactance in adolescents.  The theory of self-affirmation posits that people are motivated to protect their self-integrity and self-worth and that threats to these aspects of their identity drive people to react defensively.  However, when another aspect of their identity is affirmed in some way in the presence of a threat, the need for defensiveness is lowered (14).  Hogan and Speakman (2006) utilized this concept in developing a “covert persuasion trick”: “Resistance is diminished when people agree with the presented point of view.  Affirm the individual’s point of view” (15).  Harris and Napper (2005) examined the responses of young women to messages describing the link between alcohol and breast cancer.  Participants in the self-affirmation condition were asked to  write about the most important value in their life, the reason for its importance, and how they incorporated the value in their daily lives.  Participants in the control group were asked to write about why the least important value in their lives might be important to others.  All the participants were exposed to information regarding alcohol and breast cancer afterwards.  Harris and Napper found that the participants in the self-affirmation group, some of whom drank a significant amount, were more receptive to and more willing to consider the personal relevance of health messages regarding the connection between alcohol and breast cancer than those in the control group (14).
In a similar vein of investigation, Armitage, Harris, Hepton, and Napper (2008) demonstrated the use of self-affirmation in a study involving adult smokers.  Participants in the self-affirmation group were asked about past acts of kindness, whereas participants in the control group were asked about unrelated issues (e.g., asked for their opinion on whether chocolate was the best ice cream flavor).  All participants were then presented with antismoking information that described the harmful health effects of smoking and were asked a series of questions regarding their smoking behavior (a measure of risk), their view of the importance of smoking cessation (a measure of acceptance), and their intention to quit (a measure of intention).  The participants were offered leaflets containing information on how to quit smoking, and the experimenter covertly recorded this as a measure of effect on behavior.  The authors found that participants in the self-affirmation group showed significantly greater acceptance of the message and greater influence by the message in intention and behavior (16).
These findings demonstrate the effectiveness of self-affirmation in decreasing defensiveness and promoting changes in health-related behavior.  The study conducted by Armitage et al. is particularly relevant, as it addresses the issue of smoking cessation.  In preventing smoking initiation in adolescents, self-affirmation can similarly be used to decrease defensiveness, specifically psychological reactance, when delivering warnings on cigarette packs.  The previously used example message “You are independent and in control: why let nicotine addiction change this?” embodies this principle.  The first part of the message “You are independent and in control” is a self-affirmation mechanism: adolescents would self-affirm that they are independent and in control of their lives.  This reduces the defensiveness that is elicited by the second part of the message “why let nicotine addiction change this?”  Presented by itself, this part of the message would appear to be a direct attack on adolescents’ behavior and would provoke strong defensiveness and psychological reactance.  However, with the mitigating effect of the self-affirming part of the message, adolescents are more likely to experience less defensiveness and psychological reactance and to consider the personal relevance of the message.
Phrasing the warnings on the cigarette packs as questions would reduce psychological reactance as well.  Glock, Müller, and Ritter (2012) showed smokers cigarette packs that had text-only health warning labels, graphic health warning labels, health warnings phrased as questions, or no health warning labels printed on them.  They found that participants perceived higher risks for smoking-related diseases after viewing cigarettes packs that contained warnings phrased as questions or no warning labels.  The authors hypothesized that this may be due to lower levels of defensiveness that would otherwise have interfered with risk perception, an indirect measure of psychological reactance.  Here, lower perceived risk would indicate a higher level of defensiveness.  Furthermore, past research literature has shown that self-generated arguments are more persuasive than those originating externally; this may be why the warnings phrased as questions were more effective in the study.  Although the absence of warning labels appeared to be effective as well, the total lack of information on the harmful effects of smoking is undesirable.  As such, warnings phrased as questions may be the best method of delivering antismoking messages (17).
The message “You are independent and in control: why let nicotine addiction change this?” draws upon these findings by phrasing the warning as a question.  The question format avoids a tone of dominance.  Instead of delivering an authoritative statement, the message poses a question to adolescents and invites them to consider the issue.  The message is explicit in its meaning, but is not condemning; the clarity of the message serves to enhance the self-affirming aspects of the message.  The message contains a reason that adolescents can identify with: the message acknowledges the importance of independence and control to adolescents and asks them to weigh these values against smoking and addiction.  The combined effects of lowered dominance, heightened explicitness, and heightened reason in the message reduce the level of psychological reactance and increase the likelihood that adolescents will be receptive to and consider the meaning of the warning.
            Rather than implementing graphic cigarette health warning labels, instituting plain packaging of cigarettes and using warning messages that focus on independence and control may be more effective in preventing smoking initiation among adolescents.  Messages should furthermore embody self-affirming qualities and be presented in the format of questions.  The combination of plain packaging and self-affirming, questioning cigarette warnings eliminates the effects of branding, draws attention to the warnings through the focus on independence and control, and reduces psychological reactance.  Together, these measures maximize the effectiveness of cigarette warnings and their impact on adolescents.
1.    U.S. Food and Drug Administration. Cigarette Health Warnings - Overview: Cigarette Health Warnings. Silver Spring, MD: U.S. Food and Drug Administration. http://www.fda.gov/TobaccoProducts/Labeling/Labeling/CigaretteWarningLabels/ucm259214.htm.
2.   Associated Press. Appeals court denies rehearing on decision blocking graphic health warnings on cigarette packs. Washington Post. http://articles.washingtonpost.com/2012-12-05/business/35625639_1_cigarette-packs-new-warnings-cigarette-smoke.
3.   Escobedo LG, Anda RF, Smith PF, Remington PL, & Mast EE. Sociodemographic characteristics of cigarette smoking initiation in the United States: Implications for smoking prevention policy. JAMA: The Journal of the American Medical Association 1990; 264(12):1550–1555.
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6.   Scheffels J. A difference that makes a difference: young adult smokers’ accounts of cigarette brands and package design. Tobacco Control 2008; 17(2):118–122.
7.   Virgili M, Owen N, & Severson HH. Adolescents’ smoking behavior and risk perceptions. Journal of Substance Abuse 1991; 3(3):315–324.
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9.   Erceg-Hurn DM, & Steed LG. Does exposure to cigarette health warnings elicit psychological reactance in smokers? Journal of Applied Social Psychology 2011; 41(1):219–237.
10.                  Dillard JP, & Shen L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72(2):144–168.
11.Miller CH, Burgoon M, Grandpre JR, & Alvaro EM. Identifying principal risk factors for the initiation of adolescent smoking behaviors: the significance of psychological reactance. Health Communication 2006; 19(3):241–252.
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14.                  Harris PR, & Napper L. Self-affirmation and the biased processing of threatening health-risk information. Personality and Social Psychology Bulletin 2005; 31(9):1250–1263.
15.Hogan K, & Speakman J. Covert Persuasion: Psychological Tactics and Tricks to Win the Game. Hoboken, NJ: Wiley, 2006.
16.                  Armitage CJ, Harris PR, Hepton G, & Napper L. Self-affirmation increases acceptance of health-risk information among UK adult smokers with low socioeconomic status. Psychology of Addictive Behaviors 2008; 22(1):88–95.
17.                  Glock S, Müller BC, & Ritter S. Warning labels formulated as questions positively influence smoking-related risk perception. Journal of Health Psychology 2012; 0(0):1-11.

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At October 10, 2016 at 8:41 AM , Blogger Av van Rooyen said...

The warnings on cigarette packs actually act as affirmations to the smoker? It is accepted these days that constantly seeing a message such as "I love myself" "I am happy" "I am enough" "Day by day I am getting better and better" - has an impact on the subconscious after constant repitition. If this is the case then seeing a message such "Smoking causes cancer" 20 times a day ... each time one takes a cigarette out of the packet -will also have an impact on the subconscious and one would eventually have this imprinted on the subconscious and the body with the result of actually getting cancer? Mind/body connection? Has an investigation been done on the increase in cancers etc since these messages were put on to cigarette packs? If one believes it does no harm or is good for you - then it becomes so..... So perhaps these "subliminal messages" are really doing more harm than good.Perhaps they should be changed to: "You can stop - its not that difficult" or ""Do you really want one now?" Or "Think about your health" or "Be kind to yourself today"or "Youve had enough today"... I am sure there are psychologists who could come up with relevant and helpful statements other than the present doom and gloom statements that do the smoker no good whatsoever and dont work at all as a deterrant. Thankyou.


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