Challenging Dogma - Fall 2009

Sunday, December 13, 2009

The Cool Spot: An Assessment and Redesign of the NIAAA’s Intervention to Decrease Pre-Teen Drinking Rates – Kristen Cox


Long-term alcohol consumption has significant health implications for populations if left unaddressed by government and public health officials. In 2005 alone, alcohol abuse and addiction cost the U.S. approximately $220 billion or 10% of total healthcare expenditures (17,27).
Tween, (10 -13), and teen (14-18) drinking has been shown to significantly increase one’s risk of developing alcohol dependency later in life (18). Evidence shows that children who begin drinking before the age of 15 are five times more likely to abuse alcohol or become alcohol dependent than their peers who begin drinking at or after the age of 21 (21,29). For each year that imbibing in alcohol is delayed, the risk of alcohol dependence is decreased by 14 percent and the risk of alcohol abuse is decreased by 8 percent (8,29).
Overall, persons between the ages of 12 and 20 constitute approximately 14% of the population and they drink 11 percent of the total alcohol consumed in the U.S. (20, 21). Based on national information, the average age for the first alcoholic drink is 15 (11). Thus, public health officials have a significant stake in decreasing the number of tweens and teens that drink alcohol.
To date, government officials and public health departments have attempted numerous interventions to address teen drinking, with limited success. The following statistics regarding drinking rates for 8th graders around the nation reflect the ineffectiveness of current programs.
• 51.7% have tried alcohol (26)
• 43.1% have had an alcoholic drink in the past year (26)
• 25.1% have been drunk (26)
• 25% have had a drink one or more times in the past month (29)
• 15.2% have had 1 or more binge drinking episodes (26)

In addition to the 145,000 annual emergency room visits associated with alcohol for this age group, alcohol has been shown to have other detrimental impacts including an increased risk for unprotected or unwanted sexual activity, lower educational attainment and increased risk for depression or suicide (21, 29).

The Cool Spot: Current Program Design

The National Institute of Alcohol Abuse and Alcoholism (NIAAA), a component organization of the National Institute of Health (NIH) and Department of Health and Human Services, developed a program, targeted at 11-13 year olds, to combat the perception that alcohol use among tweens is universal (12). “The Cool Spot” allows 11-13 year olds to explore statistics related to the use of alcohol among those in their peer group as well as helps them begin to explore ways to reduce peer pressure associated with drinking.
“The Cool Spot” overwhelming relies upon the social norms theory to address tween drinking. It attempts to show children in this age group that they are not unique if they don’t want to drink (contests feeling of false uniqueness), and in fact, the majority of their peers do not engage in drinking on a regular basis (contests feeling of false consensus) (6). To view the website and get a sense of what is provided, please see Appendix A or visit
While the NIAAA has recognized that tween decisions regarding alcohol use are influenced by peers, the program design has several serious flaws. De-contextualization of tween’s behavioral desire to drink, inability to address tween’s desire to maintain certain relationships and a failure to reach target audience through effective advertising are serious issues with this approach and will be discussed in further detail in the following sections.

The Cool Spot: De-Contextualized Tween Desires

“The Cool Spot” focuses most of its content on changing the perception of alcohol use among peers and challenging peer pressure. However, the program, fails to address the actual reasons that teens say they engaged in drinking alcohol. In addition to social pressures, other reasons for drinking alcohol include: 1) boredom, 2) to “get high”, 3) to cope with distress, or 4) to manage one’s mood (22,25).
“The Cool Spot” relies upon the assumption that given the right information about risks and benefits and the social norms associated with an alcohol use, tweens’ disapproval rate of alcohol will increase as will their perceived control of their behavior. These two factors, in conjunction with a new understanding of the social norms involving alcohol will result in an intent to perform a certain behavior, eventually resulting in that behavior.
Overall, the theory of planned behavior has been shown to be quite adept at explaining intention; however, its effectiveness varies among different health-related behavior categories and is ill suited for changing the behaviors of tweens with regard to alcohol use (10). “The Cool Spot’s” reliance upon the theory of planned behavior (See Appendix B) is short-sighted as it believes that all decisions are rational and planned (14). Tweens are heavily influenced at the point of decision by their friends and it is incredibly difficult for many to feel as though they are in control of their behavior. Thus, irrational fears and desires to be seen as “cool” influence one’s decision to drink regardless of the preconceived intent. This final statement leads us into the next flaw in the design of the “The Cool Spot” – inadequately addressing the social relationships and their influence on teen behaviors.

The Cool Spot: Importance of Teen Relationships with Peers and Family Members

“The Cool Spot” makes an attempt to address the influence of peer pressure by teaching tweens to avoid falling prey to its common forms. However, without addressing the underlying social circumstances in which tweens interact, and the asymmetrical influence certain peers have on one’s behavior, attempts at resisting peer pressure are seriously compromised.
In its present state, the program fails to address the tweens’ behavioral desire to maintain certain relationships within their peer group. The social exchange theory describes a process whereby people make decisions in relation to the perceived risks and rewards of an action for a given relationship. Based on this assessment, people will choose to engage further in the relationship or abandon it altogether (30). For many children in this age group, perceived risk of being seen as “un-cool” or “unpopular” is a serious perceived risk and will heavily influence the way one behaves.
Additionally, “The Cool Spot” fails to recognize the significant impact familial relationships can have on one’s perception of alcohol and the intent to engage in such behaviors. Studies have found that parental alcohol use is significantly correlated with children’s perception of the risk, norms and behavioral expectations of drinking (31). Familial relationships, as with peer relationships, are assessed using the social exchange theory, and acceptance seeking behavior is commonplace, especially among tweens who are not as close to their parents (31). This attention seeking behavior is the tween’s attempt to feel “normal” and accepted by their family members (8). Therefore, in order to form a successful intervention to decrease the incidence of underage alcohol use, public health officials should include the influence of these important relationships in their prevention methodologies.

The Cool Spot: Reaching the Intended Target Audience

Before addressing how “The Cool Spot” attempts to engage tweens, it is important to understand the stakes at risk for alcohol producers if this market is diminished. Underage consumers are important to the alcohol industry because they provide it with immediate cash, approximately $22.5 billion or 17.5% of its total revenues from sales, and with future sales. Due to the fact that underage drinkers are more likely to develop alcohol abuse or addition later in life, alcohol distributors recognize this lucrative market, $25.8 billion or 20.1% of total annual revenues, as an extremely important component of the overall market (29).
At approximately 17.5% of total revenues, underage drinkers play a significant role in marketers’ strategies. While these companies do not directly market their products to tweens and teens, their ads are designed to appeal to this audience segment and are placed in magazines, at concert venues and in popular TV shows known to have high numbers of youth in attendance or as regular viewers (24). As in all industries, marketers have recognized the huge potential market that this age group provides, and have become very adept at creating ads that target the wants and desires of these children.
Based on market analyses that have been conducted, common elements of effective advertising to this group include the use of humor, the “cool factor” and fantasy (15). Celebrity tie-ins and branded products are also extremely important in engaging this age group (15). The emphasis of each of these elements is different between boys and girls. To appeal to girls messages include images of mini-fashionistas who love hanging out with friends and obsess over boys and pop stars. Marketing techniques for tween boys include appealing to their sense of independence and strength as well as their preoccupation with adventure, sports, music or friends (15).
“The Cool Spot” fails to incorporate any of these advertising “must-haves” into their website. There are no TV, radio or magazine ads that mention the program or the realignment of expectancies with actual social norms that the website promotes. This model relies upon the assumption that children are actively seeking information regarding the use of alcohol and how to avoid peer pressure. Further, the use of manga characters (see Appendix C for examples) depersonalizes the website’s message and doesn’t appeal to any of the key advertising components mentioned above.
In its current state, “The Cool Spot” appears to be a tool for parents and teachers to use in teaching children in the target age group about alcohol use. However, to truly appeal to tweens, NIAAA would benefit from recognizing that this age group is seeking independence and acceptance from their peer group and that initiation of some of these discussions would be better received from peers than from adults.

The Cool Spot: Proposed Redesign

“The Cool Spot” does a better job than most public health initiatives in recognizing the importance of misplaced expectations, misjudged norms and intensity of peer pressure in tweens’ decision making process. However, certain components of the program could be redesigned to make it more effective at reaching its target audience and in turn, decreasing the amount of underage drinking in the U.S. Each of the proposed redesign components is an attempt to address the underlying deficiencies in the current approach.
The first flaw, de-contextualization of tween behaviors, will be addressed by understanding that tween decisions regarding the use of alcohol are not make in a “cold” state and thus, planned behavioral intentions have little relevance (24). The intervention will attempt to incorporate reminders from the cold state into situations considered “hot” to prevent tweens from engaging in such behaviors. The second flaw will be addressed by engaging parents and peer groups in the fight against alcohol abuse. By leveraging these relationships, public health officials have a greater opportunity to prevent the use and abuse of alcohol. The final flaw, failure to advertise effectively, will be corrected by incorporating the use of a celebrity into future marketing messages and changing the website to depict real life situations and persons that the tweens can relate to.

Program Redesign Component 1: Transforming Decision Making to the Hot State

One of the core components of “The Cool Spot’s” current message is that tweens will look at, understand, internalize and form behavioral intentions regarding drinking alcohol. This approach assumes that decision making in a cold state is rational and that this rational decision making can be transferred to the point of decision making, or the hot state. However, decision making in a hot state is anything but rational (9). One’s perceptions and positive expectations are irrationally influenced by one’s current surroundings. For example, if a tween is at a party where everyone is enjoying an “alcopop” and appears to be having a great time, the tween will likely engage in such activity to fit in and to appear cool because the prior assumption that alcohol intake was risky or dangerous has been replaced with one where it appears enjoyable (3).
Therefore, it is imperative to design public health approaches that address the hot state and help remind individuals of their perspectives from the hot state. “The Cool Spot” should create a promotional product, such as a reminder bracelet or ring that would remind youth of their commitment not to drink. Such a product would be worn by tweens and serve as a reminder of the decision they made in the “cold state.” This intervention would also be a part of the redesigned advertising message that will be discussed later and if readily identifiable, would indicate to other tweens one’s outward commitment to not drinking.
Of note, “The Cool Spot” should also engage tweens in signing a commitment or in setting a “bet” before receiving their ring or bracelet. Such a tactic would form a relationship with the tween and their commitment, making it more likely that they will actually adhere to their end of the bargain. This intervention approach has been very successful for those who participate in making contracts with themselves or with others to change health behaviors at

Program Redesign Component 2: Transforming Relationships

As previously stated, relationships among peers is an extremely important determinant in one’s decision to drink alcohol or not. There is evidence that tweens have a higher disapproval rate and a greater perception of the risk involved in drinking than twelfth graders (13). Further, there appears to be differences in perceptions regarding drinking between tweens in different racial/ethnic groups with fewer Asians and African Americans reporting alcohol use than whites or Hispanics (7). These differences could be based on a variety of factors, but “The Cool Spot” could benefit from leveraging the youthful perception of alcohol use and its consequences in delaying the initiation of drinking alcohol.
The NIAA should work with local school districts to form committees that would recognize specific tweens as mentors. These selected mentors would participate in speaking events or group sessions with other tweens to discuss alcohol use and abuse without parents or teachers in attendance. This environment would allow tweens to talk openly with their peers about their feelings regarding alcohol and provide a constructive method to engage tweens in developing hands on skills to combat peer pressure.
Additionally, an important element in the program redesign would address the relationship between tweens and their parents. Many tweens still spend significant amounts of time at home and around their family members. Social learning theory implies that these familial interactions have important implications in the future decisions regarding alcohol use for these tweens (5). Parents serve as models for behavior and can reinforce either good or bad behaviors in their children. Further, parents’ decisions regarding alcohol provide both an opportunity for tweens to drink and access to alcohol.
Many parents have tried to show their children that alcohol is not “off-limits” in the hope of encouraging them to have a healthy view of drinking alcohol. However, recent studies suggest that parents could be doing more harm than good by allowing their children to imbibe small amounts of alcohol in a controlled environment (for example at a family dinner in one’s own home) (16). Recent neurological studies have shown that tweens’ brains are going through an important transition point at this age, and drinking alcohol at this early age correlates to a learned behavior (23). At this early age, the neurologic pathways are reshaped by the child’s behavior and thus, in the future, the child’s brain will be more predisposed to associate the use of alcohol with something pleasant or positive (23).
Based on this evidence, “The Cool Spot” should create information for parents to combat the assumption that treating alcohol as a non-threatening substance and allowing your child to engage in such activities before adulthood is detrimental to their long-term health and development. This information should be contained on a separate site directed specifically at parents and include the some of the same statistics and information that is found on the tween’s website. In addition, the website should have interactive scenarios for the parent to engage in and learn how to begin difficult conversations with their children regarding substance abuse in general, but focusing on alcohol use. Another component of the website should reinforce to parents that the behavior children see at home has a dramatic impact on the behaviors they model outside of the home.

Program Redesign Component 3: Transforming the Advertising Message

The third recommendation for redesigning “The Cool Spot” is to create an actual advertising message. To be effective, advertising messages need to engage the consumer and seek consumers out even if they don’t know about your product or care about your product yet. The messages should engage the viewer, and have them feel aligned with the message and engender a relationship with the company (4).
In order to achieve this mission, NIAAA will need to make a significant investment in a national advertising message. To reach young girls in this age group, NIAAA should approach Miley Cyrus and attempt to sign her as the new spokes model for the campaign. Young girls can relate to Miley Cyrus and already look to her as a role model.
To reach young boys in this age group, another spokesman will be needed. Young male tweens need a spokes model that is older and engaged in sports to appeal to the desired traits of independence and strength that young boys seek in early adolescence. The NIAA should reach out to Lebron James or Tim Tebow to sign on as a spokes model for this program.
To be maximally effective, the NIAA should judiciously allocate the locations and venues each of these advertisements are used in. Miley Cyrus ad placements should be used in magazines such as People or Seventeen or at billboards around malls or in TV shows such as “Camp Rock” or “The Suite Life of Zack and Cody” (28). Tween male ad placements should be placed in TV shows like “The Simpsons” or “High School Muscial”, at major sporting events, or in magazines such as ESPN: The Magazine (28). These recommendations, if incorporated, will transform the passive search model currently utilized by “The Cool Spot” into an active search by tweens around the country.


To conclude, this paper has presented information on “The Cool Spot” program, developed by the NIAAA, that is aimed at preventing alcohol use among tweens in the U.S. The use of social norms and acceptance that peer attitudes and pressure have a large impact on tweens’ decisions to drink alcohol are both positive aspects of the current approach. As explained above, this program’s model could benefit from several revisions to more effectively reach its target audience. These revisions include enticing tweens to sign a commitment to avoid alcohol, promoting a new social circle, engaging parents in the fight about alcohol use, and redesigning the advertising message.


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