Graphic Anti-Smoking Signs May Actually Encourage Some Teens to Smoke

Despite having a successful multi-billion dollar advertising arm, the tobacco industry has suffered some setbacks in recent years. In 2014, CVS Pharmacy stopped selling tobacco products altogether and, last month, cigarette companies started airing anti-smoking TV ads as the result of a 1999 lawsuit over deceptive marketing.

Still, tobacco products dominate an otherwise non-threatening space: checkout counters at convenience stores. Studies show these “power walls”—the massive displays of cigarettes, dip, and other tobacco products that frame cashiers from behind—make people more susceptible to smoking, so public health advocates are trying to find ways to curb their effects. But hanging graphic warning posters nearby might actually encourage some kids to light up, according to a study published today in Nicotine and Tobacco Research.

“I think the big-picture message here is that the most obvious solution might not be the best solution,” says lead study author William Shadel, a senior behavioral scientist and associate director of the population health program at the RAND Corporation, a nonprofit that develops solutions to public policy changes.

In the study, 441 kids ages 11 to 17 went shopping in the RAND lab’s mock convenience store, a 1,500-square-foot space stocked with more than 650 products. For about half the kids, he researchers hung posters near the checkout that showed a diseased mouth with the warning “smoking causes cancer.” It was one of nine anti-smoking posters made by the US Food and Drug Administration to put on cigarette packs, and kids voted it as the most effective poster in a previous study. Here it is:

Delightful.

Researchers surveyed the kids’ attitudes toward smoking (and asked them about other products) before and after shopping. About 5 percent of the kids said they’d smoked before and 20 percent were determined to be at risk for smoking in the future. They found that the poster seemed to increase susceptibility to smoking for the “at-risk” kids who had either smoked before, indicated that they might smoke in the future, or both.

The graphic poster may have intrigued the at-risk teens because of a phenomenon known as defensive processing, Shadel says. “If someone thinks communication designed to change their risky behavior threatens their self-worth or self-esteem, they may react in a way that’s opposite than the intended effect of the communication,” he explains. Did you ever refuse to wear a helmet or slather on sunscreen after your mom or dad told you to, despite the risks? Same idea.

Shadel points out that they conducted the study in a laboratory setting with a single group of consumers, and that they only tested the single poster in one size and area of the store. The gruesome image might also have diverted the adolescents’ attention to the power wall itself, which exposed them to pro-tobacco messaging. Real-world research needs to be done before they can make definitive statements about this type of warning poster, he says.

Ryan Kennedy, an assistant professor of health behavior and change at Johns Hopkins University, says the posters may have drawn attention to another sign in the mock store that restricted smoking to people 18 or older. “If you’re framing tobacco use as an adult behavior, that’s going to appeal to some youth who wish to present themselves more as adults,” he says.

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The findings aren’t damning of all graphic warning signs, says Sarah Ross-Viles, director of the tobacco studies program at the University of Washington. Other research shows they can help people quit, and those benefits might outweigh the potential risks in vulnerable kids and teens.

Plus, highlighting the dangers of smoking may have other positive effects. “Suddenly non-smokers who think that the tobacco problem is totally solved are noticing this disgusting thing in their convenience store, and does that create political will to make more effective policy change?” Ross-Viles says.

Pharmacies have no business selling tobacco products to begin with, Kennedy says. “It’s just horrible to think that someone could be getting cancer treatment drugs at the back of the pharmacy and then buying cigarettes at the front,” he says. Other countries have successfully banned tobacco power walls completely, but not the US. In 2009, New York City passed regulation requiring tobacco retailers to post graphic warnings in their stores, but it didn’t last: Tobacco companies sued and in 2012, they won.

We’re making progress in other areas, though. Smoking rates in the US dropped from 20.9 percent in 2005 to 15.1 percent in 2015, according to a recent report from the Centers for Disease Control and Prevention. Five states—Hawaii, California, New Jersey, Maine, and Oregon—have raised the legal smoking age to 21. Washington state hopes to do the same.

But some states are weighing the benefits against the actual costs of banning sales before 21, Ross-Viles says. “The biggest block to getting it passed as a state is how much revenue we would lose from kids not getting tobacco and then not becoming lifelong smokers,” she says. “Very few legislators will say, ‘Oh, I think we should smoke.’ Nobody thinks that. But do they think the state should cut out $450 million in excise taxes? They’re having a really hard time with that.”

To keep young people from picking up the bad habit, Ross-Viles says legislators should focus their resources on social marketing campaigns like #FinishIt. “The messages you see for youth these days are much more complex, and hopefully they’re culturally relevant and owned by the youth who they’re meant to target, because that’s going to have the most impact on attitudes,” Ross-Viles says. “In most tobacco policy there’s a huge fight against the industry, and you want to invest in that fight where it’s really going to make a difference.”

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