The perils of denormalization

Author: John Luik
Article Published: 15/09/2004

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One of the more disturbing contemporary trends in tobacco control is the increasing use by both anti-smoking activists and governments of “denormalization” campaigns against the industry. As used by the tobacco control movement, denormalization is as a made-up word that functions as noun and verb to describe both a state in which the tobacco industry and smoking are perceived to be non-normal, aberrant, and deviant and a series of activities designed to achieve this end.

Though there is some controversy as to where the term originated, the first systematic use of the concept can be traced to California’s series of TV attack ads launched during the 1990's as part of Proposition 99. The first and most widely known of these ads, “The Board Room”, featured actors depicting industry executives worrying about replacing their steadily dying customers and aired in 1990. The TV spot was accompanied by a print ad “First, the Smoke. Now, the Mirrors” which ran in all of the major newspapers throughout the state. The ad concluded with following lines: “So we seem to know about the smoke. But what about the really dangerous stuff - all those carefully polished, fatal illusions the tobacco industry has crafted to mess with our minds so they can mess with our lives.”

While there is significant debate as to the success of the California’s experiment with denormalization, the move to incorporate denormalization as an integral, if not central part of tobacco control programmes has rapidly spread. Massachusetts, Arizona, Oregon and Florida have all adopted parts of the California model, while anti-tobacco activists in Canada, ever the home to cutting edge failures in tobacco control,  are pushing their federal government to make denormalization the centrepiece of a new national strategy on tobacco. In fact the Canadian denormalization campaign would dwarf even California’s efforts, with about C$200 million in proposed funding over the next five years. Indeed, in part due to the influence of Canada’s representatives at the FCTC process, denormalization will be taking its place as another leading first  world tobacco control  export to the developing world.

Despite certain local variations, what defines and unifies denormalization are three things; first a core assumption about tobacco control, second a series of key goals and third a set of consistent tactics. The assumption behind the use of denormalization campaigns is that the most effective way of reducing  tobacco use in general and more particularly in preventing tobacco use by young people is to focus on changing the behaviour of the tobacco industry rather than attempting to change the behaviour of current or potential smokers. This assumption, of course, rests on a the further assumption that the industry causes the behaviour of smokers. As Canada’s Non-Smokers’ Rights Association, one of the world’s fiercest and most aggressive industry critics  notes “... forcing changes in the behaviour of the tobacco industry has far more impact than efforts to directly change the behaviour of current or potential smokers.” Thus at its core denormalization is part of a larger attempt to change industry as opposed  to smoker behaviour.

The goals of denormalization are equally sweeping, for the campaigns aim through their  focus, as the term implies, on the abnormal nature of both smoking and the tobacco industry to “change social norms about the use of tobacco” and, more importantly, the manufacturers of tobacco through portraying them as deceptive, manipulative and close  to, if not explicitly, criminal. These goals in fact frame the entire California campaign from the initial attack ad with its industry executives plotting in the stereotypical smoke-filled room to its 1994 ad “Do they think we’re stupid” which featured the company CEO’s in their congressional testimony on addiction. Each of the campaign’s components was carefully designed to highlight the industry’s allegedly deceptive and manipulative character and to imply that it was in some sense a moral outlaw operating outside the normal business environment.

More recent denormalization efforts in Massachusetts, Florida and Canada have aimed to position the tobacco industry as the money-driven “disease  vector” of the tobacco epidemic that targets kids through its advertising in order to addict them to tobacco. Denormalization advocates consistently speak about having the industry take the place in the minds of kids of such traditional anti-establishment targets as parents, adults, school and government through portraying the industry as “those people who mess with your bodies and with your mind”. Even more expansively and frankly many activists note that the real goal of denormalization is to change the public’s perception of both the industry and smoker’s in order to alter not only the judicial environment hearing tobacco litigation, but the wider social and legislative environment in order to garner support for ever more draconian tobacco policies. As Canada’s NSRA put it in a 2001 funding request “denormalization facilitates the transfer of the focus of normal teen rebellion away from parents and teachers and toward the industry which is targeting them... Denormalization has the potential to keep many teens out of the tobacco market, encourages cessation and supports the development of public policy on tobacco.”

What unifies denormalization efforts is not simply assumptions and goals, as the campaigns are also consistent in their tactics. The menu of tactics are driven by the claim, largely unargued for, that the only way in which to effect the power of the tobacco industry is to remove its legitimacy. Denormalization is tobacco control’s answer to the industry’s claim that it is a legitimate industry engaged in a legal business enterprise. For the advocates of denormalization this legitimacy is “false” in the sense that it masks the industry’s alleged lies about the risks of its products, addiction, and marketing practices. 

The tactics of denormalization are thus designed to remove the industry’s faux legitimacy through telling the so-called truth not about its products but about its behaviour. These tactics include: 

highlighting the alleged past behaviour of the industry with respect to marketing, product manipulation and smoking risks;

refuting the industry’s “myths” about not targeting youth, safer cigarettes, ETS, and addiction;

attacking the industry’s current efforts to style itself as a responsible corporate citizen through its support of youth access and education programmes;

portraying the industry as a moral outlaw outside the bounds of the regular business community and discouraging its business partners and suppliers from having normal business relationships with it;

ensuring that the industry is excluded from any meaningful participation in tobacco policy development or prevention research; emphasizing the impossibility of the industry changing in any fundamental way given that its financial viability is based on recruiting new, young smokers through deceptive marketing;

and changing the guilt that smokers have about smoking into an anger against the industry for targeting and addicting them as children.

As the menu itself suggests the neat distinction between products and behaviour breaks down since denormalization’s  criticisms of behaviour are often criticisms about products, e.g. addiction, safer cigarettes and ETS. 

There are at least two major problems with the move to denormalization, problems not simply for the industry but for anyone interested in effective public policy. The first of these problems is with the efficacy of denormalization campaigns. The problem here begins with the legitimacy of the core assumption that frames denormalization, namely that the most effective way to change the behaviour of smokers is to change the behaviour of the industry. Far from being obvious or supported by empirical evidence as the advocates of denormalization assert, most of the academic research about preventing smoking or facilitating quitting, particularly by young people, suggests that interventions to change the behaviour of smokers are the crucial ingredient of effective tobacco control programmes.

If one looks at the research which reports the most significant results in terms of prevention they have nothing to do with so-called changes in industry behaviour but everything to do with interventions to change smoker’s behaviour. In fact one could go further and argue that it is precisely the anti-smoking movement’s 20 year obsession with trying to change industry behaviour through attempts to ban marketing that has led to the failure to come to terms with youth smoking. Instead of addressing the root causes of youth smoking, both governments and the anti-smoking movement have instead focused on changing the industry’s behaviour. 

What the driving assumption behind denormalization has done is to effectively waste a generation in coming to terms with youth smoking through perpetuating an enormous confusion at the centre of tobacco control policy, namely youth smoke largely because of the marketing tactics of the industry. Once this assumption is accepted then the control menu, including denormalization readily follows. But if we were to start with a different assumption, namely, cigarettes exist, therefore as part of the process of growing up young people will experiment with them, we have the possibility of asking a genuinely open question- what it is in the process of growing up that leads young people to experiment with cigarettes and what might we do about it? And the answer to this question will, based on the overwhelming majority of the research literature,  not be the one that supports industry denormalization and demonization.

But it is not only the problem of the core assumption behind denormalization that raises questions about its efficacy, it is also the empirical results of the actual campaigns. And here the evidence comes not from the tobacco industry, but from the tobacco control community itself.  One of the problems about denormalization is that like so much in tobacco control there is a distinct unwillingness to devise measures that evaluate whether much touted programmes actually produce the only sort of changes that count- changes in smoking behaviour. Despite being around for over a decade the number of studies on denormalization programmes is still relatively small.

And these few studies suffer from a number of problems. Most are based on small, cross sectional samples that are unable to allow any causal conclusions. More disturbingly, many of the studies have been done by the same people either running or advocating denormalization programmes so they are hardly models of objective  rectitude. As Donley Studlar of West Virginia University notes “advocates of denormalization policies area sometimes also the authors of evaluation studies.” Further, most of the studies are poorly designed, being flawed with respect to control groups and use of recall data, and coming closer to advocacy rather than careful social science research.  Most of the studies fail to show that denormalization has any direct effects on smoking and it is impossible to find that any “anti-industry” effect has changed smoking behaviour. Karen Gutierrez at the Center for Disease Control has noted that denormalization campaigns “won’t make someone quit or not smoke around others...” This is echoed by C. Pechman who writes that it  ”is unclear whether ads that attack the tobacco industry can dissuade  young people from smoking.”  Studlar is even more direct arguing that it is “difficult to isolate a specific industry denormalization effect” and “modest, largely indirect effects predominate”. 

All of the “studies” are plagued by the problem that what people say they believe or will do are often at variance with their behaviour outside of the interview.

As Carolyn Celebucki of the Massachusetts Department of Public Health observes  “perceived effectiveness may be a weak proxy for impact on behaviour.” 

The two major independent studies on denormalization (Siegel and the University of CA), both found no significant effect on youth smoking in California and Massachusetts. Youth prevalence in California was not statistically different than prevalence in other states. Additionally, the study done by the National Institutes of Health concluded that denormalization campaigns had not made a difference in youth smoking in the states in which they had been used. 

The problems, however, go beyond the fact that denormalization campaigns fail in reducing youth smoking as they also work against effective tobacco control through discrediting industry supported efforts to limit youth access to tobacco products and support education programmes to discourage tobacco use by youth. But of course, this is what denormalization is designed to do: discredit the industry so that its efforts in youth prevention are discredited and it is denied any place at the tobacco control policy table.

Thus, despite its advocates claims, denormalization fails the most significant test of good public policy- effectiveness- in that through its grounding assumption it diverts resources and attention away from the root causes of youth smoking, it fails itself to reduce youth prevalence in those jurisdictions in which it has been tried and it attempts to discredit the industry’s efforts at youth education and access control.

The second problem with denormalization is what might be called the legitimacy problem, namely the question of whether a democratic government might justifiably engage in a campaign of what is effectively the stigmatization of a legal enterprise for the purposes of social engineering. There are at least two senses in which legitimacy is an issue, first with respect to stigmatization and second with respect  to social engineering.

It is, of course, one thing for the government, in the interests of health, to provide its citizens with accurate information about the consequences of various forms of risk taking. It is another thing for the government to attempt to persuade its citizens, again in the interests of health, to do one thing or avoid something else. But there is something quite different in character from either providing objective information or engaging in persuasion for a government to attempt  to “denormalize” something that it has not proscribed as illegal. It is not simply that so much that is said as a part of denormalization is demonstrably false, either by being taken out of context or directly in contradiction of the existing evidence, e.g. the claims about the purposes and effects of advertising, the nature and consequences of addiction, and the risks of second-hand tobacco smoke , but that the purpose of saying such things is to render both an industry and a class of individuals first aberrant and then abhorrent. And there is no doubt that this is precisely what denormalization is about for according to its proponents the activities of denormalization are specifically designed to use evidence of aberrance to generate feelings of abhorrence and de-legitimacy. And it is this action, this artificially generated sense of aberrance and abhorrence that is outside the scope of moral government.

It is too easy to reply that what we are dealing with here is the tobacco industry, as if this ended the need for moral rigour. But suppose that it were not the tobacco industry, suppose that the government decided in the interests of preventing AIDS- a legitimate health interest- it would henceforth attempt to denormalize homosexuality through a denormalization campaign designed to portray such activity as aberrant and abhorrent. Would we find nothing morally objectionable about such activity? The answer is that whatever our views about AIDS or sexuality we would find such actions to be morally objectionable because for a democratic government the tool for censuring either its citizens or its corporations is not denormalization but the criminal law. To forget this is to forget that the last century’s experiment in denormalization ended in the concentration camp and the gulag.

But denormalization runs afoul of legitimacy in a second sense in that it represents a vast and unacceptable instance of social engineering. Its proponents are not hesitant to trump this as its great virtue for they openly proclaim that their goal is to effectively re-order the consciousness of individuals with respect to smoking and the tobacco industry. This is not the provision of information or even reasonable  persuasion but instead social marketing designed to manipulate the social and intellectual environment so that the central aspect of democratic life- individual autonomy, the right to shape one’s own mind, behaviour and life- is effectively suppressed.

The increasing use of denormalization campaigns is worrisome then not simply because they represent another failure to address the problem of youth smoking but because they represent a new and dangerous assault on our core democratic traditions. Like so much in the tobacco wars they are a very bad prescription for supposedly good health.

 

John Luik - Published by Tobacco Reporter, September 2004