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CONSUMER BELIEFS AND BEHAVIOR WITH RESPECT TO CIGARETTE SMOKING: A CRI'PICAL ANALYSIS OF THE PUBLIC LITERATURE Martin Fishbein, Ph.D. University of Illinois at Champaign-Urbana A Report Prepared for the Staff of the Federal Trade Commission 'May 1977 'TIld/IN 0240072

Overview The Federal Trade Commission has several responsibilities with respect to the advertising and promotion of cigarettes. It is directed to prevent deceptive and unfair acts and practices; it has general authority to gather information and make reports; it has the specific obligation to report to Congress annually on current cigarette advertising and promotion; and it is empowered to make legislative recommendations. These various responsibilities all require consideration of consumer beliefs and behavior=; with respect to smoking. This report is in response to a Commission staff request for a critical and analytic examination of the social psychological literature bearing on these subjects. Although well over 10,000 references have been cons idered, this report is not a literature review. Rather, it attempts to provide a critical analysis and synthesis of what the literature presently reveals about the role of infor- mation and beliefs in decisions to smoke or not to smoke. More specifically, this report is directed at two funda- mental questions: First, it attempts to determine whether, at the present time, the American public's decision to smoke (or not to smoke) cigarettes is an informed one. Second, it attempts to determine whether there is anything more that could be done to insure that decisions to smoke are informed decisions. The report provides a method for analyzing the decision to smoke and actions to influence it, whether by government, public education groups, or cigarette advertisers. It also defines areas ::,here further research is needed, and it draws some conclusions based upon the presently available literature. It is hoped th;%t the, report will be useful to all interested* parties whe,thef:`i gQal__-of action is to insure the- sufficieney of"consumer beliefs or to-influence attitucies,, int,entions, arad behavior with respect to smoking.* Generally speaking, the main findings of this report can be summarized as follows: 1. Provic-.ing a person with a given piece of information may inform the person in at least three different ways: (1) he may Yaeco~e ~~~t.~ that the information exists; (2) he may accept the naformation .i.~ ~enera~.a and (3) he may aq ,ept-,-the ~.n'formation at a~a~sonanzed lev*1* These three ways of being informed corre ,pond to three levels of belief which can be illu- s trated as fol l.ows : Level 1(:`.wareness): A person may believe that "The Surgeon General has determined that cigarette smoking is dangerous to health." i 4 TIMN 0240073

Level 2(GeileLal acceptance): A person may believe that "Cigarette smoking is dangerous to health." Level 3(Pe-..sonalized acceptance): A person may believe that "My cigarette smoking is danger- ous to my health." Needless to say, a person may be informed on one Level but not on another. 2. At the present time, we know relatively little about the American pubLic's Level 1 or Level 3 beliefs about smoking (or not smoking). With respect to Level 2 however, there is suf f ic ient ev ide nce to conclude that the Amer ican publ ic is not well informed at the present time. For example, approximately 25% of the total population and almost 50% of all current smokers have still not fully accepted (at Level 2) the general, undifferentiated proposition that "Smoking cigarettes is dangerous to health." Further, although current data are not available, there is little question that there is even less general acceptance (Level 2) of propositions linking smoking to specific health consequences such as heart disease, emphysema, chronic bronchitus, and lowered birth weights. Since all available evidence suggests that personalized acceptance lags well behind general acceptance, the above data suggest that the American public is even less well informed at Level 3. Th^re is also evidence (although it is not current) that people may be misinformed about the position of various referents with repect to smoking. Finally, it should be noted that most Ameriuans overestimate the number-of current smokers in the U. S. popt°lation. 3. In addition to beliefs about the health hazards of smoking, there ure many other beliefs that are material to smok- ing decisions. Although the literature has pointed out that there are a mul~:itude of factors that may be related to a given smoking decisiof., there is no general consensus concerning what these factors ai'e, or how they contribute to a smoking decision. The widely held view is that different factors underlie different smoking decisions (e.g., to initiate, continue, or stop smoking) acid further, that different people may reach the same smoking de,:ision for different reasons. Thus, despite the enormous amount of research on smoking, no systematic theory of smoking behavior has been developed and there is general agreement that no single explanation of smoking behavior is possible. ii TIMN 024®®74.

4. In mar;:ed contrast to this view, we have described an empirically =supported social-psychological theory of the relationships ainong beliefs, attitudes, intentions, and behavior that is both coasistent with, and capable of explaining, all of the diverse :indings in the smoking literature. Perhaps most important, this theory allows one to identify the determi- nants of any-gi-ien smoking decision. More specifically, the theory po ints out that : A. AZy given smoking decision is ultimately determined by the information the person has concerning each of the behavioral alternatives amDng which he or she must choose. More specifi- cally, it is baaed on (a) the information (or Level 3 beliefs) one holds concerning the positive or negative consequences that will follow from one's own performance of each of the available alternatives (e.g., trying a cigarette and not trying a cigarette; continuing to snoke and stopping smoking) and/or (b) the beliefs one holds about the iv ews of various individuals, groups, or institutions concerning one's performance of each alternative. B. These two types of beliefs represent two major factors underlying any given decision: (a) a personal or attitu- dinal factor and (b) a social or normative factor. The relative importance of these two factors as determinants of any decision varies (i) as ;n function of the particular decision one is con- fronting (e.g., normative factors may be most important in the initiation of =_,moking while attitudinal factors may be most important in its maintenance or cessation) and (ii) across different individuals (e.g., attitudinal factors may be more important in ti.e decisions of adults while normative factors may be more important in the decisions of teenagers). 5. The al>il•ity to identify the determinants of any given smoking decision has many different implications, including the' following: ' A. Awareness and general acceptance of information linking smokinq to various health hazards and/or not smoki" to various heai.th benefits may be a necessary but not sufficient condition for making an informed decision. B. En order to make a fully informed decision a person should have (a) a complete and accurate set of Level 3 beliefs about the outcames (both positive and negative, health related and nonhealth•related) that will follow from his or her perfor- mance of each alternative from among which he or she must choose, and (b) a complete and accurate set of beliefs about the normative prescriptions of relevant referents, i'.e., beliefs that these referents think one should (or should not) perform each available alternative. TIMN 0240075

C. At any Level of belief, a person may be informed with respect to one smoking (or nonsmoking) alternative but not with respect to another. For example, although a person may be informed .about the health hazards associated with continu- ing to smoke,,he may not be informed about the dangers of trying a cigarette or o: starting to smoke. Similarly, although a person may be inEorx?ed about the advantages and disadvantages of continuing to smoke, he may not be informed about the advan- tages and disadvantages of continuing not to smoke or of stop- ping smoking. 6. Given the fact that the American public is presently uninformed (by almost any def inition of informed ), there is unquestionably a great deal more that can be done to insure that the public will make more informed smoking decisions. The smok- ing literature, however, provides little insight into this pro- bleai. Indeed, the general consensus seems to be that because of "the diversity of needs which impel different persons to smoke ... no general rule concerning efforts to persuade people not to smoke, oL to give up smoking, will be valid or effective ..., no singic approach will be satisfactory for more than a minority of iiAividuals ..." (see Larson and Silvette, 1968, p. 304). 7. In marked contrast to this position, the available ev idence ind icaces that it, is- poss ible to inf Iucnce smok in4 .:. decisiana_- by., pr~zviding-- tY~e public.h wifi.h inforination .a ~or example, despite the oftz~n expressed position of the tobacco industry that cigarette advertising does not influence the decision to smoke but only `_he brand choice of current smokers, the $va.ilablt . _.~, ,x evidg~~e,~suppor Gs the conclusion- that ca.garette~ advertisin~ does increase- o-Jera1.1 consumpt-fon:1 ~ Perhaps more important, there is consider4b:i<.e- _~.v_idenc:e.--thstf%- ppviding :-the- :A ner 4.c4 n 8Dut#l ic -with antismok inc_i.a~ox_ma_tion- sig~n~o` ficantlYdecreased consumPtiori and Pro Y duce3 large scale changes in other- aspect3 of smokingg behavior .iThis is not meant to imply that most educational programs or informational campaigns have been successful; indeed, the majority of such programs have ended in apparent failure. However, there are enough reported successes in the literature to warrant the conclusion that it is possible to both inform the public and to influence their smoking decisions. 8. There is little basis for assuming that a message failed to be persuasive because it `was avoided by people with contrary positions or b_-!cause it was fear arousing. A. Despite the long lasting assumption that people avoid or fail ~:od attend to information with which they disagree, there is no evi.dence to support this assumption. In fact, it b iv TIMN 0240076

appears that one s own beliefs and attitudes have little oc no influence on one's ability to Lecognize or recall information presented by an outside source. B. De=ipite the long lasting argument that cer tain types of appeals (e.g., fear appeals, rational appeals, one- sided appeals,' e:c.) are more (or less) effective than other types, there is zo evidence to substantiate this argument. In fact, it is not the type of appeal, but the content of the appeal that dete.mines its effectiveness. 9. Communi,:ation failures are primarily due to (a) the selection of ina;?propriate arguments and/or (b) a failure to select a suffici.Bnt number of appropriate arguments. For example, it must be recalled that beliefs about the negative conseq u=:nces of one's own smoking coexist with beliefs about the benefits of one's smoking as well as beliefs about the advantages azd disadvantages of one's not smoking (or quit- ting). Needless to say, providing information that may produce changes in one o: two of these beliefs may not be sufficient for either reinfarcing or changing a smoking decision. Further, if a person's smoking (or nonsmoking) behavior is primarily under normative control, changing beliefs about the consequences of one's own engaging in various smoking alternatives may have little or no influence on a person's smoking decision. Similarly, if a person's smoking decision is primarily under attitudinal control, providing him with information about the positions of various referents with respect to his performance of one or more alternatives may have little or nD influence in that decision. Considerations such as these can account, at least in part, for the reported failures of some antismoking educational compaigns. 10'. It should be possible to influence a person's smoking decision by providing information about the advantages or dis- advantages of performing various smoking and nonsmoking alter- natives and/or information about the views of relevant referents with respect to the performance of those alternatives. The exact content of the information, however, should be determined by (a) the beliefs, attitudes, and intentions already held by the public with respect to different smoking and nonsmoking alternatives; and (b) by the degree to which the decision one wishes to affect- is under attitudinal or normative control. v TIMN 0240077

At the pres:_~nt time however, we do not have enough infor- mation about eiti~er (a) or (b) above to a~d us in developing communications that would contain the most appropriate argu- ments for_ affpct-_ng a given smoking decision.-.- Thus, although there is much thtt could be done immediately to inform the public, much mor=~ research is necessary if one wishes to max- imize the likelihood that this information will also influence a smoking decision. vi TIMN 0240078

Table of Contents Overview Introduction Section I: To What Extent Is the Decision to Smoke or Not to S,toke an Informed Decision? Page i 1 3 Qi: To what ex:ent has the population of the United States 4 accepted the general, undifferentiated proposition that smoking is dangerous? Q1a: To what ex:ent does the population of the U.S. appre- 5 ciate the gravity and import of the general proposition that smokizg is dangerous? A. When does cigarette smoking become dangerous? 8 B. Are some cigarettes less hazardous (or safer) than 9 others? Q2: Are there beliefs other than the one, general belief 11 that "smoking is dangerous" that are material to the smoking decision? A. The relations among beliefs, attitudes, intentions, 12 and behavior. B. A review of the smoking literature: A brief, but 18 critical analysis. 1. Smoki.ng decisions and the intention-behavior 19 rela;:ionship. C. Beliefs and attitudes as determinants of smoking 22 intent ioris . Q2A: Given tha;: there are many potentially material 24 beliefs, ;:o what extent is the American public well informed .3t the present time? A. Beliefs .3bout specific health 'consequences of smoking and not smoking. 25 B. Beliefs about the normative prescriptions of relevant 28 others. C. Beliefs about smokers and nonsmokers. vii 29 TIMN 0240079

n. Beliefs about the percent of smokers in various segments of the U.S. population. 32 E. Beliefs about the number of cigarettes one can smoke 32 "before it becomes a habit." Summary 33 Section II: Is There Anything That Can Be Done That Would 33 Affect the Decision to Smoke or Not to Smoke? A. Factors influencing the smoking decision: A recon- 34 sideration. Qi: Does cigarette advertising affect the decision to 37 smoke? A. Cigarette advertising as a cue for smoking behavior. 40 Q2: Can anti-,moking information affect the decision not 42 to smoke:' Q2a: To what -,xtent is there evidence of selective attention 42 and percz!ption regarding information about the effects or smoking? Q2b: Are some types of appeals (e.g., fear appeals) more 48 (or lessj likely to be accepted by the general public? A. Assessing the effects of persuasive communications - 52 a brief analysis. 1. Acc-~ptance, yielding, and impact effects. 53 Q2c: To what extent have various public education programs 56 and smoking clinics been successful? A. Changes in U.S. smoking behavior. 56 1. Regional versus national samples. 59 2. Longitudinal analyses--inconsistencies between 60 cohorts. 3. Amcunt of smoking. 61 4. Per capita consumption. 63 5. Ini,erpretation and conclusions about changes 65 in U.,S. smoking behavior. viii TIMN 0240080

B. Antismoki,ng educational campaigns - a critical analysis. 69 C. Smoking ,:linics and therapy programs. 88 Summary , Conclu-cions, and Recommendations for Research C) 0 A. What is the current state of knowledge of the 90 Amer ican publ ic? B. Can anyi_hing more be done to insure that decisions 91 to smoko or not to smoke are informed ones? C. What ar_a the factors that influence a person's 92 decision to smoke or not to smoke? 1. An alternative view. 93 2. Recommendations for research - I. 96 D. What can be done to inform the public and affect 97 their decisions to smoke or not to smoke? 1. Possible effects of information on a decision 98 to s.noke. 2. Reconmendations for research - II. 101 E. Concluding comment. 102 References 103 ix TIMN 0240081