Cigarette smoking can kill you, so why do people do it?

Blog Post created by Thomas3.20.2010 on Nov 16, 2014

I’m not trying to suck up to the big boss – Warren Buffett, owner of The Buffalo News and Berkshire Hathaway – but as I worked on cigarette smoking-related stories for WNY Refresh this week, I couldn’t help but think about another company he owns.

The one that advertises: “Fifteen minutes can save you 15 percent or more on car insurance.”

Everybody knows that – and as I went into my interview earlier this week with a Roswell Park Cancer Institute researcher, I went in with the belief that everyone knows that tobacco use can kill you.

Turns out that a more people might believe a talking gecko than the U.S. surgeon general.

Roughly one in four people in Erie and Niagara counties smoke, even though there is clear evidence this can be a deadly habit.

Why? That's one of the questions I asked Maansi Bansal-Travers, a research scientist with the Department of Health Behavior at Roswell who focuses on tobacco advertising and promotion.

“It’s a complicated answer,” she said. “There are still misperceptions about the health risks. Two-thirds of people believe that nicotine is the cause of cancer. Nicotine is not the cause of cancer. It’s other carcinogens in cigarette smoke. There’s a real physical addiction with cigarette smoking and there’s also a very strong behavioral component.”

How quickly can someone become addicted to cigarette smoking and how powerful is the addiction?

“It can be as fast as the first one,” Bansal-Travers said. “It’s stronger than cocaine, heroin, alcohol. Nicotine is physiologically the strongest addiction you can have.”

She and colleagues across the globe have spent the greater part of their professional lives trying to better understand why smokers can make a choice that flies in the face of their best interests.

They have discovered that the poor and uneducated tend to smoke in greater numbers in countries where tobacco maintains a stubborn foothold, despite the cost of cigarettes. In countries where smoking or chewing is portrayed favorably in the media, movies and advertising. And in countries where addicted users choose to ignore the dangers, particularly since so many of them start at younger ages when inexperience and a since of invincibility meet the drive toward experimentation.

Bansal-Travers and colleagues across the globe are conducting work in more than 20 countries as part of the International Control Policy Evaluation Project. The project is led by K. Michael Cummings, a former Roswell researcher now at the Medical University of South Carolina, with help from his former Roswell co-workers, along with researchers from the University of Waterloo in Ontario, Australia, the United Kingdom and elsewhere.

Today’s In the Field feature in WNY Refresh focused on the research Bansal-Travers and others have conducted on cigarette packaging, particularly the impact of graphic packaging.

Bansal-Travers is a 1993 graduate of Williamsville East High School. She has a bachelor’s in human nutrition and food management from Ohio State University, a master’s in epidemiology from the University at Buffalo and her PhD in epidemiology and community health, also  from UB. She and her husband, fellow Roswell tobacco researcher Mark Travers, have two sons, Matthew, 6, and Milan, 4.

Below are excerpts from my interview with her that explored the larger scope of her work.

How did you get started down this road?

As part of a large national study where we started to look at perceptions that smokers hold about different tobacco products: what they believe, what they think, the health risks, what they believe about their products, and found that smokers hold great misperceptions about their products.

They don’t necessarily understand the health risks of their products. They don’t know the chemicals in their products. That’s the project I did for my master’s thesis.

I did two studies for my PhD dissertation. They both involved trying to educate people about their products. We found all the areas of misperception that people hold about cigarettes and smokeless tobacco and the health risks.

The other part that interests me is, How do we educate people? How do we have an informed consumer? So I worked with the New York Quitline, which is also housed here at Roswell Park, developed product-specific information for people, to educate them about their brand of cigarettes.

We thought we would do it by brand because people are very loyal to their cigarette brand and they tend to pay more attention when they can personalize the information.

Why are smokers misinformed?

The misperceptions are largely perpetuated by communications by the tobacco industry. My focus is mostly on packaging, so how does the industry use packaging to communicate with their consumer? Ever since other advertising restrictions have been imposed – including no more billboards, no more TV advertising – they’ve used packaging and point-of-sale displays as their main modes of communications. I study how they use packaging, words on packaging, colors and descriptor terms to communicate with their consumer.

I understand you have an interesting camera. Can you describe it?

I am hesitant to put it in a photo because I don’t want it to be recognized when we use it in a store. It’s a mobile eye tracking unit that’s used in marketing research. It’s not new but it has not previously been used specifically for tobacco research. It allows us to look at what people look at when they go into a store.

Some people use this in journalism.

It’s really popular in website design, to see how people look at sites. For example, people like to look across the top, then down the left and then everything else.

You say that in a store, smokers and non-smokers alike tend to be drawn to the ‘power wall’ where cigarettes are sold, starting in the middle, and Marlboro brands often can be found there. Does Philip Morris have to pay more to be in the middle?

Philip Morris generally has a contract or incentive to put them in a specific place on the power wall.

The industry pays over $10 billion a year for marketing and advertising in the United States; 84 percent of that is in the retail environment and 94 percent of that is at the point of sale.

They pay a lot of money to make sure you see their product in a store.

And labeling comes into play?

Labeling and displays work together. A pack-a-day smoker sees their pack 7,000 times a year. Part of that is the industry’s communication with the smoker, with the colors, with the label, with the brand name and associations. Part of that is the warning label that we can put on a pack to convey the health risks. The other thing the industry’s been doing, more so in the last couple of years, is integrating their packaging with their current promotional campaign. There’s clear cellophane on top of cigarette packs and they cover the cellophane with the promotion, which would cover a label.

So if you’re an 18-year-old who’s on a mailing list for Philip Morris, you see the promotion in the store, you get it by direct mail at home, you get it by email, so now they’ve expanding their reach by communicating three different ways with that smoker.

What are these promotions like?

They have different themes. Here’s one (on a Camel pack) that has the words ‘Pride’ and ‘Tradition,’ and has a 75- cent price discount on the packaging. Others have a price discount and take you to a website where you can win different prizes. It’s really multifaceted. When you look at the retail display, you’re not only looking at brands of cigarettes, you’re also looking at all the different colors and icons that they use with that brand.

Graphic warning labels and their effectiveness seem to be central to your research. What have you and other researchers discovered about these labels?

Smokers have said that once they change the pack, they don’t taste as good, and it’s the same cigarette. So it makes a difference. It’s like food, if it looks good, it probably tastes good, but if it looks terrible, sometimes that tastes the best, but it looks terrible so you won’t eat it.

What have Roswell and others determined label-wise are the most effective ways to help people stop?

There are a couple of ways we might try to address this, which would include hiding the displays but also plain packaging with graphic warning labels.

In Canada, they have a 50 percent front and back of the pack warning label, which you also see in their displays. ... In Australia, they have plain packs. They don’t have icons, like a chevron or a camel. They don’t have any descriptive terms, instead it just says ‘Fine Silver.’ So this is the only branding you have on the (bottom one-sixth of the front) cover. The rest of the front and whole back is a warning label. The U.S. warning label is on the side, text only, in the colors that the manufacturer chooses. They don’t have a color requirement. It’s one of four warnings we’ve had since 1985. It has not changed.

How effective is the Australian graphic?

It’s only been on the market for maybe a year or so. They have seen calls to their quitline number increase, because they have a quitline number on the pack. They have a specific olive green color and very specific font requirement, and they cannot use any other pictures or any other colors. So when you put them all on a display, they all look the same, except for the warning. And most of the warnings are gross.

(The Australian warnings say: “The toxic chemicals in tobacco smoke can go everywhere that your blood flows, causing harm all over your body.”)

These graphic warning labels have been found to be effective?

Extremely effective. Canada was the first country to have them, in 2001, and has seen a reduction in smoking prevalence. In different surveys that we’ve done, we have always seen a dramatic increase in people noticing the label and people reading the label. When we ask about specific diseases addressed in the label, there is increased knowledge. For example, after they put ‘Smoking causes blindness’ on the label, more people knew that smoking causes blindness.

It sounds like the philosophy of the Australian government is a little bit different. What have they determined to do there that we have not done here?

They are very effective in their tobacco control policies. The reasons are the same in any country. The risks of tobacco are well-known and they have taken a very strong stand in their public policy with packaging.

Talk about your research team, including for tobacco research at Roswell as a whole and the folks you routinely conduct research with.

I work very frequently with my colleagues here, including Dr. (Andrew) Highland and Dr. (Richard) O’Connor. I work very closely with Dr. Cummings at the Medical University of South Carolina. I work very closely with Dr. (David) Hammond and Dr. (Geoff) Fong at the University of Waterloo. I am a co-investigator of the ITC (International Tobacco Control Policy Evaluation Project) India Project. I work closely with educators at the Healis Sekhsaria (Institute of Public Health in India) I have data managers that I work with. I have a couple of project managers here that run studies for us. I am on the committee of a couple of PhD students and a couple of master’s students, both from here and the University at Buffalo School of Public Health. I’m a research assistant professor at UB. A lot of the students from UB will do their research here or in an area that is in addictions or marketing or communications with perceptions and qualitative research. I do a lot of qualitative research. I’m the only person in our department who runs focus groups and was one of the first ones to do a web survey.

What can you tell us about your current or future research?

I have a couple of proposals in to evaluate some of the marketing being done at the point of sale in the retail environment, including the change in pharmacies, with the removal of tobacco products at CVS, and how different pharmacies have responded to that voluntary removal.

Have you heard this comment that only one of three people who smoke will die from smoking? 

I have heard it. I also can tell you one out of three cancers at Roswell Park are tobacco-related. That doesn’t include heart disease, which is the number one health risk of smoking.

What have Roswell and others determined are the most effective ways to help people stop smoking.

To educate them, inform them. To decrease access. To increase price. Clean indoor air policies are very effective, and cessation support. That includes the Quitline and the distribution of (nicotine patches) and smoking medications.

It’s still hard to believe more people aren’t afraid of cigarettes.

They're available everywhere. Until 10 years ago in New York, you could smoke anywhere. Even with young people today, they think it looks cool, and movies perpetuate that belief. And it’s social norm for young people that they think it’s acceptable, that it makes them look older, more distinguished, and they see their parents do it. A lot of times, the first cigarette a child will have will be one they stole from their parent.

Can parents who smoke have any sort of an influence on this?

Sure. They could quit. The best thing they could do is quit, and show their child that they believe smoking is a dangerous habit and that smoking around their kids is dangerous for them and dangerous for themselves.