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So, we just got a nod from the Disruptive Women in Health Care blog! They put us on the blog roll. Do us a favor and go visit their awesome site!

Graphic cigarette labels ... really?

Take a look at these:

Pretty pictures of new warnings that will be included on cigarette packs per 2009 legislation.

Now, take a look at any of the following:
Ineffectiveness of fear appeals in youth
How to use fear appeals
Fear appeals in traffic safety

When a person believes that he is not vulnerable to a risk, his behaviour will not be affected by information about the serious consequences and the recommendations for effective behaviour.

In other words ... now, stay with me ... fear appeals are largely ineffective, especially among younger populations. In simple terms, this is because young people don't understand how to effectively estimate risk. This is the root of the common "it won't happen to me" phenomenon, and the reason that many teenagers are drawn to risky behavior. Their brains are quite literally unable to process the seriousness of the danger inherent in many behaviors and situations.

Also, we've tried stuff like this before, when the tobacco companies were required to advertise to prevent youngsters from initiating smoking: Evaluation of youth response to tobacco-company sponsored messages.
Not surprisingly, these companies crafted their messages to appeal to adults who needed a warm, fuzzy feeling ... but the teen smoking rate increased. That's right, the public health ads that were supposed to prevent kids from smoking actually prompted more young people to light up. Brilliant!

What makes us think, then, that young people won't just discount these messages, ridiculing them in a defensive response? My prediction is that is exactly what's going to happen. These messages will be, at best (in younger populations), completely ineffective because they're mocked by kids for being entirely too graphic.

Even more importantly, sometimes fear appeals such as these can have an iatrogenic effect; that is, the intervention worsens the problem. Fear appeals provoke a defensive mechanism that prompts target audiences to engage in dangerous behavior simply to prove that they're immune to the behavior's negative health effects. In other words, people might start smoking more as a proverbial "middle finger" to the public health campaign. "See, I can do it, and I won't die!" ... or, they'll rationalize their behavior by pointing to anecdata that supports their behavior. Ex: "My grandpa smoked a pack a day for 80 years, and he lived forever."

Anyway, way to go, FDA, for being completely unoriginal and refusing to acknowledge the massive body of research that indicates the complete worthlessness of fear appeals. This legislation passed because we have a bunch of uneducated, self-righteous politicians who want to make themselves feel better because they're doing something. Well, they did something before, involving the tobacco companies, and they succeeded in making the problem worse instead of lowering smoking rates among our nation's youth.

Only time will tell whether this intervention will follow the same path.

ETA: Does anyone else think this is going to cause an increase in the sales of cigarette cases? I would rather have my smokes in a stylish vintage box instead of one of these horrifying boxes. People really can circumvent any intervention.

UPDATE: Check out this awesome editorial, which proves my point --- Smokers unmoved by graphic ads

The Theory of Planned Behavior, operationalized

This may seem rudimentary, but did you know that the Theory of Planned Behavior, a critical behavioral model for public health interventions, can actually be operationalized with mathematical measures?

Theory of Planned Behavior ... with math!

For those of you who aren't completely familiar with this model, I've included a diagram above. Now, I have always been a little wary of simplistic models such as this, because you have to wonder whether intention directly leads to behavior; however, I like that this model includes perceived behavioral control as a factor that influences behavior as well.

At any rate, when we consider this model, we're interested in measuring how attitudes, subjective norms, and perceived behavioral control influence intention, which in turn should influence behaviors. What do all of these terms mean?

Attitude: individual evaluation of a behavior. Operationalized (measured) by considering:
- personal beliefs that a behavior will result in a specific outcome
- evaluation of the outcome
- number of beliefs relevant to the behavior

Subjective norm: how society or environment contributes to behavior. Includes:
- probability that the subject believes the behavior is appropriate
- motivation to comply with this reference point
- number of reference points

Perceived behavioral control: the extent to which the individual believes he or she can control behavior. Includes:
- beliefs about whether factors that will affect the difficulty of the behavior
- perceived power of these factors
- number of factors

Yeah, I had no idea that this model was so ... scientific. It's hard sometimes to conceptualize these models as anything except the brainchild of some doctoral student in a think tank far, far away. And I really do wonder about their ability to predict behavior with such ease. There are so many variables that play into predictors of behavior ... I have to admit, a lot of the times I have intentions to change my behavior, but something prevents me from doing so. (Ex: I can NEVER seem to eat enough vegetables. Grrrr.) I am not 100% convinced that my inability to transfer my good intentions to behavior is a factor of only perceived behavioral control. I believe I can eat more vegetables. I really do.

Anyway, the point is that we need to critically evaluate these commonly accepted models. Although I admit I'm not an expert, I hesitate to just swallow these theoretical constructs that claim to distill human behavior to such simplistic terms. Also, the models' developers are often loath to disclose limitations that they might anticipate with their constructs ... did they honestly not forsee these problems, or were they hoping to fly under the radar, hoping other scientists wouldn't notice the models' inherent shortcomings?

I wouldn't put such nefarious measures past members of our scientific community, but when our entire understanding of human behavior is built on such shifting sands, it sure does humble a student in this field. Our comprehension of ourselves and the world around us is still so ... rudimentary. For all of our happy diagrams and well-articulated arguments, we really aren't close to understanding motivation, faith, or any other nebulous human attribute.

Without this fundamental knowledge, how are we expected to facilitate change?

Polling accuracy: NY Times doesn't have it

Granted, this is kind of old news, but it makes you stop and think about the sources of "news" we're subjected to in relation to public health concerns:

During my research today at work, I came across this article that expresses Americans' general distaste for cell phone usage in vehicles: Many in U.S. Want Texting at the Wheel to Be Illegal

What's interesting about this poll, you might ask? Well, just read through the methodology here: How the poll was conducted

Does anyone else find it absolutely ridiculous that you would poll only land lines when asking questions about cell phone usage? Perhaps we should consider for a moment the 25% of Americans who don't have access to traditional telephony ... 1 in 4 have no landline. I bet their opinions about cell phone usage might be just a little different. Did anyone stop to consider that people in landline-friendly homes (or even homes with *gasp* no cell phone at all) might be a little biased against cell phone usage? They might have some kind of ideological beef against cell phones. They might be the ones yelling at the young whippersnappers to "Get Off My Lawn!!!"

So ... don't believe everything that you read. That's clearly an established idiom, but I'm consistently surprised at how organizations are allowed to get away with stuff like this.

ETA: Also, shouldn't we be thinking about how this is going to affect public health polling in general? What's our demographic shift if we are only considering those with hard-wired houses? We will be discounting impoverished communities, as well as renters and some minority groups. This is just another factor that's contributing to the continued fragmentation of efforts within the public health community; we must develop new ways of soliciting accurate information so we can take action. If even our basic premises are flawed because our methods are outdated, are we really doing our jobs at all?

Perry: Everything's better in Texas! Except for traffic safety!

Texas Governor Rick Perry vetoed legislation Friday that would have outlawed texting and driving. In doing so, he has put a damper on a rather serious education and enforcement effort that Texas public health officials are trying to promote.

Hmm, this seems like a smart plan!

Perry vetoes texting ban

It's well-known that enforcement is an important component when considering behavior change. Educational messages, when presented on their own, rarely result in behavior modification. This is especially true in traffic safety situations, including drowsy driving and drunk driving scenarios. Governor Perry, in vetoing this bill, is ignoring one of the most valuable tenets of public health: Policy must support advocacy.

Check out this site from the Insurance Institute of Highway Safety: IIHS Q&A's about alcohol enforcement

This is a great resource for the layperson who's interested in learning about general principles of traffic enforcement.

The only way you're going to get drunk drivers to sober up is through (a) increased enforcement and (b) the perception of increased enforcement. If people think they're more likely to get caught, they're less likely to engage in the behavior. This is reinforced by the basic concept of risk management, which balances the likelihood of an event with the severity of its consequences. We are far more interested in risky behavior if adverse consequences are infrequent.

Some might argue that, since enforcement for texting laws is so low in other states, having such a law on the books is irrelevant and wasteful. Again, however, the actual enforcement itself can be supplemented by efforts to increase the perception of risk. "If you text and drive, you'll be caught and get in huge trouble," would be an effective message if accompanied by even minimal increases in police officer vigilance.

The level of permissiveness that this veto demonstrates is boggling. Perry calls texting laws "micro-management of adult behavior." Well, if that's micro-managing, then we should all have the freedom to drive completely blitzed, because We're AMERICAN, dammit! Perhaps allowing blind people to drive would be wise, too, by this logic, because we wouldn't want to impede anyone's basic rights.

Not only that, but did Perry consider the impact that this law will have on individuals who populate our state's crosswalks and bike lanes? This law isn't just about protecting drivers; it's about protecting all of us.

And, on a final note, is driving a vehicle a basic right? Although many environments (particularly those of the rural persuasion) are conducive to individual vehicle ownership, a lot of people get by every day without using a car. It's hard for me to believe that, if the Founding Fathers lived today, they would include the Right to Private Transportation in the Constitution.

Ultimately, Perry is pandering to his political constitutents to further anti-government sentiment and strengthen his bid for the White House. It's infuriating that the people making these very important decisions are so obviously poorly informed ... and poorly motivated.

ETA 6/27/11:
Reading a JAMA article today about distracted driving, and the author brought up the topic of Constitutionality ... that is, can the government interfere with what drivers do inside their vehicles to improve highway safety. The answer is a resounding "Yes!"

Courts have consistently upheld mandates on drivers (eg, seat belts and motorcycle helments), and would surely find that the government's interests in protecting the population from distracted drivers outweigh individual liberties. The Supreme Court has similarly upheld congressional requirements for states to adopt safety standards as a condition of federal funding.

(Jacobson & Gostin, 2010).

Just another reason for Perry to get his act together ... although I suppose Texas, as the only state that was once its own country, has a tendency to ignore the whole concept of federal authority.

New Partnership for Prevention Case Study: Colorado’s Tobacco Cessation Leadership

Partnership for Prevention published a state case study telling the story of Colorado’s journey toward comprehensive tobacco cessation coverage. Entitled “A Collaborative Approach to Meeting the U.S. Preventive Services Task Force Recommendations on Tobacco Cessation Screening and Intervention”, it describes how the Colorado Tobacco Cessation and Sustainability Partnership worked closely with public and private health plans to provide coverage for tobacco treatment. As a result, the majority of Colorado smokers have access to free or low-cost evidence-based cessation services and support for the state’s QuitLine has been enhanced. Advances were made in spite of decreased state tobacco control program funding.

Leaders in many states have begun to work with health plans to discuss the provision of preventive services. As the implementation of federal health reform moves forward it is Partnership’s hope that states can benefit from Colorado’s pioneering work in advancing tobacco cessation treatment. As states and territories progress toward a more integrated approach to preventive health, the Colorado Tobacco Cessation and Sustainability Partnership model for engaging health plans to implement USPSTF recommendations for cessation coverage can be applied to other preventive health services.

Mother’s Day Health E-Cards

The Centers for Disease Control and Prevention (CDC) has over 100 E-Cards with healthy messages about smoking cessation, heart health, women’s health and many more. Send one to your mom for Mother’s Day to show her how much you care about her and her and wellbeing.