Smoking, Risk, Perception and Policy

Reviewer: Diana P. Hackbarth, RN, PhD

Disclosures

February 12, 2002

Smoking, Risk, Perception and Policy

Paul Slovic, Editor
Sage Publications
Copyright 2001
378 pages/$69.95 hardcover (ISBN: 0-761-923-802)
378 pages/$22.95 paperback (ISBN: 0-761-923-810)

Cigarettes are the only consumer product that, when used as directed, eventually kills one third of the users. Yet about 25% of adults continue to smoke and 3000 teenagers begin smoking every day. Are people uninformed about the risks of smoking, or is something else going on?

Smoking: Risk, Perception, and Policy explores the psychology of risk perception as well as many of the controversial policy issues surrounding tobacco use in the United States. The book is clearly written, well documented, and provocative. It incorporates theory from the fields of psychology, economics, advertising, and communication to challenge some popular beliefs about the nature of addiction, the market for tobacco products, and consumer behaviors.

The editor, Paul Slovic, is an expert in the theory and measurement of risk perception. Together with a group of contributing authors, Slovic explores the limitations of the classic economic model as it applies to young people's and adults' decisions to initiate, continue, or attempt to quit smoking. The book carefully examines existing data and presents new survey research findings to systematically refute the notion that young people accurately perceive the risks of smoking or the power of nicotine addiction when they begin experimenting with tobacco. Throughout the book, evidence is presented to challenge the arguments of the tobacco industry that smokers are fully informed of tobacco's risks, choose to smoke in a rational decision-making process, and are thus personally responsible for any ill effects of smoking that they may incur.

After summarizing the well-documented health risks of active and passive smoking familiar to most healthcare providers, the book describes the methodology and findings from the Annenberg Tobacco Surveys, 2 large telephone surveys of young people aged 14-22 carried out in 1999-2000. The goal of the surveys was to explore attitudes, beliefs, feelings, and perceptions of risk that young people and adults associate with smoking. Researchers, program evaluators, and those who work in youth prevention programs will be especially interested in the survey questions outlined in Appendixes A and B. Appendix C briefly describes causal models based on analysis of the data generated from the surveys.

The heart of the book is the analysis of data obtained from the surveys. Findings reveal that although most young people recognize some health risks of smoking, such as lung cancer, other risks are unrecognized or underestimated. More important, heightened risk perception does not deter young people from starting or continuing to smoke. In addition, young people underestimate the addictive nature of tobacco and their own risk of becoming addicted. In fact, young smokers optimistically believe that they will not smoke for very long and that they can quit smoking at any time. However, evidence of nicotine dependence has been documented in 12- to 13-year-olds after only a few days or weeks of light smoking.

Slovic proposes that affective feelings play an important role in risk perception. He argues that smokers' decisions are based on intuitive affect-based thinking. Among survey respondents, positive images and positive feelings toward cigarettes were associated with both lower risk perceptions as well as increased belief in the ease of quitting. When individuals decide to smoke, they rely on their feelings rather than on an analytical reasoning model. These findings are important for the design of school-based and media smoking prevention programs. Many messages in current prevention programs focus on short- and long-term negative consequences, including health effects. These messages assume a rational-reasoning model which Slovic argues may not be operative. Rather, efforts must be made to counteract the positive images of smoking, which distort risk perception.

Smoking: Risk, Perception, and Policy also explicates the addictive nature of tobacco. This material is essential for anyone involved in the design or delivery of smoking prevention or cessation programs. In addition, insights on addiction can be applied to other types of addictive behaviors. The authors posit that the phenomenon of addiction is one of many "visceral" (not entirely rational) behaviors that call into question the rational-choice paradigm of human behavior. In the case of smoking, it is clear that people who experiment with cigarettes can't accurately anticipate the motivational force of the craving for nicotine that occurs once a person is addicted. Young people especially underestimate this force. The authors provide evidence that the tobacco industry deliberately manipulates information to minimize the perception of risk of addiction.

Of most interest to antitobacco activists, economists, health communication researchers, and policymakers are the sections that deal with tobacco policy. Slovic discusses advertising and the diffusion of smoking behavior, and presents a causal model to explain cigarette trials among the 14-22 age group. The effects of cigarette advertising and counteradvertising in shaping young people's perceptions are examined critically. The authors demonstrate how tobacco industry advertising and promotion act to increase favorable images and feelings associated with smoking. They point out that favorable perceptions have not been effectively changed by counteradvertising.

Smoking: Risk, Perception, and Policy also systematically delineates the limits of economic theory in explaining tobacco consumption. The authors document market manipulation by the tobacco companies as well as the existence of widespread and persistent nonrational behavior by consumers. The book explores the failure of past legal regulation, such as warning labels and advertising restrictions, and, to a lesser extent, product liability litigation. Moreover, suggestions to respond to market manipulation are quite far-reaching, including the institution of a liability mechanism that forces cigarette manufacturers to incorporate the health costs of smoking into product prices -- "enterprise liability." This would require manufacturers to raise the price of cigarettes to reflect the true cost to both smokers and society.

Other suggestions focus on a youth-centered tobacco policy, and include raising the price of cigarettes through excise taxes, removing federal preemption of state and local advertising restrictions, enforcing youth access laws, and building state capacity for tobacco control. Long-term policy goals include FDA regulation of tobacco products, further restrictions on advertising and promotion, and the establishment of freedom from tobacco as the norm.

Smoking: Risk, Perception, and Policy is highly recommended. It contains valuable insights on tobacco control, risk assessment, and public policy. Healthcare providers will be most interested in the chapters on addiction and young people's perceptions of risk. Researchers will appreciate the careful analysis of the tobacco survey findings, critical analysis of previous research on risk perception, and the presentation of causal models. Economists will find the arguments that challenge classic economic theory stimulating and thought-provoking. Policymakers concerned about the health and economic costs of smoking would do well to understand the limits of the "rational model."

Powerful tobacco corporations have an economic stake in distorting the market and minimizing the public's perceptions of the inherent risks of their products. Successful public policy to reduce smoking will need to take market distortions into account.

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