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A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom,… Haines-Saah, Rebecca; Bell, Kirsten; Dennis, Simone Feb 28, 2015

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A Qualitative Content Analysis of Cigarette Health Warning Labels inAustralia, Canada, the United Kingdom, and the United StatesRebecca J. Haines-Saah, PhD, Kirsten Bell, PhD, and Simone Dennis, PhDThe legislation of health warning labels on cigarette packaging is a majorfocus for tobacco control internationally and is a key component of the WorldHealth Organization’s Framework Convention on Tobacco Control. This population-level intervention is broadly supported as a vital measure for warning people aboutthe health consequences of smoking. However, some components of this approachwarrant close critical inspection. Through a qualitative content analysis of theimagery used on health warning labels from 4 countries, we consider how thisimagery depicts people that smoke. By critically analyzing this aspect of thevisual culture of tobacco control, we argue that this imagery has the potential forunintended consequences, and obscures the social and embodied contexts inwhich smoking is experienced. (Am J Public Health. 2015;105:e61–e69. doi:10.2105/AJPH.2014.302362)Visual imagery of the health effects of smokinghas a long history in the context of antitobaccocampaigns. Such images featured prominentlyin Victorian era antismoking literature,1,2 andvisual representations of the deleterious effectsof smoking on the body have been a continu-ous thread in modern-day tobacco control andpublic health iconography. The first warninglabels mandated on cigarette packaging weretext-based only, enacted in the United Statesa year after the1964 Surgeon General’s Reportdecisively linked smoking to cancer and otheradverse health outcomes.3 In 1965, the USFederal Cigarette Labeling Act required ciga-rette cartons and packs to carry the warning,“Caution: cigarette smoking may be hazardousto your health.”4(p13) The addition of pictures towarning labels on tobacco packaging is a rela-tively recent phenomenon, legislated first inCanada in 2000.5 Following Canada’s lead,many other countries have since followed suit,with text and picture-based warnings requiredin 63 countries worldwide as of 2012.6 Theuse of visual imagery (referred to specificallyas “health warning labels”) on tobacco pack-aging has been driven by the World HealthOrganization’s Framework Convention onTobacco Control and is based on the premisethat “a picture says a thousand words.”6(p1)Article 11 sets out clear standards for healthwarning labels, which are expected to cover“as much of the principal display areas aspossible.”7(p34)For tobacco control advocates, the impetusfor visually based warning labels was clearlyprotection and empowerment against the to-bacco industry’s tactics—for children andyouths, who were seen as particularly suscep-tible to “prosmoking” media imagery, and forconsumers, who had been subject to industry“fraud” and misinformation about the healthrisks and consequences of smoking.5(p356)However, although the ostensible purpose ofthe visual imagery used on health warninglabels is to educate smokers about the effects ofsmoking, it draws some of its impetus from theassumption that the subjective emotional re-sponse the images may provoke will forcesmokers into “realizing the harm done to theirbodies.”8(p358) In other words, the transitionfrom text-based to visual warning labels reflectsa growing awareness that the labels could beused not just to transmit information but toaffect behavioral change. Indeed, health warn-ing labels on cigarette packages are seen tobe even more effective than traditional printand television campaigns because they “po-tentially reach smokers every time they pur-chase or consume tobacco products.”7(p23) Theunderlying assumption is that, in contrast tosimilar messages presented in other mediums,the warnings are unavoidable. From a publichealth standpoint, a third goal of such labels isto facilitate tobacco denormalization by chal-lenging the social and cultural acceptability ofsmoking, especially the glamorization of to-bacco in media and popular visual culture.9In this respect, the visual culture of tobaccocontrol has been heavily influenced by thetobacco industry, and aims to use its strategiesand practices against it.10Numerous studies support the view thathard-hitting graphic labels are more effectivethan text-based warning labels in stimulatingawareness of tobacco-related health risks andincreasing motivation and intentions to quitsmoking.8,11,12 Plain cigarette packaging is seento be particularly effective in reducing theappeal of smoking and focusing attention onthe image and text of the health warninglabels.13 Australia’s introduction of plain ciga-rette packaging requirements in December2012 has generated considerable interest insuch legislation. However, one limitation of theavailable research is that responses to cigarettepackages are studied in a context in whichthe ordinary coordinates of smoking are ab-sent, making effectiveness very difficult tojudge.14Critical approaches to health promotionchallenge the assumption of a simplistic orunidirectional relationship between publichealth campaigns and their intended targets, inwhich audiences are passive recipients ofhealth information. Contrary to a didacticmodel of health education and its emphasis onindividual behavioral change, critical ap-proaches recognize the structural context ofsmoking and the social, historical, and politicalcircumstances in which antismoking messagesare deployed. Thus, multiple readings and re-sponses on the part of message recipients areinevitable. In the arena of smoking cessation,this includes the potential for negative re-sponses, ranging from context dissonance15 todefiance or resistance.16---18 This recognitionFRAMING HEALTH MATTERSFebruary 2015, Vol 105, No. 2 | American Journal of Public Health Haines-Saah et al. | Peer Reviewed | Framing Health Matters | e61challenges mainstream and top-down ap-proaches in health promotion, which mayassume that health-related behavior change ismerely a matter of better education for at-riskindividuals and groups (i.e., that programmersand policymakers just need to get the messageright). These approaches also highlight the needfor public health policies to move beyond anexclusive emphasis on questions of efficacy toconsider the ethics of the strategies employed(i.e., even if they do work, at what cost?). Withoutcareful consideration of the ethical implicationsand unintended consequences of such messag-ing, the “war against smoking” may insteadbecome a counterproductive “war againstsmokers.”Our analysis of health warning labels oncigarette packaging has been informed by pre-vious research on the visual culture of publichealth, which suggests that health promotionand education campaigns are constitutive ofdeeply embedded cultural understandings ofhealth, illness, and social relations of power.19--21From this standpoint, it is useful to consider howhealth-related imagery presented as scientificand objective privileges particular ways of seeingand defining both the bodies and identities ofthose who are “healthy” and pathological bodiesat risk for illness.22--24 As critical public healthscholars suggest, health promotion campaignsnot only reinforce a normative imagery of healthbut can also contribute to social exclusion,stigmatization, and dehumanization whengraphic and confronting images designed toprovoke disgust are used.16,25 These tendencieshave been explored in the context of issues suchas injury prevention and disability,26,27 HIV/AIDS,22,28,29 obesity,25 and substance use, in-cluding alcohol30 and smoking.31,32 For example,analyses of antitobacco messages for pregnantwomen33 and campaigns directed toward ado-lescent girls34 suggest that the former promotethe notion of the “bad mother” and neglectsmoking by fathers and other men, whereas thelatter reinforce the idea that what is most valu-able about women is their external, physicalappearance.35We analyzed the visual culture of tobaccocontrol as represented by cigarette healthwarning labels in the context of 4 countries,and interpreted what this reveals about smok-ing as a social identity and practice. Such labelsprovide openings through which to see the“densely elaborated iconography”36(p107) oftobacco control and how it conceptualizessmoking and people labeled as smokers. Wecontend that the currently used and proposedsets of health warning labels ground under-standings of smoking and its effects in ways thatobscure certain dimensions of the practicewhile foregrounding and prefiguring others.In particular, they frame smoking as an in-dividual risk behavior, one entirely isolablefrom its social context. Our approach iscritical of such framing, and cuts against bothits emphasis on a biomedical imagery of the“diseased and dying” body and its diminish-ment of agency.9METHODSAlthough numerous countries have imple-mented health warning labels that includeimages, for the purpose of our analysis wechose to focus on Australia, Canada, theUnited Kingdom, and the United States. (Anonline inventory of health warning labels,including the specific images we reference, canbe found at http://www.tobaccolabels.ca,a site operated by tobacco packaging expertDavid Hammond, University of Waterloo,Canada.)Because of a legal challenge by the tobaccoindustry, the set of American labels we ana-lyzed has not yet gone into effect, but we havechosen to include them in our analysis becausethey present the intended direction for ciga-rette packaging in the United States. As theFour-Country International Tobacco ControlSurvey evidences,11 these countries are com-monly used as a basis for comparing tobaccocontrol legislation, in part because as industri-alized democracies they are broadly politicallysimilar but have different histories and inten-sities of legislation, as well as different stake-holders influencing antitobacco advocacy.37Focus on cigarette packaging labels (i.e., ex-cluding the health warning labels for little cigarsand other tobacco products) across the 4countries produced 74 images for contentanalysis. Table 1 provides a summary andcomparison of the status of legislation regardingthe health warning labels within each country.Content analysis is an umbrella term fora variety of approaches that share an interest inanalyzing “mute evidence” (i.e., written texts,images, and artifacts).38 Although quantitativecontent analysis focuses on enumerating anddetermining the “objective” content of texts,qualitative content analysis consists of “a reflexivemovement between concept development, sam-pling, data collection, data coding, data analysis,and interpretation.”39(p68) The aim is to besystematic and analytic but not overly rigid; thus,although thematic categories may initially guidethe study, others are expected to emerge throughthe analytic process, guided by constant discoveryand comparison of relevant situations.We conducted our qualitative content analysisin several steps. First, we uploaded the healthwarning labels from each country to a privateonline gallery, grouped according to their countryof origin. All 3 authors separately viewed andanalyzed each of the 74 warning labels, focusingon interpreting the manifest (the obvious orexplicit meaning) and latent (the subtext orimplicit meaning) content of the imagery andaccompanying text. Each author completed ananalysis table covering all of the labels, ensuringthat we considered their style and format, theircontext within the set of labels, and how theycompared with other national series. From ourinitial, independent written analyses and jointsubsequent discussions emerged a set of 8 broaddescriptive codes to cover the central themes weidentified (Table 2).RESULTSThere are commonalities between the labelsin all 4 countries. All emphasize the debilitatingimpacts of smoking on the physical body(codes 1---4) and consistently use confronting,visceral imagery to make their case—althoughthe text of the labels often plays an importantrole in grounding the meaning of the imagesthemselves, as some are quite ambiguouswithout the accompanying text to help theviewer “read” them. Equally apparent is thenegative focus of virtually all the labels—veryfew are positively framed or focus on thebenefits of quitting. This is particularly evidentin the Canadian warnings, which do not featurea single message of “hope” or “help” (code 8) aswe defined it. Also missing to varying degreesin all of the sets of warning labels are expla-nations as to why people smoke beyond ad-diction (code 6), which is mentioned in 3 of the4 sets of labels.FRAMING HEALTH MATTERSe62 | Framing Health Matters | Peer Reviewed | Haines-Saah et al. American Journal of Public Health | February 2015, Vol 105, No. 2Despite these broad similarities, there weresome notable differences. First, only the Aus-tralian and Canadian warnings feature depic-tions of named, identified smokers (code 4).Second, the proportion of the Australian labelsfocusing on “protection” (14%; code 5) issmaller than that of any of the other 3 coun-tries; in contrast, one third of the proposed USset emphasize the harms of smoking to others.A third difference is evident in the varyingstrength of the claims that warning labels makeacross the countries. Australia employs un-equivocal wording that denotes a causal re-lationship between smoking and ill health. Itslabels speak in absolutes: “Smoking kills,”“Smoking causes blindness,” “Smoking causesthroat cancer.” The Canadian labels are moreambiguous. They include statements such as“Smoking leads to premature death,” “Smokingmay increase your risk of blindness,” “Second-hand smoke . . . can harm an unborn baby.”Fourth, although images of White, middle-agedsmokers dominate all of the labels, the US andCanadian warnings are more ethnically diversethan the Australian or British ones. This isparticularly noticeable in the US images, at leasta third of which feature people of color.Further, although for the most part men’s andwomen’s bodies are treated interchangeably toconvey the generic effects of smoking on thehuman body, the explicitly sexed and genderedhealth effects of smoking (code 7) on the bodyfeature more prominently in the UK labels.In light of these differences and similaritiesacross the 4 national contexts, there are 4 keythemes arising from the descriptive coding thatwe considered in depth: (1) how the cigarettewarning labels represent the idea of the body(i.e., as a social entity, or object of medical andpublic scrutiny), (2) what they may communi-cate about the identities of people who smokeand their reasons for doing so, (3) how theirdepiction of the need to protect others from theeffects of tobacco may be read as gendered,and (4) how they position the issue of addictionas a health and social problem.The BodyThe effects of smoking on the physical bodyare the overwhelming focus of the warninglabels, constituting more than half (52%) of all74 labels. Moreover, all sets of labels includeconfronting images that are clearly intended toelicit strong feelings of disgust and revulsion.The Australian and UK labels, in particular, usea technique of drawing attention to the in-teriority of the body, such as the macula of theeye, the intricate networks inside the lungs(Figure A, available as a supplement to theonline version of this article at http://www.ajph.org), and the womb, to communicate anddisclose the unseen impacts of smoking. Forexample, an Australian label features an imageof a blue eye held open by specula as it isprepared for surgery (code 1; see Figure B,available as a supplement to the online versionof this article at http://www.ajph.org). Suchlabels invite the tobacco user to reflect uponunseen aspects of the body as it experiencessmoking, in this case the danger of impendingblindness. Bringing damaged, unseen regionsof the body into focus via visceral and full-colorimages aims to force the tobacco user to attendnot only to damage that might already besustained through smoking, but to foregroundTABLE 1—Comparison of Picture-Based Health Warning Label (HWL) Legislation, by CountryCountry Legislation and Agency AuthorityYear Picture-Based HWLs FirstMandatedYear Picture-Based HWLsSignificantly Changed or UpdatedNo. of Picture-Based HWLS Usedon Cigarette PackagingAustralia Competition and Consumer(Tobacco) InformationStandard (F2012C00827);Department of Health andAgeing (2012)2004—Consumer ProductInformation Standards(Tobacco) Regulations; cameinto force in 2006.2011—increased size of HWLS;2012—plain packagingintroduced.14 HWLs for cigarettes andsmoked tobacco products.Canada Tobacco Products LabellingRegulations (Cigarettes andLittle Cigars; SOR/2011-177);Health Canada (2011)2000—HWLs first required by theTobacco Act, Tobacco ProductsInformation Regulations;implemented June 2001.2011—updated set of imagesand increased-sized HWLs fortobacco and little cigars.16 HWLs for cigarettes.United Kingdom The Tobacco Products Directive,European Commission ofMember States (2003/641/EC); Department of Health (UK)(2003)2007—Came into force in 2008. 2012—addition of 14 new HWLs;2013—increased size of HWLs.42 HWLs developed by the EC;35 are used in the UK.United States Family Smoking Prevention andTobacco Control Act, (Pub L111–31, HR 1256); US Foodand Drug Administration (FDA)(2009)2009—However, the new set of 9text and picture-based GWLswere finalized by the FDA in2011.Not applicable Implementation of 9 picturewarnings was mandated forSeptember 2012; tobaccoindustry won a legal challengethat blocked this in August2012; current status unknown.Note. EC = European Commission; GWL = graphic warning label.FRAMING HEALTH MATTERSFebruary 2015, Vol 105, No. 2 | American Journal of Public Health Haines-Saah et al. | Peer Reviewed | Framing Health Matters | e63TABLE2—CodesofCigaretteWarningLabels,byCountryDescriptiveCodesAustralia,No.Canada,No.UnitedKingdom,No.UnitedStates,No.RowTotals,No.(%)Code1:attachedordisembodied(thedisembodiedbodypartaffectedbydiseasebutconnectedtoabody;includesinteriorsoflivingbodies—e.g.,X-ray)526114(19)Code2:detachedordisembodied(thedisembodiedordiseasedbodypartremovedpostmortem;includesbodilyoutput—e.g.,blood,urine)32117(9)Code3:depersonalizedorembodied(theunnamedbutembodiedsmokerswhosebodilydeteriorationanddeathisshown;includespartialfaceviews)027211(15)Code4:personalizedorembodied(thepersonalizedandidentifiedor“named”smokerwhosestorywelearn)34007(9)Code5:protection(theeffectsofsmokingoninnocents,especiallybabies,children,andfetus;includesultrasoundimagery)246315(20)Code6:addiction(anemphasisonaddictionitselfasadiseaseandaproblem)01315(7)Code7:sexandgender(thesexedorgenderedeffectsofsmoking;reproductivehealth;feminineappearance)019010(14)Code8:hopeandhelp(cessationhelpfrommedicalprofessionals;attemptsatempowermentregardingquitting)10315(7)Columntotals141635974(100)FRAMING HEALTH MATTERSe64 | Framing Health Matters | Peer Reviewed | Haines-Saah et al. American Journal of Public Health | February 2015, Vol 105, No. 2the ways in which the physical body continuesto suffer as a result of the habit.Another technique, used particularly in theAustralian and Canadian health warning labels,adds temporality and a particular notion of thebody’s future to this conception of the body.For example, in one Canadian label, a damagedheart is depicted, after extraction, from thebody of a person who has died from smoking(code 2). The label insists that people whosmoke consider not only what is currentlyhappening inside their bodies but also theirinevitable future: disfigurement, serious illhealth, and untimely death. In doing so, itattempts to foreground a view of the bodystrongly at odds with how it is habituallyexperienced in everyday life—by asking a per-son who smokes to contemplate the body as itticks down to death.Also included in code 2 are depictions ofbodily outputs that make visible the impacts ofsmoking. An image used in both Australia andCanada shows blood pooling in a toilet bowlafter it has been expelled in urine from thebody of a person who smokes, which, as thetext on this warning label spells out, is intendedto represent evidence of bladder cancer (Figure1). Whereas expert medical imagery revealsunseen illness (such as lung cancer and fetaldamage) resulting from smoking, the personwho smokes can access this kind of evidencewhen it is expelled from the body. However,there remains the split between the body thatsmokes as part of the routine of ordinaryeveryday life and the physical body that bearsthe evidence of practice in its bloody expul-sions.A final technique is deployed to demonstratewhat will happen if the tobacco user does notreconcile the everyday body that enjoyssmoking with the physical body damaged bythe practice (code 3). In these warnings,particularly well used by the proposed USlabels, the (anonymous) person who smokes isshown in the final throes of smoking-relatedillness. Here, the physical and medicalizedbody emerges in the foreground. Smokerson the brink of death are shown to be slavesto their physical bodies, as the futures pre-dicted for this body come, hideously andpainfully, to pass.Although labels make use of these concep-tions of the body to differing degrees, theoverriding message remains constant: the“everyday” social body that enjoys smoking isshadowed by the “real” physical body thatbears the cost of such activity and suffers itsinevitable consequences. People who smokeare invited to attend to its importance, and areshown the severe consequences of decliningthe invitation. As a feature of tobacco controlimagery that both predates and extends be-yond the cigarette warning labels, a primaryfunction of the graphic, medical imagery is to“open up” the bodies of smokers and renderthem transparent, making the previously in-visible visible and raising the smoker’s self-awareness of the damage they are doing totheir bodies.32 As Van Dijck40(p x) argues,“Medical images of the interior body havecome to dominate our understanding andexperience of health and illness at the sametime and by the same means as they promotetheir own primacy.” The apparently objectiveand nonrhetorical nature of images is key totheir effectiveness. According to Dumit,41(p173)technologies of visualization are seen to “cutthrough” rhetoric to tell the “truth of a subject,”with the image ostensibly speaking for itself—although experts are invariably required tohelp us interpret what we are seeing.IdentitiesAlthough most labels feature fragmented oranonymous bodies, several foreground identitythrough images and text that serve to “bringto life” and personalize smoking and its healtheffects. Put another way, these warnings refer-ence the subjectivities of tobacco users aswhole persons rather than an objectified body,although these people are imbued with verylittle agency or identity beyond their tobaccouse or status as a smoker. To this end, theCanadian labels use first-person quotes froma person who smokes, and the Australian labelstell similar stories in the third person. Repre-senting the reality and real-life stories of peoplewho are suffering and dying as a result of theirsmoking is intended to connect emotionallywith viewers and motivate them to quit(i.e., “It happened to me, it can happen to you”).The labels grouped under the code for“identity” (code 4) show men (Bryan, John, andLeroy) and women (Barb, Cinthia, and Lena)who have experienced tobacco-related illnessand death. All of these people appear to beethnically White, and the captions explain thatthe age at which they experienced morbidityand mortality from smoking was relativelyyoung. The images and text depict their re-duced quality of life and lives cut short fromcancer, stroke, and emphysema (Figure 2). Forexample, 2 almost identical images showa bald, emaciated person dying or almost deadto show “what dying of lung cancer looks like”(Barb, Canada) and “what happens to youwhen you smoke” (Bryan, Australia). Anothercommon image is that of a person with anopening in the neck for a tracheostomy tube(Leroy, Canada; John, Australia), illustrating forviewers how their basic everyday functioningwill be seriously diminished should they con-tinue to smoke (see Figure C, available asa supplement to the online version of thisarticle at http://www.ajph.org). Not unlike thediseased organ detached from the body, theseimages suggest a view of smoking that isdelinked from the everyday context in which ittakes place, as well as other important aspectsof tobacco users’ lives (especially poverty anddisadvantage) that may be critical to under-standing why they smoke are not seen.9,42Source. Health Canada, Government of CanadaFIGURE 1—“Cigarettes cause bladdercancer”: cigarette warning label,Canada, 2011.Source. Health Canada, Government of Canada.FIGURE 2—“Just breathing is torture”:cigarette warning label, Canada, 2011.FRAMING HEALTH MATTERSFebruary 2015, Vol 105, No. 2 | American Journal of Public Health Haines-Saah et al. | Peer Reviewed | Framing Health Matters | e65Although identity as a smoker was theprimary attribute emphasized in the labels,a thread running to varying degrees through-out 3 of the 4 countries was the importance ofsexual function and gender identity. The codefor sex and gender (code 7) was applied almostexclusively in the context of the warnings fromthe United Kingdom, although 1 Canadianlabel is also included in this category. SeveralUK labels are explicitly directed to men whosmoke, and focus primarily on the effects ofsmoking on sperm and erectile function. Forexample, in 1 UK label, a drooping cigarettesignifies an impotent penis, a well-known visualtrope in tobacco control campaigns.43By contrast, images oriented to women useimperatives regarding appearance as a smokingdeterrent; by using images of women andgirls, they present concerns about appearancedamage (i.e., facial wrinkles) resulting fromsmoking as a feminine characteristic. Althoughnot all of the 4 images addressing wrinkledfacial skin show actual women (one showsa wrinkled apple and another depicts ambigu-ously gendered hands), images and messagesthat smoking “makes you ugly” or “spoils yourlooks” have historically been purposefully di-rected toward women and girls.34,35 Thisspeaks to the ethical challenges that targetedpublic health messages raise. As Kass observes,although targeted messaging may often bejustified on public health grounds, “socialharms result if social stereotypes are created orperpetuated.”44(p1780)ProtectionThe labels grouped under the code for pro-tection (code 5), which are dispersed across all4 contexts, comprise 20% (15 labels) of thesample. Most warnings in this category focus onthe harms of smoking to fetuses, infants, andchildren. Images range from a baby in utero(United Kingdom)—referencing harms to anunborn child—to infants who appear to be inneonatal intensive care, presumably prematureor otherwise ill through exposure to smokingin the womb (Australia, United Kingdom,United States; see Figure D, available as a sup-plement to the online version of this article athttp://www.ajph.org). The key exception is animage from the proposed US labels, whichshows an adult woman crying, as she haspresumably experienced the health effects ofsecondhand smoke or the loss of a loved one totobacco-related disease.The labels from Canada employ a slightlydifferent motif. The first shows a masculinehand, holding a lit cigarette, trying to embracean exposed pregnant stomach, while thewoman pushes the hand away (Figure E,available as a supplement to the online versionof this article at http://www.ajph.org). Anotherlabel shows an empty crib to symbolize theinfant deceased from sudden infant deathsyndrome (SIDS). Other labels show olderchildren being exposed to secondhand tobaccosmoke in homes or in cars, and childrenwearing a nebulizer face mask—used to treatpediatric respiratory conditions such as asthma(Figure F, available as a supplement to theonline version of this article at http://www.ajph.org).The subtext of the labels grouped undercode 5 suggests that protecting a fetus in uteroor a baby or child from exposure to tobaccosmoke is a woman’s or mother’s responsibility.Indeed, although it is not explicitly stated,because responsibility for infant and childhealth is still often assumed to be “women’swork,” the subtext of these warnings is that themessages are targeted toward women andmothers. Extending beyond tobacco control,this “think of the children” appeal is a key motifin public health,45 and health promotion cam-paigns have long appealed to maternal guiltand the gendered archetype of the “goodmother.”33,46,47AddictionAnother theme within the labels is tobaccoaddiction (code 6). The 5 labels that addressaddiction are from Canada (n = 1), the UnitedStates (n = 1), and the United Kingdom (n = 3).The UK labels, in particular, use explicit imag-ery and text presenting people who smoke ashopelessly victimized by tobacco dependence.This is shown by a hospital patient unable toquit (a wheelchair-bound man who smokes,intravenous tube in arm), a person imprisonedin a jail where the bars are shown as cigarettes,and a cigarette within a syringe, with the sub-text that tobacco is as addictive as heroin.Representations of addiction in the labels areinextricably linked to how the bodies andidentities of people who smoke are portrayed.All the viewer knows is that these are peopleseverely affected by their cigarette addiction.In this sense, “addict” is their “master status”and an all-encompassing, stigmatized iden-tity.48 As we have suggested, mostly the iden-tities of those who are addicted to cigarettes arenot as important as the presence of addictionitself, and viewers are offered little informationabout the social context in which smokingtakes place. This is particularly evident ina Canadian label that shows a mother anddaughter who smoke. Although they are pre-sumably experiencing poverty (as denoted bythe “scratch it” lottery tickets and their ap-pearance and clothing), their socioeconomicstatus is rendered irrelevant. Thus, the captiontells us that “Cigarette addiction affects gener-ations,” as opposed to the more accuratemessage that tobacco addiction is linked togender and poverty. When smoking is depictedas a generational (and perhaps even genetic)predisposition to nicotine addiction, this pre-cludes an understanding of why smoking be-comes entrenched in the lives of socioeco-nomically disadvantaged families. As Frohlichet al.49 have argued, the effect of this discourseof generational smoking for marginalizedgroups is to attribute blame to a “flawedbiology” that makes people susceptible tosmoking, reinforcing a rationale for individualand behavioral interventions, as opposed toa structural approach that considers the com-plex relationship between smoking, social class,and health inequity.In contrast to confrontational or negativedepictions of addiction and its consequencesare the labels intended to inspire hope forquitting (code 8). This is seen in 3 labels fromthe United Kingdom, 1 from Australia, and 1 ofthe US proposed images (Figures G and H,available as a supplement to the online versionof this article at http://www.ajph.org). Al-though generally positive, the messages used topromote hope or help to quit smoking aresomewhat vague and do not provide specificinformation as to how people can be successfulat quitting. As Room50 notes, this view ofaddiction evokes the classic symbolism of the“monkey on the back,” where the need for thedrug arising out of the fear of going intowithdrawal is presented as all that needs to beknown to understand addiction and how totreat it. On the Canadian packages, under themain text of the health message are theFRAMING HEALTH MATTERSe66 | Framing Health Matters | Peer Reviewed | Haines-Saah et al. American Journal of Public Health | February 2015, Vol 105, No. 2statements “Need help to quit?” and “You canquit. We can help,” accompanied by the toll-free number for referral to a local telephonequitline and a link to the federal government’scessation Web site. Likewise, on the Australianpackaging are positive motivational captionssuch as “You CAN quit smoking” and “Think-ing of quitting?” or statements that help oradvice on quitting should be sought froma doctor or pharmacist. As in Canada, a link tothe national quitline and cessation Web site isprovided. (The UK labels have no referralinformation listed. While the US labels have yetto be implemented, the last version had thetoll-free quitline number prominently dis-played. Although the Canadian labels do notcontain any messages of hope, all packetscontain inserts that provide information onquitting smoking.)DISCUSSIONThrough our analysis of health warninglabels across the context of 4 countries, weprovide a starting point for thinking about theways tobacco control currently conceptualizessmoking and people who smoke and thepotential implications of these messages. Weposit that the labels are not mute objects butcan be understood more in the vein of non-human actors51 insofar as they articulate andactively cultivate certain kinds of sentimentstoward smoking and smokers. In other words,the labels are active sociopolitical objects thatenmesh viewers in their force and pull. Yet weemphasize the potential implications of thisimagery, to the extent that our critical socialscience approach represents a very specificanalytical frame, and that multiple interpreta-tions on the part of viewers and audiences arepossible.Our aim is not to undermine empirical workexploring the efficacy of health warning labelsand efforts to ensure that such labels clearlycommunicate the harms of smoking. There isobviously a place for graphic warning labels inhelping to transmit public health messages; weare not advocating “an effete sensibility inwhich even the least whiff of social disapprovalof a behavior is seen as coercive or stigmati-zing.”52(p475) But although a picture may beworth a thousand words, it is important thatthey are not the wrong ones. By raisingconcerns about the types of images and textthat dominate cigarette warning labels, a criti-cal social science approach assists in analyzinghow tobacco control efforts may require mod-ification or tailoring, if they aim to reduce theincidence and prevalence of smoking withoutplaying on and reinforcing simplistic and ste-reotypical views of smoking and people whosmoke. As Castel has noted, “The iatrogenicaspects of prevention are always operativeeven when it is consumption of such ‘suspect’products as alcohol or tobacco which is underattack.”53(p298)Moving beyond the notion of “critique forcritique’s sake,” a tendency to which criticalsocial scientists within health promotion maybe particularly vulnerable, our analysis sug-gests some important considerations for to-bacco control interventions. First, it is readilyapparent that the labels depict a narrow view ofboth smokers and smoking. They reproducea visual narrative in which smoking is reducedto the damage cigarettes cause to the bodies ofthe people who smoke (and the bodies of thosearound them). This emphasis on death anddebility implies that people who smoke arelargely unaware of the health impacts ofsmoking, or ignore them out of a misplacedsense of invulnerability. However, social sci-ence research suggests that people who smokeresist this attempt to assert an undeniablefuture of death and debility and the ways itprivileges health over other dimensions of thehabit.16,32,54,55 Understanding the health ef-fects of smoking is not usually sufficient reasonto cause anyone to quit or resist starting in thefirst place.54 Thus, although the assumption that“fear works” and “more fear works better” is thebackbone of many health promotion campaigns,such tactics can be counterproductive.56Lupton25 has argued that the confronting,graphic imagery and visual “shock tactics” seenwithin contemporary public health campaignsfor smoking and obesity prevention employa “pedagogy of disgust” that is morally, ethi-cally, and politically problematic. Campaignsthat sanction negativity and prejudice towardthose who engage in practices often viewed asdisgusting and unhealthy may serve to objectifyand dehumanize, and to increase the stigmaexperienced by individuals and groups(i.e., people who smoke or who are obese) whoare already the targets of ridicule or exclusion.In this light, the simplistic argument offered indefense of disgust- and shock-based publichealth campaigns that the “ends always justifythe means” is ethically insufficient as it elidesissues of victim blame and social justice.25(p6---7)Second, none of the labels address thereasons why people might smoke other thanaddiction. Although people who smoke em-phasize what they perceive as the immediatebenefits of smoking in their day-to-day lives interms of pleasure, stress reduction, social con-nection, and relationships, and they may feelthere are important aspects of their identitiesthat are constituted in part by their smoking,these dimensions of the practice are invisible intobacco control imagery.57 Instead, smoking isreduced only to an irrational and compulsiveact. However, because the difficulty of quittingis intimately entwined with precisely these“positive” aspects of smoking, the resultingnarrative of addiction, compulsion, and irra-tionality is likely to ring false to people whosmoke.32,58Third, the labels play on gendered stereo-types to encourage people to quit smoking. Theunderlying message, especially in the Britishlabels, seems to be that what is important aboutcessation for women is preserving their exter-nal appearance rather than health and well-being, and that what is important for men ispreserving masculine “potency.”34,35 More-over, the almost universal message that womenare the primary guardians of child health, in orex utero, reinforces stereotypes about the in-trinsically gendered nature of parental respon-sibility. It also contradicts recent gender re-search in tobacco control that suggests thata fetal-centric approach is an ineffective strat-egy for reaching pregnant women59 and con-tributes to a broader gender bias in healthpromotion by entrenching women’s roles asreproductive “vessels” and mothers.45Our analysis of the main depictions of thesmoker and smoking within the context ofcigarette warning labels concurs with previouswork from critical social science and healthresearchers, who have argued that tobaccocontrol needs to be reoriented toward a con-sideration of how social and cultural contextsinfluence smoking behaviors beyond an ad-diction framework (i.e., to understand smok-ing as a social identity and an everydaybodily practice). This movement towardFRAMING HEALTH MATTERSFebruary 2015, Vol 105, No. 2 | American Journal of Public Health Haines-Saah et al. | Peer Reviewed | Framing Health Matters | e67understanding smoking as something morethan an individual-level health behavior hasbeen in part motivated by the evidence of itsdeepening socioeconomic gradient in indus-trialized democracies such as Australia,Canada, the United Kingdom, and the UnitedStates, where those who are disadvantagedare more likely to smoke and to face greaterobstacles to cessation.For these reasons, critical health promotionresearchers—and, indeed, voices from withinmainstream tobacco control—are increasinglyadamant about the need to consider the dif-ferential effects of tobacco control interven-tions on people who smoke (who may also bemarginalized or structurally excluded) and toreframe tobacco prevention as a social justiceissue.60---63 As Nathanson suggests, structuralhierarchies of gender, race, and class are criticalto “whose voices are heard” in public healthpolicymaking, and also to how groups arerepresented in the campaigns that result fromsuch policies.37(p223) Therefore, for theso-called harder-to-reach, vulnerable groups,the blanket approach of stronger, increasinglygraphic labels neglects how smoking is tiedto the social determinants of health and hasbecome a highly visible marker of social in-equalities. Messages that position smoking asan individual-level addiction, habit, or choicecan have the unintended consequence of con-tributing to the social marginalization of peoplewho smoke, further entrenching tobacco usein the lives of persons who find themselveswithout the resources to pursue cessation andhealthy lifestyles.42,49 Although we have noclear answers regarding what the labels shouldlook like, Burris’s advice seems a good placeto start. In his words, ethical practitionersshould watch “for any sign that people whosmoke are becoming a pariah group, are beingstereotyped, are suffering status loss, or arebeginning to shamefully punish themselves.The practitioner is particularly careful of therisk that public health efforts will add fuel toexisting stigmas of, for example, minority groupor class.”52(p475) Once these issues are fore-grounded, improved health warning labels willsurely follow. jAbout the AuthorsRebecca J. Haines-Saah is with the School of Nursing andKirsten Bell is with the Department of Anthropology,University of British Columbia, Vancouver. Simone Dennisis with the School of Archaeology and Anthropology,Australian National University, Canberra.Correspondence should be sent to Rebecca J. Haines-Saah,University of British Columbia, 305-6190 Agronomy Rd,Vancouver, British Columbia, Canada, V6T 1Z3 (e-mail:rebecca.haines-saah@nursing.ubc.ca). Reprints can be or-dered at http://www.ajph.org by clicking the “Reprints” link.This article was accepted September 23, 2014.ContributorsAll authors contributed equally to the conceptual de-velopment, content analysis, and writing of the manu-script. R. J. Haines-Saah led the revisions and finalizedthe accepted version of the article.AcknowledgmentsThis research was jointly funded by a Population HealthIntervention Research Grant from the Canadian Institutesof Health Research (CIHR) and the Canadian CancerSociety Research Institute, and we gratefully acknowl-edge their support (CIHR: GIR-127071; CCSRI:2013-702183; principal investigator, K. Bell).We acknowledge the helpful feedback provided byour fellow coinvestigators, Jude Robinson and RolandMoore.Human Participant ProtectionNo protocol approval was necessary because this re-search did not involve human participants.References1. Hilton M. Smoking in British Popular Culture 1800---2000. Manchester, UK: Manchester University Press;2000.2. Tate C. CigaretteWars—The Triumph of “The LittleWhiteSlaver.” New York, NY: Oxford University Press; 1999.3. 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