Why the Soda Free Summer Campaign’s Reliance on the Health Belief Model Limits Its Efficacy in America’s Fight Against Obesity

The Added Sugar That’s Making Us Fat

Obesity in the United States has reached epidemic levels. 32.2% of adult men and 34.5% of adult women can be classified as obese (with a body mass index of 30 or more) (1) and many see sugar-sweetened beverages as a major contributor to the fattening of America. The Nurse’s Health Study II found that consumption of sugar-sweetened soft drinks was positively correlated with caloric intake, weight gain, and incidence of diabetes (2). A prospective observational study found that for each additional serving of sugar-sweetened drink consumed, body mass index and frequency of obesity both increased after adjusting for anthropometric, demographic, dietary, and lifestyle factors (3). Soda consumption in particular, has also been negatively associated with children’s nutrient intake, specifically vitamin A in all age strata, calcium in children under 12, and magnesium in children 6 years and older (4). The American Association of Pediatrics recommends that doctors suggest limiting intake of sugar-sweetened beverages to all children but those below a 5% body mass index (5).

The Soda Free Summer Campaign aims to reduce obesity and obesity-related diseases by inspiring individuals to abstain from drinking soda and other sugar-sweetened beverages for a 10-week period during the summer. The campaign, first implemented in the San Francisco Bay Area, recruits people to sign a pledge card to commit to a soda free summer and log their progress. To support the campaign they distribute informational pamphlets and promotional materials such as wrist bands, conduct Be Sugar Savvy workshops showcasing sugar content of beverages, and spread their campaign messages via local media outlets (6).

This critique of the Soda Free Summer Campaign postulates that the campaign’s reliance on the health belief model (7, 8) limits its efficacy through its focus on the individual, assumptions of rationality and unfaltering self-control, its lack of environmental and policy considerations, and its failure to provide compelling visuals or appeal to core values.

If Only Our Behavior Was Truly Individual, Rational, and Subservient to Our Long-Term Health Goals

The view that lifestyle is determined simply by the sum of behavioral choices and some intrinsic personality characteristics is antiquated at best. No consumer ever entered a restaurant demanding a bottle filled with high fructose corn syrup; consumer choices are made based on which products are produced and promoted by corporations whose goal is profit maximization (9). The idea that this consumer should be the sole target of a campaign to reduce obesity is a predictable, individualistic, and simplistic western response (10) especially given that there is little evidence that individual level interventions have had much success at the population level (11). Dietary behavioral change is not always as easy as simply deciding to make a change but is instead a complex interplay between availability and cost of alternatives, social supports, and consistent positive feedback that outweighs the barriers to making the change (12). After all, if it were as simple as deciding to make a positive change we would all stick to our New Year’s Resolutions, strictly adhere to our diets, and exercise regularly.

We humans are deeply irrational beings (13). The world in which we rationally weigh the costs and benefits of each possible choice and do only that which we intend, while remaining uninfluenced by those around us or by the environment around us, is called an economic model. In reality, we judge people’s personalities differently if we’ve been exposed to different temperatures (14), we start diets and then decide to have one more piece of chocolate cake (15), and we fail to adhere to healthy behaviors even after we’ve actually experienced a negative health outcome like cardiovascular disease, hypertension, or diabetes (16).

Rather than being isolated and independent actors, we are deeply affected by the behavior of others (17-19). Teenage girls who see other teenage girls having children are more likely to have children themselves and the GPA of a college freshman’s randomly assigned roommate can essentially predict her GPA (20). Quantitative analysis done using data from the Framingham Heart Study demonstrated that over a 32 year period individuals connected by social ties gained weight and quit smoking in concert. A person’s chance of becoming obese increased if she had a friend, spouse, or sibling who became obese in a given interval but was not affected by a neighbor becoming obese (21). In the same vein, smoking cessation of a spouse, friend, sibling, or co-worker at a small firm considerably reduced a person’s chances of smoking (22).

Consumption of sugar-sweetened beverages in particular, has been associated with other dietary patterns (23), clustered with TV viewing among teens (24), and influenced by parental consumption among Latinos (25). The focus on individual and isolated behavior ignores social influence and our current understanding of human irrationality.

Left to Our Own Devices: Why Environmental and Policy Changes Shouldn’t Be Ignored

While the 2009 Soda Free Summer Campaign gauged public support for policy changes (26), its failure to incorporate any environmental or policy nudges as part of the intervention weakened its efficacy. This decision, in keeping with the simplistic view of the health belief model, relies heavily on an individual’s self-control and fails to take advantage of the power of a small environmental nudge in the right direction.

Recent research showing the degree to which we underestimate context and overestimate our ability to behave in accordance with our good intentions has underscored the usefulness of policy and environmental interventions. It turns out that different parts of the brain are involved with planning and doing: the planner part looks out for our long-term welfare while the doer easily succumbs to temptation; a man on a diet might agree to go out with colleagues thinking that he can resist the wine and desert options but immediately orders wine once at the restaurant (27). The farther removed we are from a temptation the more self-control we have and the more self-control we believe we will have when tempted. This is why so many pregnant women say they will refuse drugs during labor but so often change their minds once actually experiencing the pain of childbirth (28) and why when given the choice of $100 in 30 days or $110 in 31 days nearly everyone chooses $110 in 31 days but when given the choice of $100 today or $110 tomorrow nearly everyone chooses the instant $100 (29).

Small environmental and policy changes can help steer us toward healthier choices without mandating or controlling our behavior. Smaller portion sizes can nudge us to eat less (30-31), musical stairs can coax us off the escalator (32), and greater access to physical activity resources encourages us to be physically active without telling us to be (33). Taxing unhealthy products is another social disincentive policy at our disposal. Cigarette taxes are seen as a useful way of reducing smoking and increasing state revenues (34) and some states have begun to implement soda taxes (35) in the same vein. Some also call for a ban on food advertising to children (36) citing studies like one published in Health Psychology showing that children consumed 45% more when exposed to food advertising (37).

In the case of sugar-sweetened beverages, a randomized, controlled pilot study almost completely eliminated sugar-sweetened beverage consumption in a diverse group of adolescents and showed a beneficial effect on body weight through delivering beverages with no added sugar to the homes of adolescents (38).

Environmental interventions and policy changes can be effectively used to incentivize healthier behaviors, discourage unhealthy behaviors, improve availability of healthy alternatives, restrict access to unhealthy foods, control marketing and advertising, and create communities that support healthy lifestyles (39). With such potential to influence behavior at the population level, they should not be ignored.

Selling Health and Statistics: No Match for the Coke & Pepsi Promise

The Soda Free Summer Campaign promises a reduction in weight gain, a reduced risk of diabetes and heart disease (40,41) and the chance at a few raffled prizes in exchange for giving up soda (42). The health promises are backed up by statistics about sugar consumption and obesity-related diseases. The campaign also created a video that reiterates the same statistics on their website and fails to provide compelling visuals or appeal to core values like independence and control.

While the Soda Free Summer Campaign sells health benefits, Coke and Pepsi make grand promises and appeal to consumers’ core values. Coke promises its consumers happiness with its “Open Happiness” advertising campaign (43) and “Share Happiness” slogan for its new 2 liter bottle and backs up its promise with images showcasing beautiful, young people looking incredibly happy (44). Pepsi makes similarly grand promises: if you drink Pepsi you will belong to a larger movement of youthful change makers (45) appealing to American values of community and positive social change. Both Coke and Pepsi have recently launched “movements”, further capitalizing on Americans’ hunger for positive change, with the Pepsi Refresh Project which awards grants to “refreshing” ideas (46) and Coke’s Live Positively Campaign which supports environmentalism, active lifestyles, and volunteerism (47).

If indeed Americans saw health as a core value, the Soda Free Summer Campaign and other health promotion campaigns who promise health would be more effective and we might see fitness facilities marketing health benefits rather than attractiveness. Time and time again, health does not motivate our behavior (48). The 5 A Day Campaign is largely considered a failure (49, 50), nutritional knowledge has been shown to have only a peripheral impact on children’s food preferences (51), and smokers who overestimate the prevalence of heart disease and cancer in smokers continue to smoke (52). This is only magnified by the fact that we have an incredibly strong optimistic bias, so that even if we know and understand the health risks and statistics related to diseases like obesity and diabetes we think our own susceptibility is below average (53, 54).

While the Soda Free Summer Campaign utilizes promotional materials, reaches out to local media, and contains a short video, it fails to be an effective social marketing campaign. An effective campaign must have a unified core position, evoke desired visual images, employ recognizable catch phrases, suggest appropriate metaphors, showcase its program as the solution, and must not attribute the problem to the individual (55). The Soda Free Summer Campaign fails to suggest any appropriate metaphors or use compelling visual images and attributes responsibility solely to the individual.

The Soda Free Summer Campaign also runs the risk of inciting reactance through its negative messaging. The campaign tells you that soda and other sugar-sweetened beverages should be completely given up, essentially a “just say no” campaign. Between the request to give up something that for many may be a daily habit and the adults in the video barraging you with facts and statistics, the campaign may elicit psychological reactance. In a study done with heavy drinkers, those exposed to “Don’t Drink” messages drank significantly more directly after exposure to messaging than those exposed to a “Drink Moderately” message (56). A video on youtube in response to New York City’s Pouring on the Pounds Campaign (57) is a concrete example of this kind of response, showcasing New Yorkers who feel angry and rebellious toward a campaign which they see as the government telling them what to do (58).

An effective social marketing campaign could go a long way in the fight to reduce American consumption of sugar-sweetened beverages but we won’t get there by putting seemingly far-off health promises up against happiness.

A Different Approach: How Using the Social Ecological Model and Advertising Theory Could Nudge People Toward Healthier Drinks And Create a Social Movement

The social ecological model with a strong social marketing component modeled on the Truth Campaign’s success has the potential to effectively reduce sugar-sweetened beverage consumption, obesity, and obesity-related diseases at the population level. The social ecological model has many advantages over other public health models as it provides an effective framework for real people living in complex environments (59). Prominent agencies like the U.S. Centers for Disease Control have used this framework to assess and coordinate school health services (60) due to its comprehensive structure that addresses the macrosystem (laws, history, culture, economic system, social conditions), exosystem (extended family, community centers, neighborhoods, mass media), and microsystem (family, peers, siblings) components that surround each individual (61).

Policy initiatives that eliminate corn subsidies, tax sugar-sweetened drinks, or even ban high fructose corn syrup, mandate 0 sugar-added drinks in schools, government buildings, and government funded community centers, and ban sugar-sweetened beverage advertising to children could significantly alter the demand and availability of sugar-sweetened beverages and nudge people to make healthier choices. A broad-based social marketing campaign modeled on the Truth Campaign’s use of advertising theory (62) could include a series of ads that promise unity and social change with desired visual images. The campaign could also harness reactance to create positive behavioral change by appealing to people’s distrust of government and corporations and inspire a Tea Party-esque outrage about corporate profit margins and institutionalized racism (63) and the government’s subsidization of the high fructose corn syrup that’s making our country fat.

Beyond Door-to-Door: How We Can Effectively Target the Population

The social ecological model and advertising theory are both group-level models. For these models we need not assume that humans make decisions in rational vacuums and we avoid the typical western trap of blaming the individual; we actually take advantage of the social influence we have on one another instead of ignoring it. Corporations like Coca-Cola and Pepsi who produce and promote sugar-sweetened beverages have always successfully aimed their promotion efforts at the population, so why should we go door-to-door?

The ecological model allows us to target the population and see population level results. Shape Up Somerville is an ecological wellness intervention that has successfully reduced body mass index of elementary-aged children at the population level (64). Its initiatives have encouraged an entire city’s children to become more active not by targeting individual children but by creating an environment that supports activity for all.

Effective social marketing like the Truth Campaign also have an essential role in modern public health promotion (65). They successfully target a wide range of groups in an array of settings (66) and address the population as a whole (67). Successful campaigns have increased demand for everything from condoms in Zambia (68) to syphilis testing among gay and bisexual men in San Francisco (69).

Nudged: How Environmental and Policy Changes Can Help Us Make Healthier Choices

Policy and environmental changes give the planner in us a chance to follow-through on our good intentions by creating an environment that supports healthier options. We have seen these interventions work to combat smoking (70) and increase healthy behavior in schools (71).

Getting rid of corn subsidies would eliminate the artificially low price of high fructose corn syrup, a base ingredient in the most popular sugar-sweetened drinks. A sugar-sweetened beverage tax would further increase the price and a ban on high fructose corn syrup might be considered given its other negative health effects (72-74). The American Public Health Association supports a soda tax citing that it is just as appropriate as a cigarette tax and could help pay for the $47.5 billion a year that the government spends on medical care related to obesity through Medicaid and Medicare (75). Economists estimate that a 58% soft drink tax would result in a small but real decrease in body mass index (a reduction of 0.16 points) (76) so just think what a broader sugar-sweetened beverage tax could do.

Mandating 0 sugar-added drinks in schools, government buildings, and government funded community centers and a ban on sugar-sweetened beverage advertising to children would improve environmental support for healthy choices and allow for mindless choosing of healthier options in schools and other public institutions. This could improve health and change social norms in much the same way as cigarette bans have (77, 78).

A New Truth: High Fructose Corn Syrup, Sugar-Sweetened Beverages and Obesity

Public Health campaigns have an enormous opportunity to learn from commercial branding and marketing strategy. We need to cultivate brand recognition, promise core values, and deliver on those promises (79). If we strategically reframe the issue of sugar-sweetened beverages we can affect population consumption by selling core values, harnessing reactance, and starting a social movement.

The VERB Campaign and the Truth Campaign were highly successful social marketing campaigns that used advertising theory to begin positive social movements and significantly increased physical activity (80, 81) and reduced smoking respectively. The VERB Campaign and associated advertisements promised community and opportunity. The campaign sent yellow balls all over the country and put kids in charge. VERB challenged kids to invent new games that could be played with the ball and then pass the ball on to someone else giving kids an opportunity to feel in control (82). The Truth Campaign appealed to adolescent values of rebellion and independence (83) and created a counter-industry movement that significantly reduced the prevalence of smoking in Florida teens (84-88).

The issues surrounding sugar-sweetened beverages, high fructose corn syrup, and obesity are rife with material that would make an excellent Truth Campaign. Instead of selling abstinence of sugar-added beverages, a social marketing campaign could sell freedom, independence, control, and rebellion. It could inspire a movement that stood for community and rebellion against the corporations and government subsidies that conspire to make Americans fat. The “product” being sold would be identity as a fit and attractive person in charge of her appearance and rebellion against the feelings of unattractiveness and lack of control over her appearance (89).

Uniting Against Obesity: Conclusion and Call to Action

The Soda Free Summer Campaign has severe limitations due to its reliance on the health belief model, its focus on isolated and rational behavior, its failure to address policy and environmental change, its weak promise backed up by statistics, and its failure to provide compelling visual imagery. The campaign could be improved by addressing any one of these failures.

Obesity is arguably the most serious health issue in America today. The public health community needs to incorporate best practices from successful public health marketing campaigns and ecological model approaches in order to target the population and stop blaming the individual, nudge us toward healthier choices with smart policy and environmental supports, and inspire us to join a movement where we stand up against government subsidies and corporate agendas and say enough is enough.

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Hyperlinks:

Soda Free Summer Campaign Video:

http://www.sodafreesummer.org/news.html

Coca-Cola Commercials:

http://www.youtube.com/watch?v=3hj0JMCHZpI

http://www.youtube.com/watch?v=nlpZRK2Yfd0

Coca-Cola Live Positively Project:

http://www.livepositively.com/#/home

Pepsi Commercial:

http://www.youtube.com/watch?v=-Ob2HGQtQWo

Pepsi Refresh Project:

http://www.youtube.com/pepsi?utm_source=pepsi&utm_medium=banner&utm_content=panel&utm_campaign=refresh#p/u/17/2fS39FitsoQ

Sprite Commercial:

http://www.youtube.com/watch?v=KtJ6bXnoQxE

The Truth Campaign Commercials:

http://www.thetruth.com/videos/

NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=-F4t8zL6F0c

ABA’s Response to NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=K65TAi_siCo

The Fun Theory:

http://www.youtube.com/watch?v=2lXh2n0aPyw

People get fat in groups:

http://content.nejm.org/cgi/content/full/357/4/370/DC2

People quick smoking in groups:

http://content.nejm.org/cgi/content/full/358/21/2249/DC1

Decreasing Obesity or Increasing Guilt? A Critique of the Labeling of Menus with Calories – Francine L Maloney

Introduction

On March 23, 2010 President Obama signed Public Law 111-148, previously known as the Health Reform Bill, into act. Among the 904 pages, there are new laws regarding health insurance among Americans, taxes on tanning salons and tax rebates for small business owners; all of which received vast media attention. But about half-way through the document one will stumble upon “Section 4205. Nutrition Labeling of Standard Menu Items in Chain Restaurants,” a part of which states, a “retail food establishment that is part of a chain with 20 or more locations…shall disclose in a clear and conspicuous manner …the number of calories contained on the standard menu item” (1).

In the past 30 years, the prevalence of obesity in the United States has increased substantially, from 23% to 31%, most of which has been attributed to a decrease in exercise and an increase in calorie consumption (2). In 1990, while obesity was still on the rise, the Food and Drug Administration (FDA) required nutrition labels be placed on food products (3). It would take another 14 years before the FDA’s Obesity Working Group would recommend providing nutritional information at the point of sale in restaurants (3).

Since 2004, restaurants across the United States, most notably fast food chains, have been mandated to have nutritional information available to customers. As customers have noticed, and the media has reported on, these brochures are not always in the most obvious of locations. Some chain restaurants have tried to curb this problem by putting in kiosks, which their customers can easily step up to while waiting for their table, look through the menu of available items and find the full list of nutritional information. While this may solve the problems of misplaced brochures and small print, it also creates a host of new issues. For example, the Unos Chicago Grill Restaurant does not list all menu items in their kiosks, and those that are offered are often in multiple serving sizes – potentially misleading some customers into thinking their pasta dish has 640 calories when there are really two servings and 1280 calories (excluding the calories from the breadstick that is served with the dish) (4).

The current passage of this public law will attempt to use the social expectations theory of public health. The social expectations theory works on the foundation of taking the thought, or individual, out of the decision making process and changing the drive of behaviors by law (5). There are numerous laws in the United States that use the social expectations theory effectively, such as prohibiting drinking and driving. Once driving under the influence was no longer an option under new laws, the social expectation was to have a designated driver whenever drinking was going to take place. The thought process of whether or not to drink and drive was eliminated and it was replaced with a new expectation (5).

Although social expectation theory is often effective at changing social norms, especially when linked to policy changes, there is clear evidence that groups of individuals will break the social norm. Just as teenagers often do not wear seatbelts, while the majority of society abides by the social expectation of wearing one; I believe there will be classes of individuals who will not follow the expectations of how the new menu labeling will affect food choices.

Critique Argument 1: Lack of Information

Under the new law, only calorie information needs to displayed on the menu, along with an anchor of the daily caloric needs for most individuals (presumably 2,000 kcal/day) (1). Unfortunately, providing only caloric information is not representative of whether or not the food is good for you. A calorie is the amount of energy needed to raise 1 liter of water 1 degree Celsius from 14.5°C to 15.5°C at 1 atmosphere, but that does not tell the average person whether they should order the small or medium fries; and neither does showing them only calorie information and omitting the other nutritional contents (3).

In 1990, the Nutrition Labeling and Education Act put into effect food labeling on all products, which had to include serving size, the number of servings in the container, calories per serving, total amount of fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, total protein, and dietary fiber (6). Except for a few small changes this is the same information we see on food labels today, and this is the information in which people are used to assessing before making a decision based on nutritional information.

Beyond the gross lack in all nutritional information, studies have shown that various individuals use different pieces of information before deciding upon what to eat. These factors include, individual characteristics (e.g. age, gender, education), situational, behavioral and attitudinal characteristics (e.g. income, working status, special diet status, diet-health awareness, organic buyers, type of household, meal planners, area of residence), nutrition knowledge, motivation, attitude toward nutrition, and product nutrition factors (e.g. price, nutrition, taste) (7). An example of how ones age and use of nutritional label use was summarized by Drichoutis et al, stating “specifically, as age increases so is the likelihood of using information about fat content, cholesterol content, and health benefits” (7).

By only providing caloric information the customer is left in the dark about how the nutrition is divided among the food. Exactly how many calories from fat or whether the meal is largely protein or carbohydrate based cannot be told from calorie information alone. If the goal is for the public to make an educated decision regarding their food intake, we must give them all the information to make those decisions.

Critique Argument 2: Downstream problem-solving for an upstream problem

Menu labeling is an attempt to solve the obesity epidemic by scratching at the surface of a problem in which its roots are not only deeply planted but difficult to understand. Changing a person’s eating behavior has been notoriously difficult (8). In addition, physical activity level, understanding genetic factors, and the psychological influence are all important factors in trying to combat the obesity epidemic.

As soon as an individual looks to lose weight they are advised to cut their intake, mostly through the use of calorie counting. Mann et al conducted a review of studies that looked at the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity (8). While one might expect individuals to lose a substantial amount of weight on calorie-restricting diets, the evidence shows otherwise. The studies indicated that one third to two thirds of dieters regain more weight than they lost on their diets. In addition, these studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change (8). While one of the goals of menu labeling is to make individuals more aware of the calories, and therefore choose the lower-calorie option, may seem like a reasonable solution to cutting a person’s caloric intake – studies do not support this as an effective way of decreasing obesity.

On the other hand, let’s give menu labeling the benefit of the doubt and say that it will help some individuals make “better” choices. Maybe they will choose the 800 calorie meal over the 1,100 calorie option. While some might view that a step in the right direction it would only be addressing one issue. The United States Department of Agriculture recommends every individual has “physical activity [that] should be moderate or vigorous and add up to at least 30 minutes a day” (8). Menu labeling does not even address lack of physical activity as part of the trend in obesity. While one campaign cannot be expected to address every problem, the combination of exercise and healthy food choices may be effective at helping individuals at sustaining weight loss –some studies have shown the best outcomes have come from exercise alone (8).

Finally, displaying caloric information will not help to understand or solve the genetic and psychological drives that individuals have when making food choices. Over the past two decades research has focused on the nature versus nurture debate of obesity; and while it is hard to distinguish completely it has been estimated that the “heritability of body mass index would be in the range of 40 to 70%” by studying a sample monozygotic twins raised together and a sample raised apart (10). Our genes are not the only thing that plays a role in our food choices; our mood is likely to have a large impact as well. As all individual’s have experienced, when we are tired, happy, frustrated, sad, or overwhelmed the food choices we make tend to change. The psychological impact on our decisions cannot be ignored nor can it be minimized. When a person feels rushed and tired, they reach for something that is comforting – as “dietary indulgence is often cited as a consumer’s self-control problem” (7).

Critique Argument 3: Optimistic Bias – Underestimating Risk and Overestimating Labeling

Despite the overwhelming belief that humans are rational beings, all evidence points to the fact that we are repeatedly make irrational decisions (11). One of the most classic forms of irrationality is through the optimistic bias. This theory shows that individuals tend to underestimate risks that apply to them (12). While any one person may understand perfectly well the entire risk, there is an irrational process that overrides their risk.

The most classic example of the optimistic bias is from cigarette smokers. When a group of smokers were asked what percentage of smokers they thought will eventually develop lung cancer, the result was an astounding 43% (the true answer is between 5-10%). But when then asked if they think they are at increased risk of developing heart disease and having a heart attack, 29% did not recognize that they were at an increased risk of disease (12). This universal human phenomenon leaves individuals believing that for every good outcome their own chances are higher than average, while for every bad outcome their own chances are less than average – otherwise known as “it will never happen to me” thinking.

As stated previously, the 1990 legislation of the National Labeling and Education Act (NLEA) required food disclosure of the nutritional content of foods and a standardized labeling on all packages (6). By 1994 the legislation was mandated and all companies had nutritional labels on their products. The theory behind the legislation is similar to today - if individuals are provided with the nutritional information of their food, then they will make better, healthier, food choices.

However, even though nutritional labeling is theorized to allow consumers to make healthier food choices, obesity is still rising and cannot solely be attributed to restaurants (7). While trying to provide more information and give more autonomy to an individual might seem helpful, it might be hurtful. “Ironically, remedy messages boomerang on people they are intended to help most because some consumers appear less risk averse when remedies are available.” (7). Additional studies did not detect any changes in consumers’ search for nutritional information or their recall of this information in the pre- and post- NLEA period (7). While other researchers found “consumers preferences and purchasing patterns within the prepared frozen meals category did not change significantly after implementation on NLEA” (7), which may be more indicative of the behaviors of individuals food preferences in restaurants.

But NLEA went into effect over 15 years ago and discrimination towards the obese has only increased. Some may argue that as a society we will be empowered to make better food choices, we have learned more about nutrition, the media has inundated us with enough guilt that we are ready to make choices that are healthier – at least this is in part what New York City thought in 2008 when it became the first US jurisdiction to mandated calorie labeling on menus of restaurants with 15 or more locations nationwide (13).

It is important to recognize some of the similarities between the calorie labeling in New York City and the national implementation to be mandated, as well as provide some of the rationale provided by New York City’s push for calorie labeling. As stated, New York City mandates all restaurants with 15 or more locations nationwide must take part, for these chains account for a disproportionate share of meals served and “have standardized sources, menus, recipes, and portion sizes, facilitating reasonable accurate calorie labeling” (14). The food items to be covered include all items for which there is a name and a price, or a name on an item tag to highlight the effect of portion size. The only information required for display are calories, for “calories amount is the single most important value in public health” and “calories generally correlate with carbohydrates, fat, and sodium” (14) . A final issue, one not yet addressed by the national mandate, is items with multiple servings (such as a whole pizza or bucket of chicken). For this, calories must be calculated for the item as served, for the posting the entire calorie amount provides full disclosure for people who will consume the item alone (14).

Since only 2 years have passed since the mandate of calorie labeling on fast-food and sit down restaurants in New York City, few studies have examined the effects on purchasing behaviors among the public. Elbel et al conducted their study over a 2-week period in July 2008, capturing both pre- and post- calorie labeling data. Using a city in New Jersey as a control site, the researchers found that “27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, [they] did not detect a change in calories purchased after the introduction of calorie labeling” (13). In fact, the raw data shows that the average number of calories purchased in the New York as 825 pre-implementation with an increase of 21 calories to 846 post-implementation. The control group (Newark, NJ) had an average number of calories purchased as 823 pre-implementation and 826 post-implementation (13). Just as smokers who know the overall risk of smoking but do not believe they themselves are at increased risk; these individuals looked at the calorie information and thought it affected their choice but in reality they were still choosing a meal with equivalent calories prior to implementation – the optimistic bias was in full effect.

Proposed Intervention:

While the flaws of the menu labeling initiative are apparent, the law has yet to be mandated or presented to the public and there are more interventions that can accompany the law that may help it to succeed.

I suggest that if we are to label menus we must first educate the public about nutrition labels through a mass campaign with the help of clinicians. Additionally, if we are to only use calorie information as part of restaurant labeling, individuals must understand how fat, carbohydrates, protein and sodium influence calories. Secondly, I propose in conjunction with the menu labeling, restaurants be mandated to change either the preparation style or serving size of a single dish that exceeds any daily value on a nutrition label. By enforcing such a rule, the government would be taking an upstream approach at solving the obesity epidemic while also helping to eliminate any guilt or shame people may feel when making food choices. Finally, advertisements must use individual stories with people the public can relate to showing how to incorporate restaurant meals into everyday living. The public should not be made to feel shamed or vilified for choosing to eat in restaurants nor should they feel obligated to only choose the lowest calorie option. Instead, a model of incorporating all types of food, even high-calorie, into a diet should be shown in an appropriate manner.

Defense of Intervention 1: Education

Nutritional food labeling has only been implemented in the United states for 20 years, mandated for 16, and in many respects can still be viewed as in its infancy stages of education and public awareness. As the first generation to receive a full education using the food guide pyramid and learning how to interpret a nutrition label from kindergarten through high school, it is easy to understand why the obesity epidemic is still on the rise. Unlike other labeling initiatives (e.g. tobacco label warnings), nutritional labels are meant to provide the consumer with information that must be processed, understood, and comprehended in order to make a decision. If we expect consumers to make choices based on nutrition labels we need to educate them how to properly interpret labels.

Despite being the in age of ever growing technology and wide internet availability, I believe that easy to comprehend paper brochures explaining nutrition labels should be made available to the public. While most individuals have access to the internet, whether it is at home, work, or even their phone, the paper brochure could be strategically offered in more appropriate locations, such as hospitals and physician offices. Through the use of a brochure, an individual would have the opportunity to self teach key concept of nutrition labels, as well as ask medical professionals about more advanced concepts, such as percent daily values (which vary based on an individual’s need and physical activity level).

A study done by Cohen et al. used the primary care physicians as a vehicle to increase their effect on their patients who smoke (15). By randomizing both physicians and patients (regardless of whether they wanted to quit) into groups with various levels of physician education, physician reminders for smoking cessation counseling, and nicotine gum availability to patients, the study was able to show physicians in the intervention group not only spent significantly more time counseling their patients about smoking but the success rates of quitting were also statistically significant between group (15).

Just as the smoking intervention helped increase quitting success rates, a nutrition labeling brochure can only increase the knowledge base for individuals on how to use this tool effectively. While it may be necessary for the physician to be reminded to ask about the brochure, the prompt may help to open the lines of communication and really allow for the clinician to see the level of understanding their patient has regarding nutritional labels.

Defense of Intervention 2: Upstream Actions

Mandating calorie labeling is a downstream action, relying on customers to make educated decisions on which foods to eat based on calorie information alone. There are numerous steps that could be taken before calorie labeling goes into effect in order to help the public, or even eliminate the need for calorie labeling.

One of the main pushes behind labeling calories comes from the high calorie food items found in some restaurant’s items. By labeling the menu we are choosing to guilt the customers into making what society deems the more appropriate, lower calorie, choices. But what if items that contain over the entire daily need of calories, fat, carbohydrates, etc were prohibited from being sold?

It has already been stated that the positive forces of menu labeling may be its indirect effect on restaurant preparation of items, specifically those that contain the highest calories. “The New York City Health Department’s more systematic evaluation, as yet unpublished, suggests that calorie reductions of about 10% have been common” (3). This force has also been the primary push from many politicians behind menu labeling. Therefore, if this is our goal, why not address the issue directly instead of hoping it will indirectly happen through a separate policy.

I would propose in addition to menu labeling, restaurants must also be enforced to change the preparation style or decrease the serving size of any dish that is over the daily requirement based on a 2,000 kcal/day diet. For example, the Beef Ribs offered at the Cheesecake Factory contain 2,310 calories per dish (not including sides) (16). By enforcing such a policy individual customers would not be put in a situation in which guilt and shame could be induced for wanting to order an item off a menu, instead the restaurants would be held responsible for healthfulness of their food choices.

Defense of Intervention 3: Personal Stories

The use of personal stories have been used effectively in both media advertising to sell products and in public health as a means to reduce the influence of an individual’s optimistic bias. As stated previously, the optimistic bias is the theory that people tend to underestimate risks that apply to them. While they may try to understand perfectly well the entire risk, there is an irrational process that overrides their ability to access their risk (12).

One of the effective public health campaigns to reduce the number of tobacco smokers was by telling the store of Pam Laffin. The Massachusetts Department of Public Health began airing commercials featuring a 31 year old female, her two young children and the effects smoking had on their lives. The campaign focused on the life of Pam’s disease, children’s lives, and personal grips with death (17). It allowed the viewing audience to see exactly how one individual can be affected by smoking, instead of using blanket warnings, hate campaigns against the tobacco industry, or healthy actors telling an audience they should not smoke. This was something people could relate to. Biener et al conducted a study regarding Pam Laffin’s commercial advertisements to promote smoking cessation. A portion of his results found that when a group of recent quitters were asked “did television commercials about tobacco contribute to quitting?” those who answered in the affirmative reported the influence of television (29%) than nicotine replacement therapy (18%), professional consultation (13%), or self materials (5%) (18).

Just as the Pam Laffin commercials had a tremendous impact on the choices people made about smoking cigarettes, I believe using a personal story to promote healthy eating can have a positive impact on society. I would propose to use an individual that multiple demographics can relate to, such as a working mom/dad, college student, or man/woman that works long hours and does not typically have time to prepare meals. The main purpose of the commercials would be to provide examples to the pubic of how they can incorporate restaurant meals into their eating habits, possibly even daily, in an effective way while still promoting balanced meals.

It is important that these messages do not come across as shaming individuals for choosing to eat in restaurants or fast-food establishments. Society must learn that all foods can be eaten, including the higher calorie options at restaurants, when they are balanced with overall nutritional needs. So much of the focus in today’s public campaigning is to strive to eat balanced, ideal meals at every single meal time. Unfortunately, this is not always realistic with either individual’s schedules or food cravings. If the advertisement can show relatable consumers making reasonable meal choices (not just the lowest calorie option), I believe the public would be influenced in a positive light to understand more realistic options for consuming a more rounded diet.

In the end I believe the labeling of menus with calorie information can be an effective tool for providing individuals with a sense of autonomy over their meal choices if implemented appropriately. The danger of invoking shame and guilt onto individuals is real and one that we all need to be aware of. Living in a society that idolizes thinness is difficult enough; we cannot be having more people feel shamed for not choosing the lowest calorie item.

References:

1. The Patient Protection and Affordable Care Act, 455 §§ 148-4205-4206 (2010). Print. http://www.washingtonwatch.com/bills/show/111_PL_111-148.html

2. Christakis N, Folwer J. The Spread of Obesity in a Large Sample over 32 Years. N Engl J Med 2007;357:370-9.

3. Nestle M. Health Care Reform in Action – Calorie Labeling Goes National. N Engl J Med 2010; epub http://healthcarereform.nejm.org/?p=3278.

4. Unos Chicago Grill Restaurant. Nutrition Information: Rattlesnake Pasta. Boston, MA: Pizzeria Uno Corporation. http://www.unos.com/kiosk/nutritionUnos.html

5. Siegel M. “Social Expectations Theory and Psychological Reactance Theory.” Social and Behavioral Sciences for Public Health. Boston University, Boston. 18 Mar. 2010. Lecture.

6. U.S. Food and Drug Administration. Nutritional Labeling and Education Act (NLEA) Requirements. Silver Springs, MD: U.S. Food and Drug Administration. http://www.fda.gov.ezproxy.bu.edu/ICECI/Inspections/InspectionGuides/ucm074948.htm

7. Drichoutis AC, Lazaridis P, Nayga RM. Consumers’ Use of Nutritional Labels: A Review of Research Studies and Issues. Academy of Marketing Science Review 2006;2006(9)

8. Mann T, Tomiyama J, Westling E, Lew A, Samuels B, Chatman J. Medicare’s Search for Effective Obesity Treatment: Diets Are Not The Answer. American Psychologist 2007;62(3):220-33.

9. United States Department of Agriculture. Inside My Pyramid: Physical Activity. Alexandria, VA: USDA Center for Nutrition Policy and Promotion. http://www.mypyramid.gov/pyramid/physical_activity.html

10. Bouchard C, Perusse L. Genetics of Obesity. Annu Rev Nutr 1993;13:337-54.

11.Ariely D. Predictably Irrational. New York, NY: HarperCollins Publishers, 2009.

12. Siegel M. “Social Network Theory, Maslow’s Hierarchy of Needs, the Law of Small Numbers, and Optimistic Bias and Illusion of Control.” Social and Behavioral Sciences for Public Health. Boston University, Boston. 1 April 2010. Lecture.

13. Elbel B, Kersh R, Brescoll V, Dixon B. Calorie Labeling and Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs 2009;28(6):w1110-21.

14. Farley T, Caffarelli A, Bassett M, Silver L, Frieden T. New York’s Fight Over Calorie Labeling. Health Affairs 2009;28(6):w1098-w1109.

15.Cohen S, Stookey G, Katz B, Drook C, Smith D. Encouraging Primary Care Physicians To Help Smokers Quit: A Randomized, Controlled Trial. Annals of Internal Medicine 1989;110(8):648-52.

16. NutriSoft. Cheesecake Factory: Nutrition. NutriSoft, LLC. http://www.cheesecakefactorynutrition.com/restaurant-nutrition-chart.php?rid=58

17. YouTube. Pam Laffin – Difference. San Bruno, CA: YouTube, LLC. http://www.youtube.com/watch?v=F3D3NnLXYNg&feature=related

18. Biener L, Taylor TM. The continuing importance of emotion in tobacco control media campaigns: a response to Hastings and MacFayden. Tob Control 2002;11:75-7.

Why Iowa’s “Take a Dose of Truth” Campaign May Not Be Working - Brent Ardaugh

Introduction

The main goal of Iowa’s Take a Dose of Truth (TAD) campaign is to increase public awareness of the risks associated with the abuse and misuse of prescription and over-the-counter (OTC) drugs (1). The TAD campaign targets mostly teen audiences, although resources for parents, the elderly, and health professionals are also found on the TAD Web site. Although Iowa’s Office of Drug Control Policy (ODCP) has identified an important public health issue and demonstrated its willingness to act on the issue, the TAD campaign violates three important social science theories: social marketing theory, reactance theory, and social expectations theory. Poor use of these theories will cause almost any health campaign to fail; however, thoughtful and strategic use of these theories can contribute to a campaign’s success. The aim of this review is to critically analyze the shortcomings of the TAD campaign, and to discuss alternative solutions to influencing teen behavior.

Critique Argument 1 – Poor Use of Social Marketing/Advertising Theory

The term social marketing was coined in 1971 in a pioneering article by Kotler and Zaltman (2). Social marketing is the process of applying marketing principles and techniques to influence the behavior of a target audience, and it is intended to benefit both the target audience and society (3). Social marketing differs from commercial marketing because it aims to market ideas and behaviors.

The TAD campaign is trying to “sell” a healthy behavior to teens, but the campaign fails to communicate the benefit teens get from not misusing and abusing prescription drugs. The campaign is one-sided and communicates messages that only benefit ODCP. At most, the campaign is communicating to teens: “Don’t do drugs because they are bad for you” and “Help save the State of Iowa millions of dollars annually by allowing our police officers to focus on other crimes.” If ODCP would like teens to avoid drug abuse and misuse, ODCP needs to promise teens something more compelling than health, which is a product most teens (and other people) do not care to “buy.” According to Ogilvy, the selection of a promise should never be left to guesswork, and what is said is more important than how it is said (4). How might ODCP find out what promise to make Iowa teens? One way is to use Ogilvy’s method described in Confessions of an Advertising Man (4); the other way is to conduct market research, which is the first element of social marketing.

Social marketing comprises the following five elements: research, planning, development, implementation, and assessment (5). The goal of market research is gain an understanding of the target audience. Knowledge of sociodemographic and behavioral characteristics (e.g., education, age, needs, desires, wants, values, and beliefs), for example, enables social marketers to make predictions about their target audiences and ultimately influence behavioral outcomes (6). Planning is the second element, and it focuses on the intended delivery or presentation (i.e., frame) of the product to the target audience. This decision should be informed by research. Development is the third element, and it entails creating programs for specific audiences on which research was conducted. The last two elements, implementation and assessment, focus on the carrying out of the marketing plan and the continual evaluation of its performance.

The hallmark trait of social marketing is research, and if ODCP would like for teens to abstain from abusing and misusing drugs, ODCP should learn everything they can about the wants and needs of their teen market. A health campaign should be implemented only after market research is conducted, and following implementation, the campaign should undergo additional scrutiny on its effectiveness. It is one thing to implement a health campaign; it is another thing to implement one that works. Social marketing helps ensure that happens.

Critique Argument 2 – Poor Use of Reactance Theory

Reactance theory suggests that people become motivationally aroused by a threat to or elimination of a behavioral freedom (7). A threat to a particular behavior, even if the behavior is unhealthy or undesirable, motivates the individual to restore the behavior. An example of reactance theory is demonstrated on Philip Morris’s (PM) Web site, where it states: “Kids should not smoke or use any tobacco products. As the largest tobacco manufacturer in the US, we believe we have an important role to play in helping reduce underage tobacco use (8).” The literal meaning of this message suggests that PM discourages tobacco use among kids. However, PM knows about reactance theory, and PM intentionally publicized this reactive message to prompt kids to buy tobacco.

Although ODCP should frame the TAD campaign so that it does not threaten the behavioral freedoms of teens, there are parts of the TAD campaign that are reactive, and may actually prompt teens to abuse or misuse prescription drugs. Below are a few examples of reactive messages from the TAD Web site (1).

· “They [teens] see them [drugs] advertised on television, they see their parents and other adults take them, but they don’t hear about the negative consequences of their use.”

· “They [teens] don’t know that abusing these drugs can alter their brain activity and lead to drug addiction or severe medical problems, especially when they’re combined with illegal drugs or alcohol.”

The TAD commercial released by ODCP is too authoritative. The commercial essentially tells teen viewers they should not abuse and misuse prescription drugs because their parents and ODCP say so. Because most teens (and other people) find it exciting to rebel against authority, these health messages are reactive. After seeing these messages, many teens will ask: “Who is the government or my parents to tell me what to do? Because they told me not to engage in that behavior, I am now going to go ahead and do it.” Of course, that is the exact opposite action the commercial asks teen viewers to take.

Another disadvantage of this TAD commercial is it implies a two-sided power struggle: parents and ODCP vs. teens. Using this strategy, both sides will have an aspiration to be the winner and such competition promotes forcible resistance from both sides. When dealing with drugs, as we know, that battle can be both time consuming, expensive, and dangerous.

Critique Argument 3 – Poor Use Social Expectations Theory

Social expectations theory holds that people tend to internalize the norms, role definitions, and other understandings of social organization from their environment (9). In other words, people will try to “fit the role” expected of them when in particular groups or scenarios. For example, let us say that at the starting line of the Boston Marathon, one runner turns to another and says: “You look really pale, are you feeling all right?” The runner will now fit the role of a sick person and probably run poorly.

Social expectations theory can be used in positive ways and negative ways, and the TAD campaign uses social expectations theory in negative ways. The commercials released by ODCP label teens as people who use Rx drugs to get high, which causes many teens to feel they need to fit that role and use Rx drugs to get high.

The following commercials [Commercial 1, Commercial 2] use social expectations theory in negative ways by expecting that teens use Rx drugs to get high. Instead of using positive expectation that might say something like, “The ODCP trusts you’re smart and will do the right thing,” the ODCP places an expectation on teens that promotes unhealthy and illegal behaviors. If teens listen to ODCP and attempt to fit the role of a person who uses Rx drugs to get high, the ODCP will be partially responsible for the teens’ actions.

Articulation of Proposed Intervention

The alternative intervention proposed for the TAD campaign is based only on modifications to the existing campaign. Although many of the existing messages and theoretical applications of the TAD campaign are ineffective and flawed, the campaign does actually have a lot of favorable qualities. First, the ODCP has the willingness and desire to act on a public health issue. Many other states do not demonstrate such a strong commitment. Second, the ODCP is able to afford airtime and use the media as tools for reaching teen audiences. Third, the TAD Web site offers information about drugs commonly used by teens. The TAD Web site just does not tell people drugs are bad for their health; it gives them reasons why.

The proposed intervention for the TAD campaign entails using social marketing theory, reactance theory, and social expectations theory, more thoughtfully and strategically. In the next section, methods for improving the TAD campaign are suggested based on the previous criticisms.

Defense of Intervention Section 1 – Good Use of Social Marketing Theory

Using prescription drug abuse and misuse as an example, let us say that while researching, market researchers learn that in addition to independence, power, relationships, and autonomy, teenagers aspire to have control over their lives. The market researchers now know the aspirations of their target audience, and they can frame promises that will deter teens from abusing and misusing prescription drugs. As stated previously, if ODCP would like for teens to abstain from drug use, ODCP must be able to offer teens something compelling. By learning the values of the target audience through market research, ODCP is ensuring their messages appeal to the teen audience. Notice, however, that the teens get something out of the transaction—the promise made by ODCP. According to Ogilvy, the promise does not have to be true; it only has to be large (4). The promise is a critical part of the campaign’s communications strategy.

There are four major components of a communications strategy: messages, messengers, creative strategy, and communication channels (3). The message ODCP wants to communicate is that abusing and misusing prescription drugs is risky and hazardous to teen health. There is nothing wrong with this message; however, as it stands, there is a problem with the messenger of the campaign. In the opinion of the teen audience, ODCP may not be a knowledgeable, trustworthy, or likable source of information. According to Kotler and Lee, what a target audience thinks about a particular messenger can make or break the deal (3). Therefore, the TAD campaign would most likely benefit from a teen or young adult telling his/her story about prescription drug abuse, and how it infringed on the values of independence, power, relationships, autonomy, and self-control.

The power of story-telling in health messages is beautifully illustrated in a documentary about OxyContin^® abuse (see OxyContin^® Express at: http://www.hulu.com/watch/100279/vanguard-the-oxycontin-express), where a young man claims that his physician sells him prescription drugs when the physician knows the young man is addicted. This story alone would be a powerful addition to a health campaign because it shows how drugs threaten the teen values of independence, power, autonomy, and self-control. Not to mention, the fact that the physician-dealer is concerned only with his own self-interests would make most teens feel manipulated and taken advantage of. The TAD campaign could amplify the message that one way to be free from the manipulation of the drug dealer is to stop buying drugs. This situation would benefit both the ODCP and teens. Notice, however, that health is not the product being sold; the product is freedom from the manipulation of the drug dealer.

The third component of communications strategy, creative strategy, entails translating the content of the intended messages to specific communications (3). This component deals mainly with the presentation of the message. For example, what logos, fonts, visuals, and catch phrases will be used? How will the message be framed? These questions are all answered during this stage. Communication channels, the fourth component, deals with where and when the health messages will appear. Because the TAD campaign was not deficient in this area, no recommendations are made.

Defense of Intervention Section 2 – Good Use of Reactance Theory

The main issue for reactance theory is to determine when teens do and do not show reactance in the face of threats to freedom (10). One of the best ways ODCP could learn whether the TAD messages engender reactance is to test messages before they go public. These tests may be conducted in teen focus groups, where the teens would tell the ODCP what works and what does not. This strategy could help save time, energy, and tax-payer money while simultaneously investing in the health of Iowa teens.

Another strategy is not telling teens what to think; give teens the information they need to make their own choices. For example, if somebody were to claim that all pizza tastes horrible, a reasonable person might say: “Don’t tell me what tastes good and what does not taste good; let me find out on my own.” This example emphasizes the importance of not telling people what to think or do. It does not mean, however, that messages cannot be framed or strategically communicated to prompt desired actions.

The TAD campaign may reduce reactance in its commercials by making them less authoritative. For example, the OCDP may have two teens talking about drug use as opposed to a teen with his mother. Another way to reduce authoritativeness is to remove the oversized OCDP logos from the campaigns. The TAD campaign should portray parents and the ODCP as resources, not the superior parties. Everybody should be on the same team: there should be no winners or losers.

Defense of Intervention Section 3 – Good Use of Social Expectations Theory

The TAD campaign needs to give teens the benefit of the doubt because not all Iowa teens use prescription drugs to get high. There are many responsible teens who use prescription drugs according to their physicians’ instructions. If ODCP publicizes that Iowa teens use prescription drugs to get high, then teens will have a tendency to fit that role. The current TAD campaign places such a high degree of stigma on being an Iowa teen that it is almost shameful and embarrassing to be one. This campaign is one of the poorest examples of a good use of social expectations theory, and anybody who approved the use of the “Iowa teens use Rx drugs to get high” slogan should be fired.

Social expectations theory should be used in the TAD campaign to inspire teens to make the right choices. The campaign should have positive, high expectations for teens and give them an opportunity to become better people. The campaign should not bring teens down; it should bring them up. For example, the TAD campaign may communicate a message that asks teens to talk to their friends about abuse and misuse of prescription drugs. This strategy accomplishes two goals: first, it conveys that the government trusts teens as responsible people who can help disseminate knowledge, and second, it gives teens an opportunity to fit the roles of being intelligent, independent, and free individuals.

REFERENCES

1. Iowa Governor's Office of Drug Control Policy. Take a Dose of Truth. Des Moines, IA: Iowa Governor's Office of Drug Control Policy. http://www.takeadoseoftruth.com/.

2. Kotler P, Zaltman G. Social Marketing: An Approach to Planned Social Change. Journal of Marketing 1971;35:3-12.

3. Kotler P, Lee NR. Social Marketing: Influencing Behaviors for Good. Thousand Oaks, CA: Sage Publications, 2008.

4. Ogilvy, D. Confessions of An Advertising Man. New York, NY: H. Wolff, 1963.

5. Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett, 2004.

6. Kotler P, Roberto EL. Social Marketing: Strategies for Changing Public Behavior. New York, NY: The Free Press, 1989.

7. Brehm JW. Psychological Reactance: Theory and Applications (pp. 72-5). In: Srull TK, ed. Advances in Consumer Research. Provo, UT: Association for Consumer Research, 1989.

8. Philip Morris USA. Help Reduce Underage Tobacco Use. Mansfield, MA: http://www.pmusa.com/en/cms/Responsibility/Helping_Nav/Helping_Reduce_Underage_Tobacco_Use/default.aspx

9. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication. White Plains, NY: Longman, 1989.

10. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005;27:277-84.