Issues with Parental Refusal of Vaccinations: Critiques and Recommendations using Social Science Theories -Mary Gaeddert

Introduction
Vaccinations are widely viewed as one of the best preventive measures in public health that have dramatically reduced the burden of disease. However, not everyone shares that opinion, and there is a vocal group of people that openly question and criticize vaccines. As a result of this distrust of vaccines, there has been a growing number of parents who are refusing some or all of the recommended vaccinations for their children.
A large part of this debate is focused around the claim that the MMR (measles-mumps-rubella) vaccine causes autism. This was based on a study published in 1998 by Andrew Wakefield which sparked an international crisis of confidence in the safety of the MMR vaccine. Although this paper has been widely discredited by the scientific community and even retracted by the Lancet (1), the damage has been done to the public perception of vaccine safety.
The refusal of some parents to have their children vaccinated has led to a growing number of children who are susceptible to vaccine-preventable diseases. This has led to weakening of herd immunity and more outbreaks of measles, mumps, and other vaccine-preventable diseases. A current example of this is the outbreak of mumps going on in the New York-New Jersey area; over 1500 cases have been reported since June of 2009, and is the largest mumps outbreak in the US since 2006 (2).
The issue of parental vaccine refusal and outbreaks of disease is a public health problem that had been receiving more recognition from medical and public health professionals recently. One example is a study done looking at a outbreak of measles in San Diego in 2008 in which the authors discuss the role of the intentionally under-vaccinated (3). This paper will critique the existing approach to this public health issue and provide recommendations for an alternative approach focusing on three elements: framing of the issue, comprehensive national response, and the doctor-parent interaction.

Critique 1: Framing the Issue
People often act irrationally, and one example of this irrationality is the concept of “framing”: the way in which the issue is framed, or presented, has a huge effect on how it is viewed and accepted. Two equivalent outcomes of a decision can be presented in either positive or negative terms, and the positively framed messages will be more effective than negatively framed ones for increasing prevention behaviors (4). Framing has been found to have a biological basis, which shows a key role for the emotional part of the brain in mediating decision-making (5).
The way that vaccinations are currently framed by the majority of medical and public health professionals is that vaccines are wonderful, have minimal risks, the benefits far outweigh any risks, and that all children should get every recommended vaccine on schedule from their doctor. However, the anti-vaccine movement frames the issue in a much more negative light. Many parents are focused on the harm posed to their children by vaccines which they do not feel are safe.
A study was done analyzing the growing number of anti-vaccination websites, and reveals the main concerns and arguments. Anti-vaccine groups avoid using the term “immunization” because they do not believe that vaccines provide immunity. Every site reviewed in the study made claims that vaccines are poisonous, cause illness, and weaken the immune system. They assert that vaccine-preventable diseases are trivial, and do not acknowledge the serious complications of these diseases. Alternative and naturopathic medicine are common themes. Claims of conspiracy theories are also common themes. Most of these websites reject the scientific data supporting the safety and efficacy of vaccines, showing an overall lack of trust in the scientific and medical establishments. This lack of trust in published research, rejection of expert opinion, and fear of conspiracies in the system reveal how large the gap is in framing the issue of vaccines (6).
This study also shows how opposition to vaccines has created a counter-culture movement, where the social norm is rejection of vaccination and the traditional medical establishment. Several social-behavioral models, including the Theory of Planned Behavior, used the component of social norms. This can be described as subjective norms that predict whether a certain behavior, like vaccination, will be approved or disapproved by the social group influencing an individual, such a parent (7). This use of social norms accounts for the social context surrounding someone’s decision making. So if a parent is influenced by this anti-vaccination movement, social norms may play a role in predicting whether or not the parent will vaccinate their child. Because this movement frames the medical establishment and doctors in general and not trustworthy, it may have the additional impact of negating any positively framed messages about vaccines that come from the child’s pediatrician (6).

Critique 2: Lack of National Level Response
One of the main criticisms of this paper is that there has not been a coordinated response on the national level that is publicly visible. In general, the topic of vaccination, framed in a positive way from public health groups, is generally not visible. One of the exceptions has been during the H1N1 flu pandemic when a large effort was made to promote flu vaccination to the general public, and was accompanied by reassurances about the safety of the flu vaccine.
The current coordination of vaccination issues is led by the Centers for Disease Control and Prevention, which publishes information and recommendations (www.cdc.gov/vaccines). An example of a current public health effort relating to vaccinations is the “Project Tomorrow” campaign led by the American Academy of Pediatrics; this is a national education awareness campaign designed to promote the importance of vaccines and encourage parents to talk to their doctors.
Outbreaks of vaccine-preventable diseases, such as those mentioned in the introduction (3), are often handled by the local public health departments. The focus in those situations is to control the outbreak immediately, and there may not be funding or resources available to do large-scale educational campaigns. The only public communication about the outbreak may be press releases made after the outbreak has started (2). This approach to situation waits until an outbreak begins, and reacts to it, instead of working more proactively to prevent outbreaks.
In contrast to the relative silence of public health officials on vaccine safety at a national level, the media is constantly reporting the opposite side. The media has an influential role during vaccine scares, and the influence of press coverage has been found to effect parental acceptance or non-acceptance of vaccines (4). A brief glance through news headlines on the topic of vaccines will show that media outlets have picked up on the negative framing of the issue. Most stories talk about controversies in vaccine safety, like how vaccines are dangerous and cause side-effects. Celebrities go on talk shows describing how the MMR vaccine caused autism in their child. These stories are sensational and make strong emotional appeals, and while lacking the rigor of scientific research publications, have a stronger impact on public opinion.
So, as a result of a steady stream of negative information coming from the media, and not very much positive information coming from public health officials, the public associates vaccines more with risks of receiving the vaccine itself than with the benefit of disease prevention. Another factor at work is that many of the diseases prevented by vaccines are no longer common, so many parents today have not seen any active cases of measles or mumps. This leads to an underestimation of the severity of the vaccine-preventable diseases, many of which can be fatal or leave the child with permanent disabilities (8).
There are also social-behavioral factors at play. The availability heuristic describes how people tend to infer general truth from a vivid example. Perceived risk often does not align with actual risks because people judge the likelihood of something happening based on how easily and example of it comes to mind (9). Another piece of irrationality at work is the law of small numbers: people view a small sample randomly drawn from a population as highly representative, and are over-confident that the conclusions based on small samples are valid (10).
This explains why powerful stories that can be easily recalled are more compelling that statistics and data. And why one heart-wrenching story on the news about a child who died after receiving a vaccine seems to be representative of all children at risk for vaccine side-effects. While it would seem rational to present numerous studies on the the safety of vaccines and rarity of severe adverse events, it is hard to counter these few emotional examples with volumes of scientific data. In contrast, stories are not published every time a child is vaccinated and has no side effects, or every time a case of disease is prevented through vaccination, so the numerous benefits are not readily available for people to draw on.

Critique 3: Reliance on doctor-parent education
Currently, the main response to the issue of vaccine refusals is to encourage parents to talk to their doctors when they have any concerns, and for doctors to thoroughly educate parents about the risks and benefits of vaccines (11). This paper argues that too heavy a reliance is place on this as the main solution to vaccine refusals.
As has been already shown, there is a growing anti-vaccine movement that is characterized by mistrust of doctors and the medical profession. Simply telling doctors and parents to talk over the issue without any other guidance is not sufficient.
The theory of psychological reactance may be helpful in understanding the dynamics of the doctor-parent interaction in these situations. This theory explains how individuals value their sense of freedom and self-efficacy, and will react when social pressures threaten this. Experiments supporting this theory have shown that when attempts are made to restrict a person’s freedom, these attempts often result in them doing the opposite behavior; attempts to limit freedom will actually increase the likelihood of someone doing the opposite (9). Applying this theory to the doctor-parent interaction, it can be seen that if a parent feels as if the doctor is pressuring them to accept vaccines for their child, the parent may react with the opposite behavior and refuse vaccination.
Many of the parents who decide to opt-out of recommended vaccines tend to place a high value on “natural living” and alternative medicine, and distrust the “westernized” medical approach. There has been more emphasis on taking a more active role in making health decisions, and parents want to make an active decision about whether or not to vaccinate. This requires more time and involved discussion with the doctor. They are also generally more educated about vaccines and health in general. It is not enough for a doctor to simply tell a parent that they should vaccinate their child because the doctor says so (12). This kind of approach may trigger psychological reactance, resulting in the parent refusing the vaccine, and possibly other health care related messages.
The issue of parents refusing vaccines for their children and refusing the recommendations of their doctors has gone so far that some doctors will dismiss these families from their practice. This raises many legal, ethical, and public health concerns. One of the ethical concerns is in not respecting the autonomy of the parent to make medical decisions for their children. Dismissing such families from an individual medical practice cuts off the lines of communication between the doctor and the parent, and also cuts off any possibility that a solution can be worked out. As a result, parents who are dismissed from practices may become more distrustful of the medical system and drop out of the formal health care system altogether (13).
Another social-behavioral factor that be behind parents’ concern over vaccine safety is omission bias. This is a term used in medical decision-making that describes how people are more likely to accept the risk of passively not doing anything, over the risk of actively choosing an intervention. Experiments have shown that people acting the role of the parent were less likely to choose the active treatment, while those in the role of medical professionals were more likely to choose the active treatment to maximize the patient’s survival. (14). So it may be easy for doctors to objectively weigh the risk and benefits, and recommend vaccination; but from the other perspective it may be more difficult for a parent to actively choose to do something that carries a risk, however small, to their child. Parents will feel responsible for harming their child if the vaccine has side-effects.

Proposed Intervention
The following recommendations are being made to address the problems highlighted in the above critique of the issues surrounding parental refusal of vaccinations. The main goal is to take back control over the issue of vaccinations from the anti-vaccine movement. The public health response has been mainly reacting to criticism in the media and responding to outbreaks caused by falling levels of immunity.
This paper proposed an intervention to take a more proactive role in leading the debate on vaccine safety and effectiveness. Key parts of the intervention will be to reframe the issue, and develop a visible public information campaign specifically designed at addressing the fears of parents that vaccinations will harm their children, especially the MMR-autism link that is so commonly mentioned in the media.

Defense 1: Reframe the issue
In order to restore public confidence in vaccines, the issue needs to be reframed. When a large number of children are intentionally un-vaccinated, they are at risk individually, but they also put all the other children in their school and community at risk due to waning herd immunity. There are some children who are too young to receive immunizations, and others who cannot be vaccinated because of specific medical reasons (3). The reason it is necessary to maintain high immunization levels in the population is to create herd immunity, so that those who are not able to vaccinated will still be protected.
The issue can be re-framed in terms of collective responsibility. American culture is predisposed to individual explanations, and in order to reframe public issues, it is necessary to shift the focus to balance out individual and group outcomes (15). One parent’s decision to vaccinate their child will protect not only their own child, but it will also protect all the children in their classroom. To look at this the other way, one parent’s decision to not vaccinate their child will put all the other children at risk. While a parent may be comfortable making this decision for their own child based on individual beliefs, they may not feel comfortable when those beliefs may be harming other children who are vulnerable.

Defense 2: Develop a Comprehensive national response
The public health sector must actively, and publicly, engage this issue on a national level. Interventions must be developed to address the concerns over vaccine safety on a larger scope than just relying on the individual doctors talking to parents. One way to do this is to launch a national media campaign. This campaign must be more than just simply an educational campaign that warns people about the risks of disease, and tells them they should be vaccinated. As already discussed, this approach may raise psychological reactance, and be drowned out in the media by the sensational stories of side-effects caused by vaccine conspiracies.
A national media campaign should be based on the principles of advertising and marketing theory, creating a public health “brand”. A brand is a set of associations linked to a name and associated with a product or service. Public health brands aim to change health behaviors and knowledge to improve overall health outcomes (16). The brand can be specific to vaccines, or can include other health behaviors, such as other routine prevention measures for children.
The campaign should emphasize the number of children who are vaccinated,and who do not get sick or have any side effects. It should also include the emotional appeal
of saving children's’ lives. This can be done through emotional stories about how much doctors care about health of children because they are parents too, and because they want their children to be healthy, they choose vaccination. The campaign can also appeal to the protective side of parents, by using the reframed issue of vaccinating your child to protect other children who are not able to be vaccinated. Messages on the severity of vaccine-preventable diseases can included, but without over-emphasizing the fear component. For example, parents whose un-vaccinated children were infected during recent outbreaks can talk about how scary it was to see their child fall sick with measles, and how it could have been prevented.

Defense 3: Improve Doctor-Parent Counseling
The doctor-parent interaction is a key part in working with parents who are questioning vaccines, and it is necessary to give doctors better tools to work with. It is important that the doctors have open discussions with parents about vaccinations while respecting their autonomy to make medical decisions for their children. Both the doctor and parent want what is best for the child, and that should be made clear throughout the discussions.
If a parent has refused vaccination for their child, that family should not be dismissed from the practice. As discussed before, this action has a wide range of ethical and legal considerations, and may further push the parents away from communication with the medical establishment (17). However, if the parents are still undecided, it is important to keep an open and respectful dialogue. Reframing the issue, and asking the parents what they would do if they were facing the decision for someone else may be useful (14).
Most parents who question vaccines have already done research of their own, but the doctor must sift through what knowledge they have and clear up any misinformation. Parents need to be empowered to educate themselves in order to make a thoughtful and evidence-based decision (4). The doctor is in a key role to assist by giving the appropriate information on vaccines in general, and answer any questions about specific vaccines or safety concerns, without overwhelming the parents with data.

Conclusion
The issue of parents refusing to vaccinate their children poses a significant risk to public health by weakening herd immunity and leading to new outbreaks of disease. The anti-vaccine movement has been growing in recent years, and similar situations exists in other countries, including England, Ireland, Canada, New Zealand, Australia, Switzerland. When planning interventions for educating parents about immunizations, it is important to keep in mind social behavioral principles, including framing and psychological reactance.
The main public health approach to this issue has been that better education is needed, but most parents refusing vaccines are well-educated. They are getting their information from other sources and are inherently distrustful of anything that comes from the government and research studies, so planning a general education campaign will not be as effective. The issue is more complex than just having experts tell parents what to do, and assuming the public will trust them because they are doctors and experts. Interventions should be designed to clearly and openly address the concerns over the safety of vaccines, dispel any myths about the link to autism, and have an open public dialogue about the best way to protect the health and safety of children.

References

1. Editors of the Lancet. Retraction-Ileal-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children. The Lancet 2010; 375 (9713):445 Freed M, Clark S, Butchart A, Singer D, Davis M. Parental Vaccine Safety Concerns in 2009. Pediatrics 2010; 125:654-659
2. Centers for Disease Control and Prevention. Update: Mumps Outbreak-New York and New Jersey, June 2009-January 2010. Morbidity and Morality Weekly Report (MMWR) 2010; 59(05): 125-129
3. Sugerman DE, Barskey AE, Delea MG, Ortega-Sanchez IR, Bi D, Ralston KJ, Rota PA, Waters-Montijo K, Lebaron CW. Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated. Pediatrics 2010; 125 (4): 747-755
4. Sturm LA, Mays RM, Zimet GD. Parental Beliefs and Decision Making About Child and Adolescent Immunization: From Polio to Sexually Transmitted Infections. Developmental and Behavioral Pediatrics 2005; 26(6): 441-452.
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‘Physical Activity. The Arthritis Pain Reliever.’ A Critique of a Public Health Intervention – Nichole Hinkley

Considering the disease prevalence and impact on the population, arthritis is a significant public health issue. An estimated 21.4 % of adults report having arthritis as diagnosed by their physician. Arthritis can have a substantially disabling effect on an individual, interfering with one’s ability to work, socialize, and care for family and friends. Arthritis is the most common cause of disability and 41% of persons with the disease report activity limitations (1). Physical activity may lower the disease burden and improve the quality of life for those living with arthritis (2). As such, increasing physical activity and promoting self-management in persons with arthritis have become top public health priorities. The Centers for Disease Control and Prevention (CDC) has been central to the public health response by providing funding and ready-made interventions to state health departments (1). “Physical Activity. The Arthritis Pain Reliever.” is one example of such an intervention.
“Physical Activity. The Arthritis Pain Reliever.” is a communication campaign promoting physical activity as a method of arthritis pain management (2, 3). The campaign targets lower-income, African-American and Caucasian adults (aged 45-64) who are already suffering arthritis-related activity limitations. Demonstration projects were concentrated in low-income neighborhoods and rural areas. Stated campaign objectives include a) Raising awareness of physical activity as a way to manage pain and increase function b) Increase understanding of how to use physical activity to ease arthritis symptoms and prevent further disability c) Enhance the confidence or belief of persons with arthritis they can become physically active, and d) Increase trial of physical activity behaviors. Ready-made intervention materials provided to state health departments include an audience profile, public service announcements and messages, radio advertisements, and print materials (2). A critique of these materials and the underlying objectives reveal numerous flaws in the intervention’s design and approach. This paper will identify and discuss three major issues that render this intervention inept: a) misalignment of the intervention’s goals and design with respect to the target audience b) the intervention’s approach is insensitive to the target population’s barriers, and c) the use of inappropriate and inadequate marketing techniques.
Misalignment of Intervention Goals and Design
“Physical Activity. The Arthritis Pain Reliever.” relies on the dissemination of educational materials to raise awareness of the benefits of physical activity on arthritis symptoms. The informational materials are designed to increase the understanding of how using physical activity can ease arthritis symptoms and prevent further disability while enhancing the confidence and belief of persons with arthritis they can be physically active (2, 3). Similar goals and strategies are found throughout social and behavioral models, indicating the intervention is modeled on fundamental behavior-change theories.
Two fundamental behavior change theories, social cognitive theory and social learning theory, stress the importance of observational learning and the concept of self-efficacy and are often utilized to develop public health interventions (3). For the CDC’s arthritis intervention, the concept of self-efficacy may be construed as the “confidence” and “belief” of persons with arthritis they can be physically active. Many public health interventions employ community education to increase awareness of risk factors based on the theoretical potential to modify factors through behavior change (4,6). However, such interventions are not always effective. The Pawtucket Heart Health Program, based heavily on social learning theory, was unsuccessful in demonstrating a decrease in the prevalence of physical inactivity when comparison to a similar, control community (4,5). In fact, studies found the intervention had virtually no measurable effect and suggested possible problems were related to a limited target population (5). Such public health failures may be suggestive of intervention design and outcome goal incompatibilities.
Educational campaigns with the objective to modify health behaviors are potentially problematic because the theories tend to oversimplify behavior determinants (7). Two theories frequently applied to public health intervention models, the Health Belief Model and the Theory of Planned Behavior, cite self-efficacy and weighing perceived benefits and perceived costs of a behavior as major factors in predicating health behaviors (6). In the case of arthritis, this cost benefit analysis would include the perceived susceptibility and severity of related symptoms. Thus, the success of such interventions depends on intention translating into behavior without considering other contextual factors (7). So, intervention failure may suggest the employed models are an inadequate basis to design an effective public health intervention. Therefore, the CDC’s design for “Physical Activity. The Arthritis Pain Reliever.” may be insufficient to achieve its stated objectives.
Moreover, the target population profile suggests an inappropriate application of the models. Formative research was utilized to establish the campaign materials and provide a profile of the target audience. Overall, research indicates the target population generally values good health, is concerned about the limitations of having arthritis, and values self-management. Four in five audience members agree that their health depends on how well they take care of themselves and over half say they do everything they can to stay healthy (2, 3). Based on this assessment, one could argue the target population already shows a high perceived susceptibility and severity of arthritis complications, key components of the Health Belief Model and Theory of Planned Behavior (6). This indicates the outcome expectations may be inappropriate for the intervention’s target audience. Furthermore, the campaign focus is on those with symptoms advanced to the point where arthritis is perceived as interfering with one or more daily life activities. This is also suggestive of the target population’s awareness of the perceived benefits and costs. As such, the campaign's potential benefits to the target population are substantially limited by design.
Barrier Insensitivity
Design flaws are also indicated by the campaign’s insensitivity to barriers. Although campaign background materials cite perceived barriers to disease self-management within the audience profile, the campaign makes little effort to address such barriers. For instance, the intervention does not address motivational barriers for the target population. Selling physical activity to people experiencing arthritis–related activity limitations may require stronger intervention efforts, especially if these individuals were generally inactive prior to onset of severe symptoms. According to Maslow’s Theory of Human Motivation, basic physiological and safety needs must be met before higher goals of motivation can realize (8). These basic needs may be jeopardized when pain begins to affect one’s ability to care for themselves. Thus, pain may create an impenetrable barrier for the entire target audience. Failure to address this significant complication may limit the campaign’s reach.
The intervention also ignores environmental barriers associated with certain characteristics of the target population. Populations most at risk for inactivity are those having lower income and education levels (9, 10) both of which are characteristics enumerated in the target audience profile. Moreover, research indicates lower income and rural neighborhoods have fewer physical-activity related outlets (10). Therefore, the target audience’s environment may not be supportive of physical activity. For instance, fitness facilities may be too expensive or inaccessible, or neighborhood attributes may be unsupportive of physical activity. Environmental supports for physical activity may include maintained sidewalks, streetlights, and positive perceptions of surrounding neighborhood. Unsupportive factors may include crime, heavy traffic, and other safety concerns (9-12). Some studies conclude that closer proximity and higher density of exercise facilities are significantly associated with an increase of physical activity (11, 12). Although the audience profile acknowledges physical activity-specific barriers of time, cost, location, and convenience, they are not addressed in the interventional design. This illustrates the intervention’s ignorance of contextual factors that may play a bigger role than self-efficacy and perceived costs/benefits in determining behavior. The importance of environmental variables as determinants to health behavior is consistent with the social-ecological theories of health behavior (9). In other words, the social-ecological perspective acknowledges that health behaviors are determined by a number of contextual issues that should be considered in designing an intervention to increase physical activity.
Campaign Marketing
Public health interventions may utilize basic marketing principles in order to promote the program. This requires formative research to define and frame the product in a way that speaks to the intended audience (13). In other words, marketing a public health program requires the identification of core values, desires, and needs of the target audience in order to promote the program. While valuable research data was obtained and conveyed in the campaign’s instructional materials, the advertisements and materials are not reflective of the research findings.
The target audience fears future loss of independence; reduced pain and ease of movement are intertwined with independence. In terms of marketing, independence may be viewed as the core value desired by the target population. This value is essential to packaging and framing the program to the audience in a meaningful way (13). Instead, campaign literature generally conveys a command, such as “take a walk.” For example, one brochure headline reads, “Take a Walk. Take a Bike Ride. Take a Swim.” It then goes on to explain how physical activity can decrease arthritis related pain. It also mentions that even though “it may hurt a little at first… most people begin to feel better within four to six weeks.” Though it may be truthful, this frames the issue in a most undesirable way. This message is essentially offering “pain” as its product. A second brochure states, “If you experience the pain and stiffness of arthritis, there’s something you can do about it.” Although this may engage the audience in a more meaningful way by offering empowerment to sufferers, the campaign failed to reinforce the core value supported in research findings. In fact, the majority of campaign media communications are centered on empowering the individual to self-manage.
The focus on empowerment has failed in a number of public health policies. For example, consumer empowerment was a failed policy approach to reducing health care costs. Proponents of these policies argue consumer insensitivity to health care costs contributes to overspending and therefore sought to modify patient behaviors by publicizing hospital cost and quality data (14). Ideally, consumers would utilize advertised data to select the lowest cost, highest quality product available and foster competitors to adjust price or production costs to meet the new demand (15, 16). Among other problems, these policies did not adequately market and advertise the information they were attempting to disseminate. The public was largely unaware of the data’s existence; therefore, the intervention did not achieve its cost cutting objectives. This policy failure highlights the importance of marketing principles in public policy ventures. So, although the campaign acquired requisite data in order to promote a successful public health campaign, it was not utilized to effectively frame the issue.
Conclusion
The CDC’s public health campaign, “Physical Activity. The Arthritis Pain Reliever.” displays a number of design concerns that individually and cumulatively lower its effectiveness. Three major concerns have been established with this intervention: the misalignment of the intervention’s goals and design, ignorance of target population’s barriers and finally, the inadequate use of marketing techniques. Poorly designed interventions will do little to address serious public health issues such as arthritis. In short, this campaign is representative of a failing approach to address a public health issue.
Redesigning for Success: An Intervention Proposal – Nichole Hinkley
Although research demonstrates the need for more innovative approaches to successfully achieving public health objectives, intervention failures are not uncommon. As indicated in the critique of “Physical Activity. The Arthritis Pain Reliever,” tragic flaws include the intervention’s misalignment of goals with design, an insensitive approach to the target population’s barriers and contextual issues, and the inadequate use of marketing strategies. The objective of this proposal is to provide an alternative approach to increasing physical activity behaviors in persons with arthritis than provided by the Centers for Disease Control and Prevention. A more successful intervention requires three modifications: integrating alternative behavioral models, addressing contextual barriers, and improving the marketing techniques. As this proposal will indicate, these modifications will address all major concerns with “Physical Activity. The Arthritis Pain Reliever.”
Aligning Goals with Design
The initial step to redesigning this intervention is to align the design strategy with its intended goals. To increase physical activity behaviors in persons with arthritis-related activity limitation, it may be beneficial to address a larger audience. A broadly-based intervention strategy yields greater outcome potential while allowing for the consideration of the target population’s characteristics and barriers. Better still, encouraging physical activity in the population at large places greater emphasis on prevention of arthritis pain thus reinforcing a public health ideal. Over time, this focus would mitigate pain as a significant barrier to activity. Already, this revised strategy addresses a number of the potential barriers presented by the original design.
According to the campaign goals, the social network theory would be an appropriate basis for the intervention design. Recent studies suggest that network phenomena are relevant to obesity-related behavioral traits. Obesity has shown to have an association with physical inactivity and both obesity and physical inactivity are shown to have an association with arthritis, so this approach should have similar interventional implications in terms of modifying behavioral traits (17). Thus, aligning outcome goals with appropriate design strategies is the first step to improving the effectiveness of public health interventions.
Addressing Barriers
Social-ecological perspectives of health suggest that social and environmental factors play an important role in increasing physical activity behavior (8). As such, significant social and environmental barriers should be addressed in redesigning the intervention. As mentioned, the social network theory approach involves intervening on a group level. Therefore, the intervention should operate through health clinics, community centers, centers for independent living, and other health facilities frequented by the target population. For example, new or already established arthritis/disability support groups or meetings could provide the base of the network cohort and an opportunity to communicate audience-appropriate campaign materials. Concentrating interventional activities may help to address a portion of the perceived environmental barriers such as location, time, and convenience, especially for those who may be experiencing arthritis related movement limitations. The social network created by this group-based strategy offers motivational support and may alleviate some of the aforementioned environmental barriers. For example, safety may be less of a concern if a group of individuals are able to coordinate fitness activities together. Similarly, peer-communicated advice may be a more effective motivational tool than educational materials. Although this partially addresses significant barriers that were ignored in “Physical Activity. The Arthritis Pain Reliever,” this intervention should also include efforts to develop low cost solutions to enhance environment to support physical activity, such as parks and recreation centers. As indicated by research, closer proximity and higher density of exercise facilities to be significantly associated with an increase of physical activity, indicating the importance of removing environmental barriers to achieve positive outcomes (10, 11). These efforts should be made at the level of each local network in order to provide the most effective and supportive modifications.
Promoting physical activity is a major public health priority across a number of populations. Interventional efforts via network levels would penetrate various populations and ideally spread desirable outcomes. Therefore, the social network theory approach to increasing physical activity in persons with arthritis could also benefit other populations. The spread of healthy behaviors may be further encouraged by incorporating an element of the diffusion of innovations theory. A “change agent” is a well-connected individual in the intervention who would serve as a positive role model for incorporating the desired outcomes for the rest of the network. Identifying “change agents” for strategic incorporation into cohorts might promote the uptake of healthy behaviors (18). Not only do alternative models suggest a greater success in achieving intended outcomes but in achieving broader public health objectives.
Successful Marketing
Perhaps most importantly, the intervention redesign should employ marketing techniques in order to successfully promote the campaign. Although the CDC’s intervention materials provided detailed requisite data to launch a successful public health campaign, it was not utilized to effectively frame the issue. Addressing the underlying values associated with the desired health behavior is essential to successful promotion. Data from the audience profile indicates independence and autonomy are core values and concerns for people with arthritis, therefore, campaign materials should be framed around these values. This may be accomplished by essentially “selling” autonomy and independence in campaign advertisements. For example, an alternative brochure headline may not contain any words at all but portray an image of age-appropriate individuals enjoying their freedom and autonomy amongst their friends. One image may include four, laughing women in a red convertible with the top down. This portrays an image of freedom, success, and happiness. Although physical activity is the health behavior associated with such emotions, it should not be the focus of campaign messages. Proper advertising and marketing strategies will help sell public health products.
Conclusion
Poorly designed interventions will do little to address serious public health issues such as arthritis. As such, innovative approaches are necessary to address the goals defined in “Physical Activity. The Arthritis Pain Reliever.” In summary, the proposed redesign uses the social network theory as basis for increasing physical activity in persons with arthritis while utilizing marketing principles to promote the public health campaign. In addition to the intervention’s increased sensitivity to barriers, the incorporation of alternative theories effectively addresses the dilemmas unearthed in the critique of the Center for Disease Control’s campaign. The proposal may also offer a more effective, sweeping approach to addressing a number of significant health problems while emphasizing prevention, a public health principle.
REFERENCES
(1) Brady T., Jernick S., Hootman J., and J. Sniezek. Public Health Interventions for Arthritis: Expanding the Toolbox of Evidence-Based Interventions. Journal of Women’s Health 2009; 18 (12):1905-1917.
(2) Centers for Disease Control and Prevention. Arthritis Intervention Campaigns. “Physical Activity. The Arthritis Pain Reliever.” How to guide: http://www.cdc.gov/arthritis/docs/howto_guide.pdf
(3) Centers for Disease Control and Prevention. Arthritis Intervention Campaigns. http://www.cdc.gov/arthritis/interventions/physical/overview.htm
(4) Carleton R., Lasater T., Assaf A., Feldman H., McKinlay S. and the Pawtucket Heart Health Program Writing Group. The Pawtucket Heart Health Program: Community Changes in Cardiovascular Risk Factors and Projected Disease Risk. American Journal of Public Health 1995; 85:777-785.

(5) Eaton C., Lapane K., Garber C., Gans K., Lasater T. and R. Carleton. Effects of a Community-Based Intervention on Physical Activity: The Pawtucket Heart Health Program. American Journal of Public Health 1999; 89 (11): 1741-1744.
(6) National Canter Institute. Theory at a Glance: A Guild for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp 9-21 (NIH Publication No. 05-3896). http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf

(7) Marks DF. Health Psychology in Context. Journal of Health Psychology 1996; 1:7-21.
(8) Maslow AH. A Theory of Human Motivation. Psychological Review 1943; 50:376-396.

(9) Addy C., Wilson D., Kitland K., Ainsworth B., Sharpe P. and D. Kimsey. Associations of Perceived Social and Physical Environmental Supports with Physical Activity and Walking Behavior. American Journal of Public Health 2004; 94 (3): 440-443.

(10) Powell L., Slater S., Chaloupka F. and D. Harper. Availability of Physical Activity-Related Facilities and Neighborhood Demographic and Socioeconomic Characteristics: A National Study. American Journal of Public Health 2006; 96:1676-1680.

(11) Sallis J., Hovell M., Hofstetter R. et al. Distance between homes and exercise facilities related to frequency of exercise among San Diego residents. Public Health Reports 1990; 105:179-185.

(12) Linenger J., Chesson C. and D. Nice. Physical fitness gains following simple environmental change. Journal of Preventative Medicine 1991; 7:298-310.

(13) Siegel M. Marketing Social Change: An opportunity for the public health practitioner (pp 45-71). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones and Bartlett Publishers, 2007.

(14) United States Government Accountability Office. Comptroller General's Forum on Health Care: Unsustainable Trends Necessitate Comprehensive and Fundamental Reforms to Control Spending and Improve Value. U.S. Government Accountability Office: 2007.

(15) Nichols, L., Ginsburg, P., Berenson, R., Christianson, J. and R. Hurley. Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence is Waning. Health Affairs 2004; 23 (2); 8-21.

(16) Poteliakhoff, E. Price data published by CMS: 'Payer Power Plan'. Health Policy Monitor. 2006. http://www.hpm.org/survey/us/c8/3

(17) Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357:370-379.

(18) Introduction (pp 3-14). In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000.

A Critique of Fight 4 Your Life, a Massachusetts Tobacco Cessation Campaign – Andrea Lenco

Fight 4 Your Life is a tobacco cessation public health campaign created in 2008 by the Massachusetts Tobacco Cessation and Prevention Program at the Massachusetts Department of Public Health. The campaign involves television commercials, subway posters, and a website that feature vignettes of real people who successfully battled to quit smoking (1). The vignettes focus on how difficult it is to quit smoking, and the rewards to quitting, such as health, a longer life, and being able to take care of one’s family. Despite pre- and post-campaign telephone survey evaluations that found a 9.4% increase in quit attempts among the target audience, I argue that the Fight 4 Your Life campaign is flawed for three main reasons (1). First, as an individual level approach, the campaign seeks to change risk behaviors of one person at a time, framing smoking as an individual failure. This is inefficient and unrealistic. Second, the campaign focuses on avoiding negative health outcomes rather than gaining positive outcomes through smoking cessation. Third, the Fight 4 Your Life campaign is based on a model that assumes people engage in planned, rational behavior.
A Critique of Individual Level Interventions
The Fight 4 Your Life smoking cessation campaign is an individual level intervention; it seeks to alter tobacco-related risk behaviors of the population, one person at a time. Campaigns focused on individual behavior change rely on unrealistic notions of the impact of personal behavior on health, and fail to address the environmental factors associated with the risk behavior. The disease or unhealthy behavior is framed as a failure of the individual and the wider social context in which the individual’s behaviors and beliefs exist, such as family and social influences, and community acceptance or promotion of risk behaviors, are ignored. Individual level interventions also fail to identify the political barriers to behavior change, and who constructs and benefits from these barriers – such as the excess advertising by the tobacco industry in lower-income neighborhoods (2).
Smedley and Syme’s discussion of the ecological perspective tells us that there are multiple levels of influence affecting the health behaviors of individuals, such as social relationships, neighborhoods and communities, and social and economic policies (3). In the case of smoking, individuals often smoke in a social context, and are heavily influenced by the behaviors and attitudes of their peers. Neighborhoods and communities can promote or deter smoking by, for instance, strictly upholding laws that prohibit tobacco sales to minors. Social and economic policies affect smoking behaviors in the population with smoking bans in restaurants and other public places, and heavy taxes on tobacco products. Dhalgren and Whitehead’s general framework for the determinants of health depict these layers of influences as an onion-like structure, with the individual at the center, surrounded by the larger context of social and community influences, living and working conditions, and general socioeconomic or environmental conditions (4).
Social Cognitive Theory introduces the concept of reciprocal determinism, which describes “interactions between behavior, personal factors, and environment, where each influences the others” (3). This theory explains some drivers of individual behavior change such as positive or negative reinforcement. Examples of negative reinforcement for smoking might include smoking outside in the cold while patronizing a bar that no longer allows smoking indoors, and doing so alone while all of one’s friends (perhaps former smokers who have successfully quit) remain inside to socialize.
The Diffusion of Innovations is a useful group level model that describes the way in which behavior change moves through populations of people through geographic proximity and the pressure of social networks (5). As opposed to individual level models that predict each person choosing and executing behavior change in isolation, this group level model identifies direct interactions between individuals as the precursor to adoption of a new behavior. The behavior adoption progresses through the network in an exponential fashion, until only individuals who are strongly opposed to the new behavior have not adopted the behavior change. Because of this exponential spread of behavior change, the Diffusion of Innovations model describes adoption of a new behavior as a network-based decision. Behavior change has a cumulatively increasing influence on a network of peers. As the pressure to conform builds and perceived risks decrease as more peers adopt the behavior (5). Studies show that smoking cessation programs that modify a person’s social network by providing peer support groups are more successful than those that rely on isolated individual behavior change (6). The Fight 4 Your Life campaign does not appear to provide any type of support – particularly peer support – to the target population.
A Critique of the Fight 4 Your Life Frame
The Massachusetts Department of Health’s Fight 4 Your Life campaign focuses on avoidance of possible future negative health outcomes related to smoking, some – such as lung cancer – which may not materialize for decades. Studies in the Journal of Personality and Social Psychology show us that people are unrealistically optimistic about future life events, and believe that experiencing future negative events is unlikely. These studies ascertain that educating individuals about the attributes, actions, and outcomes of others, as in the Fight 4 Your Life campaign vignettes, works to reduce optimistic bias but does not eliminate it (7). Further nationally representative studies show that even heavy smokers and those with other cardiac risk factors have unjustifiable optimism in regard to the possibility of future heart attacks or lung cancer (8).
If individuals commonly deny their own personal risks from unhealthy behaviors, this means that smokers are not likely to worry that they could be affected by tobacco-related illness in the future when viewing a public health advertisement that warns about the risks of disease caused by smoking. A more effective public health intervention would approach behavior change in a way that offers something desirable to the individual in exchange for behavior change, rather than simply rewarding the behavior change with an avoidance of future negative health outcomes.
Marketing Theory tells us that to successfully sell a healthy behavior change to the population, we must appeal to their core values, such as freedom or free enterprise, independence or economic opportunity, control, fairness or equality, and community or a sense of belonging, among others (9). Fight 4 Your Life does not invoke a promise of fulfillment of these core values in the campaign’s attempt to convince the population to buy into smoking cessation. Theories of social branding indicate that public health campaigns like Fight 4 Your Life fail to establish trust with the target audience because they do not take into consideration the perceived benefits of the risk behavior. This type of campaign also has a negative tone and does not appeal to emotion or offer any realistic behavioral alternative (10).
Framing Theory describes the ways in which we position an issue to the public (9). The Fight 4 Your Life campaign attributes the responsibility for smoking, and smoking cessation, to the individual. This does not set up smokers for success, as the frame used isolates the individual and blames them for their failure. A more strategic use of framing would frame the behavior change, or the identity of “non-smoker” as aligning with some core value of the public, such as independence or economic freedom.
The Fight 4 Your Life campaign was intended to reach people in lower-educated and lower-income groups, where smoking rates have remained high despite a steady decline in other demographics over the past twenty years (1). The only apparent way the campaign reaches out to this demographic in particular is by using the stories of real lower-educated and lower-income people in the vignettes. The campaign seems to ignore the fact that those working and living in disadvantaged communities inherently exhibit more health risk behaviors as a means of coping with stressful circumstances, and have fewer resources (such as time and money) with which to manage behavior change (4). A more effective public health intervention would directly address the environmental and social factors that disproportionately affect the health behaviors of socio-economically disadvantaged groups, by reshaping social policies and cultural norms that, for instance, target lower-income areas for heavy tobacco advertising.
A Critique of Planned Behavior
The Fight 4 Your Life campaign is based on a model that assumes individuals are engaging in a rational cost/benefit analysis and planning out their quit attempts. The individual is defined outside of any context in which there may be emotional rewards for continuing to smoke. In reality, human behavior is usually unplanned and driven by visceral influences that crowd out all logic and self-efficacy. Critiques of the Transtheoretical (Stages of Change) Model, in which individuals plan to change a behavior and take steps toward that change, claim that human behavior reflects the moment-to-moment balance of motives, is often irrational, and entrenched in context (11).
Several studies on smoking cessation have shown that more than half of reported quit attempts involve no planning or preparation – not even as far as finishing the current pack of cigarettes (12,13). These unplanned quit attempts were also more likely to be successful. The results of these studies indicate that a “catastrophe theory” or “chaos theory” is a more accurate description of the complex and ultimately unstable motivational forces behind individual behavior change. As it is unknown what factors will ultimately tip the balance and lead an individual to quit smoking, public health can encourage smokers to recognize and act on opportunities to quit spontaneously (such as running out of cigarettes while in an inconvenient position to pick up more), rather than planning a date to quit (12).
The findings of studies on unplanned smoking cessation attempts also raise the possibility that a quit attempt is more likely to be successful if the decision to quit is acted on immediately. In motivating smokers to quit, this time scale should be described explicitly as a key in the quitting process for many (12). The Fight 4 Your Life campaign does not give such details on how one might be most successful at quitting smoking.
An Alternative Smoking Cessation Intervention
An alternative intervention to the Massachusetts Tobacco Cessation and Prevention Program’s Fight 4 Your Life smoking cessation campaign might involve the following components.
1. Implement a smoking ban within 100 feet of any building that serves as a place of employment. This state or citywide policy would be passed under the legal premise of creating a safe work environment for employees, and would address the obtrusive cloud of second hand smoke often found directly outside workplace doors. The law would also create an inconvenience for smokers wishing to take cigarette breaks during work, as they would have to travel not only 100 feet away from their own place of employment, but just as far from every place of employment for a cigarette break. Reducing the opportunities for people to smoke would necessarily decrease the amount of cigarettes they consume, and in turn decrease their nicotine dependence.
2. Broadcasting television commercials that sell the idea of being a non-smoker. Alternative television spots to those utilized by Fight 4 Your Life would sell positive images and core values, such as financial independence, worldliness, and romance. They would not even necessarily be linked to the promise of future good health. A commercial would feature no dialog, only music and a video montage: An attractive young woman runs out of cigarettes in her city apartment. She looks out the window to see heavy rain and a dark thunderstorm. Smiling, she tosses her empty pack of cigarettes and a pack of matches into the trashcan. She grabs an empty jar and puts her cigarette money in it. We see a series of shots of her happily adding her cigarette money to the savings jar each day. She researches tropical vacations online, and buys a plane ticket. We see her reclining in a first class seat, smiling and looking up as the “No Smoking” sign lights up above her. In the last scene she is lounging on a beach in a tropical location, and a handsome man approaches to offer her a cocktail. She smiles at him, and we see that a romantic connection will ensue. Several different commercials would show a similar type of scenario for each specific demographic we are targeting with the campaign.
Altering the Environment for Health Promotion
As discussed earlier, the ecological perspective of health behavior describes that individuals exist within a larger social and economic context, with multiple layers of influence affecting their decisions around health behavior (3,4). While the Fight 4 Your Life campaign focuses solely on convincing individuals to tackle behavior change, the alternative approach outlined above broadens the focus of the intervention to create an environment where smoking cessation is supported, and continuing to smoke regularly becomes inconvenient.
This alternative intervention is in line with critical feminist perspectives of the individual level Health Belief Model of behavior change calls for a more holistic examination of the motivators and barriers to healthy behaviors (2). The intervention is supported by studies show that lasting behavior change requires consistent a balance of motivators that favors an alternative whenever the opportunity to engage in the risky behavior arises (11). A smoking ban within 100 feet of all places of employment provides consistent reinforcement for opting not to take a cigarette break, as finding a location for a cigarette break becomes very inconvenient and more time is necessary to accommodate smoking a cigarette.
Networking Theory and the Social Acceptance of Smoking
Networking theory indicates that behavior change, such as smoking cessation, moves through a population via social ties. Groups of interconnected people appear to quit smoking in concert, and smokers become increasingly socially marginalized, until few connections remain between smoking and non-smoking groups. (6). Part 1 of our alternative campaign, a smoking ban within 100 feet of all places of employment, is an intervention that decreases the social acceptability of smoking. By affecting what appears to be socially acceptable in regard to smoking behaviors, public health can plant the seed of behavior change in some people in the community, who will in turn spread their new ideas of what is socially acceptable to their peers. The new ideas of socially acceptable smoking behavior will in turn spread exponentially throughout the community as fewer and fewer people see smoking in public as acceptable. Since smoking is a social behavior, more people will quit when they run out of easily available contacts to smoke with (6).
Selling Core Values in Public Health
Research shows that effective social marketing begins with recognizing the desires and values of our target population and promising these benefits in exchange for healthy behavior changes, rather than asking the population to change their values (9). The alternative commercial described above sells universal core values to our target population: financial independence, exotic travel or worldliness, and romance or love.
The commercial also advertises a desirable lifestyle: the luxurious, young “jet-set” with freedom, independence, and disposable income. Evans and Hastings’ discussion of public health branding describes the benefits of selling a lifestyle choice to consumers (10). Public health can compete with the tobacco industry’s corporate interests by offering the benefits of a desirable alternative lifestyle to consumers who choose to quit smoking. The consumer earns the benefits of the core values in the advertisement – financial independence, exotic travel or worldliness, and romance – by choosing to be a non-smoker and therefore the lifestyle that comes with it. Branding constructs are persuasive as a marketing tool because they speak to the population’s aspiration to appealing external ideals (10).
The commercial described as part of this alternative intervention showcases the story of a woman who successfully quits smoking spontaneously. This lines up with West and Sohal’s version of “catastrophe theory,” which suggests that public health should focus on creating or identifying these spontaneous opportunities for people to change their behavior (13). Studies show that many quit attempts are spontaneous and that unplanned quit attempts are much more likely to be successful (12,13). Public health can aim to trigger these spontaneous quit attempts in smokers who are on the cusp of behavior change by advertising the idea that individuals should look for opportunities to quit, rather than planning a quit attempt in advance.
Conclusion
The Massachusetts Tobacco Cessation and Prevention Program’s Fight 4 Your Life smoking cessation campaign is flawed in several major aspects. The program is an individual level approach to behavior change, which leaves out necessary discussion of the social and environmental factors supporting the risk behavior. The program frames the main benefit of quitting smoking as avoiding future negative health outcomes, which is less effective than offering the promise of a positive reward to those trying to quit. Fight 4 Your Life also takes for granted the assumption that people are making rational cost/benefit analyses and planning out their quit attempts, an assumption about human nature which is known to be flawed. The alternative approach outlined here would better serve our target population. This approach creates a workplace environment that is unfavorable to smoking, altering the public perception of smoking as socially acceptable. The alternative approach also uses television commercials and marketing theory to make healthy behavior change look alluring and positive by promising core values such as economic freedom.






REFERENCES
1. Massachusetts Tobacco Cessation and Prevention Program. Fight 4 Your Life campaign. Massachusetts Department of Public Health. http://www.makesmokinghistory.org/en_US/about-mtcp/Fight-4-Your-Life.html
2. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995;11:246-252.
3. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Institutes of Health publication 2005.
4. Marks DF. Health Psychology in Context. Journal of Health Psychology 1996;1:179-193.
5. Wejnert, Barbara. Integrating models of diffusion of innovations: a conceptual framework. Annual Review of Sociology 2002;30:297+.
6. Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. MEJM 2008;358:2249-2258.
7. Weinstein ND. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980;39:806-820.
8. Ayanian J, Cleary P. Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers. JAMA 1999;281:1019-1021.
9. Siegel M. Marketing Public Health – An Opportunity for the Public Health Practitioner (pp 127-152). In Siegel M. Marketing Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
10. Evans WD, Hastings G. Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (pp 3-24). In Evans WD, Hastings G. Public Health Branding: Applying Marketing for Social Change. New York, NY: Oxford University Press, 2008.
11. West R. Time for a Change: Putting the Transtheoretical (Stages of Change) Model to Rest. Addiction 2005;100:1036-1039.
12. Larabie LC. To what extent to smokers plan quit attempts? Tobacco Control 2005;14:425-428.
13. West R, Sohal T. “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ 2006;332:458-60.

A Horse Of The Same Color: Why The Family Smoking Prevention And Control Act Fails To Curb Tobacco Use – Tyler Collins

Smoking is the leading cause of preventable death in the United States (US) (1). It is responsible for approximately one in five deaths annually, with smokers dying on average 13 to 14 years earlier than none smokers (2). Nearly 20% of all US adults are current smokers and 1800 Americans over the age of 18 are added to their ranks daily (2). This is in part due to the fact that the tobacco industry spends $13 billion annually on advertisements and promotions (2). This staggering number can be looked as a partial explanation to why the 70% of smokers, who wish to quit, often fail (2). Not only has the tobacco industry engrained itself into the fabric of society, through its constant barrage of advertisements, but also through the 1998 Master Settlement Agreement (MSA). This arrangement requires the industry to pay 46 states, over the next 25 years, to combat smoking related disease and disability (3). States have come to depend on this settlement money, though, to fill budget deficits. This usage of funds, straying from its original purpose, has allowed big tobacco to influence government agendas (4). As a result, most interventions bent on targeting the industry will fail because of state government ties to tobacco’s success.
Fast forward 11 years and you will find one such intervention that has failed since its inception. This intervention is the Family Smoking Prevention and Tobacco Control Act and was signed by President Barack Obama in 2009. It has been heralded by the media as a “sweeping anti-smoking bill” and praises it for providing critically needed protection to future generations (5). Unfortunately, it falls short of providing the critical care so desperately needed. In a country influenced from the top down, the entanglement of tobacco into the finances of state government sours any chance to change social norms. What has transpired instead is a restoration of previously ineffective plans that completely disregards certain groups. Although many pages of legislation create seemingly groundbreaking advancements, it is merely a charlatan attempting to hoodwink the American public. A true intervention must take place not only to save the government from big tobacco, but also its citizenry.

New Interventions Will Fail Because Government Has Failed

To understand where the United States went wrong requires a look at the historical underpinnings of how the tobacco industry wrapped its tentacles around state budgets. Then a clear distinction can be made between an intervention aimed at the root cause of tobacco’s success and one cast aimlessly out. The research thus starts with the 1998 Master Settlement Agreement between big tobacco and 46 states. The MSA was originally a settlement with these states where the 4 big tobacco companies would pay $206 billion over 25 years to help cover the cost of tobacco related disease and disability (3). But, with few stipulations in the plan as to how the money was to be spent, states have elected to veer the money from its original purpose to more pressing budget deficits (4). In 2007, only 3% of the $24.9 billion available was used in tobacco control programs, with the rest going to fill budget shortfalls (2). As a result, programs have remained underfunded, government has come to rely on tobacco money as a lifeline, and successful programs have been cut so as not to threaten tobacco’s profits too greatly (4). This was seen when the wildly successful “truth” campaign in Florida was cut because it threatened to actually work at curbing tobacco use (6). This campaign was able to retract youth smoking rates from 18.5% to 11.1% among middle school students and from 27.4% to 22.6% among high school students in Florida (7). Sadly, this success became the programs downfall and it was discontinued because it threatened market profitability for the tobacco industry, which threatened MSA settlement payouts to the state of Florida. This clear conflict of interest silences any attempt at government taking meaningful steps to ensure stringent regulation of cigarettes and shows a failure of the system as a whole.
This conflict can be seen through social science models. As shown in the Social Ecological Model, the most overarching determinant of human behavior is the social structure, policy and systems in which one lives (8). If an intervention wants to have a sweeping effect in producing change, a policy or law promoting that change is the surest way to compliance. This understanding is further echoed through the guise of the Social Expectations Model, which dictates that if a social behavior wants to be changed, social norms must be changed (9-10). One way to ensure that change is through government action. This is often in the form of a change in regulations, laws, or policies that affect social behavior (10).
One such example of successful curbing of socially undesirable practices is the implementation of mandated seat belt use in automobiles. Prior to the enactment of seat belt laws, less than 20% of motorists voluntarily buckled up (10). This was in the face of “extensive advertising campaigns and buzzer systems” that attempted to promote buckling up for safety (10). In the first months after the law was enforced in New York State, the first state to require seat belt usage, compliance jumped to between 45% and 60% (10). As is seen in the case of the seat belt, social norms changed only once laws changed. Unfortunately, this will not be the case with the Family Smoking Prevention and Tobacco Control Act.
Through this legislation the Food and Drug Administration (FDA) is going to work closely with the Centers for Disease Control and Prevention (CDC) to “establish contracts with states to support the public health goals of the Tobacco Control Act” (11). This sounds just on the surface, but when states are spending only 3% of their MSA funds on tobacco related issues, collaboration between federal departments and states will only produce minimal benefits (2). The CDC recommends that adequate control of tobacco require 15% of MSA funds to be used for that purpose (2). So, unless more funding is given to tobacco control, no sweeping changes will occur as the law has been heralded to produce (5).

Tobacco Legislation Threatens To Fail To Market Change Properly

The Family Smoking Prevention and Tobacco Control Act plans to increase marketing that informs individuals of the harm posed by smoking cigarettes (11). Sadly, this marketing follows the same mantra of so many failed public health initiatives before it. With this new legislation, “the FDA…intends to propose new graphic health-warning labels to cover 50% of the front and back of each cigarette pack” (11). Furthermore, the FDA believes that many Americans do not truly know the risks of smoking cigarettes and feel that they are often duped into believing that “light” and “low tar” cigarettes are safe to use (11). To combat these misunderstandings, the FDA plans to educate consumers about the true danger of these cigarettes, with the assumption that such understanding will curb usage (11). This belief is bolstered by a 1999 study, which found that the majority of smokers do not believe they are at greater risk of heart disease and cancer than their non-smoking counterparts (12). But, as outlined in Advertising and Marketing Theory, educating consumers and telling them what they should desire is like placing the cart before the horse (13).
The first step in creating a successful marketing campaign is to research what the consumer desires (13). Then, the marketer packages their product to meet those needs (13). Contrary to this theory, the prevailing assumption in public health interventions is to rely on the practitioner’s intuition to judge what society should want and then package their product accordingly (13). This only appeals to those who are conscious of the importance of good health. Regrettably, health is not always a core value in society and is frequently overshadowed by other desires. This is understood by advertisers and marketers, but not by public health practitioners. To illustrate this concept, a study was conducted in 1993 on the rates of smoking cessation after the diagnosis of lung cancer (14). The study found that 21% of smokers diagnosed with lung cancer continued to smoke even after diagnosis (14). These findings are clearly divergent from long held public health assumptions.
According to the FDA and the Family Smoking Prevention and Tobacco Control Act, most smokers do not know the true risk of their habit and if educated, would likely discontinue such habits (11). If this is true, then why would smokers diagnosed with lung cancer, resulting from their cigarette smoking, continue to smoke? The answer can only be that health is not a core value for many individuals and those interventions designed to promote health, through education on the problem, are ineffective. Given this knowledge, interventions like the one proposed in the latest tobacco control legislation continue to follow old, ineffective habits, rather than looking to newer, and more successful ways of producing societal adherence to healthy practices.

The Family Smoking Prevention And Tobacco Control Act Ignores Minority Groups

The Family Smoking Prevention and Tobacco Control Act has established guidelines on how tobacco may market their products and which products may be sold (15). This marketing and removal of certain products may unconsciously allow certain minorities to be targeted by tobacco firms and to an extent borders on institutionalized racism. The group targeted by such racism is primarily black smokers. Currently, nearly 20% of African American adults smoke on a daily basis (2). White and Native American adults are the only two groups to surpass African Americans in smoking percentages (2). Black smokers also tend to prefer a particular type of flavored cigarette; a preference not shared widely by other consumers (16). Luckily, the new legislation mandates the removal of all candy-flavored cigarettes; except for one (11-15). The one flavored cigarette that is not removed from the market is menthol-flavored cigarettes (15). Coincidently, this type of cigarette is the most popular flavor among African American smokers (16). This trend has been noted in numerous studies. One such study conducted a year before the Family Smoking Prevention and Tobacco Control Act found not only that black smokers consume the greatest proportion of menthol cigarettes, but also that menthol cigarette smoking resulted in a higher rate of cigarette consumption overall (16). The study went on to state that any legislation on tobacco control should take into account menthol cigarette usage by blacks and the high consumption such products encourage (16).
As such, it can be inferred that cigarette sales in large part are dependent on the product needs of African American smokers. To this end, menthol cigarettes also comprise a large proportion of cigarette sales in the US. Unlike other candy-flavored cigarettes, which clearly accounts for nearly no sales of cigarettes, menthol is a highly desired flavor. Yet, no restrictions have been placed on their distribution. So, a cigarette that clearly is at the forefront of contributing to major health problems for one particular group, African Americans, has no regulation stemming from this new bill (15).
This is a clear example of one of Camara Jones’ Levels of Racism, which she calls Institutionalized racism. She defines it as the “differential access to the goods, services, and opportunities of society by race” (17). This is undoubtedly what the sale of menthol cigarettes poses to black individuals. Rather than being an inaccessibility of such goods and services, it is an over accessibility to a certain harmful product. Now, this may or may not be a conscious act of racism on the government’s part, but it certainly can be framed as such. It can also be said that some ignoring of scientific findings took place in the drafting of the new tobacco control legislation. Prior to the enactment of this legislation, studies noted the high consumption of menthol flavored cigarettes by black smokers and suggested that legislation curtail this trend (16). The reasoning behind the lack of regulations controlling menthol cigarettes has as much to do with institutionalized racism as it does with the prior criticisms in this paper. This includes the financial ties tobacco firms have to state government budgets (3-4).

Tobacco Control Must Come In The Form Of Effective Legislation

Before any headway can be made on tobacco control, state governments need to get out of the pockets of tobacco firms. Tobacco has state governments right where it wants them by tying settlement payouts to the sale of cigarettes (3-4). Now, state governments have a vested interest in the profitability of tobacco. This is further exacerbated by the current economic downturn and the increasing budget deficits among states. This has allowed money that was intended to curb tobacco related cost and usage to be used to fill gaps (2). Government has since become dependent on these payouts to fulfill the shortcomings in their budgets. Until this trend changes, government will have a stake in how profitable tobacco is. State tobacco control programs could be fully funded to CDC recommended levels if the percent of MSA settlement money used to fund such programs was raised by 12% (2). This would still leave $21.2 billion in settlement funds that states could use for other purposes. This increase from the $747 million currently put toward tobacco control would have a substantial impact on initiation and continuance of smoking by individuals.

Marketing Strategies To Curb Tobacco Usage Should Follow Standard Advertising Practices

Attempts made to market the harms incurred to individuals by smoking must be carefully constructed. It is no easy task to try and stop individuals from partaking in a habit-forming practice. Some basic rules that are commonly followed by advertising agencies can ensure a greater success in interventions aimed at decreasing cigarette consumption. The specific issues with the current legislation is the proposed placement of “graphic health warning” labels on cigarettes (11). Trying to disgust people into giving up cigarettes is not an effective way and would not be recommended by any advertising firm. As described above, smokers know smoking is harmful to their health and even after the effects of the habit have manifested into smoking related disease and disability, many still continue the habit. In order to see meaningful change in the consumption of cigarettes, marketing strategies must be taken to discover what is important to smokers and then market the intervention around those needs and wants. If the current public health practice of using intuition to make an assumption of what average individuals should want, warning labels will be ignored just as other interventions have been.

Greater Emphasis Must Be Taken To Ensure Equality Of Interventions

Interventions regarding tobacco use must encompass all users of tobacco products. Only banning substances that are already not used by individuals helps no one. Considerations must be made to face the full spectrum of the problem, not just pieces. If the objective is to appear as though headway is being made in the fight against the tobacco industry, then a continuation of the status quo is an effective approach. But, if the objective is to truly limit tobacco use, then the proper steps must be taken to limit the use in all groups.
It is clear through multiple studies that menthol cigarettes are used disproportionately by black smokers compared to other smokers (16). It has also been shown that menthol cigarettes lead to a higher consumption of cigarettes in general (16). So not only are African American the highest proportion of menthol cigarette smokers, but they also consume a greater quantity of cigarettes in relation to other groups. This issue must be addressed for the future safety and well being of the black community. Any future legislation should ban the sale of menthol cigarettes just as the current legislation has banned the sale of other candy-flavored cigarettes. Only then will a reduction in the usage of tobacco be evident in the United States.

Conclusion

Tobacco related disease and disability is a worldwide issue. Even so, some aspects of the problem are uniquely American and some problems span the entire spectrum. The newest legislation, the Family Smoking Prevention and Tobacco Control Act does have some merit and may in fact prove effective in some parts. It does have its flaws though, many of which are historical in nature. In order to understand why this legislation is so limited in its scope, one must look the 1998 Master Settlement Agreement for how government finances got so entwined in tobacco sales. Furthermore, a general overhaul in the way public health professionals think and act when implementing interventions should take place. New research shows what is effective in changing behaviors if the profession only looks to them. These new tactics of how to frame issues alone could increase the effectiveness of interventions drastically. This being said, if something does not happen to change the historical tendencies in this country to exclude some groups from the advances of policy and social standards, no intervention will truly be all encompassing. In the case of the newest tobacco legislation, black smokers are passed over in protection from deadly menthol cigarettes. This is not to say that this overlook was intentional, but as Camara Jones illustrates in her analogy of the gardener with the two gardens, the gardener must realize that the problem with some flower’s stunted growth is in its roots (17). Society needs to take all of these tools to cultivate a more prosperous garden for all.

REFERENCES

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-2212.
2. Department of Health and Human Services: Centers for Disease Control and Prevention. Smoking and Tobacco Use. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/
3. Office of the Attorney General. Tobacco Master Settlement Agreement. California: Office of Attorney General.

4. Join Together. Tobacco Settlement Helping to Ensure Profitability of Industry. Join Together. Accessed on April 27, 2010 at
5. Associated Press. Obama Signs Sweeping Anti-Smoking Bill. MSNBC. Accessed on April 27, 2010 at
6. Dietz NA, Westphal L, Arheart KL, Lee DJ, Huang Y, Sly DF, Davila E. Changes in youth cigarette use following the dismantling of an anti-tobacco media campaign in Florida. Preventing Chronic Disease. 2010;7(3):A65. http://www.ncbi.nlm.nih.gov.ezproxy.bu.edu/pubmed/20394704
7. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
8. Gregson, Jennifer, et al. System, Environmental, and Policy Changes: Using the Social Ecological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs with Low-Income Audiences. Journal of Nutrition Education. 2001;33:1.
9. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
10. Weinstein, Neil D. Taking care: understanding and encouraging self-protective behavior. Cambridge, MA: Cambridge University Press, 1987.
11. Deyton, L, Sharfstein, J, Hamburg, M. Tobacco Product Regulation — A Public Health Approach. NEJM 2010. Accessed on April 27, 2010 at
12. Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.
13. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp. 25-41.
14. Richardson GE, Tucker MA, Venzon DJ, Linnoila RI, et al. Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers. Annals of Internal Medicine 1993. Accessed April 27, 2010 at
15. Congress of the United States. H.R. 1256: family smoking prevention and tobacco control act. Govtrack.us 2009. Accessed on April 27, 2010 at
16. Muilenburg, JL, Legge, JS Jr. African American adolescents and menthol cigarettes: smoking behavior among secondary school students. Journal of Adolescent Health 2008; 43(6):570-575.
17. Jones CP. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health 2000; 90:1212-1215.

Failure Of The National Anti-Meth Campaign- Heather Elder

Introduction
Methamphetamine is a stimulant that affects the central nervous system by increasing the production and blocking the reuptake of the neurotransmitter dopamine. This increase in dopamine causes the user to feel euphoria or a rush. Prolonged use of this drug can result in physical, chemical, and molecular brain changes. These brain changes are what drive the user’s need to attain more of the drug, which results in addiction. The most common form of meth is a white crystalline powder that is easily dissolved in alcohol or water to be taken orally. It can also be injected, smoked or taken through the nostrils. The few medical applications for this drug require only extremely small amounts, which would not be sufficient to meet the needs of abusers. The 2008 National Survey on Drug Use and Health reported a decrease in the number users 12 years and older between 2006 and 2008, particularly in the age groups 12 to 17 and 18 to 25 (1). Although the use of methamphetamine among young adults has decreased over recent years, there is still a need for intervention programs that target these age groups.
Intervention
Since 2007, the National Youth Anti-Drug Media Campaign has run the National Anti-Meth Campaign. The target audience of this media based campaign is young adults 18 to 34 years old, as well as the families and friends of meth users. The age demographic selected has the highest rate of starting and using meth. The campaign focuses on the sixteen states with the highest rates of meth use. The campaign attempts to reach its audience through TV, print, online, and radio advertisements. In 2009, the Anti-Meth Campaign was re-launched with the intent to focus on educating the public about the consequences of methamphetamine use. The main campaign ended in November 2009, however the materials are now available as customizable public service announcements for non-profit and other anti drug organizations (2). The key components of this intervention program, such as their website and media advertisements, were based on a behavior model that proved to be ineffective in use. Thus, the continued use of these materials will be ineffective.
Issues Facing this Intervention
The intervention program is media based, using posters, television and online advertisements, and a website.2 The website and advertisements were designed using the Health Belief Model, which is an individual based rational decision-making model. The model examines an individual’s behavior choices through three factors: modifying behaviors, an individual’s perception, and likelihood of action. The key assumptions of this model are that all behavior is pre-determined and individuals are rational. The model is typically used for predicting preventative health behaviors such as receiving vaccinations. However, it is less effective for complex decisions due to the key assumptions being incorrect. Individuals are not rational and behavior is not pre-planned. The model also fails to account for cultural factors, past experiences or socioeconomic status. Additionally, an individual’s intention to act doesn’t always result in an action (3). These limitations make this model ineffective for anti-drug programs.
When designing an anti-drug program, it is key to understand how people make the decision to try drugs. This decision is often affected by social motivations, such as culture and socioeconomic status. It is also often unplanned. An intervention program needs to account for these factors, which the National Anti-Meth Campaign does not. The campaign only provides educational material to the public with few additional resources. This educational material is meant to provide the public with enough facts and statistics to make the logical decision about meth use. The logical approach is maintained during the campaign’s appeal to the loved ones of addicts. By using this logical information based approach the campaign fails to connect with the target audience on an emotional or cultural level. It also ignores the factors that make the drug accessible and desirable. By using the Health Belief Model, the National Anti-Meth Campaign limits its ability to connect with its target audience, which minimizes its ability to motivate behavioral change.
One key component of this campaign is the website. The website provides drug facts, intervention instructions, legal consequences, treatment options, and copies of the advertisements. Currently, it is also providing information on a new intervention program for tribal lands, which is comparable to previous intervention programs run by the campaign. The facts provided by the site are meant to educate the public on the importance of the harmful physical and social affects of meth, and the legal consequences if an addict is caught. Under the “Enforcement” section, there is a subsection that provides information on arrests and sentences of addicts. This is meant to give the target audience a clear understanding of what will happen if they are caught using this illegal substance. The section is also meant to scare individuals away from trying the drug because of the severe consequences. There is a subsection on diversion, which explains how the drug is made and ways drug dealers attain the required indigents. Additionally, there is information on how law enforcement officials track meth distribution and manufacturing. This section outlines the social consequences, which communities face as a result of this drug industry (2).
Although this section provides many facts and statistics, it will not stop people from trying meth. Individuals may perceive this information as a threat by the government regarding meth use. The message people will take away is that if one uses meth, and then one will get arrested and sentenced to years in prison. People will react in several different ways to this kind of threat. Some individuals will see this threat as a dare, which will cause them to be tempted to try the drug to see what will happen. Additionally, the manner in which the campaign message is conveyed does not provide a way for the target audience to connect with these consequences. This lack of connection will result in people reading the information, but believing that they would never get caught if they chose to try the drug. If there is no convincing threat of getting caught, then people will ignore this message and maybe try the drug. To try to correct this ineffective use of information distribution, the campaign should use stories of people from the target group, so the audience can connect with them.
Another section that has several problems is the “Intervention and Treatment” section. The treatment subsection implies that the best treatment for meth is to never use it in the first place. Although this is true, it suggests that the process of quitting is almost impossible. The authors of this subsection do state that it is possible to recover, but that it is extremely difficult. However, if one does want to take the initiative to quit, then the best solution is cognitive behavior therapy or pharmaceuticals (2). The tone of this subsection is not written in a manner, which would motivate addicts to seek treatment.
If this is the message the National Anti-Meth Campaign wants to give current addicts and their loved ones about treatment, then few will seek it or try to intervene. An anti-drug campaign is meant, not only to steer people away from trying drugs, but to encourage addicts to quit and help families realize they can step in to save their loved ones. The negative tone of the intervention subsection implies that one method to deal with addicts is to leave them in the hands of the justice system. By using a negative tone and taking this stance, the campaign is biasing people towards inaction rather than motivating them to intervene. The negative tone will make people question how much they want to help an addict, because it portrays addicts as being extremely dangerous. It is true that meth addicts can be extremely dangerous. Thus, caution is required for preparing and doing interventions. Therefore, the campaign should do more to support these individuals by providing information on interventions, and additional support such as places to talk to other who are going through the same things. This campaign should motivate people to help others, and encourage addicts to seek treatment. With the current phrasing and content of the website, the campaign is failing on both of these key points as an intervention program.
Not only does the content of the campaign’s website fail to effectively motivate the target audience to stay away from meth, but also fails to make a connection with them. By only providing facts with some additional resource links, the opportunity to form a connection is lost. If the designers of the campaign had realized the need to connect, then the website would be much more effective. The website should include a section highlighting the stories of real meth addicts, a place where people could blog, or a group that people would be able to join to show their support for the anti-meth message. All of these methods would help people form this needed connection with the campaign’s message. The website should be utilized as a key tool to motivate the target audience by including them in the fight against meth. By including the target audience, the campaign is giving individuals power and a stake in the anti-meth movement. If people have a connection with or an investment in the message, then the campaign will be much more effective.
The use of the behavioral model was not only utilized in the construction of the website contents, but also as the foundation of the design of the advertisements. Multiple posters and TV advertisements were created by the campaign to convey its message to the target audience. The advertisements are used as a tool to connect with the audience, but they fail to do so. Although there were posters and TV advertisements, only the posters will be focused on. The format of the posters was not well conceptualized from a design standpoint, and they fail to convey the desired message. The content of the posters also has some issue, but it is the design that hinders the message. There are three posters, which are particularly bad at achieving their desired affect; these are ‘Little Boy’, ‘I Lost’, and ‘Trapped’.
The ‘Little Boy’ poster is an image of a young Caucasian boy, about three years old, on one side and the statement ‘Look at all you could loose’ on the other. The image is placed within the word “METH” (2). When one first looks at this picture, the eyes are drawn towards the image of the sad child. Eventually, the text is also noticed. Overall, it is a very interesting composition, but people may fail to make a connection between the image of the child and the message. It is apparent, when viewing the poster, as a whole, there is a clear divide between the textual and the visual messages. This division is formed by the negative space between the E and T in meth. The negative area completely cuts the boy off from the message. Thus, the viewer will not make the desired connection. There are several simple solutions that the designers could have done to improve the poster. The first would be to make the image of the boy larger, so that part of his shirt is on the letter E where the message is located. This would unite his image with the text. The second solution would be to not completely block out the image from the original picture of the boy by providing a faint ghost image of the original picture in the background. The area of the image outside of “METH” would be screened back to allow the dominant message to read. The screened image would still unite the visual and textual message. The campaign could have also taken the additional step of providing multiple versions of this poster with children of different races. This last alteration would allow the campaign to reach other groups.
The ‘I Lost’ poster depicts a young Caucasian male, against a blank wall. To his left the text “my friends…” appears. On the other side is text explaining that he lost those things to meth addiction (2). He is not the stereotypical image that the public associates with a meth addict because he appears to be healthy and has some personal hygiene. By placing him in the center of the poster, the viewer’s eyes are drawn directly to him, but at the same time he acts as a barrier between the list of items and the “lost” statement. As a result of this placement, the viewer doesn’t make the connection between the two sets of text. By just listing what the young man lost to meth, there is no connection made between the viewers and what was lost. It is more difficult for viewers to form an emotional connection with a list of words than images. There are some changes that can be made to the poster to make it slightly more effective. The most important change would be to connect the two sets of text by placing them on the same side of the poster. The next would be to change the background to a depressing place such as a dark ally. The text should then be placed on an adjacent brick wall. The text should also be changed to focus on key core values of the target audience such as independence, self-control, and safety. The third change needs to be to his appearance. He should look not only sad, but also dirty and unhealthy, like he has lost everything. This poster needs to form an emotional connection with its audience. Like the ‘Little Boy’ poster, several versions should be made to address different sub target audiences.
The ‘Trapped’ poster is the most visually simple poster in the anti-meth campaign. All it consists of is an image of a hand beneath a plastic sheet trying to push its’ way out. A small set of statements about meth is in the bottom corner of the poster (2). This poster doesn’t appear to have any connection to the anti-meth message. When viewers first look at this image, they would have no idea what it is about. It has the slight appearance of a movie poster. The designers are trying to provide the audience with a visual image of the idea that meth will trap and control all those who try it. The designers want the target audience to understand the threat that meth poses to their self-control and independence. Though this is a visually evocative poster, it does not help the viewers make a connection with the message because it is not clear what the message is. The designers could attempt to alter the poster to make it more relevant by adding another hand and a face. This creates a stronger image of a person and the audience may be more likely to identify with being trapped by meth addiction. The statements should also be enlarged to provide a stronger visual presence. The statements should focus on the loss of independence and self-control, which is very important to those in the target audience.
The National Anti-Meth Campaign is based on the wrong health behavioral model and has an ineffective media program. However, changes can be made to correct many of these issues by selecting a more effective health behavior model and by making attempts to connect and support its target audience. The new health behavior model should be one that is designed to include social aspects and past experiences that are key in complex decision-making. The model should also be used to focus on the target audience’s core value in order to motivate behavior changes. The additional use of a social group will bring the target audience into the campaign and use them to help spread the message. The posters should form an emotional connection with the viewers’ by the use of strong visual images and supported by more than facts. With these changes, the National Anti-Meth Campaign will more easily achieve its goals.
New National Anti-Meth Campaign
The new National Anti-Meth Campaign would be constructed using Advertising Theory with the use of additional features. Unlike the Health Belief Model, Advertising Theory is not individual based, doesn’t require rational decision making, and does not assume that all behavior is pre-determined. Although Advertising Theory doesn’t require facts to effect behavior change, it is important that an anti-drug campaign provides them. The key feature of this theory is the promise that is made to the target audience. This promise should be something that is a core value to them such as freedom, happiness, independence, self-control, and safety. The theory also implies that the larger the promise, the more effective it is at causing behavior change. The campaign will be design to make these promises to the target audience (4). The message will be that if they make the decision to use meth, they will loose these key values that are so important to them. This promise will still be used for all target groups, but slightly altered for addicts or the their loved ones. The campaign will promise that if addicts decide to seek treatment for meth, then they can regain the core values they had lost to the drug. The campaign will motivate the loved ones of addicts by encouraging the idea that they are not hopeless and can help those they care about.
To adequately provide the needed motivation to all three groups, the campaign must still present the public with information on treatment options, intervention methods, and general facts about meth. The basic information about the drug will be provided, because many people do not know all of the physical, emotional, and social effects meth can have on individuals and families. The information section will explain why the campaign is being run. The tone of the content that is currently used on the website will be altered to provide a more optimistic view of recovery and interventions.
Not all the information that is currently on the campaign website will be retained. The information on sentencing, laws, and how dealers attain their materials will be removed because it does not help to deter people from the drug. This information is only designed to arouse fear in order to deter them from trying the drug. Fear is not always the best tool at predicting and altering complex decisions (5). In the case of this campaign, fear will turn people away from the message, before they have a chance to fully understand it. The fear tactic will not only turn off non-users, but makes users and their loved ones less likely to change or help other change. The new campaign will focus on making people want to remain drug free or become drug free. It will not try to scare them into treatment or away from the drug. Instead it will use support and encouragement, which are two of the most important components to recovering from such an addictive drug.
The campaign’s website will focus on providing some information, personal stories of addicts and their loved ones, a place for people to blog, and a social networking group that focuses on spreading the anti-meth message. It is important for the site to attract and hold the interest of the audience. In order to hold the attention of the target audience, key changes must happen to the format of the site. If the audience’s attention is not engaged, then the message will not be retained. Small changes such as background, font choice, and a complete overhaul of the logo have to happen first. The logo must be visually stimulating and youthful. It has to catch peoples’ attention and make them want to find out more about the program. By changing the font and background, the whole site will be more attuned to the culture of the target audience.
Currently, the advertisements run in a corner of the home page. This feature will be removed and replaced by the current leading personal story. This story is intended to form an emotional connection between the individual and the audience. The story will not only tell about what happened to that individual, but also make a connection to the core values that the campaign is selling through the promise. These selected people will recount how the drug took their freedom, independence, self-control, and individuality away. The stories will mention family, but focus on the values because that is the focus of the campaign’s promise. The home page will also feature group activities and pictures, which members are encouraged to participate in. It will also have a place where interested parties can join the anti-meth movement.
The section headers will feature resources, the social group, blogs, personal stories, and key information about meth. The resource section will provide addicts and their loved ones with the available treatment options, how to find local programs, first steps that can be taken to quit, and additional support. Recovering from meth or getting someone to agree to rehab is extremely difficult. These people will need all the help and support that they can get. This program will provide them with resources for the difficult path that will lie ahead of them. The blog will allow non-users, loved ones, and recovering addicts to talk about what is going on in their lives. The addicts and loved ones will be able to get additional support from the online community found at the site. This support will help motivate them to continue their recovery or to step in to help a loved one who is an addict. The personal stories can be considered another form of support for the addicts and families because these will be people who went through the same experiences and got through it successfully. The personal stories are meant to serve as additional support and a deterrent for those who have not tried the drug yet. Non-users will be able to form a connection with the personal stories and realize the importance of staying drug free.
The group and blogs are completely new features to the anti-meth program. The group is designed to promote/promise the core values of freedom, independence, self-control, and individuality. It will motivate people to stand up and fight for the values that are so important to them in their young lives. This motivation will occur by labeling the drug as a control mechanism. The campaign will not use facts to attract group members, but use the promise that joining the group will be a way to ensure that meth will not take away their independence, freedom, self-control, and individuality. The group will have merchandise and online activities. These features will make members feel like they belong to something. It will give them a stake in the anti meth movement. By giving a person something, they are more willing to fight for it because they perceive it as theirs (6). Since the blog will be open to everyone, members and non-members can provide support to recovering addicts and their loved ones. The blog will also be a tool for people to discuss different ways to remain drug-free.
The new campaign will continue to have a large media section. These advertisements will be designed using Advertising theory. They all will focus on selling the selected core values to the target audience. The advertisements will not provide facts about the drug because that is not how to reach a mass audience. In order to reach a mass audience, one has to provide them with a chance to get or keep something that is very important to them. Companies use this theory to sell their products. Large companies sell the values of youth, beauty, independence, freedom, individuality, and family to make people want their products. The ads are designed to convince people that by buying the products, they will be able to attain those values. This campaign will do the same thing, but instead of a product, the anti-meth message will be sold to the audience.
Posters and TV advertisements will be utilized by this campaign. The posters will continue to feature individuals, so that the audience can associate a face with the message. The posters will be similar to the personal stories on the website. By telling the story of even one person, in a large-scale media campaign, people will develop a connection with that individual. This person will illustrate the experience of losing their core values to the drug. Some of the posters will provide images of people choosing their values over meth. All the posters will contain the core values because that is what is being sold to the public. There will be some TV advertisements that are directly connected to some of the posters. Others will focus on selling the core values to the target audience through the use of visual images. These posters and TV advertisements are meant to make people want to keep the selected values or get them back. The campaign will display the TV advertisements during peak viewing hours and on the top shows of the target audience. The posters will be placed is area with high traffic of the target audience such as around school, in malls, and by parks.
This new campaign is very different from the majority of traditional public health campaigns because it is not based on one of the traditional behavior models. Most traditional intervention programs are individual based and require rational decision-making. This makes it very difficult to alter the behavior of groups of people at the same time. The re-designed campaign doesn’t require people to make the logical choice about drugs, but it makes them want to protect or get back parts of their lives that are so important to them. By making people see the anti-meth message as more than just a simple “say no” message, they will begin to see it as being important. This program is designed to motivate people to stay meth free, become meth-free, or help others to regain their core personal values.


References
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