At the Intersection of Health, Health Care and Policy Cite this article as: Amy L. Fairchild, Ronald Bayer and James Colgrove Risky Business: New York City's Experience With Fear-Based Public Health Campaigns Health Affairs, 34, no.5 (2015):844-851 doi: 10.1377/hlthaff.2014.1236

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Public Health Campaigns By Amy L. Fairchild, Ronald Bayer, and James Colgrove 10.1377/hlthaff.2014.1236 HEALTH AFFAIRS 34, NO. 5 (2015): 844–851 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.

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Amy L. Fairchild (alf4@ columbia.edu) is a professor in the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, in New York City. Ronald Bayer is a professor at the Mailman School of Public Health, Columbia University. James Colgrove is a professor in the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University.

Risky Business: New York City’s Experience With Fear-Based Public Health Campaigns Fear-based public health campaigns have been the subject of an intense moral and empirical debate. We examined how New York City, under Mayor Michael Bloomberg, used fear-based appeals to confront three challenges to public health: high rates of tobacco use, obesity, and HIV infection. New York City’s use of this type of messaging may have set a precedent. Other state and local health departments will have to navigate how and whether to use fear in a context where it is possible to assert that it can serve the interests of public health. But this will not reduce the need to carefully balance efficacy, uncertainty, stigma, marginalization, emotional burdens, justice, community participation, and scientific credibility. ABSTRACT

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n the face of HIV prevention efforts in the 1980s that equated sex with death, activists asserted that fear is a bad motivator for change,1 claiming not only that it would not produce any behavior change but also that fear always backfired and resulted in stigmatization and marginalization. We examined how New York City, under the leadership of Mayor Michael Bloomberg, used fear-based campaigns provoking feelings of susceptibility to health threats as it addressed three challenges to public health: tobacco use, obesity, and HIV infection. Admired by some, excoriated by others who saw in these efforts an exemplification of the “Nanny State,” the New York experience from 2002 to 2013 was informed by a large if contested body of evidence about the motivational effects of fear. Previous studies indicating that anything other than moderate levels of fear would be counterproductive had defined thinking about the use of fear in public health messaging.1 As a consequence, two eminent fear theorists and researchers argued that “two generations of health educators were taught that fear arousing messages backfire, and are to be avoided at all times.”1(p330) The authors of two meta-analyses focused on HIV 844

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prevention conducted since 2000 rejected fearbased appeals.2,3 Six meta-analyses from the same time period that considered all fear-based studies suggested that the stronger the fear appeal the better, provided that people believe they have the capacity to act.4–9 Importantly, the HIVbased analyses agree that long-term behavior change relies on “resolving fear.”3 While there is no one definition of what constitutes a fear-based appeal, creating an emotional reaction to the “threat” of disease, disfigurement, or death is key. Humor is often employed to make more palatable an otherwise harsh confrontation with risk. Fear-based appeals also call on other emotions, such as disgust and shame.10 Sometimes by design, sometimes an unintended consequence of the images and messages employed, fear-based campaigns may imply the loss of social standing. As a consequence, they are commonly critiqued as producing and reinforcing social stigma, imposing hardships on already vulnerable populations.11–13 Campaigns freighted by concerns about stigma become especially politically charged, motivating impassioned ethical debate.14 As a consequence, relying on fear is risky business. The decision about whether to use a fear-

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based campaign and how far to go is not simply a technical, evidence-based determination. Decisions are almost always political, reflecting a calculation of how to balance issues of effectiveness, uncertainty, stigma, marginalization, emotional burdens, justice, community participation, and scientific credibility.

Tobacco: Fear Unbridled New York City had a long history of efforts to address smoking in the city. However, Thomas Frieden, who headed the NYC Department of Health and Mental Hygiene from 2002 to 2009 as commissioner, fundamentally changed the tone of the city’s approach to smoking. Frieden later went on to lead the Centers for Disease Control and Prevention. He came to the position of health commissioner well known for his aggressive and effective management of the city’s multidrug-resistant tuberculosis outbreak in the early 1990s. Highly influenced by the work of the Australian researcher Melanie Wakefield, who was central in making the case that fear worked to achieve tobacco control,15 Frieden “came in feeling we needed to be hard-hitting” (Jeffrey Escoffier, Health Media and Marketing Group, Department of Health, personal communication, June 9, 2014). While “hard-hitting” is not necessarily limited to fear-based appeals, for many in the field, explained Escoffier, director of the Department of Health’s Health Media and Marketing Group and director of digital communications, “hard-hitting is a euphemism for fearbased.” We use the terms interchangeably. While the Department of Health continued to put out “aspirational” ads featuring “happy quitters” through 2005,16 the aggressive Australian antismoking approach would become “the mama of our style” (Escoffier, personal communication, June 9, 2014). Smoking cessation rates had stalled.17 Both nationally and in New York City, about 22 percent of adults smoked.18,19 Funding was seen as a major contributor to the stagnation. Over the five-year period leading up to 2006, industry spending on marketing campaigns doubled, whereas state tobacco control funding dropped about 20 percent. Health officials were determined to call upon what both an extensive review of the literature and their own focus groups of current smokers were telling them: “In focus groups, fear and graphic imagery created the most emotional reactions and the most discussions” (Elizabeth Kilgore, Bureau of Chronic Disease Prevention and Tobacco Control, personal communication, January 17, 2014). The city’s first foray into hard-hitting antismoking appeals in December 2005 used the

extremely graphic Australian campaign, “Every Cigarette Is Doing You Damage.” The message began to attract approving media attention along with a few complaints from shocked viewers. But the city’s next effort, in late May 2006, would stir more mixed reactions. The city used a campaign developed by the Massachusetts Department of Public Health featuring Ronaldo, a man with a permanent tracheotomy. It was “scary enough” to trigger a wave of 311 calls,20 the main measure of success at the time. “Ronaldo, I would say, hit the first home run,” Escoffier said (personal communication, June 9, 2014). Key to this campaign, which reminded viewers “nothing will ever be the same,” was not the risk of death but lifelong suffering, which focus groups had identified as the major dread (Kilgore, personal communication, January 17, 2014). Ronaldo stressed the steps he had to take to care for himself and the activities he had to give up: “I will have to do this for the rest of my life.”21 The use of someone who had actually suffered gave this warning its emotional heft (Kilgore, personal communication, January 17, 2014; Escoffier, personal communication, June 9, 2014). There was a stark contrast not only when it came to the calls for help but also in the level of complaints compared to the initial campaign. Of the fifty-six recorded objections, most either underscored how hard it was for those who had lost a loved one to smoking to see these ads or protested that these images weren’t appropriate for children. Health officials recalled no complaints that such an approach stigmatized smokers (Kilgore, personal communication, January 17, 2014). The public reaction convinced the city that it needed its own supply of strong ads. Its original hard-hitting campaign, first aired in 2006, sounded the theme, “Cigarettes Are Eating You Alive.” Posters and health bulletins complemented television spots. The campaign showed close-ups of a diseased heart, lung, mouth, teeth, and throat, vividly illustrating the warning that “smoking eats away at nearly every vital organ and tissue of the body.”22 Variants depicted the damage and suffering that smoking could inflict on infants and young children—zooming in on babies gasping for breath, cribs left empty.23 The city followed up the campaign with free matchbooks, distributed at 132 cigarette retailers, with graphic illustrations of lung, oral, and throat cancer; gum disease; and other consequences of smoking.24 Health department officials reported immediate, marked declines in smoking.25 Said one viewer of the ads, “They are disgusting, horrible, and distasteful; and they helped.”20 Tobacco companies, predictably, fought back. Although they had no legal basis for challenging May 2 015

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Public Health Campaigns the city’s antismoking ads, they attacked a new city requirement for tobacco retailers to post campaign material “within three inches of cash registers or in each place where tobacco products are displayed.” A joint lawsuit with the New York State Association of Convenience Stores charged that the requirement infringed “the First Amendment rights of store owners who disagree with their messages, and that the placards are so disgusting that they hurt business by discouraging people from buying not only cigarettes but also more wholesome merchandise like milk and sandwiches.”26 It was not the “gruesome images,” however, but violation of federal law that led the US District Court in Manhattan to overturn the 2009 rule: Only the federal government held regulatory authority over tobacco advertising. Over the course of many decades, smoking had become concentrated among people of lower socioeconomic status and less access to the levers of power; it had become “denormalized”—seen by the majority of people as a deviant or antisocial behavior.27 These changes created a political climate within which the use of fear, even if it generated pushback from citizens, was viewed as politically uncontroversial. Fear was a socially acceptable response to smoking. This would not hold true in the case of either obesity or HIV.

Obesity: Pouring On The Fear The approach to tobacco set the tone for the whole NYC Department of Health and Mental Hygiene even after Tom Farley, who had served the department as a consultant and saw Bloomberg as “a kindred spirit,”28 took the helm in 2009 after Frieden’s departure. Farley had signaled his willingness to use the power of government to restrict unhealthy choices in his 2005 book, Prescription for a Healthy Nation.29 When he came to New York City as health commissioner, he would stand in strong support of the mayor’s proposal to prohibit the use of food stamps for soda purchases.30,31 For critics, such a limit implied that the poor were incapable of making wise choices for themselves—a pejorative, stigmatizing characterization. The first forays into hard-hitting obesity tactics in 2009 stirred only mild controversy. At issue was what became a viral video, “Man Drinking Fat,” which featured a casually dressed, trim, white, attractive twenty-something popping open a can of soda. He pours semi-congealed fat into a glass and takes a single long draw, the yellowish, brownish sludge oozing down his face. “Don’t drink yourself fat,” the ad warns.32 The “stomach-churning” images of fat being imbibed,33 although humorous, entailed a threat. 846

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Fear was a socially acceptable response to smoking. This would not hold true in the case of either obesity or HIV.

As Farley stated, “I think what people fear is getting fat, so we need some statement about what is bad about consuming so many calories.”34 The fear of getting fat certainly played on worries about becoming unattractive in the eyes of others, but the goal for health officials was to associate gaining weight with health risks. In “Man Eating Sugar,” the fat drinker returned, this time throwing back packets of sugar—one after another—at a diner counter while his neighbors looked on with a mix of contempt and bafflement—unwittingly getting their own sixteen packets in the form of soda— hence the tag line, “You’d never EAT 16 packs of sugar.”35 The implication was that we should regard drinking this much sugar with the same scorn that we’d regard eating it. Farley justified the approach with the argument commonly used to support graphic fear-based campaigns: They break through the socially structured fog that encouraged the consumption of toxic substances because of a simple lack of awareness. “This new campaign shows how easy it is to drink a staggering amount of sugar in one day without realizing it,” he said.36 But if the fat-drinking and sugar-eating ads suggested that to continue knowingly with such unhealthy consumption was not only foolish but also irresponsible, the next generation of ads, targeting portion size, would turn up the fear and lay the groundwork for a different kind of critique. As the city extended its sugar-sweetened beverages campaign to juice, sports drinks, and other high-calorie drinks in 2013, it turned to the tried and true techniques that had made “Cigarettes Are Eating You Alive” so powerful, more intimately highlighting real bodies, real organs: an overweight African American man guzzling a bright blue sports drink, followed by a cut to his sagging bare chest and bulging stomach; the feet of a diabetic patient surgically wrapped after toes had been amputated, writhing in pain; surgical

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In the case of AIDS, community-based organizations had already successfully challenged the use of fear-based appeals.

instruments probing a bloody, beating heart, accompanied by irregular heartbeats that resolve into the familiar sound of flat-lining.37 Some videos used computer-generated images to show fat crowding out organs, x-ray images of toes and feet being systematically amputated, and eyeballs seeming to burn up like old celluloid film to depict blindness.38,39 Variants, which featured women, men, Hispanics, African Americans, and children, emphasized cardiovascular disease or stroke, showing hearts and brains blackening before our eyes.40 Although health officials reported that, indeed, they did get some complaints about stigmatizing the poor, it was a different debate about another New York City campaign targeting teenage pregnancy that ultimately pushed forward the issue of stigma. As the health department was launching its campaign against sports drinks and sugary fruit juice, the Human Resources Administration was hitting the subways with images of forlorn, teary-eyed toddlers in a campaign aimed at reducing teenage pregnancy. Mostly children of color, the tots warned, “Honestly Mom…chances are he won’t stay with you.What happens to me?” or “I’m twice as likely not to graduate high school because you had me as a teen.”41 In the face of bitter backlash,42 the mayor defended the teen pregnancy effort, arguing that it was “past time” for a “value neutral” approach.43 The health department, which had so successfully pressed forward with a hard-hitting tobacco campaign, found itself working in a hostile environment. The Human Resources Administration controversy made it necessary to weigh the political costs of fear-based campaigns in other city agencies. The Department of Health was quick to agree that stigma was not “an effective way to communicate these issues.” Thereafter, “everything was always really carefully scrutinized for the potential impact it would have in that regard” (Escoffier, personal communica-

tion, June 9, 2014). Nonetheless, recognition of a new set of limits and concerns did not undercut a commitment to hard-hitting campaigns.

‘It’s Never Just HIV’: The Price Of Fear The controversy over “Pouring on the Pounds” was nothing compared to the pitched battle that would erupt when the NYC Department of Health determined that longstanding efforts using humor or affirmation—known as “sex-positive” approaches—had failed to reduce HIV incidence among young men who had sex with men, especially among blacks and Latinos. The city’s assistant commissioner for HIV/AIDS Prevention and Control at the Department of Health, Monica Sweeney, who had been hired by Frieden for her straight talking, no-nonsense approach, initially spearheaded a more cautious effort: “Tonight’s hookup could be the hookup of a lifetime. Use condoms.” Another stressed the ubiquity of vulnerability: “Tops, Bottoms, Versatiles: HIV has no favorite position.” Sweeney explained, “Frieden didn’t like them. They didn’t have enough punch. We gave them to a [communitybased organization] that used them.” But she, too, was reaching for something less “sex positive”: “I looked at the data on young [men who have sex with men] in brown/black communities—saw it getting worse, not better; Frieden saw that the HIV numbers were increasing and said we had to do better” (Monica Sweeney, Department of Health and Mental Hygiene, personal communication, January 17, 2014). Sweeney would draw explicitly on the department’s experience with fear-based tobacco ads to frame a new initiative, again with community reinforcement: “We did focus groups with black and Latino men. The consensus was that we don’t do the hard-hitting stuff, the stuff that we did with smoking. All we hear on TV is all you need is one pill a day” (Sweeney, personal communication, January 17, 2014). But the politics of fear in the realm of HIV differed from those in tobacco control, where nonsmokers’ rights groups and national organizations such as the American Cancer Society, not smokers themselves, helped define the agenda early on. In the case of AIDS, community-based organizations had already successfully challenged the use of fear-based appeals.1 Sweeney recalled that “there were no concerns about this unleashing a firestorm.” As the Department of Health developed “It’s Never Just HIV,” Farley kept the mayor’s office well informed: “Decisions were never made about these things without going to City Hall first,” Sweeney said. Farley got “sign off every Friday” (Sweeney, M ay 2 0 1 5

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Public Health Campaigns personal communication, January 17, 2014). No doubt the controversy over obesity dictated a cautious, deliberate approach. Before launching, Sweeney and her staff reviewed the HIV initiative with opinion leaders in the affected community (Sweeney, personal communication, January 17, 2014). “It’s Never Just HIV” ran in the form of thirtysecond television ads and subway posters. Video spots evoked a kind of B horror movie.Young gay men glance fearfully (even shamefully) at the camera. As the sound of a heartbeat quickens behind the menacing voice-over, the viewer sees the consequences of osteoporosis (a femur, shown in x-ray, snapping on the dance floor), dementia (a brain scan shows gray matter shriveling, the victim grasping his head in the agony of unbearable confusion), and anal cancer (a digitally enhanced internal view of the body fades to a bloody, raw anus, with Frankenstein-like surgery scars, of an African American man). Some affected men in the television spots dissolve into tears, others stare vacantly from a hospital bed.44 Subway ads featured the same grisly images of co-infections—other conditions that take hold in the immune-compromised system. “Stay HIV Free. Always use a condom,” was the take-home message, accompanied by instructions to call for more information. The campaign was released on Thursday, December 7, 2010. “The whole weekend I kept thinking, why haven’t I heard anything?” The next week, remembered Sweeney, “all hell broke loose. Critics said they were going directly to the mayor. I spent the whole week on my knees begging Tom [Farley] not to pull it” (Sweeney, personal communication, January 17, 2014). The campaign ran in the subways and on television for a month, in the end exceeding its original budget. Much of the coverage in the mainstream media was not critical of the campaign, viewing it as communicating new understandings of the disease.45–47 The reaction of activist segments of the gay community, however, threw into high relief the reality that although the health department had tested the ad and gained strong approval from the target audience, communities and their leaders do not speak with a single voice. The campaign drew pointed, sustained fire from those who viewed themselves as socially vulnerable.48 Francisco Roque of the Gay Men’s Health Crisis (GMHC) argued, “It really paints this picture of gay men as these sort of disease-ridden vessels, and so the message is really sort of, ‘Stay away from gay men.’”49 The GMHC’s executive director, Marjorie Hill, focused on the empirical issues: “We know from our longstanding HIV prevention work that portraying gay and bisexu848

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As of 2015 the hardhitting approach seems to have been shelved for HIV.

al men as dispensing diseases is counterproductive. Studies have shown that scare tactics are not effective.”48 Others within the gay community condoned the fear-based messaging. Long-time AIDS activist Larry Kramer, who founded first the GMHC and then the AIDS Coalition to Unleash Power (ACT-UP), had famously written in 1983, “I am sick of everyone in this community who tells me to stop creating a panic. How many of us have to die before you get scared off your ass and into action?”50 Kramer, unsurprisingly, again took a contrarian stance to the public voice of the gay community thirty years later. “This ad is honest and true and scary, all of which it should be,” he said. “All attempts to curtail it via lily-livered nicey-nicey ‘prevention’ tactics have failed.”48 The Department of Health echoed some of Kramer’s themes as it defended the campaign. “These ads are hard hitting and sometimes unpleasant,” said Sweeney in response to the controversy, “but so is HIV. And silence isn’t stopping the spread.”51 Recognizing the extent to which fear-based campaigns might increase the social isolation of gay men, she stated, “We condemn stigma, we support community efforts to combat it, but we cannot ignore the continuing spread of a preventable, incurable infection. HIV is no longer a death sentence, but it is still a life sentence.”51 But as with obesity, the use of fear could not be measured simply in terms of efficacy. Behavioral achievements came with a political price. Although the Department of Health has continued with its fear-based obesity and tobacco efforts, as of 2015 the hard-hitting approach seems to have been shelved for HIV.

Conclusion New York City’s fear-based public health campaigns must be viewed, in substance and style, against the backdrop of broad strategies adopted by the Bloomberg administration during its tenure and executed with mixed success by two commissioners of health who were deeply committed to using forceful tactics. The city had turned to

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Emotionally evocative, graphic, even disturbing images and messages were neither as restrictive as bans nor as burdensome as high taxes.

taxes to increase the price of cigarettes. That effort was successful in making cigarettes in New York City among the most expensive in the United States, although the proposed New York State tax on sugar-sweetened beverages supported by the city failed. The city imposed bans on products and public behaviors with important public health implications. Trans fats were barred; smoking in parks, on beaches, and in other public venues was banned. But the courts blocked efforts to impose restrictions on the sale of supersize drinks. This concerted effort to use the power of government to shape people’s choices by regulating the market for unhealthy consumer products and by imposing prohibitions on behavior involved a critical determination: There were circumstances when the collective good justified limits on liberty. In response to charges of unwarranted paternalism, Bloomberg and his health commissioners drew on evidence-based analyses suggesting that the prospect of saving lives and reducing suffering provided sufficient warrant to intervene: Public health held a trump card that could and should be played. The same logic was applied to fear-based campaigns, which challenged public health conventions. The fear-based public health campaigns directed at tobacco, obesity, and HIV explicitly rejected the notion that public health officials have done enough when they dispassionately convey health information to populations, leaving it to them to calculate the risks. Public health professionals saw “so-called positive” campaigns that merely communicated probabilistic data about risk or associated health and fitness with appealing models and images of best behaviors as woefully inadequate for some situations.When a warning was demanded, they felt a duty to nudge, pres-

sure, even scare populations away from risky behavior.52 Emotionally evocative, graphic, even disturbing images and messages were neither as restrictive as bans nor as burdensome as high taxes. The campaigns shared a belief that in all three cases, risk behavior was shaped at least in part by corporate practice. But in sharp contrast to the Truth Campaign against youth smoking, which directly attacked the tobacco industry, the efforts we considered here focused on illuminating individual choice. To be sure, broader ethical debate has consistently raised questions about the extent to which fear-based campaigns were coercive,12 with the majority of analyses concluding that the use of fear limits autonomy. But what is so striking about the political debate is the degree to which these concerns were not raised. Instead, given the fundamental focus on behavior, it was stigma that potentially tarred fearbased appeals as “a health promotion profanity.”52 The tobacco campaigns were no doubt the least controversial precisely because there already existed a shared understanding about the necessity of using the full panoply of public health interventions to press the end game of smoking. As we have noted, there is now empirical evidence that when carefully designed, fear-based appeals can work. But were they effective in the cases we have examined? In the New York City experience, each was part of a broad, multiprong effort. The tobacco campaigns were paired with increases in cigarette taxes, smoke-free measures, and distribution of nicotine replacement aids. The fear-based appeals increased calls to the help quit lines and boosted enrollment in cessation programs.15 Overall, the city’s smoking rate declined by 35 percent, dropping from 22 percent in 2002 to 14 percent in 2010.16 This was much steeper than the national rate of decline. All of the decrease cannot be attributed to advertising efforts alone, but it is noteworthy that the city’s smoking rates ticked back up in 2014, for the first time since 2002, a trend that health officials linked to substantial budgetary reductions. Tobacco control programs suffered more than a 50 percent cutback between 2009 and 2014.53 While the obesity and HIV campaigns also increased calls to the city’s help line, the task of proving a causal link to obesity rates and HIV rates—both dependent on complex behaviors and risk environments—would be a challenge even within a carefully controlled experimental study.What can be made, for example, of the data that showed a statistically significant drop of 5.5 percent in childhood obesity between 2006 and 2011, the period during which the DepartM ay 20 1 5

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Tobacco control programs suffered a more than 50 percent cutback between 2009 and 2014. New York City’s smoking rates ticked up in 2014 for the first time since 2002.

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Public Health Campaigns ment of Health launched “Pouring on the Pounds,” while for adults the picture “remained bleak”?54 How is one to understand the apparent continuing increase of HIV diagnoses among young men of color having sex with men, an extremely hard-to-reach group in terms of research and prevention?55 How other state and local health departments, and even the city itself, will navigate the pitfalls and potential of fear-based initiatives (whether they will see in New York in the Bloomberg years Portions of this article were presented at the American Public Health Association Meeting in New Orleans,

an example to emulate or to avoid)—indeed, how New York in the post-Bloomberg era will decide on the role of fear-based campaign—cannot be predicted. The Bloomberg-era model has been adopted by other countries. Likewise, the department continues to be solicited for advice about adopting its signature approach. But decisions regarding fear-based messages will need to be made in a context where it is no longer possible to assert that fear-based efforts can never serve the interests of public health. ▪

Louisiana, November 2014. The authors thank David Michael Vaughan and students and faculty at the Center for

the History and Ethics of Public Health, Mailman School of Public Health, Columbia University, for comments.

Rev Gen Psych. 2007;11(3):258–85. 9 Peters GJ, Ruiter RA, Kok G. Threatening communication: a critical re-analysis and a revised metaanalytic test for fear appeal theory. Health Psychol Rev. 2013;7(Suppl 1): S8–31. 10 Unger LS, Stearns JM. The use of fear and guilt messages in television advertising: issues and evidence. In: Murphy PE, et al., editors. 1983 AMA educators proceedings, series no. 9. Chicago (IL): American Marketing Association; 1983. p. 16–20. 11 Guttman N, Salmon CT. Guilt, fear, stigma, and knowledge gaps: ethical issues in public health communication interventions. Bioethics. 2004; 18(6):531–52. 12 Hastings G, Stead M, Webb J. Fear appeals in social marketing: strategic and ethical reasons for concern. Psychol Market. 2004;21(11): 961–86. 13 Lupton D. A postmodern public health? Aust N Z J Public Health. 1998;22(1):3–5. 14 Callahan D. Obesity: chasing an elusive epidemic. Hastings Cent Rep. 2013;43(1):34–40. 15 Wakefield M, Flay B, Nichter M, Giovino G. Effects of anti-smoking advertising on youth smoking: a review. J Health Commun. 2003;8(3): 229–47. 16 Kilgore EA, Mandel-Ricci J, Johns M, Coady MH, Perl SB, Goodman A, et al. Making it harder to smoke and easier to quit: the effect of 10 years of tobacco control in New York City. Am J Pub Health. 2014;104(6):e5–8. 17 Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2006. MMWR Morb Mortal Wkly Rep. 2007;56(44):1157–61. 18 Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2002. MMWR Morb Mortal Wkly Rep. 2004;53(20):427–31.

19 New York City Department of Health and Mental Hygiene. Trends in cigarette use among adults in New York City, 2002–2010. New York (NY): Epi Data Brief; 2011. No. 12. 20 Atkinson C. Missing a larynx, he’s become the voice of antismoking efforts. New York Times. 2007 Jul 17; Sect. C:9. 21 Make Smoking History MA. Fight for your life: Ronaldo [video on the Internet]. Boston (MA): Massachusetts Department of Public Health; 2011 Apr 29 [cited 2015 Mar 20]. Available from: https://www.you tube.com/watch?v=H_CZ02zkrx8 22 NYC Health. Cigarettes are eating you alive (30 seconds) [video on the Internet]. New York (NY): New York City Department of Health and Mental Hygiene; 2014 Jul 15 [cited 2015 Mar 23]. Available from: https://www.youtube.com/watch? v=fkXHzhTF5-c&list=UUGNw2snuIMnbooSelbxIzg 23 NYC Health. Cigarettes are eating you alive (baby-30 seconds) [video on the Internet]. New York (NY): New York City Department of Health and Mental Hygiene; 2014 Jul 15 [cited 2015 Mar 23]. Available from: https://www.youtube.com/watch? v=eMfnFia-Jz0&list=UUGNw2snuIMnbooSelbxIzg 24 Chan S. Health depart. distributes matchbooks with grim alert. New York Times. 2008 Sep 23;Sect. B:3. 25 Ramirez A. City smokers’ ranks drop 19%, study says. New York Times. 2007 Jun 22;Sect. B:3. 26 Hartocollis A. Cigarette makers and retailers sue to block rule requiring antismoking posters. New York Times. 2010 Jun 5;Sect. A:19. 27 Brandt AM. The cigarette century: the rise, fall, and deadly persistence of the product that defined America. New York (NY): Basic Books; 2007. 28 Hartocollis A. Running for your life. New York Times. 2010 Nov 7;Sect. MB:1.

NOTES 1 Green EC, Witte K. Can fear arousal in public health campaigns contribute to the decline of HIV prevalence? J Health Commun. 2006;11(3): 245–59. 2 Albarracín D, Gillette JC, Earl AN, Glassman LR, Durantini MR, Ho MH. A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychol Bull. 2005;131(6): 856–97. 3 Earl A, Albarracín D. Nature, decay, and the spiraling of the effects of fear-inducing arguments and HIV counseling and testing: a metaanalysis of the short- and long-term outcomes of HIV-prevention interventions. Health Psychol. 2007; 26(4):496–506. 4 Boster FJ, Mongeau P. Fear-arousing persuasive arguments. In: Bostrom RN, Westley BH, editors. Communication yearbook: an annual review published for the International Communication Assn. (no. 8). Newbury Park (CA): Sage; 1984. p. 330–74. 5 Mongeau P. Another look at feararousing messages. In: Allen M, Preiss RW, editors. Persuasion: advances through meta-analysis. Cresskill (NJ): Hampton Press; 1998. p. 53–68. 6 Sutton SR. Fear-arousing communications: a critical examination of theory and research. In: Eiser JR, editor. Social psychology and behavioral medicine. London: Wiley; 1982. p. 303–37. 7 Witte K, Allen M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav. 2000;27(5):591–615. 8 de Hoog N, Stroebe W, de Wit JBF. The impact of vulnerability to and severity of a health risk on processing and acceptance of fear-arousing communications: a meta-analysis.

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