By Cheryl K. Olson
As part of its new strategic plan, the U.S. Food and Drug Administration’s Center for Tobacco Products is committing to sharing “timely, clear and accessible” information. This includes communicating with adults who smoke about tobacco product relative risks.
Last month, I highlighted dangerous tobacco-related misconceptions and groups of people in dire need of accurate relative risk information. Studies suggest we’re moving backward on accurate perceptions of nicotine harm and product relative risks. Why is this so hard to fix? Let’s look at a few examples of things that get in the way of harm reduction communication and how we might start to circumvent those barriers.
Knowing Does Not Equal Doing
Health communication campaigns often measure successes in facts and attitudes. Such as, what percentage of the population of Argentina is aware that smoking causes lung cancer?
This study, “Beyond Educating the Masses: The Role of Public Health Education in Addressing Socioeconomic[-Based] and Residence-Based Disparities in Tobacco Risk Perception,” is typical. The authors are with the Harvard School of Public Health, where I received my training in health communications. They assessed exposure to anti-smoking messages and risk perceptions of smoking. Some subgroups have lower risk perceptions? Expose them to more facts about the dangers of smoking. It’s assumed that changing risk perceptions will lead to different risk and protective behaviors and thus to improved health.
When popular theories that underlie these messaging campaigns are rigorously tested—not just in lazy studies that ask samples of university students to report on themselves—they aren’t that great at predicting behavior in the real world. We see this in a new analysis of U.S. National Youth Tobacco Survey findings. The focus was on “How much do you think people harm themselves when they use e-cigarettes?” and e-cigarette addictiveness compared to cigarettes.
Over six years, harm beliefs shifted in the approved direction. Researchers gave credit to campaigns such as The Real Cost and to (bogus) publicity about vaping-caused lung injury for this increased perception of risk. However, they were puzzled to find that over time, beliefs about harmfulness became less and less useful for predicting teen interest in and use of e-cigarettes.
Arguments about the accuracy of campaign messages aside … humans don’t always change their behavior in response to facts and beliefs. Sometimes, behaviors change first, and attitudes and beliefs adapt.
Websites that share stories of people who accidentally switched from smoking to vaping are a great example. Responses like this one upend our expectations of how people change: “I was firmly committed to smoking and didn’t care what anyone had to say about it. I was OK with dual use for convenience and ended up quitting cigs altogether without planning to.” Research studies on “smokers with no plans to quit” bear this out.
I’m not suggesting we throw out all theory-based behavior change campaigns. But let’s incorporate more real-world experience. Why not study the factors that encourage people to try and switch to alternatives in the real world and test the effects of communications based on their stories?
In a wonderful article on lessons from success and failure in risk communication from Swedish government agencies, the most entertaining examples come from campaigns gone wrong. One lesson learned: When multiple agencies communicate about a risk issue, the message must be consistent.
This may be an impossible ask when it comes to nicotine misinformation and tobacco product relative risks. The current emphasis of government communication and regulation has been on keeping youth away from nicotine. Accumulating data show that vaping is not a gateway to smoking and that youth smoking has reached unprecedented lows. This ought to lead to rearrangement of priorities to focus attention on those at highest risk, such as older people who are longtime smokers. Because, as Kenneth Warner has put it, it is difficult to think, not feel, about tobacco harm reduction, it may be a long time before government entities can reach consensus on the facts.
It seems possible that agencies could agree on a simple, brief message that nicotine does not cause cancer. However, as the article about Swedish government notes, the goals of a risk communication campaign affect how we measure its success or effectiveness. Do we seek to persuade and manipulate with information or to empower free agents?
One example is this study on the “Dilemma of Correcting Nicotine Misperceptions.” The title refers to concerns that people who smoke, when informed of the true risks of nicotine, will draw the “wrong” conclusions. Instead of using nicotine-replacement therapies, they might choose to use e-cigarettes! Other well-intended researchers, when testing comparative risk messages, have fretted that such education could deter quitting or increase dual use. These are exactly the kinds of concerns that could bog down a bureaucratic entity and end with inaction.
Another difficulty is that issues of tobacco harm reduction don’t lend themselves well to simple slogans. A recent focus group study looked at creating effective messages about switching from cigarettes to e-cigarettes. They found that simple statements often created doubt and mistrust or even spawned new misinformation. Discussion was needed to address underlying issues, such as the health effects of nicotine.
No agreement on core facts. No simple and clear behavioral goal (in contrast to “don’t smoke”). Traditional health message campaigns may be the wrong tool for the task of relative risk education.
Person to Person
A more promising approach may be person-to-person, story-based communication about tobacco harm reduction.
Jeffrey Smith is a neuroscientist who has moved from academia to industry, and most recently to R Street, a Washington, D.C., think tank. He has learned the hard way that when it comes to nicotine and tobacco, data are almost impossible to separate from context and connotations.
“I was always taught, and have taught others, that science isn’t personal. It is just a conversation related to theory, methods, analyses and conclusions,” he says. “I was truly disheartened when I would approach scientists at scientific meetings and was completely ignored and shunned due to my affiliation with industry.”
“I came into industry believing that my data are what mattered; I learned very quickly that was not the case,” he added.
That experience shapes his views on how best to move forward with harm reduction education. He doesn’t see industry, or academics, or the national regulatory or health agencies as optimal outreach partners in the current climate. He’s an advocate of working from the grassroots up rather than the top down.
Smith refers to the concept of “nothing about us without us,” where advocacy comes from those most directly affected by it: “That means people who have improved their health by switching to reduced-risk products, communicating that story to members of the community and with their healthcare providers.”
“It is much more of an arduous process starting at the national level first,” he concludes. “Things can change, and change quickly, in communities.”
Bethea (Annie) Kleykamp, a tobacco harm reduction researcher, shared her experience with peer-to-peer education. She recently started a post as assistant professor in psychiatry at the University of Maryland Baltimore School of Medicine. For decades, they have run an addiction treatment clinic focused on reducing harm for people who use opiates.
Kleykamp found that her new colleagues, focused on overdoses, wound care, HIV and other crises, had simply lacked time for and exposure to tobacco harm reduction concepts. She was able to show how her focus on tobacco was a good fit with their existing values and approach.
“Just talking to them. Explaining that a little over half of people in addiction treatment will actually die of tobacco-related disease,” she says. “I want the harm reduction thread to extend across all behaviors. And they hear that.”
She is also respectful of their constraints and competing priorities. As a starting point, she’s working toward a simple change in clinic procedures to wedge in one message. “My goal, that they’re open to, is educating patients briefly about the tobacco harm continuum with a graphic,” says Kleykamp.