Smoking Cessation: A Gain-Framed Counseling Approach


To watch a video interview with Dr. Benjamin Toll, click here.

Anti-smoking advertisements today range from encouraging to grossly disturbing. A YouTube search for “anti-smoking ads” presents one jarring Australian advertisement featuring a woman with mouth cancer. Another commercial on the same page displays a man on his deathbed, suffering from lung cancer, urging smokers to quit in order to avoid his fate. In recent decades, there has been an increase in the use of negative imaging – that is, a “loss-framed” approach – to promote smoking cessation. Simultaneously, there is a noticeable dearth in “gain-framed” advertising – positively-framed messages that urge for the same change in behavior.

Most people will agree that a loss-framed approach that is both disturbing and galvanizing better promotes smoking cessation in today’s society. With public opinion overwhelmingly for the loss-framed approach to smoking cessation, is there any value in promoting gain-framed messages? Assistant Psychiatry Professor Benjamin Toll believes that there are indeed benefits to a gain-framed approach and investigates this psychological framing technique to maximize effectiveness in counseling protocols and treatment design.

Photo courtesy of “Stop Smoking Tips”

Gain-Framed vs. Loss-Framed History
Amos Tversky and Daniel Kahneman developed the concept of prospect theory and the gain-framed/risk-framed duality in the early 1980s. In short, prospect theory describes the psychology of decision making when the options involve risk. Tversky and Kahneman conducted an experimental design that illustrated how message framing affected decision-making. The classic example states: “You have been selected to choose one of two solutions for 600 people affected by a deadly disease. Solution A saves 200 people; Solution B has a 33.3% chance of saving everyone and a 66.6% chance of saving no one. Which will you pick?” Both solutions have an expected value of 200 saved lives, yet it is clear that solution B sounds riskier; solution A appears more reassuring and hopeful. If you chose solution A, you would be in the majority. In Tversky and Kahneman’s experiment, 72% of the people chose solution A while only 28% chose solution B. The result of their experiment is undeniably clear: the framing of options has important consequences for decision-making.

Message framing has practical applications in the study of smoking cessation counseling and advertising. With regard to smoking cessation, an example of a gain-framed message is, “You will save money if you stop smoking,” while the corresponding loss-framed message is, “You will lose money if you continue smoking.” Because smoking cessation is a preventive, low-risk, gain-associated behavior, prospect theory suggests that a gain-framed message would be the more effective approach. Applying the rationale of prospect theory to preventive smoking measures, Toll conducts clinical trials to test this hypothesis and works to maximize treatment and counseling effectiveness.

Experimenting With Gain-Framed Messages
Toll’s interest in psychological research on smoking cessation came about inadvertently. Toll says, “We simply kind of fall into these things.” During his junior year in Cornell University, Toll participated in a drug and alcohol treatment internship in Australia that introduced him to the methodology behind smoking and alcohol counseling. He brought his experience and newfound interest back to the United States and began conducting research in a similar field during his graduate school years. For Toll, his education truly nurtured his passion for message framing and its efficacy in smoking abstinence treatments. In 2001, Toll arrived at Yale to complete his post-doctoral fellowship and begin his clinical trials.

Toll’s 2007 clinical trial was the first psychological clinical trial to investigate how message framing should be used in conjunction with medical treatment to best achieve smoking cessation. The average age of his clinical trial subjects is 45, and most of them have smoked for over twenty-five years. As a part of the trial, participants received a standardized dose of bupropion, a smoking cessation aid, followed by questionnaires. They then viewed one of two videos that featured either a gain-framed anti-smoking message (e.g. “If you hold on to your reasons for quitting, you will have a better chance of success”) or a loss-framed message (e.g. “If you do not hold on to your reasons for quitting, you will have a great chance of failure”).

Examples of loss-framed (A) and gain-framed (B) messages for smoking cessation. Images courtesy of Professor Benjamin Toll.

The participants also received water bottles, anti-smoking handouts, and air fresheners with either gain-framed or loss-framed smoking cessation messages. The messages highlighted both the short- and long-term benefits of smoking cessation. Participants returned every two weeks for medication refills and further questionnaire evaluations. The smoking cessation outcomes were measured throughout the length of the six week trial, and the primary data collected were the subjects’ reports of smoking abstinence beginning from the initial quit date. Each subject’s abstinence report was verified by a breath test that biochemically measures carbon monoxide levels. A truthful abstinence report was defined as having carbon monoxide levels less than or equal to 10 ppm.

In analyzing the results of the clinical trial, Toll found that participants who completed treatment and counseling under the gain-framed conditions were more likely to report continuous abstinence from smoking. Toll attributes this result to the validity of prospect theory and its application to the smoking cessation approach. He identifies gain-framed, short-term messaging as the more appealing option, though the quantitative level of this assumption remains to be measured and explored in future clinical trials. The exact degree of the gain-framed appeal is not quantifiable yet, but Toll’s findings do identify the gain-framed approach as the more effective approach. Simply put, the beneficial and risk-free messages option in gain-framed messaging may be a more powerful motivating factor in encouraging smoking cessation than negatively framed messaging.

Toll describes his work and research as “meaningful…a rich experience in helping people who are suffering right now.” For him, the greatest reward is the direct impact of his work on people’s lives. He describes smoking addiction as a complex disorder that is both strongly behavioral and biological in nature. Smoking one pack per day for twenty or more years results in enormous intakes of nicotine and other toxins in addition to the development of a strong habitual trend that becomes cripplingly difficult to break. So while there is a strong biochemical component to smoking addiction, large contributors to the disorder are the behavioral and habitual aspects. For that reason, Toll finds effecting successful smoking abstinence in patients challenging yet immensely rewarding.

Photo courtesy of Chris Dellavedova
Photo courtesy of Chris Dellavedova

Implementing Findings: The New York State Smokers’ Quitline and Beyond
Since his 2007 clinical trial, Toll has incorporated the success of the gain-framed messaging experiments to programs outside of his personal office. In recent years, Toll has worked with the New York State Smokers’ Quitline. Unlike the environment of a personal one-to-one counseling session, Quitline provides call-to-quit services for those interested in smoking abstinence. In many ways, Quitline provides Toll with an environment that has a lower threshold to intervention. The telephone-counseling program is brief, but it offers the possibility of reaching out to more people. For an alternative approach to counseling sessions, Quitline provides an excellent intervention method for smokers.

Funded by the New York Department of Health, the program is free for New York state residents and includes a free two-week nicotine replacement kit (patches, gums, or lozenges) in addition to a quit coach to counsel and guide them through the process. Here, Toll has investigated the presentation of gain-framed counseling as well as the materials presented to callers that accentuate the benefits and risk-free aspects of smoking cessation. The New York State Smokers’ Quitline allows Toll to test his findings on the benefits of gain-framed messaging in a statewide program that has a wide range of participants.

In addition to the Quitline, Toll is currently developing a program with the Smilow Cancer Hospital in New Haven that offers smoking cessation counseling to interested cancer patients. Targeting primarily patients admitted to the head and neck cancer, lung cancer, and breast cancer programs, the smoking cessation program aims to complement traditional cancer treatments with an additional smoking treatment component. The program is still under development, but Toll is excited for its addition to the anti-smoking arsenals of the center as it will offer an extra dimension of treatment to interested patients. The program at Smilow will offer another venue for Toll to explore the efficacy of gain-framed messaging for smoking cessation and other types of preventive health measures.

About the Author
JONATHAN SETIABRATA is a Chemical Engineering major in Davenport College. He works under Professor Haller and Professor Pfefferle, exploring different synthetic routes of nanomaterials.

The author would like to thank Professor Benjamin Toll for his time and help with this article.

Further Reading
Croyle, Robert T. “Increasing the Effectiveness of Tobacco Quitlines.” January 7, 2010.
Toll, Benjamin, et al. “Comparing Gain- and Loss-Framed Messages for Smoking Cessation With Sustained-Release Bupropion: A Randomized Controlled Trial.” Psychology of Addictive Behavior 24, No. 4 (2007): 534-544.
Toll, Benjamin, et al. “Low-dose naltrexone augmentation of nicotine replacement for smoking cessation with reduced weight gain: A randomized trial.” Drug and Alcohol Dependence 111, No. 3 (2010): 200-206.