The Ick Factor

Imagine that you wanted to lose weight, but you love ice cream. What if every time you reached for that carton of Ben & Jerry's, you had to look at a photo of a morbidly obese man dying from a heart attack? Would that make you less likely to indulge?

That's the theory behind the new warning labels on cigarettes that the Food and Drug Administration unveiled this week, devised in part as a result of the increased authority over smoking the FDA was granted by the Family Smoking Prevention and Tobacco Control Act, a law passed in the first months of Barack Obama's presidency. The labels, which will go on cigarette packs starting in 2012, contain large pictures (taking up 50 percent of the space on both the front and back of the pack) showing things like rotting teeth and lips, a horrifyingly diseased lung next to a healthy one, and a man smoking out of a hole in his throat. (There is one positive image among the 10 the FDA will be using: a man with a T-shirt reading "I quit" with the words "Quitting smoking now greatly reduces serious risks to your health" beside the image.) All the labels include a phone number (1-800-QUIT-NOW) where one can presumably get help quitting.

The FDA is following the lead of many other countries that have employed "push/pull" strategies in which they emblazon packs with shocking images but also try to tell smokers that quitting is within their power. If you bought a pack of smokes lately in Canada or the UK, you've already seen something like it.

Cigarettes got their first warning labels in 1965 ("Cigarette smoking may be hazardous to your health"), in the wake of a report from the Surgeon General synopsizing thousands of studies linking smoking and cancer. As hard as the tobacco companies fought against the labels, they were simple text and appeared on a small portion of a cigarette pack. The warnings changed slightly over the years to become more emphatic, but all the while public-health officials and the tobacco companies have been at war over what messages people ought to get about smoking. Cigarettes were advertised extensively on television until a 1967 ruling by the Federal Communication Commission (FCC) that the Fairness Doctrine, which required that anyone with a broadcast license present controversial issues in a balanced way, demanded one anti-smoking public service announcement for every three cigarette ads. The tobacco companies quickly decided that the accompanying PSAs were doing more harm to their product than their own advertising was doing good, and voluntarily pulled their ads. Though the Fairness Doctrine has since disappeared, the manufacturers never went back to television, no doubt assuming that doing so would invite more regulation than they'd like.

They didn't stop advertising elsewhere, of course (and you'll be seeing the FDA's new labels on cigarette ads in print as well as on the packs themselves). Public-health officials tried to counter with public service announcements warning people about the dangers of smoking. But it turned out that much of what the anti-smoking forces tried in those early years was ineffectual at best, and at worst even led to more smoking, particularly among the children and adolescents who are often the target of anti-smoking campaigns (around 9 out of 10 smokers start during adolescence). Those just-say-no-style messages failed because they didn't take into account the particular psychology of the American teenager. But eventually, officials realized they could harness the teenage impulse toward rebellion instead of fighting it, devising advertising defining the tobacco companies as a force trying to manipulate and control them and take away their independence. The result was efforts like the "Truth" campaign, which portrayed teens as courageous rebels standing up to the tobacco companies, but barely mentioned the health effects of smoking.

Those ads were financed by the master settlement reached in 1998 between tobacco companies and the states that had sued them to recover billions of dollars in medical costs attributable to smoking. In exchange for the end of the lawsuits, the companies agreed to pay $206 billion to the states, stop some kinds of marketing aimed at children ("Joe Camel" being the most well-known example), and provide $1.45 billion to establish the American Legacy Foundation, which funded the "Truth" campaign.

But that doesn't mean the companies have stopped trying to get people to smoke, and anti-smoking forces have been trying just as hard to get people to stop. So does this kind of in-your-face anti-smoking message work? The available evidence (see here, for example), suggests that it does increase the degree to which people associate cigarettes with health risks and harbors the intention to quit. These kinds of graphic images are meant to grab your attention and stay in your memory. If they do, that can have both individual and social effects. Ideally, you'd be convinced not only that if you smoke you'll be a disgusting, smelly, cancer-ridden excuse for a human being, but also that anyone you know who smokes will be the same, and therefore not someone you'd want to hang out with.

We've come a long way from the days when Edward R. Murrow used to deliver the news on television while smoking a cigarette (just try to imagine how bizarre it would be today to see Brian Williams or Diane Sawyer sucking on a Camel while telling you about the latest negotiations over the debt ceiling). It's true that no other consumer product gets this kind of treatment, but on the other hand, no other consumer product is as addictive and kills 440,000 Americans every year. As the health insurance provider for millions of Americans on Medicare, Medicaid, and veterans' health benefits, the government has a direct interest in holding down medical costs. So while they aren't going to ban smoking, the government will do what it can to make it as unpleasant as possible.

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