Challenging Dogma

Sunday, May 6, 2012

The X-Buddy Campaign: A Counterproposal to the CDC’s “Tips From Former Smokers” – Dominick Leone

The Centers for Disease Control and Prevention (CDC) launched a new campaign on March 15th, 2012, to encourage individual adult smokers to quit by providing information as to the effects of smoking and the severity of those possible consequences. The campaign, “Tips from Former Smokers,” utilizes patients suffering from smoking-related diseases to inform the public of the dangers of smoking through telling their life story. Their approach, however, may not reach its potential due to the reliance on an individual-level intervention, susceptibility to a possible boomerang-effect, and an ineffectual use of media. Instead, the “X-Buddy Campaign”, a new social group-level intervention, is proposed that will address the deficits in the CDC’s current campaign. 
Introduction: The Problem of Quitting
The large number of smokers in the United States face major hurdles that threaten their attempts at quitting. According to the CDC, 19.3 % of adults over 18 years of age, or 45.3 million Americans, currently smoke (1). The obstacles faced by these smokers are: procrastination, the necessity to make continuous decisions to remain smoke-free; and the social dynamics involved in smoking. To be effective, any anti-smoking campaign must address these aspects of smoking.
In rational terms, a smoker must commit to a decision not to smoke, however, our human nature and the nature of smoking cessation thwart the majority of attempts. Although approximately 70% of smokers state a desire to quit, only about a third will be successful (2). Procrastination, the inaction following an initial decision to cease smoking, is universally recognized as part of the human condition. Most smokers have tried and failed at cessation attempts at least twice before being successful (3).  This may be partly due to the continuous nature of the quitting effort. Neither smoking nor quitting are one-time decisions, but rather are made many times in a day and influenced by many triggers, or even visual depictions of smoking.
Smoking is not done in a social vacuum, in that both the behavior of smoking and quitting occurs as part of a social phenomenon. Although individuals smoke, group pressures are the important drivers of smoking behavior. When smokers and quitters are mapped-out, their behavior appears to occur in large groups or networks (4). Also, the need for social participation in successful cessation attempts is well documented (5). It would, therefore, be advantageous to use a group level intervention that could address the human aspects quitting – both on an individual and social basis.
“Tips from Former Smokers”: A Flawed Approach
The CDC’s campaign is stymied by its dependence on an individual-level intervention. Their public health effort is based on social behavioral models that have faulty assumptions. “Tips” provides smokers with their risks and vulnerability in an attempt to change their intent to smoke. The underlying assumption is that smoking is the result of rational decision-making, and the intent to quit will necessarily lead to smoking cessation.
Critique #1: A Reliance on an Individual-Level Model
The Irrational Reliance on Smokers’ Rationality
To alter smokers’ intentions, the CDC’s campaign strives to change knowledge, attitudes and beliefs. A section labeled, “Get the Facts,” on the campaign website along with “Real Stories” attempt to provide information about the consequences of continuing to smoke, as well as the severity of those consequences. The real stories these patients tell are aimed at convincing current smokers of their susceptibility to the disease from which they now must live. The CDC spent a great deal of time, money, and effort putting forth this effort to change smokers attitudes and beliefs under an assumption that if information were provided as to the “real costs” of smoking, then current users would decide not to smoke using a cost-benefit type analysis; this assumption may not be valid.
            The assumption that smokers will “weigh” their risks in a rational manner, originates with the models on which the intervention are founded. Modeled on the Expectancy-Value theory, the Theory of Reasoned Action, and Theory of Planned Behavior, the CDC’s campaign shares all the same leaps in logic: that beliefs and attitudes are shaped by a rational decision making process.
“Tips from Former Smokers” depends on rational decision making – much to its own detriment – when what we know of human behavior points to our irrationality in making some of the most important decisions. The Generalized Axiom of Reveled Preference (GARP) can be applied to test this assumption. As a hypothetical, we could say that, all things being equal, most rational people prefer living to dying. Smoking is generally understood to lead to death, therefore a rational person, according to GARP, would not prefer to smoke and would quit – but they don’t. Studies show people know smoking causes cancer and death and they still (irrationally) choose to smoke. So, if smoking were rational and quitting were a consequence of rational decision-making then GARP would be observed – but it is not and decisions to smoke are therefore not rational. Furthermore, a well-known irrational trigger is stress (6-8). Smoking is therefore not only irrational, but also emotional.
Failures to Account for Procrastination and the Nature of Habit Formation
The assumption of rationality in an individual-level, antismoking, intervention has the further consequence of obscuring the possibility of smokers’ procrastination. This is due to a faulty assumption that changes in intention to quit will lead to the behavior of quitting. The CDC’s assumption arises from the intervention’s reliance on a model similar to the Theory of Planned behavior.  Theoretically, the timeframe between a behavioral intent and the behavior is not well delineated (9). Because of this limitation, the intervention does not address procrastination, a well-established human behavior and frequent problem for smokers attempting to quit.
Another consequence of the behavioral-intent assumption is the inability of the CDC campaign to adequately address the day-to-day difficulties of remaining smoke-free after initially deciding to quit. An underlying problem with the model on which “Tips” rests is that it doesn’t adequately address the formation of the new habit of “not smoking”. Operant Conditioning and Modeling Theory suggest that new habit formation involves reinforcement of a new behavior with a reward, satisfaction, or relief (10). In theory, repetitive “trials” that are rewarded (by providing satisfaction or providing relief) increase the probability of repetition of “not smoking”.  However it is unlikely that smokers will experience reinforcement along this type of schedule. The consequences of smoking occur over a much longer term, and thus there is a very low probability of immediate reward – hence a change in behavior is also unlikely leading to recidivism. This phenomenon is so common among smokers attempting to quit, they have even have named it “cheating”.
Critique #2: Concern for Possible “Boomerang Effect”
Coordinated efforts to change smoking behavior can result, paradoxically, in increased smoking. This is referred to as the “Boomerang Effect,” and can result from cognitive dissonance and psychological reactance because smokers have identified with, and taken ownership, of the behavior. Attempts to rationally alter smokers’ behavior through changes in beliefs and values are especially at risk of causing boomeranging.
The Effect of Cognitive Dissonance
Cognitive Dissonance could reduce the efficacy of the CDC’s campaign. When confronted with conflicting cognitions (ideas, beliefs, and values), smokers are motivated to reduce this conflict (dissonance) and restore consistency by altering cognitions, i.e. by rationalization (11).  Dissonance has been shown to be a good predictor of success in smoking treatments (12). The CDC’s campaign does not address smokers’ use of rationalizations and therefore cognitive dissonance is likely to persist (13). For example, a current smoker might have the following prior cognition: “Smoking helps make me feel better by relieving stress.” The CDC’s Ads may strengthen cognitions such as, “Smoking will make me feel worse by causing a stroke, loosing a limb, or having a hole in my neck”. Such a smoker might then alleviate dissonance by utilizing rationalizations. These ideations might entail downplaying the odds of developing an illness portrayed or not identifying with people in ads (“models”). Secondarily, this could limit the effectiveness of the CDC’s campaign. If credibility is lost, and the behavior of quitting, instead of being modeled by target smokers, results in the reduction, nullification, or even a reversal – smokers could actually smoke more if dissonance leads to an increase in psychological reactance by decreasing credibility.
The Effect of Psychological Reactance
Psychological reactance, an emotional response to a perceived threat to a specific behavioral freedom, might result from the “Tips” campaign.  Smokers are more likely to perceive the campaign’s messages as a threat to their freedom to smoke because of the importance (14) they connect to their smoking: prior ideations of “ownership” of the smoking behavior and identification with the “smoker” identity has likely attached a great amount of value to their smoking. For example, Jessica’s Asthma Ad, a TV spot from the campaign that encourages parents to speak-up against smokers engaging in the behavior close to their children, might be perceived as “blaming” smokers for their children’s ill health. This perception of blame might increase reactance if the smokers perceive “dominance” (15) from the ad.
In general, the attitudes and beliefs that the “Tips” campaign is attempting to adopt are substantially different from those of current smokers – and thus there is a high probability of reactance. In, Covert Persuasion, Kevin Hogan reminds us that people have an easier time conforming to ideas and beliefs that are closer to their own (16). For example, smokers are likely to value smoking as benefit (e.g. a waitress who sees smoking as a short term break from their work duties and a chance to socialize with workers).  The CDC is attempting to change this value-structure into one conducive to not smoking, an effort likely to result in psychological reactance.
Finally, the risk of reactance in targeted smokers is dependent upon the value they place in the evidence presented by a campaign. Elements of “Tips”, such as the Anthem Ad (17), offer poor “reasons” as support for not smoking. Smokers who are expose to the ad might reason “if I keep smoking I might end up with a hole in my throat.” If the viewer is not convinced of the severity of the consequences of smoking, because they do not place importance in having a hole in their neck, then reactance is more likely to occur. A recent example of this occurred when children exposed to “Above the Influence” campaign actually smoked more than those not exposed, due to possible reactance (18).
Critique #3: A Flaccid Use of Media
The media is one of the strongest possible tools in the arsenal of public health, however “Tips”, the CDC’s current campaign strategy, is confusing and not effective. Promoted is an ethereal state of health that lacks the drive to change behavior, and some of the evidence provided to support a promise of better health from cessation, is at best confusing, and at worse disempowering and depressing. Instead of using the social media, such as Twitter and Facebook to its full advantage, “Tips,” instead, utilizes social media as merely another communication channel.
Anemic Framing of the “Tips From Former Smokers” Campaign
The CDC’s use of “health”, as a core-value, limits their effectiveness due a weakening of the frame of the campaign. People are very susceptible to how information is presented, referred to as the “framing effect”, and this can have a significant impact on people’s behavior (19). This is most significant when the contextual information is presented in frames with more emotional core-values. People respond more to emotional core-values because their brains are hard-wired to respond to this type of stimulation. This is supported by fMRI studies of amygdala-activation during the viewing of various frames (20).  This area of the brain is an emotional processing area, and the results further refute the reliance on rational-based models in public health interventions such as the “Tips” campaign. More likely, smokers might receive the depressing images of sick patients depicted as being inevitable. Instead of empowering smokers to quit, the opposite could then occur.
Use of Advertising Results in Erroneous and Distracting Messages
The CDC’s message has mixed and confusing promises. Advertising theory posits that to be effective, media should make promises that are supported with evidence. However, this has strange implications when the campaign ads are examined through the lens of Advertising Theory. In the Anthem Ad, we see people with tracheotomies discussing tips for living with this consequence of smoking. It would seem to imply (promise) that if you were to quit smoking you would get a hole in your throat. Furthermore in another ad, Cessation Tips, we see a former smoker who is now a runner, which seems to absurdly promise that if “you were to quit smoking you would be able to run in a marathon with a robot-leg”(21). Not only does the misuse of advertising fail, it can also, lead to reactance.
Ostensible Use of Social Media
“Tips” doesn’t just fumble in its use of traditional media, but also misuses social media as merely another outlet. Instead of using the intrinsic power of this media to affect behavior change on a large scale, the CDC’s campaign has only a nominal presence on Facebook and Twitter, and their advantage of being able to differentially target audiences based on users profiles is untapped.  Counter-intuitively, interested smokers have to seek-out and “friend” the campaign, when it should be the campaign that seeks out the smokers.
The choice of an individual level intervention for the CDC’s campaign, because of a dependence on rational decision making, is inefficient at changing behavior, leaves targeted smokers vulnerable to a boomerang effect, and does not take full advantage of the media. To address these deficiencies, a new group-level intervention is proposed that will be targeted current adult smokers and friends of those who are currently attempting to quit.
‘The X-Buddy’ Campaign: An Alternative Intervention

Intervention Summary
The new campaign is centered on the establishment of a social network of ex-smoker friends, called ‘X-buddy’, that uses social media to reach potential target smokers and help those attempting to quit remain smoke free. This new campaign seeks to change the smoking behavior of groups of smokers instead of individuals. The X-Buddy’s user interface will be composed of a campaign website, smart-phone applications, as well as Twitter and Facebook commercial marketing accounts. The intervention will utilize branding as part of larger marketing scheme that will include clothing and merchandise. The X-Buddy logo, an ‘X’ created from a matrix barcode, will allow targeted smokers to identify and connect with the X-Buddy campaign network. Those who join the campaign, known as “X-ers”, will be encouraged to announce to their friends on Twitter and Facebook (through a X-Buddy interface), their commitment to smoke free living.
Addressing deficits in CDC’s campaign (Overview)
The X-Buddy is a group-level intervention that changes smoking behavior, en mass, without having to change beliefs, attitudes or intents to quit smoking. This campaign therefore is not limited by rational decision-making, and is much less likely to cause a boomerang effect, cause dissonance, or psychological reactance. It addresses the social nature of smoking, prevents procrastination, and reduces the likelihood of recidivism through social cues. X-Buddy will drive a new media and cultural sensation due to its competent marketing through available print, video, and social media.
A Group Level Intervention: ‘The X-Buddy’
Smoking and quitting, as previously stated, occurs in networks. One of the difficulties of quitting is the loss of social identity that occurs when individuals cease smoking exclusive of their network of friends. If they stop smoking when everyone else in their group continues, they face the choice of isolation or conformity (a return to smoking). To address this, X-Buddy targets groups of smokers. Networking theory predicts that smoking cessation among groups is most effective when key members of the group chose to quit. To successfully convert smoking groups’ behavior, those individuals with a large number of connections will be selected by the X-Buddy (computer) algorithm.  The system would then target their key friends for conversion, that is to say the program will market to these friends the non-smoking behavior.
X-Buddy is derived from a group-level model of social behavior and does not assume rational decisions. Therefore, this new campaign does not waste money and effort by attempting to change knowledge through educating smokers, nor attempting to change attitudes and beliefs. The behavior of quitting in the new model is no longer tied to individuals’ decisions, but is spread similar to a “Diffusion of Innovations” (22). Instead, efforts are directed at branding X-Buddy, marketing in areas where smokers typically congregate (such as designated smoking areas), and using social media to reduce procrastination and recidivism.
To address the problem of procrastination, X-Buddy encourages “X-ers” (members) to proclaim a “X-Date” (or quit date) that is broadcast over social media channels. It is expected that a “spotlight effect” (23) will reduce their likelihood of not quitting by procrastination, and could also reduce recidivism (or cheating on their proclamation). Inherent in this tactic is that smokers who see their friends’ “X-date”, are given a social nudge to quit themselves due to a perceived social norm of quitting. Social expectations must not be so overwhelming as to threaten smokers’ perception of freedom and foster a rebound of smoking.
Preventing a Boomerang Effect
The X-Buddy Logo – The Use of Branding
The paradoxical Boomeranging of behavior following an interventional campaign is less likely with X-Buddy due to its use of group-level models. The independence from rational decision-making is a buffer to the effect but may not render smokers immune. To protect the campaign from this potentially damaging effect, X-Buddy utilizes branding and a “labeling effect” to help members identity with being non-smokers. Accomplishing this goal requires seeking-out target smokers, wherever they are.
X-Buddy will use branding to assist targeted smokers in identifying with the campaign to reduce potential cognitive dissonance and psychological reactance.
The “X-logo”, part of the X-Buddy branding, is to be imbedded into the structure of a matrix barcode (also known as a QR code) and will create a graphical representation of an “X”. These modern barcodes are a well-featured component of many current successful marketing campaigns, and are effective because of their ability to link a target customer, not only to websites, but also other ancillary marketing (24).
The cessation message will reach smokers through the use of the X-logo, placed conspicuously and visible to current smoking groups. This includes designated smoking areas as well as random public areas where people usually gather to smoke: outside hospitals, universities, hotels, and restaurants.  The campaign goal is to target huge networks of smokers, so the type and physical characteristics of where marketing is placed will be just as diverse – from stucco walls to the side of dumpsters.  Thankfully, newer QR codes can be scanned from irregular or non-uniform backgrounds with a cell phone camera (25,26).
X-Buddy uses the QR codes to extract cell phone users name, phone number, and email address to personalize the marketing of “not smoking”. When a potential target captures the X-Buddy logo using a QR code app on their cell phone, they are taken to the campaign website where they are greeted, by name, along with the name of any of their Facebook or Tweeter friends who are already an X-er. They are then asked to join their friends and become one of majority –  “one of US”.  If they choose to join as an X-er, their preferences and information will be stored at a data-center (called the X-center), and they will be sent a schedule of encouraging texts to their cell phones, instant messenger, or social media accounts.
The X-Center
To compliment the marketing of X-buddy, the automated data-center will both, search out (new) potential targets — in addition to those responding to QR codes – to join the campaign through social media marketing, while also re-enforcing cessation for those who have already joined the network.  The X-center will have cross-platform capabilities across AIM, Yahoo-Chat, MSN Messenger, Facebook, and Tweeter. Messages will be sent out across the network to (X-er) friends, and will act as social nudges. These social nudges will consist of either short affirmative supporting text messages or simple graphics. Texts (to cell phones or social media accounts) will use statements such as “You are not a smoker” or “You do not smoke” for those who have quit; for target smokers who have not joined (and may not have quit) the messages might read, “You do not need to smoke” or “You were not born a smoker”.
Locating potential X-ers is done through the use of a computer algorithm, which will scan social media sites for users’ posts (and “Tweets”) for keywords indicating they might be open to behavioral conversion. For example, a woman tweeting the news of her recent pregnancy might see an ad when she logs in to her Tweeter account that shows mothers cradling their infants and the X-logo.
Several influences might affect a cessation in smoking and prevent boomeranging. X-Buddy messages, serve to “label” the X-er (and even potential X-ers who are viewing the ads) as a non-smoker. Labels are known to have a sustaining effect, and could reduce both recidivism and reactance to the campaign by increasing ownership in the effort. Also, the campaign’s labeling efforts might give them self-esteem thereby helping to affect behavioral change. According to Maslow, people seek to meet lower-level needs before attempting to meet higher-level ones (27). Smokers can, if lower-level needs of self-esteem are met with assistance from X-Buddy, address higher level needs such as long-term health by concentrating efforts on smoking cessation. A “Spotlight Effect” (28) may also further reduce procrastination and recidivism by drawing social attention to their efforts to quit or their lack of progress.
Market Testing
The best means of reducing a boomerang effect is to survey a test audience to determine if the X-campaign is at risk, and to identify potential sources of a paradoxical backlash. Initially, focus groups will be solicited to determine their psychographic profile. The survey results of a questionnaire would then reflect the lifestyle of the target smoker to whom X-Buddy wishes to market, and the campaign can be tailored to the findings. For instance, older psychographic profiles collected by tobacco companies showed smokers to be middle-class conservatives. If X-Buddy focus groups showed similar results, a set of core-values around security and family might be utilized. The goal of packaging the campaign to the target smokers’ values and beliefs should therefore reduce both cognitive dissonance, if at all present, along with psychological reactance. To test for the potential of cognitive dissonance and reactance, test-audiences will be surveyed three times: prior to viewing the new campaign; immediately afterwards, and six months after the viewing. For example, participants might be assessed for reactance by being asked to judge their agreement to the following on a Likert scale: “the ad made me feel pressured”; “I feel threatened”; “I feel angry”, and ”The ad made me feel free to make my own choices”.  To test for cognitive dissonance, some of the questions on the survey would attempt to test for possible rationalizations on the part of the participant. Such questions might read, “I’m not like the people in the ad”; “this doesn’t apply to me”, “I don’t care about my smoking”, or “I have control over my actions”(29).
The Media At Its Finest
So that advertising and marketing of X-Buddy can be massively effective, the campaign must utilize the media to its fullest capabilities. As we have already seen, the new campaign leverages social media and its intrinsic networking capabilities to increase market influence through existing personal connections as well as seeking new links. This type of wildly successful marketing, of a group-level behavior, is often referred to as “going viral”. The X-Buddy campaign will achievement its goal by: purchasing, on per click basis, ad space on Facebook and Twitter; placing videos on YouTube; posting ads in Photobucket; and creating an app for X-ers.  The X-Buddy App helps foster spontaneous urban gatherings and will demonstrate members’ commitment to a smoke free life.
The marketing, which will have begun for so many X-ers as a bar-coded logo, will also appear on t-shirts, hats, other clothing and merchandise for sale. The media and the marketing will foster each other by driving targeted smokers to the other. When people identify the X-logo, they will purchase goods from the campaign, and when those items are displayed in public (e.g. worn as a shirt) it will help people identify the brand when placed in smoking areas, thus increasing the effectiveness of that aspect of the campaign as well.
Social media is more than just another means to channel communications. This was an area of major misuse by the CDC in the “Tips” campaign. Instead, X-Buddy uses outlets such as Facebook to identify and utilize key individuals in social groups who will drive group-level behavior change because of the large number of social connections they possess.
Smart phones, ubiquitous in the American culture, open new avenues for social behavior change. One important consequence is the viral video, which has become commonplace with the spread of smart phones. Their increased daily use, and the cameras they carry, allows anyone and everyone to become a reporter on unprompted events as they occur. To encourage the behavior of not smoking, spontaneous gatherings of X-ers through a Google-like map interface on the X-Buddy App will be facilitated. These groupings, to be called “Xits”, will be filmed and posted online. The goal is for these Xits to “go viral”, however they serve a more immediate purpose. For Xers struggling with addiction, and their urge to smoke, they can look on a smart phone and see if there are any Xers in their area. If so, they can shoot a quick message to that person to see if they want to take an alternative to a “smoke break”. Such a message could read, “Wanna Xit together”? For a smoker who is crippled with the physical and psychological addiction to tobacco, this other X-er might be a social “life-saver” to help guide them through a momentary weakness.
The Framing of X-Buddy
The images used to frame the X-Buddy advertising will convey a warm emotional tone that supports the campaign’s promises. The core position is that by not smoking, you will be liberated to have fun with your friends and family. The entire frame of the campaign is designed around the values of friends, family, freedom, and the associations of “good times”. Targeted smokers are promised, that if you quit smoking, you will live an enjoyable life with the person they always wanted to meet. This will be supported by images of:  friends smiling and talking, apparently “hanging out”; buddies playing sports; a group of girls shopping in the mall, and guys walking down the beach and flirting with a group of attractive women. All marketing will use warm colors to promote emotional trust. Experiments with physical warmth have been shown to elicit interpersonal warmth and trust, and that research has also been extended to warm colors (30,31).
The marketing of X-Buddy is a huge leap from the framing of “health” that is used by the CDC in the “Tips” Campaign. Employed is a broad use of media that includes full use of social media to specifically target current networks of smokers and their key members by marketing based on their specific wants and needs as determined by a focus groups.
X-Buddy is to be marketed as a social phenomenon, and in doing so liberates the campaign from the limits of an individual-level campaign. Without having to rely on convincing individual smokers, through rational decision making, as to the benefits of smoking cessation, this new campaign can efficiently reach a larger number of smokers with almost none of backlashing or boomeranging that is possible under the CDC’s current campaign. Moreover the social networking of ex-smokers increases ownership in the antismoking effort and fosters a supportive environment that reduces the changes of behavioral backsliding and regression by returning to the old smoking habits. For these reasons, the current “Tips from Former Smokers” campaign should be replaced by the newer X-Buddy campaign.
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