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Graphic Antismoking Images: Will They Work?

By Jennifer Van Pelt, MA

This year marked the first appearance of graphic antismoking advertisements on television, billboards, and social media outlets. Sponsored by the Centers for Disease Control and Prevention (CDC), this national media campaign, “Tips From Former Smokers,” is designed to shock smokers into quitting and prevent others from starting to smoke by demonstrating real-life, painful, debilitating, and fatal consequences of smoking. Eight television ads (including one in Spanish) and several radio and print ads depict former smokers with severe ailments describing the dangers of smoking. The campaign targets those aged 18 to 54, but the CDC and other public health professionals are hoping to also impact children and young teens.

Devaluing Smoking
According to a recent U.S. Surgeon General’s report, more than 80% of smokers begin before the age of 18, and nearly one in five high school teens smokes. Although the rate of teen smoking has declined since the 1990s, the rate of decline has begun to slow down.

Public health experts believe the key to smoking prevention is making the health consequences of smoking more visible, especially in the vulnerable teen population. Initially, the FDA was expected to join in this antismoking campaign with a federal mandate requiring tobacco companies to place graphic warnings on cigarette packages. However, in early 2012, a judge ruled that this requirement violated free speech. According to the FDA website, an appeal is ongoing, and a tentative date of September 2012 has been set to begin implementation of the new mandate.

“The purpose of these images, from my perspective, is to dissuade new smokers from starting and to facilitate cessation for those in the process of contemplating quitting,” says Warren K. Bickel, PhD, director of the Addiction Recovery Research Center at Virginia Tech Carilion Research Institute. “I do not see this as a replacement to cessation treatment but rather another method used in concert with others to prevent smoking or facilitating the effort to quit.”

Decreasing valuation of an addictive behavior has been useful in some types of addiction treatment. It is hoped that associating negative images with smoking will decrease its valuation in the mind of the smoker and promote cessation, he adds.

Bickel has been researching the neurocognitive process in smokers and other addicts for several years to develop new methods to improve addiction-related decisions. Studying the changes in decision making among recovering addicts led to the creation of the National Quit and Recovery Registry in September 2011. “It employs crowd-sourcing technology to establish, maintain, and grow an extensive community of research participants who are in recovery and have volunteered to provide not only initial information but also to participate in subsequent research,” Bickel explains.

The registry’s purpose is to better understand why some individuals succeed in overcoming addictions while others relapse, with the intention of advancing scientific understanding of addiction recovery and motivating struggling addicts. The website includes testimonials from recovering addicts, including one former three-pack-a-day smoker who was “spooked” into quitting when he realized he had the hacking cough of an elder man with emphysema.

“Most people consider treatment because of some type of negative event,” Bickel says. He believes the new graphic images may decrease the barriers to smoking addiction treatment. “This negative imagery, along with other life events, may have an additive or supra-additive effect in facilitating quit attempts,” he notes.

The CDC, the FDA, and others concerned with smoking cessation hope the new graphic images will scare away those considering starting smoking and jump-start smokers into quitting.

“Research shows that graphic warning labels are more likely to be remembered, increase knowledge about the health harms of tobacco, and increase intentions to quit. We also know that emotional and graphic communications, especially combined with information on quitting—for example, a quitline phone number or website—are effective,” says Daniel McGoldrick, MA, vice president of research at the Campaign for Tobacco-Free Kids, where he supervises marketing and communications research to support the campaign’s mission and provides assistance for state-based comprehensive tobacco prevention programs and smoking policy changes.

The new graphic warnings are not a method of quitting, he says, but rather a way to communicate the health consequences of smoking, which can then lead to quitting. “They are not an alternative or a substitute for the evidence-based interventions that actually assist people in the quit attempt but rather a complement to them that will encourage people to try to quit,” McGoldrick explains.

Goldye Donner, LCSW, a counselor and psychotherapist who is also a certified Quit Smart Stop Smoking program leader, is skeptical of the actual impact the antismoking ad campaign will have on smokers based on her experience. While she does believe the purpose of the new graphic ads is to induce smokers to feel the risk of smoking with the intent to change behavior, she questions their effectiveness outside the research setting, especially in long-term smokers.

“My anecdotal impression from smokers whom I have spoken with is that these images will have little impact for most of them. In order to continue smoking, smokers have already mastered the capacity to disconnect from feeling the risks involved in smoking. This capacity to shut out negative aspects of smoking and dissociate from feelings of risk may render these images ineffective,” she says.

For long-term, older smokers, the impact of the graphic warnings is debatable. But for those considering starting smoking, more impressionable children and teens, and ex-smokers, it is hoped the new antismoking campaign will be an effective addition to smoking cessation and prevention efforts. McGoldrick hopes the new graphic warnings will help counter tobacco companies’ aggressive $10 billion-per-year cigarette marketing campaigns by changing the affect around tobacco products.

“Tobacco companies spend billions annually to make smoking appear cool, sexy, and normal, and they do it through multiple channels: marketing, package design, product placement,” he says. The new antismoking campaign via media outlets and, hopefully, cigarette packages adds public health education to a comprehensive tobacco prevention effort that includes increased tobacco taxes and smoke-free laws. The ultimate goal, he emphasizes, is to change the sociocultural environment in which children, teens, and young adults make smoking decisions and to encourage the healthier choice to not smoke.

An April multinational study of ex-smokers by Partos et al, to be published in Tobacco Control, reported that health-risk warning labels on cigarette packages helped with relapse avoidance when the warnings were actively used as part of a strategy to remain smoke free. Simple exposure to the warnings was actually associated with a greater risk of relapse, likely due to concurrent exposure to cigarette availability. However, when the warnings were used by individuals to help them generate reasons for resisting temptations to relapse, risk of relapse was lower.

In the study, warning labels were text only for U.S. smokers, but for residents of other countries, warnings were larger and more graphic. Although the researchers found no difference based on the ex-smokers’ country, they did find that the size and novelty of the warnings correlated with smoking abstinence, suggesting that adding larger graphic warnings to U.S. cigarette packages may have a greater influence on ex-smokers in decisions to relapse.

According to data collected by the National Cancer Institute and provided by the Campaign for Tobacco-Free Kids, weekly call volume to smoking quitlines has roughly doubled since the graphic ad campaign began, from 14,437 calls the week of March 12, immediately prior to the campaign launch, to 33,262 calls the week of March 19. This increased volume was maintained through the end of April. These data indicate the effectiveness of the new graphic ads in prompting smokers to seek help in quitting.

For social workers in the field of addiction counseling, drawing attention to the new graphic antismoking warnings may add to the arsenal of smoking cessation strategies.

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer and a frequent contributor to Social Work Today.