The Diminishing Returns of Education for Health Behavior Change

TheWant someone to quit tobacco? Chances are your persuasive tactics to get them to stop smoking will include some cold hard facts about the damage that cigarettes can cause to your lungs and heart. Maybe you’ll use some photos that show the aging effects of smoking on skin and teeth. Or perhaps you can share statistics around the rates of disease for people who smoke compared to people who don’t. These approaches may make intuitive sense, but they rarely work to get someone to quit smoking. Knowledge alone doesn’t change behavior.

What’s missing in the health education approach is motivation. Without motivation , people won’t use the education to make changes.

One reason why is that education often doesn’t give people new news about health.  Everyone knows smoking is harmful, to take one example. Ongoing efforts to put more graphic anti-smoking warnings on cigarette packages may reduce brand appeal (which could stop people from beginning to smoke in the first place), but they won’t target the actual levers of behavior change. (Not to mention that the typographic designs in the current warning labels seem deliberately chosen to minimize reading and comprehension.)

A memorable anti-smoking ad from my youth. Did it work?
A memorable anti-smoking ad from my youth. Did it work?

I’m down on cigarette package warnings despite a recently published study in JAMA that shows increased quit attempts among smokers who receive packages with graphic warnings versus plain wrappers (Brewer et al., 2016). Two things separate the research study from “real life” that matter here: One, people knew they were in a study, and this might artificially elevate the rate of quit attempts across both the control and experimental groups. Two, a quit attempt does not equal successful long term behavior change. Most former smokers had to quit many times before it finally “took.” The four-week study isn’t long enough to gauge whether pictorial warnings lead to long-term smoking cessation; I’d lay money on the answer being no. In fact, another meta-analysis found that while graphic cigarette pack warnings increased quit intentions, the data wasn’t available to support any conclusions about actual behavior (Noar et al., 2015).

[Side note: This is not to say I don’t think the Brewer study is valuable! Motivational interventions + graphic warnings may be smoking cessation magic!]

Why is education not sufficient to motivate smoking cessation?

Psychology tells us people who smoke and don’t want to quit can sidestep the information in a health education intervention a few ways (and these are just a sample):

  • Health belief model“I believe that smoking is harmful, but I don’t feel particularly vulnerable to those risks, It won’t happen to me.”
  • Terror management theory: “We all die someday. I’m going to make the most of my youth and enjoy myself.”
  • Social learning theory: “My friends smoke; celebrities smoke; my parents smoke! All of these people are doing just fine.”
  • Selective attention: “Smoking may have some harmful effects, but it also has some positive ones like helping me manage my weight.”

It’s even possible that a smoker might look at the warning, understand and process the information, and arrive at a rational decision to keep smoking because the pleasure of the activity outweighs the sacrifice of quitting. Smoking has its upsides: It’s physiologically and psychologically pleasurable, and it may be part of a social routine. (In fact, part of lasting behavior change is making it possible for people to exercise these types of autonomous decisions even when they conflict with the prevailing medical wisdom [Ryan & Deci, 2006].)

It’s not just smoking where information is perhaps-necessary-but-insufficient-for-change. Brian Wansink, an expert on mindless eating,  believes behavior change happens through restructuring the environment and perceptions rather than education. If you want a quick and entertaining overview of his work in this area, I suggest this episode of the Bite podcast (it’s about 20 minutes long).

Where can education help?

I think education is a critical tool for the motivated to apply to their behavior change efforts. This is more true when the behavior to be changed is complex, or when the goal requires someone to change multiple behaviors.

Here's an example of what someone with Type 1 diabetes may be dealing with. Clearly, education is needed to do this well.
Here’s an example of what someone with Type 1 diabetes may be dealing with. Clearly, education is needed to do this well.

My favorite example is diabetes management. A few years ago I had a chance to go through a multi-day training through the Johnson & Johnson Diabetes Institute that’s typically offered to diabetes educators. I thought I knew a lot about diabetes. I was floored by what I learned. For someone with diabetes, managing your blood sugar levels is like an ongoing mathematical brainteaser that you can’t ever put aside. The math you need to do is for real. And you need to have some understanding of what’s in the food you’re eating, how insulin affects your blood sugar based on whether or not and what you’ve eaten, how exercise, sleep, illness, stress, and a million other things affect your blood sugar . . . it’s a lot of work. For someone who has to cope with a challenge like managing diabetes, education is clearly necessary. But, the value of that education will come only after the person decides they want to work on diabetes management.

Another type of education that can be very helpful to a motivated person is “how” education. For the person who wants to quit smoking, we probably don’t need to hammer on how smoking is bad for your lungs. Helpful education might be how to cope with nicotine cravings, where to purchase nicotine substitute products, and behavioral tactics to push through withdrawal symptoms. In this example, education is a tool to achieve the behavior change.

Education is necessary but not sufficient for lasting behavior change

I keep coming back to Fogg’s definition of ability as the scarcest resource available at a point in time. To me, the greatest value of education in a behavior change journey is when it enhances a person’s ability to make the change. I’m sure that for some people, health education caused the “a-ha moment” where all of a sudden, they were motivated to change. But for most of us, motivation comes from somewhere besides education, particularly education about the negative consequences of our health choices. In fact, if finger-wagging education about health is what prompts a behavior change, that’s likely to be at best introjected motivation, which we know doesn’t sustain change over the long haul (Ng et al., 2012).

In thinking about coaching people through health behavior change, then, wouldn’t it make more sense to design for motivation and then supply the education as needed to enhance ability?


Brewer, N. T., et al. (2016). Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. JAMA Internal Medicine, published online June 6, 2016. doi: 10.1001/jamainternmed.2016.2621

Ng, J. Y. Y., et al. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325-340. doi: 10.1177/1745691612447309

Noar, S. M., et al. (2015). Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tobacco Control, 25(3), 341-354. doi: 10.1136/tobaccocontrol-2014-051978

Ryan, R. M., & Deci, E. L. (2006). Self-regulation and the problem of human autonomy: Does psychology need choice, self-determination, and will? Journal of Personality, 74(6), 1557-1586. doi: 10.1111/j.1467-6494.2006.00420.x