We have (nearly) forgotten what we learned from the anti-smoking campaigns of the sixties and seventies.
On December 1, 1966, a lawyer in his 20s named John Banzhaf – later to become a professor at George Washington University Law School – petitioned WCBS-TV in New York City to provide free air time to respond to the pro-smoking views embedded in the cigarette commercials that the television station had been broadcasting. After two years of litigation, the United States Court of Appeals for the District of Columbia Circuit, in an opinion written by Chief Judge David L. Bazelon, found in Banzhaf’s favor. The Court upheld a ruling by the Federal Communications Commission requiring every TV station to broadcast one anti-smoking public service announcement during prime time for every three cigarette commercials it aired.
There followed a sustained period of prime-time anti-smoking ads, running night after night until the U.S. Congress finally banned all TV and radio advertising of cigarettes effective January 2, 1971. From 1968–1969, per capita cigarette consumption in the U.S. fell by 4.6 percent — a drop in smoking rates not seen since the lung cancer scare of December 1953, and not seen again until a major, nationwide increase in the federal cigarette excise tax in 1983.
Here, we reproduce what was arguably the most influential public service advertisement of the period, sponsored by the American Cancer Society, lasting all of eight seconds.
Combining Trust in Healthcare Providers with Peer Influence
The American Cancer Society public service ad worked because it combined two critical themes. First, the television-viewing public trusted healthcare providers – physicians, in particular – to offer reliable advice. Second, the salient reference to a large round number with lots of trailing zeros added the element of peer influence. The fusion of these two themes sent a clear message to many who doubted a connection between smoking and disease, or who felt they didn’t have the willpower to quit: All those doctors must know something.
When it comes to COVID-19 vaccine hesitancy, there is by now no shortage of commentators rightly observing that physicians and nurses can be vital vaccine messengers, and we, too, have joined in the chorus. Nor is there a paucity of position papers propounding the power of peer influence, and we’ve again joined the crowd. The new We Can Do This campaign is based, in great part, on the idea that everybody’s doing it.
So let’s bring back the nearly forgotten motif from a half-century ago. To that end, we first need to do some arithmetic. An estimated 84.5% of the nation’s 3.8 million registered nurses work in healthcare. There are 985,000 actively practicing physicians in the United States. A recent Kaiser Family Foundation survey, in the field during February 11 – March 7, 2021, reported that 68 percent of doctors and nurses in the United States had received at least one vaccine dose. (We do not include those expressing an intention to be vaccinated.) Putting all the numbers together, and recognizing that the survey data are already two months old, we end up with a conservative tally of at least 3 million vaccinated doctors and nurses.
So, here is our reincarnation of the American Cancer Society public service ad of 1969.
Social Desirability Bias: The Achilles Heel of COVID-19 Vaccine Surveys
In 1978, a decade after the prime-time, anti-smoking TV ads had begun to put the brakes on the 20th century tobacco juggernaut, Ken Warner, a young economist on the faculty of the University of Michigan School of Public Health in Ann Arbor, pointed out how survey-based estimates of cigarette smoking rates fell increasingly short of actual consumption based on tax receipts. With smoking rates then on the decline, Prof. Warner worried that survey respondents were ever more reluctant to tell the interviewer that they were engaging in a “socially undesirable” activity.
Even at the time, social desirability bias (SDB) had been a concern of survey experts. Rather than reveal their true intentions or beliefs, the problem was that people would tell the interviewer what they thought the interviewer wanted to hear. During the intervening 43 years, there has been an abundance of studies of the influence of SDB in surveys of such personal health-related behaviors as substance abuse and physical activity. Extensive reviews have been published. The problem has persisted even in apparently anonymous online surveys. In the modern version of SDB, survey researchers worry that respondents, ever wary of empty assurances of anonymity, will click on the button they want the online survey software to record.
When it comes to surveys of intentions to get vaccinated against COVID-19, social desirability bias has once again reared its ugly head. A handful of academic studies have at least acknowledged the problem, but only in passing. A worldwide review of vaccine hesitancy does not mention this problem at all. Nor does a recent interpretive synthesis in a major medical journal.
The Kaiser Family Foundation vaccine monitor recently reported that the proportion of U.S. adults who said they’d already received one dose of the vaccine or intended to do so as soon as possible increased from 61 percent in March to 64 percent in April. Polling data from the Pew Research Center, in the field on February 21, indicated that 69 percent of U.S. adults either had already received one dose of the vaccine or were probably or definitely planning to get vaccinated. Yet the Center Center for Disease Control’s Vaccine Tracker reports that 58 percent of the U.S. adult population has actually had at least one vaccine dose and only 44 percent had been fully vaccinated. These data would suggest that there remains considerable excess demand for the COVID-19 vaccine. Yet there are signs that demand has slowed, and some states are returning allotted vaccine doses because of excess supply.
The concern here is not just that a particular survey at a particular point in time may have overstated vaccination intentions. The more knotty problem is that the increasing promotion of vaccination itself enhances the magnitude of the social desirability bias and thus exaggerates the apparent rise in vaccine acceptance. That’s exactly what Prof. Warner worried about in an entirely different context more than four decades ago. What made smoking increasingly undesirable way back then was the growing movement of the 1970s to restrict smoking in public places.
Continuum of Resistance to Behavior Change
As the daily pace of vaccination has decelerated in the United States, a new wave of commentary has become fashionable. The basic theme is that vaccine hesitancy is deeply ingrained in some people because of their distrust of the medical establishment or authority in general, or their core beliefs about personal freedom or the inviolability of the body, or their hardened sense of fatalism.
What we learned from the anti-smoking campaigns is that resistance to behavioral change lies along a continuum. At one end of the spectrum, tens of millions of smokers quit when they got the facts about tobacco and health, and tens of millions of people lined up to get their shot when they got the facts about the efficacy of the COVID-19 vaccines. At the other end, many smokers remained addicted and in denial, but came around when they could no longer bear the ostracism of having to smoke outside the office in the cold, or when they had to pay more for life insurance, or when they suddenly found themselves tethered to a heart monitor in the intensive care unit. Others who remain hesitant to get vaccinated will similarly come around when they find out – as inevitably will be the case – that proof of vaccination has become the access key to open the portal to life as we once knew it.