Smoking cigarettes accounts for 480,000 deaths in the U.S., and is the leading cause of morbidity and mortality (U.S. Department of Health and Human Services, 2014). While smoking cigarettes have declined, vulnerable populations continue to smoke at high rates (Jamal et al., 2018). In addition, new nicotine products have hit the market resulting in an exponential rise of initiation and use of products such as electronic nicotine delivery systems (Willett et al., 2018). Tackling smoking and use of tobacco products requires continued public health efforts including health communications and policy changes.
Graphic health warnings (GHWs) and anti-tobacco campaign ads are essential in disseminating information about the dangers of tobacco use to help prevent and stop tobacco use, as well as advocate for policy changes. One way GHWs and anti-tobacco ads try to accomplish this is by eliciting strong emotional arousal such as fear and disgust. Highly emotional anti-tobacco ads are perceived to be more effective than non-emotional anti-tobacco ads and are important predictors of positive outcomes (i.e. intention to quit, quitting) (S. J. Durkin, Biener, & Wakefield, 2009; Hafstad, Aarø, & Langmark, 1996; Wakefield, Flay, Nichter, & Giovino, 2003). However, research on fear-appeals show that they do not always work and are not always effective in changing behavior. Thus, whether tobacco-related cognitions (i.e. intentions) and behaviors can be influenced by emotions that are largely used in GHW and other health communication ads are not fully understood.
Moreover, there are opposing views of the role of emotions. One argument views emotions as coercive. For example, the tobacco industry has criticized the U.S. FDA on their use of emotions in their proposed graphic health warnings for cigarettes. The industry stated that emotions were used just to evoke negative emotions and to force people to quit, rather than convey information ("R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al.," 2012). However, empirical evidence has demonstrated that emotions are important in processing information. According to health advocates, emotion is no longer thought of as a chaotic attribute, but rather is found to be salient in information processes and health outcomes. The Appraisal-Tendency Framework (ATF) describes the differential effect emotions have on decision-making. The ATF has been used to explain outcomes related to risks such as terrorism threats and driving, however studies on emotions and their effect on health behaviors, such as smoking, are scarce. Understanding the effect emotions have on tobacco-related outcomes is helpful in tobacco control efforts in developing effective anti-tobacco campaigns to decrease smoking and increase advocacy for smoking restriction policies. Based on the ATF and subsequent research, emotions are helpful in processing information, and that in turn, informs judgments and decision-making. Implications from this dissertation seek to add to the ATF and tobacco control literature by demonstrating effects and applicability of discrete emotions on tobacco-related judgments and decisions.
This dissertation explores the effects discrete emotions, specifically fear, anger, sadness, and disgust, have on tobacco-related outcomes. First, a systematic review of the literature was conducted to span the literature and consolidate findings that fear, anger, sadness, and disgust had on smoking-related outcomes. Out of the thirteen studies that met inclusion criteria, fear (n=12) was the most common researched emotion, followed by disgust (n=2) and anger (n=2), and then sadness (n=1). Outcomes varied from smoking-related intentions to quit to anti-smoking ad perceived effectiveness. Overall, there was a positive association with fear and smoking-related intentions to not smoke in nonsmokers, anger had an impact on attitudes towards indoor air policies, disgust is important in ad effectiveness, and sadness increases intentions to quit smoking.
Second, the Emotions and Health Study, an experimental study intended to elicit emotions, was conducted to test the causal effect of fear, anger, sadness, and disgust on smoking-related judgments. In multivariate analyses controlling for sociodemographics, anger and sadness increased perceptions of risk of smoking and perceptions of responsibility towards the tobacco companies. Perceptions of health risk are important in decreasing smoking initiation and perceptions of responsibility may be helpful in advocating for tobacco policy changes. Future studies are needed to fully understand how smoking-related perceptions of responsibility can affect tobacco-related behavior, such as advocacy for tobacco-related policy changes. Surprisingly intensity of fear and disgust, most common emotional-appeals used in graphic health warnings (GHW), were not associated with perceptions in this study. Therefore, this study demonstrated the utility of anger and sadness, especially their usefulness in GHW that may be used to keep GHW novel and effective.
Third, using data from the Emotions and Health Study, applicability of discrete emotions on smoking-related policy intentions related to smoking restrictions in permanent (i.e. multiunit housing) and temporary (hotel/Airbnb) living spaces, public areas, and in one’s own personal driving vehicle were investigated. In multivariate analyses, attitudes on smoking restrictions and sociodemographics were associated with smoking ban advocacy intentions. However, emotions were not related to increasing advocacy and behavioral intentions around smoking ban policies. The only emotions examined were fear, anger, sadness, and disgust, and it is possible that other emotions such as worry or hope may be more applicable. More research is needed to understand the applicability of emotion on smoking-related policy intentions.
Overall emotions are helpful in processing information and have been found to have differential effects in smoking-related outcomes. Fear, anger, sadness, and disgust are common emotions elicited from anti-smoking campaigns and have the ability to increase intentions to not smoke, increase ad campaign effectiveness, and increase perceptions of risk and responsibility. Continued research is needed in this field of emotions and decision-making, especially around health behaviors such as smoking.