Research articleTobacco Denormalization and Industry Beliefs Among Smokers from Four Countries
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
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