What surrounds us shapes us: Making the environmental case for tobacco control

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February 23, 2016

Part I — Making the case for environmental change

Creating healthy environments starts with knowing what you want to change. Then you have to find the right language to effectively talk about it. Language is important because how an issue is described, or framed, can affect whether it has popular or political support.

Linguists say that framing is how our minds recognize patterns of ideas, categorize them, and derive meaning from them. Framing is the translation process between incoming things we see, read or hear — and the ideas already in our heads. Frames are important to advocates because they influence how people react to ideas.

When the tobacco industry frames point of sale tobacco marketing as 'freedom of speech' or as 'providing customers with information,' people may not feel inclined to see this marketing as harmful. When the issue is framed differently — 'certain communities are unfairly burdened by retail marketing' — people may be more inclined to recognize the problem. Language can create a "frame of mind" that makes some ideas attractive and others not.

This Framing Brief suggests how to create messages based on frames that can help people see that environments affect health. When people understand that connection, they are more likely to support policies that improve those environments.

Shifting from portrait to landscape

Research shows that in the U.S., most people think that individuals are masters of their own destiny. People believe that hard work, discipline, and self-determination are all it takes to succeed; underlying this rugged individualism frame is the value of personal responsibility. This value extends to people's perceptions about health as well: their gut-level assumption — what we call the default frame — is that individuals can control their own health outcomes if they make the right choices.

The problem with the default frame is that it hides the influence of other factors in people's success: the conditions of the places where people live, work and play. The default frame is like a portrait, focused narrowly on the details of a single person. To create a conversation that is conducive to change, issues need to be framed more like landscapes — frames that include people, but also the context that surrounds them.

Those who want to encourage positive public health changes can slip into the default frame when they encourage people to eat more fruits and vegetables and fewer fatty foods, without mentioning the need for all neighborhoods to have stores that sell healthy foods at affordable prices; or when they tell parents to make sure their children get enough exercise but don't make the case for neighborhoods and schools that offer safe, crime-free places for children to play; or when they tell people not to smoke while ignoring the ubiquitous tobacco marketing bombarding certain neighborhoods.

To create a positive change in the environment, the default frame needs to be broadened from its exclusive focus on the individual — or portrait — to a landscape perspective that makes visible the external factors in the environment. Painting a broader picture can help people see that neighborhoods, schools and workplaces influence health. Only then will polices that improve places make sense to people.

To make the landscape visible, those who advocate for an environmental change need to think about what they say and ask themselves: What assumptions does our language trigger? What pictures are we bringing to mind? Do our words lead to support for our policy and reinforce our values? Messages should start with a frame that brings to mind the place. Then the conversation can lead to the people in those places and the policies that will improve everyone's health.

child on scooter entering traffic

Triggering an environmental frame

How can language trigger the idea that contexts shape individual's health? Reminding people that where we live, work, or play (including homes, schools, offices, businesses, stores, parks and any other physical spaces), influences our daily lives, including our health. When we improve and maintain these environments, the health of the people who live and work there improves as well.

A message can trigger an environmental frame by starting with a vivid description of the environment that contributes to poor health, as well as the kind of place that supports health. Those who support an environmental change will help their audiences connect with their message if they state the value that motivates them to make the change they seek. To that they can add a clear, simple description of the solutions they support. The task is to create an image of the world that is based on values, accommodates policy solutions and creates the desired place-based frame.

Below is an equation that incorporates each of the variables needed to create the desired frame:

Environmental Trigger + Value + Policy = Desired Frame

For example, community members concerned about point of sale tobacco advertising could combine their goal of reducing the impact of tobacco marketing with the value of fairness and say something like this:

When neighborhoods are flooded by tobacco outlets and marketing, the health of the people in those neighborhoods is compromised. It's not fair that some people live and work in environments that emphasize a healthy way of living while other neighborhoods are exposed to tobacco retailers, tobacco ads and tobacco products everywhere they turn. That's why we need to limit the tobacco industry's intrusion in those communities — so all communities can have healthy environments.

The order of the statement matters because audiences will be able to understand the relevance of the policy only if they understand that environments matter when it comes to health. You may arrive at different ways to trigger that idea, but the important thing is that you do set the trigger first. Usually there's more to say about the environment than time to say it; emphasize those parts of the environment that logically link to the policy solutions you seek.

Incorporating values

Linking three commonly shared values — fairness, ingenuity, and prevention — to environmental triggers can inspire positive responses to public policy among different audiences. Here are some ways to use these values to create environmental frames:

  • Use fairness to show that people living in certain communities are burdened with an unhealthy environment, and that policy change will help level the playing field so all individuals in all communities have a fair shot at health.
  • Ingenuity, or "can-do spirit" — the idea that communities can and do work together to create lasting and meaningful change — will help people see that it is possible to establish policies that benefit the common good, even in the face of challenges. We've done it before and we can do it again.
  • When you trigger context, you can talk about our responsibility as a community to prevent health problems by creating the environments in which all people can enjoy long-term good health.

An environmental trigger with the fairness value: People are healthier when they live and work in environments without a concentration of unhealthy products. It's not fair that some people in New York inhabit this kind of environment and others don't.

An environmental trigger with the ingenuity value: Everyone wants their family to be healthy. We have the smarts and the motivation to create environments where people are not overwhelmed by unhealthy messages and triggers.

An environmental trigger with the prevention value: Children and adults are healthier when they live and play in an environment that emphasizes good health. We can prevent poor health now and in the future if we create healthier environments now.

Messages need to be considered in light of your overall objective. A frame that fits well with one objective may not fit with another. Or you may want to frame your argument differently depending on your target. For example, if your goal is to educate about the impact of point of sale tobacco marketing, you may want to emphasize the fairness of providing healthy environments for all communities when talking to parents, but emphasize how point of sale marketing can hinder tobacco prevention and cessation support when talking to policymakers. Experiment with language you feel comfortable using in connection with the goals you seek.

The downfall of "choice:" — A common trap

Those seeking environmental change want to expand the conversation about health from a narrow focus on personal responsibility to include institutional accountability and the environmental landscape. Reporters and policy makers, however, will often draw the conversation back to individuals by talking about "choice." The danger is that the more you talk about choice the more you reinforce the dominant frame of individualism. Choice is important, but the idea itself triggers an individualistic understanding of the world that distracts from the environment in which the choices are made.

So, when reporters or others ask about choice, use it as an opportunity to move the conversation toward environmental problems, to evidence-based policy solutions, and the values you hold. Here's an example of a statement you could use to pivot away from choice to an environmental frame using our commonly held values:

Sure, people ultimately choose whether or not to smoke. But most of them are young and certainly did not choose to be targeted by tobacco industry marketing. It's not fair that some people live in environments that make it harder to be healthy.

And, of course, when it comes to tobacco the concept of "choice" is further clouded by the addictive nature of the product. The decision to use tobacco is made early and is often followed by years of regret after being too addicted to be able to make the choice to quit. To the above could be added:

And remember, those who are targeted by the tobacco industry make the "choice" to first use tobacco when they are teenagers — or even preteens! After that, addiction to tobacco effectively precludes the ability to make a choice.

Conclusion

Most of the time in policy battles, Grantees will be trying to energize and motivate their supporters to solve a problem. They will be successful when they clearly state the problem, their solutions, use frames that help people understand that environments make a difference to health, and express their values about why implementing a solution matters.

Part II — Practical Tips

Interview gone wrong

Once we have figured out the problem, what has to be done, who has to do it, and how to frame the issue, then we have to talk about it — in public and on the record. Talking with journalists is especially important since policy makers pay close attention to the news. Whenever we talk with reporters we have the opportunity to educate them about the problems we see and what to do about them. But talking with reporters can be intimidating. Sometimes it's hard to stay focused on our message, including the policy options and other solutions. Let's use the example of policies to restrict the places tobacco may be sold and see what can happen under the pressure of an interview.

Reporter: What should we do to reduce smoking?

Answer: A good approach is to focus on populations that have higher than average smoking rates. For example, low-income populations are disproportionately subjected to tobacco marketing and price promotions in tobacco retail outlets. We should work to curb that.

Reporter: You're talking about things like coupons and signs in retail stores?

Answer: That's some of it. This marketing bombardment makes it harder to quit and means more people are using tobacco. That is unfair for our community.

So far, so good. Let's keep going ...

Reporter: But how does a sign make someone smoke — everybody sees signs but not everyone makes the choice to smoke, right?

Answer: Everyone has a choice, but advertising can lead people into making bad ones.

Reporter: So, you're saying that new laws are needed because people — especially poor people — can't be trusted to make good decisions for themselves?

Answer: No, no — people can make good decisions, but it's never a good decision to start smoking.

Now you're off track. These are valid points, but instead of focusing on specific policy options to reduce point of sale tobacco marketing through limiting the places tobacco can be sold, you're talking about smoking as primarily a matter of individual choice. Let's try again:

Reporter: But how does a sign make someone smoke — everybody sees signs but not everyone makes the choice to smoke, right?

Answer: Signs — and other examples of tobacco marketing — change the environment. They make tobacco seem common and accepted; each sign serves as a smoking cue and can trigger cravings in people trying to quit. What's worse is that the marketing environment is different in some communities than in others.

Reporter: So, you're saying that new laws are needed because people — especially poor people — can't be trusted to make good decisions for themselves?

Answer: What I'm worried about is whether we can trust our policymakers to make good decisions. The issue is about the overwhelming concentration of marketing materials that contaminate the environments in which people are making their decisions.

Reporter: Are you saying that poor people can't make good decisions?

Answer: Not at all. Some communities have been unfairly targeted by the tobacco industry. The industry knows that more money spent on marketing equals more people buying their product. When tobacco companies focus on any community, that community is going to suffer the health consequences.

Now you're on the right track. The reporter may follow-up with some specific questions about potential policy solutions — or, may continue to ask questions that lead in the wrong direction. By continuing to stay on track, you'll have the discussion you want to have, focused on policy solutions to the problem you've described.

Messengers — Alternative, authentic spokespersons

You may not always the best person to speak for your organization or cause. Different people convey different kinds of credibility. In various situations, there may be alternative spokespeople who could more effectively or persuasively communicate the message to a particular audience. For example:

  • If you are speaking to a newspaper reporter about limiting tobacco point of sale marketing, you could refer the reporter to a Reality Check youth who is exposed to this marketing on the way to and from school.
  • If you are speaking to legislative staff, and feel hindered by lobbying restrictions, you could ask an advocacy group representative to join you and lead the discussion on legislative solutions.
  • If you are asked to give a television interview about the impact of tobacco marketing, you could refer the producer to an academic researcher with expertise in this area or a community member whose struggles with quitting have been made more difficult by exposure to abundant tobacco marketing. Or, you could refer the reporter to a coalition member who can give them a tour of a marketing-saturated neighborhood.

Alternative spokespeople could also include others on your staff, young people in your community, business owners who support changes in business regulations or members of partnering community groups. Even in the middle of an interview, it might be wise to refer a specific question to others. (e.g. "You're asking about legal issues now and, while I can talk generally about the impact of a law, I can refer you to lawyers who can give you more details and background about implementing a law.")

Of course, be sure your alternative spokespeople are up to the task — up to speed on the issue(s) at hand, trained in answering tough questions, and experienced in speaking with reporters and others.

Audiences — Different emphasis for different values

As you prepare to speak with different audiences, think about the values each audience holds. It's not likely that the values will be totally different or in opposition to each other — you won't be meeting with some groups that favor justice and fairness and other groups that support injustice and unfairness.

But different groups will have different definitions for what is just and fair. A community group concerned with local schools may hold the value of protecting children as most important. An assemblyperson and staff may hold the value of economic fairness and feasibility as most important.

As an example, here are three messages that support reducing youths' exposure to point of sale tobacco marketing but that emphasize different values for different audiences:

To parents/schools group: Our kids should be able to walk to school or stop in a convenience store without being bombarded by tobacco industry ads. [value: protecting kids]

To media/general public: It isn't fair that people in some neighborhoods can go shopping without being bombarded by tobacco industry ads, but people living in other neighborhoods can't avoid them. [values: fairness, justice]

To assemblyperson: We shouldn't allow our communities to become billboards for the tobacco companies. Reducing exposure to tobacco ads in neighborhood stores is a quick, feasible way of creating a healthier local environment. [values: feasibility; fairness]

When thinking about your audience, be very careful about the language you use. Some words or terms may be effective for some audiences but ineffective for others. The term "health equity", for example, may sound fine when talking to colleagues or other public health professionals. But to some audiences, the term may sound like jargon or could be difficult to understand. Simply using the word "fairness" could be a better alternative. Similarly, the term "social justice" could sound fine to some but too utopian to others. An alternative could be to simply talk about why all communities should be treated fairly. Consider the language you use and how it might be interpreted by your audience.

Avoiding common mistakes

Early in the 1992 presidential election campaign, Bill Clinton's campaign manager, James Carville, was asked to explain his role. He said, "Let's say you ask a politician what time it is.

Some politicians will tell you the time. Some will tell you how to build a clock. Bill Clinton will tell you how to build a Swiss Village. The consultant's job is to say: "Governor, just tell them it's time for a change.'"1

As a public health expert who spends a lot of time thinking about tobacco control, you probably know an enormous amount about tobacco control policies. All of the information you have about tobacco control may be important and it may be tempting to convey as much of it as possible whenever you get the chance. But it is more effective to discuss complicated issues clearly and succinctly in ways that anyone can understand.

Issue experts tend to make several mistakes during interviews:

  • Using inside lingo. You're used to using shortcuts such as POS or point of sale instead of "retail environment" or "the industry" instead of the tobacco industry or "Big Tobacco." Shortcuts are fine when you are talking to colleagues, but for anyone else, it's better to simplify your language and use terms that everyone will understand.
  • Being too technical. You might be enmeshed in the technical details of policy implementation and be able to talk at length about the legislative process, but your audience may not need to hear all of these details. Be prepared to explain technical issues in simple, clear language. (And don't forget that resources such as model policies or Policy Center lawyers are available to provide assistance.)
  • Trying to say too much. There will always be more that you can say about a subject, but it is important to know when to stop. That's what it means to be 'on message': say what you need to say about the matter at hand and avoid the temptation to drift over to other issues, even when they are important and closely related.

Consider two different answers to one very simple straightforward question: Can you tell me about the problem of marketing cheap tobacco products?

Answer #1 — The tobacco industry has been very creative in developing pricing strategies to reduce the real price paid per pack of cigarettes. Discounts include those offered to wholesalers, retailers or directly to consumers. The specific strategies range from publicly distributed coupons to more complex financial arrangements with retailers. Consumers — especially those who are most price-sensitive — need to be protected from these strategies. Pricing strategies are part of the industry's overall goal to improve their retail presence. The more product they sell, the worse off we are.

Answer #2 — Tobacco companies are targeting consumers in our state with cheap tobacco products. Sometimes this is done through discount coupons and sometimes through financial incentives provided directly to the stores that sell cigarettes. Kids are especially vulnerable to these tactics since they have less money to spend. Restricting coupons and other promotions would go a long way toward solving this problem and when we can do something to improve the health of the community, we have an obligation to do it.

The first answer uses jargon ("pricing strategies," "the industry"); is too technical, goes on too long, wanders into other subjects and discusses the problem without noting potential solutions. The second answer makes the same point but with fewer words. It also takes the important step of describing the solution to the problem and provides a values statement to help connect the audience to the issue.

Suggested answers to difficult questions

Below are suggested answers to typical questions that might come from reporters, business owners, legislators or anyone else concerned about the issues on which you're working. The sample answers attempt to draw on commonly held values and avoid the common mistakes outlined above.

Of course, these are just general suggestions. Providing a specific answer that is authentic i.e. that is appropriate for your context and that you are comfortable delivering is most important.

Is marketing that effective? I don't know anyone who has started smoking because they saw tobacco ads. Besides, everyone sees tobacco ads - if ads are so effective, why doesn't everyone smoke? Has anyone ever started smoking because they saw an ad in a store? Tobacco Marketing works and tobacco companies know it works. That's why they are willing to spend billions of dollars on it — to recruit their next generation of smokers — our kids.

I never see anyone smoke anymore. Are there any smokers left?
Smoking rates are increasingly concentrated on certain segments of society — people living in poverty, for example. While overall smoking rates aren't as high as they were 40-50 years ago, there's been far less progress lowering smoking rates within certain segments of society.

Tobacco control has been amazingly effective over the last 30 years. Isn't the problem basically under control now? Isn't it time to move on to more pressing problems?
Sadly, tobacco use remains the number one preventable killer in New York. Everyday more than 75 people die in New York because of tobacco. One simple thing we can do right now to reduce the number of young people in New York from becoming one of those statistics is to limit the tobacco marketing that kids and smokers trying to quit see in their neighborhood stores.

I don't like tobacco use either, but tobacco is a legal product. Shouldn't businesses be free to sell any legal product they want to?
We already have many regulations that govern what businesses can sell and how they can sell it. Only stores with special licenses can sell alcohol, guns or prescription drugs for example. And there are zoning laws that say where businesses can be located. There is no reason that tobacco — a uniquely dangerous product which kills half of its regular users — should be exempt from these same type of common sense sales regulations.

I don't like tobacco use either, but tobacco retailers exist because people want the product. If there weren't a demand for tobacco, stores wouldn't be selling it.
Yes, but that's not all that's going on. Retailers sell tobacco because tobacco companies give them financial incentives to do so. The "demand" is created by tobacco marketing that research shows significantly contributes to youth smoking and undermines quit attempts by smokers. Tobacco sales can remain legal, but communities are under no obligation to allow tobacco outlets to open on every corner.

The economy is bad and our neighborhoods need all the businesses we can get. We shouldn't be trying to drive away our local retailers.
Tobacco marketing is a problem generated by the tobacco industry, not by our local retailers. There is no evidence that common sense sales restrictions will put any retailer out of business but there is ample evidence that these policies will prevent youth smoking and encourage cessation. We can't afford not to make these changes.

Do we really need more regulations on businesses? Aren't there too many regulations already?
Our community works hard to make a safe and healthful environment for everyone. We put up street lights and crosswalks, maintain safe parks, determine where businesses can and can't be located, enforce noise and light pollution reduction and a lot of other things to improve our environment. Preventing tobacco use is consistent with our desire to have a safe and healthy community.

Where is this going to stop? Junk food, sugar, sports drinks — they're all bad for you, too.
Tobacco is unique. It's the only product that kills over half its regular users when used as intended and is manufactured by an industry that a federal court found has deliberately and fraudulently lied to the public about the health risks of their products for at least half a century.

Social math: Making facts and figures meaningful

Large numbers often become part of discussions about tobacco control policy: the amount of money spent on tobacco marketing, tobacco-related health care costs, the number of tobacco users, etc. These numbers can be so large that they are difficult to comprehend or understand. In 2012, tobacco companies spent $9.6 billion in advertising and promotion, but what does that mean? Nine billion dollars is a lot of money, but how does it compare to other expenditures and what does it mean to my community?

Social math is the practice of making large numbers comprehensible and compelling by placing them in a social context that provides meaning.2 There are several ways to do this:

Break down numbers by time. For example, the $9.6 billion spent by tobacco companies on advertising and promotion is an annual figure that breaks down to over $26 million per day or over $1 million per hour — every hour throughout the year. Spending over $1 million an hour is a very dramatic number and easier to comprehend than $9.6 billion over a year.

Break down numbers by place. Again, consider the tobacco companies annual advertising and promotion budget — a number that accounts for marketing activity throughout the United States. The Campaign for Tobacco-Free Kids estimates that the portion of the tobacco industry's annual marketing budget spent for New York each year is $235.1 million. (The estimate is based on the total number of cigarette packs sold in New York.) That works out to almost $3.8 million for each of New York's 62 counties.

Provide comparisons with familiar things. Even if they don't know the exact number, people have a general sense of, say, how many fast food restaurants there are in a community or neighborhood. But they probably have very little sense of how many tobacco outlets there are (people don't generally think of gas stations, drug stores, grocery stores, etc. as tobacco outlets.) Putting a number on these two categories could dramatize the number of tobacco control outlets there are in a community. People think there are McDonalds everywhere; think how dramatic it would be if they knew there were 10 (or 20 or 30 ... ) times as many tobacco retail outlets.

Provide ironic comparisons. What is the budget for libraries in your community? How does that compare to the amount of money spent on tobacco advertising and promotion? Wouldn't it be terrible if people knew how much more money was being spent to market tobacco products than to provide the myriad community resources available through the library?

Personalize the number. Go back to the tobacco advertising and promotion budget: $9.6 billion buys a lot of things — everything from price discounts to ads in magazines. But what does that mean for the average person? Consider having some school kids do an informal survey by counting the number of tobacco ads they see walking to and from school. In some areas that number could be quite large, but even if it's only 6 or 8 or 10, that is still a number made more dramatic by putting a personal face on it: 'Tobacco company marketing is putting a pro-tobacco message in front of my child six times a day every day she walks to school.'

Social math calls for creative thinking and a little bit of math. Of course, be sure to use accurate sources and be able to show how you developed your numbers.

References

1. Quoted in Wallack, et al., Media Advocacy and Public Health: Power for Prevention, Sage Publications, 1993, p. 114.

2. Wallack, L., et al., News for a Change: An Advocate's Guide to Working with the Media, Sage Publications, 1999, p. 63.

Acknowledgments

Public Health and Tobacco Policy Center

Contact:
Public Health Advocacy Institute
at Northeastern University School of Law
360 Huntington Ave, 117CU
Boston, MA 02115
Phone: 617-373-8494
tobacco@tobaccopolicycenter.org

The Public Health and Tobacco Policy Center is a resource for the New York Department of Health. It is funded by the New York State Department of Health and works with the New York State Tobacco Control Program, the New York Cancer Prevention Program, as well as the programs' contractors and partners to develop and support policy initiatives that will reduce the incidence of cancer and tobacco-related morbidity and mortality.

This work provides educational materials and research support for policy initiatives. The legal information provided does not constitute and cannot be relied upon as legal advice.

Berkeley Media Studies Group

Contact:
Berkeley Media Studies Group
2130 Center Street, Suite 302
Berkeley, CA 94704
www.bmsg.org

BMSG is a nonprofit organization dedicated to expanding advocates' ability to improve the systems and structures that determine health. We are a project of the Public Health Institute. Our office is based in California, but we work nationwide.

This brief was authored by Berkeley Media Studies Group, adapted from its earlier framing brief What Surrounds Us Shapes Us: Making the Case for Environmental Change, to help tobacco control advocates in New York better explain the connection between environments and health.

February 2016. All rights reserved. Berkeley Media Studies Group.

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