The Continuum of Care: Is It an Effective Way of Helping Homeless People with Mental Illness/Substance Abuse Recover? - Feng-Hang Chang

Introduction
Homelessness is a growing social and public health problem in developed countries (1). In the U.S., approximately 3.5 million people experience homelessness, and the number is steadily increasing every year (2). Most people who are homeless have suffered severe hardship, including physical and sexual abuse, childhood trauma, poverty, disability, and disease (3). Moreover, homeless people showed a higher prevalence of mental disorders, such as schizophrenia (54.8%), bipolar disorders (19.8%), and substance-related problems (60.5%) compared with people who were not homeless (4).
Helping homeless people with mental illness/substance abuse go back from the street to a stable and independent life is a big challenge. To help them improve and maintain their health and well-being, the intervention does not only have to aim on housing situation, but also have to stress on the treatment of improving their mental health or/and drug abstention(5).
The Continuum of Care is a nationwide standard homelessness intervention strategy recommended by the Department of Housing and Urban Development (HUD) (6). It is a community plan which organizes and delivers housing and services to meet homeless people's needs, especially for those with mental illness and/or substance abuse disorders. The components of a Continuum of Care model include: 1) outreach, intake, and assessment, 2) emergency shelter, 3) transitional housing, and 4) permanent housing and permanent supportive housing (See figure1).


Figure 1 Components of a Continuum of Care Homeless System

This approach includes two key characteristics: 1) the provider determines when a client is "housing ready," and 2) the participants are required to get psychiatric and substance abuse treatment. Additionally, two assumptions are contained in this model: 1) homeless adults need transitional and permanent housing in order to develop the daily living skills they either lost or never had; 2) housing readiness depends on a period of sobriety and compliance with psychiatric treatment if deemed necessary. If the individuals demonstrate more compliance with treatment and sobriety, they can get less restrictive residences; if they fail to comply or relapse, they will return to a more restrictive environment (7).
Although the Continuum of Care is a linear process as stressing on restoring clients' mental health and stop using substance, the effect is not as good as we thought. First, clients report a lot of frustration and dissatisfaction in this program since the "journey" of graduating from the program is very long and complicated, which lead them to give up (8). In addition, comparing with other programs (i.e., Housing First or Pathways to Housing program), the Continuum of Care program shows lower effect on many aspects such as psychiatric symptoms, psychiatric hospitalization, substance use rate, and residential stability (7,9,10). Especially for homeless people with addiction, the Continuum of Care presents less than ideal result (11). These results indicate the program and the factors that contribute to its low effect need to be examined.

The criticisms of the Continuum of Care
1. Disobeying Maslow's Hierarchy of Needs
One of the most likely reasons that the Continuum of Care intervention does not work as well as expected is that it ignores the point that housing is one of the basic needs of human beings that need to be satisfied.
Based on Maslow's Hierarchy of Needs, the fulfillment of the lower level needs is a prerequisite to addressing the higher needs (12). In Maslow's hierarchy, the first level of needs, we call it the physiological needs, including food, drink, shelter, sleep, and sex, is the foundation of human beings' motivation. The second level is safety, including security, stability, and protection. The third level of need is belonging and love. The fourth level is esteem needs, which are fulfilled by mastery of the environment and the prestige of social recognition. The fifth level is the need for self-actualization, is to maximize one's unique potential in life. Once the lower needs are satisfied, the higher needs can be pursued (12).
For homeless individuals, apparently, the basic physiological and safety needs can hardly to be satisfied without stable housing. Stable housing forms the foundation on which an individual can establish daily routines and begin to address other issues (13). Contrarily, living in an unstable or bad environment may expose one to the cold, promote sleepless, and cause food shortage and cooking difficulties. Moreover, living on the street or temporary shelters can expose one to dangerous situations, which hardly offers security and stability, the safety needs. If those basic needs are not satisfied, how can we expect homeless people to pay attention on the mental health and substance abuse treatment?
Many studies support this statement. Studies showed that Homeless people perceive the basic needs of food, shelter, and safety as higher priority needs than health issues (14-16). Gelberg and Gallagher (1997) found that competing priority is an important nonfinancial barrier to the utilization of health services homeless people tend to pursue the housing and necessity prior to anything else. Kyle and Dunn (2008) also found empirical evidence that stable and appropriate housing situation can benefit mental ill people's health and quality of life.
Nevertheless, the Continuum of Care regards housing as an outcome, like employment, of therapeutic intervention rather than a precondition before healthcare (17). People cannot get permanent houses if they fail to comply with mental health/substance abuse treatment. However, this process disobeys the Maslow's Hierarchy of Needs and the empirical evidence. In fact, it seems to put the cart before the horse. If we want those people to comply with treatment, we have to let them see the value of treatment. But how can we expect them to value the treatment if their basic needs are not satisfied? The housing should not be seen as a "result" or "reward," but a necessity and human right.
2. Inducing the reactance
The reactance theory can also explain the limited success of the Continuum of Care. The reactance is the psychological response that people may experience when they perceive their freedom is threatened (18). It motivates people to restore the threatened freedom by adopting or strengthening a view or attitude that is contrary to the threatening message (18).
As an intervention focusing on recovery from disease and substance abuse, the Continuum of Care does not provide much autonomy to homeless people. First, the homeless people are "required" to attend treatment and have to "graduate" from the program. If they fail to show their capability of engagement and attendance in the treatment, they cannot get a permanent house (7). In the process, the treatment is like a mandate and requirement, which can probably become a freedom-threatening message to those individuals who want a house. Second, the providers are the ones to decide whether a client is "housing ready" or not. The client does not have much opportunity to get involved in the decision-making process but only wait for the judgment like a student or prisoner. This process may increase the sense of losing control. Some research supports this statement. Owen, Rutherford, and Jones (1996) found that clients feel dissatisfied and frustrated with a system that provides what it thinks they need, rather than what they say they need. Third, in the intervention process, if the clients relapse, they will be sent back to a more restrictive environment, such as a collective shelter, which may deprive their freedom and independence. Actually, most of emergency shelters and transitional housing are dirty, dangerous, disempowering, and associated with a range of negative outcomes such as negative affect and lowered independent functioning (19). It leads some clients to drop out of the system to resume their "normal lives," independently, on the street (8).
As a result, the Continuum of Care may not only induce the clients' reactance by threatening their freedom, but also influence their independence and satisfaction. Further, the clients may choose to go back to the street due to fail to follow the "rules" and fear of losing their independence. These can all cause the intervention to fail.
3. Fail to address other factors which may influence the compliance with treatment
Finally, the model regards the adherence to prescribed treatment and sobriety as the capacity of housing readiness. The client who is not able to maintain the compliance at any level or relapse into alcohol and drug use will be seen as lack of capacity. However, even if compliance with treatment is one indication of understanding whether a client is able to maintain his/her life, this postulation overlooks other factors which may influence a client's healthcare use, including taking prescribed medication and visiting the psychiatric clinic regularly.
In fact, a lot of factors can influence one's healthcare use. Based on Andersen's Behavioral Model, the factors including demographic factors (such as age and gender), social structural factors (such as education, ethnicity, and culture), health beliefs, community and personal enabling resources (such as transportation, income, insurance coverage), illness level, and many other environmental factors (such as stigma, policy, and prevailing norms of the society) may all affect an individual's healthcare use and health behaviors (20). Although having a disadvantage on any of these factors may contribute to ones' difficulty of using healthcare, homeless people could be even more vulnerable on several aspects than others. For example, they are usually lack of health insurance, health related knowledge, and social resources like family support and community support, income, and are usually stigmatized (21). Among these factors, stigma is one of the biggest barriers that we need to highlight (3).
Some researchers contend that homeless people face tremendous stigma in life and healthcare due to the stigma on poor and mental illness (4). The stigma may not only come from the social public, but also come from health providers. A phenomenological study shows that homeless people encounter serious barriers while entering healthcare services. These barriers include being labeled or stigmatized, being treated with disrespect, and feeling invisible to healthcare providers (3). Applying the knowledge to the adherence of treatment, the failure to comply wider treatment may due to the negative experience during the process of healthcare. While homeless individuals are facing stigmas and disrespects from the healthcare providers, it becomes extremely hard for them to seek help continually. Further, homeless people with mental illness tend not to consistently seek mental health care due to the fear of facing social reject (22). All these factors can affect a homeless individual's willingness and compliance with psychiatric/substance abuse treatment. As a result, while they fail to comply with treatment, it is unfair to postulate they lack "readiness" regardless of other personal and environmental factors.

Intervening program: A Home with Rehab
To develop a more effective intervention program for the recovery of homeless people with mental illness/substance abuse, we have to avoid making the same mistakes as the Continuum of Care does. The new intervention program I recommend is “A Home with Rehab.” This program has several new characteristics. First, when a client enters in the program, we help him/her get a home first by providing a safe apartment and necessities. The “home” is free for the first month, but after that, the client needs to pay for at least 30% of the rent and expenses, which can motivate him/her to manage his/her money or find a job. Second, if the client has mental illness/ substance abuse that needs treatment, rehabilitation will be offered after the client settles into the housing. A case manager will develop a relationship with the client, and discuss the rehabilitation plan with him/her in an empowering way rather than in a forcing way. Family members, if there is any, will also be invited to join the meetings. After completing counseling, the client can decide whether or not he/she wants to participate in psychiatric/substance abuse rehabilitation. Third, each client is cared for by a strong professional health team, including a case manager, physicians, psychiatrists, occupational therapists, nurses, rehabilitation counselors, and social workers. If the client has any health or life needs, he/she can seek help from the case manager, and the manager will call for the required personnel. For example, if the client wants to find a job, the case manager will gather the clients’ occupational therapist and rehabilitation counselor to discuss the issue with the client, make a job search or work skills training plan, and help him/her find a job. Fourth, health education group activities will be provided to the clients in the apartment. The health education goals include improving personal health behaviors, enhancing necessary health services use, and increasing their seeking and participating in psychiatric rehabilitation and substance cessation. The communication will decrease the reactance among the clients by sending unthreatened messages. Last but not least, the program stresses “anti-stigma” education for health providers. To make sure all of the health providers in our program have indiscriminate attitude and respect toward the clients, all of the providers need to take the anti stigma training and be evaluated before and after entering the program.
To attain these goals, the execution of the program is very important. I will now elaborate the details of this program and discuss how this intervention avoids the flaws of the Continuum of Care. First of all, based on Maslow's Hierarchy of Needs, the basic needs should be fulfilled prior to other needs. Therefore, we will help the clients settle into the stable housing and get necessities before conducting psychiatric or substance abstention rehabilitation. After satisfying the basic needs, we can expect that clients will have more motivation to improve their health, well-being, and other higher level needs. Some studies have shown that homeless individuals with mental illness who are placed directly into permanent housing first are more likely to stay engaged in a program and be residentially stable compared to those who get treatment first (2). Furthermore, the types and conditions of housing should also be considered. A dirty, crowded, and disordered shelter may not make clients feel secure. To satisfy the clients' needs for safety, the program will offer an independent, comfortable, or at least well-organized, apartment.
Next, the intervention will avoid inducing clients' reactance. The "mandate" of complying with treatment before getting a house will be eliminated since it threatens the clients' freedom of choice. Our message will not stress the need to complete rehabilitation before getting housing. On the other hand, we will let the clients know that they have the freedom to decide whether or not to engage in their treatment services. We will send positive messages such as "Wanna get rid off the pills? It's time to make your own decision." "The door to AA group is open for you anytime." "Wanna find someone to listen to your feelings? The Psych clinic welcomes you." These messages will be put in the flyers posted on the walls where clients can see easily, and in the health education groups that people can get when they participate in the activities. The healthcare providers will also provide those messages to clients during the meetings.
Additionally, to increase the power of persuasion, we will invite some successfully recovered homeless people to speak to the clients, or show videos about their own recovery stories. Based on the study, the similarity between the communicator and the clients can increase the power of persuasion and decrease resistance (18). The modeling theory also asserts that people tend to imitate the behaviors from those whom they identify as models (23). Therefore, it is important to build up those "models," for example, those successful homeless people, and demonstrate their engagement in rehabilitation. If engaging in rehabilitation could be shown as problem-solving and rewarding, such as bringing a more independent life, more people may like to adopt this behavior (23). As a result, clients will more likely to comply with treatment.
Finally, to encourage homeless people with mental illness/substance abuse to keep seeking treatment, we will aim to remove barriers that they may face in the healthcare system. The case managers will meet with the clients regularly and explore if they have any difficulty of using health services. If there are barriers which interfere with the clients' health services use, for example, the client is lack of knowledge about when and where to seek for rehabilitation; we will help them to eliminate the barriers, for example, by using health education.
In addition, based on the problem I addressed before, one big challenge for homeless people is the stigma from healthcare providers. According to the stigma theory, a stigma is an attribute that is socially defined as “deeply discrediting,” spoiling one’s identity and disqualifying one from full social acceptance (24). The homeless population has been facing a public stigma for a long time based on people's negative perceptions related to the poor, the mentally ill, and substance abusers (24). Moreover, many people's perception of homeless people is influenced strongly by the media or by the unsavory behaviors of a few but highly visible homeless people (4). Unfortunately, healthcare providers show the similar negative attitudes toward homeless people when homeless people walk in and seek help (25, 26). Because of that, our primary task is to remove the stigma from healthcare providers. Ways to change attitude include education and direct contact, which both focus on increasing healthcare providers' familiarity with the homeless population and decreasing the unknowns (6). In addition, interaction with the stigmatized population is regarded as a key to reducing discrimination and prejudice (6). Based on that, delivering adequate knowledge about the homeless population to health providers is very important, as is helping them get in experience with treating homeless people (25). These are all effective ways of removing the barriers and helping homeless people enter and continue following the treatment.
In conclusion, in helping homeless people with mental illness/substance abuse recover and return to the community, we should help them settle in a stable and safe house first in terms of satisfying their basic needs. Next, the health services should be provided in an acceptable way. We can offer abundant information and services and encourage them to comply with treatment by using some persuasive techniques, but the clients should have the right and autonomy to make treatment decisions. Even if they fail to comply with treatment, their needs and barriers need to be understood rather than blamed. One of the biggest barriers, stigma, especially needs to be addressed and removed to help clients comply with treatment. Therefore, education for health providers and increased opportunity for them to interact with homeless people is important.
It is never easy to help homeless people recover from illness and return to their lives. That is why it is so important to develop an effective intervention program and make relevant policies. We may not be able to build up a "perfect" program; however, we can always improve the programs by examining the problems of the ones we are using. The process will help us find more possibilities in the future.








References
1. Henry, J., Boyer, L., Belzeaux, R., Baumstarck-Barrau, K., & Samuelian, J. (2010). Mental disorders among homeless people admitted to a French psychiatric emergency service. Psychiatric Services, 61(3), 264-271.
2. The National Coalition for the Homeless. (2009). How many people experience homelessness? Retrieved 04/26, 2010, from http://www.nationalhomeless.org/factsheets/How_Many.html
3. Martins, D. C. (2008). Experiences of homeless people in the health care delivery system: A descriptive phenomenological study. Public Health Nursing, 25(5), 420 - 430.
4. Folsom, D. P., Hawthorne, W., Lindamer, L., Gilmer, T., Bailey, A., Golshan, S., et al. (2005). Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. The American Journal of Psychiatry, 162, 370-376.
5. Hopper, K., & Barrow, S. M. (2003). Two genealogies of supported housing and their implications for outcome assessment. Psychiatric Services, 54(1), 50-54.
6. U.S. Department of Housing and Urban Development. (1999). Guide to continuum of care planning and implementation, 2010, from http://www.hudhre.info/documents/CoCGuide.pdf
7. Greenwood, R. M., Schaefer-McDaniel, N. J., & Winkel, G. (2005). Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American Journal of Community Psychology, 36(3/4), 223-238.
8. Howie The Harp. (1990). Independent living with support services: The goals and future for mental health consumers. Psychosocial Rehabilitation Journal, 13, 85-89.
9. Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., & Fischer, S. N. (2003). Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. Journal of Community & Applied Social Psychology, 13(2), 171-186.
10. Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656.
11. Kertesz, S. G., Crouch, K., Milby, J. B., Cusimano, R. E., & Schumacher, J. E. (2009). Housing first for homeless persons with active addiction: Are we overreaching? Milbank Quarterly, 87(2), 495-534.
12. Zalenski, R. J., & Raspa, R. (2006). Maslow's hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine, 9(5), 1120-1127.
13. Kyle, T., & Dunn, J. R. (2008). Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: A review. Health and Social Care in the Community, 16(1), 1-15.
14. Gelberg, L., Gallagher, T. C., Andersen, R. M., & Koegel, P. (1997). Competing priorities as a barrier to medical care among homeless adults in Los Angeles. American Journal of Public Health, 87(2), 217-220.
15. Ball, F. L. J., & Havassy, B. E. (1984). A survey of the problems and needs of homeless consumers of acute psychiatric services. Hospital and Community Psychiatry, 35, 917-921.
16. Gelberg, L., & Linn, L. S. (1988). Social and physical health among homeless adults previously treated for mental health problems. Hospital and Community Psychiatry, 39, 510-516.
17. McLellan, A. T., & Woody, G. E. (1996). Evaluating the effectiveness of addiction treatments, Milbank Quarterly, 74(1), 51.
18. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic & Applied Social Psychology, 27(3), 277-284.
19. McCarthy, J., & Nelson, G. (1991). An evaluation of supportive housing for current and former psychiatric patients. Psychiatric Services, 42(12), 1254-1256.
20. Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), pp. 1-10.
21. Stein, J. A., Andersen, R. M., & Koegel, P. (2000). Predicting health services utilization among homeless adults: A prospective analysis. Journal of Health Care for the Poor and Underserved, 11(2), 212-230.
22. Kim, M. M., Swanson, J. W., Swartz, M. S., Bradford, D. W., Mustillo, S. A., & Elbogen, E. B. (2007). Healthcare barriers among severely mentally ill homeless adults: Evidence from the five-site health and risk study. Administration and Policy in Mental Health and Mental Health Services Research, 34(4), 363-375.
23. DeFleur, M. L., & Ball-Rokeach, S. J. (1989). Socialization and theories of indirect influence. In W. Plains (Ed.), Theories of mass communication (5th edition ed., pp. 202-227). NY: Longman Inc.
24. Phelan, J., Link, B. G., Moore, R. E., & Stueve, A. (1997). The stigma of homelessness: The impact of the label "homeless" on attitudes toward poor persons. Social Psychology Quarterly, 60(4), pp. 323-337.
25. Ugarriza, D. N., & Fallon, T. (1994). Nurses' attitudes toward homeless women: A barrier to change. Nursing Outlook, 42(1), 26-29.
26. Pescosolido, B. A., Martin, J. K., Lang, A., & Olafsdottir, S. (2008). Rethinking theoretical approaches to stigma: A framework integrating normative influences on stigma (FINIS). Social Science & Medicine, 67(3), 431-440.

Advertising Moguls in Public Health: How Advertising Theory Can Help Inform the National Youth Anti-Drug Media Campaign - Krupa Vithlani

Adolescent drug use in the Unites States has been a cause of major concern over the last quarter of the twentieth century, with lifetime prevalence among youth continuing to increase throughout high school for some drugs such as marijuana, cocaine, and other stimulants (1). In 1975, a majority consisting of 55% of the nation’s youth had used an illicit drug by the time they graduated from high school, a trend that rose to 66% until the 1980s and returned to a previous high of 55% by the year 1999 (2). More recently, a 2007 study found that just under half (47%) of the nation’s high school students have tried an illicit drug by the time they graduate, which is still a considerably high rate of incidence (3). Though the annual prevalence rates of youth drug use are currently below their recent peaks, no significant further decline has occurred in 2007 as compared to previous years. The use of marijuana, on the other hand, is reported to be most pervasive, with approximately 20% of youth engaging in the activity as of 2007 (3-4).
In 1998, the U.S. Congress created the National Youth Anti-Drug Media Campaign (the campaign), in an attempt to curb the use of illicit drugs among the nation’s youth. The campaign’s stated primary goals are to prevent as well as to reduce the use of illicit drugs, with a central strategy using nationwide paid advertising to disseminate anti-drug messages to target youth populations (ages 9 to 18) and their parents (5). Administered by the White House Office of National Drug Control Policy (ONDCP), the campaign is the nation’s largest anti-drug media campaign and is generally regarded as the single largest source of drug-prevention messaging directed to youth. Although the campaign was initiated in 1998 with the overall aim of educating youth about the ill-effects of illicit and licit substances such as alcohol, methamphetamine, ecstasy and marijuana among others, it shifted its primary focus towards preventing teen marijuana use between 2002 and 2004.
According to the Government Accountability Office (GAO), however, the government’s investment of 1.4 billion dollars from 1998 to 2006 has yielded no significant favorable effect on marijuana initiation among non-drug-using youth or on discontinuing or declining use among prior users (6). What is more, the GAO, basing its conclusions on research conducted by Westat Incorporation, believed that the campaign may have even encouraged more teens to use marijuana (5). In spite of the GAO’s recommendation to stop funding for the campaign unless new strategies can be applied, the Bush administration sought an additional 120 million dollars in funding for the campaign in 2007, an increase in 20 million dollars from the campaign’s 2006 budget appropriations (6). In 2005, the campaign shifted focus from targeting parents and peers as the “Anti Drug” to encouraging teens to live “Above the Influence.” However, this shift in theme has not bought about a change in philosophy, as the campaign still erroneously conforms to the Theory of Reasoned Action (TRA) rationale in order to convey its anti-drug messages to youth.
The Theory of Reasoned Action (TRA) is an individual-centered model that views human behavior as a function of interactions between individual attitudes, social norms, and intention. A person’s intention is determined by weighing their personal attitude against perceived social norms. This intention then directly leads to behavior (7). Individual attitude towards a specific behavior is comprised of his or her opinion whether performing the behavior is good or bad. This attitude is influenced by the beliefs of the individual towards that behavior, referred to as behavioral beliefs (7). Social norms are comprised of the individual’s perceptions of the social pressures put on him or her to perform or not perform the behavior in question (7). These social norms, in turn, are influenced by individuals’ normative beliefs. It should be noted that the TRA model presumes behavior to be a rational process whereby individuals deliberate, whether consciously or unconsciously, the costs and benefits of performing a particular behavior. Additionally, it also assumes that behavior is planned and logically pre-analyzed, leaving little room for consideration of spontaneous behavior or a momentary change of mind on the individual’s part (7 & 8).
The TRA may be considered a reasonable theory to utilize when creating anti-drug interventions as it takes into consideration the power of social norms in shaping individual behavior. That is, the TRA model accounts for the individual’s intrinsic attitude as well as his or her social environment as embodied in the attitude of others. The individual’s own attitude towards drug use and his or her perception of the opinions of others (including peers and parents), are arguably two of the most important factors in shaping one’s intentions regarding drug use. A TRA-based intervention could potentially seek to manipulate the target youth’s personal attitudes and their perceived social norms in order to affect behavioral change. As such, anti-drug campaigns could attempt to instill a negative attitude in teens regarding marijuana use, expecting to negatively reinforce the use of drugs by depicting the use of marijuana as an undesirable social norm. Or conversely, a TRA-based intervention could be designed so as to positively influence youth by presenting social norms that promote a healthy, drug-free lifestyle. It appears that the Above the Influence campaign focuses on the former strategy of negative reinforcement, but it largely fails to do so effectively. A part of the failure of the campaign to effectively convey anti-drug messages to youth stems from basic limitations of the TRA model. This conventional logic model is mathematically structured such that it fails to appreciate the true dynamics of decision-making and is ineffective when it comes to predicting spontaneous behavior. Hence, TRA-based interventions cannot prevent or reduce risk behaviors such as smoking, drinking or drug use in social situations where teens, in an irrational or “hot” state of mind (9) that comes with their age-defined need for peer approval and social popularity, are unlikely to stop to carefully weigh the costs and benefits of the behavior they are about to engage in. Such is the case with the National Youth Anti-Drug Media Campaign and its Above the Influence message brand.
Above the Influence: Enduring Obstacles to Effective Campaign Messaging
One major setback of the campaign is that the commercials depict negative social norms associated with marijuana use in a highly exaggerated manner. It is important to recognize that health risks associated with substance abuse, sexual behavior and general well-being nevertheless rank low among the average adolescent’s other concerns (10). For the most part, an under-assessment of the risks related to drug use on the part of the youth presents a challenge in their ability to accurately relate to the negative consequences depicted in these commercials. What is more, several Above the Influence commercials portray negative consequences of drug use in an unrealistic fashion, such that they further undermine their own credibility and relevance to the reality of their target population. For instance, the “Not again” ad shows a couple with the ‘boy’ smoking marijuana as the ‘girl’ looks on in disappointment, with the words “not again” appearing next to her head. A space ship subsequently appears out of the sky, and an ‘alien’ emerges from it. It approaches the couple, and the boy offers him marijuana, which it turns down saying “no thanks.” The girl is pleasantly surprised by this gesture – as suggested by the heart symbol blinking near her head – and she decides to fly away with the alien instead, leaving the boy pondering at what just happened (11).
In accordance with the principles prescribed by the TRA model, the “Not again” commercial tries to influence the behavior of teenagers by showing that society (including the extraterrestrial civilization) disapproves of individuals who smoke marijuana. This negative social norm against the use of marijuana is primarily represented in the unfavorable reaction of the girl. Moreover, her abandonment of the boy is an attempt to manipulate the perceived social norms of adolescent marijuana users by indicating that their friends will leave them or avoid them if they continue their drug habit. While the message of this commercial may be reasonable, the manner in which it is communicated is highly unrealistic. The presence of an alien itself takes away any semblance of reality that the commercial might have otherwise held, leaving teens unable to relate with it. Additionally, this commercial might even be offensive to adolescents who may feel that it underestimates their intelligence, believing them to be foolish or naive. Whereas the use of stick or cartoon figures in this commercial might be appealing to elementary children, they are further likely to undermine the commercial’s credibility and serious message among its target teenage population.
An equally unrealistic Above the Influence commercial is the “Stop looking at me” ad, which depicts a pet dog reprimanding his adolescent owner for using marijuana (12). This commercial also fails to resonate with its target population, not taking into account that adolescents are less likely to take the idea of a talking dog seriously. The depiction of social norms against the use of marijuana – in this case the pet dog being disappointed – also represents an ineffective communication strategy of the campaign’s intended anti-drug message. That is to say, targeted adolescents are less likely to identify with negative social norms that come from a talking dog due to its sheer discrepancy with reality. Thus, a combination of the unrealistic depictions of negative social opinions regarding drug use and the tendency of the Above the Influence ads to underestimate teenagers’ sophistication and intelligence levels has resulted in anti-drug messaging that adolescents are largely unable to relate to. Consequently, commercials in the Above the Influence portfolio, such as “Not again,” “Stop looking and me,” and others, are not inclined to produce the desired change in behavior, whether prevention or reduction of drug use.
Another significant flaw in the Above the Influence campaign is that its commercials focus solely on the negative effects of smoking marijuana without presenting adolescents with any positive activities they can engage in as sound alternatives to drug use. Peers have an enormous impact, both negative and position, on the actions and behaviors of an adolescent with regard to risk behaviors such as alcohol consumption and marijuana use (8 & 10). A study conducted on this subject showed that adolescents, who had friends that were involved in ‘deviant’ behaviors such as marijuana use, were more likely to engage in such behaviors themselves (8). On the other hand, teens whose friends engaged in numerous school and community activities (like athletics, drama or volunteering) were less likely to engage in harmful behaviors like marijuana consumption (10). According to these studies, in order to be effective, anti-drug campaign ads need to portray teenagers involved in positive social activities instead of negative ones such as drinking or using drugs. Unfortunately, as they currently stand, most Above the Influence campaign ads are in complete contradiction to these findings. A majority of these commercials – “Dog,” “Not again,” “Shadow,” “Fire,” “Cocoon,” to name just a few – portray teenagers who are using marijuana, as opposed to showing positive examples of adolescents actively staying above the influence by engaging in alternative activities. The single exception to this trend is the “Fitting in” ad, which I believe is the only Above the Influence commercial that seeks to positively reinforce anti-drug attitudes in teenagers. This commercial shows an adolescent boy actively maneuvering to “fit” into different frames of various social situations and activities such as hanging out with friends at a café or skateboarding. However, when a frame depicting two youth engaging in marijuana use approaches the forefront of the screen, the protagonist makes the choice to walk away. The commercial then begs the target viewer to consider: “is everything worth fitting into?” (13). Unlike other ads in the Above the Influence campaign, “Fitting in” sympathizes with adolescents’ age-appropriate need to “fit in,” but it sends a strong message of youth empowerment by indicating that not all activities, especially drug use, may be worthwhile as there are always other “frames” or alternative activities one can opt for in order to gain social acceptance or peer approval.
A third important drawback of the Above the Influence campaign is that it does not effectively change individual attitudes towards marijuana use. That is to say, it fails to appeal to the core values adolescents commonly subscribe to, including independence, control, social or peer acceptance, and rebellion against authority. Studies have shown that teenagers, due to the influence of puberty and hormonal changes associated with it, are more likely to engage in rebellious, sensation seeking behavior than any other age group (14). Sensation seeking behavior, in turn, is directly proportional to the early onset of alcohol and drug abuse amongst teenagers (15 & 16). Most adolescents have positive personal attitudes towards marijuana because the use of it allows them to engage in sensation seeking, rebellious and risky behavior – values that they aspire or closely associate with. Thus, in order to prevent teenagers from partaking in the risky behavior of drug abuse, anti-drug campaigns like Above the Influence are burdened with off-setting adolescents’ pull towards marijuana use.
However, until now, the Above the Influence campaign has largely failed to take advantage of or associate its anti-drug messages with the aforementioned core values that adolescents strongly adhere to. In fact, unfortunately most of the campaign commercials do the exact opposite. These ads project the act of using marijuana as one that society (by extension authority figures such as parents, educational & professional institutions, and the law) disapproves of, thus unintentionally associating its use with core adolescent values of rebellion and independence. For instance, the “Not again” commercial conveys societal disapproval of drug use in the reactions of the ‘girl’ as well as the ‘alien’ who eventually abandon the ‘boy’ using marijuana. Unfortunately, it is the very condemnation of drug use that so widely appeals to the core teen value of rebellion, and is viewed in a positive rather than a negative light by most adolescents. The combination of such rebellion-conducive messages and portrayal of adolescents smoking marijuana without facing any realistic negative consequences may be contributing factors to the GAO/Westat Inc. report’s findings of higher propensities to use marijuana amongst youth. Ultimately, the inability of the Above the Influence campaign to alter individual attitudes towards marijuana use has rendered it ineffective in controlling the growing rates of drug use amongst adolescents.
The Use of Advertising Theory to Bolster Campaign Messaging
In order to effectively reduce marijuana consumption and use of other illicit drugs amongst U.S. teenagers, extensive changes in intervention models are required in the field of public health. Instead of relying on traditional public health models, such as the theory of reasoned action, which overlook essential social factors influencing the decision-making process of teenagers indulging in high-risk behavior, focus needs to shift on newer and more comprehensive alternative models that cater to the core values of the target population (17).
The creators and supporters of the campaign tend to distinguish it from previous efforts of its kind by emphasizing that it is “…modeled on advertising industry and market research best practices.” As part of its initial phases, the campaign executed “exploratory research” which includes literature reviews, expert opinions, scientific claims, interviews of affected communities, and communication with an “expert panel.” Subsequent best practices that the campaign professes to have employed include qualitative or “focus group” testing, quantitative or “copy” testing, as well as tracking ad assessment studies measuring teen awareness and memory of the commercials (18).
At first glance, many Above the Influence ads strike one as being well made and unique; almost all commercials follow a story or message directly related to youth, while many hold the attention of the viewer well. For instance, the “Stop looking at me” ad depicts an engaging dialogue between the dog and its adolescent owner that compels the viewer to follow their exchange, conveyed in the form of scribbled writing above stick drawings of the protagonists. Though this ad is at first visually appealing and can capture the attention of its target audience, the use of comic images and the idea of a judgmental pet dog separate it from reality, consequently undermining the ability of teenagers to identify with the substance and content of the message.
Although the visual quality of most Above the Influence commercials indicates consultation of advertising industry experts, a deeper evaluation of the campaign on the basis of “the advertising theory” is called for. Two principles of this theory form the essence of all commercial advertisements: “the Promise,” and the “Support” for that promise. According to this theory, the Promise is a fundamental element of all ads and is essentially the selling point of any commercial (19). On the other hand, the Support refers to the combined effect of select images, words, symbols, metaphors, background music, and overall feel of the commercial to support that Promise and persuade the viewer that they want the product being advertised. The Promise is the center-piece of any advertisement; and the best ones are carefully crafted such that “[p]romise, large promise is the soul of the advertisement.” (19). In other words, the larger the Promise, the more effective the advertisement. In the world of commercials, even a Promise so huge that it is absurd has the potential to be enormously successful if it offers the consumer something he or she aspires. Conversely, the key function of the Support is to reinforce “the promise of happiness engineered by advertisers through the consumption of images which appeal to human needs and sensuality” (20). It should be noted that with the simple formula of the Promise and the Support, commercial advertisements calculatingly appeal to the core values of its target population. In other words, successful commercials rarely sell the material product they are representing; instead they seek to assimilate with human aspirations and values such as love, freedom, independence, beauty, youth, acceptance, accomplishment, and control.
The ultimate objective of public health, on the other hand, is usually to discourage or encourage a particular health behavior or lifestyle choice among its constituents. However, years of failed or vaguely successful public health campaigns have proven that health does not sell. In light of this, the market strategy of appealing to core human values has an incredible potential to bolster such public health campaigns that often experience difficulty on the account that they are lacking a material product to “sell” to their target population.
As it currently stands, the Above the Influence campaign just scratches the surface of advertising and marketing principles, focusing more on the outer appearance and attractiveness of the ads as opposed to critically analyzing what most appeals to adolescents. The advertising theory, if used wisely and constructively, has the potential to transform the Above the Influence campaign into a successful endeavor capable of reducing marijuana use amongst youth. In order to strike a chord among its target population, the campaign must consciously utilize core youth values such as rebellion, independence, control and social acceptance.
To begin with, the social consequences of marijuana consumption need to be more realistically depicted. Current campaign commercials such as “Not again,” “Dog,” and “Don’t look at me” are ineffectual. Teenagers cannot relate to the consequences of marijuana consumption depicted in these commercials, since they are not reasonably portrayed. That is to say, that although their central message or Promise may be reasonable, the Support for these ads is weak and unrealistic. Your girlfriend leaving you for an alien because you are using marijuana or your talking pet dog reproaching you for the same are exaggerated consequences of marijuana use that teenagers can not relate to. One key way in which the consequences can be made more realistic is by fortifying the Support for these commercials. Campaign ads such as “Not again,” “Stop looking at me,” and “Dog” need to be replaced with commercials that depict real-life teenagers delivering the anti-marijuana message. By showing other youth – rather than cartoon stick figures and animals – delivering the anti-drug message, these commercials will better connect with marijuana users who will be able to relate to the intended message. Additionally, marijuana using teens will be more accepting of an anti-marijuana message delivered by peers who are similar to them in that they are experiencing the same everyday conflictions and emotional ups and downs. In addition, this strategy incorporates a compelling personal story and a face into the commercial, further strengthening the Support for the anti-drug message. Thus, using teenagers as familiar conveyers of the message is an effective way of presenting the consequences of using marijuana more persuasively.
There are, in fact, several Above the Influence commercials, such as “Fire” and “Achievements” for instance, that do portray other teenagers delivering the anti-marijuana message. However, these commercials remain ineffective because the content of the message is negative, rather than positive. Instead of expressing an appealing Promise by depicting teenagers participating in healthy, alternative activities these commercials focus solely on the negative outcomes of marijuana use. On the contrary, improved ads that employ a positive Promise with appropriate Support are more likely to succeed in empowering youth and reinforcing a positive identity of adolescents that resist drugs.
The “Achievements” commercial shows several marijuana using teenagers talking about how they abandoned their friends, disappointed their mother or got failing grades because they were addicted to marijuana (21). This commercial portrays marijuana users in a negative light, labeling them as irresponsible and reckless. Additionally, it fails to provide them with any alternative healthy activities they can engage in. Likewise, the “Fire” commercial depicts three teenagers abandoning the activities that they are involved in because of marijuana. The girl burns her athletic certificates in the fireplace, one of the boys chars his guitar on the grill, meanwhile the other sets fire to his car (22). The commercial attempts to show that using marijuana will eventually lead to the individual giving up healthier hobbies that he or she was once interested in. Again, though both these commercials have strong Support due to the memorable and jarring images used to convey their anti-drug message, the Promise they both offer is weak in that they focus on the negative aspects of smoking marijuana without highlighting any positive outcomes of not smoking marijuana.
As mentioned before, teenagers are easily influenced by their surrounding environment. Research has shown that youth who had friends that were involved in undesirable behaviors – such as using marijuana – were more likely to indulge in such behaviors themselves. In contrast, teenagers whose friends were involved in alternative activities such as sports or community service were more averse to using marijuana. Accordingly, it is essential that Above the Influence campaign commercials focus on portraying teenagers partaking in desirable alternative activities, rather than depicting teens who are using marijuana. For this reason, campaign commercials would be more successful by presenting teens involved in activities like playing sports, participating in the school musical, creating artwork and other such enjoyable and healthy activities. As mentioned earlier, the sole Above the Influence campaign that has succeeding in doing so is “Fitting in.” Alternatively, the “Try football” ad, as suggested by its title, also tries to urge youth in participating in alternative activities, but it does so rather ineffectively. This ad depicts a tall boy smoking marijuana who smugly tells a smaller boy passing by with his dog that he uses drug to “impress the ladies.” The smaller boy simply responds by suggesting that he “try football” instead (23). Though the message of this ad is positive and sound, it has been made with poor Support in that it employs unrealistic and childish images (cartoon stick figures of the same style that was used for the ads “Not again” and “Stop Looking at me).
In addition to focusing on positive outcomes of not using marijuana, it is important for the campaign to affect change in individual attitudes towards marijuana use. Hence, the message relayed through the campaign needs to appeal to the core values of the target population. As previously stated, teenagers are more likely to engage in rebellious, sensation-seeking which drives them to try risky, and at most times, unhealthy activities such as alcohol use and drug abuse, including marijuana consumption (15 & 16). Consequently, in order for campaigns like Above the Influence to be effective in changing individual attitudes towards marijuana, it needs to abandon conventionality and opt for an element of vigor and rebellion. On the contrary, current Above the Influence commercials – “Not again” being a prime example – present the act of marijuana consumption as a negative activity that society frowns upon. While this message appears to be reasonable to adults with the expectation that it would lead to the logical conclusion that marijuana should not be used due to the negative social opinions associated with it. However, to the average adolescent who gains satisfaction from rebelling against societal norms that they view as authority, this message encourages them to use marijuana simply because that makes them a rebel, a desirable teenager trait.
The Above the Influence campaign can draw from the example of the anti-tobacco Truth campaign in appealing to the core values that teenagers strongly adhere to. The anti-smoking message delivered by this campaign is peppered with essential youth core values. The campaign ads depict mature and sophisticated youth rebelling against big tobacco, exposing their research as biased, and challenging them to reveal the facts about smoking. These commercials portray non-smoking youth as smart, cool and independent individuals who are defying the authority – in this case, the tobacco industry – that is pushing them towards smoking. The Truth campaign depicts the act of not smoking, rather than that of smoking, as the rebellious thing to do, thus appealing to the important core value of rebellion that teenagers hold dear. Moreover, these campaign commercials do not just show one individual, but instead a group of like-minded individuals who are all committed to fighting big tobacco. The objective behind such imagery is to instill a desire amongst teenagers to become part of a continuously growing movement, providing them with a feeling of independence and belonging, both essential teen core values. The Above the Influence campaign needs to similarly depict groups of young non-marijuana users as independent, unique and intelligent individuals rebelling against the norm of smoking marijuana amongst teenagers. Such positive labeling of non- users will encourage teenagers to not consume marijuana, leading to a reduction in the high rates of teenage marijuana use.
The Above the Influence campaign is based on traditional public health models that are obsolete and inadequate for designing effective health interventions. In order to be successful, campaign creators and administrators need to rethink their advertising strategy to ensure that all future ads are comprised of both a powerful, positive Promise as well as age-appropriate Support that does not leave the target youth with the feeling that the ad is an insult to his/her intelligence and hence inapplicable or irrelevant to them.





REFERENCES
1. Oetting, E. R., Beauvais, Fred. (1990). Adolescent Drug Use: Findings of National and Local Surveys, pp. 385. Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 4, 385-394.
2. Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (2000). Monitoring the Future national survey results on adolescent drug use: Overview of key findings. Bethesda, MD: National Institute on Drug Abuse, 1999.
3. Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2008). Monitoring the Future national results on adolescent drug use: Overview of key findings, pp. 6. Bethesda, MD: National Institute on Drug Abuse, 2007.
4. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings. (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293).
5. United States Government Accountability Office. Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC:GAO 06-818, 2006.
6. Leinwand, D. (August 2006) Anti-drug advertising campaign a failure, GAO report says. USA Today. Retrieved December 6, 2009, from: http://www.usatoday.com/news/washington/2006-08-28-anti-drug-ads_x.htm.
7. Ajzen, I., & Fishbein, M. Understanding attitudes and predicting social behavior. New York: Psychology Press, 1980.
8. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007.
9. Ariely, D., Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins, 2008.
10. Eme, R., Maisiak, R., Goodale, W. Seriousness of adolescent problems. Adolescence 1979; 14 53: 93–99.
11. Above The Influence. “Not Again” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav
12. Above The Influence. “Stop Looking At Me” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav
13. Above The Influence. “Fitting in” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav
14. Zuckerman, M. Behavioral Expressions and Biosocial Bases of Sensation Seeking. New York: Cambridge University Press, 1994.
15. Ball, S.A., Carroll, K.M., Rounsaville, B.J. Sensation seeking, substance abuse, and psychopathology in treatment-seeking and community cocaine abusers. Journal of Consulting and Clinical Psychology 1994; 62:1053–1057.
16. Kosten, T.A., Ball, S.A., Rounsaville, B.J. A sibling study of sensation seeking and opiate addiction. The Journal of Nervous and Mental Disease 1994; 182:284–289.
17. Siegal, M., & Donner, L. Marketing Public Health: Strategies to Promote Social Change. Sudbury: Jones and Bartlett Publishers, 2004.
18. National Youth Anti-Drug Media Campaign. Washington, DC: White House Office of National Drug Control Policy (ONDCP). http://www.mediacampaign.org/about.html.

19. Ogilvy, D. How to Build Great Campaigns (pp. 98-103). In: Confessions of an Advertising Man. New York, NY: Atheneum, 1964.
20. Harms, J., Kellner, D. Toward a Critical Theory of Advertising. Southwest Missouri State University & University of Texas at Austin. Retrieved December 8, 2009, from http://www.uta.edu/huma/illuminations/kell6.htm.
21. Above The Influence. “Achievements” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav
22. Above The Influence. “Fire” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav
23. Above The Influence. “Try Football” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav

Don’t Be a Patsy: A Critique of The Partnership for a Drug-Free America’s Campaign to Connect Parents with their Teens – Adam J. Tapply

I. Introduction
The war on teen drug use is one that has no end in sight. In one of the most recent studies, the Monitoring the Future Study asked high school seniors, "On how many occasions, if any, have you used drugs or alcohol during the last 12 months or month?"( ). Of high school seniors in 2008, 42.6% reported having ever used marijuana, 7.2% reported having ever used cocaine, and 1.3% reported having ever used heroin ( ). The rates for all illicit drugs have varied over the years, but the trend remains rather steady ( ). The increase in marijuana use (past-month use) has been especially pronounced. Between 1992 and 2008, past-month use of marijuana increased from 12% to 19% among high school seniors, 8% to 14% among 10th graders, and 4% to 6% among 8th graders ( ). The Monitoring the Future study also found high percentages of students reporting they could obtain certain drugs fairly easily or very easily in 2008 with marijuana having the highest percentage at 83.9% followed by amphetamines at 47.9% and cocaine at 42.4% ( ). In 2007, 22% of all students in grades 9 through 12 reported someone had offered, sold, or given them an illegal drug on school property ( ). Data from a 2007 survey showed that marijuana and cocaine use is the most prevalent among persons age 18 to 25 ( ). Teen and young adult drug use is not a new issue, but the fact that the combined might of all the public health interventions implemented over the years has failed to make a pronounced impact is alarming.
The majority of teen drug interventions target the teens themselves. Some studies have found, however, that interventions centered on the parents may be more effective in curbing teen drug use. One study used data from substance abuse surveys of 7th to 12th graders to explore the relationship of parent-child communication to drug involvement and found that (a) parents are most often identified as the individuals who have talked to a child about drugs; (b) youth consider parents to be credible sources of information about drugs; (c) as perceived family sanctions go up, drug involvement goes down; (d) youth with the highest levels of drug involvement are the group most likely both to have had no one talk to them and to have had the largest number of people talk to them about drugs; and (e) perceived family sanctions increase dramatically for highly drug-involved youth once they have been talked to by one person ( ). Another survey found that teens with “hands on” parents – parents who have established a household culture of rules and expectations for their teen's behavior and monitor what their teens do – are at one quarter the risk of using drugs as teens ( ). Another study, at the time the largest study ever of U.S. teenagers, found that adolescents are far less likely to use alcohol and drugs, or engage in other dangerous behavior, when they feel loved and nurtured at home ( ). The importance of quality parental interaction with teens is unquestionable and this has been the focus of one of the Partnership for a Drug-Free America’s most recent campaigns.
Beginning in October of 2008 and continuing to this day, the Partnership for a Drug-Free America has run an anti-drug ad campaign focused on getting parents to seek advice on how to talk to their teens about drugs. They relied on data from the 2007 Partnership Attitude Tracking Study (PATS), which found that half of all parents (51 percent), with kids in 6th-8th grade, feel they lack the tools and information to prevent drug and alcohol use ( ). The research found, in general, that there is an increased need for parents to find a way to talk with their kids. The main platform for this campaign has been a series of television commercials starring Patsy, a well-intentioned, high-energy mother with a Midwestern accent, ready to go to any length to keep her kids from using drugs and alcohol.
The “Patsy” campaign consists of four 30-second and two 15-second TV spots (which can all be found on the drugfree.org website: http://www.drugfree.org/parent/ConnectingWithYourKids/), five “webisodes” for YouTube, one radio spot and 2 print executions. Each commercial has the premise of having Patsy act as a renegade Youtube-style blogger showing the audience via home-video how she communicates with her children about drugs. In the commercials, Patsy not only uses a drug-sniffing dog, she sneaks up on her teen son in the shower, drills him on drug facts, and demonstrates a benevolent, police-style “Patsy pat-down.” Patsy also shows off her own method for preventing abuse of prescription medications – she removes the labels from every bottle in the medicine cabinet ( ). Patsy is deliberately positioned as a well-intentioned mother who is mistaken in how best to communicate with her children about drugs, thus the prompting at the end of each ad: “Don’t be a Patsy. Learn a Better Way at Drugfree.org.” Alon Shoval, the executive creative director of the campaign, says, “By creating Patsy, a mom who gets it all wrong, we allow real moms to laugh at themselves and realize they don’t have all the answers” ( ). In effect, when parents laugh at Patsy, they get her point without having to hear a lecture. The underlying purpose is to get parents to access the content on drugfee.org website – an expansive “Parent Resource Center” that offers “Advice by Age”, help “Understanding Teens”, “Protecting Your Kids”, advice on “How to Spot Drug & Alcohol Abuse”, and “How to Help if They’re Using”, among other resources.
This paper will focus on the TV / Youtube portion of the ad campaign rather than the online content. Though I’m not one myself, I found the online content to be an excellent source of resources for parents. The ad campaign that is supposed to draw attention to this content, however, is flawed in my opinion. In the next section, I will detail these flaws and describe how and why they detract from the effectiveness of the commercials. In the final section, I will illustrate how the commercials could be changed in accordance with social and behavioral science principles to be more effective.
II. A Critique of the “Don’t Be a Patsy” Ad Campaign
This section argues that the Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign is flawed for three main reasons. First, the campaign fails to incorporate basic principles of advertising theory into its message. Second, the campaign fails to consider spontaneous situations. Third, the campaign underestimates the importance of context.
A. The “Don’t Be a Patsy” Campaign Fails to Incorporate Basic Principles of Advertising and Marketing Theory
The “Don’t Be a Patsy” campaign is based around the idea that parents will (Step 1) watch these commercials, (Step 2) laugh at them, and then (Step 3) go to the online website. The idea is that, when they laugh at Patsy, the mother in the commercial, they are really laughing at someone like themselves who doesn’t really know how to talk to her children about drugs. In my opinion, Step 1 and Step 2 work, but Step 2 does not connect effectively to Step 3. The campaign therefore fails because the parent doesn’t access the important content on the drugfree.org website, which is the entire purpose of the campaign.
Watching Patsy, the parent is supposed to laugh, but it’s an uncomfortable laugh. There’s a veiled threat in the message of this campaign: parents do not know how to talk to their children about drugs, so they may be able to get away with anything. This may not be the intended message, but there is clearly no explicit message. The campaign is using an implied threat to inspire a level of fear in parents, which, as I will discuss, can be effective as long as it’s employed correctly.
Advertising theory is based around a “Promise” and “Support” for that promise. The promise generally concerns the product being advertised and its promised benefits ( ). The next step is to support the promise with an example of its benefits in the form of a story, images, symbols, and/or metaphors ( ). The “Don’t Be a Patsy” campaign’s commercials make the promise that, if you act like Patsy, your children will not connect or communicate with you and will therefore be more likely to do drugs. This is basically the support provided in the commercials set up as a quick example / story, though the teens are never actually shown doing drugs. One could also look at the promise this way: parents are completely clueless when it comes to their children and drugs and they (the children) can get away with anything. Because there’s no explicit message, it’s up to the viewer to figure out what the message is and here it is simply not coming across as it should.
The Persuasive Health Message (PHM) Framework offers another approach for creating a persuasive message. A persuasive health message should contain a threat message and an efficacy message ( ). The threat portion of the message tries to make the audience feel susceptible to a severe threat. The efficacy portion tries to convince individuals they are able to perform the recommended response (i.e. self-efficacy) and that the recommended response effectively averts the threat ( ). Evidence from fear-appeal research suggests that messages are most effective when there are high levels of both threat and efficacy ( ). Applying this to the “Don’t Be a Patsy” ads, we see a low level threat that’s implied, not explicit: you don’t know how to communicate with your children about drugs; and no efficacy at all. The efficacy portion would only emerge if the parent was inspired to go to the online content, which is unlikely since the threat message is so weak.
The message of the “Don’t Be a Patsy” ads doesn’t effectively sell parents on the idea of logging onto the online website. They merely provide a humorous example of what not to do without giving the viewer any pressing reason to learn how they should make a change in their own behavior.
B. The “Don’t Be a Patsy” Campaign Fails to Consider Spontaneous Situations
The nature of the “Don’t Be a Patsy” ads are, by design, planned. Each ad starts off with Patsy speaking to the camera about how she is about to interact with her child. In most of these situations, the child is simply walking by: coming down the stairs in one ad, coming through the front door in another. The behavior of Patsy looks to follow the Theory of Reasoned Action. This theory suggests that a person's behavior is determined by his/her intention to perform the behavior and that this intention is, in turn, a function of his/her attitude toward the behavior and his/her subjective norm ( ). This theory assumes that behavior is planned and is static. To a degree, Patsy’s behavior in the commercials is probably a little accurate: many parents do not know how to talk with their children about drugs and resort to “traps” – planned confrontations – like the ones employed by Patsy. Life and human behavior is generally not like this, however, and the drugfree.org online content recognizes this.
The parent toolkit on the drugfree.org website encourages parents to take advantage of “teachable moments”: this refers to using every day events in your life to point out things you’d like your child to know about, including drug situations going on in your own neighborhood, drug-related headlines in the news, and other situations on TV and in the media ( ). This behavior (the correct behavior) is far more spontaneous than the behavior demonstrated by Patsy. The audience should clearly understand that Patsy’s behavior is wrong, but what should they do about it? The correct behavior is not illustrated, so therefore the audience has no idea how to perform a behavior that actually works.
The Theory of Planned Behavior adds self-efficacy to the Theory of Reasoned Action equation. Self-efficacy relates to the belief that you’re capable of doing a particular behavior ( ). I cannot apply how Patsy is affected by self-efficacy because she is a fake person, but, as I mentioned in the previous section, self-efficacy is an important part of the viewer’s experience here. There is no self-efficacy present in these messages, however, because Patsy performs an improper behavior that clearly doesn’t work. It would have been far more effective to show a Pasty-type character demonstrate one of the teachable moments described on the drugfree.org website and show how the correct behavior causes the appropriate reaction in her child. The self-efficacy would come across and the viewer would gain confidence that they could themselves perform that correct behavior.
C. The “Don’t Be a Patsy” Campaign Underestimates the Importance of Context
Darley and Batson’s classic study on helping behavior (the “good Samaritan” study) demonstrated how much of an effect context can have on behavior. The results of this study showed that a person in a hurry is less likely to help people, even if he is going to speak on the parable of the Good Samaritan. This shows, basically, that behavior is strongly affected by the context in which it occurs. Consider the context in which the “Don’t Be a Patsy” commercials take place: most of the ads have Patsy cornering her child in a normal, relatively context-free situation (coming down the stairs or entering in the front door, as mentioned before). Is this the right time to talk to your child about drugs? The Partnership for a Drug-Free America clearly doesn’t believe so, as evidenced by the online parenting guide, which directs parents to make use of “teachable moments.”
The fundamental attribution error is a common type of cognitive bias in social psychology. Essentially, the fundamental attribution error involves placing a heavy emphasis on internal personality characteristics to explain someone's behavior in a given situation, rather than thinking about external situational factors ( ). When we see Patsy fail in her attempt to communicate with her children, the fundamental attribution error would argue that the audience blames Patsy and her personal characteristics for her communication failure. This is rather misleading, because the context of the situation in these ads also plays a part in determining the outcome of her little interventions. The Partnership for a Drug-Free America clearly intends to highlight this failed context because it shows parents how to use context to their advantage in the “teachable moments” section of its website. Their ad backfires, however, because the audience is not receiving the failed context message. The fundamental attribution error explains that the audience is going to interpret the overall failure as due to Patsy’s personal characteristics instead. In addition to being an overall ineffective message, the parent viewing this commercial may simply reflect on the ad they’ve just seen and think, “I’m not like Patsy. This won’t happen to me.” Therefore, when faced with a situation where they would talk to their children about drugs, the parents are more inclined to think that their own behavior is more important to the outcome than the context of the situation in which the interaction is taking place. The end result is the parent is far less likely to respond to the prompt to go online and access the drugfree.org website’s content containing helpful tips for parents.
III. A Reformulation of The Partnership for a Drug-Free America’s “Don’t Be a Patsy” Ad Campaign
The critiques of the Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign suggest subtle changes in the format of the ads may make them more effective. For my reformulation of the campaign, I am going to stick with the general format of the ads (home-video with a mother figure and a child), but alter the content of the ads so they are in line with the critiques I made in the previous section. Like the “Don’t Be a Patsy” ads, the goal of the new ads will be to convince the parents in the audience to go online and access the drugfree.org content geared towards parents.
The message of the original “Don’t Be a Patsy” ads was garbled – it didn’t come across loud and clear that parents need help in figuring out how to communicate with their children and that they should go to the drugfree.org website for help. The reasons for this were (1) the ad’s “promise” wasn’t clear, and the “promise” wasn’t backed by proper support, (2) the ad lacked a sufficient threat message, and (3) the ad didn’t incorporate self-efficacy into its support.
A. The Campaign Should Have a New, Clearer Message
A good persuasive health message contains a powerful threat message and an accompanying efficacy message ( ). The threat portion of the message tries to make the audience feel susceptible to a severe threat. The efficacy portion tries to convince individuals they are able to perform the recommended response and that the recommended response effectively averts the threat ( ). The threat in these ads is targeted at parents and should be created accordingly. A good threat message is simply: “your children will do drugs.” Adding self-efficacy to the messages results in the final message: “your children will do drugs unless you can communicate with them about the dangers of doing drugs.” The threat is clear, as is the recommended response that can effectively nullify the threat. How this message is conveyed through the ad will determine how effectively the message is received by the audience. Accordingly, the direction of the ads – meaning the scenes they show – should be changed.
B. The Campaign Should Have a New “Promise” and Proper “Support” in Accordance with Advertising Theory
Shifting to Advertising Theory, the message conceived in the previous section can be translated into a “promise”: “if you communicate effectively with your child about drugs, he/she will be less likely to do drugs.” Next, support needs to be designed that conveys this promise effectively to the parent viewing the ad. I envisage these ads taking place in three scenes. In Scene 1, a teenager is making an arrangement with a friend (via texting, for example) to go drink some alcohol or smoke some marijuana. Scene 2, presents a situation between the time the arrangement is make and when the drug activity actually takes place. This, in my opinion, is the perfect time to apply one of the Partnership for a Drug-Free America’s “teachable moments”. A parent can be shown talking to her child, who is intending to go do drugs soon afterwards, in a teachable moment. For example, they’re watching TV together when a news update pops on the screen about a local teen that just died of a drug-related condition (maybe alcohol poisoning or a heroin overdose), which leads to a conversation about the dangers of drugs. Or maybe the parent is actually driving the child to his/her friend’s house and the parent points out a homeless man drinking from a liquor bottle on the side of the road, which leads to a conversation about the dangers of drugs. The final scene seals the promise of the ad. The child meets up with the friend with whom he/she was intending to do drugs and simply chooses not to engage in that behavior.
Over the course of a 30 second commercial, the audience is shown (1) intention to do drugs, (2) the intervention, and (3) no intention to do drugs. The parent watching the ad is clearly shown that the intervention – communicating effectively with the child about the dangers of drugs – can change the behavior of the child in the intended way: there’s no longer an intention to do drugs. This is all done by telling a simple 30 second story that could happen to any parent with a teen any day of the week. Furthermore, self-efficacy is incorporated into the ad, here, by showing how the recommended response to the threat (communicating with your child about the dangers of drugs) effectively averts the threat (changed intention). It helps that all of these “teachable moments” presented by drugfree.org website are examples that can truly happen in day to day life; there’s no special skills needed outside of ordinary parenting skills. Showing the parents in the audience how a “teachable moment” can be correctly and effectively employed should effectively convey the message of the ads: “if you communicate effectively with your child about the dangers of drugs, your child will be more likely to choose not to do drugs… learn more effective strategies at drugfree.org”
C. The Context of the Campaign’s Ads Should be Changed
Most of the changes to the ads’ context have already been discussed in the previous section. The main purpose of this change in context is to get the ads out of the mentality of staged interventions employed by Patsy. The setups used by Patsy – grilling her son with questions while he’s in the shower, patting down her daughter as she’s coming down the stairs, forcing her son to pass a drug-sniffing dog as he enters the house – are simply unrealistic and detract from the effectiveness of the message.
The changes I described in the last section make use of real life situations (or potential real life situations, at least). The parent isn’t charged with planning out the behavior of communicating the dangers of drugs to her child; she is simply taking advantage of a spontaneous situation (like a news report, or something seen while driving) and using it to frame a certain context. This is a much better model of human behavior. It doesn’t assume behavior is planned like Patsy does. Furthermore, the new ad accounts for spontaneous events and understands how context can affect the outcome of a conversation.
IV. Conclusion
The Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign ads are pretty funny, there’s no disputing that. This humor directed at parents, however, is misplaced. There’s little evidence to suggest that laughing at yourself is a good model for encouraging behavior change. Using established social and behavioral science models it is possible to create a more effective ad campaign that employs the same goal as the “Don’t Be a Patsy” campaign. The Partnership for a Drug-Free America may have been aiming for a so-called viral marketing campaign (whether or not it ever reached that status is debatable), but which is really more effective at teaching parents how to talk to their children about drugs: a viral campaign that is ineffective at getting parents to go online and learn about communication techniques? Or a well-designed, though perhaps not as funny, that effectively convinces parents that they need help talking to their kids? In my hypothetical campaign, I’m investing in the latter.

REFERENCES

1. Press release: Various stimulant drugs show continuing gradual declines among teens in 2008, most illicit drugs hold steady, University of Michigan News and Information Services, December 11, 2008, http://monitoringthefuture.org/pressreleases/08drugpr_complete.pdf
2. Bureau of Justice Statistics Drugs and Crime Facts: Drug use in the general population, http://www.ojp.gov/bjs/dcf/du.htm
3. Id.
4. University of Michigan, Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings 2008, May 2009, http://monitoringthefuture.org/pubs/monographs/overview2008.pdf
5. Id. at Note 1.
6. BJS jointly with the U.S. Department of Education, Indicators of School Crime and Safety, 2008, NCJ 226343, April 2009, http://www.ojp.gov/bjs/abstract/iscs08.htm
7. SAMHSA, Office of Applied Studies, 2007 National Survey on Drug Use and Health: National Findings, September 2008.
8. Kelly, KJ. “Parent Child Communication, Perceived Sanctions Against Drug Use, and Youth Drug Involvement,” Adolescence 2002; 37; 148.
9. National Center on Addiction & Substance Abuse (CASA) at Columbia University, Report: CASA 2000 Teen Survey: Teens With "Hands-off" Parents at Four Times Greater Risk of Smoking, Drinking and Using Illegal Drugs as Teens With "Hands-On" Parents, Sep 18, 2002.
10. Epstein, JH. "Nurturing teenagers to a better future: massive study confirms importance of parental care." The Futurist Mar. 1998; 32; 2.
11. Press Release: Foundation for a Drug-Free America, “Patsy” Teaches Parents How to Talk with Their Kids About Drugs, October 3, 2008, http://www.digital50.com/news/7657
12. Partnership for a Drug-Free America: Connect With Your Kids Ad Campaign Videos: http://www.drugfree.org/parent/ConnectingWithYourKids/
13. Id. at Note 11.
14. Ogilvy, D. Confessions of an Advertising Man, New York: 1964, p. 93-94.
15. Id.
16. Id.
17. Witte, K. “Using the Persuasive Health Message Framework to Generate Effective Campaign Messages”, in Designing Health Messages by E. Maibach and R. Parrott (Eds.), Sage Publications, California, 1996: p. 146.
18. Id. at p. 147.
19. Id.
20. Ajzen, I. “The theory of planned behavior.” Organizational Behavior and Human Decision Processes, 50, 1991: p. 179-211.
21. Partnership for a Drug-Free America: Online Content: http://www.drugfree.org/parent/ConnectingWithYourKids/Articles/Dont_Be_A_Patsy.aspx
22. Id. at Note 20.
23. Darley, JM, and Batson, CD, "From Jerusalem to Jericho": A study of Situational and Dispositional Variables in Helping Behavior". JPSP, 1973, 27, 100-108.
24. Ross, L. The intuitive psychologist and his shortcomings: Distortions in the attribution process. 'In L. Berkowitz (Ed.), Advances in experimental social psychology, 1977, vol. 10: pp. 173–220.
25. Id. at Note 17.
26. Id.

Parents: The Anti-Drug – A Critique and Rethinking of Parent-focused Anti-Drug Campaigns

– Kevin Delaney

Introduction

The United States government has long sought to control and eliminate drug use by its citizens, particularly by adolescents. Traditionally, this has been done through the criminal justice system, in the announcement of the “War on Drugs” by President Nixon in 1971 (1). These efforts focused on instituting harsh penalties on users of drugs, hoping to create a strong negative incentive, by which users would rationally choose to abstain. However, over the last thirty years, there has been a move to use public health initiatives to accomplish this goal. The anti-drug messaging ramped up in the 1980’s with Nancy Reagan’s “Just Say No” campaign and the establishment of the D.A.R.E. campaign, two public health initiatives to reduce and eliminate drug usage amongst teenagers that showed limited effectiveness (2,3). These measures focused on creating awareness amongst teenagers of the health risks of drug use through education, and focusing on kids making rational choices. However, particularly with the D.A.R.E. campaign, the emphasis was still on the negative incentives of drug use, as the education program is done in conjunction with local police forces (4). Recently, the federal government’s initiatives have focused more on the social aspects of teen drug use and acknowledging the strong social forces that influence it.

In this vein, the government has created the “Parents: The Anti-Drug” campaign. This initiative is aimed at taking advantage of the parent-child relationship to curtail drug use: “TheAntiDrug.com was created by the National Youth Anti-Drug Media Campaign to equip parents and other adult caregivers with the tools they need to raise drug-free kids” (5) Since parents are so integrally involved in the lives of their children, it would make sense to use them as a resource for anti-drug messaging. In addition, parents have a natural incentive to protect their children from the harmful effects of drug use. In a lot of ways, this initiative makes good sense. Indeed, there are studies that indicate that the level of monitoring that parents perform does have mitigating effects on their children’s drug use (6). However, when viewing this campaign within the framework of certain behavioral theories, the claim of parents being the “anti-drug” is exaggerated, and the potential effectiveness of this campaign is dubious.

Peers Have More Influence Than Parents – Social Expectations Theory

Despite the wishes of their parents, teenagers are often much more influenced by the behavior of their peers than the rules or guidelines of their parents. A constant theme throughout history is the adolescent who acts out against the strictures of his parent: the rebellion of the child. This social phenomenon, while causing much angst to the parents of America, has its roots in a well-established behavioral construct: social expectations theory.

While most of the population of the United States believes that freedom and autonomy guide their decisions, and that rational choices can be made, there is a lot of evidence that human behavior is as much determined by the social environment of the group as by the inner thought processes of the individual. Within society, social norms, roles and expectations guide how people make decisions. “Roles permit people acting collectively in a coordinated manner to accomplish goals that could not be achieved if each member acted independently” (7). Indeed, it seems that socialization is an adaptive trait that enhanced the evolution of humanity. However, it can have some maladaptive qualities.

Within the context of teenagers and drug use, there are powerful social dynamics that make drug use more common. As teenagers create social bonds, they do so in schools with their age-stratified cohort. As anyone who has survived the American high school experience can attest, cliques arise, within which there are heavily stratified social roles. Some members have a powerful role and set the norms of the group, whereas others strive to mitigate their dissonance from the group by performing compliant behavior (8). As drugs are seen as a dangerous and “bad,” they become the way that teenagers are allowed to rebel against their parents. From there, social dynamics take over. The powerful of the group can set the agenda for the others by using drugs. The members of the group that react in a compliant way will either feel overt pressure to take part, or will do so without any prodding. The influence of the peer taking precedence over the influence of the parent in drug use has been well established (9)

Within this social dynamic, there is no role for the parent. They are generally not part of the social group, and therefore do not have much influence over the behavior during the time that the group is using drugs. In fact, while at home, teenagers can perform an entirely different role within the family social group, one that can be entirely dissonant to the role within the peer group. Because of this, the Parents: The Anti-Drug” has major barriers to overcome to be effective. The campaign’s main drive is to communicate to parents to take a more active role in their child’s lives, which is supposed to result in decreased drug use. The main tool is a series of commercials reminding parents of their role. There is also a website that gives parents a lot of information about drugs and advice about how to talk to their kids about drugs. While this information is critical for any parent to know, there is only little mention about how influential the social interactions that teenagers have within their peer groups. There is a section of the website devoted to chronicling the “pressure to fit in,” but there is no mention of what to do about it (10). The only advice that parents have to relate to their teenagers is to learn how to “talk teen.” However, this advice can backfire if parents attempt to transform their social role from parent to friend without authenticity (7).

Marketing the Anti-Drug Message to Parents Subverts Teenager Autonomy

Another potential misstep by this campaign is that it has the potential to communicate the wrong values to teenagers. The tenets of marketing theory hold that in order for a messaging campaign to be successful, it must appeal to the values of its target audience (11). In the “Parents” campaign, the target audience is the parent. In this respect, the campaign is successful, in that it appeals well to the values that parents hold: that they are integral to the behavior of their children. By making parents feel that they have some level of control over the drug use of their children, the campaign gives them hope and should be successful in getting parents to have a greater level of involvement in their children’s lives. This will no doubt have a certain level in reducing the drug use of children, as there is evidence that decreased parental monitoring of children is associated with increased health risk behaviors (6).

However, this has the large potential to backfire in the true intention of the “Parents” commercials, which is to curtail the drug use of teenagers. While parental monitoring does have an effect on the behavior of teenagers, as mentioned above, the effects of peer groups have a larger effect on these behaviors (9). In addition, teens strive to increase their autonomy as they get older. In fact, this desire for autonomy is a crucial factor in their rebellious behavior: teens can demonstrate their autonomy by acting in a way that their parents forbid. Most of the marketing messages that are aimed at teenagers by consumer product companies create a feeling of freedom and autonomy in the brands. The strength of the “truth” anti-smoking campaign was in its ability to portray tobacco companies as agents of control over the lives of teenagers. The “truth” brand was successful in creating a feeling of rebellion against tobacco companies and smoking (12). The “Parents” commercials may have the opposite effect, as there should be no doubt that teenagers see these messages on television. While they are aimed at parents, teenagers may associate their parents as agents of control over their decisions to use drugs.

The Campaign Communicates the Wrong Message of Who Controls Drug Use

Closely associated with the other two failings of this campaign is the issue of control, which is a subtle relation to autonomy. By marketing the concept of teenage drug use to parents, the campaign ignores the role that teenagers have in controlling drug use. It puts the decision to not use drugs in the purview of parents, who are in a different social group, so that teenagers have no control over it. This creates an incentive problem for teenagers to participate in their own abstinence from drug use. As Langer writes in explaining the illusion of control, “[p]eople are motivated to control their environment” (13). In fact, the issue of control is very often a motivation for teenagers to begin using drugs, as it is one way that they can express their personality.

Children have very little legal standing, as they are the responsibility and the dependents of their parents. For very good reasons, parents control a lot of what their children do. However, teenagers most likely do not understand this legal argument, and only understand that they are not in control of many aspects of their lives, as many decisions are made for them. Therefore, the areas that they can control are very important to them. This is why teenagers focus a lot of energy on their friends and their personal products. The decision to use drugs is also an area that they can manage. Therefore, using drugs in reaction to their parents’ wishes is a way to feel that they make their own decisions. Even though, as mentioned above, people make their decisions within a social context, they still feel as if they are autonomous. By communicating to parents, the campaign inadvertently subverts the autonomy of teenagers and bypasses them in the anti-drug message.

Currently, the National Youth Anti-Drug Media Campaign, which is run by the Office of National Drug Control Policy and is in charge of the “Parents” campaign (14), has a concurrent marketing message named “Above the Influence” (15). This campaign is geared towards teenagers and attempts to use the tools of social networking that they utilize in their peer groups. While there are some good items on this website, and in this campaign, the intervention can be strengthened. Mostly, this website focuses on giving teenagers information about what to do with friends who use drugs and empathizing over the pressures that they face:

Our goal is to help you stay above the influence. The more aware you are of the influences around you, the better prepared you will be to stand up to the pressures that keep you down. We're not telling you how to live your life, but are giving you another perspective and the latest facts. You need to make your own smart decisions.

You might even consider this Web site an influence. We know that you're very smart when it comes to the messages you see and hear. That's great and you should question us, too. One way to do that is to review our sources. The numbers at the end of many of the facts are footnotes. You can click on them to find out where we got the information. (16)

Unfortunately, this website and the concomitant ads still rely on the messaging that drugs are bad and for teenagers to make individual decisions based on facts. While this may appear to give teenagers a level of control, it relies on the individual health belief model to weigh choices (17). It doesn’t offer a social solution to replace the feeling of being part of a group and controlling the social outcomes of losing the control of drug choice.

The Proposed Intervention

In order to effectively combat teen drug use, teenagers need to feel empowered to make decisions that affect their lives, and given the autonomy to do so. In addition to this, the aspects of social interactions amongst teenagers need to be incorporated in any campaign. In a paradoxical way, the empowerment of teenagers to control their decisions has to be created at the group level. Therefore, the proposed intervention will be a social media campaign that is focused on reaching and targeting the intended audience: teenagers. It will act as a revision of the “Above the Influence” campaign and will supersede the “Parents” campaign. Instead of targeting parents, which might have a deleterious effect, the campaign will be a positive outreach effort that will take advantage of the social roles and norms that occur within teenage groups. In addition, the campaign will attempt to create a movement using social networks to make the anti-drug message a “teen thing.”

Utilize Social Norms and Roles To Propagate Anti-Drug Message

As mentioned above, Social Expectation theory states that individuals often make choices based on the roles and norms of the group of which they are a part. The traditional method to combat teen drug use, which is utilized by the “Above the Influence” campaign, is to enable teens to stand up to these roles and norms. In other words, teenagers should break out of the role of reactance behavior and make an active decision based on facts that agencies provide. Unfortunately, while this approach may be laudable, it will have limited effectiveness, as it is asking teenagers to go against their natural instincts. Instead, public health agencies should use those instincts in their campaign.

In a study conducted to research the social dynamics of smoking, researchers found that social networks play a large part in health behaviors, both in the decision to smoke as well as the decision to quit. “This finding suggests that decisions to quit smoking are not made solely by isolated persons, but rather they reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation” (18). This dynamic should be used in crafting a mechanism for an anti-drug campaign. If the members of the social group that set the agenda are recruited into a potential anti-drug movement, then there will be a cascading effect through social groups. In the smoking cessation study, it was found that “connected clusters within the social network stopped smoking roughly in concert” (18). This effect can be duplicated if social networking sites are used to bring in entire groups into the movement. As upperclassmen in high school have a large influence on the social norms on younger students, there should be sponsored programs that recruit seniors for this message. In addition, key media influencers, such as teenage movie stars, should be recruited to be a part of this movement. Of course, this has been used in the past to convince kids to not use drugs, so the actual messaging is very important.

Create a Movement that Emphasizes Freedom and Autonomy

Simply putting out a traditional anti-drug message will not work any better, even if it is using modern social networking sites. Therefore, the message needs to change. Traditionally, anti-drug messages have focused on how bad drugs are for kids, e.g., the brain on drugs message. While this is true, these scare tactics have not been effective, and should be abandoned. Using Marketing theory, a movement emphasizing freedom and autonomy, while de-emphasizing the actual anti-drug message, should be created. This message will focus on emphasizing the positive aspects of a teenager’s life without drugs, as opposed to how drugs limit one’s autonomy. Presenting positive images of a movement that is led by teenagers will go a long way to establishing new social norms.

In addition to this new message, the public health agency should establish partnerships with consumer product companies that advertise to teenagers. In the partnership, the commercials that are advertised to teenagers should show how the products that teenagers consume are part of a drug-free life. This message should be subtle and not overwhelm the message of the product ad.

Another way to capture the effects of Marketing theory would be to be to capitalize on the success of the “truth” campaigns against tobacco companies. While there aren’t any illegal drug companies to target, the current unrest in Mexico over the drug trade could offer a way to produce outrage in teenagers. This message cannot emphasize that teenager drug use kills people in Mexico, which would cause guilt feelings. Similar to the “truth” campaign, teenagers should be seen as leaders of outrage against crimes that are committed by Mexican drug lords. There is a tenuous balance here, as the drug war is a very dangerous affair, but if used effectively, teenagers could see that their use of drugs is a limit of their autonomy by drug cartels. These messages should not be in concert with the positive messages described above.

Create a Feeling of Control of the Anti-Drug Message by Teenagers

The main failing of the “Parents” and “Above the Influence” campaigns is that there is the sense that adults are creating the message and teenagers are simply participants in the battle over drug use. While there is reason for this dichotomy, teenagers should be empowered to feel control over the anti-drug / positive-life movement. Not only are they empowered to make individual decisions, but there should be messaging that they to have the power to influence the decisions of other teenagers. In other words, instead of “Parents: The Anti-Drug,” it should be “Friends: The Anti-Drug.” The focus of this new message should be on helping teenagers realize that they have influence over others, and that they be a source of positive changes in the lives of others.

Conclusion

While the “Parents” campaign has laudable goals, its targeting and labeling of parents as the anti-drug is misdirected. This message, in concert with the weak “Above the Influence” campaign, reinforces social norms and roles that propagate drug use amongst teenagers. Campaigns to dissuade teenagers from using drugs are now 30 years old, and the message that these campaigns have used have only been revised slightly in that time period. While there has been some variation in teen drug use from the early 1980’s, it is hard to say that these campaigns have been successful (3). It is hard to deduce that these campaigns have done anything at all.

In order for the stated goals of the media campaign to be successful, the entire message and approach must be overhauled. The hackneyed reiteration that drugs are bad and will ruin your life, while dubious in truth as it lumps all drugs together, should be shelved, and approaches that emphasize teenage freedom and control in positive lifestyles should be adopted.

References

(1) National Public Radio. (2007 2-April). Timeline: America's War on Drugs. http://www.npr.org/templates/story/story.php?storyId=9252490

(2) United States General Accounting Office. Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs. Washington, DC, 2003.

(3) Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236.

(4) Drug Abuse Resistance Education. About D.A.R.E. http://www.dare.com/home/about_dare.asp

(5) Parents: The Anti-Drug. About Us. Washington, DC: The Office of National Drug Control Policy. http://www.theantidrug.com/about.asp

(6) DiClemente, R; Wingood, G; Crosby, R; Sionean, C; Cobb, B; Harrington, K; Davies, S; Hook, E; Oh, M. Parental Monitoring: Association With Adolescents’ Risk Behaviors. Pediatrics 2001; 107:1363-1368.

(7) DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

(8) Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

(9) Grube, J; Morgan, M. Attitude-Social Support Interactions: Contingent Consistency Effects in the Prediction of Adolescent Smoking, Drinking, and Drug Use. Social Psychology Quarterly December 1990; 53: 329-339.

(10) Parents: The Anti-Drug. Pressures on Teens. Washington, DC: The Office of National Drug Control Policy. http://www.theantidrug.com/advice/teens-today/navigating-the-teen-years/pressures-on-teens.aspx

(11) Siegel M. Marketing social change: An opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2^ndedition). Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 45-71.

(12) Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

(13) Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.

(14) National Youth Anti-Drug Media Campaign. Resources. Washington, DC: The Office of National Drug Control Policy. http://www.mediacampaign.org/resources.html

(15) Above the Influence. Above the Influence. Washington, DC: The Office of National Drug Control Policy. http://www.abovetheinfluence.com/

(16) Above the Influence. About Us. Washington, DC: The Office of National Drug Control Policy. http://www.abovetheinfluence.com/

(17) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs1974; 2:328-335.

(18) Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England Journal of Medicine 2008; 358:2249-2258.