“Bulletproof skeptics in life's jungle”: which self-exempting beliefs about smoking most predict lack of progression towards quitting?
Introduction
In Australia during 1974, 45.3% of men and 29.6% of women smoked at least once per week [1]. By 2001, this had fallen to 23.1% of men and 19.3% of women (with 21.1% men and 18.0% women smoking daily) [2]. The intervening period—particularly since 1982 when the first major quit campaign commenced—saw the introduction of three generations of pack warnings (1973, 1987, 1995) [3], the elimination of all tobacco advertising, the introduction of smoke-free public transport and restaurants [4] and many workplaces [5], the deregulation of nicotine replacement therapy allowing direct to the public advertising about smoking cessation, and large-scale government sponsored public awareness campaigns [6]. In addition, these measures have all generated widespread community debate and news coverage that has been overwhelmingly negative to smoking [7].
Australia has one of the most comprehensive and robust tobacco control programs in the world, yet around one in five of the population aged 14 and over still smoke daily [8]. This presents a significant challenge to tobacco control policy, as many of its traditional platforms have already been implemented in Australia. Discussion about the potential for “paradigm shifts” in the focus of communication about smoking and health are common among Australian tobacco control workers.
To date, appeals to smokers to consider quitting have been dominated by messages highlighting the health consequences of smoking, with occasional efforts targeting the growing social unacceptability of smoking, its cost and strategies for quitting and avoiding relapse. One area postulated to hold potential to further erode smoking is to design communicative interventions that take account of the various ways that many smokers rationalize their smoking. In communicative environments like Australia where considerable effort has been expended trying to make the risks of smoking seem more personally relevant, it may be that efforts to undermine or psychologically “inoculate” [9] against these rationalizations could prove fruitful.
In 1957, Festinger [10] hypothesized that smoking in the face of information about its health effects creates cognitive dissonance that smokers must dissipate through mediating beliefs or rationalizations. In 1991, Chapman et al. [11] found that Australian smokers were more likely than ex-smokers to hold self-exempting beliefs about smoking that might act to dissipate cognitive dissonance. Subsequent studies have shown that such beliefs are common among smokers. Despite often near universal awareness of claims made about smoking being harmful to health, many smokers remain skeptical about these claims and the level of risk associated with smoking [12], [13].
In this paper, we report on a survey that extends the 1991 study, following a decade of intensive tobacco control in Australia when adult smoking prevalence fell from 26.0% to 21.2% [2], [14]. We report on a national survey of smokers and recent quitters undertaken in 2002 examining the prevalence and correlates of 18 self-exempting beliefs precategorized into three broad types:
- 1.
Beliefs suggesting smokers think they have some personal immunity to the health effects of smoking—“bulletproof” beliefs
- 2.
Beliefs indicating smokers do not believe medical evidence about smoking and disease—“skeptic” beliefs
- 3.
Beliefs normalizing the dangers of smoking because of the ubiquity of risks (“life's a jungle'”)—“jungle” beliefs
It was hypothesized (a) that these beliefs would form coherent scales using factor analysis; (b) that self-exempting beliefs would be most prevalent among the older and less well educated; (c) that intention to quit would be related to each self-exempting belief scale; and (d) that the relationship would be cumulative, with greater adherence to self-exempting beliefs associated with lower intention to quit.
Section snippets
Self-exempting beliefs measure
Self-exempting belief items were generated by participants in a closed international tobacco control email list server, Globalink, who were invited to submit examples of self- exempting statements commonly expressed by smokers. From suggestions submitted, 18 distinct self-exempting beliefs were selected, including 7 based on items from the previous paper [11]. Respondents to the community survey (see below) rated their agreement with each self-exempting belief statement from 1 to 5 (1 = totally
Results
A small group of smokers and recent quitters still claim to not believe that smoking causes lung cancer (7.6% of all respondents) and heart disease (11%), with disagreement that passive smoking causes lung cancer in others remaining widespread (29.2%). Only 49% knew smoking was the largest cause of death in Australia and 50.2% answered correctly that smokers on average lose six or more years of life. The mean of the combined knowledge scale was 3.5 out of a possible 5.
Smokers with lower
Discussion
The results of this study show that all four types of self-exempting beliefs are related to interest in quitting, but suggest that some types of self-exempting beliefs are more important than others in influencing progression towards cessation. Furthermore, the beliefs (or sets of beliefs) play largely independent roles in inhibiting cessation. The intuitively plausible hypothesis that the beliefs function as a form of armory: the more beliefs to which you subscribe, the more protected you are,
Acknowledgements
This project was funded by a grant from the Australian Smoking Cessation Consortium provided by GlaxoSmithKline Consumer Health Care.
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