Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations about health literacy with some pretty amazing people.

Today, I’m talking with Dr. Michael Siegel, a professor in the Department of Community Health Sciences at The Boston University School of Public Health.

Dr. Siegel is a longtime researcher in tobacco control and has published extensively on topics that include secondhand smoke, tobacco policy and national strategies to reduce tobacco use.

He is a leader in the anti-tobacco movement, testifying in support of smoke-free workplace laws and serving as an expert witness in lawsuits against tobacco companies.

I had the pleasure of talking with Dr. Siegel in person. We realized we share an a lot in common about our concerns about the ethics of communicating our health messages.

Welcome, Dr. Siegel.

Dr. Michael Siegel: Thank you. It’s good to be with you.

Helen Osborne: We are both interested in the ethics of how we communicate our health message. I consider that the ethics of simplicity. Who are we talking to? What are we talking about? What do we include and, more importantly, what do we not include in our messages?

When you think about communicating public health messages, what’s on your mind?

Dr. Michael Siegel: I think that the most important thing is to realize that, when we’re communicating as scientists or as public health practitioners, we have choices. It’s not as simple as just taking whatever information is out there and relaying it to the public. You have choices to make about what type of information you provide.

Helen Osborne: I know your work is a lot about tobacco. What kinds of choices? Cigarettes are bad. What’s the choice there?

Dr. Michael Siegel: Not everything is black and white. Obviously, we don’t want people to smoke, but there are situations where there are relative risks between different products. For example, electronic cigarettes are a new product on the market, which is really an alternative to tobacco cigarettes, which is a lot safer.

Helen Osborne: Wait. The electronic ones are safer?

Dr. Michael Siegel: Yes, the electronic ones are much safer than regular cigarettes because they don’t have any tobacco in them and there’s no combustion.

Then you get into a difficult issue of what do we do. Do we start recommending that people switch from regular cigarettes to electronic cigarettes? Is that going to improve the public health? Is there a risk that, if people are told that there’s this option for you, maybe the people who would otherwise have quit completely might still be on these electronic cigarettes?

Helen Osborne: You’re saying it’s a much more nuanced message. You’re also dealing with products too, so you come from this position as a scientist, a physician, a researcher and a public health person. You know a lot about all these decisions in there.

I guess the marketing companies for the e-cigarettes or the tobacco industry know how to convey their message clearly and simply. How do you get it to the public?

Dr. Michael Siegel: I think you’re right that it’s really nuanced. This is not something that’s black and white, so we have to make decisions about what information is most critical for the public to hear.

I think another key issue is what is our goal? Are we trying to persuade the public to do something, or are we just trying to inform people of information and then let them make their own choices?

Helen Osborne: I’m really glad you framed it as persuade or inform. In my work in health literacy, I’m faced with that all the time, whether we’re writing a patient-ed fact sheet or something. We have this huge body of information. It’s ambiguous and ever changing, but it’s really important.

How do we decide which points to emphasize, which ones to include and which ones to omit? What’s our point? Is it to let people make a reasoned choice between some alternatives, or is it to get them to move in one direction? Do you face those kinds of issues too?

Dr. Michael Siegel: Absolutely. We face this all the time in that, because we’re in the field of public health, we have a certain type of decision that we want people to make. We want them to get flu shots, quit smoking and do things that are healthy.

On the one hand, there is an incentive to try to persuade people to do these things. On the other hand, the question arises of is it ethical to get people to do what you want by giving them exaggerated information?

We could really get everyone to get vaccinated if we told them that the flu is much more serious than it actually is, so it raises this ethical issue of how do you balance the desire to try to persuade people versus the principle of being honest and transparent?

Helen Osborne: And scaring them to do it. Wow. I can see that scare or fear mongering as we’ve seen in a lot of health incidents that have come along the way. They’re just so scary and then a few months later it’s like, whoops, that went away. That must do some damage too.

Dr. Michael Siegel: Yes. I think a perfect example of that is several years ago when the Swine Flu first emerged in the United States.

The health authorities were basically sending the message that this is tremendously high risk, there are going to be thousands of deaths and it’s going to be the end of the world. They were actually comparing it to the influenza epidemic of 1918, which killed hundreds of thousands of people.

As it turns out, because of that scare, the vaccination rates were extremely high that first year.

Helen Osborne: Scare mongering worked.

Dr. Michael Siegel: It worked and everybody got vaccinated, but the problem was that the next year, after people saw that the Swine Flu wasn’t anything as bad as it was supposed to be or as they were told it was going to be, they basically got a false sense of security and therefore very few people got the Swine Flu vaccine the second year.

Helen Osborne: Oh my goodness. Was it complacency or was it cynicism, like, “You didn’t tell me the truth last year, so I’m not going to believe you this year”?

Dr. Michael Siegel: I think that was it. I think there was a lack of trust. People said, “Last year, you told me this was going to be the end of the world, so clearly you’re not telling me the truth,” and people just dismissed it completely. As a result, there were many more deaths than there needed to be because a lot of people weren’t vaccinated.

Although the Swine Flu isn’t the end of the world, it still does cause severe influenza and can cause pneumonia, especially in people who are elderly, very young or immunocompromised.

Helen Osborne: In my work in health literacy and as a plain language writer, sometimes people go into this thinking, “It’s just another part of the job. I’m just going to cut out some syllables today and my work will be done.”

I take the path that it is much more important than that. We have a true responsibility to communicate this information clearly and in ways that someone can take reasonable, thoughtful actions. Indeed, someone might be reading our handout or our website and truly make life and death decisions about that information.

I think I can speak for our podcast audience. We care a lot. We want to do this right. You and I both have been giving this a lot of thought. From your perspective, especially in public health, as a scientist and as a physician, how can we make it a little bit better today and tomorrow for those we care about?

Dr. Michael Siegel: I think that there are three main principles that we should all pay attention to following.

The first is simplicity, to try to make the message something that people can understand. It’s not going to help to use scientific jargon or to give complicated facts and statistics that people can’t interpret, so I think keeping it simple is very important.

Helen Osborne: Can you give an example? Pick an example of an issue and I’d love to hear how you would simplify it. I know it’s hard to be simple. If you can, give us an example about an issue and how you might simplify it.

Dr. Michael Siegel: I think that one of the ways to simplify an issue is to use analogies to things that people can readily understand. When you’re talking about the risk of something happening, I think to just tell the public that your risk is 1 in 1,000 or that there are 3,000 cases of this every year doesn’t help. People can’t interpret that, so I think it helps to make an analogy.

For instance, your risk of getting this particular disease is the same as your risk of being struck by lightning or the same as your risk of being in a motor vehicle accident. I think, by comparing it to the things that people understand, it helps simplify it.

People don’t understand absolute risk. You really need to make an analogy and compare it to something that they’re familiar with.

Helen Osborne: It’s really putting it into context. You and I were talking and we share a concern about the ethics of doing this. Is it possible to ever make it too simple?

Dr. Michael Siegel: It is. Sometimes what that can result in is choosing facts that are so simple that they don’t actually give people an accurate view.

One example of this is a recent article that came out of looking at a flavoring in electronic cigarettes called diacetyl. It’s a chemical that, in very high levels, can cause lung disease.

The researchers basically gave out the information that, based on their study, there was diacetyl found in electronic cigarettes. What they didn’t tell the public was that the level of diacetyl was actually 750 times lower than it is in tobacco cigarettes.

Helen Osborne: Oh my goodness. The truth is that it is there and it is present. What wasn’t mentioned was the amount of it and how scary that is.

Dr. Michael Siegel: Exactly. They didn’t compare it to something that people are familiar with, which is smoking. By not making that comparison and just giving out partial information, they gave the public the impression that using e-cigarettes is just as bad or even worse than smoking.

It has negative consequences, because as a result of this scare tactic, many former smokers, because they had quit using e-cigarettes, decided, “I might as well go back to smoking.”

Literally, it can have, as you said, life and death implications for people.

Helen Osborne: Wow. You also talked about giving just partial information. In my work, I can’t imagine giving everyone all the information. It’s overwhelming. It’s another balancing act that we as communicators have to decide how much information to include. Are we overwhelming people or are we giving them sufficient information?

Dr. Michael Siegel: I think that is a huge challenge. That’s the art of health communication, really. It is making a decision about what the important information is that people need and what the information is that they don’t need.

How do you balance the two goals of persuading people a certain direction, but at the same time informing them honestly in a way that they can make their own informed decisions?

It’s that balancing act that really makes health communication such an art and, I think, in some ways more fun, but also it adds responsibility to us as health communicators.

Helen Osborne: We do. We have a huge responsibility. Are there any other tips that you’d like to share with listeners?

Dr. Michael Siegel: I think the most important thing is honesty and transparency. At the end of the day, the worst mistake that I think we can make in health communication is not being honest with people.

Although we may have desire to get them to behave in a certain way and we may think that if we exaggerate or extend the risks beyond what they really are that will be successful in getting people to do that, and it probably is true. But what we have to remember is at the end of the day it’s the credibility of the communicator that’s important.

If we exaggerate one thing and the public finds out that it actually isn’t as bad, they’re not going to believe us the next time. Once we lose our credibility as communicators, we lose all persuasive ability altogether.

Helen Osborne: It also sounds like it’s almost short-term versus long-term success. I don’t know how you measure success, but for the example you were giving on Swine Flu, in ways, your campaign was a success because a lot of people got the shot. However, in ways, it wasn’t a success because the next year they didn’t get the flu shot for the coming flu season. Is it a way to look at that in different timeframes?

Dr. Michael Siegel: I think that’s a perfect way to look at it. I think that we have short-term goals that we want people to act in a certain way on a certain issue, but what we need to realize is that, as communicators, especially in the area of health communication, we always are going to have messages that we need to get to the public.

The key to being able to do that is to develop a relationship with our audience, and that relationship is one that has to be built on trust. If we lose that trust at any point, the relationship basically ends and we can no longer get across any points to the public.

I always tell people, “Don’t sacrifice the long-term credibility of public health or health communication just to try to get one point across and make sure that people do a certain thing that seems important today, because down the road we really need the long-term trust.” Unfortunately, when you lose that, it’s permanent.

Helen Osborne: I think of that in many situations, just like these podcasts have that long-term trust with the listeners. It’s built over time. Even for a short-term public health message or any kind of a health message, we need to consider who the audience is, what they need to know now and what they need to understand at a deeper level about that nuanced communication.

The last question is how would you determine success of a message?

Dr. Michael Siegel: I think that the determination of success of a message is two things. One is that the public is taking the action that you want. If the message is to get vaccinated, people are getting vaccinated.

I think the second part of it is that people have an honest and accurate appreciation of the degree of risk and that you’re not over exaggerating the risk or underestimating the risk.

On the one hand, you can measure success by getting people to do what it is that you want them to do, but I think at the same time you also have to look at whether or not people have an accurate perception of risks that they face.

While it may seem that, for the short term, exaggerating a particular risk is a successful or effective way of getting people to do something, in the long run if people’s overall sense of risk becomes distorted, they’re not going to make the most appropriate health decisions.

Helen Osborne: That’s what we’re really all in this work for, to help people and help others make some choices that matter to them that are for their greater good and for our greater good.

Thank you so much for doing all you do and for sharing your words of wisdom with us on Health Literacy Out Loud.

Dr. Michael Siegel: My pleasure. I really enjoy talking to you.

Helen Osborne: As we just heard from Dr. Michael Siegel, there is so much to consider when communicating our health messages. Doing so in ways that are respectful, informative, appropriate, actionable and in keeping with all those health literacy principles can be hard to do.

For help communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the monthly e-newsletter, What’s New in Health Literacy Consulting.

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Until next time, I’m Helen Osborne.

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