Got Salt ? It Could Cost You Your Health – Patrice Barrett

The Issue – Excessive Sodium Consumption in Americans

The United States Departments of Agriculture and Health and Human Services recommend a daily intake of no more than 2300 mg. of salt for those older than two years of age. This is the equivalent of one teaspoon of salt. Lower guidelines of just under 1500 mg. a day are recommended for people over 40 years of age, African Americans, elderly and those already diagnosed with hypertension. These populations are already at high risk for cardiac disease and stroke. (1)(2) The average US adult was consuming about one and a half times the maximum recommended 2300 mg. daily at the end of 2006. The highest consumption levels are in the 14 to 50 years old age groups. (3)High salt intake is associated with negative health effects, including hypertension, renal disease, cardiovascular disease and stroke. These illnesses can cause significant physical disability and immediately result in death. Sodium dietary intake levels have been steadily rising since 1971. Some adult males now consume over 4000 mg a day. (4)

The US Institute of Medicine of the National Academies (further known as IOM) released on April 20, 2010 a consensus report on strategic plans the United States government should institute to reduce sodium intake in our citizens. This report was issued in response to a US Congressional request in 2008 to recommend strategies to address the issue. Wide media coverage of the excessive sodium consumption issue in the few days after the release of the report seems to have made the topic more visible to the public. (5-9)

The Public Health Impact of the Issue

Treatment of diseases resulting from the current levels of salt consumed in American diets costs the US health care system annually between $10 and 24 billion. (10)Reducing sodium intake in American diets to about 1500 mg. daily would save between 44,000 to 92,000 lost lives a year .(11)All population segments are projected to benefit from the sodium reduction, especially African Americans, women at high risk for strokes and younger age groups subject to becoming hypertensive early in their lives . (12) Various medical professionals and public health stakeholders have made efforts for over forty years in the US to change high dietary sodium consumption. These have not been very successful to date, given the rising consumption in recent years. (13)(14)

The Current Proposed Intervention – New York State Legislation

A New York State Assembly member introduced a bill on March 5, 2010 to prohibit owners or operators of restaurants in New York state from using salt in the preparation of any food that customers consume in that establishment. (15)This includes food a restaurant may prepare and serve at an off-site location in catering operations. A proven violation of this law would result in a maximum $1,000 penalty for each incident. Each use of salt would constitute a separate violation. Review of the state assembly web site on May 1, 2010 revealed the bill had been referred to the Assembly health committee. No legislative chamber votes were taken on the bill in this session. (16) The bill language states “restaurant” globally with no delineation between different categories of eating establishments.

There is no mention about what government agency is charged with enforcing the legislation if it becomes law. It does not address frozen foods served at restaurants that come prepared with sodium content. This would be a large issue in fast food restaurants. Burger King should not sprinkle salt on the French fries after frying them. Disregard the salt content in the frozen prepackaged French fries ! In Fall, 2009, New York state was home to only 38,596 of the total 578, 353 restaurants in the nation, a mere 6.6%. (17)

Assemblyman Felix Ortiz states the bill he authored is designed to save lives, similar to measures undertaken with banning trans fats in foods. Mr. Ortiz issued a clarification of the bill the day after its introduction. He did not intend to stop restaurants from using salt as a functional part of a recipe, only prohibit it being used on an additive basis when “piling on” large amounts of salt. He hoped the bill would receive enough legislative support to become law. His motivation was reading a recent medical journal article and WHO report about the deleterious health effects of excessive salt use. (18)

The First Problem: Americans Eating at Home

Americans do not consume all of their food at restaurants. Very far from it. I am certain even the wealthiest residents in our nation often have meals prepared for them at home by household staff using ingredients purchased at grocery retailers. Those travelling for work may find themselves eating at restaurants for intermittent stretches of time, but not every day of the year. New York’s proposed legislation to only reduce the use of salt in foods prepared at restaurants leaves the largest venue of food consumption without any intervention at all: Home. The legislation is a mere proverbial drop in the bucket in addressing the behaviors associated with salt ingestion. Restaurant cooks and owners are only two of the many players in the salt consumption story.

The Pew Research Center study on eating habits in 2006 had a nationally representative sample of 2250 adult subjects. It revealed one third ate in a restaurant less than once a week and another one third ate in a restaurant only about once a week. (19) A study commissioned by the US Centers for Disease Control and Prevention in May and June of 2004 had a stratified national random sample of 4345 subjects. These respondents 18 years and older were representative of 2000 Census data with respect to geographic residential region, household income , age, and included a special survey for households with children to evaluate those younger than 18 years old. Subjects were asked to respond based on activities during the previous week. This study revealed 86% made dinner at home 3 to 7 days of the week, 35% ate at home 6 to 7 days of the week. 64% ate less than two meals a week away from home and 59% did not even bring home prepared items from food establishments. (20)

Individuals or families are eating even a conservative ten meals a week at home. This is five times greater than what is consumed in restaurants by a small segment of the population. Citizens in lower socioeconomic classes probably cannot afford to eat meals often in restaurants. 17.1 million US households were food insecure at some time in 2008. They did not have or were unable to acquire enough food for the members of their household because of a lack of financial resources. (21)This large number of people would very likely not benefit from the salt restrictions New York is proposing for restaurants.

The Second Problem: What About the Grocery Foods We Purchase ?

The preceding data reveals Americans do not frequently eat in restaurants. They are buying food to prepare and consume at home. The Centers for Disease Control and Prevention report 77% of our sodium consumption comes from processed foods we consume, 12% of our salt is naturally occurring, 6% is added at the table and only 5% is added during cooking. (22) The proposed New York legislation would at best address 5% of our salt consumption. If salt was banned on the table in restaurants in addition to use in cooking, only a total of 11% of our salt consumption would be addressed.

The foods we buy in grocery stores and other retail outlets are playing the largest role in our risk for cardiovascular disease and stroke. The majority of Americans may very well not understand this danger. Food manufacturers’ addition of salt and other sodium compounds in packaged foods is generally recognized as safe (GRAS) under the US Food and Drug Administration Food, Drug and Cosmetic Act. Sodium is added for flavor, but also as content thickeners, preservatives, and to enhance the texture. The majority of foods have very little naturally occurring sodium.(23)

Foods considered healthy choices in our diets have high sodium content. Some people may know canned foods and those prepared in recipes from boxed ingredients are high in sodium. Other foods are not as obvious. A four inch egg bagel has 449 mg. sodium, each slice of Arnold whole grain bread has 162 mg. for a total of 324 mg. if using two slices, Kellogg’s Complete Wheat Bran Flakes has 207 mg. in ¾ of a cup of dry cereal. Two Eggo waffles have 410 mg. Before Americans even leave the house in the morning, ingesting a prepared breakfast food one may think has good nutrient value contains up to one fourth the Institute of Medicine recommended healthy sodium consumption level of 1500 mg. daily The three Oreo cookies you eat later in the day for a well deserved treat have 160mg of sodium or 11% of the recommended daily ingestion level. Fresh fruits and vegetables all have very low levels of naturally occurring sodium, most with less than 20 mg per one cup serving. (24)

Problem Three: No Consumer Education Component

Consumers do not have control over how much sodium is added to the foods they purchase. They can make healthy choices to consume foods with lower salt content. Social and environmental factors play large roles in shaping human behaviors. This includes food consumption. Prepackaged foods are quicker and easier to prepare at home, even at home. These foods are usually more accessible and less expensive than lower sodium and healthier diet choices. (25) Individual awareness and knowledge about the excessive salt consumption issue will play an important role in the future demand for lower sodium food choices in both restaurants and grocery stores. Consumers need to be educated about the positive benefits of reducing sodium intake and the deleterious effects of continuing it through their lifespan. Mr. Ortiz’s proposed legislation would remove salt from foods cooked in restaurants. It provides for no communication with the consumers about why this is being done or the health benefits they will derive from the measure.

The American palate is accustomed to the taste of salt in foods. There is scientific evidence humans, like other vertebrates, develop a complex neural network in brain centers to trigger hormone signals to maintain certain sodium concentrations in bodily fluids. These concentrations are based on what level the body has become acclimated to. (26) Lahey Clinic cardiologists acknowledge salt is very addicting and patients have a difficult time reducing their consumption for medical reasons. (27) The Institute of Medicine recommends the sodium reduction in packaged and restaurant foods occur in step wise fashion to slowly acclimate American palates. (28)

Plans for A Better Intervention

The recent consensus report by the US IOM took a classic public health approach for strategies to reduce sodium consumption at the population level. A coalition of stakeholders should play a role in designing and implementing a national campaign to accomplish the goal. The coalition includes public health professionals, government agencies, consumer organizations, food manufacturers, restaurants, and medical professionals. The groups should receive leadership at the national level from the US Secretary of Health and Human Services to set a reasonable time line for the goal. (29) The roles of the groups could be designed in a myriad of ways. This is too great a topic to cover in the short length of this paper.

The New York City Department of Health and Mental Hygiene started a coordinated national effort in 2008to address the goals – The National Salt Reduction Initiative. The federal government might use this as a model to gain insights. The department joined with now forty state and city health departments and other organizations to try and realize a twenty percent reduction in sodium consumption over five years. This will be through voluntary efforts from restaurants and packaged food manufacturers and based on a model in the United Kingdom. Restaurants in New York are part of this agenda. Mr. Ortiz’s proposed legislation would have some benefit here. The Initiative already gained commitments from Goya and Kraft Foods, Boar’s Head meats, Au Bon Pain, Subway, Starbucks and other food manufacturers. (30) These commitments demonstrate some success of the initiative to date.

A More Effective Intervention

This course was designed to learn about the effects of social and behavioral factors on health behaviors. The final assignment requires a proposal for an intervention to help reduce American dietary sodium ingestion. Consumer education about excessive salt consumption has been very successful in Finland and the United Kingdom. One third of the population understands the need to lower salt intake to reduce health risks. (31) Salt is ubiquitous in most of the foods Americans consume. Federal agencies may enact measures for manufacturers to follow for reducing salt in the foods they produce. The public must be educated about why this is a necessary goal and the health benefits gained from doing it.

The traditional individual models of behavior change stand out as not at all suitable for the issue of excessive dietary sodium consumption. Large numbers of people need to be targeted. Strategic use of marketing principles can help public health practitioners effectively market population based preventive programs when there may be little demand for it.(32) The use of branding can be a very effective marketing tool to create an association in consumers’ lives with an issue. It can influence changes in behaviors by offering an external ideal consumers can aspire to and associate with imagery. Research has shown there have been significant effects of branded messages on health behaviors. (33)Reductions in salt consumption at the US population level require promoting nutritious eating behavior in the media.

I watch very little television and rarely read mass media publications. One branded campaign has repeatedly caught my attention despite my limited exposure to the usual popular media avenues : the Got Milk ? campaign with celebrities wearing milk mustaches. The most recent celebrity to be part of the campaign is Christie Brinkley. The branded philosophy of the milk campaign is interesting. “Drink well. Live well. Recognize what’s really important. Feel good inside and out. Making sure that milk is always on the table can ……..” (34)The word drink can easily be replaced by eat, with additional messages related to reducing sodium consumption with what foods are offered on the meal tables in American homes. Christie Brinkley and the celebrities from many different professions preceding her in the campaign have represented health, vitality, and success.

I recommend a widespread campaign modeled after Got Milk ? in print, television and internet media channels to reach large portions of the American public. This would attract attention to the issue of lower sodium consumption in a positive way and can offer opportunity to learn more about the issue. The IOM acknowledged the need for a gradual reduction in sodium in foods to change consumer palate preferences. A campaign similar in quiet tone to this one would draw attention to the sodium issue. It may need to be followed by other campaigns at later times with different tones. One caveat is that the campaign should feature some celebrities that are significant to children. The sodium consumption issue is one that needs to be addressed in all age groups. Even young people are at risk for developing hypertension at early ages from ingesting large quantities of salt. Hypertension places them at risk for more serious disease as they age. The guidelines for healthy consumption levels specifically referred to those two years of age and older.

References

1. Applications of lower sodium intake recommendations to adults – United States 1999-2006. MMWR. Morbidity and Mortality Weekly Report. 2009. 58: 281-283
2. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010
3. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
4. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
5. Neumann, William. FDA Is Urged to Set Limits for Levels of Salt in Food. The New York Times. April 21, 2010. http://www.nytimes.com/2010/04/21/us/21salt.html?src=mv. Accessed April 30, 2010
6. Marsh, Bill. Stealth Salt in the Pantry. The New York Times. April 24, 2010. http://www.nytimes.com/2010/04/25/weekinreview/25marsh.html?ref=us. Accessed April 30, 2010
7. At A Glance: Changes in Sodium Levels in Food. The Miami Herald. April 21, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=NN6MxXG3fWm0RM
8. Matthews, Karen. Salt Taking Cut in Groceries. The Washington Post. April 26, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=GEylyANncLPO0M
9. Healy, Melissa. FDA Calls for Salt Cutbacks. The Los Angeles Times. April 21, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=Ab6fnARAXr7EXM
10. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
11. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010
12. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
13. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010

14. Sacks, Frank M., et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine. 2001. 344: 3-10. http://content.nejm.org.ezproxy.bu.edu/. Accessed April 29, 2010
15. Goldsmith, Samuel. Brooklyn Dem Felix Ortiz wants to ban use of salt in New York restaurants. The New York Daily News. March 11, 2010. http://www.nydailynews.com/ny_local/2010/03/11/2010-03-11_assault_on_salt_an_insult_chefs.html. Accessed April 27, 2010
16. The New York State Assembly. Bill A10129 Summary. http://assembly.state.ny.us/leg/?default_fld=&bn=A10129&Summary=Y&Actions=Y&Votes=Y&Text=Y. Accessed April 27, 2010 and April 29, 2010
17. National Restaurant Association. Research and Insights: State Statistics. http://www.restaurant.org/research/state/
18. Benjamin, Elizabeth. Reports of Salt’s Death Have Been Greatly Exaggerated. The New York Daily News. March 12, 2010. http://www.nydailynews.com/blogs/dailypolitics/2010/03/reports-of-salts-death-have-be.html? Accessed May 1, 2010
19. Pew Research Center. Eating More; Enjoying Less. April 19, 2006. http://pewresearch.org/pubs/309/eating-more-enjoying-less. Accessed May 1, 2010
20. Kruger, Judy, et al. Dietary Practices, Dining Out Behavior and Physical Correlates of Weight Loss Behavior. Prevention of Chronic Diseases. 2008. 5:1-14. http://www.cdc.gov/pcd/issues/2008/jan/06_0158.htm. Accessed May 1, 2010
21. The United States Department of Agriculture Economic Research Service. Food Security in The United States. Updated November 16, 2009. http://www.ers.usda.gov/Briefing/FoodSecurity/stats_graphs.htm#food_secure. Accessed May 2, 2010
22. Marsh, Bill. Stealth Salt in the Pantry. The New York Times. April 24, 2010. http://www.nytimes.com/2010/04/25/weekinreview/25marsh.html?ref=us. Accessed April 30, 2010
23. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
24. United States Department of Agriculture Agricultural Research Service. USDA National Nutrient Database for Standard Reference Release 22. Last modified 11/20/2009. http://www.ars.usda.gov/Services/docs.htm?docid=8964. Accessed May 1, 2010.
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26. McCarron, David, et al.Can Dietary Sodium Intake Be Modified by Public Policy ? Clinical Journal of the American Society of Nephrology. 2009. 4: 1878-1882
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28. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
29. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
30. New York City Department of Health and Mental Hygiene. Cutting Salt, Improving Health. 2010. http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml. Accessed May 1, 2010
31. Mohan, Sailesh, et al. Effective population wide public health interventions to promote sodium reduction. Canadian Medical Association Journal. 2009. 181:605-609. www.cmaj.ca. Accessed May 1, 2010
32. Marketing public health – an opportunity for the public health practitioner. In Siegel, M, Doner, L. Marketing Public Health: Strategies to Promote Social Change. (2nd edition). Sudbury, MA. Jones and Bartlett Publishers, Inc. 2007.
33. Evans, WD, Hastings G. Public health branding: Recognition, promise and delivery of healthy lifestyles. In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008
34. Got milk ? Mild Mustache Celebrities. Milk: Building Strong Families. http://www.whymilk.com/celebrity/christie_brinkley. Accessed May 2, 2010

Improper Use of Theory Leads to an Ineffective “If You’re High, You Can’t Drive” Campaign – Julianne Burns

Marijuana, also known as cannabis or weed, is the most commonly abused illicit drug in the United States (1). According to the National Survey on Drug Use and Health from 2008, 15.2 million people aged 12 or older reported using marijuana within the past month. In that same year, 10 million people aged 12 or older reported driving under the influence of illicit drugs (2). Another report, the 2007 State of Maryland Adolescent Survey, showed that 11.1 percent of the state’s adolescent drivers reported driving while under the influence of marijuana on three or more occasions (3).

When marijuana is smoked, it causes a high that has many short-term effects, including memory and learning problems, distorted perception, difficulty thinking or problem solving, loss of coordination, and other effects (4). Studies have shown that being under the influence of marijuana increases one’s risk of getting into a car accident by reducing reaction time, affecting the ability to think, and decreasing ability to stay in one’s lane. These effects can last up to six hours after smoking occurs (4-5). With the commonness of marijuana use among the youth of today, and the dangers of driving while high, this poses a major public health concern.

Among marijuana users, it is thought that driving under the influence of marijuana has little, if any, affect on one’s risk of getting into a car accident (6-9). This incorrect understanding, along with select studies that argue that marijuana produces a small degree of driving impairment (10), it is difficult to deter adolescents from performing this activity. On top of that, testing the amount of marijuana in a person’s system is not an easy task. Therefore, it makes it difficult for law enforcement officials to properly and effectively prosecute drivers who have smoked marijuana during routine, road-side pullovers. With the complexity of testing marijuana levels, the enforcement of driving under the influence of drug laws is ineffective at best (4). With the current debate over the legalization of marijuana, and new legislations being passed that are more lenient with marijuana possession charges, there needs to be public health interventions to reduce the commonness of driving while high.

In order to fight driving while under the influence of marijuana, Mothers Against Drunk Driving (MADD) Canada created the “If you’re high, you can’t drive” campaign in 2005. The goal of this campaign was to raise awareness of the dangers of driving while high. MADD Canada released commercials aimed at young adults that attempted to show that smoking marijuana and driving is not acceptable (11). These commercials were ineffective in delivering that message for several reasons, three of which will be discussed here. I will use three of MADD Canada’s commercials to defend my arguments.

Critique 1 = Theory of Reasoned Action Misused, part 1

In the three commercials that will be discussed here, an inanimate object – specifically an alien on a t-shirt, a pirate on a rolling papers package, and a wooden mask hanging on a wall – attempt to convince the teenagers in the commercial that driving while high is a bad idea (12-14). In one of these commercials, an alien that is printed on one of the youth’s t-shirts speaks in a foreign alien-sounding language. Luckily, the commercial provides English subtitles for translation, and the viewer can see that the alien says: “I don’t know about this, guys. Why don’t we just stay here? That party sounds pretty lame. And let’s be honest, driving isn’t exactly a good idea right now. Not a good idea at all!” (12).

All three of these commercials are based on the Theory of Reasoned Action, a social science behavior model. According to this model, one will compare and evaluate his/her attitudes with the subjective norms for a specific behavior before making a decision. A person’s attitudes consist of all of the different beliefs the person has towards doing this behavior, weighted with the strength of each belief. Social norms take into account the attitudes of others, weighted against how highly the individual values each opinion. Before making a decision, one will analyze and compare his/her attitudes with the subjective norms for the behavior, and then will develop a behavioral intention that they will act upon (15-16).

In the previously mentioned commercial, MADD Canada is trying to convince adolescents that driving while under the influence of marijuana is not a good idea by showing you that some people think this action is dangerous – in this case, the alien. According to the Theory of Reasoned Action, if MADD Canada can make teenagers realize that others view driving high as wrong, they can change the subjective norms on driving high. The goal of this commercial is to change these subjective norms, and then in turn change the behavioral intention, favoring a decision to not drive while under the influence of marijuana.

An important aspect of the Theory of Reasoned Action that this commercial did not take into account is how important the attitude and opinion of these inanimate objects would be to adolescents. According to this theory, the importance of the opinion of others is weighted against the actual opinion of others, and all of those weighted opinions collectively make up the subjective norms (15-16). It is unrealistic to assume that teenagers will value the opinion of an alien on a t-shirt, a pirate on a bag of rolling papers, or a wooden mask hanging on the wall. Therefore, adolescents will not take the commercial seriously, and the desired behavior change that MADD Canada hopes to see will not be seen.

Critique 2 = Theory of Reasoned Action Misused, part 2

A major public health concern plaguing the United States is driving while under the influence of alcohol. There is a great deal of attention paid to this issue, especially how dangerous it is and how stupid one has to be to drive drunk, so as a result, drinking and driving is frowned upon. When compared to driving while drunk, driving while high does not have as negative an association attached to it. There is much less media attention dedicated to educating youth about the dangers of driving while high, and it is consequently viewed differently. When compared against alcohol, marijuana is viewed as far less dangerous than alcohol (6-8). A common misunderstanding among teenagers is that driving while under the influence of marijuana is not harmful and does not affect one’s driving (9). It is even thought that marijuana can have some positive affects on driving (8-9). For example, it may be argued that being under the influence of marijuana can help to make one more cautious and/or relaxed, help one to concentrate more, and make one more in tune with the driving task (8). Because of these general misconceptions about the dangers of driving while high, teens need to be re-educated, and need to hear the truth about the effects of driving high.

One of the major goals of MADD Canada’s campaign was to shed light on the dangers of driving while high. As was stated previously, the commercial attempted to deter adolescents from driving while under the influence of marijuana by portraying this behavior as socially unacceptable. However, no explanation as to why this behavior is socially unacceptable was provided. There is no evidence given in this commercial, so the general misconceptions could not be corrected. If teenagers have false beliefs that marijuana will not affect their driving, and these beliefs are deeply rooted, having someone tell them that driving while high is dangerous without providing an explanation will not be effective.

Within this Theory of Reasoned Action, the commercial producers focused on the wrong aspect of the theory. Instead of focusing on the subjective norms, they should have focused on the each individual’s attitude towards this situation. The root of the problem is the misconception that driving while high is not dangerous, and this is a belief that is shared by many adolescents. Therefore, individual attitudes rather than the subjective norms should have been focused on for a more effective commercial. A study by Diane M. Morrison concluded that changing one’s attitudes would have more of an affect than changing the norms towards marijuana use (17). By completely ignoring the attitudes aspect of the Theory of Reasoned Action, the effectiveness of the campaign was greatly affected.

Critique 3 = Commercial May Cause Psychological Reactance

In one of the commercials, a mask that was hanging on the wall of a teen’s room reprimanded him and his friend. This wooden mask shouted:

I can’t believe you boys! I’m so disappointed in the two of you. Why are you so stupid sometimes? Getting behind the wheel? What were you thinking? You’re smoking pot and then thinking that you were going to drive? Get out of my sight and use your heads next time. Stupid! Stupid! Mind boggling. (13)

Due to the demanding nature of the mask, this commercial may be ineffective. Having an unkind, condescending mask telling a teenager what to do may cause this teen to experience psychological reactance. In a study that looked at why the National Youth Anti-Drug Media Campaign didn’t work, the researchers suggested that psychological reactance may have been to blame for the ineffectiveness of the campaign (18). According to the Psychological Reactance theory, if a person feels like his/her perceived behavioral freedoms are threatened or reduced, he/she will react against whatever is threatening those freedoms. This reaction against the threat in order to restore one’s perceived behavioral freedoms is called reactance. This oftentimes occurs when someone feels pressured to accept a certain opinion or engage in a specific behavior (19-20).

In our example, the commercial may cause the adolescents to feel like their freedom to choose whether or not to drive while under the influence of marijuana is being threatened. In response to this perceived threat, the adolescent will try to regain this freedom by reacting against it. One way to restore the threatened freedom is to engage in the forbidden behavior (19). This kind of response is known as the boomerang effect, where the opposite effect that was desired was observed in response to persuasive messages (21). If this were to occur in response to these MADD Canada commercials, not only would the commercial be ineffective, but it would have the opposite effect – you may see an increase in the prevalence of driving while high.

When MADD Canada made this particular commercial, they ignored the sensitivity and mindset of teenagers. Adolescence is often viewed as a time of rebellion. Studies have shown that adolescents are more susceptible to engaging in risky or dangerous behavior (22). Adolescents need to feel autonomous, self-determined and competent, which are three human needs that are considered when discussing psychological reactance (23). If a message is delivered using controlling language, and the content is overly proscriptive, the message may result in the boomerang effect, and cause the opposite behavior to be experienced (23). In this commercial, the mask is yelling at and speaking condescendingly towards the teenagers. This could make the teenager feel like his/her autonomy and self-determination are threatened. When the mask uses negative, blaming words, such as “stupid”, and employs name calling, this could make the teenager feel like his/her competence is being threatened. These are the three human needs that are considered in psychological reactance, and would therefore spark a reaction on the part of the teenager to regain those freedoms. The message and method of delivery in this commercial could be viewed as controlling and condescending, and because of this, will cause the commercial to be ineffective.

Alternative Approach Proposal

In order to create an effective campaign to combat driving while under the influence of marijuana, several things should have been done differently than MADD Canada’s “If you’re high, you can’t drive” campaign. The overall goal of this new campaign, which will be called “Riding High”, will be to change the attitude of teenagers, and to correct the misconceptions that they have about the dangers of driving while high. It will consist of several commercials and advertisements that capture the teenagers’ attention, relay information about the dangers of driving while under the influence of marijuana, and direct them to further educational resources. The educational resources will be easily accessible though a fantastic web site called “RidingHigh.com” that will be extremely user friendly, appealing, educational, and fun. The information that will be available at this web site will range from personal stories from teenagers who have experienced the dangers of driving while high, to scientific research papers that explain why driving high is dangerous, to scary statistics. There will be chat rooms and discussion boards for anyone who wants to speak with others or share knowledge.

The commercials for this campaign will have a scenario that is similar to the following scenario. The commercial will open with a group of teenagers laughing and having a good time while walking towards a car. On the way to the car, they will see Snoop Dog walking by, or some other celebrity who is notorious for smoking marijuana. The teenagers will start talking to Snoop Dog, and will tell him that they’re on their way to McDonald’s. Snoop Dog will reply by saying something like, “Why don’t you boys just take a cab? I don’t know about you, but I have a much slower reaction time when I’m stoned, and I don’t drive my best after a blunt or two. Everyone says that they drive better when they’re high, but that’s bull. Any given time on any given day you will see me smoking, but you will never see me behind the wheel.” The commercial will continue with back and forth, friendly conversation, and it will end with all of them reaching an agreement together that taking a taxi is a better decision than driving their car. At the end of the commercial, the “Riding High” web site will be shown, and it will state that you can get more information at www.ridinghigh.com. Also, to draw teenagers to this website, there will be something that is appealing to the adolescents besides knowledge. For example, it may say, “Come to this web site to enter in for a chance to win two front-row tickets to Snoop Dog’s next concert”. Whoever partners with the campaign to be featured on the commercial or website will also be asked to donate something like concert tickets in order to promote the campaign.

The campaign will also consist of several initiative-taking actions. There will be a major push to lobby for more effective laws against driving while under the influence of marijuana and more effective ways to detect the marijuana levels at road-side pullovers. There will be chat rooms, discussion boards and external links to places where you can learn more information about how you can make a difference. The basic goal is to spread information about the dangers of driving while high to everyone so that it can be seen as a social norm that if you’re high, you don’t drive.

Alternative Approach Reason 1 = Need to Use People With Highly Regarded Opinions

Whoever is delivering the messages in the “Flying High” commercials need to have highly regarded opinions, from the perspective of teenagers. According to the Theory of Reasoned Action, subjective norms are an important part of the decision-making process. If teenagers don’t respect the opinions of the message deliverer, such as in the case of the MADD Canada commercials where inanimate objects were the message deliverers, the commercial will not be effective, and behavior change will not likely be seen. Therefore, we need to find out who it is that adolescents respect, and have them express their opinions on our commercials.
The main character of the commercial will be a role model, who is someone whom teenagers respect, whether it’s a celebrity, a parent, or any other respected individual. If an older role model is on the commercial explaining the dangers of driving while high, teens are more likely to listen and follow that advice than if they were listening to the advice of an inanimate object. It would also be beneficial to have a celebrity who is known to smoke. Our target audience will be young adults who enjoy smoking weed and getting high. If we have a role model who likes to get high, but warns teenagers of the dangers of driving while high, it will be more effective than having a role model who is against getting high in general because the teens will see that they can still get high, as long as they are responsible about it.

It will also be helpful to have other teenagers involved in the commercial. Studies have shown that peer drug use has a large influence on one’s current drug use (24-26). Peer influence is especially instrumental in the start and persistence of smoking marijuana (26). If along with the role model there were teenagers in the commercials, and there was friendly, educational conversation occurring, this would be very effective. In the MADD Canada commercials, the teenagers in the commercials did not say anything – the conversation was very one-sided. In the “Riding High” commercials, there will be a dialog, with the teenagers and the role model discussing the issue and coming to the conclusion together that driving while high is dangerous. Therefore, at the end of the commercial, teenage viewers will see that the opinion of one of their role models, along with other teenagers who are like themselves and their peers, is that driving high is dangerous. Hopefully, this will cause behavior change, favoring not driving while high.

Alternative Approach Reason 2 = Using the Health Belief Model

In the commercials that will be created for this campaign, it is also important that information about why it is dangerous to drive while under the influence of marijuana be provided. As was said before, the root of the problem is that teenagers have a misconception that driving while high is not dangerous. One of the main goals of the commercial should be to change these misconceptions, and thus change the attitudes of adolescents. A model of behavior that may be helpful for this situation would be the Health Belief Model. According to this model, before an individual makes a decision, he/she will weigh the perceived barriers of doing an action with the perceived benefits. When looking at the perceived benefits of performing an action, one will look at his/her perceived susceptibility of getting a condition and the perceived severity of that condition (27-28). In this situation, the behavior would be choosing or not choosing to drive if one was under the influence of marijuana. The perceived susceptibility would be the perceived likelihood that the teenager will experience a negative effect of driving while high, such as getting into an accident. The perceived severity would be how bad the teenager feels these negative effects will be, such as how bad of an accident they get into will be.

When using the Health Believe Model in our particular situation, we want to increase each teenager’s perceived benefits of avoiding driving while under the influence of marijuana. To do this, we need to educate these teenagers on the dangers of driving. We need to inform these adolescents that marijuana impairs one’s judgment, affects concentration and decreases reaction time, and thus increases one’s risk of getting into a car accident if he/she drove while under the influence of marijuana (5). If teenagers understood this danger, their perceived susceptibility of being negatively affected by driving high would increase, since they would know that their chance of getting into an accident would increase. Their perceived severity of being negatively affected by driving high would also increase, since they will know all of the negative affects that come from car accidents. With these new perceptions, the teenagers will see a large perceived benefit of avoiding getting behind the wheel after smoking marijuana, and hopefully they will come to the conclusion that driving while high is a bad idea.

Another way to deter adolescents from driving while high using the Health Belief Model would be to increase the effectiveness of detection of people who drive under the influence of marijuana, and increasing the punishment that goes along with being caught. Researchers need to come up with a valid and effective means of testing whether or not someone is stoned, and then have a harsh consequence for this action. Unlike driving while high, many young people are deterred from driving under the influence of alcohol because the legal penalties are so severe. If an individual has been drinking, in theory they would weigh the perceived barriers and benefits of driving home drunk. Although it may appear more convenient to drive oneself home, the perceived susceptibility of getting pulled over and arrested for driving under the influence of alcohol is high, especially with breathalyzers, random road sobriety checkpoints, and the wild driving that accompanies being drunk. The perceived severity of this offense would be major, since the individual would get charged with a Driving Under the Influence charge. In this case, the perceived benefits of not driving while drunk outweigh the convenience of driving oneself home. Therefore, according to the Health Belief Model, the adolescent will choose to not get behind the wheel.

In our country, it is very difficult for law enforcement officers to detect the amount of marijuana that a person has smoked while doing a road-side pull-over (10). Because of this, there are lots of people who can get away with driving while under the influence of marijuana. There is little motivation to not drive while high if everyone knows they won’t get caught. With an effective detection technique and severe penalties to punish those who drive while high, this may deter many teenagers. Their perceived susceptibility of getting caught would increase and the severity of the consequences of doing this will also increase. A study by McCarthy et al. showed that a majority of adolescents would be deterred from driving under the influence if there was effective roadside drug testing and consequences (7). Therefore, a good way to change the behavior of teenagers regarding driving while high would be to use the Health Belief Model to change individual attitudes.

Alternative Approach Reason 3 = Avoid Psychological Reactance

In this alternative campaign, a large attempt should be made to avoid reactance on the part of teenagers, and especially avoid the boomerang effect. To do this, we need to ensure that the commercials avoid threatening persuasion tactics (20). In the commercial with the mask hanging on the wall, the mask is very threatening and belittling. It even goes so far as to call the adolescents “stupid”. Instead of making the teenagers feel threatened, and taking away their freedoms, the people on the commercial should take a more friendly and positive approach. In our example commercial, Snoop Dog did not tell the children they were wrong. He did not use threatening words or talk condescendingly. He had a friendly conversation with the teenagers, and together, they reached an agreement that smoking while high was wrong.

A method of decreasing reactance would be to include a person on the commercial that most adolescents can relate to. Studies have shown that if people feel like they have something in common with a message deliverer, they are less likely to experience reactance (29). In our example commercial, the viewer and Snoop Dog both like to smoke marijuana – it is what they have in common. When Snoop Dog tells them not to drive while high rather than telling them to stop smoking marijuana all together. He is basically saying, “You know what boys, I like to smoke marijuana, too. We have that in common. Just be responsible about it.” With this kind of approach, the teenagers don’t feel like their perceived freedom to smoke marijuana is affected, and they also feel like they can make a responsible decision when they smoke.

The reason why other teenagers were included in the commercial was because it is someone that the viewer can possibly relate to, so that the chance of reactance can decrease. In the commercial, there will be three or four different teenagers and they will all be a little different. If some of the viewers can relate to one of these characters in the commercial, they will be more likely to listen to the message.

Conclusion

MADD Canada’s campaign to combat driving while under the influence of marijuana was ineffective. When MADD Canada tried to influence adolescent’s subjective norms of driving while high using the Theory or Reasoned Action, they fell short for two reasons. Firstly, they didn’t take into account how teenagers would value (or in our case, not value) the opinion of an inanimate object. They did not include people who are well-respected among teenagers in their commercials. Also, they focused on the subjective norms side of the Theory of Reasoned Action instead of focusing on the attitudes. MADD Canada should have focused on changing the attitudes that adolescents have about driving while high, since the misconceptions are the main problems. MADD Canada also failed to consider that this commercial may cause psychological reactance among the audience of teenagers.

In order to effectively deter teenagers from driving while high, the most important thing that needs to be done is education. Teenagers need to be taught why driving while under the influence of marijuana is dangerous. From here, we can create negative associations between driving and being stoned, and make this somewhat of a social norm. It is also important that the commercials effectively use the Theory or Reasoned Action and the Health Believe Model, and try to avoid any Psychological reactance.

With the prevalence of marijuana smoking among teenagers, the growing leniency of marijuana laws, and the common misconceptions about driving while high, it is important that we start educating youth now. Although it may take a while for everyone to fully understand the dangers of driving high, and it may be even longer before effective detection of marijuana levels and punishment of driving while high are in effect, we need to start somewhere.

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Critique of Anti-Drinking Campaigns That Use Guilt and Shame-Candace Linehan

Introduction

Over one hundred years ago Reverend Henning Jacobson was fined five dollars for refusing the smallpox vaccination in the city of Cambridge. This landmark case, Jacobson v. Massachusetts, is used to demonstrate a state’s ability to use their police power to infringe on an individual’s civil rights in order to protect the greater good. In this case it was an infringement on the first amendment- the right to privacy-by requiring that everyone submit to a vaccination against small pox to avoid a widespread epidemic. To this day we truly do not know the real reasons for Reverend Jacobson’s declination, but they seem to stem from mistrust in the vaccine’s efficacy and general mistrust in the Cambridge Board of Public Health. This case reminds us that resistance to public health initiatives is often neither isolated nor idiosyncratic; but rather can result from a myriad of religious, social and ideological factors (1). In designing a successful public health campaign, one must gain the public’s trust in order to succeed in promoting any type of initiative. For example, during Jacobson’s time there was a grassroots “Antivaccinationism”, movement that stemmed from religious beliefs, concern about civil liberties and skepticism about medicine (1). Furthermore, Jacobson was an immigrant and a Reverend in a minority religion, two factors that may have further alienated him from widespread public health measures (1). Public health and medical officials must appreciate that different social groups view public health interventions from different perspectives; understanding this point is imperative for public health measures to gain acceptance(1).

Today, many anti-alcohol advertising campaigns commit the same fallacy as the Cambridge Board of Health in 1902; they fail to gain the trust of the public. It seems that the creators of these advertisements do not comprehend that attitudes and beliefs of their market. After a ten year decline in alcohol use among American teens, youth alcohol use is again on the rise (2). Alcohol has been linked to nearly 79,000 deaths in the United Stated per year (3) and is an especially significant problem at universities where it contributes to about 1,700 student deaths, 600,000 injuries, 700,000 assaults, 90,000 sexual assaults and 470,000 cases of unprotected sex (4). New research suggests anti-drinking ads that use guilt and shame in their messages actually lead to increased alcohol use (2). This new study comes from Northwestern’s Kellogg School of Management and involved polling 1,200 undergraduate college students about their drinking behaviors. Those students who were exposed to anti-alcohol ads that employed guilt and shame tactics reported that they would be more likely to binge drink (2). The reasoning behind this focuses on something called “defensive processing” when a person reacts adversely to a particular message that provokes guilt and shame (2).

Guilt and shame are common features of PSAs used by the National Institutes of Health and the Centers for Disease Control (2). Their current advertising campaigns about responsible and appropriate alcohol use have failed to gain the trust of viewers and have been shown to cause even more alcohol misuse. The public health and marketing communities expend considerable capital on these campaigns and have long since suspected that they were less effective than hoped, stated Adam Duhacheck, co-author of the Northwestern study (2). The concept of behavioral capability is part of the Social Cognitive Theory, it describes the knowledge and skill to perform a given behavior-in the case of anti-drinking ads it would be the behavior of not drinking alcohol. Shame and guilt advertisements offer no solution for behavioral capability to change drinking habits, they simply show the problem. Campaigns that employ strategies to control excessive or illegal drinking, or even recalling instances when the temptation to engage in risky drinking behavior was avoided may provide a pathway to reducing these undesirable behaviors more effectively (5).

Critique Argument 1- campaigns use guilt and shame to assuage youths from drinking

Shame is the tendency to feel bad about oneself following a specific event. It appears that individuals who are prone to shame when dealing with a variety of life's problems also may turn toward alcohol and other drugs to cope with this emotion (3). Defensive processing explains that an individual reacts adversely to messages that provoke feelings of guilt and shame, this reaction is heightened in those who were already feeling guilt sentiments for other reasons (2) During the Northwestern study, subjects were asked to reflect on a moment of shame or a moment of guilt that they had experienced and then view two advertisements. These ads depicted a person crouched over a toilet bowl after imbibing too much and one that focused on the impact that excessive drinking can have on loved ones, such as a car accident (2) The guiltier the participants looking at the guilt laden ads, the more likely they were to drink and similarly with the shame group. Those experiencing the most guilt or shame were also least likely to think that excessive drinking could lead to negative implications in their own lives, such as getting sick or in a fight,(2) and the consequences only befall other people(5). Furthermore, those who may have already had alcohol related transgressions are particularly vulnerable to the backlash these ads might cause since the shame and guilt message is felt more personally (3).

Successful anti-drinking campaigns need to avoid messages that elicit feelings of guilt and shame. Social Cognitive Theory discusses the concept of reciprocal determinism, that there is an interaction between the person, behavior and the environment where this behavior occurs. When watching advertisements using shame and quilt, viewers completely separate themselves from these situations displayed in the ads since they elicit such an emotional response. The viewers are so upset by the message that they disassociate from the situation leaving the ads message not received. Those experiencing guilt and shame seem to drink more and are less likely to feel that those potential negative outcomes of irresponsible use apply to them. The classic idea that we must shame or guilt the public into behavior change seems to fail when it comes to alcohol use and continued promotion of messages using guilt and shame could cause increased alcohol misuse and further injury.

Critique Argument 2-Campaigns use fear to promote responsible alcohol use

The current dogma in alcohol campaign design seems to stem from the idea that, “if we scare them enough, it’s always going to be a good thing.” (2) Typically ads that use scare techniques cause the viewer to shut down and not process or remember that ad’s message (6). Fear advertising is often used to promote health behaviors such as female self breast examination. A 2004 study investigated the impact that high fear advertising had on college aged women and whether fear motivated them to examine their breasts more regularly. The study found that the accessibility, the retention and recall, of attitudes toward self-examination and breast cancer were faster in a low-fear, high efficacy condition (7). In this experiment, low fear appeal messages were the most effective in attitude accessibility and formation of adaptive behaviors (7). The study showed that fear appeared to negatively impact the health promoting practice for self breast examination.

Arousing fear in individuals in order to spark change is a more complicated process than it was once thought to be. It seems that individuals usually handle fear differently, and also handle fear differently in different situations (7). Furthermore, what causes fear in one person may be ignored by another (7). In some cases fear can be an alluring motivator for those who seek sensation and thrill, especially in adolescents (7).

The Northwestern study shows a far more active response to fear advertising. These advertisements were so relevant to the emotions that the individual was experiencing and so deeply personal that they could not simply dismiss the advertisements; rather, they began to believe they were immune to such consequences that these ads depicted (5). In believing that they are distanced from the consequences shown in the advertisements, the target audience may even drink more after viewing fear ridden ads (6). The research found circumstances where this campaign strategy is not only ineffective, but that it can cause a backlash where people actually drink more than if they hadn’t been exposed the ads (2). Campaign designers need to consider the detrimental effect that using fear advertising can have on the public’s well being, as well as recognize that understanding the target audience’s sentiment about alcohol is imperative for running a successful campaign.

Critique Argument 3-Making misuse of alcohol seem like a youth only issue.

It is useful to consider advertising campaigns aimed at reducing cigarette smoking in youth as they have goals comparable to anti-alcohol campaigns. Similar trends are seen in anti smoking advertising research- some anti-smoking advertisements have an effect of nearly six times that of cigarette advertising (4). The simple visibility, especially in young people, of alcohol can increase the public’s awareness and potentially their use of this substance. Again, showing the backlash effect that poorly constructed, out of touch advertising can have on the youth market. In smoking, as well as in drinking alcohol, advertisements that encourage youths not to smoke, or focus on the short term and long term health effects of smoking are found to be the least effective (4). Also similar to smoking, alcohol is one of the few initiations into adulthood; it symbolizes growing up and maturity, young people are eager to participate in drinking alcohol in efforts to seem more sophisticated and independent (4). Austin argued that a “common mistake in campaign design has been assuming that portraying behavior as bad or unhealthy will cause children to reject it. In fact, the prohibition of behaviors may enhance their appeal to adolescents.

Campaigns that focus on misuse of alcohol strictly as a youth issue can further alienate young people and assure that any anti-alcohol campaign message goes unheeded. Misuse of alcohol is an issue that spans all age, legal and responsible use of alcohol should be marketed to youth as well as adults. Framing smoking as an adult behavior has been shown to make it more appealing to youths (4). Behaviors that are restricted to adults and not adolescents are seen as symbols of adult status and reinforce adolescents’ perception of alcohol use as a sign of maturity (4). Youth may view advertisements showing adults in unpleasant predicaments due to their alcohol use and feel that these situations do not apply to them. Similarly, adults may feel that they are seasoned drinkers and that a hang-over or car accidents are restricted to young, inexperienced drinkers. The defensive processing phenomenon, suggested by the Northwestern study, explains that viewers of these types of advertisements think that they do not apply to them and they are immune to the consequences.

Successful and prudent responsible alcohol use advertising will apply to all drinkers, perhaps even under aged college students. Drinking alcohol on college campuses is a large part social campus life, but blatant and dangerous intoxication does not have to be. Advertising that leaves few viewers out of the target audience can have the most overall impact and be the most recognizable.

Proposed Intervention

In order to assimilate a successful public health campaign to encourage responsible and legal alcohol use, we will need to do considerable planning and research. The Ecological Perspective guides this campaign since it takes into consideration the many factors that influence one’s behavior, including community factors, public policy and interpersonal relationships (8). There will need to be significant formative research done prior to the campaign’s release to clearly define as well as understand the target audience. Focus groups and market research can assure that we can promote our message to them in a way that will be well received. Polling various groups about their perceptions, motivations, skills and their social environment will be key to understanding what impacts their behavior surrounding alcohol use (8). A goal of constructing a campaign that can fit several markets will be useful in targeting different demographics of alcohol users (12). A simple, consistent emphasis of a widely held core value will give any campaign and its message a long shelf life. (12) Contemporary health promotion involves more than simply educating individuals about healthy practices; it includes efforts to change behavior as well as the physical and social environment of communities (8).

I propose a public health campaign with a two pronged approach. First, in the form of television advertisements that show people resisting temptation employing humor and catchy elevator music. These ads would show, for instance: a middle aged woman in a department store with one hundred pairs of shoes, a man at a hardware store with one hundred power drills, a young, college-aged, woman at a luxury store with one hundred pocketbooks, another young man at an electronics store with one hundred new video games-all of these people looking pensively at the beautiful alluring products in front of them. The slogan would read, “You know you can enjoy yourself with just one”, and show the happy person leaving the store, whistling along with the catchy music, carrying one of the products- not over indulging by buying several. The ad would later show the same person in a social situation-be it a sports game, a dinner party, a bar- just having one drink, declining a second, and enjoying them self. The ads would remind people that they have the power to resist temptation and show them that they resist other temptations already.

The second part of the campaign would involve partnership with local news broadcasts and an effort to report frequently and consistently on local mishaps involving alcohol. These mishaps could involve motor vehicle accidents, arrests, destruction of property, rape and even fatalities. Honest and open reporting of these local events can raise awareness of the significant impact misuse of alcohol has on the community and its members.

Defense of Intervention: Section 1- Offer positive strategies to control alcohol use- no more shame and guilt

The current trend of using shame and guilt in advertising is not adequately reaching the target audience and potentially exacerbating the problem they aim to fix. Applying the ecological perspective can help emphasize the interaction between; and the interdependence of, factors within and across all levels of a particular health problem (8). A successful advertising campaign needs to account for behavior effecting and being affected by many factors. In the case of alcohol, it seems making people feel shame and guilt about excess drinking fails to help them drink in moderation since it misses the root of why people are drinking in excess to begin with. The Northwestern study gives an example of a way that we can get information from people about their beliefs and emotions about alcohol. Randomized control groups would be incredibly helpful in assuring that the campaign appropriately reaches and respects its target group. Formative research about alcohol beliefs and habits of many different groups can assure that an advertising campaign addresses responsible alcohol use in a way that resonates positively with the public. Armed with information about what effects decision making in those who use alcohol, a campaign could begin to promote behavioral changes specifically designed to support responsible alcohol use.

Rather than use shame and guilt, the proposed campaign uses light humor interlaced with real life situations that appeal to a wide demographic. By enticing the consumer’s sense of independence and prudent decision making, these ads can empower their audience to drink responsibly.

Defense of Intervention: Section 2- Temper scary reality with the idea that it can be avoided

Duhachek offers the tactic of “using the carrot along with the stick” to reduce irresponsible alcohol use (9). In essence, he is suggesting teaching the solution along with discussing the problem. Having coverage of fatalities, arrests, injuries and destruction of property on the news may be a way to honestly show the public the possible repercussions of alcohol abuse. News coverage is typically unbiased, matter-of-fact and open, eliminating any feelings of judgment a viewer might have from the news anchor. Data exists suggesting that news coverage of drinking behavior and negative outcomes related to intoxication can reduce drinking among youths (12). Whether or not this reduction is related to heightened awareness of this issue to policy makers or heightened prevalence in the minds of youth is uncertain.

A partnership between local news stations and this ad campaign would ensure consistent reporting and advertising. Quietly and habitually reporting on local fatalities and injuries result from misuse of alcohol has the potential to raise awareness of the serious consequences of intoxication.

The proposed quick and simple public service announcements during this time can help drive home the importance of responsible alcohol use. These ads are especially useful when shown in conjunction with the reality and consequences of alcohol misuse shown on the news. According to the ecological perspective, what people know and think will affect how they act (8). Attempting to change the way people think may be a challenge, providing real facts and stories about tragedies surrounding alcohol abuse will increase public knowledge about the prevalence and gravity of alcohol abuse.

The key to promoting responsible alcohol use is empowering the public with the tools to resist imbibing excessively. Helping the target audience recall an instance when they resisted the temptation to engage in risk drinking behavior may provide a pathway to reducing these undesirable behaviors more effectively (9) Promoting recalling positive memories may be a way to influence public thinking and help people become more proactive in their reasonable alcohol consumption.

The proposed advertisements would show people of all demographics able to resist non-alcohol as well as alcohol temptations. These PSAs begin with the general idea of restraint in spending money, but tie in the idea of restraint in drinking alcohol. Financial restraint, especially in our current economic climate, is a common theme in magazines, news programs and advertisements; nearly every consumer can recall a time when for one reason or another, they had to choose to spend less. By beginning the advertisements with this usual and nonjudgmental premise those who do struggle with alcohol will not feel as judged and may be more receptive to the message. Finally, the PSA’s message is simple and ubiquitous, making it easy to understand and easy to remember-just spend/drink less, you’ve done it before, you can do it again.

Defense of Intervention: Section 3 – Make responsible and legal alcohol use an issue that spans all ages.

Public health campaigns have long attempted to get Americans to stop smoking, not to smoke less, but rather to quit entirely(8). An important aspect about alcohol that sets it apart from cigarettes is that it has a historic place in our society (8). Alcohol is often used to celebrate, relax, unwind and share with friends and loved ones; moderate long term use is widely acceptable. Nearly 90% of those who consume alcohol do so safely (8). There is no safe amount of tobacco, yet some studies have shown that certain amounts of alcohol may be beneficial to one’s health (8).

The most successful anti tobacco advertisements have centered on revealing that tobacco companies have no regard for the wellbeing of their costumers and are purely out to make a profit. The tactic of vilifying the industry, which has been quite successful in anti-tobacco campaigns, may not generate the same type of response from viewers when concerning the alcohol industry. There is less ammunition to generate outrage and anger towards the alcohol industry then there is for the tobacco industry. These advertisements vilifying the tobacco industry are also targeted specifically at young people to try to get them to stop smoking or never start; the ads had less appeal to adult or long time smokers.

Social Cognitive Theory touches on the importance of observational learning as a determinate in behavior change (12). Observational learning is done by many types of audiences, without regard for age. An advertising campaign that showed a person taking part in an easily reproducible action, with a positive outcome, could encourage viewers to take the same action. In this case, the action would be modeling the choice to exercise restraint.

A campaign with a simple and consistent message can be tailored to target different demographics. Such a campaign will be highly visible and employ less outrageous tactics, alienating less and encompassing more of the public. The proposed PSA would show several different types of people, young and old, but maintain the same message. Having the same message of restraint and responsibility shown in advertisements with different people and in varied situations will keep the message easily recognizable and applicable to more viewers.
An ad campaign with a strong core message can be translated to a variety of media and can target varied audiences with little alteration. Showing a still frame of the PSA in magazines or at bus stations with the slogan could trigger the viewer to remember the entire TV ad, again reiterating its message. One aspect of this campaign that would never change would be the background music; this would further solidify the pervasive quality of the advertisements. All of the actors would leave the store whistling the song, perhaps when a viewer heard that song again the message would return to their thoughts. A catchy tune can also linger with a listener for hours, giving the message in the PSA the same staying power.

The focus of an advertisement should not be that certain people need to drink less or not at all; it should be that everyone needs to exercise some restraint. An additional focus on enjoyment rather than excess will especially ring true with many viewers. The Ecological Perspective assumes that knowledge is necessary for, but not sufficient to produce most behavior changes (12). Increased news coverage of the repercussions of alcohol misuse combined with a public health campaign that focuses on self-efficacy and empowerment has the capability to impact health beliefs and behaviors. Research on the target audience of this public health campaign will assure that it addresses alcohol use at many levels, not just with the individual. Not only will the proposed responsible alcohol campaign empower individuals to make good decisions about their alcohol use, it will target the community at large by offering a new social norm (12). These advertisements will show different types of people that are able to drink responsibly in hopes to support all the market audience’s efforts to reduce the temptation to overindulge. By studying campaigns efforts that have failed, such as those who target only one demographic, employ fear tactics or use messages to induce feelings of guilt and shame, this campaign can avoid those pit falls and market a health promotion message effectively and respectfully to a varied market audience.

REFERENCES

1. Parmet W. Individual Rights versus the Public’s Health-100 years after Jacobson v. Massachusetts. New England Journal of Medicine 2005; 352:7 652-654.
2. Drummond, K. Study: Anti-drinking Ads May Backfire.AOL News, March, 5,
2010.
3. Duhacheck, A. Emotional Compatibility and the Effectiveness of Anti-drinking Messages: A Defensive Processing Perspective on Shame and Guilt. Journal Of Marketing Research April 2010; 47:2 263-273
4. Nauert, R. Anti-drinking Ads Often Backfire. Psych Central, February 24,2010
5. IU News Room. Study: Anti-drinking Ads Can Increase Alcohol Use. February 24, 2010
6. Seigel, M. Mass Media Antismoking Campaigns: A Powerful Tool for Health Promotion. Annals of Internal Medicine July 1998; 129:2 128-132.
7. Mayfield, Z. Fear Appeal Messages and Their Effectiveness in Advertising. Associated Content, April 2006.
8. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2 Bethesda MD: National Cancer Institute, 2005, pp.9-21.
9. Behavioral Health Central. Study Shows Guilt-Based Anti-Drinking Ads May Actually Increase Binge Drinking. March 12, 2010.
10. Preidt, R. Anti-Drinking Ads That Engender Guilt May Not Work. Health Day, March 5,2010
11. Yanovitzky, I. Effect of News Coverage on the Prevalence of Drunk-Driving Behavior: Evidence from a Longitudinal Study. Journal Of Studies on Alcohol May 2002 342-351
12. Poor, Nancy. Ingredients of a Successful Advertising Campaign: focus, flexibility and consistency. Franchising World. November 1, 2002.

Why Abstinence-Only Education Doesn’t Work and Why Federal Policy Needs To Change—Kelly Walker

Abstinence-only education has been federally funded under the Social Security Act since the Clinton administration passed welfare reform in 1996. Beginning in 1998, and continuing through today, $50 million a year has been dedicated to abstinence-only education programs throughout the nation that try to impress on adolescents that “abstinence from sexual activity outside of marriage [is] the expected standard for school-age children.” (1,2) Abstinence-only education is rooted in eight elements, commonly referred to as the A through H definition. Examples of some of the elements include:
• teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems
• teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity
• teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects

If states accept federal dollars to teach abstinence-only education, they must follow the A through H rules in order to be compliant with federal abstinence-only education rules. States that accept the federally funded dollars must also provide 3 dollars for ever 4 federal dollars received, nearly doubling the nation’s monetary investment in abstinence-education. (3)
Despite the heavy federal and state funding of abstinence-programs, numerous studies conducted on their efficacy have continually found that abstinence-only education has no quantifiable effect on teenage sexual behavior, and may actually increase the incidence of risky sexual behavior in adolescents. (3) Analyzing abstinence-only education through the lens of social behavioral theory can help to explain why abstinence-only programs are undoubtedly failing contemporary adolescents.

Sexual behavior is NOT rational

Most of the leading social science theories applied in public health interventions assume rationality in decision-making concerning personal health. Abstinence-only education does the same. The Health Belief model, the Theory of Reasoned Action, and the Transtheoretical model all propose a similar notion; that is, as long as someone has a positive attitude towards a behavior and believes the behavior will positively impact their life, they will carry out that behavior, as long as the benefits outweigh the costs (4). This idea has been widely criticized by today’s social scientists, who have posited that these models do not take into account an individual’s personality traits, demographic characteristics and other factors which may influence their behavior (5, 6).

The benefits of abstinence among adolescents are great—it is obviously the most effective way to completely halt the transmission of STDs and HIV, and prevent teen pregnancy completely. Unfortunately though, the decision to have sexual intercourse is one which adolescents typically do not approach by rationally weighing the costs and benefits, as described in the socio-behavioral theories above. Instead, adolescents are much more influenced by other factors, involving their peers, their environment, and their own biology. (7-10)

Adolescence is a time of tremendous change in a young person’s body. In the past most of adolescent risk-taking was attributed to new hormones flooding the body during puberty. But recent research suggests that adolescents’ inclination for dangerous behaviors actually stems from a complex combination of hormonal changes and ongoing brain development. (11) Parts of the adolescent brain which control emotional function are not completely developed by adolescence, and this can lead even intelligent teenagers to act irrationally when faced with serious, and potential dangerous sexual situations. (11)

Considering this, abstinence-only education’s focus on the rational benefits of restraining oneself from sex is bound to fail. How can adolescents possibly be expected to approach sex rationally, something that most adults can’t even do, when their brains are not fully developed, and under the influence of powerful new hormones?

No Consideration of the Environment

Another drawback of abstinence-only education is that it expects adolescents to always say no to sex in every situation. As noted above, the goal of abstinence-only education is to express to adolescents that abstinence is the only acceptable alternative to marital sexual relations. This view is extremely restrictive and fails to take into account both the immediate environment in which an adolescent may be attempting to have sex, and more abstractly, the environment of an adolescent dating relationship.

The socio-ecological model stresses the importance of considering environment when studying patterns of behavior. (12) Many people understand how physical environmental factors affect health—pollution in the air or contamination in a water supply can make people sick because of the ingestion of dangerous chemicals. But the socio-ecological model posits that health risks are also found in the social environment. (12)

In adolescence, different social environments—the high school classroom, the after-school program, the Saturday night party, or the varsity soccer game—all hold different health risks and opportunities. The common thread connecting all of these environments is the extreme influence that peers have on adolescents in any one of these environments. Adolescents examine the behavior of their peers and replicate their behavior in an effort to learn what they believe is correct socio-normative behavior. (13)

Although all adolescent behavior is somewhat influenced by peers, each adolescent is unique and friends and peers will have varying degrees of influence on each individual. A study has found that the more likely an adolescent is to peer influence, the more likely they are to participate in deviant behavior—including drug and alcohol use and risky sexual behavior. (14) Some of the risk factors that make an adolescent susceptible to peer influence are: younger age, family dysfunction, and depression. (15, 16)

Considering this fact, we can see that whether or not an adolescent is around friends at the time of risky sexual behavior, or if the potential sexual partner is someone the adolescent wants to impress, this can have a large effect on their ability to restrain from sexual contact. The sexual encounter does not occur in a vacuum, like abstinence-only education would have us believe.
Further, some teens are having sex within the environment of a healthy monogamous relationship, in which they are protecting themselves from pregnancy and sexually transmitted disease through condoms (or protecting themselves exclusively from pregnancy through another form of birth control). The 1995 Survey of Family Growth found that among teenagers who had sex prior to age 18, 52% of teens who had just met their partner did not use contraception, while only 24% of those in serious relationships did not use contraception. (17)

Although some studies link adolescent relationships to depressive symptoms (18), other surveys have found that adolescents in healthy, steady relationships have reported higher self-esteem. (19) It has further been suggested that healthy relationships during adolescence can offer opportunities for growth and fulfillment that can improve one’s health and happiness and increase resilience in later relationships. (20) If this is true, it may benefit adolescents to experiment with forming romantic relationships, and experiencing sexual intercourse, as a precursor to forming a healthy emotional and sexual relationship or marriage later on in adulthood.

Fails to promote self-efficacy

Many of the traditional socio-behavioral models include an element known as self-efficacy. Self-efficacy is defined as a person’s personal belief in his or her ability to complete an action. (4) Self-efficacy is important, because if a person has a high degree of self-efficacy they will be more likely to carry out a certain positive behavior, or at least attempt to carry it out, due to their increased confidence. Conversely, someone with a low degree of self-efficacy may put off attempting a positive change in health behaviors, because it will seem futile due to their low amount of personal self-confidence. Both the Health Belief Model and the Social Cognitive Theory include self-efficacy as an integral part of their behavior change models. (4, 21)
Albert Bandura considered self-efficacy so important that he updated his original Social Learning Theory with the addition of self-efficacy, and named it Social Cognitive Theory. Bandura posits that self-efficacy is the most important part of this model—and believes that an individual’s perceived self-efficacy has an influence on an individual’s coping behavior, level of psychological stress reactance, degree of resignation and despondency, and motivation to achieve personal or career goals. (22)

Abstinence-only programs fail to teach and promote self-efficacy to adolescents by avoiding educating young people about their options involving sexual intercourse and relationships. Because abstinence-only education stresses that abstinence is the only 100% effective way to avoid sexually transmitted diseases and pregnancy, it robs those students who aren’t practicing abstinence of self-efficacy by increasing self-doubt in their own attempts to avoid the negative outcomes of intercourse.

For example, if two adolescents are engaging in sex, but using condoms each time, they are protecting themselves at nearly the same efficacy rate as abstinence (condoms, when used correctly work 98% of the time). (23) But if these two young people are being taught at school that abstinence is the only truly effective, and truly acceptable, way to avoid negative outcomes of intercourse, then they may start to feel shame and doubt about their own personal experience with contraception and condoms.

Unfortunately, abstinence-only education not only advocates solely for abstinence, but also undermines the use of effective contraception. Since federal guidelines restrict abstinence-only education to endorsing abstinence outside of marriage, contraception is only mentioned extremely briefly and only mentioned in terms of failure rates. (24) The highlighting of negative information about condoms, the birth control pill, and other forms of contraception by trusted adults can seriously skew an adolescent’s belief in their effectiveness, and consequently, take away an adolescent’s confidence and self-efficacy concerning using contraception as a part of safe sex.

By failing to consider the absence of rationality in adolescence, by failing to consider the environment in which adolescents have intercourse, and by robbing adolescents of their self-efficacy, abstinence-only education has failed contemporary adolescents. By failing to trust adolescents to engage in sexual relations safely, the federal government has missed an opportunity to help foster healthy sexuality in the next generation of Americans.

The Solution: Comprehensive Sex Education

The best alternative to abstinence-only education is a federal policy mandating that comprehensive sexuality education be taught in classrooms across the country. Comprehensive sexuality education includes, unlike abstinence-only education, the true success and failure rates of various contraceptive devices, the endorsement of healthy relationships (even those which aren’t marriages), and the most accurate and up to date information on preventing unwanted, unhealthy outcomes of sexual activity, including sexually transmitted infections and pregnancies.

A federal policy endorsing teaching only comprehensive sexuality education would replace the Title V, Section 510 provision in the Social Security Act supporting abstinence-only education. This policy’s main purpose would be stated as educating adolescents about their sexual health and providing them with relevant tools with which to avoid possible negative outcomes of sexual relations.

Accepting the irrationality of adolescence

Unlike abstinence-only education’s supposition that adolescents should be able to use rational thought and adhere to abstinence at all times, the new federally-mandated comprehensive sexuality education curriculum instituted would acknowledge the irrationality of adolescence, as well as the irrationality of sex, and deliver its curriculum in consideration of these facts.
Adolescents, for the most part, are not able to make rational decisions due to the fact that their brain, especially their frontal lobe, is still in the midst of developing. Because of this, adolescents are far more likely to respond impulsively, rather than rationally, in emotional situations. (25) Sex, especially first time sex, would certainly be considered a highly emotional situation for an adolescent. Considering this, activities like sexual communication role plays are especially important.

Studies have shown that communication between an adolescent and a potential sexual partner is an essential part to having a safe and enjoyable sexual experience, because it allows an adolescent to better understand their potential partner’s past sexual experience, health and disease status, and desires in a sexual relationship. (26) But due to the implicit impulsivity of adolescents, this conversation is often bypassed, and adolescents increase their risk of contracting a sexually transmitted infection or getting pregnant accidentally.

Role plays are a way for adolescents to practice communicating about sex a situation which is not as emotionally charged as a true sexual experience. The Centers for Disease Control and Prevention’s list of best-evidence sexual health interventions has found that programs that include role play elements significantly influenced adolescents’ sexual behaviors. Youth that were in interventions that included role plays were found to have higher rates of condom use, lower rates of sexual initiation if they weren’t already sexually active, and lower rates of reported unprotected sex. (27) This suggests that role plays might be a mitigating factor in correcting for the irrationality of teens when it comes to sexual intercourse.

For this reason, the comprehensive sexual education program that will be federally mandated will include opportunities for adolescents to role play in order to practice the skill of negotiating with a potential sexual partner, and providing adolescents with the confidence to practice safer sex.

Considering Environmental Factors in Adolescent Sex

The suggested comprehensive sexual education programming would also be more effective than abstinence-only programming when considering environmental factors that affect adolescent sexual relations. An issue which is not touched upon in abstinence-only education, but would be included in the federally mandated comprehensive sexually education classes is the use of substances among the teenage population and its connection to sex.

According to the 2007 Youth Risk Behavior Survey, 22.5% of currently sexually active high school students had drunk alcohol or used drugs before their last sexual intercourse. (28) This suggests that for many high school students sexually activity is closely linked to substance use. This is likely due to the nervousness many adolescents experience while attempting sexual intercourse, and the ability to relax with the aid of substances such as alcohol or marijuana. It also suggests that sexual intercourse is not occurring in a vacuum, but instead in a certain environment in which adolescents can get access to alcohol or drugs, like a party.

Considering this, it is highly important that alcohol and drug information be included in the federally mandated comprehensive sexual education program. Topics which would be discussed in the curriculum would include not only statistics on substance abuse affects one’s sexual health, for example how heavier drinkers have a higher number of partners (29), but also would include a complete overview of drugs and alcohol in general. Teaching adolescents about the immediate dangers of drugs and alcohol outside of their sexual lives, and then synthesizing the information with the dangerous effects it has on their risk for sexually transmitted diseases and possible pregnancies would strengthen the argument against use at all.

Role playing would also be initiated during the drug and alcohol use part of the sexual education curriculum, and would have teenagers practice how to negotiate being offered drugs and explore what they might do if they found themselves under the influence of drugs or alcohol and being pressured to have sexual intercourse.

Promoting Self-Efficacy through Empowering Adolescents

The last and most important subject that would be addressed in the federally mandated comprehensive sexual education program is the self-efficacy of adolescents. One of the most important things that public health can do for adolescents is to support them with both relevant educational programming and with as many resources as possible to make them self-sufficient about keeping themselves healthy. This is especially true when public health is attempting to address a subject as intimate as sexual health. Adolescents faced with choices to make about their sexual habits will often make those choices alone, as the choice to have sex with someone is an extremely personal decision.

In order to make sure that adolescents make healthy decisions we have to educate them on how to have sex safely, and also to be honest about how safe each method of contraception is. The unique benefits and risks of the birth control pill, the condom, the intrauterine device or the Depo-Provera shot should all be discussed in relation to how they would work in a certain adolescent’s life. Special attention should be paid in the comprehensive sexual education program on teaching teenagers how to get and use condoms, as they are the most likely contraceptive device used during adolescent sex (with 49 percent of men, and 45 percent of women age 15-19 using condoms at their first sexual experience). (30) Programs that make this information explicit to adolescents have been shown to increase the number of students who felt confident about both obtaining and using condoms. (31) If students feel confident about their abilities concerning condoms, they are more likely to actually use them during intercourse, and subsequently less likely to experience a negative outcome related to sexual intercourse.

Conclusion

Abstinence-only education has sadly left many high school students across the country in the dark about their sexual health. By modifying federal policy to mandate comprehensive sexual education be taught in all high schools across America, we could correct information adolescents have been given about failure rates and empower them with the information they need to have safe sex. By using role plays as part of this education, we will appropriately take into consideration the irrational nature of the adolescent brain and their sexual lives. And by synthesizing alcohol and substance abuse information with sex information, we will be acknowledging the fact that adolescent sex hardly occurs in a vacuum, but instead in sometimes dangerous and emotionally charged environments. This comprehensive curriculum would serve adolescents better than abstinence-only programs that simply tell adolescents to wait; it would truly prepare adolescents to make their own decisions regarding sex, and to gain the self-efficacy to negotiate sex with a partner, understand why using substances while having sex is dangerous, and empower them to use contraceptive devices, all to the end of more emotionally and physically safer sex.

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