Research article
Tobacco Denormalization and Industry Beliefs Among Smokers from Four Countries

https://doi.org/10.1016/j.amepre.2006.04.004Get rights and content

Background

Tobacco denormalization is an important concept for understanding smoking behavior. The present study sought to assess beliefs about the tobacco industry and the social acceptability of smoking among nationally representative samples of adult smokers from four countries, and to assess the relationship of these measures to cessation behavior and tobacco-control policy.

Design

A longitudinal survey of 9058 adult smokers from Canada (n =2214), the United States (n =2138), the United Kingdom (n =2401), and Australia (n =2305), was conducted in October–December 2002 and again in June and August 2003 (75% follow-up rate). The analyses were conducted in 2005.

Results

The findings indicate that few smokers perceive approval for their smoking, and most hold relatively antagonistic beliefs toward the tobacco industry. For example, 80% of smokers reported that society disapproves of smoking, and more than three quarters reported that tobacco companies cannot be trusted to tell the truth. Social and industry denormalization were independently associated with intentions to quit smoking. Baseline levels of social denormalization were associated with abstinence at the 8-month follow-up, as were changes in industry denormalization beliefs between baseline and follow-up. Anti-industry beliefs at baseline did not predict abstinence at follow-up. A similar pattern of findings was observed across all four countries. In addition, social denormalization and anti-industry beliefs were significantly associated with tobacco-control policies, such as noticing health warnings on packages and greater workplace smoking restrictions.

Conclusions

Tobacco denormalization constructs were independently linked to cessation-related outcomes among adults from four countries. Tobacco-industry denormalization themes in mass media campaigns may help to reduce tobacco use above and beyond more traditional communications that target social norms.

Introduction

Tobacco use, as with many health behaviors, is strongly influenced by social norms and one’s perception of acceptable behavior. Among youth, for example, peer influences and school smoking prevalence are important determinants of smoking initiation.1, 2, 3 Tobacco industry documents also highlight the importance of social acceptability in the progression toward regular smoking, as well as the maintenance of smoking behavior among established smokers.4, 5, 6 Indeed, a socially acceptable image of smoking is one of the central themes of tobacco industry marketing, particularly in advertisements aimed at young people.7

The public health community has used various media and educational strategies to counter these efforts and to reduce the acceptability of smoking. Traditional social denormalization strategies seek “to change the broad social norms around using tobacco—to push tobacco use out of the charmed circle of normal, desirable practice to being an abnormal practice.”8 Thus, social denormalization initiatives commonly target key beliefs about tobacco use, such as challenging the belief that smoking is a “cool” desirable behavior, and correcting the tendency among youth to over-estimate the prevalence of smoking.9

More recently, a newer generation of tobacco denormalization initiatives has focused specifically on the tobacco industry and its conduct.10, 11 Tobacco industry denormalization seeks “to raise people’s awareness of the responsibility of the tobacco industry for tobacco-related disease, and to expose the industry’s manipulative tactics.”12 In many cases, industry denormalization messages use specific quotes or images drawn from the industry in an effort to resonate with youths’ concerns about being manipulated or exploited.13, 14

Industry denormalization gained widespread prominence following the success of the truth media campaigns in the United States, as well as a state-run campaign in California.15, 16 These campaigns gained notoriety for their engaging and, at times, confrontational nature, but also for their effectiveness. Indeed, there is growing evidence that industry denormalization campaigns can change psychosocial predictors of tobacco use, including intentions to smoke among youth, as well as behavior outcomes such as smoking cessation.17, 18, 19, 20, 21, 22

Although tobacco denormalization is increasingly being recognized as a key component of comprehensive tobacco control programs, many jurisdictions are reluctant to engage in overt industry denormalization due to a lack of political will and fear of industry litigation.23, 24, 25 The question facing many policymakers is whether social forms of denormalization are adequate, or whether campaigns would benefit from incorporating industry themes in their communications. One challenge in answering this question is that industry denormalization is a relatively new construct.26, 27 In addition, we are unaware of any published research that has examined social and industry denormalization concurrently in order to tease out their independent influences on smoking behavior.

Beyond media campaigns that specifically target the tobacco industry or the social acceptability of smoking, other tobacco-control policies may also have a strong influence on tobacco denormalization. For example, environmental tobacco smoke (ETS) laws may marginalize smoking by removing it from indoor public areas and by reinforcing an image of smoking as dangerous to others, as well as to oneself. Pictorial cigarette warning labels may erode brand imagery that is especially appealing to younger smokers, and replace these images with pictures of undesirable health effects.28 Although these policies are not intended as denormalization policies per se, they may play an important role in shaping the acceptability of smoking, as well as people’s attitudes toward the tobacco industry and its products.29

Another unknown is the extent to which denormalization beliefs are related to smoking behavior among adults. To date, most of the denormalization research has focused on beliefs among youth. Denormalization beliefs among adults may be important for two reasons: first, denormalization may increase motivation to quit smoking and to remain quit; and second, denormalization may promote support for more-comprehensive tobacco control policies and regulatory restrictions.

The current study sought to (1) characterize social and industry denormalization beliefs among representative samples of adult smokers from four countries—Canada, the United States, Australia, and the United Kingdom; (2) examine whether demographic variables, smoking behavior, and policy-related variables are associated with denormalization; and (3) determine whether social and industry denormalization have independent associations to smoking behavior.

Section snippets

Methods

The International Tobacco Control (ITC) Four-Country Survey is a cohort survey conducted annually with adult smokers from Canada, the United States, the United Kingdom, and Australia. The ITC Four-Country Survey is designed to evaluate the impact of key nation-level tobacco control policies on behavioral and psychosocial predictors of tobacco use, including tobacco denormalization.

Sample Characteristics

Table 1 provides the sample characteristics for each country.

Denormalization Domains

Table 2 lists each of the items used to assess denormalization beliefs, along with the distribution of responses in each of the ITC countries. Overall, few smokers reported social approval for their smoking. Smokers also reported relatively strong anti-industry beliefs, particularly regarding the extent to which tobacco companies can be trusted to tell the truth. The social and industry scales were moderately correlated with each

Discussion and Conclusions

The current study suggests that smokers in Canada, the United States, the United Kingdom, and Australia perceive little approval for their smoking and hold relatively antagonistic beliefs toward the tobacco industry. For example, 80% of smokers agreed that society disapproves of smoking, and more than three quarters did not feel that tobacco companies can be trusted to tell the truth. This is consistent with findings published elsewhere, that virtually all adult smokers regret ever having

References (45)

  • A model for changethe California experience in tobacco control

    (1998)
  • A historical review of efforts to reduce smoking in the United States

  • A. Blum

    Medicine vs. Madison Avenue. Fighting smoke with smoke

    JAMA

    (1980)
  • A model for changethe California experience in tobacco control

    (1998)
  • D. Evans et al.

    Branding behaviorthe strategy behind the truth campaign

    Social Marketing Q

    (2002)
  • J.C. Hersey et al.

    The theory of “truth”how counter-industry campaigns affect smoking behavior among teens

    Health Psychol

    (2005)
  • D.G. Bal et al.

    Reducing tobacco consumption in California. Development of a statewide anti-tobacco use campaign

    JAMA

    (1990)
  • L. Dorfman et al.

    Advertising healththe case for counter-ads

    Public Health Rep

    (1993)
  • M. Wakefield et al.

    Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA

    Tob Control

    (2000)
  • L.K. Goldman et al.

    Evaluation of antismoking advertising campaigns

    JAMA

    (1998)
  • M. Siegel et al.

    The impact of an antismoking media campaign on progression to established smokingresults of a longitudinal youth study

    Am J Public Health

    (2000)
  • D.F. Sly et al.

    The Florida “truth” anti-tobacco media evaluationdesign, first year results, and implications for planning future state media evaluations

    Tob Control

    (2001)
  • Cited by (202)

    • Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

      2022, Preventive Medicine
      Citation Excerpt :

      To address these issues, warning labels have emerged as a strategy to provide factual and salient point-of-purchase information to inform consumers (Taillie et al., 2020a). Warning labels may also improve health behaviors by shifting attitudes, beliefs, intentions and social norms (Grummon and Hall, 2020; Hammond et al., 2006) and by encouraging product reformulation (Bleich et al., 2017; Roberto et al., 2021). Consequently, in 2016 and 2018, to address the similar issue of sodium in restaurants—New York City (NYC) and Philadelphia passed laws requiring chain restaurants to place warning labels next to items containing more sodium than the recommended daily limit (Philadelphia. Co. Bill No. 180001-A, 2021; New York City Department of Health and Mental Hygiene, 2022).

    View all citing articles on Scopus

    The full text of this article is available via AJPM Online at www.ajpm-online.net.

    View full text