The Factors that Determine Success in Attitude Change Programs

Abstract: Due to the severe and unrelenting problems associated with tobacco smoking, this essay is an attempt to present the factors that best predict successful attitude change. After an analysis of theory, research and Australia’s current anti-smoking campaign, it is determined that several theories guide the factors that predict attitude change, including, cognitive dissonance theory, fear appeals, the elaboration likelihood model and the heuristic-systemic model. In short, counter-attitudinal information, short and long-term fear appeals, effective coping measures, personal relevance, perceived self-involvement, and the utilisation of credible and expert sources, have all been implicated in successful attempts to change attitudes. The amalgamation of these factors is proposed to provide the foundations of a multidimensional model of attitude change, in the hope to assist future attitude change endeavours.

Tobacco smoking is a worldwide problem, with 1.3 billion people currently smoking cigarettes worldwide, and tobacco related illnesses killing one person every six seconds (World Health Organisation [WHO], 2008). Although smoking rates are on a steady decline, tobacco smoking remains a national issue in Australia, with 16.6 percent of Australian persons aged 14 or over smoking on a daily basis (Australian Institute of Health and Welfare [AIHW], 2008). International authorities describe Australia as a forerunner in tobacco control, facilitating large scale, nationally promoted anti-smoking campaigns since the 1970’s (Chapman, Byrne & Carter, 2003). These campaigns have driven other nations such as America, to attempt to replicate the success of Australian programs and reduce the level of tobacco use worldwide (Chapman et al.). Chang (2006) reports that these campaigns invariably utilise attitude change theories, to promote anti-smoking attitudes among the campaigns’ targeted populations. This essay is an attempt to propose the characteristics that determine the success of attitude change programs, in relation to anti-smoking campaigns. Consequently, this essay will present attitude change research and theories, including Cognitive Dissonance Theory, Fear Appeals, the Elaboration Likelihood Model and the Heuristic-Systemic Model. The Australia’s National Tobacco Strategy, 2004-2009, will be utilised as an example.

Due to the alarming prevalence of tobacco use worldwide, a variety of assisted smoking cessation techniques have long been available, including pharmacology, brief intervention counselling, and community-wide programs (Viswesvaran & Schmidt, 1992). However, a meta-analytic comparison of the effectiveness of these smoking cessation methods, indicates that the success of these techniques is relatively poor (Viswesvaran & Schmidt). As a result, government and non-government authorities continue to implement nation-wide anti-smoking campaigns in Australia. In 1997, the Commonwealth government founded the National Tobacco Strategy (NTS) in collaboration with both government and non-government sectors in all Australia’s States and Territories (Commonwealth Department of Health and Aged Care [CDHAC], 2001). According to the Ministerial Council on Drug Strategy (MCDS, 2005) Australia’s current tobacco strategy is an attempt to adopt a comprehensive approach to tobacco control, building on international and local successes in slowing the tobacco pandemic. The long-term goal of the campaign is to improve the health of all Australians significantly, by reducing smoking and overall population exposure to tobacco toxins, and to reduce the social costs caused by tobacco (MCDS, 2005). Campaign coordinators and researchers agree that these goals may be achieved in many nations, including Australia, by changing social attitudes to smoking through ‘hard-hitting’ media campaigns (MCDS, 2005).

Research has found anti-smoking campaigns to be effective in changing the attitudes of smokers and non-smokers alike, which is important in both the prevention and cessation of tobacco smoking practices (Gilbert, 2005). According to Eagly and Chaiken (1993) an attitude is a psychological tendency that is formulated by evaluating people, groups, situations, objects, activities and intangible ideas, in terms of their favourable and unfavourable qualities. Prior to the introduction of the current national tobacco strategy, research of Australian attitudes commonly found that Australians display strong favourable attitudes towards tobacco smoking. An early baseline survey of Australian attitudes, found that people report tobacco smoking behaviour as pleasurable, enjoyable, relaxing, and stress and boredom relieving (Shanahan, 2001). Following the introduction of the NTS, researchers reported a significant change in the attitudes regarding tobacco and the smoking behaviours of the Australian public (Commonwealth of Australia, 2004). Since 1997, 88% of respondents surveyed consistently agreed, “every cigarette you smoke is doing damage to your health” (Kinsman, 2005, p. 9). Furthermore, 61% of regular tobacco smokers reported that it was “very likely, or certain” that they would suffer future illness from continued smoking behaviours (Kinsman, p. 10). The demonstrated success of Australia’s NTS in the altering Australian attitudes towards tobacco smoking, suggests that an inquiry into the attitude theories and models utilised throughout the campaign is appropriate.

Cognitive dissonance theory (CDT), developed by Leon Festinger in 1957, posits that discrepancies or inconsistencies in cognitions cause psychological discomfort, which will motivate an individual to attempt to reduce or eliminate the dissonance and achieve consonance (Zimbardo, Ebbesen & Maslach, 1977). Harmon-Jones (2000) asserts that genuine cognitive changes occur as a result of cognitive dissonance. Wood (2000) furthers this point, alleging that attitudes may in fact change, to maintain cognitive consistency. In relation to smoking behaviour, however, Clark, McCann, Rowe and Lazenbatt (2004) report that people who smoke may avoid cognitive dissonance and refuse to accept aversive, negative health information. Conversely, credible research has shown that advertising campaigns that evoke cognitive dissonance in smokers are effective in fostering quit intentions (Biener, McCallum-Keeler & Nyman, 2000). The findings from an experiential intervention study, conducted by Simmons, Webb, and Brandon (2000) found that dissonance was positively correlated with the use of dissonance-reducing strategies, including the intention to quit smoking. Furthermore, recent research findings suggest that negative counter-attitudinal information can indeed change positive attitudes (Rydell, McConnell, Strain, Claypod & Hugenberg, 2007).

The NTS employs the basic tenets of CDT, utilising counter-attitudinal information to promote cognitive dissonance among the Australian public. Consider for example, an Australian smoker exposed to the NTS, which features aversive graphics of black lungs, cancerous growths and other information regarding the negative consequences of tobacco smoking, on television advertisements and cigarette packages. Prior to exposure the person may convey positive cognitions towards smoking, for example, “I enjoy smoking”, “I like the taste of cigarettes”, or “I am a smoker”. The new information, the negative consequences of smoking, is incongruent with the person’s initial cognitions, thus resulting in dissonance. Providing that the assumptions of CDT are correct, the smoker will change his positive attitudes towards smoking in an attempt to reduce cognitive dissonance For example “I don’t smoke”, or the person may retain the advertising slogan “Every cigarette you smoke is doing you damage”. The attitude change successes demonstrated by the NTS and other research studies, suggests that CDT is successful in creating cognitive dissonance and facilitating attitude change, and may be utilised effectively in other attitude change programs.

According to Friedman and Arndt (2005), reminders of mortality can also intensify individuals’ efforts to reduce dissonance. Developed by Greenberg, Pyszcynski and Solomon in 1986, Terror Management Theory (TMC) posits that the awareness of the certainty of death creates high levels of fear (Friedman & Arndt). However, health campaigns typically utilise less extreme fear appeal theories, which generally purport that making campaign recipients afraid will persuade them to discontinue a maladaptive behaviour and reduce dissonance, such as quitting smoking (Gleicher & Petty, 1992). Protection Motivation Theory (PMT), developed in 1975 by Roger, is just one example of the many fear appeal theories offered to date (Wood, 2000). PMT places emphasis on fear inducing individuals’ motivation to protect the self, or to maintain healthy living (Gleicher & Petty). In regards to health campaigns and attitude change, PMT is utilised on the premise that fear arousal, or concern about an issue will lead to attitude change (Gleicher & Petty). Indeed, research suggests that campaign messages that effectively induce fear, whilst also providing adequate means of coping, result in successful attitude change (Wood). However, minority researchers have expressed concerns regarding the use of fear appeal advertising with adolescents.

Early research indicates that attempts to alter smoking attitudes and behaviours, which utilised fear appeals among adolescents, were largely ineffective (Botvin, Epstein & Botvin, 1998). Smith and Stutts (2003) suggest that this may be due to the implication of merely physical threats and long-term health fear appeals in anti-tobacco advertising campaigns. Due to the positive baseline attitudes displayed by adolescents regarding smoking, Wood (2000) asserts that physical threats may not effectively influence adolescents to change their attitudes. A survey of adolescent attitudes toward smoking indicates that regardless of advertising campaigns, young people often continue to underestimate the objective risks associated with smoking (Romer & Jamieson, 2001). Furthermore, adolescents underestimate their own personal risk of smoking, whilst overestimating the ease of quitting smoking (Romer & Jamieson). Smith and Stutts suggest that to overcome these attitudes and subsequent barriers to successful attitude change, anti-tobacco campaigns must emphasise social threats and the short-term cosmetic consequences of smoking, as well as the more universally incorporated long-term health consequences of smoking. Investigating their proposal, Smith and Stutts found that short-term, cosmetic appeals appear to be more effective with male adolescents, whilst long-term health appeals appear to be more effective with female adolescents. Indeed, a recent study also found that long-term fear appeals are more successful with female adolescents (Tangari, Burton, Andrews & Netemeyer, 2007). These findings have important implications for effectively reaching adolescents in anti-tobacco campaigns.

Following the above recommendations, the NTS utilises both short-term and long-term fear appeal techniques, to ensure exposure to all age groups and genders. According to White, Tan, Wakefield and Hill (2003), fear appeals are utilised in the NTS’s advertising, in anticipation that an increase in the perceived severity of health risks associated with smoking will increase individuals’ perceived susceptibility to suffering from those health risks, which will subsequently increase intentions to quit smoking. Negative health risks and long-term health appeals, are heavily implicated in NTS advertising. Both television advertisements and cigarette packages commonly portray adults suffering the negative consequences of their smoking. An example of a disturbing graphic representation of the long-term illness caused by smoking, is the ‘Mouth Cancer’ advertisement. The advertisement depicts a woman visibly suffering from mouth cancer describing her experiences with radiotherapy and chemotherapy (For more information, see, Cancer Institute NSW, 2008b). Research has shown, that this type of graphic advertising, which highlights the long-term suffering caused by tobacco smoking, effectively influences the attitudes of the Australian public (Commonwealth of Australia, 2004).

An example of the short-term, more cosmetic fear appeals utilised in the NTS is the ‘If Smoking was a Friend Campaign’. This campaign portrays a smoker reflecting on his relationship with cigarettes, demonstrating to the audience the controlling nature of addiction. The advertisement ends with the slogan, “If smoking was a friend, you’d want him out of your life” (to view the advertisement, see Cancer Institute NSW, 2008c). Following the research findings regarding the use of fear appeals with adolescents, this advertisement may be more effective with young males. However, the NTS has demonstrated that communicating the negative impacts smoking has on daily life, is an effective message with all age groups and genders (Commonwealth of Australia, 2004). Surveys of the Australian public have found that people identify smoking with negative social and lifestyle factors, such as the high financial and short-term illness costs of smoking behaviours (Shanahan, 2001). The established success of the NTS in changing the attitudes of Australians of all ages, implies that long-term health risk fear appeals, and short-term cosmetic fear appeals are important inclusions in attitude change programs.

To ensure the success of the addition of fear appeals in attitude change campaigns, researchers recommend the portrayal of effective measures of coping to campaign recipients (Gleicher & Petty, 1992). According to research conducted by Wood (2000), recipients are less likely to accept a message when threat levels are high, and self-perceived coping availability is low. Therefore, it is important to provide sufficient coping mechanisms to the recipient throughout the campaign. The NTS provides the Australian public with ‘quit’ information (such as the Quitline) at the conclusion of every television advertisement, and on cigarette packages. Prior to providing quit information, the NTS furthers the recipients quit intentions with the statement, “Quitting is hard, not quitting is harder”. This strong statement in combination with quit information, effectively facilitates attitude change and quit intentions (Commonwealth of Australia, 2004). To further strengthen these achievements, the NTS devised the ‘Quitline Services Campaign’, which is specifically intended to inform the Australian public of the services and support available to assist them to quit smoking. To provide message recipients with effective coping assistance, the various television advertisements provide an insight into the Quitline and the support available (to view the advertisements, see, Cancer Institute NSW, 2008d). Including coping information in future attitude change campaigns, concurrent with the NTS’s success, supports the theory of achieving higher levels of acceptance and attitude change, when perceived threat and coping are both high (Wood).

The NTS’s demonstrated success is also due in part to the utilisation of dualistic process theories in the campaigns development. Although cognitive mechanisms are involved in the Elaboration Likelihood Model and the Heuristic-Systematic Model, these theories differ from CDT and other theories, as they do not implicate argument-based processing in achieving attitude change (Eagly & Chaiken, 1993). Although there are application differences between the two theories, for the purpose of this analysis, a discussion of the common themes will be presented (for a comprehensive comparison of the two theories, see, e.g. Eagly & Chaiken, 1993). The Elaboration Likelihood Model (ELM), developed by Petty and Cacioppo in 1986, and the Heuristic-Systematic Model (HSM), developed by Chaiken in 1980, posits two meditational routes to persuasion, the central and peripheral (Axsom, Yates, & Chaiken, 1987). ELM and HSM propose that when an individual’s capacity and motivation are relatively high, the said individual will carefully consider and evaluate the available information, utilising the central or systemic route (Van Overwalle & Siebler, 2005). In contrast, when capacity and motivations are low, an individual will process the information on a more trivial level, utilising only the peripheral or heuristic route. This results in the individual retrieving simple schemas or stored decision rules to evaluate the information being presented (Axsom et al.; Van Overwalle & Siebler).

The ELM and the HSM hypothesise that attitude changes resulting from central or systemic processing will show greater persistence, resistance, and will better predict behaviour (Eagly & Chaiken, 1993). Evidence for the relevance of the ELM and the HSM in attitude change success has been demonstrated by the NTS and in several recent studies. In an attempt to achieve persistent and resistant attitude change, the NTS utilises the central route of processing, through a variety of media advertising. The use of personal stories, such as the ‘Anthony campaign’ (currently showing on national television), utilise the central route of processing and provide an element of personal relevance. Anthony is shown in hospital, diagnosed with throat and lung cancer, as he communicates his condition and his plans to see his daughter in the near future. The audience is informed that Anthony died ten days following filming, never seeing his daughter (to view the advertisement, see Cancer Institute NSW, 2008a). Personal relevance and involvement is described as a primary factor in both the ELM and the HSM (Ajzen, 2001). Personal relevance and perceived self-involvement have also been associated with increases in attitude strength and greater information processing (Ajzen). Indeed, Park, Levine, Kingsley Westerman, Orfgen and Foregger (2001) regard personal relevance as the key to success in persuasive attempts.

Providing support for the ELM and the HSM, a study conducted by Petty, Brinol and DeMarre (2007) found that during the attitude change process, people engage in a higher level of information processing. The strong negative health messages and arguments presented by the NTS, such as health related statistics and personal information, require a greater level of information processing, which results in the utilisation of the central or systemic route of processing. The success of the NTS and other research studies, have important implications for the ELM and HSM, suggesting that the central or systemic route hypothesis is indeed correct. To ensure widespread campaign exposure, however, the NTS also utilises the peripheral route of processing. According to Axsom et al. (1987), heuristic processing is relatively effortless and the receiver of a message typically evaluates message validity without full consideration of the semantic content. The inclusion of ‘expert’ authorities in NTS’s television advertisements, such credible sources including surgeons and doctors, allows the audience to evaluate the message quickly with a low level of processing. This usually results in the easy retrieval of a stored decision rule, such as “experts can be trusted” (Van Overwalle & Siebler, 2005). The aversive graphic content of smoking related diseases depicted on television and cigarette packages, also allows for peripheral processing. Repeated exposure to the stimulus over time, results in the recipient processing the information quickly, evaluating the content as unpleasant, or disturbing. A negative evaluation of advertising content enhances the campaign’s level of persuasion and credibility, whilst also promoting a sense of urgency among the Australian public (Commonwealth of Australia, 2004). Due to these findings, it is recommended that future endeavours to change attitudes include techniques that utilise both the central and peripheral routes of processing.

Due to high levels of tobacco smoking, and the often positive tobacco smoking attitudes conveyed by Australian people, it is crucial to develop an understanding of the underlying factors that determine the success of attitude change programs. This essay has presented a mere sample of the potential factors that have demonstrated success in theory, research and throughout the administration of Australia’s national tobacco strategy. It is proposed that future attitude change campaigns would benefit from the inclusion of factors guided by cognitive dissonance theory, fear appeals, the elaboration likelihood model and the heuristic-systemic model. More specifically, the factors that have demonstrated success in research and the national tobacco strategy include, counter-attitudinal information, facilitating cognitive dissonance, and both short and long-term fear appeals in combination with the conveyance of effective coping measures. The creation of personal relevance and perceived self-involvement, which induces high levels of processing, and utilising credible and expert sources to encourage low levels of information processing, are also important factors to consider in attitude change programs. The factors described in this essay contribute to a multidimensional model of attitude change, demonstrating success in Australia’s National Tobacco Strategy, and providing guidance to authorities attempting large-scale attitude change in the future.

References: Ajzen, I. (2001). Nature and operation of attitudes. Annual Review of Psychology, 52, 27-58. Australian Institute of Health and Welfare (2008). 2007 national drug strategy household survey: State and territory supplement. Canberra: Author. Axsom, D., Yates, S., & Chaiken, S. (1987). Audience response as a heuristic cue in persuasion. Journal of Personality and Social Psychology, 53, 30-40. Biener, L., McCallum-Keeler, G., & Hyman, A. L. (2000). Adults’ response to Massachusetts anti-tobacco television advertisements: Impact of viewer and advertisement characteristics. Tobacco Control, 9, 401-407. Botvin, G. J., Epstein, J. A., & Botvin, E. M. (1998). Adolescent cigarette smoking: Prevalence, causes, and intervention approaches. Adolescent Medicine, 9, 299-313. Cancer Institute NSW (2008a). Anthony campaign. Retrieved October 11, 2008, from http://www.cancerinstitute.org.au/cancer_inst/campaigns/anthony.html Cancer Institute NSW (2008b). Health warnings campaign: Mouth cancer. Retrieved October 11, 2008, from http://www.cancerinstitute.org.au/cancer_inst/ campaigns/healthwarnings2006.html Cancer Institute NSW (2008c). If smoking was a friend campaign. Retrieved October 11, 2008, from http://www.cancerinstitute.org.au/cancer_inst/campaigns/ friend.html Cancer Institute NSW (2008d). Quitline services campaign: 13 QUIT. Retrieved October 11, 2008, from http://www.cancerinstitute.org.au/cancer_inst/ campaigns/13quit.html Chang, C. (2006). Changing smoking attitudes by strengthening weak antismoking beliefs: Taiwan as an example. Journal of Health Communication, 11, 769-788. Chapman, S., Byrne, F., Carter, S. M. (2003). Australia is one of the darkest markets in the world: The global importance of Australian tobacco control. Tobacco Control, 12, iii1-iii3. Clark, E., McCann, T. V., Rowe, K., & Lazenbatt, A. (2004). Cognitive dissonance and undergraduate nursing students’ knowledge of, and attitudes about, smoking. Journal of Advanced Nursing 46, 586-594. Commonwealth Department of Health and Aged Care (2001). Review of health warnings on tobacco products in Australia. Retrieved October 11, 2008, from www.health.gov.au/internet/main/publishing.nsf/Content/474DA5DAC70608F2CA2571A1001C7DFE/$File/tobacco.pdf Commonwealth of Australia (2004). Australia’s national tobacco campaign: Evaluation report volume three. Retrieved October 11, 2008, from, http://web.archive.org/web/20080726150242/http://health.gov.au/internet/main/publishing.nsf/Content/88ED1349FD03EB05CA257331000C3A17/$File/tobccamp3-cp.pdf Eagly, A. H., & Chaiken, S. (1993). The psychology of attitudes. USA: Harcourt Brace Jovanovich College Publishers. Friedman, R. S., & Arndt, J. (2005). Re-exploring the connection between terror management theory and dissonance theory. Personality and Social Psychology Bulletin, 31, 1217-1225. Gilbert, E. (2005). Contextualising the medical risks of cigarette smoking: Australian young women’s perceptions of anti-smoking campaigns. Health, Risk and Society, 7, 227-245. Gleicher, F., & Petty, R. E. (1992). Expectations of reassurance influence the nature of fear-stimulated attitude change. Journal of Experimental Social Psychology, 28, 86-100. Harmon-Jones, E. (2000). Cognitive dissonance and experienced negative affect: Evidence that dissonance increases experienced negative affect even in the absence of aversive consequences. Personality and Social Psychology Bulletin, 26, 1490-1501. Kinsman, T. (2005). 2004 national tobacco campaign evaluation. Retrieved October 11, 2008, from http://www.quitnow.info.au/internet/quitnow/publishing.nsf/ Content/A290E7F6AFAA3F1ACA257475001ADBEE/$File/2004report.pdf Ministerial Council on Drug Strategy (2005). National tobacco strategy, 2004–2009: The strategy. Retrieved October 12, 2008 from http://www.aodgp.gov.au /internet/main/publishing.nsf/Content/E955EA2B5D178432CA256FD30017A522/$File/tobccstrat2.pdf Park, H S., Levine, T. R., Kingsley Westerman, C. Y., Orfgen, T., & Foregger, S. (2007). The effects of argument quality and involvement type on attitude formation and attitude change: A test of dual-process and social judgment predictions. Human Communication Research 33, 81-102. Petty, R. E., Brinol, P., & DeMarree, K. G. (2007). The meta-cognitive model (MCM) of attitudes: Implications for attitude measurement, change and strength. Social Cognition, 25, 657-686. Petty, R. E., & Cacioppo, J. T. (1986). The elaboration likelihood model of persuasion. Advances in Experimental Social Psychology, 19, 123-205. Romer, D., & Jamieson, P. (2001). Do adolescents appreciate the risks of smoking? Evidence from a national survey. Journal of Adolescent Health, 29, 12-21. Rydell, R. J., McConnell, A. R., Strain, L. M., Claypool, H. M., & Hugenberg, K. (2007). Implicit and explicit attitudes respond differently to increasing amounts of counter-attitudinal information. European Journal of Social Psychology, 37, 867-878. Shanahan, P. (2001). Evaluation of the health warnings and explanatory health messages on tobacco products. Retrieved October 11, 2008, from http://web.archive.org/web/20090908092409/http://www.health.gov.au/internet/main/publishing.nsf/Content/474DA5DAC70608F2CA2571A1001C7DFE/$File/warnings.pdf Simmons, V. N., Webb, M. S., & Brandon, T. H. (2004). College-student smoking: An initial test of experiential dissonance-enhancing intervention. Addictive Behaviors, 29, 1129-1136. Smith, K. H., & Stutts, M. A. (2003). Effects of short-term cosmetic versus long-term health fear appeals in anti-smoking advertisements on the smoking behaviour of adolescents. Journal of Consumer Behavior, 3, 157-177. Tangari, A. H., Burton, S., Andrews, J. C., & Netemeyer, R. G. (2007). How do anti-tobacco campaign advertising and smoking status affect beliefs and intentions? Some similarities and differences between adults and adolescents. Journal of Public Policy and Marketing, 26, 60-74. Van Overwalle, F., & Siebler, F. (2005). A connectionist model of attitude formation and change. Personality and Social Psychology Review, 9, 231-274. Viswesvaran, C., & Schmidt, F. L. (1992). A meta-analytic comparison of the effectiveness of smoking cessation methods. Journal of Applied Psychology, 77, 554-561. White, V., Tan, N., Wakefield, M., & Hill, D. (2003). Do adult focused anti-smoking campaigns have an impact on adolescents? The case of the Australian national tobacco campaign. Tobacco Control, 12, ii23-ii29. Wood, W. (2000). Attitude change: Persuasion and social influence. Annual Review of Psychology, 51, 539-570. World Health Organisation (2008). WHO report on the global tobacco epidemic: The MPower package. Retrieved October 11, 2008, from http://www.who.int/ tobacco/mpower/mpower_report_full_2008.pdf Zimbardo, P. G., Ebbesen, E. B., & Maslach, C. (1977). Influencing attitudes and changing behaviour: An introduction to method, theory and applications of social control and personal power. (2nd ed.). USA: Addison-Wesley Publishing Company.