The D.A.R.E. Program for Adolescents: Ineffective Long-Term Intervention – Jackie Liu

Drug use, as well as abuse, among adolescents and young adults remains a major public health issue in the United States. Over 20% of 8th graders and 9th graders and over 30% of 10th-12th graders have reportedly used drugs at least once in their lifetime. In 2006, an estimated 38,396 deaths were caused by substance abuse in the U.S. and has increased from previous years (5). Although there has been slight declines in use of certain drugs such as alcohol, hallucinogens, LSD, and even marijuana, prevalence rates for use of prescription drugs has increased because they are deemed the safer drugs by adolescents (9). The fact that a portion of adolescents continue to or are starting to use drugs at as young as 12 years of age suggests that current interventions may not be sufficient.
Drug abuse can lead to deaths from motor vehicle accidents, suicidal actions, intoxication, etc. It can cause negative behavioral changes, mental retardation, psychological disorders, and further permanent distresses that may impair the quality of life. The younger a person starts using drugs, the likelier it is that he/she will have developmental problems (9). Various studies indicate that adolescents who use and abuse drugs are more likely to exhibit deviant attitudes, drop out of school, and become delinquent. Because this is an issue that can have detrimental effects on the functional abilities of the young generations who will be the future, it is crucial that effective public health interventions be in place.
Although there have been numerous campaigns targeted towards the prevention of drug use and abuse among individuals of all ages, statistics as aforementioned over the years indicate only a slight decline in prevalence rates among high school students. Despite the law enforcements in prohibiting the distribution of drugs, individuals under the age of 18 continue to have access to legal and illegal drugs. Adolescents have access to drugs through friends who have access, drug stores, older siblings, parents who use drugs, the internet, etc. Today, approximately 5.3 million Americans from age 12 and over have abused cocaine in their lifetimes (9). Access has definitely increased, and the effected population has increased and is beginning to include much younger children. The effects of drugs are endless and can be detrimental to a child’s physical and mental development, especially when introduced at an early age (9). Again, the prevalence of drug abuse among adolescents emphasizes the need for effective public health interventions in this area. It is critical to educate adolescents on the consequences of drug use and abuse. This is the exact reason for the development of the well-known Drug Abuse Resistance Education (D.A.R.E.) program whose mission is to “provide children with the information and skills they need to live drug-and-violence-free lives” (4) and to help children avoid actions that will lead to drug use.
D.A.R.E. PROGRAM
The D.A.R.E. program was founded in 1983 in Los Angeles and since then has undergone multiple revisions as studies continue to suggest that it is ineffective in decreasing the prevalence of drug use in teenagers (4). Regardless of any negative results from studies, the program has increasingly been implemented in secondary schools in an attempt to intervene drug use with the younger population. It is a program that brings together law enforcement and schools. It is incorporated into the school curriculums to teach young students about the consequences of drug use, how to avoid involvement with drugs, and what appropriate actions to take when in a peer-pressured environment (4). The involvement of law enforcement allows the students to have immediate answers to their questions related to drugs and violence. The program’s curriculum consists of a series of lessons taught over the span of 10 weeks, one class per week, and focuses on understanding the consequences of drug use, examining the students’ beliefs regarding drug use, developing communication and resistance skills, and making good life choices (3). The lessons are typically taught by police-officers who are able to respond to students’ questions about crime and drugs. The officers are required to undergo 80 hours of training in child development, classroom management, and communication skills prior to working for the D.A.R.E. program (4).
Although this program has been implemented into roughly 80% of the school districts in the country, it does not show promising results in positively changing the perspectives adolescents have on drugs. One article compiled results from multiple studies and concluded that while the D.A.R.E. program may reduce drug use in its students, the effects do not last (1). The revised program remains flawed because it instructs adolescents and young adults on what not to do, it ineffectively delivers its intended message, and it fails to consider the background of its audiences. When reviewing the program and its structure, it is obvious that several social health theories are already violated by the curriculum itself. Further examination of the program in the context of these theories may provide a better solution to revising and improving the program for future generations of adolescents and young adults.
D.A.R.E. ENCOURAGES REBELLION
The D.A.R.E. program simply educates the adolescents and young adults by using their curriculum to introduce the horrors of drug use and abuse and to show how to say “no” to drugs. Ironically though and of course, unintentionally, it dares its students to try drugs and to think about drugs because the program is saying their bodies will not tolerate the effects (8). Though the program’s abbreviation was likely meant to be used in slogans such as “DARE to resist drugs and violence”, that one word could also be easily manipulated by high school students to “DARE to use drugs”. To the targeted population, the lessons may seem as an effort to take away their potential freedom. Before attending any D.A.R.E. lectures, they may probably have never been exposed to drugs or information about drugs. In those situations, the program would be essentially teaching the students what drugs are, what the effects are and then telling them that is what they should stay away from. For those who have already been exposed to drugs, the program may be completely ineffective. Drug users have personally experienced the effects of drugs and believe the drugs help them feel happier, more confident, and have more control. The program’s messages of staying away from drugs would therefore be interpreted by that particular group as taking away their freedom and enjoyment.
The psychological reactance theory states that an individual will rebel against an instruction if it threatens to take away their freedom (13). This is exactly what the D.A.R.E. program does. It instructs the students on what not to do. The theory also implies that a person will rebel against what they are being told to do by doing the opposite, which in this case would be to use drugs (13). The program would seem to take away the freedom for not only the current drug users but also the newly informed. Adolescents do not enjoy being told what to do and so by teaching them to stay away from drugs, it is taking away their freedom to decide on their own. Even at a young age, children become more curious and interested in what they are not allowed to do and will find ways to do it secretly. They are unlikely to consider the consequences of their “banned” action because they are still at a developmental stage during which they are curious about everything. The organization of the D.A.R.E. program completely violates the psychological reactance theory and studies evidently show how drug use has increased among this young population (8).
D.A.R.E. MESSAGES ARE NOT GETTING THROUGH
At their age, it is unlikely that these adolescents have ever been exposed to drugs. The D.A.R.E. program may actually be the first exposure and leads them to thinking more about drugs. Most people will not look into something unless they were exposed to it. Adolescents today are not going to randomly search a topic online unless they heard about it on the media or from their friends. By informing them about drugs at an early age will only stimulate their curiosity about the issue and cause them to conduct their own research via friends or online. Their understanding will then be corrupted if their friends mention anything positive about using drugs such as increased popularity in school or the feeling of freedom and control. The D.A.R.E. program is flawed in the sense that it initiates its efforts at the wrong time and its target population may not be ready for the information it delivers (1).
For middle school and high school students, role models are usually their older siblings, parents, and occasionally teachers. Any officer in law enforcement is probably the last person these students will look up to because of the association with crime and punishment. This structural part of the program can be related to the marketing techniques of businesses. The basic marketing theory states that you must first recognize your target population as a collection of people, rather than many individuals (15). The D.A.R.E. program does approach groups of students and attempts to change the “herd” at the same time, but like most public health interventions, it is thrusting upon the students a product and trying to sell it. It attempts to sell “anti-drug actions” but it is unsuccessful because it is not what the students want at that age. Businesses successfully sell their products by first figuring out what their target consumers are interested in and what product they can develop to sell to these consumers. The D.A.R.E. program needs to do more research on the adolescents and young adults before trying to tell them what not to do.
In terms of marketing, the D.A.R.E. program fails to convey the message in a way that appeals to its audience, the students. Having a lecture presented by a uniformed police officer may not be the best idea because it gives them the feeling that they have done something bad (1). Furthermore, if it is the first time a student is hearing about drugs, it is unlikely he/she will care, and the lack of any interaction during the lessons simply adds to the boredom among the students (1). As mentioned in an article about the ineffectiveness of this program, the students will probably “tune out” the words coming from the authoritative officer (1). Therefore, having a police officer present the information is not the best way to market their product of not using drugs.
D.A.R.E. FAILS TO RECOGNIZE ALL SAFETY CONCERNS
In middle and high school, students are concerned about not having friends and not fitting in with the right groups. Short-term or long-term health is probably the least of their worries. Chances are they do not even know what simple diseases are. The program is being implemented in the wrong setting. Interventions should be designed with the needs of the population in mind. Schools are using the program as a way to intervene and prevent drug abuse in young adults by educating them about the terrifying consequences before they consider using drugs. But the problem is the program facilitators are not doing prior research on what it is the students are interested in at their age. Sure, the program tries to respond to the peer pressure and the need to fit in by emphasizing that it is OK to say no to drugs, but this fails to solve the problem of peer pressure which is prevalent in all environments and especially important during secondary school.
Adolescents who refuse to use drugs and are able to escape peer pressure may not be able to escape any bullying due to their refusal (6). Safety in this case is a major concern that the program neglects to consider for those who do in fact say no to drugs. It does not address the current needs of these children, adolescents, and young adults. Needs of each different age group will vary and the curriculums should not be the same for everyone. According to the Maslow’s hierarchy, safety of one’s own body is on the same level as one’s health (14). Peer pressure threatens the immediate health of one’s body and yet, the D.A.R.E. program warns that drugs threaten the long-term health of one’s body. It is not hard to conclude that adolescents will probably be more concerned about their current health when they encounter peer pressure.
Certainly, the program does not consider the various backgrounds of these young individuals when telling them to stay away from drugs. A majority of the adolescents who use drugs come from families with low-income, unstable families, and other settings that may contribute to depression and lead to use of drugs as the solution to their problems.
IMPROVING THE PROGRAM
The D.A.R.E. program’s past revisions were a response to the studies that proved its ineffectiveness in minimizing drug abuse and use in children and adolescents. The program remains flawed as the prevalence of adolescents using drugs has not diminished across the country. Some studies even suggest that the programs might have actually increased the use of certain drugs because it increased the students’ curiosity about drugs and resulted in earlier experimentation with drugs (12). It seems that even a new addition known as D.A.R.E. Plus program has not yet shown improvements, except that it was more effective than the original D.A.R.E. program in reducing tobacco use (10). However, based on the aforementioned social theories, the program can be further modified for the better and perhaps become a strong contributor in preventing drug use and abuse in children and young adults.
A main modification to the current D.A.R.E. programs across the country that should be considered is the entire curriculum and how it is executed. By correctly interpreting and applying the psychological reactance theory to the structure of the curriculum, the program would be able to better grasp the attention of its students. The purpose of the lessons should not be to lecture adolescents and young adults on what not to do, but rather to tell them what they should do. Currently, the lessons emphasize the intolerance of drugs by the adolescents, which can make them rebel and want to prove that they can tolerate the effects of the drugs (8).
The program should also employ the marketing and advertising theories in order to make its product appealing to the middle-school and high-school students. Thorough research should be conducted to figure out what it is these students at their age want and will accept. For example, it would be helpful to learn what they are interested in, their family backgrounds (general idea), and the ways in which they fulfill their needs. The program is promoting health and long life, which are not necessarily the most important things in an adolescent’s life. The D.A.R.E. program should also structure their curriculums by the age groups or grades, because each age group is on a different developmental stage and their thoughts and interpretation of one simple message may differ. For instance, eighth graders are going to think differently than ninth graders even if the age gap is small simply because they are in two separate environments. A message that may seem straightforward and easy to follow for one group may seem complex and overwhelming for another.
When a company markets its new products, they create numerous unique advertisements and commercials depending on who their targeted consumers are. They are not promoting their products with just one universal advertisement. Another reason the D.A.R.E. program curriculums should be different for the grades is most students attend the same middle school for 6th, 7th, and 8th grades and if the program runs for all three groups, most students would be sitting through the same presentation three times. By the second and third time, they already know what the presentation is about and the communication becomes less effective. One study that focused on the effectiveness of the D.A.R.E. and D.A.R.E. Plus programs in middle and junior high school found that more than 94% of the students had already been exposed to the program’s curriculum, which could explain the lack of changes in drug use and violence in the schools studied (10). In contrast, successful companies typically design new advertisements and commercials periodically to keep their consumers attentive. This is a technique that may benefit the D.A.R.E. programs since it is taught starting from the 5th grade through high school.
Another modification that could be increase the effectiveness of the program is the gap between the lecturer and the students. The idea of having an officer deliver the important message of “Don’t use drugs” is not going to appeal to all the adolescents and young adults. The information should be provided by someone who the students will listen to and can relate to, especially at their age. The design of the lessons and the messenger who communicates the information are all part of the marketing concept of packaging and putting things together (15). Imagery is a powerful tool that, when applied at the right time and place, can change the way groups of people react to a product. It is a concept that is ubiquitous in the business world and has proven successful. For example, Nike’s commercials often features sports celebrities, commercials for beauty products typically include famous actresses, etc. These are the ways in which brand name companies gain new consumers and keep current and past consumers. The consumers are interested in what the company has to offer because of the core values associated with the products. Again, the D.A.R.E. program promotes health to adolescents whose most important core values probably do not include good health. The current D.A.R.E. programs should be redesigned to tell these young individuals what to do rather than what not to do, to focus not so much on the “zero-tolerance” and also to tell them through the voice of an influential person (10). For high school students, the program could recruit current high school students who have successfully quit the use of drugs and who are able to relay the D.A.R.E. message to students of their own age.
The last area in which the D.A.R.E. program is flawed is its attention to the peer pressure that exists in schools today. Peer pressure is almost always a challenge for adolescents and young adults. Students in both middle and high schools ridicule their peers for being different, smart, poor, overweight, etc. Thus it is not surprising that kids would get teased by their peers after refusal of using drugs. The lessons on peer pressure advise the adolescents to report any abuse from their peers to authoritative personnel but that is something most adolescents will not do, especially if they know they will only get into more trouble with their peers if they tell. Bullying in school is another issue that cannot go unnoticed. Adolescents are highly susceptible to the psychological effects of verbal bullying, which very often results in deaths (11). Hence, drug abuse prevention programs like D.A.R.E. must take into account the obstacles that a student must face before they tell a student it is ok to say no.
CONCLUSION
The D.A.R.E. program should be modified and continue to be used because it has already established its name in most of the school districts in the U.S. It is a program that is well-known and if a revised version becomes effective, it can easily be used in the schools. The problem with the current programs is not that they lack the resources or research; there is definitely a vast amount of literature available on it. The problem is they are not able to translate the results into the implementation of a program that actually works. They are also not reaching the targeted population the right way. In other words, research results are not effectively taken into account in the clinical settings. Nevertheless, if the D.A.R.E. programs were to be reconstructed for each grade level, then more research may need to be performed. Public health interventions should conduct research among each and every grade in middle school and high school and then go onto constructing a program that is tailored to each groups’ needs rather than putting together a program first. Changing this long-term drug abuse prevention program so that it has customized curriculums for each grade may be time-consuming and challenging but would be a worthwhile investment. This particular drug abuse prevention program remains ineffective but can benefit from the psychological reactance theory and use of the marketing techniques that have worked for most successful companies.



REFERENCES
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3. D.A.R.E. Massachusetts. Malden, MA: D.A.R.E. Massachusetts. http://www.darema.org/
4. Drug Abuse Resistance Education. The D.A.R.E. Mission. Log Angeles, CA: D.A.R.E. America. http://www.dare.org/home/THEDAREMISSION.asp
5. Heron, M., Hoyert, DL., Murphy, SL., et al. Deaths: Final Data for 2006. National Vital Statistics Reports 2009; 57, 14:1-136.
6. Kheswa, JG. A descriptive analysis of alcohol and drug use amongst adolescents in Soweto. University of Johannesburg 2008.
7. Lloyd, JD., O’Malley, PM., Bachman, JG., et al. Monitoring the future: national results on adolescent drug use. Overview of key findings. National Institutes of Health 2006.
8. Marlatt, GA. & Witkiewitz, K. Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addictive Behaviors 2000; 27:867-886.
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10. Perry, CL., Komro, KA., Mortenson, SV., et al. A randomized controlled trial of the middle and junior high school D.A.R.E. and D.A.R.E. plus programs. Archives of Pediatrics & Adolescent Medicine 2003; 157:178-184.
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14. Hawley, PH. Social Dominance in Childhood and Adolescence: Why Social Competence and Aggression May Go Hand In Hand (pp. 1-30). In: Hawley, PH., Little, TD., & Rodkin, PC. Aggression and Adaptation: The Bright Side to Bad Behavior. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2007.
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The National Organization Of Fetal Alcohol Syndrome And Its Responsibility To Focus On Prevention And Early Intervention-Lauren Goldberg

Birth defects occur in 1 out of every 33 babies born in the United States. Defects account for more than 20% of infant deaths. Seventy-percent of birth defects are from unknown causes, however, some such as those caused by Fetal Alcohol Syndrome (FAS) are preventable. FAS is caused by an alcohol –exposed pregnancy that results in mental retardation and neurodevelopmental disorders such as hyperactivity, distractibility, short attention span, poor judgment, impulsivity, poor social skills, and poor visual and auditory memory. Alcohol exposure directly causes these physical manifestations in addition to growth impairment and craniofacial abnormalities (1). Despite the fact that Fetal Alcohol Syndrome is 100% preventable, this birth defect affects 2 newborns per 1,000 live births in the United States.
FAS occurs more frequently in some populations and will not definitely occur in all fetus’ exposed to alcohol. A study on the permissive factors associated with FAS concluded that predisposing factors such as a mother’s socioeconomic status and culture, along with alcohol exposure, can increase a fetus’ vulnerability to developing Alcohol-Related Birth Defects (2). This phenomenon is evident in the fact that FAS rates were higher in inner-city women of low-socioeconomic status than those among Caucasian upper-middle women who are alcoholics. Since overall infant mortality rates are higher in women of low socioeconomic status, this study also concluded that permissive factors (e.g. ethnicity, SES) are more indicative of FAS development than biological factors. Additionally, factors such as poor nutrition status, tobacco use, and physical and psychological stress may also increase vulnerability to the development of FAS. These factors intensify fetal vulnerability to oxidative stress and free-radical induced cell damage, the two ways in which alcohol produces its teratogenic effects. Without fetal alcohol exposure, FAS does not occur. It is not enough to say alcohol exposure alone causes the development of FAS.
Not only is the incidence of FAS high, but the number of women consuming alcohol during pregnancy is high as well: 45.4% of women consume alcohol in their first trimester and 20.7% of women continue to drink even when they are aware of their pregnancy (3). Counsel against alcohol use is an effective way in which practitioners decrease these consumption rates. However, not all pregnant women seek help from practitioners. Since this disease is preventable, a national organization has been developed to combat it.

National Organization on Fetal Alcohol Syndrome

The National Organization on Fetal Alcohol Syndrome “is dedicated to eliminating birth defects caused by alcohol consumption during pregnancy and to improving the quality of life for those affected individuals and families (4).” With primary funding from the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities, it is the national voice for FAS prevention and advocacy. The approach of this particular organization is to educate addiction healthcare professionals on how to educate on both prevention and treatment strategies for FAS during prenatal and perinatal consultations. The organization gives workshops to parents on how to care for and nurture their child living with FAS. It also provides resources for women suffering from alcoholism who are pregnant or may become pregnant. The website also provides information about FAS like statistics and distribution materials. They also screen pregnant and non-pregnant women at select community health centers for alcoholism. Finally, this organization also brings together women who have consumed alcohol during pregnancy and may have a child or children living with FAS in a program called Birth Mother’s Network. The NOFAS helps create a positive environment for families but fails in other areas. Many communities may benefit from this type of approach but others need more tailored interventions (5). The NOFAS fails to target women who are at risk for an alcohol-exposed pregnancy prior to conception, relying on women to see out their clinics, and ignore the underlying causes of FAS.
The NOFAS also fails to target women who are most at risk before they conceive. Populations with the highest incidence of FAS are Native Alaskans, American Indians, and African Americans (6). These populations may not be living in a supportive environment that is conducive to change and need a strong presence from NOFAS. There are modifications that need to be made to this approach in order to reduce alcohol consumption during pregnancy and incidences of FAS.

Care is provided too late

A flaw in the NOFAS approach is that care is often provided too late in pregnancies to prevent FAS. The NOFAS relies heavily on the use of prenatal care to educate women on the risks of alcohol consumption during pregnancy and to screen for alcoholism in these women. However, irreversible damage has often already occurred by the time women seek care (7). While prenatal care and screenings are essential, for some women it may be too late to prevent a defect from occuring. The NOFAS must address the importance of initiating prenatal care during early pregnancy and even before conception. For example, 6.5% of African American women failed to receive or received late prenatal care and only 69.3% of American Indian women received early prenatal care (8). Furthermore, women who initiate prenatal care late in pregnancy are unlikely to show a change in substance abuse by delivery (9). NOFAS fails to initiate care early enough to prevent irreversible defects and cause a reduction in alcohol consumption.
Since 49% of all pregnancies in the United States are unplanned, many women are not aware that they are pregnant when consuming alcohol (10). Consequently, FAS might occur before she is even aware of the risk. If a woman who consistently drinks was not planning on conceiving and suddenly discovers she’s pregnant, breaking her habit immediately will be necessary and crucial. Unfortunately, eliminating alcohol addiction, along with other addictive behaviors, is often a time consuming process. The NOFAS does not foster preconception education which is crucial to the success of any program aimed at eliminating the incidence of FAS.
The NOFAS has built their intervention approach based on the Health Belief Model. According to this theory, women will be able to weigh the costs and benefits of drinking while pregnant after they seek help from a practitioner. Accordingly, NOFAS assumes that women will ultimately choose that the risks of drinking while pregnant outweigh the benefits. This theory however, fails to take into account the mother’s relationship with her environment and the biological implications that accompany addictive behavior. It cannot be assumed that alcohol consumption, a highly addictive behavior, will be stopped in enough time prevent FAS. Therefore, this emphasizes the need for NOFAS to educate these populations on the effects of coupling alcohol with unintended pregnancy before they engage in risky behavior. They also need to be given the option of testing themselves for pregnancy before they consume alcohol. This would help to instill awareness every time they drink. In addition, routine testing will allow them to know they are pregnant earlier than they might’ve realized otherwise. The earlier they know, the earlier they can seek prenatal care.
Women often perceive barriers to seeking prenatal care that cause late or lack of initiation. These barriers include lack of transportation, opinions of healthcare, partners’ opinions of healthcare, depression, fear of disclosure, and the fear of medical procedures (11). NOFAS must address these barriers in order to increase earlier initiation. However, motivating women to initiate prenatal care can also be a challenging.

Failure to seek out expectant mothers

Initiating prenatal care is a voluntary and beneficial process. In a study of urban black women, research found that unplanned pregnancies in this population were more likely to be accompanied by alcohol consumption and prenatal care initiation in the third trimester (12). Therefore, the NOFAS is presented with the difficult challenge of getting pregnant women into community health centers and getting them in early. A flaw in the NOFAS approach is that they wait for women to come to clinics on their own rather than actively trying to draw them in. The NOFAS fails to recognize there is little motivation for women to seek treatment early if it at all. In assuming that people are intrinsically motivated, the NOFAS effectively takes the Health Action Process Approach. This behavior change model is often used to predict whether or not a person will modify an unhealthy behavior or initiate a healthy behavior. An important component of the model is the idea that planning facilitates behavior change (11). The NOFAS unrealistically expects that women who have unplanned pregnancies with alcohol use will plan to seek prenatal care. The NOFAS cannot assume these women will plan to take action without offering an extrinsic motivating factor. If this were true, prenatal initiation would be higher and sooner in this population. Since it has been proven that women with unplanned pregnancies are less likely to receive prenatal care than those whose pregnancies were planned and neither population has perfect initiation rates, this stresses the need for the NOFAS to offer another motivating factor (13).

Failure to address underlying causes

Since women often initiate prenatal care after irreversible defects have already taken shape, there is a need for NOFAS to focus on the underlying causes of fetal alcohol exposure (14). A flaw in the NOFAS approach is that they do not attempt to eliminate the underlying causes of FAS. In the fifteen year period from 1990 or 2005 there has been no significant change in the prevalence of pregnant mothers who consume alcohol, therefore, the NOFAS has failed to eliminate the factors that cause an alcohol-exposed pregnancy (15). Educational campaigns have not reduced high levels of drinking during pregnancy. There is a need for the NOFAS to recognize that vulnerable populations such as Alaskan Natives, American Indians, and African Americans, need interventions related to lifestyle modifications. Currently, the focus is on alcohol abuse, but they fail to focus on the underlying problems that cause this behavior. It is estimated that 1 to 2% of women of childbearing age are binge drinking, sexually active, not using adequate protection have had multiple male sex partners in the past six months, have a history of physical abuse, have been treated for drug or alcohol problems, have been treated in a mental institution, and are less educated (16). These are underlying cause s for an alcohol-exposed pregnancy and FAS that the NOFAS has not addressed. These are also the causes that NOFAS fails to focus on. NOFAS should recognize that getting a mother to eliminate alcohol while she is pregnant does not eliminate the environment that may have caused her to drink the first place. NOFAS can prevent alcohol abuse before conception by channeling more of their resources toward empowering women and teaching them to not get involved in drug use, maintain safe relationships, be more sexually responsible, and stay in school. The NOFAS’ goal should be to help women adopt healthy behaviors to avoid risk of an alcohol exposed pregnancy. Primary prevention of FAS must include ways to eliminate these risks before conception (16).

Modifying the NOFAS approach to reducing the incidence of FAS

The NOFAS is a program designed to better the lives of children and families living with FAS and to prevent FAS in expectant mothers. This program must be expanded to include more primary prevention in the form of preconception awareness and interventions. The NOFAS must act more broadly in order to successfully decreased FAS incidence in Native Alaskan, American Indian, and African American populations. The NOFAS must also modify their prenatal initiation approach by creating incentives for expectant mothers.

Priming while purchasing

Women in vulnerable populations need to be reminded they could be pregnant each time they purchase alcohol. Pregnancy is usually not on a person’s mind when they walk into a liquor store. In order to reach women before they conceive, NOFAS needs to permeate their lives in an obvious way and emphasize the importance of early prenatal care initiation. A great way for NOFAS to make their message visible in the community is through local liquor stores. Each time a women purchases alcohol in a liquor store, she should be offered a pregnancy test. Even though she may not take the test, this primes her to think about the possibility she may be pregnant each time she purchases or consumes alcohol. There may come a day when she does accept the pregnancy test after repeated offers. Taking the test will allow her to know sooner than she normally would have. This gets women to think about just how risky alcohol exposed pregnancies really are, and will help them they are pregnancy sooner than later. This intervention will cause people in the community to engage in a discussion about such a seemingly strange occurrence at their local liquor store. If there are incentives to visit a prenatal clinic early in pregnancy, women will be more likely to visit very soon after a positive pregnancy test. It is also important to note that FAS does not only occur in babies with alcoholic mothers. Any amount of exposure can be harmful; therefore any women purchasing alcohol at a liquor store would be impacted (3). As a public health organization, the NOFAS needs to use a “cue” accompanying the purchase of alcohol in order to remind them of the risks associated with drinking while pregnant. Women will be able to develop an increased sensitivity to the purchase of alcohol each time they are offered a cue or in this case, a pregnancy test. Whether a women suspects she may be pregnant, or if she is already pregnant, this cue will force women of child-bearing age to associate purchasing alcohol with FAS (17). This intervention can help NOFAS bring women into their clinics sooner and before a defect has occurred.
It is also crucial to use this intervention as a way to eliminate any perceived women may have to initiating early prenatal care. As part of this intervention, each pregnancy test box will have written on it the services offered by NOFAS. These services will include prenatal care in addition to transportation to and from appointments, financial help to pay for visits, confidentiality on the part of the medical team, and painless medical care. Eliminating these barriers will also help women initiate prenatal care sooner.

Prenatal care initiation

Offering prenatal care is an important and essential service that NOFAS offers at community health centers. Without offering incentives to visit these clinics, NOFAS is running the risk of women seeing practitioners late in their pregnancies because of the aforementioned barriers. The fetus is most at risk for developing FAS in the first trimester of pregnancy (3). In unplanned pregnancies, initiating prenatal care often occurs in the third trimester. In order to get women at risk for an alcohol exposed pregnancy into their clinics, NOFAS needs to offer rewards that would benefit moms-to-be and actively draw them into clinics. An important of this intervention would be offering expectant mothers a free package of pampers every visit. After each trimester of consistent visits, expectant mothers would also receive a large gift such as a baby carriage or crib. Since this would be a costly intervention, NOFAS could partner with a major corporation such as Huggies®. These incentives could also get expectant mothers in the mindset of preparing for a newborn and may foster a maternal drive towards having a healthy baby and changing their risky habits. Expectant mothers will also have a positive attitude toward the prenatal care process and will therefore be more likely to make and follow-through with their appointments (18). Expectant mothers will be also be positively influenced by other mothers in the community who have also had positive outcomes from participation in this program. As a result, initiation prenatal care could become a norm in high-risk communities.
There are many psychosocial characteristics on the part of the mother that can affect the baby’s outcome (19). Therefore, the NOFAS must not only strive towards making the most from prenatal visits, but must also work to better the lives of expectant mothers. Initiation can be encouraged with referrals to food banks, stipends for continuing education, referrals to therapists, and help with employment. Regardless of the outcome after delivery, a healthier mom means a healthier baby. This would help NOFAS bring more women through the doors of the clinics. Additionally, the NOFAS can also strive to decrease the incidence of FAS on a more global level.

Preventing risk factors for an alcohol- exposed pregnancy

From an early age, women need to know they have the power to set goals and make decisions to achieve those goals. Young girls need to have role models and adult females they can learn from. The NOFAS needs to reach out to young teens living in vulnerable communities to help prevent them from engaging in risky behaviors associated with an alcohol exposed pregnancy. Empowering young girls and promoting healthy behaviors decreases the risks associated with an alcohol-exposed pregnancy. With this approach, the NOFAS will indirectly decrease their risks of having a child born with FAS. From eighth grade and throughout high school, young girls need hear first-hand accounts from women of what it’s like to be an alcoholic, or in an abusive relationship, or even what it’s like to have a child with FAS. These women would share the story of their struggles, make connections with young girls who need guidance, and encourage them to stay in school. In contrast, adolescent girls also need to learn from women who’ve set goals and achieved their dreams. They need to see women who’ve faced adversity and risen above it. Public health practitioners need to instill messages of empowerment and give young girls the self-efficacy they need to achieve goals. Students’ self-efficacy is linked to achievement goal orientation and self-regulation. Students who believe they can succeed will set goals and show more resilience when they encounter difficulties. This self-efficacy however, must grow from praise and the successful completion of smaller goals in a classroom setting. If students learn to overcome small obstacles and succeed in small ways, they will build the self-efficacy needed accomplish larger endeavors and to overcome larger tribulations (19). Girls will learn their decisions in the present can affect their future. By building stronger communities, NOFAS can indirectly decrease the incidence of FAS.
There is a great necessity to understand the types of environments women with alcohol-exposed pregnancies come from. Lack of both maternal and paternal education is also an important risk factor to consider (20). NOFAS must address this issue before they can see a marked decrease in alcohol consumption in pregnant women. They must use their time in the classroom to encourage young girls to finish high school and pursue higher education. With these guest speakers, the NOFAS can them what it’s like to succeed in life and what it is like to constantly struggle. The NOFAS’ mission should apply this broader approach to their interventions if they want to see better outcomes in their target populations and a decrease in the risk factors associated with an alcohol-exposed pregnancy. This type of primary prevention is a crucial component of any public health organization, including the NOFAS.

Looking towards the future

The NOFAS has a responsibility to all women, especially those of vulnerable populations, to expand the care they provide. They must recognize women need to be drawn into their clinics at the onset of pregnancy. The risks associated with an alcohol-exposed pregnancy are far too great not to act quickly. By eliminating some of the barriers to care the NOFAS will reach more women. The rewards and expanded services that go along with attending prenatal care will not only draw expectant mothers in, but will improve their quality of life. This will allow the NOFAS to have a “complete care” approach in which they will provide prenatal care and help provide a better life for a mother and her unborn child.
The NOFAS also has a responsibility to address the underlying causes of FAS if their goal is to decrease its prevalence in high-risk populations. They need to help empower women so they can live a life free of drugs, physical abuse, sexual promiscuity, and achieve higher education. The NOFAS will not only be decreasing the incidence of FAS but will provide guidance for young women in need of a supportive environment.
If NOFAS chooses to stand idle, this will mean thousands of new birth defects each year from a disease that is 100% preventable…thousands of newborn babies forced to bear the burden of a preventable disease for the rest of their lives.

References

1. Burd, L., Kerbeshian, J., Klug, M.G., & Martsolf, J.T. (2003). Diagnosis of FAS: A comparison of the Fetal Alcohol Syndrome Diagnostic Checklist and the Institute of Medicine Criteria for Fetal Alcohol Syndrome. [Electronic version] Neurotoxicology and Teratology, 25, 719-724.

2. Abel, E.L., & Hannigan, J.H. (1995). Maternal Risk Factors in Fetal Alcohol Syndrome: Provocative and Permissive Influences. [Electronic version] Journal of Neuraltoxicology and Teratology, 17, 44-462.

3. Donaldson, T., & Mitchell, K.T. (1999). Preventing fetal alcohol syndrome. [Electronic version] Journal of Pediatric Healthcare, 13, 87-89.

4. National Organization on Fetal Alcohol Syndrome. NOFAS. National Center on Birth Defects and Developmental Disabilities. http://www.nofas.org

5. Bolton, B., Cperich, Floyd, R.L., S., Ingersoll, K., Mullen, Nagaraja, J., Nettleman, M., Skarpness, B., Sobell, L., P., Sobell, M., Sternberg, K.v., Velasquez, M.M., and Project Choices Efficacy Study Group. (2007). Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial. [Electronic version] American Journal of Preventive Medicine, 32, 1-10.

6. May, P.A., & Gossage, J.P. Estimating the Prevalence of Fetal Alcohol Syndrome: A Summary. National Institute on Alcohol Abuse and Alcoholism. Retrieved from http://pubs.niaaa.nih.gov/publications/arh25-3/159-167.htm.

7. Chang, G., Haug, L.W., Mcnamara, T.K., & Orav, E.J. (2006). Brief intervention for prenatal alcohol use: The role of drinking goal selection. [Electronic version] Journal of Substance Abuse Treatment, 31, 419-424. Hastings-Tolsma, M., Park, J.H., & Vincent, D., (2007). Disparity in prenatal care among women of colour in the USA. [Electronic version] Midwifery, 23, 28-37.

8. Hastings-Tolsma, M., Park, J.H., & Vincent, D., (2007). Disparity in prenatal care among women of colour in the USA. [Electronic version] Midwifery, 23, 28-37.

9. Corse, S.J., & Smith, M. (1998). Reducing Substance Abuse During Pregnancy: Discriminating Among Levels of Response in a Prenatal Setting. [Electronic version] Journal of Substance Abuse Treatment, 15, 457-467.

10. James, S.A., Orr, S.T., & Reiter, J.P. (2008). Unintended Pregnancy and Prenatal Behaviors Among Urban, Black Women in Baltimore, Maryland: The Baltimore Preterm Birth Study. [Electronic version] Annals of Epidemiology, 18, 545-551.

11. Phillippi, J.C. (2009). Women's Perceptions of Access to Prenatal Care in the United States: A Literature Review. [Electronic version] Journal of Midwifery and Women’s Health, 54, 219-225.

12. Chow, S., & Mullan, B. (2009). Predicting food hygiene. An investigation of social factors and past behaviour in an extended model of the Health Action Process Approach. [Electronic version] Appetite, 54, 126-133

13. Eggleston, E. (2000). Unintended pregnancy and women’s use of prenatal care in Ecuador. [Electronic version] Social Science and Medicine, 51, 1011-1018.

14. McCormick, M.C., & Siegel, J.E. (2005). Recent evidence on the effectiveness of prenatal care. Ambulatory Pediatrics, 1, 321-325.

15. CDC. Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age -United States, 1991--2005. MMWR 58(19);529-532.

16. Project CHOICES Research Group. (2002) Alcohol-exposed pregnancy: Characteristics associated with risk. [Electronic version] American Journal of Preventive Medicine, 23, 166-173.

17. Fishbein, M., & Yzer, M.C. n.d., Using Theory to Define Effective Health Behavior Interventions. http://www.stesapes.med.ulg.ac.be/Documents_electroniques/MET/MET-COM/ELE%20MET-COM%20A-8127.pdf.

18. Kanekar, A., & Sharma, M. (2007). Theory of Reasoned Action & Theory of Planned Behavior in alcohol and drug education. Retrived on 28 April 2010 from http://www.britannica.com/bps/additionalcontent/18/25057335/Theory-of-Reasoned-Action-ampTheory-of-Planned-Behavior-in-Alcohol-and-Drug-Education

19. Pajares, F., & Usher, E.L. (2006). Sources of academic and self-regulatory efficacy beliefs of entering middle school students. [Electronic version] Contemporary Educational Psychology, 31, 125-141.

20. Benz, B., Burd, L., Kerbesian, J., Klug, M.G., & Martsolf, J.T. (2003). A comparison of the effects of parental risk markers on pre- and perinatal variables in multiple patient cohorts with fetal alcohol syndrome, autism, Tourette syndrome, and sudden infant death syndrome: an enviromic analysis. [Electronic version] Neurotoxicology and Teratology, 25, 707-717.

Parents: The Anti-Drug and the Target of a Bad Anti-Drug Campaign – Jason Blanchette

Adolescent substance use

Preventing adolescent substance use and abuse is a common concern among parents, educators, and politicians. According to the 2008 “Monitoring the Future” survey, 47% percent of high school seniors have used an illicit drug in their lifetime and 72% have used alcohol (1). Teen substance use is associated with more harm than just deaths. It plays a significant role in risky sexual behavior, including unwanted, unintended, and unprotected sexual activity (2, 3). It is also associated with developing substance dependence, contracting a sexually transmitted disease, being arrested for a crime, becoming pregnant early in life (4), and academic failure (5). Adolescent brains go through a dramatic developmental restructuring (6) and are susceptible to alterations in development or damage resulting from alcohol use (7).

Parents: The Anti-Drug

To combat underage substance use, The Office of National Drug Control Policy (ONDCP) has been implementing a youth anti-drug campaign since 1998, and has included with that a parent campaign branded “Parents: The anti-drug” (8). Campaign ads have appeared on television, on the radio, and in print.

The parent campaign encourages parents to protect their children from the risks of drug use (8). The logic for this theme stems from research demonstrating that parents have a tremendous influence on the behaviors of their children (9-16). For example, children who feel stronger connection to and support from their parents and families are at a decreased risk of substance use and delinquency (17-19), and children whose parents have less favorable and more restrictive attitudes about alcohol and underage drinking are less likely to drink heavily (11, 20-22).

The “Parents: The Anti-Drug” campaign attempts to increase parental monitoring of youth and increase parent-child communication regarding substance use. Parental monitoring of adolescents is a strong family protective factor against adolescent substance use (12-13, 16). The strength of the association of parent-child communication as a protective factor is not always as consistent as for monitoring (12, 23-24). However, children who have strong relationships with their parents are more likely to accept their parents’ influence about drinking, which may lead to reduced drinking (25), and therefore the type of communication could also impact the outcome. In addition, effective parent-child communication may modify parenting practices such as providing regulation and structure, monitoring, and communicating expectations (26).

Adolescents reported in one study that a top risk associated with drug use is “disappointing their parents” (27). In other studies, parents’ disapproval of underage drinking and their ability to set limits and enforce rules were identified as protective factors [14, 20, and 28). Therefore, it may be crucial for parents to effectively communicate their attitudes and rules against substance use. Parental communication can have protective effects against unhealthy drinking even after offspring have left for college (29-31).

A report released in 2006 provided evaluation results from years 2000 through 2004 of the campaign (8). The data reveals some small positive changes and some small negative changes, but mostly lacks evidence for effectiveness. Results demonstrate an increasing trend for parental monitoring of adolescents with a small but statistically significant effect size for the 12.5 to 13 age group and for the 14 to 16 age group. The parent reports and the adolescent reports in regards to the parental monitoring trend are very similar for every age group. However, the delayed effect analysis shows the number of advertisements viewed by parents as reported by parents in one round of data collection does not correspond with increased monitoring in the following round of data collection as reported by parents or adolescents.

The authors note that during the time period of the evaluation, the parent-child communication messages were implemented less often than parental monitoring messages (8). Despite that, it is evident that parent-child communication changed during the duration of the campaign evaluation, although the actual trend might not be positive. Parents of all age groups reported increased parent-child communication at the last round of data collection compared to the first round, with a communication index score increase from 2.24 to 2.46 on a scale of zero to three (8). The authors tout this as the strongest evidence of positive effects from the campaign. However, the adolescent reports demonstrate the opposite effect – they reported a decreasing trend of parent-child communication, a small but statistically significant decrease from 1.5 to 1.34. Research consistently demonstrates that when parent and child reports differ, it is the child reports that are more accurate predictors of child outcomes (32-34).

While it may be difficult to know whether talking behaviors increased or decreased during this time period, it is less likely that the increasing trend reported by parents had positive effects on adolescent substance use.

The only delayed effect for parent campaign exposure according to adolescent reports in regards to parent-child communication was that exposure in round 3 correlated positively to adolescent reports of parent-child communication in round 4 with a gamma coefficient score of .08, which although is statistically significant it can be described at best as a very weak correlation. The other rounds of data collection did not reveal such a statistically significant correlation, but in fact an analysis of round 2 data with round 3 data revealed a non-statistically-significant decrease. Three aspects of this study should put into question the validity of the very weak positive correlation. First, the correlation is very weak at best. Second, this is a cohort study. And last, adolescents reported overall a decreasing trend of parent-child communication, which is considerable for this campaign given that 84% of surveyed parents reported at least one campaign exposure per month (8).

Another possible explanation for the above positive correlation (gamma = .08) should be considered – whether parents who engage in the most effective preventive parenting strategies are the most observant of the campaign material and therefore more likely to recall exposure, and that the increased parent-child communication among those parents was a result of their children’s increasing age and increasing exposure to drug risks. In the presence of the very weak gamma score of .08 it is still possible that the campaign had either zero impact, or worse, had a negative impact on effective parent-child communication. It is also important to note that parent exposure did not correlate with adolescent substance use in following rounds of data collection.

It is absolutely necessary to evaluate and revamp the campaign in regards to parent-child communication while using modern research and social science theory. There was a downward trend of parent-child communication reported by adolescents. Increasing the effectiveness of the campaign in regards to parent-child communication can improve teen health outcomes. Failing to do so could result in harmful consequences.

Critique #1: The campaign’s use of the Health Belief Model discourages authoritative parenting.

Human behavior from the perspective of the health belief model is conceived to be a process of pulls by positive forces and repels by negative forces (35). The theory states that people make decisions by weighing the perceived costs and benefits of their options, and then selecting the seemingly most rational choices. In order for the campaign designers to influence parents to engage in preventive parenting strategies, from the perspective of the health belief model, they must convince those parents that their children are at an increased susceptibility to drug use and that the problem will be severe if they do not act on it.

Thomas (36) criticized the health belief model for being overly simplistic in predicting and attempting to change human behaviors within her nursing discipline. She wrote, “Personal histories and experiences are not validated and sharing and dialogue appear irrelevant to the process, and imbalanced power relationships ultimately result.” Similarly, use of the health belief model to change parental behaviors will likely produce interventions that ignore the quality, history, and the ongoing nature of parent-child relationships, and disregard the complexity of parenting and the unique aspects of each parent-child relationship.

It is effective for parents to clearly communicate rules and consistently enforce those rules in order to prevent adolescent substance use (14, 20, and 28). But it is also effective for children to be allowed to express their own thoughts and to communicate openly with their parents in order for them to develop increased psychological autonomy and self-regulation (9, 37-39) and be less likely to use substances (40). This blend of parenting behaviors characterized by consistent enforcement of clear standards in combination with support, responsiveness, and open communication is termed the authoritative parenting style. The authoritative parenting style is associated with the best combination of child outcomes, including psychological and social competence, academic success, and decreased substance use (9, 41-42). During open, trusting, and assertive parent-child communication, children’s self-worths are being validated and they are carefully thinking through the discussions, strengthening their psychological, cognitive, and social competence. They could develop less of a need to follow bad behaviors of peers but greater abilities to reject offers from peers to engage in bad behaviors. Stephenson et al.’s study (43) demonstrated that authoritative parents engage in the best combination of parenting practices shown to protect children against substance use.

Using the health belief model is likely to result in a “fear” or “threat” based campaign that is likely to be more successful at wedging a strict and commanding “drug talk” into each parent-child dyad than increasing open and conversational sharing of ideas and feelings that is inherent in authoritative parenting. The “Parents: The Anti-Drug” campaign ads do in fact attempt to increase parents’ beliefs that their children are susceptible to drug use, and that the drug use will lead to severe problems. Stephenson et al. (44) revealed in a content analysis of “Parents: The Anti-Drug” that the most common messages were ones that attempted to increase parental perception of their children’s drug risk, which included their children’s susceptibility of drug use or the severity of drug use problems. For example, one print ad reads, “Teens are abusing pills, prescriptions, and medicines that are easily accessible in the home. This behavior has many dangerous outcomes, including possible death.” An ad that portrays normal teen behavior as sneaky reads, “It can be medication left over from your last surgery. Maybe they’re the pills you keep on the dresser or tucked inside your purse. Teens are finding prescription drugs wherever people they know keep them — and abusing them to get high.” A campaign letter to parents goes as far as to suggest that their child’s drug and alcohol use is inevitable when they write, “We’re talking about your child’s drug or alcohol use.”

If the “Parents: The Anti-Drug” campaign is successful in establishing increased sense of child susceptibility and severity to drug use, it will also likely be successful in increasing parental worry, anxiety, agitation, and a sense of danger. The campaign is more likely to result in parental one-way communicative attempts at commanding and instructing than it is to increase healthy two-way expression of ideas in a conversational nature. Children who are discouraged from autonomous thinking are less likely to develop psychological and social competence (9, 38). Therefore, the campaign is potentially harmful in its effects on adolescent development and substance use.

Critique #2: Self fulfilling prophecy: Parent expectations directly influence child outcomes

The campaign increases parents’ expectations that their children will use substances, and therefore can encourage adolescents to use substances through the self-fulfilling prophecy. Some ads attempt to convince parents that today’s adolescent cultural norm is to abuse substances. One ad reads, “When you were a teen, you had about 20 channels. Your teen has over 200. Now apply that to drugs.” One internet ad shows a teen girl putting on make-up and words flash across the ad, “These days, teenage girls are into a lot more than makeup” followed by the change of view into her make-up mirror holder which is full of pills.

These ads may be troubling to parents and could increase their intentions to take action against their adolescent’s potential drug use. But increasing parents’ perceptions of their children’s susceptibility to drug use as an approach to increase parent action may simultaneously increase adolescent’s drug use through the self-fulfilling prophecy. The self-fulfilling prophecy states that the perceiver’s expectations can actually lead to its own fulfillment. For example, teachers’ expectations from randomly assigned assessments actually correlated directly with the outcome of their students (45) and military instructors’ expectations from randomly assigned assessments also influenced the outcomes of their recruits (46).

There is evidence that the self-fulfilling prophecy plays a role in parents’ expectations and adolescent substance use. A mother’s expectation of her children’s future alcohol use predicts her children’s future alcohol use (47), which appears to occur from the self-fulfilling prophecy through the process of “self-verification (48). According to self-verification theory, people desire to confirm their self-concepts because it provides a stable sense of self and it provides a more predictable social environment. Willard (49) found that children with lower self-efficacy to refuse alcohol from peers were more influenced by parents’ over-estimation of their alcohol use. A mother’s continued over-estimation of her children’s alcohol use seems to exacerbate her children’s alcohol use over time (50) and an over-estimation of both parents’ beliefs acts synergistically on their children’s future alcohol use (51).

One advertisement reads, “So lay down a few laws for your kids. And the sooner the better, because the average age when teens first try marijuana is under 14 years old.” Unfortunately, this is misleading for many parents who live in communities where the average age of marijuana may be well above 14 years old. Even for communities where the age is at or below 14, this ad presents the information as if teenage marijuana use is the societal norm regardless of the adolescent or the family the adolescent comes from.

Critique #3: Framing parents as the “saviors” during drug talk repels teenagers

“Parents: The Anti-Drug” discourages adolescents from engaging in a healthy and trusting relationship with their parents. By presenting to parents that the “drug talk” must occur soon in order to protect their children from imminent danger, the talk is framed as if parents are the “saviors” of their children’s bad choices. Although these advertisements are intended for parents, they can potentially influence adolescents’ perceptions of parent-child drug talk for two reasons. For one, some youth are going to be exposed to parent advertisements. And second, parents who present a “drug talk” in this way will essentially teach their children that this is the standard way that parents and youth communicate about drugs.

Adolescents experience cognitive changes that cause in them a need to develop their own sense of autonomy (52) and therefore can result in them rejecting or avoiding parental influences that seem to threaten their sense of autonomy. Communicating openly and freely with respect for each other’s autonomy is one way for parents to promote healthier adolescent development. It will allow parents to impress their healthy views and opinions onto their adolescents with less rejection from the adolescents. It can also promote their adolescent’s decision making skills through conversation.

Youth can benefit from open and ongoing communication with parents about alcohol and drugs. For example, Austin et al. (53) found that parent-child communication mediated the media’s negative influence on adolescent alcohol use. Therefore, it may be valuable for parents and teens to feel comfortable discussing alcohol and drugs as they arise in the media, whether in movies, television, advertisements, or inside the news.

The “Truth” anti-smoking campaign is a prime example of how to take into consideration adolescent development when designing public health interventions. It was a tremendous success at decreasing adolescent smoking (54). A large reason for its success may be because the campaign designers understood adolescents’ needs to develop a sense of autonomy and the designers formulated messages that were not preachy (54).

There is a risk that “Parents: The Anti-Drug” will disconnect parents and their children because of a tone that is likely to feel to adolescents as a threat to their immerging sense of autonomy. The tone might discourage adolescents from accepting parents’ influence and it risks encouraging adolescents to avoid discussions with parents that include mention of drugs or alcohol.

Improved intervention without the harmful flaws

The designers of “Parents: The Anti-Drug” were wise to target parents in a media campaign as a strategy to reduce adolescent substance use. Parents have a tremendous influence on their adolescents, and a media campaign has the ability to reach a wide spread of parents. This strategy should be maintained, but the campaign should be improved.

To revamp the campaign into a new intervention that encourages healthy parental action without harmful unintended effects, it is necessary to completely abandon attempts to scare parents. Instead, a campaign should influence parents in a more positive way. It should focus on promoting parent-child communication more than focusing in on their children’s risk of drug use, and then implicitly connect communication with open and honest discussions about substance use. The campaign should promote feelings of warmth, trust, and connectedness. It should promote drug talk as two-way communication occurring openly and as new ideas arise. In order to accomplish this, practitioners should consider advertising theory, social norms theory, and framing theory.

Suggestion #1: Advertising theory

Advertising theory can be utilized in order to promote parental action. A good campaign designed from advertising theory packages the target audience’s deepest aspirations with the behavior change that is intended by the campaign, and then promotes that behavior change by promising that the target audience can fulfill those aspirations if they engage in the behavior. Using advertising theory rather than the health belief model will allow campaign designers to abandon the use of scare tactics that essentially can drive a wedge in between healthy parent and child discourse. It could likely turn out to produce more compelling messages if the designers properly research parent core values and effectively connect those core values with the desired behaviors.

The “Truth” anti-smoking campaign reduced adolescent smoking significantly by using a campaign approach that paralleled advertising theory (54). In the case of the “Truth” anti-smoking campaign, the campaign designers packaged adolescent core values of rebellion, independence, and autonomy with the desired behavior of “not smoking.” The implicit promise was that teenagers can have these core values by not smoking. Siegel and Lotenberg (55) explain that “Often [the promise] is never explicitly stated. Rather, it is a conclusion that people draw after exposure to the communication.” In the case of the “Truth” campaign, the advertisers were able to compel teens to conclude that an increased sense of rebellion will come from not smoking by depicting adolescent rebellion against the tobacco industry (54).

In order to use advertising theory for a parent campaign it is crucial that the advertisers engage in thorough formative research to truly understand parents’ deepest aspirations. Their aspirations are likely going to be found within their parent-child bonding, their communication with their children, or something else in regard to their relationships. However, practitioners should not assume they understand parents even if they themselves are parents, but rather they should conduct research to get into the skin of their target audience and develop a deeper understanding of their emotions and aspirations. Once they discover the deep emotional and aspirational understanding, campaign designers have the task of designing a campaign that promises those aspirations will be fulfilled if parents engage in the behavior that is intended by the campaign.

Successful creation of such a campaign will lead parents to believe and feel that those aspirations are coming true by engaging in the promoted behavior. The key here is that parents must feel that it came true, because if they felt it then it became real. Such a campaign has the potential to be very powerful and without the harmful effects that come from using scare tactics.

Suggestion #2: Social norms

Social norms are simply the behaviors that people regard to be socially acceptable, desirable, or expected standards, and are considered the “normal” way of acting. The belief that a behavior is the expected and normal standard adds social pressure for others to engage in that same behavior.

The campaign designers attempted to increase parents’ beliefs that adolescent drug use was the “norm” in order to increase parent-child communication about drug use. Because that approach can be harmful to adolescents through the self fulfilling prophecy, it is necessary to abandon that approach and instead consider encouraging parent-child communication, rather than substance use, as the “norm.”

A successful campaign utilizing social norms will promote the desired behavior, such as healthy parent-child communication, as the expected and normal standard in our culture. It will show pictures or vignettes of parents and adolescents communicating in a healthy and positive manner, as if they engage in that behavior regularly and with enjoyment. That displayed behavior should be connected to advertising messages about parent-child drug talk. There will be two significant benefits. First, parents will be compelled to engage in that behavior if they see it working for other parents and also if they see that it is normal or expected for parents and children to engage in those healthy conversations with their children. The other benefit will be that children will not feel threatened from drug talk, but instead they will have greater expectations that their parents will respect their ideas during conversation and will therefore be more likely to engage in those discussions.

Suggestion #3: Framing

There are at least two ways to frame parent-child drug talks and both could include parents clearly defining rules and expectations. One could be a one-shot and one-way authoritarian attempt to control adolescents. Another could be a two-way, open, and ongoing discussion where opinions are respected. It is unnecessary for the “Parents: The Anti-Drug” campaign to frame the drug talk as a grim and grave discussion that is crucial to occur soon in order for parents to “save” their adolescents. Framing it as a comfortable conversation part of an ongoing discussion within parent-child relationships will likely yield a greater number of discussions as opportunities arise, such as when alcohol arises in the media or with the news that a friend was caught drinking underage. In addition, this more open frame will likely lead to increased acceptance of parental influence.

There is considerable evidence supporting the notion that people perceive situations and make decisions based from the way options or topics are framed or presented (56-57). Adolescents who perceive parent-child drug talks as one-way and didactic communication may feel uncomfortable engaging in such a talk and avoid discussion with parents that involves mention of drugs or alcohol. But on the contrary, presenting drug talk as a positive and comfortable discussion, both parents and adolescents can feel more comfortable going into the discussion and sharing openly. Therefore, advertisements should show two-way communication that includes children expressing themselves and the parents listening.

Children who feel stronger connection to and support from their parents and families are at a decreased risk of substance use and delinquency (17-19) and children who have strong relationships with their parents are more likely to accept their parents’ influence about drinking (25). To assure that this campaign has the most positive impact on parent-child communication it is essential to frame the parent-child drug talk in a way that will foster respect and acceptance for each other.

Conclusion:

Parents are in a promising position to be their children’s most powerful anti-drug. Unfortunately, many parents are in disbelief that they can effectively cause their youth to avoid drugs (58). One challenge for ONDCP and other prevention organizations is to effectively encourage increased effective parenting behaviors. It is not enough for advertisements to encourage a behavior, such as talking, but instead the advertisements should be careful to encourage effective parenting behaviors, such as healthy and open communication.

It is ineffective for ONDCP to use fear or threat based messages to scare parents into talking. Such strategies can drive a wedge in between healthy parent-child communication, cause parents to react to their children in potentially harmful manners, and cause adolescents to avoid communications with their parents. Although it is uncertain whether effective parenting communication increased or decreased during this campaign, it is more likely that the downward trend of adolescent reporting of parent-child communication signifies fewer instances of healthy parent-child communication.

Tugging at the parents’ positive emotions about parent-child communication, encouraging healthy drug talk as the cultural norm, and presenting the parent-child communication in a healthy and two-way frame should be the new challenges for designers of parent anti-drug campaigns in order to create the most effective campaigns.

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Improper Design Of “Above The Influence” Anti-Drug Campaign Leads To Counterintuitive Outcomes – Jenna Volpe

“Above the Influence” is an advertising campaign in public health that was designed with intentions of reducing and preventing the use and abuse of alcohol and drugs among adolescents in the United States (3). This campaign was created in 1998 for the National Youth Anti-Drug Media Campaign, which is a program currently funded by the Office of National Drug Control Policy (1, 2). The overall goal of this policy is “to educate and enable America’s youth to reject illegal drugs, to prevent youth from initiating use of drugs…and to convince occasional users of these…to stop using drugs” (3). The “Above the Influence” campaign reaches out to adolescents via an official online website (www.abovetheinfluence.com), a collection of television commercials, and magazine ads which were all designed to make teens in America more aware of which factors most strongly influence the decisions they make (2). The campaign also claims to reflect what teens nation-wide have reported is going on in their lives regarding peer pressure, stress, and self-control (2). However, despite the “Above the Influence” campaign’s attempts and efforts to minimize drug use among the American youth, ample evidence supports that the campaign has been ineffective and perhaps even counterproductive, “leading those exposed to an increased perception that others use marijuana” (1). One reason why the “Above the Influence” campaign has been ineffective is that the messages it is trying to convey are largely based on assumptions from the Health Belief Model, which has not been an accurate model in predicting or controlling people’s behavior (6). Another major flaw of the campaign is that the messages it sends out are negative and mixed; the campaign focuses on showing teens what they do not want to happen, as well as some of the worst-case scenarios that could result from using drugs, rather then zoning in on the potential positive benefits of staying sober and drug-free. Research has proven that the most powerful brand-name companies in the U.S are those which are able to convey positive feelings in their consumers by airing commercials which associate their product with great and wonderful ambience, as demonstrated in the Marketing Theory (9).

Evidence supports adverse effects of campaign

A large study was conducted by Westat from 1999 to 2004 which reported that the “Above the Influence” campaign has been counterproductive (3). The study was designed to measure changes in drug-related knowledge, attitudes, beliefs and behavior in youth and parents, as well as to assess the relationship between these factors and self-reported measures of media exposure (3). Additional objectives of the study were to assess the association between parents’ drug-related knowledge, attitudes, beliefs and behavior with those of their children, and to assess the changes in these factors which may be related to the “Above the Influence” campaign (3). The study finally examined the effects of the campaign by comparing groups of people with high exposure to groups with low exposure to the ads (3). After collecting longitudinal data through conducting multiple observations on a set of participants over a long period of time, Westat investigated if there was a relationship between exposure to campaign advertisements and both drug use and intermediate outcomes (3). Analyses of data concluded that when non-drug-using youth in America were exposed to the “Above the Influence” campaign, “greater exposure to the campaign was associated with weaker anti-drug norms and increases in the perceptions that others use marijuana” (3). Despite a favorable relationship between campaign exposure and parental beliefs and behaviors, there was no relationship found to lead to correlating changes in their children’s beliefs and behaviors regarding drug use (3).
According to Above the Influence of Wasteful Spending by Houston (2006), the Marijuana Policy Project (MPP) has been fighting to reduce funding for the anti-drug Media Campaign after reading in Westat’s 2003 independent report which stated that messages conveyed in “Above the Influence” ads are thought to cause a boomerang effect in drug use among American youth (4). Houston expresses deep concern for teens which have been exposed to “Above the Influence” ads because under the assumption that the above statement is true, these teens are more likely to have developed attitudes approving of drug use over time (4). Houston also refers to campaigns within the White House’s Offices of National Drug Control Policy such as the “Above the Influence” campaign as “wasteful, misleading, and ineffective anti-marijuana campaigns” (4). In spite of overwhelming evidence for the campaign’s lack of success in influencing teen attitudes and behaviors regarding drug use, as well as discernible efforts to cut funding for the “Above the Influence” campaign, it is clear that this public health campaign is severely flawed and in need of reform. However, before reforming the campaign it is important to examine why it is at fault and what needs to be changed.

Health Belief Model was a poor model to choose as frame for campaign design

Although there are multiple factors which can be accounted for the adverse effects of the “Above the Influence” campaign, a major determinant of ‘boomerang’ results is the campaign’s emphasis on assumptions and values which are stated in the Health Belief Model. The Health Belief Model is psychological and attempts to predict and explain human health behaviors by focusing on an individual’s attitudes and beliefs (5). According to the Health Belief Model, an individual’s health behavior is motivated by four factors: perceived susceptibility (of a health problem), perceived severity of the potential health problem, perceived benefits of an action, and perceived barriers of taking that action (6). In this case, the action being measured is the choice not to use drugs. The potential health problem would be negative physiological and psychological consequences of drug use. However, growing bodies of evidence are suggesting that the Health Belief Model is not effective in predicting or manipulating health behaviors of people, especially adolescents, for several reasons (6). The Health Belief Model operates under the assumption that people think rationally and plan their decisions and actions through a cost-benefit analysis, assessing the risks, severity, and possible outcomes of an action (6). However, studies have shown that there are many other factors influencing people’s decisions, such as social, environmental, and socioeconomic circumstances (6). In reality, it has been observed that people behave in predictably irrational ways and make decisions spontaneously (7). Another limitation in the Health Belief Model is that it “defines motivation as a combination of likelihood and severity of beliefs” (15). This assumption is inaccurate because many other dimensions to motivation have been identified, such as social norms which are described in the Theory of Reasoned Action and self efficacy which is emphasized in the Theory of Planned Behavior (15). An additional weakness of the Health Belief Model which severely inhibits its effectiveness in reaching out to a large target population is that the model is individually-focused (7). Models with an individual focus are severely limited in that they do not take into account the “wider social context within which the individual must circulate, such as the families and any communities of which that individual may be a member” (7).
Components of the Health Belief Model are demonstrated on the website for “Above the Influence” in that much of its content contains detailed facts and information about the negative effects of drugs on the body, assuming this will make teens more conscious and aware of their decisions. For example, there is a link explaining detailed facts about alcohol, cocaine, ecstasy, gamma-Hydroxybutyric acid (GHB), hallucinogens, heroin, inhalants, ketamine, marijuana, crystal meth, prescriptiond, over-the-counter drugs, Rohypnol, steroids, and tobacco (12). Many young people may not have heard of these drugs, and exposing them to new information about drugs could increase the likelihood that they will try new drugs because the website is promoting curiosity. The official website for “Above the Influence” also contains a list of street terms for drugs and explains in detail how each substance is made and ingested, as well as the physiological and psychological effects of each drug (12). A list of potential negative consequences and long-term health problems are provided at the bottom of the page (12). For example, when a teen clicks on facts about marijuana, he or she will be bombarded with a long list of health risks including: impaired judgment and motor coordination, shortened attention span and distractibility, anxiety and panic attacks, increased heart rate, increased risk of heart attack, increased risk for schizophrenia in vulnerable individuals, impaired judgment, problems with memory and learning, lowered motivation, decreased alertness and coordination, addiction, and withdrawal symptoms from stopping drug use (in a chronic user) such as irritability, sleeplessness, anxiety, impaired appetite, and aggression (13). Since the Health Belief Model has been proven to be ineffective in influencing one’s actual health behaviors regardless of his or her intentions, the long list of risk factors for each drug is not going to make teens less likely to try the drug; if anything, the website could be promoting curiosity about new drugs.

Campaign advertisements convey negative and confusing messages to youth

Another reason why the “Above the Influence” campaign has produced adverse effects is that its advertisements and commercials are delivering negative and mixed messages to teens. This is especially demonstrated in the “Shoulders” commercial shown on television and displayed on the website. In this ad, a teenage boy is offered a joint at a party (8). Prior to making the decision to accept or reject the joint, the boy looks down onto his left shoulder and sees a devil, a “stoner girl”, a pizza-delivery man, and a fifty-something year old “Flower-child” woman from the 60s with a smoker’s rasp, pressuring him to take the hit because they “turned out okay” and it’s the cool thing to do (8). On the right shoulder, the teen sees an angel, an astronaut, four members of his basketball team, Shakespeare, and his parents (8). These people argue that he should not smoke because if he does then he will ruin his future, jeopardize his basketball team, not get into a good school, and make his mother cry (8). In the midst of the boy weighing out both sides and listening to everyone’s arguments at once, a narrator states: “The only voice that matters is yours” (8). At the very end of the ad, the boy chooses not to take the joint. Although this commercial is intended to represent the pressures that teens must face when offered drugs, and how teens must deal with them, it exposes teens to negative consequences of drug use and delivers a very mixed message. The “Shoulders” ad is attempting to tell teens that aspects of their life such as their future, teammates, academics and family are going to be negatively affected it they smoke weed, without directly telling them not to smoke weed, because teens do not like being told what to do. However, the narrator’s statement at the end of the commercial (“the only voice that matters is yours”) implies that one should disregard the voices of other people in their lives, including their parents and teammates. Teens will see this and infer that regardless of what others tell them, they should and will do what they want because that is what matters, even if what they want is to use drugs.
In the “Human Puppet” ad by “Above the Influence”, a teenage girl is shown intoxicated and passed out at a party. The girl is surrounded by other peers at the party, who are drawing on her and making fun of her. One of the voices refers to the girl as a “puppet”, and another voice exclaims that she is going to have “such a headache” the next day (8). At the end of the commercial, everyone ditches the girl and a written message is displayed at the bottom of the screen that says: “If you’re not in control, who is?” (8). A major problem with the “Human Puppet” ad is that teens who see it will most likely disagree with the message being implied. Teens could argue that if and when they drink, they will not get as intoxicated as the girl from the puppet ad. Teens could also conclude that if they ever did get intoxicated to the same extent as the girl from the ad, then their friends would not treat them the way this girl was treated, thus making the premises of the commercial invalid. One can rationally conclude from the puppet ad that “Above the Influence” does not want adolescents not to drink because that they are going to pass out, be made fun of and have a headache, therefore it is very likely that adolescents will decide they are willing to take these silly risks and surround themselves with friends who will not treat them like a puppet if they pass out.
A third example of a mixed message sent out by “Above the Influence” is their list of reasons why people do drugs, which can be found on the campaign’s website (14). This message is counterintuitive in that teens are being told not to use drugs, yet they are being bombarded with reasons why people their age are using drugs. If teens are on the website and come across this long list of reasons, even if the reasons are negative and/or do not necessarily apply to their own personal life, teens will be more likely to believe that lots of people are using drugs, which was previously confirmed in Westat’s study (3). If public health campaigns aim to successfully reach out and send a message across to youth in efforts to manipulate their knowledge, beliefs, attitudes and behavior, these campaigns need to do more than merely provide health facts and negative, mixed messages. The message should be positive, clear, and concise. The underlying reasons behind why company brand products are noticed, retained and popular are hidden within the message of the company’s advertisement. Figuring out what type of message attracts the American public to a particular brand product advertisement is crucial to designing or improving a public health campaign.

Anti-drug campaign improved through the Marketing Theory

In order for a campaign to effectively reach out to a target audience and affect their knowledge, attitudes, beliefs, and behaviors regarding drug use, the campaign’s message must be appealing (9). A successful public health campaign should be designed based on a theory or model which has been proven to work. One of the most influential social science theories used in media and advertising is the Marketing Theory, which has been applied to ads by many brand-name companies in order to sell a product to their consumer market (9). Rather than trying to convince a target population to avoid doing something bad, public health interventions should aim to promote something positive and desirable to viewers. The Marketing Paradigm within the Marketing Theory states that a company or brand must first find out what people want, and then create and package their product so that it fulfills those needs and wants, appealing to more basic human values (9). According to Siegel (2007),
“The key is for public health practitioners to abandon the traditional approach of deciding what they want the target audience to buy…Instead, public health professionals must first find out what the consumer wants and then redefine, repackage, reposition, and reframe the product in such a way that it satisfies an existing demand among the target audience” (9).
This concept is demonstrated in the Nike commercial featuring Kobe Bryant and five other athletes; these athletes are filmed excelling in different sports, while wearing a pair of Nike sneakers (10). Although this advertisement is intending to sell Nike sneakers to an athletic population group, it clearly demonstrates the Marketing Theory and advertising techniques through three basic principles: the promise, the support, and the core values (9). In marketing and advertising, the promise does not have to be something true, but it must be large; it must relate back to the consumer, not the product (9). The promise of a brand’s ad targets the deep aspirations of people. For example, Nike sends out a promise message stating that “Anything is possible” (10).
The ad should reinforce values that are already present or fill a void of values that are desired or lacking (9). Common examples of core values that are promoted in the world of advertising include love, freedom, opportunity, power, sex, and self-esteem because they are typically desired by consumers and yet portrayed as tangible through advertisements (9). The Nike commercial with the athletes makes Nike sneakers appealing to consumers because the ad is supporting how Nike can provide core values such as control and autonomy. This support is provided to viewers by flashing very brief scenes featuring each athlete excelling in his or her sport of choice (10). The Nike ad is effective in manipulating people’s attitudes, beliefs and behaviors subconsciously because it is supportive and positive, showing consumers what they can have. Although consumers will not necessarily achieve what the ad is promising, the ad is still effective because it invokes feelings of wanting or being able to attain those core values.
The main problem with the “Above the Influence” campaign and with public health campaigns in general is that they tend to focus on the actual product and support it with data (9). Another problem is that these campaigns emphasize negative consequences that result from a particular action (i.e. using drugs) which viewers do not want to experience. Ads for an anti-drug campaign could be significantly improved if they were based on the Marketing Theory and not the Health Belief Model because the Marketing Theory is positive rather than negative, group-focused rather than individually-focused, and proven through research to be favorable (9). A more conducive anti-drug ad to reach out to adolescents in America would be one which is positive and promotes the attainability of core values rather than threatening people’s health or exposing people to the possibility of losing core values (9).

Intervention

I would like to propose an anti-drug use campaign called the “Choose Sobriety” campaign. The target population for this campaign is American youth, just like the “Above the Influence” campaign. However, the frame for “Choose Sobriety” is derived primarily from the premises of the Marketing Theory and not the Health Belief Model. The commercial and magazine ads for this campaign would deliver a large promise to teens by implying that choosing to be sober offers many positive outcomes in life (core values) such as opportunity, relationships, love, security, empowerment, autonomy, dreams, family, and purpose. The support for the promise of these core values would be demonstrated in each of five different scenes which depict a person or people fulfilling an accomplishment or enjoying a special moment, experiencing the core values which were made possible by choosing sobriety.
One of the five scenes in the “Choose Sobriety” commercial is a senior male in his cap and gown, receiving a high school diploma on graduation day. Another scene is of a young couple smiling and bonding with their baby, outside on a beautiful day. The third scene in the ad is of a young man or woman running a marathon. The fourth scene is of an all-star athlete with a clean, sober drug history, whom American youth admire and respect, practicing his sport alone in a gym or outside. The final scene will feature a teenage girl playing her little sister.
In the beginning of the commercial, each of the five scenes will alternate flashing across the screen (a few seconds at a time) while catchy, positive music is playing in the background. After each scene has been shown several times, the first scene with the graduating senior will appear. The boy (holding his diploma) will look at the camera and exclaim, “I choose sobriety because I’ve worked hard and I have big dreams for the future.” This scene will fade; the scene with the married couple and their baby will emerge. The young woman will look at her husband and baby, then at the camera, stating: “I chose to be sober because I wanted to fall in love and establish a family.” Next, this scene will disappear and the third scene will come into view. The marathoner will run across the finish line victoriously, look at the camera and say: “I chose to be sober so that I could follow my dream to finish a full marathon.” Next, the famous athlete will be shown practicing the sport alone in a gym or outside, and then scoring a goal in a real game. The scene will go back to the athlete when he or she is alone in the gym or outside, and the athlete will state: “I chose sobriety because I’m passionate about (insert sport). When I play (insert sport) I feel strong, free and empowered.” Finally, the fifth scene will appear. The teenage girl playing with her younger sister will exclaim, “I choose sobriety because my loved ones are counting on me.” The music will have been playing in the background throughout the ad. At the very end, either a narrator or words will read the campaign slogan: Live your life to the fullest. Make big plans. Achieve your goals. Follow your dreams. Choose sobriety.
In order to maintain a consistency within the campaign so that viewers will be able to easily identify with and remember it, “Choose Sobriety” magazine ads and billboards would consist of the same five scenes described above, but individually. An example of a magazine ad for “Choose Sobriety” would be a picture of the teenage girl from the fifth scene, playing with her little sister. Text would be written at the top of the page reading, “I choose sobriety because my loved ones are counting on me.” Each of the five scenes would have a different message written at the top of the page, respectively. The campaign’s slogan Live your life to the fullest. Make big plans. Achieve your goals. Follow your dreams. Choose sobriety would appear at the bottom of the page for all five variations of “Choose Sobriety” magazine ads.
Contrary to the focus of www.abovetheinfluence.com, the “Choose Sobriety” campaign would make a website called www.choosesobriety.com which would provide links leading to people (especially teens) stating what is important to them in their lives and why they choose to be sober and drug-free. Another link would lead teens to information about the positive benefits of being sober. The website would also contain statements intended to motivate, inspire, and encourage teens to make the most out of their lives.
The “Choose Sobriety” campaign would have a large, positive impact on the knowledge, beliefs, attitudes, and behaviors of teenagers throughout America for several reasons. “Choose Sobriety” would work because it is not individually-focused; the message being conveyed is simple, and it is one to which everybody can relate. This campaign is strong and concise; there are no mixed messages about what this campaign is advocating for, unlike those created by the “Above the Influence” campaign. The core values demonstrated in this campaign are positive and desirable, and they are portrayed as tangible and attainable through choosing the right path in life (sobriety versus drugs). The advertisements for “Choose Sobriety” are inspiring in that they are encouraging the youth of America to make the personal choice to be sober and work hard, setting goals and following their own dreams for the future.

References

1. Amentano, Paul: "Must Not See TV: Stoners in the Mist", page 18. High Times, September 2008.
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9. http://www.youtube.com/watch?v=v9nCPbbngmI
10. http://www.abovetheinfluence.com/facts/default.aspx?path=nav
11. http://www.abovetheinfluence.com/facts/drug-facts.aspx
12. http://www.abovetheinfluence.com/facts/drugs-marijuana.aspx
13. http://www.abovetheinfluence.com/facts/whydrugs.aspx
14. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 29:128-135.