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Debate is a series offering opposing sides of a continuing controversial issue in tobacco control. In this and the following article, the use of emotional or “fear” messages in tobacco control media campaigns is debated by Gerard Hastings and Lynn MacFadyen from the Centre for Tobacco Control Research at the University of Strathclyde in Glasgow, UK, and by Lois Biener and Tory Taylor from the Center for Survey Research at the University of Massachusetts in Boston, USA.
Anyone who doesn't believe that fear messages can change behaviour should try going into a crowded theatre and shouting “FIRE!”
Certainly, such messages have served tobacco control well over the last 50 years. Even a casual glance at prevalence trends demonstrates the impact of the major revelations about smoking and ill health. The power of warnings is enhanced with evocative creative executions, provided the resulting fear does not overwhelm the audience, and adequate support with quitting is offered. The recent Australian campaign demonstrates the potential of this approach.1,2
However, in tobacco control we have to be especially sensitive to the all too successful tactics of the tobacco industry, and these, along with those of other commercial marketers, have undergone a paradigm shift in the last 20 years. The traditional fixation with transactions and sales has been replaced by a focus on customer relationships and satisfaction. In this piece we argue that we can learn from these developments.
Specifically, they can tell us much about how advertising works, why people smoke, and how marketing exploits the resulting opportunities. All of this suggests that fear messages may be of limited value as we enter what has been dubbed the “second generation” of tobacco control (R Cameron, personal communication). Indeed it suggests that tobacco control is in need of its own paradigm shift.
Our suggestions are contentious, but the aim is to stimulate what we feel is a crucial debate.
Fear messages assume a direct, stimulus response, effect by the media: the individual hears, understands, accepts, and then acts on the message. In the advertising literature this is known as a “linear sequential” model3–5 and it takes many forms, but all characterise advertising as having a measurable and predictable effect on a basically passive individual. Analogies have been drawn between this “hypodermic syringe” view of media effect, and the medical model in health promotion.6 Linear sequential models have dominated commercial advertising since 1900.7 One of their most endearing characteristics is that they provide reassuringly clear objectives and facilitate rigorous evaluation.
However, they have also been severely criticised.7 They ignore the fact that mass media messages are mediated in various ways by significant others.8,9 The passivity they assume on the part of the audience is contradicted by uses and gratifications theory,10 and multi-step communication models,11 which suggest that it is at least as relevant to ask “what do people do to advertising?” as “what does advertising do to people?”.12 English health promoters have been all too aware of this since the mid 1980s, when teenagers were found to be stealing supposedly off-putting “Heroin screws you up”' posters and hanging them on their bedroom walls.
Finally, linear sequential models ignore all the thinking that has emerged from post-modernism. This overlooks vital insights into the importance of symbolism and cultural meaning to consumption, whether of products or messages.13 We now know that audiences, especially young ones, are extremely sophisticated consumers of the media. Thus, meaning has to be negotiated, not imposed.
However, it is important to recognise that their expertise is in consumption, not in health communication or message design. Fear campaigns are frequently justified on the grounds that smokers ask for them, preferring some variant on the blackened, cancerous lung—the gorier the better. This misses the point of pretesting. Smokers have a great deal to tell us about what it is like to be on the receiving end of our messages, but they don't know which ones are most effective. They are consumers, not consultants.
In other, closely related, spheres we readily accept this argument. We recognise, for instance, that most people are not experts in human behaviour, not even their own. So we would not simply ask smokers why they smoke, and take their answers at face value. Indeed, in the 1980s, when the tobacco industry did precisely this to try and show that advertising had no effect on children's smoking,14 we rightly dismissed their research.
WHY SMOKERS SMOKE
Linear sequential paradigms also assume that audiences are completely rational. Faced with the public health facts they will do the sensible thing. The reality is much more complex and inconvenient.
The fact is, in the developed world at least, people know about the health risks of tobacco15 and around two thirds want to quit.16 However, millions continue to smoke, partly because of nicotine addiction, but also because smoking brings lots of other benefits, from social acceptability to rebellion.17 In the latter case, the health consequences of tobacco may actually be seen as a benefit.
This contrariness, this irrationality should not come as a surprise. We all do lots of apparently senseless things—we support hopelessly unsuccessful football teams, enjoy the Scottish climate, and marry unsuitable partners. We do these things, despite the contraindications, because some element of each also brings emotional benefits. Tobacco marketers know this.
Marketing works by identifying people's needs and offering solutions—products or services—that will meet these needs, in return for money.18 The basic unit of analysis is exchange,19 which is voluntary. Customers do not have to buy the product and can reject, ignore or undermine advertising messages.
Tobacco companies, therefore, cannot force people to smoke. Their tactics with children are instructive. In the developed world at least, they make no overt approaches at all, except to say that they don't want children to smoke. Indeed the tobacco industry recently ran a children's anti-smoking campaign across Europe. This is disingenuous; we know that they will be out of business in a generation if they don't attract their quota of new recruits. But their tactics are subtle. They know that the best way of getting teens to do one thing is to tell them to do another. They appreciate the appeal of forbidden fruit and that marketing (apparently) targeted at older people will be inherently attractive to a group that covets adulthood.
These are hard lessons for tobacco control advocates to swallow. We know tobacco kills in devastating numbers. When people reject or ignore our messages, the temptation to insist is very powerful. However, we are constrained by the same realities as Big Tobacco; our exchanges are also voluntary. We cannot insist.
In commercial marketing the notion of exchange has now been melded with strategic planning. The business literature is replete20,21 with cases of companies that have thrived, not by focusing on ad hoc transactions, but by building long term relationships with their customers. Data base marketing, new media, powerful branding, and loyalty schemes are used to attain the crucial competitive advantage of customer satisfaction. The tobacco industry has been quick to harness this new philosophy. Its brands have long been supreme, databases are now being skilfully honed, and retailers, politicians, and pundits are being courted as actively as the public.
Tobacco control can and should be competing in this arena. Quit lines, for example, generate ideal databases and offer the opportunity to keep regular contact with an important customer group. We know that smoking is emotionally involving and that quitting is a hard, often drawn out process. It cries out for relationship building that, at the very least, will make quitters feel better about themselves. And, incidentally, politicians will also be more likely to fund initiatives that make voters feel good.
Fear messages do not sit easily with this thinking. If they have any relational dimension at all, it is as the hectoring parent to the erring child, rather than the adult to adult of commercial marketing. They may succeed in pushing people to attempt quitting, but it is difficult for the source of such messages to then provide the “helpful relationships” that are needed at the action stage of Prochaska and Diclemente's model.22
PUBLIC HEALTH MYOPIA
As with most business philosophies, relationship marketing has its origins in the bottom line. Companies have established that winning new customers is much more expensive than retaining old ones. We should recognise that the same is true in public health. If we can only empower people and convince them of the very real benefits—both immediate and deferred—that are in their grasp if they make certain lifestyle choices, then we won't just encourage cessation but good diet, exercise, and safer sex as well. It is no accident that middle class groups don't just smoke less, but have healthier habits generally.
Instead, we fragment health into different topics and engage in an odd kind of consequence proliferation, where smoking, driving, having sex, and a dozen other behaviours vie with each other to present more dramatic risks. In the process, we end up telling people that if the cigarettes don't get them, a drunk driver, sexually transmitted disease or an over-abundance of butter surely will. The net effect is to turn health promotion from a tremendous opportunity for people to enhance their enjoyment of life, into a clutch of disparate and capricious threats.
Fear messages are important. The first step in tobacco control is to inform people of the dangers of smoking. But repeating this to a population that knows it, two thirds of whom already want to quit, is of questionable value. To return to our initial example, there comes a point where the theatre-goer shouting “fire” is reduced to the irritation of a malfunctioning alarm. Furthermore, searching for evermore powerful warnings is fruitless. There is no ultimate deterrent in smoking, no mother of all health warnings that will finally alert smokers to the error of their ways.
A paradigm shift is needed to equip us for the next generation of tobacco control. This should recognise the cultural, as well as the individual, determinants of smoking, and begin to address these with broad, empowering messages. We need to play the industry at their own game, create brands that are trusted and respected, and above all begin to build long term, adult relationships with our target audiences.
The challenges are formidable, but not insurmountable. The success of the Florida Truth campaign,23,24 for example, suggests we can create our own brands. In any case, our suggestions are not so shocking or revolutionary. All we have to do is be a better friend to the smoker than the tobacco industry. Surely we can manage that.
The Centre for Tobacco Control Research is core funded by the Cancer Research Campaign