Medical Examiner

There’s a Proven Public Health Strategy We Could Use to Encourage Vaccination

As we learned with smoking, showing people visceral possible health outcomes effectively scares them into behaving differently.

Child shows a classic day-four rash with measles.
Images of children with the measles grab more attention than any cheerfully sanitized infographic.*
CDC/NIP/Barbara Rice

In 2012, the Centers for Disease Control and Prevention launched “Tips From Former Smokers,” its first-ever paid national anti-tobacco campaign. “Tips” featured real people suffering real medical conditions resulting from their exposure to tobacco smoke. The campaign gave them a direct platform to share their experiences, which the CDC thought would encourage current smokers to quit and dissuade future smokers from ever starting.

What distinguished this public health campaign was its visceral intimacy. In one poster, a former smoker named Shawn is posed with a lathered face, facing the camera as if it were a mirror while shaving his neck with a safety razor. The gaping orifice of his stoma—the breathing hole in his trachea surgically created after his larynx was removed—gapes at the viewer, the rim ragged with radiation scarring, a glistening red plane of muscle clearly visible under the skin. “BE CAREFUL NOT TO CUT YOUR STOMA,” the bold print reads.

In another, a double amputee sits up on the edge of his bed, the stumps below his knees stippled with reddened pressure sores as he prepares to put on his prosthetics. “ALLOW EXTRA TIME TO PUT ON YOUR LEGS,” this tip advises, with a note that the man suffered from Buerger’s disease, a circulatory problem resulting from tobacco use.

A man shaving around his stoma.
CDC

Yet another shows a woman who suffered recurrent smoking-related oral cancer, necessitating the surgical removal of half her jaw. In the print ad, she looks directly into the camera with a lower left face almost completely collapsed, the scars from her multiple skin grafts alternately pulling and bulging. The ad reads, “I didn’t think I smoked that much either.”

These ads are starkly clinical, shockingly vivid, and uncomfortable to look at. They also work. Per data collected by the CDC, from 2012 to 2015, more than 9 million smokers attempted to quit because of exposure to the “Tips From Former Smokers” campaign. More than half a million quit permanently, by conservative estimates. In the first year the campaign ran, approximately 17,000 premature deaths were estimated to have been averted, which meant that, given the $48 million price tag, the effort was both successful and cost-effective. (For reference, the CDC notes that the tobacco industry spends approximately $8 billion annually marketing its products to consumers.) In 2015, Thomas Frieden referred to the “Tips From Former Smokers” campaign as “one of the things I’m most proud of in my time as CDC director … these ads make a difference.”

A woman with half of her jaw removed from smoking.
CDC

The fact that tobacco smoke exposure increases an individual’s risk for cancer, heart disease, strokes, and breathing problems is widely known. Even current smokers understand that the habit is harmful. The question, then, is why the “Tips” campaign worked so well while other informational anti-smoking campaigns did not.

One practical advantage the “Tips” project had was funding. Through the Affordable Care Act, the CDC was granted a total of $102.5 million to produce and run the ads in the first two years of the campaign, and it continues to receive funds that allow it to create a polished product and buy high-visibility airtime to reach more viewers. A study from the Tobacco Research Network has shown that well-funded anti-smoking campaigns are the third-most-effective means of reducing smoking levels (behind raising cigarette taxes and public smoking bans).

But production value and distribution aside, one of the main reasons this campaign continues to be so effective is because those behind its design understood precisely what they had to accomplish to incentivize people to quit: They had to scare people.

Why weren’t smokers scared already? The CDC had long been warning that cigarette smoking could decrease one’s life expectancy by more than 10 years. It also advised that by quitting smoking early enough, smokers could aim to gain most of those life years back, which would seem to be as powerful an incentive as any.

But that message seems to be abstract, distant, or just too easy to dismiss. For whatever reason, a premature death wasn’t a frightening-enough prospect to propel many people to actually move toward change. The prospect of permanent disability, disfiguring disease, or loss of bodily autonomy, however, seemed to have more of an impact. Tim McAfee, former director of the Office on Smoking and Health at the CDC, put it more succinctly: “[Smokers] were less motivated by the fear of dying than the fear of suffering.”* And the “Tips” campaign leveraged this fear masterfully, by not just telling, but showing.

The campaign’s public health success doesn’t have to be limited to smoking. It should also provide a model for how we should be talking about vaccination.

The World Health Organization named “vaccine hesitancy” (defined as “the reluctance or refusal to vaccinate despite the availability of vaccines”) one of the top 10 threats to global health in 2019. Currently, the United States is host to several measles outbreaks clustered around underimmunized communities in Washington, New York, Texas, and Illinois. While overall national immunization rates remain high, there is a small population of children who have received only some or none of their recommended vaccinations, and their numbers are growing. Federal health data found that the proportion of children under the age of 2 who have received no vaccines at all has quadrupled since 2001.

There are many reasons why children remain unvaccinated. Some of these relate to health care access: Twice as many children living in rural areas are unvaccinated compared with their urban-dwelling counterparts, which might point to issues related to rural provider shortages or difficulty in accessing transportation. Furthermore, health insurance coverage is a significant factor, and uninsured children are almost nine times as likely to be unvaccinated as children covered by private insurance. (Even without health insurance, all children are eligible for free vaccinations under the federal Vaccines for Children program, though some parents may not be aware of this resource.)

Outside of these factors, a growing number of parents are deliberately choosing not to vaccinate their children. Eighteen states allow nonmedical exceptions for school immunization requirements, and the percentage of children attending school under these exemptions has slightly ticked upward over the past three years. There are several reasons why parents might choose to forgo recommended childhood immunizations—apprehension about “chemical” additives, concerns about side effects, distrust in the health care system—but the overarching theme is that fears of the vaccines outweigh the fears of the diseases vaccines prevent.

This means that anti-vaxxers are scared of the wrong things. And as we learned from the “Tips From Former Smokers” campaign, this can be corrected. To date, the visual campaign around increasing childhood vaccine coverage has been soft at best and self-sabotaging at worst. Infographics from the CDC feature cutesy drawings of cartoon children and winsome polka dots even while blaring grim statistics about morbidity and death rates. They warn parents that “measles isn’t just a little rash” while the accompanying adorable illustrations show it to be precisely that.

An infographic showing the number of child deaths a day from measles.
CDC
An infographic illustrating the seriousness of measles.
CDC

Could the strategy behind anti-smoking public health campaigns work to encourage more universal vaccine coverage? While there is little research on this specific approach with regard to immunization, health communications theory indicates that such tactics are generalizable.* Development of the “Tips” campaign was based on formative health communications research, and these types of hard-hitting ads, with real-life health consequences presented in a stark new way, have long been demonstrated to be the most effective. The reason the “Tips” campaign has seen such notable success is because scaring people out of unsafe behavior works better than nearly anything else.

So why is our current messaging about the importance of vaccination so gentle? It could be because we are generally more sensitive about issues surrounding children and parenting. Maybe it’s because vaccination has somehow, against all science and reason, become a highly polarized political issue around which people tread lightly. Maybe it’s because it’s frankly very disturbing to look at pictures of suffering children. But if vaccine hesitancy is indeed one of the top 10 global health threats, it’s time to stop being oblique and start using methods we know can produce the best results.

A well-funded public health campaign focusing on the real-life health consequences of underimmunization could have an enormous impact. Images of children with the measles—febrile, splotchy, eyes red, congested and miserable—would grab more attention than any cheerfully sanitized infographic. Interviews with people suffering the long-term chronic consequences of the diseases routine immunizations prevent could highlight the complications we have the luxury of rarely encountering. Male infertility as a result of mumps infection. Brain swelling from the chicken pox. Infant death after infection with the flu virus. An ad simply showing 30 seconds of raw footage of a toddler with whooping cough—hacking and gasping and struggling to breathe—could turn the focus of fear away from the vaccines and toward the disease in a way that the sterile regurgitation of facts and recommendations never could.

Stronger messaging about the dangers of vaccine-preventable diseases wouldn’t make headway on income or geographic disadvantages, which are the top two barriers to accessing immunization services. However, such a public health campaign could increase the urgency with which people seek out this form of preventative care. We already know that patients will go to greater efforts—wait longer, travel farther distances, research alternate resources—when a health threat is perceived to be dire or the need for a certain service is felt to be high. While the larger societal issues that stand in the way of improving health care access overall are vast and will involve slow, incremental change and a large investment of resources, a well-endowed, unapologetically graphic anti-disease campaign in the model of “Tips From Former Smokers” could yield cost-effective results relatively rapidly.

Starkly clinical images might indeed be difficult to see, but they’d help the vaccine-hesitant fully understand what they’re opting into by forgoing immunization. And if those types of realistic medical images are simply too uncomfortable, too gruesome, or too tragic to witness, it may well encourage people not to re-create them with the choices they make for their own children.

Correction, March 12, 2019: The first image in this post originally depicted a person with hand, foot, and mouth disease, but the caption stated the person had measles. The image has been updated to show a person with measles.

Correction, March 14, 2019: This piece originally misstated that Tim McAfee is still the director of the CDC’s Office on Smoking and Health. He is the former director.

Update, March 19, 2019: The original version of this story stated that there was no research on using scary imaging to prompt vaccination. There is some initial research, though its results are inconclusive and more research is necessary.