The Institute of Medicine and the National Research Council released some damaging numbers this month: Americans ranks startlingly low in life expectancy, compared to 16 other similarly developed countries. This is especially true for younger Americans. Indeed, among people 55 and under, we rank dead last. Among those 50-80 years old, our life expectancy is 3rd or 2nd to last.
Sabrina Tavernise at the New York Times reports that the “major contributors” to low life expectancy among younger Americans are high rates of death from guns, car accidents, and drug overdoses. We also have the highest rate of diabetes and the second-highest death rate from lung and heart disease.
Americans had “the lowest probability over all of surviving to the age of 50.” The numbers for American men were slightly worse than those for women. Overall, life expectancy for men was 17 out of 17; women came in 16th. Education and poverty made a difference too, as did the more generous social services provided by the other countries in the study.
Mark Fischetti has posted an interactive graphic at Scientific American that lets you look at the prevalence of several behaviors or characteristics measured on the Centers for Disease Control and Prevention’s survey on risk factors. The graphic includes data on exercise, tobacco use, heavy drinking, binge drinking, and obesity. Commenters on the post suggested it’s unnecessarily snarky about obesity; that said, it provides a quick snapshot of several behaviors demographers often use to judge general trends in health. For each topic, a graph shows the state where it is highest and lowest; you can also select up to 3 additional states to compare.
For instance, the percent of people who took part in a physical activity in the last month is highest in Oregon and lowest in Mississippi; I added my home state of Oklahoma (dark blue) and current residence of Nevada (light blue) too:
You also get a map for each topic that shows where it’s most or least common. Here’s the map for smoking:
Sconnies, you may not be surprised to know that Wisconsin leads the nation in binge drinking:
Last month the Centers for Disease Control (CDC) released a series of graphic anti-smoking ads intended to “raise awareness of the human suffering caused by smoking and to encourage smokers to quit.” The campaign, titled “Tips From Former Smokers,” depicts individuals who have experienced some of the potential effects of tobacco use, including stomas, stroke, lung removal, heart attack, limb amputations, and asthma. For example, this ad features several former smokers who offer “tips” on how to live with a throat stoma (hole), such as “Crouch, don’t bend over—you don’t want to lose the food in your stomach”:
This ad shows Terrie, a throat cancer survivor, completing the morning routine she performs in order to maintain her appearance after losing her hair and teeth and having a tracheotomy:
Finally, this ad depicts several people who suffered a vascular disease brought on by smoking who had to have limbs amputated:
In addition to the whether these ads will be effective in persuading smokers to quit, we might ask whether fear and stigma are appropriate health promotion strategies. Is it possible or ethical to scare people into changing their behaviors? What are the implications of using stigmatized people to serve as a warning label to others?
What’s most striking about these ads is how they use and portray the human body. Medical sociologist Deborah Lupton suggests that health promotion campaigns such as this one do not simply depict bodies but also produce them; that is, the ways we talk about and create images of certain bodies says something about who or what that body is and what it does. She argues that when the body is seen as uncontrolled, say, with holes or missing limbs, then the self is understood as undisciplined. For these former smokers, their undisciplined selves resulted in their uncontrolled bodies. Lupton suggests that by producing the body as a site of contamination or catastrophe the rest of us can be kept in line by fear.
In these ads, a group of disabled people and cancer survivors are used as a warning for current smokers to quit. The ads invite us to feel disgust at their bodies and fear at what could happen to our own. In particular, Terrie’s ad invokes gendered beauty norms and prompts viewers to imagine themselves without traditional markers of attractiveness such a full head of hair.
Paying attention to how health promotion images use the body is one way to think more critically about bodies, well-being, and how to effectively promote healthy behaviors.
Christie Barcelos is a doctoral candidate in Public Health/Community Health Education at the University of Massachusetts Amherst.
Edward Bernays (1891-1995) is largely considered the founder of public relations (or “engineering consent,” as he called it) but is not known very well outside of the marketing and advertising fields. A nephew of Sigmund Freud, Bernays was the first to theorize that people could be made to want things they don’t need by appealing to unconscious desires (to be free, to be successful etc.). Bernays, and propaganda theorist Walter Lippman, were members of the U.S. Government’s Committee on Public Information (CPI), which successfully convinced formally isolationist Americans to support entrance into World War I. While propaganda was commonly thought of as a negative way of manipulating the masses that should be avoided, Bernays believed that it was necessary for the functioning of a society, as otherwise people would be overwhelmed with too many choices. In his words:
Modern propaganda is a consistent, enduring effort to create or shape events to influence the relations of the public to an enterprise, idea or group.
[Source: Bernays, Propaganda, 1928, p. 52; available here.]
After WWI, Bernays was hired by the American Tobacco Company to encourage women to start smoking. While men smoked cigarettes, it was not publicly acceptable for women to smoke. Bernays staged a dramatic public display of women smoking during the Easter Day Parade in New York City. He then told the press to expect that women suffragists would light up “torches of freedom” during the parade to show they were equal to men. Like the “You’ve come a long way, baby” ads, this campaign commodified women’s progress and desire to be considered equal to men (relevant clip starts at 3:00):
“Cigarettes were a symbol of the penis and of male sexual power…Women would smoke because it was then that they’d have their own penises.”
Here are some of the news photographs of women smoking publicly during the Easter Parade:
The campaign was considered successful as sales to women increased afterward. Cigarette companies followed Bernays’s lead and created ad campaigns that targeted women. Lucky Brand Cigarettes capitalized on recent fashions for skinny women by telling women to “Reach for a Lucky instead of a sweet”:
Marlboro, in stark contrast to the Marlboro Man ads we’re familiar with today, started the “Mild as May” campaign to encourage women to take up smoking cigarettes that were appropriately mild and easier to smoke:
Chesterfield, in a 1930s ad, argued that “women started to smoke…just about the time they began to vote”:
A later ad for Phillip Morris tells women to “Believe in yourself!”
Cigarette makers also worked to teach women how to smoke properly. Ads often depicted women in the act of smoking. Some companies, like Philip Morris, even held smoking demonstrations for women: [Via.]
The article describes how a “pretty registered nurse” is touring the country to teach women proper smoking etiquette. The article also lists “men’s pet peeves” and “women’s pet peeves” for men and women smokers. (Full text after the jump below.)
Together, these efforts to conflate smoking with freedom and make smoking acceptable for women created a new set of consumers and reinforced Bernays’s argument that demand could be created.
If you take the smoking rates by state, and throw them into the Google Correlate hopper, you can see the 100 search terms that are most highly correlated with that reported smoking behavior. That is, the terms that are most likely to be used in high-smoking states and least likely to be used in the low-smoking states.
Is the result just a lot of noise? Maybe, but I don’t think so. Here are the smoking-related terms in the top 100:
camel no 9
my time to quit
time to quit
fire safe cigarettes
ways to stop smoking
So that’s good for face validity — a list of random search terms isn’t likely to have all those smoking terms on it.
But after the smoking terms, the thing that jumps out is the health-related terms. We know from the Google flu tracker that people search for their symptoms. So these caught my eye.
Here is a screen shot of the first page of results:
I selected “stages of copd” as the term to map. The map on the left is the smoking rates; the one on the right is the relative frequency of searches for “stages of copd.” That is, chronic obstructive pulmonary disease, a nasty disease the most common cause of which is smoking.
Here is the complete list of health-related terms among the top-100 correlates with smoking rates:
Lymph node swelling, which is implicated in the jaw and neck searches, most often reflects infection — which smoking causes.
How strong are the connections? They’re not the strongest I’ve seen on Google Correlate. The “stages of copd” search is correlated with smoking rates at .77 on a scale of 0 to 1. It’s not uncommon to find correlations of .93 (which is the relationship between “quiche” and “volvo v70 xc”).
But considering the smoking rates come from a sample survey (the National Survey on Drug Use and Health) which includes random error, and states are somewhat arbitrary geographic units, that correlation seems pretty high to me. Here’s the scatterplot:
What is the correlation causality story here? I can’t say. But the simplest explanation is that these are the terms smokers (and maybe those who know or care for them) are most likely to Google relative to non-smokers — not that they are the most common searches smokers do, of course, but the searches that differentiate them from non-smokers. The simplest explanation is the best place to start.
I like this list of conditions because in my experience smokers sometimes have the attitude of “you have to die of something.” But it’s not just the chance of dying that smoking increases — it’s a lot of possible forms of suffering along the way.
The Supreme Court’s decision in the Dukes v. Wal-Mart case, Justice Scalia acknowledged that Wal-Mart’s many local managers had a lot of discretion in their personnel decisions, even though the company had a written policy against gender discrimination (who doesn’t?). But he gave the company credit for a vague policy and let it off the hook for a systematic pattern of disparity between men and women. So, when does a toothless, vague policy with wide discretion lead to a bad outcome, and is failing to prevent it the same as causing it?
A path-breaking sociological analysis of organizational affirmative action outcomes has shown that the companies that successfully diversify their management are most likely to have policies with teeth – where accountability is built into the diversity goal. In light of the Wal-Mart case, this led to a rollicking debate about how to think about “corporate culture” versus policies, and when to blame whom, legally or otherwise – which even divided sociologists.
Smoking in the movies
Here’s an interesting, at-least-vaguely related case. Positive depictions of smoking in the movies are widely understood to be harmful. Yet, smoking is also glamorous, artistic, and popular – representing both anti-adult rebellion and maturity. So, what to do? The Centers for Disease Control, in the always-riveting Morbidity and Mortality Weekly Report, has published a fascinating report on this topic. They report the number of tobacco incidents* in top-grossing, youth-rated (G, PG, PG-13) movies, and divide them between those that implemented an anti-tobacco policy and those that didn’t — helpfully cutting the movie industry roughly in half — and provide a simple before-and-after tabulation:
From 2005 to 2010, among the three major motion picture companies (half of the six members of the Motion Picture Association of America [MPAA]) with policies aimed at reducing tobacco use in their movies, the number of tobacco incidents per youth-rated movie decreased 95.8%, from an average of 23.1 incidents per movie to an average of 1.0 incident. For independent companies (which are not MPAA members) and the three MPAA members with no antitobacco policies, tobacco incidents decreased 41.7%, from an average of 17.9 incidents per youth-rated movie in 2005 to 10.4 in 2010, a 10-fold higher rate than the rate for the companies with policies. Among the three companies with antitobacco policies, 88.2% of their top-grossing movies had no tobacco incidents, compared with 57.4% of movies among companies without policies.
The difference is dramatic, as indicated by this image about the images. (Because I turned the columns into cigarettes, this is not just a graph, but an infographic):
The policies provide what may be an ideal mix of accountability and responsibility, short of a simplistic ban.
[The policies] provide for review of scripts, story boards, daily footage, rough cuts, and the final edited film by managers in each studio with the authority to implement the policies. However, although the three companies have eliminated depictions of tobacco use almost entirely from their G, PG, and PG-13 movies, as of June 2011 none of the three policies completely banned smoking or other tobacco imagery in the youth-rated films that they produced or distributed.
Maybe this formula is effective because there already has been a strong cultural shift against smoking — as strong, even, as the shift against excluding women from management positions?
Graphic addendum (disturbing image below)
Whether smoking in movies actually encourages young people to take up smoking is of course a not a settled issue — especially on websites sponsored by tobacco sellers, as seen in this ironic screen-shot from Smokers News:
One reason to have an explicit policy is that it’s easy to assume viewers will see through the glamour to the negative outcomes. “Surely no one will want to be like that character…” But people – maybe especially young people? – have an amazing capacity to celebrate selectively from the characters they see. I have learned from experience that, in children’s stories, even those who get their comeuppance in the end still manage to emerge as role models for their bad behavior. So maybe some people want to relive this from Pulp Fiction…
…and aren’t put off by this:
* “A new incident occurred each time 1) a tobacco product went off screen and then back on screen, 2) a different actor was shown with a tobacco product, or 3) a scene changed, and the new scene contained the use or implied off-screen use of a tobacco product.”
Kristina K. sent in a link to an interactive map at the New York Times that shows the results of Gallup’s 2010 polls of well-being. [UPDATE: Reader Danielle pointed out I forgot to provide a link to the map. Sorry! You can find it here.] Gallup surveys 1,000 people per day about a variety of indicators of well-being, including questions about physical, mental, and emotional health, various health-related behaviors, ability to access health care, access to adequate food and housing, and perceptions of their communities. Here are the overall composite scores, by congressional district (a higher score is better):
The general geographic pattern indicates a swath of relatively low well-being curving from Louisiana up through Michigan, while those in the upper Great Plains and the inter-mountain West are doing better than average.
Percent reporting experiencing a lot of stress:
Percent who have ever been told they have depression:
Of course, this may reflect differences in rates of depression, but it could also reflect differences in medical professionals’ likelihood of identifying a set of symptoms as depression and bringing it up with a patient. For example, we see significant differences by state in the frequency of Caesarean sections among pregnant women.
Percent of people who smoke:
Percent reporting an inability to buy sufficient food:
The Gallup page on well-being presents more data. Here is a map of 2009 overall well-being that is a bit easier to read since it’s presented by state rather than congressional district:
Hawaii had the highest overall score, at 70.2; West Virginia had the lowest, 60.5. If you go to their site and click on a state, you can get a breakdown of scores in each area (emotional well-being, physical health, healthy behaviors, and so on).
Iconic Photos documents at least two instances in which the U.S. postal service rewrote history, so to speak, taking smoking out of the stamp:
Pollack and Johnson are important figures in American history, who smoked before it carried the stigma it carries today, and whose smoking represents the time and culture that inspired their genius. How do you balance the desire to be historically accurate and true to the individual, with the desire to avoid endorsing a habit newly framed as a social problem?