Cigarette use has declined dramatically since the smoky days of Mad Men. In 1965, 42 percent of American adults smoked. By 2011, only 19 percent did. But this extraordinary reduction in smoking rates seems to have stalled in recent years. A 2012 CDC report found no statistically significant change in the prevalence of adult smoking from 2010 to 2011.
Meanwhile, smoking continues to kill 440,000 Americans a year. This makes finding new, effective ways to motivate more smokers to kick the habit an urgent public health priority.
But it’s hard to catch people’s attention.
In today’s media-rich environment, when people are constantly surrounded by eye-catching YouTube videos and hilarious tweets, it can be difficult for a sobering public health message to stand out from the crowd. In an effort to find strategies that work to reach an audience, public health advocates have resorted to increasingly scary and graphic tactics.
In 2012, with $54 million available through the Affordable Care Act, the CDC launched the first federally funded anti-smoking mass media campaign. Called “Tips From Former Smokers,” the series of ads includes emotional stories graphically depicting the devastating health consequences of smoking, and messages encouraging smokers to quit.
These ads are especially powerful and compelling because they rely on the stories and experiences of the true experts on the consequences of smoking: former smokers. For instance, one video from the campaign featured former smoker Terrie Hall, who had developed head and neck cancer, speaking using an artificial voice box. She tells viewers that “The only voice my grandsons ever heard is this one.” Ms. Hall died of cancer on September 10, 2013.
In that same month, The Lancet published an article which evaluated the effectiveness of the “Tips” campaign. The authors reported that the campaign had reached nearly 80 percent of American smokers, and was associated with a 12 percent relative increase in attempts to quit smoking. Based on these numbers, they calculated that 1.6 million people had tried to quit smoking and 100,000 succeeded.
Not only did “Tips” prompt huge numbers of people to quit smoking, it also improved the health of thousands of Americans for relatively little money. As Dr. Tim McAfee, who directed the study, told NBC News, “This study shows that we save a year of life for less than $200. That makes it one of the most cost-effective prevention efforts.”
The authors concluded that their findings demonstrated the effectiveness of “a national campaign using hard-hitting messages delivered in emotional, graphic personal stories.” Or, as one blogger more colorfully put it, “The CDC’s Scary-Ass Anti-Smoking Commercials Are Working.”
Enthusiastic about this success, tobacco prevention advocates are seeking to replicate it. Susan Liss, Executive Director of the Campaign for Tobacco-Free Kids, told NBC News, “To win the fight against tobacco, we need more media campaigns like this, both nationally and in the states (….) Similar national campaigns must be continued and expanded in the future.”
But the increasingly common use of graphic scare tactics in public health campaigns raises some important ethical concerns, even when such campaigns effectively scare and shame people into better health behaviors. As Columbia Professor Ron Bayer has asked, when and how is it acceptable for governments “to tap the power of shame and guilt to affect social norms?”
Relying on fear-based appeals can have potent negative consequences. Of particular concern is how inspiring fear of the conditions associated with smoking, such as lung cancer or heart disease, can sometimes turn into inspiring fear and even loathing of smokers themselves.
Ads that promote fear and stigma can have significant adverse effects. In a 2004 article on ethical issues in public health communications, Nurit Guttman and Charles Salmon noted that “Once stereotypes and stigma are established, they can result in individuals being feared, avoided, regarded as deviant, and even blamed for engaging in the immoral behaviors that must have elicited the punishment of their affliction.”
This concern goes beyond anti-smoking campaigns to public health advertisements addressing a range of health problems, including obesity, teenage pregnancy, and HIV/AIDS. Examples of these ads can be seen down below this article.
Sending messages that blame individuals, implicitly or explicitly, for their health status may not only have harmful psychological effects. Blame, stigma and discrimination may actually worsen physical health. According to a July 2013 article published in Plos One, participants who experienced weight discrimination were about 2.5 times more likely to become obese than those who did not experience such discrimination. The authors concluded that rather than encouraging people to lose weight, discrimination “can actually have the opposite effect: it is associated with the development and maintenance of obesity.”
Jeremiah Johnson, a public health advocate who helped change the Peace Corps’ policy to allow HIV-positive volunteers to continue their service, has sharply critiqued the use of fear and shame in public health outreach. He argues that we don’t want “a public health campaign or a doctor’s office to feel like Friday the 13th (….) These types of messages send out the idea that if you are unable to protect yourself, if you are unable to get your risk down to zero, that you may be stupid, you may be irresponsible, and you may on some level be a bad person.”
The “Tips” campaign can be interpreted as giving a voice to former smokers who honestly and bravely communicate the reality of smoking’s devastating effects. But public health campaigners should tread cautiously as they seek to tap into the power of fear. In crafting effective graphic campaigns, advocates should be very attentive to the other messages they may be sending. Effectively—and cost-effectively—preventing disease and death is of urgent importance. But ultimately, public health and well-being may be best promoted by campaigns that foster empowerment and understanding, not fear and loathing.
1) Tips from former smokers: Terrie’s ad
In this graphic ad, the most popular spot of the “Tips” campaign, Terrie Hall shows how cancer has affected her morning routine, as she puts in her false teeth and covers her stoma with a scarf. She felt strongly about conveying the effects of smoking. In memorializing her, Tom Frieden, the director of the CDC, noted that “She insisted on being filmed in her hospital bed just two days before her death, sharing the final effects of smoking on her body.”
2) It’s never just HIV
In responding to this campaign, HIV/AIDS advocate Jeremiah Johnson, reflected that: “While I knew that this was meant to make these men afraid of a virus, I couldn’t tell if that fearful look that he had on his face was fear that he had for someone like me, someone living with HIV.”
3) Stop childhood obesity: Why am I fat?
This highly controversial ad campaign, released in Georgia by the Strong4Life campaign and Children’s Healthcare of Atlanta, depicts overweight children with taglines such as “Being fat takes the fun out of being a kid” and “My fat may be funny to you, but it’s killing me.” In this ad, a child asks his mother “Why am I fat?” while she sighs and looks ashamed in response. Marsha Davis, who researches child obesity prevention at the University of Georgia’s College of Public Health, told the Atlanta Journal-Consitution, “We need to fight obesity, not obese people.”
4) The real cost of teen pregnancy
Haydee Morales, Vice President of Education and Training at Planned Parenthood, told CNN that the ads create “stigma, hostility and negative public opinions about teen pregnancy and parenthood rather than offering alternative aspirations for young people.”
Edited by Joshua Brooks