Why the ugly cancer pictures don’t work against smoking
This is one of the best—maybe the best—video I've ever seen that breaks down the role of choice-making and rationality when it comes to public health policy. If that sounds boring, it's really not! The whole video is about fucking and injecting drugs, the epidemiologist Elizabeth Pisani who gives the talk roots as much of it as possible in vernacular English, choosing slang terms over medical terms (using the terms "junk" and "smack" instead of "heroin", for instance) as possible, which keeps it warm and lively. It's about why people do stupid things that get them infected with HIV, or, more specifically, it's about why decisions that look stupid to outsiders (like having unprotected sex or sharing needles) are actually the most rational decision for people in some circumstances. Less than 20 minutes, and you'll probably have a profoundly better understanding of how to evaluate public healthy policy claims that are about people's decision-making.
I bring it up, because Tracy Clark-Flory had a thoughtful piece up about why the new, grotesque pictures of lung cancer on the sides of cigarette boxes will not work to make anyone quit. And she's right! Watch the video; Pisani explains how a heroin addict will sit and watch 21 people shoot up with the same needle before him, and watch that needle get blood-drenched and dull and all he can think is, "I hope there's enough for me." And he's being rational, in a way. The thing is that often what is irrational in the long term is perfectly rational in the short term, and in his case the short term decision to get high is really obvious. Smokers aren't unaware of the long-term problems related to smoking anymore than heroin users are unaware of the threat of AIDS. They probably think about it a lot more than non-addicts do! The notion that someone will quit because the cigarettes gross them out is really naive.
That said, I'm not entirely unconvinced that the packaging couldn't prevent new smokers from starting up. The rational reasons people have for picking up smoking is a) it's relaxing and b) it makes you look cool. The packaging might damage both desires. It might also remind you that not all smokers are the cool kids hanging out by the school, but some are craggy old addicts. You might even do better by putting pictures of old people smoking cigarettes through trachael tubes on the packaging, just to put some distance between cigarettes and coolness.
But even then, I'm largely unconvinced, I have to admit. People will start to tune the pictures out, but the appeal of cigarettes to newbies will remain, and of course addicts have their own set of problems. The problem with initiatives like this is that they don't address why people smoke at all, and that's what Tracy was getting at—the initiatives assume that lack of education on the dangers of smoking is the problem. In reality, it's because the short term benefits to smoking still outstrip the long term benefits to not-smoking for a whole lot of people. Also, as Tracy's post shows, these initiatives don't even have clear goals in mind. Are they there to help current smokers quit or to prevent new smokers? These are entirely different groups and need to be addressed through different means.
I'm personally of the opinion that anti-smoking efforts (or similar public health initiatives) probably work best if you approach the whole situation like you do a cat you're trying to get to stop scratching a chair. Frustrate the undesired behavior, replace with an alternative that works for everyone. That's why clean needle programs work if implemented correctly (i.e. with no punishments for needle carrying or use of the program to round up users). It's how seat belt wearing became widespread—it was a combination of making it a bad idea to not wear one plus, and this is critical, making it super easy to wear one. Cars that beep at you if you don't wear one are the best, since they offer a direct disincentive not to wear a seat belt.
With that in mind, I think that the best bet still to stop new smokers is to make it expensive to buy cigarettes and, probably most importantly, make it really hard to smoke in places that are associated with being cool. The decline in smoking that accompanied banning it in bars has made me, somewhat reluctantly, come around to supporting the ban. You could probably do more to curtail smoking with high school students by making the smoking lounge in the principal's office than banishing them across the street. Stuff like that. Removing the incentives to smoke can go a long way towards curtailing the behavior.