June 30th, 2011

Conscious Intent vs. Actual Behavior: On Meth, Cigarettes, and Not Trusting What People Say

By Kyle Morich

The girl, barely 16, studies herself in the bathroom mirror as she confirms plans with her best friend. “Yeah, my parents think I’m sleeping at your house,” she confirms, “Okay, bye.”  She hangs up and gets into the shower.  As she begins to bathe, something catches her eye in the tub below her.  She glances down and a gasp escapes her lips—there’s blood and dirt pooling in the bathtub around her feet.  She looks around in shock, trying to find the source.  Her eyes discover the culprit, a skinny and broken girl her same age, curled into a ball at the end of the tub, face and arms are covered in fresh cuts and bruises, eyes are sunken in, and entire body laboring with each wheezy breath.  The girl’s horror becomes fully realized when she recognizes this spectral creature: it is herself.  She screams in terror.  The ghastly version of herself shakes her head and rasps, “Don’t do it.  Don’t do it.”  The screen goes to black and the slogan appears: Meth.  Not Even Once.

Titles at the end of the Meth Project “Bathtub” ad

Georgia has a meth problem.  The state of Georgia is a national center for the production, sale, and use of methamphetamine, costing the state $1.3 billion annually.  The drug is so powerful that only a fraction of those who use are successfully treated, so the Georgia Meth Project was launched to target those who have never tried meth and keep it that way. The hard-hitting ads, like the 30-second “Bathtub” spot above, are broadcast on television and radio throughout the state. Recently, the non-profit released study results that they believe demonstrate that these scare tactics are working.  Of teens participating in a “Methamphetamine Use & Attitudes” survey, 78% said the ads made them less likely to try or use meth, and 85% said the ads showed them that the drug is more dangerous than they had originally believed.

True, it is a great endeavor to ensure that Georgia teens know about the harmful effects of meth and are decreasing their intentions to use, but are these harrowing ads actually translating those intentions into behavior? Nowhere in the study were references to any changes in actual meth use, so I looked into the 2009 CDC Youth Risk Behavior Surveillance System, a bi-annual monitoring of health-risk behaviors that contribute to the leading causes of death and disability among youth and adults, to see how methamphetamine use has changed.  The YRBS showed no statistical difference in meth usage for Georgia 9th through 12th graders from 2007 (when the Georgia Meth Project began) to 2009.  My first assumption was that perhaps meth use remained flat while usage increased for other illegal drugs, but the YRBS shows statistically unchanged numbers for cocaine, marijuana, inhalants, and heroin over the same time period.

The Georgia Meth Project is not the only one of its kind. The original Meth Project was founded in Montana in 2005, and it proudly reports a 63% drop in meth use among Montana high school students from 2005 to 2009 as a result of the campaign.  So why did Montana have success while Georgia did not? David Erceg-Hurn, a PhD student in the School of Psychology at the University of Western Australia, launched an investigation into the Montana Meth Project in late 2008, and it appears that the purported success may not be entirely accurate.  Montana had been experiencing a steady decrease in teen meth use for six years prior to the Meth Project launch (falling 39% from 1999 to 2005).  The launch of the campaign also coincided with several large policy initiatives aimed at decreasing the production and sale of methamphetamine, which may have also contributed to the drop. The research is simply not robust enough to accurately measure the Meth Project’s impact.  This has not stopped the Meth Project from raising money and expanding, however.  In addition to Georgia, there are now Meth Project initiatives in Arizona, Colorado, Hawaii, Idaho, Illinois, and Wyoming.

This all raises an important question: do emotion-laden warnings impact behavior? This is particularly important in the wake of the FDAs new requirement for prominent health warning labels on all cigarette packaging and advertising.  Earlier cigarette labels—the plain text boxes describing the associated health risks for smoking—had little influence on tobacco sales.[1] These new graphics are, well, graphic: diseased lungs, a man blowing smoke from his tracheostoma, yellowed and decaying teeth, and a dead body are among the selection tobacco companies have to choose from.  These labels are designed to “increase awareness of the specific health risks associated with smoking, encourage smokers to quit, and empower[2] youth to say no to tobacco.” Nearly 50 million Americans still smoke, and smoking remains the largest preventable source of mortality in the US.  The FDA is hopeful that these warnings will have a significant impact on the number of smokers, and, in turn, save lives and lower medical costs.

The “Smoking Stoma” label

The concept behind the warning labels is that the smoker will be presented with a highly emotional reminder of the dangers of smoking every time he or she reaches for a pack of cigarettes.  Emotional reactions and subsequent recall of the messages will impact attitudes and beliefs, driving intentions to quit smoking and leading to long-term behavioral change. The FDA began with thirty-six warning messages and their accompanying graphics, conducting an 18,000-person study[3] to determine which graphic labels would have the greatest impact.  The FDA decided to use the cigarette label images that elicited the strongest emotional reactions compared to control group testing of plain text labels (both smokers and non-smokers were tested).

Actually reading the study, however, uncovers some interesting revelations about the labels’ effectiveness.  The images were primarily chosen for the self-reported emotional impact on the consumer and for strength of recall after one week of time.  The labels also were positively associated with ‘quit intentions,’ such as “I intend to stop smoking in the next 30 days,” or “I will stop smoking in the next year.” However, after tracking these consumers over the next month, the authors state that they “did not find strong evidence that the warning labels tested in this experiment had much of an impact on this measure of cessation.”

Prior to the FDA-commissioned report, a similar study[4] tested US consumer reactions to Canadian cigarette warning labels, which have featured gory and emotional images for several years, and found that the causal influence of the labels was unclear.  Smokers who already intended to quit may have been primed to read and discuss the labels, and new cigarette taxes and smoking bans had occurred prior to the study and were difficult to control for.  Smokers who quit after the labels were introduced were more 2.8 times more likely to cite the warning labels as a quitting influence than those quitting prior to their introduction, but its inconclusive whether the salience of the graphic labels just provide an accessible rationalization or actually drove the smoker to quit. And according to a four-country survey by the International Tobacco Control policy evaluation project[5], while graphic warning labels may lead to more quit attempts, there has been no consistent effects on quit success.

So what? If the labels get even one more person to quit smoking, then it’s all worth it, right?  A virulent open letter[6] written by social psychologist Dr. Robert Ruiter to the European Journal of Public Health in 2005 disagrees.  In his letter, Ruiter rebukes one of the primary references backing the FDA warning label reearch, a 2004 study that demonstrated the first evidence that graphic warning labels were successful in changing smoker behavior.[7] Ruiter points out several experimental flaws, including the lack of a control group and no pre-test data, that ignore the potential influence of ‘third variables,’ such as regulations and smokers’ prior intentions to quit.  But Ruiter’s biggest critique of graphic warning labels is that they fail to acknowledge research around fear-arousing communications that indicates those most at risk react defensively to those messages.  Ruiter cites several experiments (including a few of his own) to show that even though smokers will prefer fear-arousing messages because of the expected effectiveness in helping them quit, the messages lead to a protective response wherein smoking cessation becomes less of a priority[8] and—confirmed through EEG/ERP analyses[9]—less attention is allocated toward the threatening messages.  These labels are, at best, being ignored, and, at worst, reducing the chances of a smoker quitting.

A larger concern that I have with the labels relates to how the unconscious mind creates cues. There is a saying: “Neurons that fire together, wire together.”  It is in the physical nature of the brain to associate stimuli with behaviors as they are repeated over time.  I think it’s quite likely that these images of crying babies and autopsy tables will eventually be perceived by smokers’ unconscious minds as triggers for smoking.  These messages are not doing anything to disrupt the positive reinforcement that the nicotine has inside the brain—they’re just sitting there on the pack, waiting to be looked at every time a new cigarette is lit.

As with the Meth Project, I don’t have a problem with the FDA trying to stop people from smoking.  My problem stems from the presumption that rational messages to the conscious mind will have a sustained impact on behavior.  Cigarette marketers are not rocket scientists.  What they sell is a product that directly impacts the pleasure centers of the brain and creates an incredibly reinforcing behavioral dynamic.  All they have to do is get someone to try it once.  Getting someone to stop smoking, on the other hand, requires far more effort than bold text and creepy imagery.  The FDA needs to recognize the intractable nature of habits and design messaging that directly interacts with the unconscious mind.

 


[1] Robinson, R. & Killen, J. (1997). Do cigarette warning labels reduce smoking? Paradoxical effects among adolescents. Archives of Pediatrics and Adolescent Medicine, 151, 267-272

[2] Whenever you see the word ‘empower,’ you can guarantee there were marketers involved

[3] Nonnemaker, J., Farrelly, M., Kamyab, K., Busey, A., Mann, N (2010). Experimental Study of Graphic Cigarette Warning Labels: Final Results Report. Final Report. Contract No. HHSF-223-2009-10135G. Prepared for Center for Tobacco Products – Food and Drug Administration.

[4] Peters, E., et al. (2007). The impact and acceptability of Canadian-style cigarette warning labels among US smokers and non-smokers. Nicotine & Tobacco Research, 9, 4, 473-481.

[5] Borland, R., Yong, H., Wilson, N., Fong, G., Hammond, D., Cummings, K.M., Hosking, W., & McNeill, A. (2009). How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction. Vol. 104, No. 4, 669 – 675

[6] Ruiter, R., Kok, G. (2005). Saying is not (always) doing: Cigarette warning labels are useless. European Journal of Public Health, Vol. 15, No. 3, 329-330

[7] Hammond D, Fong GT, McDonald PW, et al. (2004). Graphic Canadian cigarette warnings labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health, 94, 1442 – 1445.

[8] Ruiter, R. (2004). Effects of fear-arousing TV commercials. Final report. Contract No.: 2200.0087. Funded by The Netherlands Organisation for Health Research and Developments. Maastricht, The Netherlands: Maastricht University, Department of Experimental Psychology.

[9] Wouters, L., Ruiter, R., Schmitt, B. (2002). The effects of threatening health commercials on attention: A social neurocognitive approach. In: Van Dijk E, Kluwer E, Wigboldus D, Editors. Delft: Eburon, 383 – 395.

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2 Responses to “Conscious Intent vs. Actual Behavior: On Meth, Cigarettes, and Not Trusting What People Say”

  1. Ari says:

    I find your critique of the government very unpatriotic.

    Other than that, this is quite informative and I rather agree that most people who smoke will probably start treating their cigarette boxes like Pokemon cards, trying to collect all the different boxes, rather than saying “oh, i dont want my lungs to look like that- i’ll stop right now”

  2. Cati says:

    Very interesting assessment, Kyle. You had me hooked in… but I want to hear more about solutions or alternative assessments to attitude that might be a proxy for following people around to see how much they engage in a certain behavior.

    Also, you say that cigarette marketers are not rocket scientists. Totally, but they are normal people with an extraordinary amount of money to spend.