Shame-based appeals in a tobacco control public health campaign: potential harms and benefits.

Smoking is the leading preventable cause of death worldwide, responsible for 1 in 10 deaths globally (>5 million a year). Tobacco use adversely impacts not just smokers, but also those around them through secondhand smoke exposure. Given the significant personal and societal costs of tobacco use, any strategy to reduce smoking should be considered. In this issue, Amonini et al report on development and evaluation of a shamebased public health campaign in Perth, Australia. Public health media campaigns in Australia, in particular, have raised awareness and instigated behaviour change via approaches ranging from direct and forceful (eg, ‘Belt Up or Suffer the Pain’ seatbelt campaign) to humorous and memorable (eg, ‘Slip! Slop! Slap!’ for skin cancer prevention). In developing their tobacco control ad campaign, Amonini et al conducted focus groups with smokers and interviewed former smokers, identifying salient themes of social isolation (eg, “you feel like a ‘leper’”). Next, they created and piloted an ad prototype in an experimental setting, which demonstrated believability/relevance and perceived efficacy in stopping smokers from smoking. Finally, they created the shame-based ad, evaluating it in a publicly launched campaign where a majority of respondents self-reported in the first several weeks that they reduced cigarette consumption (36%), attempted cessation (16%) or quit (2%). While suggestive as a promising public health approach, the potential for harm associated with an emphasis on shame also bears consideration, particularly when in relation to a behaviour sustained through addiction and increasingly concentrated among marginalised groups. Today, smokers in Australia and other industrialised countries are largely characterised by lower income and education, ethnic minority status and co-occurring mental and physical health disorders. Capitalisation on shame-based public health campaigns will, in effect, target these groups. In contrast, the tobacco industry’s campaigns have emphasised themes of freedom, affluence and excitement, creating the perception that smoking is a choice of free will. In this context, when smokers fail to quit, they often blame themselves.