The failure and solutions to the Food Allergen Labeling Consumer Protection Act and MA Allergen Awareness Law—Felix I. Zemel

Introduction
A recent report by the National Institute of Allergy and Infectious Diseases stated that as many as 5% of children under 5 years old and 4% of teenagers and adults currently suffer from food allergies in the United States [1]. These numbers are nearly double those that were estimated merely one decade ago [6]. Food allergies annually result in about 30,000 patient visits to hospital Emergency Departments, 2,000 hospitalizations, and 150 deaths [2,10]. 90% of these adverse health effects are caused by one of 8 “major food allergens”: peanuts, tree nuts, milk, soy, crustacean shellfish, fish, eggs, and wheat [8]. It was also determined that about half of the allergic reactions occurred as a result of prepared foods, and of those about 75% resulted from food prepared at a restaurant [28]. As a result of these startling numbers, the First Session of the 108th U.S. Congress enacted the Food Allergen Labeling Consumer Protection Act of 2004, which requires packaged food manufacturers to properly label products with the common name of any of the major food allergens that the food could potentially have had cross-contact with.
The Commonwealth of Massachusetts took allergen awareness regulation a step further when Governor Patrick signed the Act Relative to Food Allergy Awareness in Restaurants into law in January 2009. In this new amendment, the legislature required “all food establishments that cook, prepare, or serve food intended for immediate consumption either on or off the premises” to comply with multiple requirements related to posting a specific allergen notice on the establishments menu and menu board; post an allergy awareness poster in a conspicuous place for all food handlers to see; and for all certified food protection managers to view a 30-minute training video and for all other food handlers to view a 10-minute video about allergen awareness [3,11]. These regulations were to be implemented at various points in time (October 1, 2010 for the poster and signage; Feb 1, 2011 for the video).
Critique of the FALCPA and the MA Allergen Awareness Law
Both the FALCPA and the MA Allergen Awareness law have similar a similar goal: to decrease the morbidity and mortality of individuals resulting from accidental exposure (more specifically, ingestion) of food allergens to which they may be allergic. The method by which they each plan to achieve this goal is rooted deep within the Health Belief Model and the Theory of Reasoned Action.
The Health Belief Model, the basic premise of which is described by Rosenstock (1974) is that “…in order for an individual to avoid action to a disease he would need to believe (1) that he was personally susceptible to it, (2) that the occurrence of the disease would have at least a moderate severity on some component of his life, and (3) that taking a particular action would in fact be beneficial by reducing his susceptibility to the condition or, if the disease occurred, by reducing its severity, and that it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment” [17]. Salazar (1991) described the Theory of Reasoned Action by explaining that “behavioral change ultimately is the result of changes in beliefs, and that people will perform behavior if they think they should perform it…” [18]. Following the Health Belief Model, the logic behind the FALCPA and the MA Allergen Awareness Law was that if individual consumers was warned of the risks inherent in the consumption of particular packaged or prepared foods, that they would inherently choose not to consume those foods because their susceptibility to have an allergic reaction would be much greater and less beneficial than avoiding the food altogether. This would also follow the Theory of Reasoned Action, whereas once the belief is put in place that consumption of these particular foods is harmful, that the consumer would choose not to take the risk, and would thus forgo consuming the product.
The FALCPA has now been in effect for approximately 6 years. A variety of research studies have been performed in recent years to determine the effects (if any) that mandatory labeling of packaged foods has had on the behavior of individuals with food allergies [7,14,15,24,28]. The result of the research is startling. Researchers found that individuals with food allergies were significantly more likely to purchase a product with an allergen warning label in 2006 (after the enactment of the FALCPA) than in 2003 (prior to the enactment of the FALCPA) [7]. The research further showed that there were significant differences in the individuals’ likelihood of avoiding particular products based on the types of labeling that was placed on the packaging. Food manufacturers, especially large ones, have one big thing in common with large tobacco manufacturers: they “want to help the community”. The labeling on packaging for food originally started as a voluntary addition to food labels by manufacturers. Similar to the anti-smoking campaigns, where tobacco companies like Phillip Morris donated millions of dollars to fund inherently flawed campaigns to stop children from smoking, food manufacturers placed labels with allergen warnings ranging from “may contain…” to “may contain traces of…” to “manufactured in a facility that also uses…” to the greatest extreme of “packaged in a facility that also packages products containing…” [7]. As can be understood, the marketing specialists at large food manufacturing companies understand the basics of advertising theory and framing. Ogilvy (1964) said it well when he stated “a good advertisement is one which sells the product without drawing attention to itself. By utilizing different forms of framing, the food manufacturers were able to balance their perceived interest in preventing allergic reactions to their products while also not jeopardizing their bottom lines.
The US Food and Drug Administration (FDA), who is the enforcing authority for the FALCPA stated that “advisory labels must be truthful and not misleading” [15]. After the adoption of the FALCPA, the food manufacturers took advantage of this requirement even more. Pieretti et al (2009) found multiple violations of the FDA where manufacturers labeling packages with nonspecific verbiage, such as those described above, but then included derivatives of one of the top 8 allergens in the ingredients list. The manufacturers technically are not lying or misleading, because they are still warning the consumer of the risk of exposure to a potential allergen, but they are also downplaying the severity of the risk. When applying this to the Health Belief Model, the downplayed severity makes the individual consumer feel less susceptible to the adverse health effect and causes him/her to decide that maybe the risk is worth taking—resulting in him/her purchasing and subsequently consuming the food (following the Theory of Reasoned Action). Examples of this deceptive practice are when the ingredients list items like gelatin, but do not specify if it is pork, beef, or fish gelatin—as fish is one of the top 8 allergens. Another common practice was listing lecithin in the ingredient line, without listing its source (soy, sunflower seeds, eggs, or rice [15].
Similar to the fact that manufacturers are misleading individuals into believing that their risk of ingestion of a food that they may be allergic to is low, but they also list these items in understanding that individuals do not necessarily know all of the foods and other products that are derived from common allergens. If food manufacturers properly apply advertising and marketing theory through framing products’ perceived risk in particular settings, then they gain the trust of the individuals. A common item that the lack of labeling specific items as allergens has is that it also attempts to account for individuals not knowing if a particular ingredient is a derivative of one of the allergens that must be labeled. This is the major flaw of the MA Allergen Awareness Law. Although retail food establishments must post notice in all of their menus and on their menu boards telling the consumer “before placing your order, please inform your server if a person in your party has a food allergy” and have their staff be trained in allergen awareness, the law does not account for lack of basic knowledge on the part of both ends of the transaction. There is a common misconception that mayonnaise is a dairy product, leading many people to avoid due to milk allergy or lactose intolerance. In actuality, mayonnaise is based on eggs, which is a totally different food allergen (although 72% of individuals with an egg allergy also have a milk allergy [20]).
If neither party in the transaction knows that a particular food is a derivative of specific allergens, then the labeling requirement mandated by Massachusetts law is pointless. When applying the Health Belief Model and the Theory of Reasoned Action to a situation where neither party knows that an item like mayonnaise is derived from eggs, the following situation can be potentially fatal to the consumer: (1) the consumer notifies his/her server that (s)he is allergic to eggs, and asks the server if the tuna salad sandwich had eggs in it; (2) the server asks the cook if the tuna salad sandwich has eggs, the cook thinks that mayonnaise is dairy-based and tells the server that there were no egg ingredients in the tuna salad sandwich; (3) the server relays this message to the consumer, who subsequently purchases the tuna salad sandwich, has an anaphylactic reaction to the eggs in the mayonnaise resulting in respiratory arrest. In the preceding scenario, the consumer used the Health Belief Model to frame his risk in ingesting eggs. When he was told that there were no eggs in the tuna salad sandwich, the Theory of Reasoned Action made him decide that the potential risk of an allergic reaction was low resulting in him purchasing and consuming the tuna salad sandwich and having a severe allergic reaction to the egg that he did not know was even in the product.
These flaws are inherent in an intervention that relies so heavily on individual knowledge and understanding. It is also because of this lack of understanding of the differences and the lack of specificity in the labels that are places on packages of food that consumers are paying less and less attention to the labels. The Health Behavior Model and Theory of Reasoned Action were originally required in order to make it simpler for individuals who have particular food allergies to know which foods to avoid and which ones are safe. The fact that there is no consistency in the verbiage used on labels and that manufacturers are not listing (or framing in such a way that the individual consumer perceives a smaller risk than actually exists) decreases confidence of individuals who have food allergies, resulting in them not paying attention to the labels at much higher levels that existed prior to the enactment of the FALCPA. The lack of knowledge by food handlers makes is impossible for consumers to make a proper reasoned choice of purchasing/consuming the food item or not.
A new intervention must be developed that builds upon the existing interventions by eliminating their flaws of misleading labeling of which ingredients are actually allergens, lack of knowledge of the ingredients in particular items by consumers and/or food handlers, and the lack of consistency in the verbiage of labels on packaged foods—which allows manufacturers to frame the perception of risk to the consumer however the manufacturer wants. These practices show application of a large variety of social and behavioral theories that manufacturers utilize in order to manipulate decisions made by consumers [13]. If an intervention is successful at addressing these flaws, then its odds of effectiveness are greater.
A proposed intervention
As stated earlier, the three lethal flaws in the FACLPA and the MA Allergen Awareness Law were manufacturers’ use of misleading labeling information, a lack of knowledge by individuals and food handlers, and inconsistency in the labeling verbiage. A successful intervention can utilize the basic framework and social and behavioral theories that exist in the original flawed ones, but improve them by applying other theories and practices in order to eliminate the inherent flaws. In order for this to happen, a comprehensive view of the problem must be observed. The flaws described above were rooted in the ability of food manufacturers to utilize social and behavioral science theories in an effort to subvert the intentions of laws. These same social and behavioral science theories are used in the following intervention to subvert the subversions by food manufacturers in order to get closer, if not totally, to decrease or eliminate the number of deaths and injuries of individuals caused by accidental ingestion of food products to which they are allergic. This intervention addresses the flaws by implementing the following items: creation of a series of “symbols” indicating the allergen of concern; standardizing the verbiage permitted for use on FALCPA-mandated labels; and mandatory review of all menus (and changes thereof) by the local board of health (or other government subdivision charged with enforcement of food service codes) before the implementation of a new menu or any changes thereof. Through the addition of these interventions to the FALCPA and the MA Allergen Awareness Law, the flaws that are causing gaping holes in the effectiveness of those regulations can be resolved, resulting in a potential decrease of the incidence of morbidity and/or mortality of individuals as a result of accidental allergic reactions to food allergens.
The use of universally-accepted symbols has been successfully implemented in a variety of public health campaigns through the years. Two symbols that come to mind the quickest are the universal symbols of two hands being washed with soap and water, and the international symbol for no smoking. When people see these two symbols, they can be expected to think about the meaning of the change and then weigh their options and use reasoned action to make a final decision leading to a final action. This application of the Theories of Reasoned Action and the Health Belief Model can be directly applied to the concerns about allergen awareness. Many restaurants list items on their menus with different asterisks, stars, check-marks, or other symbols to send the reader a particular message without wasting the space for words. A common symbol used for this is the () symbol used in menus to indicate an item is heart-healthy. An easy to implement intervention is to first develop what is to become a universally accepted indicator of a particular food allergen—say an picture of an egg, soybean, fish, peanut, tree nut, or crustacean shellfish (like a lobster), a gallon of milk, or a stalk of wheat—and then mandate that restaurants and producers of packaged foods label each of their menu [or packaged] items with one or more of the symbols in order to portray which allergen a consumer is at risk of coming into contact with.
The creation of these symbols will have benefits on multiple levels. The first benefit is that it will better illuminate the potential risks if the particular food item is consumed. This can then be translated through cognitive functioning into a belief about if the person should choose to make one action or another, letting the Theory of Reasoned Action take control. Although there are many factors, such as herd behavior, that can confound the reasoning process, the basic premise of the Health Behavior Model and Theory of Reasoned Action still stand. It can be assumed that if a person is a member of a particular group that is heading to a restaurant, (s)he is more likely to take heed of a warning that is blaring on the menu next to the name of the item than of wording that tells the consumer to notify his/her server if (s)he has a food allergy or a label on a bag of chips that states “this product was packaged on a line that also packages soy products” when lecithin is listed as one of the ingredients just a couple of lines above. Herd behavior often takes control over the individual when in a group setting, invalidating many of the theories that make up individual behavior change models, but the potential of their strength is potentially significantly lessened with proper signage and forced awareness [23,25].
Another intervention that will decrease the numbers of people ignoring the allergen warning labels on food packaging is forced consistency. At the onset of the MA Allergen Awareness Law, many foodservice companies did exactly what large food manufacturers still do about labeling the allergen warnings on the packaging: they applied advertising and marketing principles in order to frame the apparent risk in a much lower light. In anticipation of this behavior occurring the MA legislature added verbiage into the actual statute that all foodservice establishments in the Commonwealth of Massachusetts must have on all of their menus in order to maintain compliance with the law. The FALCPA must be amended where the law should mandate specific verbiage for labels on packaged foods.
Framing is used to bias individuals into thinking a particular way about a particular topic [4]. Its effects can be devastating to an improperly designed or implemented public health intervention, as is seen with the FALCPA. Research shows that people had much higher rates of paying attention to labels that stated “may contain…” or “may contain traces of…” labels versus ones that had convoluted statements like “packaged in a facility that also packages products containing…” (89% and 85% in 2006 versus 59% in 2006, respectively) [7]. Based upon the startling differences in responses between the three ways of saying the same thing (with different implications), the legislature should only allow one or two versions of the allergy warning label on packaged foods.
In addition to the consistency in the verbiage, the government must give further guidance in order to avoid what can easily be construed as misleading and untruthful labeling practices by food manufacturers. Regulations must be strengthened along with the verbiage too also require that derivatives of the 8 top food allergens be placed under the same category as the main food allergen. This would be alleviated somewhat if the wording so convoluted as “packaged in a facility that also packages products containing…” would be eliminated and the standardized labeling verbiage were put into place instead.
This leads into the final prong of the new intervention: local approval of menus and menu labeling for foodservice establishments. This is both its own intervention, but it brings the previous two together as well. Currently in Massachusetts, each of the 351 cities and towns has its own board of health that has the ability to create its own regulations, as long as they do not conflict with state or federal laws or regulations by weakening them. One of the primary responsibilities of local boards of health or health departments is the licensing and subsequent inspection of all foodservice establishments within its perimeter. Among the duties included in this is plan review and annual renewal of foodservice licenses.
Menus are a vital part of the foodservice establishment’s food service and safety plans. As was stated earlier, labeling of items containing major food allergens with symbols is imperative to bringing better awareness to the risks involved in consuming a particular food item. It was shown how this labeling plays into the decision making process by an individual consumer and applied to an action through use of the Health Behavior Model and the Theory of Reasoned Action. As was described earlier, food manufacturers use either deceptive practices or just lack the knowledge to know exactly what items contain major food allergens. Because of this, the verification must be made during the preliminary steps to the establishments’ opening: during plan review.
Local boards of health and health departments must implement a regulation that all menus must be properly labeled with appropriate symbols to indicate risks of consumption, and should require that all foodservice establishments provide the board of health or health department with a list of all of the ingredients in each particular item on the menu in order for the person reading the plans to verify that the warning symbols are correct. Foodservice establishments should not be permitted to change items on their menu without the prior approval from the local board of health of the particular food items. This would not preclude establishments from having rotating specials or other food items, if the list of ingredients for each of the rotating items was submitted and approved during the plan review.
The mandatory approval from the local board of health or health department will also eliminate any bias resulting from framing or other advertising methods utilized by businesses to subvert the attempts at improving the public’s health. Maintaining and improving the public’s health should be a priority of not just the policymakers or individual activists, but also of those who are interfacing with the public. Businesses have shown that they favor market forces much more than the potential for improving health. Marketing campaigns by businesses frame items in such a way that not only do they subvert the law, but they also place susceptible members of the public at risk of serious adverse health effects or death due to their negligence and greed. A public health intervention that counteracts the marketing and framing techniques utilized by businesses benefits the public’s health dramatically.
References
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(2) Buchanan R, Dennis S, Acheson D, Assimon SA, Beru N, Bolger P, et al. Approaches to establishment thresholds for major food allergens and for gluten in food: A report by the Threshold Working Group. The Center for Food Safety and Applied Nutrition, Food and Drug Administration 2006 March.
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(10) Lowey N. Public Law 108-282: Food Allergen Labeling and Consumer Protection Act of 2004. 2004 2 August; H.R. 3684(108th Congress, First Session).
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Why Transtheoretical Model is Making Small Step Campaign Have a Small Impact: A Critique Based on . . .

. . . Social Marketing and Integrated Theory of Health Behavior Change – Annie Peer

For a limited time only the price to get you 640 calories and 39 grams of fat will get you double - nearly 1300 calories and 80 grams of fat! Soon you too will be on your way to craving this many calories at every meal until you are in the “select” group of 72 million Americans in the obesity club. (1). If Burger King advertised their new buy one Original Chicken Sandwich and get one free offer in this way, obesity would not be such an issue as it is in America today. Instead Burger King focuses on people getting people what they want, how they want it, and with bigger portions than they imagined. The sandwich is described as being “unchanged since 1979, which no other burger can say” and “not a handful but a handsful”. Even the website allows the consumer to decide how much food, fun, and king images they want on the main menu as seen below:
Figure 1 www.bk.com
This is what public health intervention against obesity is up against. “Obesity is the second leading cause of preventable premature death in this country, with some researchers predicting it may soon outpace smoking as the leading cause of preventable death. A solution will likely be multi-faceted, with emphases on prevention, improvements in treatments, policy change, and environmental changes, among others” (1). One attempt to make exercise and healthy living more “do-able” is the Small Step campaign that was started by the government. This makes exercise look easy by just getting into the habit of small changes everyday that will make you healthier such as taking the stairs instead of the elevator.
Using the six-stage behavior change theory (transtheoretical model) to plan their approach, researchers determined that the public is aware of the dangers of obesity but remains complacent about it (has yet to take action, see rewards from doing so, and commit to ongoing change). Why? Because people want a quick-fix in modern life and none of the promised "quick-fix" diet plans actually work, so consumers have concluded that it's impossible to get healthy.
The transtheoretical model shows the six stages that a person must pass through to achieve behavioral change:
Consciousness/Awareness
Emotional Arousal/Interest
Self-evaluation/Preparation
Commitment/Action
Reward/Positive Reinforcement
Self Liberation/On-going Commitment to Change
(2)
Critique 1 – Transtheoretical Model Does Not Account for Everyone
The primary use of the transtheoretical model is the first mistake this campaign makes. This model “integrates two interrelated dimensions of change, stages of change and processes of change, along with the constructs of self-efficacy and decisional balance. Stages of change represent when an individual is ready to change. Self-efficacy refers to the conviction that one can successfully execute the behavior required to produce the desired outcomes, and decisional balance encompasses the pros and cons or perceived benefits and barriers of making the change” (3). The stages of change reflect a person’s intention to change or the degree to which a person gives serious consideration to change. Individuals may progress through stages at varying rates, may regress, and may reenter the continuum of change at carrying points.
Cons to the physical exercise model showed that “precontemplators” see physical activity as having nearly as much cost as it has benefits and score highest on the cons of engaging in physical activity. (3). A study by Marcus, et al. (4) found that, similar to self-efficacy, pros and cons of physical activity were related to physical activity behavior only indirectly. The pros and cons constructs were related to stage of physical activity readiness (intention), and stage of physical activity readiness served as the mediator influencing actual physical activity patterns. Compared to individuals who were not regularly physically active, individuals who engaged in regular physical activity used physical activity to cope with unpleasant emotions such as stress and fatigue, rewarded themselves for engaging in physical activity, made a commitment to be physically active, and employed reminders to be physically active. Furthermore, these regularly active individuals had more confidence in their ability to be physically active and placed greater emphasis on the benefits of being physically active. It appears that those who were not physically active had less confidence in their ability to be physically active and perceived the barriers to engaging in physical activity as outweighing the benefits. (3).
Transtheoretical Model posits that decisional balance, self-efficacy and processes of change are the most important stage transition determinants. (5). The evidence for the importance of these constructs is mostly based on cross-sectional data and more convincing evidence based on longitudinal data or experimental research is mostly lacking.
Critique 2- Food Ads Dominate in Exposure Time over Small Campaign
The fact that unhealthy food advertisements are dominant and result in fatter people is the second critique. Small Steps’ handful of ads and website isn’t nearly enough to counteract the pervasiveness of advertisements for unhealthy food -- particularly for teens. A study (6) found that fast-food restaurant advertisements were found to make up 23.1% of all food ads seen by adolescents (21.5% and 23.6% for African-American and white teens respectively), and McDonald’s and Burger King advertisements made up approximately 44% of fast-food ads seen by teens. Sweets and beverages ads counted for 22% and 17% of all food ads, respectively, while cereal ads made up 11%.

Figure 2 shows the distribution of the advertisements seen by a group of adolescents in a study done by Powell et al. (6).
Food advertising that promoted snacking, fun, happiness and excitement (i.e., the majority of children’s food advertisements) directly contributed to increased food intake. In addition, these effects occurred regardless of participants’ initial hunger. (7). Furthermore, the amount of calories consumed by the participants after viewing snack advertisements was completely dissociated with the adults’ reported hunger. This was particularly true for men and those attempting to diet. (7). In addition, the effects persisted after the viewing session.
It is not even as simple as restricting television advertising of calorie-dense, nutrient-poor foods… one study (8) proposed a food marketing defense model that posits four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability and motivation to resist. While it is extremely complicated and involved to control the effect of advertising, is it suggested here under the understanding category, to propose a way to effectively market foods and healthy behaviors is a way to defend against food marketing. The way to successfully achieve this will be discussed later in the improved intervention. Psychological theories predict that food marketing, in all its forms, has a profound negative impact on public health among young people and adults. Similarly they predict that proposals by the food industry, such as increased marketing of “better for you” foods or the inclusion of physical activity in food advertising, would not even begin to counteract these effects, and could make them worse. (8).
Critique 3- Health Belief Model Does Not Account For Social And Environmental Factors
The last critique is that the website is based on the health belief model and that people just need education to adopt a healthier lifestyle. This idea of the public simply needing information about nutrition is very wrong. A study (9) showed that providing calorie information at the point-of-purchase on a fast food restaurant menu had little effect on food selection and consumption among a sample of adolescents and adults who eat regularly at fast food restaurants.
Even when people are familiar with a specific risk, social norms and support play a huge role in a campaign’s success. When looking at diabetes prevention in Latino and other racial/ethnic populations (10) they found that integrating cultural factors into prevention interventions involves a proactive analysis of the needs of a specific cultural sub-group, and of how specific cultural factors (perceptions, attitudes, skills in self-regulation, family obligations, low social supports for a healthy lifestyle, etc.) may operate as personal or cultural barriers (or a facilitators) of sustained behavior change.
Broad contextual factors found that cultural influence included aspects of the built environment, as well as local norms and national policies that influence lifestyle choices. Consideration of these factors may augment cultural sensitivity, ideally facilitating program participation and thus enhancing the efficacy of interventions designed to change dietary and exercise behaviors. The Small Step program’s website focuses on educating the public about nutrition, while social norms and individual environments are not addressed.
The consumeR Campaign
The “consumeR” campaign will show how consumerism in America has made Americans fat. The blame for being fat will be placed on the companies’ campaigns to manipulate people into eating more thereby making them more money. This campaign will have people rebelling against fast-food by creating their own independent thoughts. The person that is a member of this “I am not a consumeR” web group will live up to this rebellious title according to the labeling theory. The R in consumeR will always be capitalized to emphasize that resisting consumption at these types of establishments relates to the second part of the campaign called “Reality check”. The “Reality” will take people behind big business to have people question the messages behind the ads and why they are getting bigger sizes or second hamburgers for free.
Since public health campaigns do not typically have large budgets, the considerable amount of the influential food advertisements would be combated by this rebellion against big food companies. Additionally, a website will be made where people can sign up for text messages to motivate them to exercise and stay away from fast-food. A section of the website will be a forum where members can post a ridiculous ad put out by companies designed to get them to eat more. When told that these companies are trying to get the consumers to not think and just be followers, they will rebel.
Solution 1- Segmentation to Appeal to Each Segment of the Population
Since the Small Step campaign does not appeal to “precontemplators”, the new campaign will take into account that all people need to be healthy and will use a variety of mediums to appeal to a diverse population. Developing interventions that are indeed stage-matched requires knowledge about important and modifiable stage transition determinants…making specific action plans may help people to turn their intentions into health promoting action. (5). The Transtheoretical model used in Small Step does not account for all people. It assumes that everyone watching is at point of being willing to make the changes necessary to live a healthier lifestyle.
There are nearly 66% of Americans who are overweight and they do not form a homogeneous group - attitudes, demographic characteristics and lifestyle choices vary greatly within this subset of the US population. (11). Segmentation theory tells us that a “one size fits all” approach to marketing social change may not meet the needs of all people. Further, marketing research has revealed the importance and effectiveness of tailoring messages and incentives to meet the needs of different population segments. Social marketing is defined as “a social change campaign organized by a group which intends to persuade others to accept, modify or abandon certain ideas, attitudes, practices or behavior” (11). Just as the “truth” campaign was able to appeal to the teens’ need for a feeling of independence and rebellion using the social marketing theory against smoking (11), this new campaign for obesity prevention will target different segments too. While overweight adults will primarily be the television ad viewers, teens and kids will be more into the website design. Looking at the following screen shots of the facts pages on the “truth” and “Small Step” campaign, it is easy to see which one is more appealing to teens.

Figure 3 www.thetruth.com

Versus:


Figure 4 www.smallstep.gov
Another way to appeal to more people is through the use of more technology. A study (12) found that text messages were shown to be highly effective and used in several ways: to promote interaction with the intervention, send motivational messages (e.g., reminders of the benefits of exercise), challenge dysfunctional beliefs, or provide a cue to action. Use of communicative functions, especially access to an advisor to request advice, also tended to be effective. It may be that, although the Internet provides a suitable medium for delivering interventions, personal contact via email, online, or text message helps to support behavior change.
Solution 2- Marketing Healthy Behaviors
Social marketing of health behavior change posit that educational interventions may help to improve motivation to change, but that better opportunities for healthy behavior are needed to move people to action. (13). Findings suggest that in contexts like physical activity, condom use and recycling, negative messages about non-enactment will be inherently less efficient than positive messages about enactments. In contrast, in substance abuse-related contexts, the use of positive messages will be inherently less efficient than negative messages due to the negated linguistic form of the target, anchoring concepts denoting non-enactment. (13). While the consumeR campaign with not directly focus on physical activity and labeling people with being active, it will focus on encouraging people to not fall prey to big food chain advertisements by thinking for themselves.
One possible solution to the inefficiency problem is to utilize affirmative brand names to anchor associations with non-enactment concepts. A predominate example of this strategy is “truth” campaign, which was intended to establish “truth” as an aspirational nonsmoking brand. (14). Teens’ social images of smoking (e.g., promoting the appeal of nonsmoking as a way of achieving a desired personal image of independence or rebelliousness) appears to be a useful framework within which to understand intended campaign effects. Evaluation of the campaign’s effectiveness suggests that “truth” has affected social imagery about nonsmoking, achieved high brand equity among its target audience, and contributed to reduced rates of smoking initiation. (15). In other words, blame company instead of yourself.
The campaign should have people revolting against the ridiculousness of unhealthy food commercials since they have been shown to increase food consumption. Therefore, the campaign that sells exercise, as way for people to maintain their freedom and youth will be successful because it focused not on the product but on the desires of the audience. Key core ideals that people do not want taken away include youthfulness and freedom.
Solution 3 – Social Support and Environment Addressed
To assist people working to live healthier lifestyles, the Integrated Theory of Health Behavior change has been found (16) to be helpful. The ITBC is an integration of past successes and makes substantive contributions to understanding health behavior by combining knowledge and beliefs, self-regulation processes, and social facilitation. According to this theory, persons will be more likely to engage in the recommended health behaviors if they have information about and embrace health beliefs consistent with behavior, if they develop self-regulation ability to change their behavior, and if they experience social facilitation that positively influences and supports their engagement in preventative health behaviors.
Knowledge and belief systems impact behavior-specific self-efficacy, outcome expectancy, and goal congruence. Self-regulation is the process used to change health behavior and includes activities such as goal setting, self-monitoring and reflective thinking, decision making, planning for and engaging in specific behaviors, and self-evaluation and self-managing physical, emotional, and cognitive responses associated with health behavior change. Social facilitation includes the concepts of social influence, social support, and negotiated collaboration between individuals and families and healthcare professionals.
Figure 5: Integrated Theory of Health Behavior Change (16).
Another study found that one of the strongest correlations with a child’s BMI was a parent’s BMI. (17). Since the environment in America is so commercialized with a heavy emphasis on food, the social norms and environment must be accounted for in obesity intervention. Although altering American social regarding fast-food will not be an easy task, a website that challenges these norms will be a good start. Members will be a part of a rebellious group going up against food companies that prey on their vulnerabilities.
Competing against huge corporations that have succeeded in controlling the emotions of a majority of Americans is a difficult task. However, the “consumeR” campaign will draw attention to unnoticed unhealthy behaviors by highlighting the absurdity of food advertisements. Social support is given through a fun and resourceful website with forums and text/email motivation. The “consumeR” campaign will draw attention to the lack of thought that Americans put into food and exercise choices. The campaign’s revelation that people are merely blind consumers getting tricked into making harmful personal choices by the advertisements of multibillion-dollar food companies will motivate rebellion. Furthermore, allowing people who never considered themselves as unhealthy - merely because they are not obese- to think differently, will be a huge benefit in setting them on healthier paths and preventing a worsening obesity epidemic in America.
REFERENCES

1. Bean, M. K., Stewart, K., & Olbrisch, M. E. Obesity in america: Implications for clinical and health psychologists. Journal of Clinical Psychology in Medical Settings 2008; 15(3): 214-224.
2. Woods, C., Mutrie, N., & Scott, M. Physical activity intervention: A transtheoretical model-based intervention designed to help sedentary young adults become active. Health Education Research 2002; 17(4): 451-460.
3. Barrett, B. S. An application of the transtheoretical model to physical activity. Ph.D. dissertation, University of Minnesota, United States -- Minnesota. 2007. Retrieved December 3, 2010, from Dissertations & Theses: Full Text.(Publication No. AAT 9815016).
4. Marcus, B. H., Eaton, C. A., Rossi, J.S., & Harlow, L. L. Self-efficacy, decision-making, and stages of change: An intergrative model of physical exercise. Journal of Applied Social Psychology 1994; 24:489-508.
5. Gollwitzer, P.M. Implementation intentions: strong effects of simple plans. American Psychologist 1999; 54: 493-503.
6. Powell, L. M., Szczypka, G., & Chaloupka, F. J. Adolescent exposure to food advertising on television. American Journal of Preventive Medicine 2007; 33(4, Supplement 1): S251-S256.
7. Harris, J. L., Bargh, J. A., & Brownell, K. D. Priming effects of television food advertising on eating behavior. Health Psychology 2009; 28(4): 404-413.
8. Harris, J. L., Brownell, K. D., & Bargh, J. A. The food marketing defense model: Integrating psychological research to protect youth and inform public policy. Social Issues Policy Review 2009; 3(1): 211-271.
9. Harnack, L. J., French, S. A., Oakes, M., Story, M. T., Jeffery, R. W., & Rydell, S. A. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trail. International Journal of Behavioral Nutrition and Physical Activity 2008; 5(63).
10. Castro, F. G., Shaibi, G. Q., & Boehm-Smith, E. Ecodevelopmental contexts for prevention type 2 diabetes in Latino and other racial/ethnic minority populations. Journal of Behavioral Medicine 2009; 32(1): 89-105.
11. Kolodinsky, J. & Reynolds, T. Segmentation of overweight Americans and opportunities for social marketing. International Journal of Behavioral Nutrition and Physical Activity 2009; 6(13).
12. Webb, T. L., Joseph, J., Yardley, L., & Michie, S. Using the Internet to promotes health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change technique, and mode of delivery on efficacy. Journal of Medical Internet Research 2010; 12(1): e4.
13. Brug, J., Conner, M., Harré, N., Kremers, S., McKellar, S., & Whitelaw, S. The transtheoretical model and stages of change: A critique. observations by five commentators on the paper by adams, J. and white, M. (2004) why don't stage-based activity promotion interventions work? Health Education Research 2005; 20(2): 244-258.
14. Freeman, D., Shapiro, S., Brucks, M. Memory issues pertaining to social marketing messages about behavior enactment versus non-enactment. Journal of Consumer Psychology 2009; 19(4): 629-642.
15. Evans, W. D., Wasserman, J., Bertolotti, E., Martino, S. Branding behavior: The strategy behind the Truth campaign. Social Marketing Quarterly 2002; 8: 17-29.
16. Ryan, Polly. Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist 2009; 23(3): 161-172.
17. Elder, J. P. et al. Individual, family, and community environmental correlates of obesity on Latino elementary school children. Journal of School Health 2010; 18(1): 20-31.

Roll Back Malaria: Rolling out the Resources without Rolling out the Behavior – Ashley Dunkle

Introduction
Many international public health initiatives use innovative technologies developed in the West that need to be implemented in a developing context, often requiring behavior change of communities and individuals. One major international health problem that has been the target technological initiatives by many public health campaigns is that of malaria. Malaria is a leading global killer, particularly of children under 5 years of age (1). Over half of the world’s population is at risk of malaria while 350-500 million illnesses occur each year (1). A multitude of studies have shown the substantial economic, social, and health burden of areas of high endemic malaria (2,3).
Roll Back Malaria (RBM) is a partnership campaign that was formed in 1998 in order to align global health and development advocates in the fight against malaria (1). Recently RBM has developed a Global Malaria Action Plan (GMAP), which outlines techniques for partners to use in programming in prevention and treatment of malaria (4). One of the most important factors in preventing morbidity and mortality of malaria is vector control, reflected in the main intervention for prevention promoted by RBM: the scaling up of use of insecticide-treated bed nets (ITNs). ITNs are a technology developed to cover the beds of individuals in malaria endemic regions in order to prevent mosquito bites at night, when most malaria transmission occurs (5). This innovative technology is relatively cheap and has proven to be an effective prevention measure for the spread of malaria (6). Around 120 studies have shown the effectiveness of ITNs in reducing malaria transmission, and as a result, morbidity and mortality (6). In order to promote ITN use, RBM states they are working to a) organize public education campaigns in malaria-endemic areas, b) lobby for the reduction or waiver of taxes and tariffs on mosquito nets, netting, materials, and insecticides, c) stimulate local ITN industries and social marketing schemes so ITNs are available at a price affordable by everyone, and d) to capitalize on the potential of newly developed long-lasting treated mosquito nets (5). However, despite large donations and wide disbursement of ITNs and the implementation of RBM’s GMAP, malaria continues to be a major problem worldwide with little overall change in morbidity and mortality (7). This analysis will look at why RBM has largely failed in preventing malaria through its ITN initiative and offer ways in which the GMAP strategy could be improved to increase the use of ITNs worldwide.
CRITIQUE 1 – Assuming Induced-Demand Reflects Intended Use - Application to the Theory of Planned Behavior
RBM’s major indicator for use of ITNs among its beneficiaries is ownership of a net (1). Because ITNs are so effective at preventing transmission of malaria, many initiatives have targeted getting ITNs to the people in endemic, high-risk areas. In order to increase ownership, RBM’s methods involve inducing demand through social marketing (4). This first means inducing an increase in supply of ITNs by manufacturing organizations. After doing so, RBM focuses on getting ITNs to the people by giving ITNs away for free, subsidizing the cost, or delivering vouchers to exchange for ITNs, all of which is intended to induce demand (1). Recent reports by RBM has shown impressive scaling up in ITN ownership among individuals in endemic areas (1). However, despite widespread availability and possession of ITNs by people in malaria endemic areas, malaria is continuing to be a problem (7).
The major fallacy in RBM’s GMAP regarding ITNs is that they are only focusing on the possession of ITNs, not the actual behavior of use. In many of their reports, they provide accolade of the amount of nets disbursed throughout the world without measurement of the actual use of the nets (4). It is as though RBM is assuming that the “demand” they are seeing, which they induced, will lead to an intention to use the ITNs. We can apply this assumption to the Theory of Planned Behavior (TPB), an individual-based behavioral theory that focuses on rational, cognitive decision-making which presumes that people think about what they do before they do it (8). This theory states there are four factors leading to the intention to perform a behavior and that intention will lead to actual behavior. These factors are: 1) attitudes - the person’s belief about the outcome of the behavior and whether it is good or bad, 2) subjective norms - the person’s belief that other people in their social group approve of the behavior and there is motivation to conform, 3) perceived behavioral control – the person’s belief about the existence of factors that promote or prevent the behavior, and 4) perceived power – the person’s belief in the amount of power they have over the behavior. TBM assumes all of these factors influence behavioral intention and that behavioral intention then results in behavior (9).
What RBM seems to be assuming is that the demand they induced reflects attitudes that owners of ITNs believe there is a positive outcome from use (attitude) and that other people in the social group approve of its use, as ITNs are now widespread (social norms). They also appear to assume that by providing ITNs, RBM is reducing the difficulty of performing the behavior (perceived behavioral control) and the person believes they have power to perform the behavior now that they posses an ITN (perceived power). As ownership of ITNs is presupposed to reflect these aspects of the TBM, RBM believes these individuals will intend to use the ITNs regularly (behavioral intention) and that intention will lead to behavior. However, these factors that lead to behavioral intention are not necessarily existent among new ITN owners. For example, just owning something does not mean you have a positive attitude about its intended use. Many people will take free things because they are free and may not value them for their intended use (10). In fact, regarding bed nets, a study evaluating their use in a village in Kenya found 25% of individuals used the ITNs for alternative purposes, such as fishing netting and hanging fish to dry (11).
Likewise, rational decision-making does not always result in performing the intended behavior. Other factors beyond conscious cognition motivate behavior, such as environmental and social factors (8). Many reports have shown that barriers to use exist beyond obtaining ITNs. One study revealed a statistically significant reason for lack of adherence to ITN use, among participants who were given free nets, was temperature (12). One participant stated that it was “too hot” sleeping under the nets (12). Social reasons also influence use such as the disruption of normal sleeping arrangements for various reasons such as visitors or multiple beds (12). Additionally, technical factors can be a barrier such as people stated, “cannot hang the net properly, difficult to spread net over mat, returned home too late to put up the net,” and “net is too hard to put up and take down,” (12). RBM’s assumption that ownership will lead to intended use via the TPB and ultimately result in ITN use is false. Demand does not reflect behavioral intent and there are other factors, social, environmental, and technical, that can prevent ITN use by beneficiaries of ITN social marketing.
CRITIQUE 2 – Focusing on Education Campaigns - The Fallacy of the Health Belief Model
Another error in RBM methods for increasing ITN use is reliance on the Health Belief Model (HBM) through community-based education to encourage use of ITNs. HBM, like TPB, is a theory based on cognitive decision-making about what motivates health behavior. It assumes beliefs concerning perceived risk, costs, and benefits to participate in a healthy behavior, such as bed net use, are considered in a rational way, and will influence health behavior (13). There are six factors in the HBM which will be explained in relation to malaria and ITN use: 1) perceived susceptibility – the degree to which the person feels they are at risk of contracting malaria, 2) perceived severity – the degree to which a person believes the outcomes of contracting malaria are severe, 3) perceived benefits – perception of the positive outcome of using ITNs to prevent contracting malaria, 4) perceived barriers – the negative outcomes of using ITNs, 5) cues to action – an external event, such as someone in the community dying from malaria, that motivates use, and 6) self-efficacy – a person’s belief they are able to effectively use the ITN (8).
RBM’s GMAP proposes the use of community education programs in order to target these HBM factors assuming this will result in the behavior of ITN use. In fact, in the GMAP, Bill Gates, a major donor to RBM, is quoted as saying, “I believe that if you show people a problem, and then you show them the solution, they will be moved to act. The Global Malaria Action Plan lays out an achievable blueprint for fighting malaria – now it is time for the world to take action,” (1). RBM relies heavily on the HBM in that education of the susceptibility and severity of malaria, the benefits and limited barriers to ITN use, and promoting self-efficacy through educational cues to action will result in ITN use.
Like TPB, one of the major problems with HBM is its focus on individual decisions without addressing social and environmental factors (8). An individual’s cognitive and rational processes exist within a social and environmental context in which external influences affect behavior and can counteract rational thoughts and intentions (8). A randomized controlled trial performed in western Kenya evaluated adherence to ITN use with free ITNs and extensive educational activities focusing on many of the factors in HBM (12). These educational activities taught individuals about malaria, its prevalence in the area, the outcomes if adults and/or children contracted malaria, and ITN’s effectiveness in reducing transmission (4). Despite knowledge of malaria and ITN use, as well as free ITNs, “adherence” was still only around 70% (12). Teachers also emphasized to participants that malaria is a more serious ailment in children than older people and it was very important that children are a priority in sleeping under the nets. However, one of the statistically significant findings in this study was older people were more likely to sleep under the ITNs than children (p=0.0001) (12). Another important indication of ITN use by this study was that ITN use decreased over time, a factor that was observed in other efficacy trials surrounding ITN use (12). Allaii et al. states, “That this occurred in spite of our educational campaign illustrates how difficult it is to impact human behavior…” (12). This study shows the limitations of the HBM and RBM initiatives in education resulting in behavior change. This approach relies too much on the client and fails to take into account the wider social and environmental factors that influence behavior (14). Thus, knowledge alone does not always mean behavior change.
CRITIQUE 3 – Inducing Psychological Reactance Through Education
As shown in the second critique, education is intended to teach individuals about why it is important to their health to use ITNs, but health education campaigns have not proven to be very productive in changing behavior. Whitehead and Russell reiterate the difficulty found of changing behavior in the Kenya randomized controlled trial by stating, “‘Fully’ informing individuals about health and health risk does not necessarily lead to a change in behavior” (14). In fact, sometimes it induces the exact opposite of what is intended, which in this case would motivate individuals to not use ITNs (14). Evidence that health education can sometimes be counterproductive is explained by the Theory of Psychological Reactance. This theory was developed by Jack W. Brehm in the 1960s and has been supported by a number of empirical studies, particularly those related to health behavior (15). This theory suggests that when someone is told what to do, the individual perceives a threat or reduction in their freedom, and will act in a way to restore that freedom, often doing the opposite of what was told to them (15). To explain in more detail, Brehm (16) states there are four elements fundamental to reactance theory: 1) freedom, 2) threat to freedom, 3) reactance, and 4) restoration of freedom (15). Individuals first have a perceived sense of freedom. In response to a stimulus, such as an authoritative voice, individual’s feel this freedom is threatened. Individual’s then react to the threat and are motivated to act in order to restore the freedom (17). While reactance can take many effects, often the result is a boomerang effect, in which the individual will engage in the behavior related to the challenge of freedom (18). For example, if a child is told not to eat a piece of candy, they will feel their freedom threatened and will want to eat that piece of candy to restore their sense of freedom. Education campaigns and programs are a type of social influence that often induce reactance and prompt freedom-restoring responses leading to rejection of the message, resulting in ineffective persuasion to change behavior(17).
Psychological reactance theory may explain why some individuals do not use ITNs. When people are told to use ITNs, particularly when the source of the information are individuals from outside of the cultures of the individuals being taught, it is likely that a boomerang effect may occur. People value freedom and control and telling someone it is imperative that they sleep under ITNs violates these values by seemingly challenging their freedom to choose how they sleep and how they take care of their own families. By someone telling individuals to use ITNs at night, it is likely they feel these freedoms threatened, and in response, they may refuse to use the ITNs as a means of gaining back this challenged freedom, thus ignoring the rationale of the education campaign. RBM’s educational programs may therefore be causing individuals to not use the ITNs, by threatening their freedom through the intent of instruction – the opposite of RBM’s goals.
Proposal 1 – Market ITN Use, Not Just Ownership
As this analysis has delineated, RBM has focused on increasing uptake of ITNs through inducing demand and encouraging their use through education. But as has been shown, ownership of a net and education do not necessarily lead to the behavior of using ITNs. Instead on inducing demand of ownership of ITNs and focusing on individuals’ rational, cognitive-decision making through education about malaria and ITNs, RBM could include in their GMAP, direct marketing of ITN use. Rather than inducing demand of the product, RBM would be marketing a behavior – the use of ITNs. Using principles in marketing theory, RBM could greatly revamp their action plan to reach many more people in numbers and reach them at heart - a much greater motivator than knowledge.
Marketing is defined as “human activity directed at satisfying needs and wants through exchange processes” (19). RBM wants their beneficiaries to benefit from the use of the ITNs they provide. However, RBM needs to consider the wants and needs of these beneficiaries. Marketing theory starts by looking at the wants and needs of individuals’, and then packages and promotes products for exchange based on these values (20). Effective marketers do not try to make the target audience accept their values and beliefs, as RBM has done, but rather start from the standpoint of the audience’s wants and needs, values, and perceptions (21). While RBM claims methods of social marketing, it really is only focusing on the exchange part, ignoring the wants and needs of their consumer. Marketing theory suggests that rather than telling people to use ITNs because the educator thinks it is the right thing to do, coming at ITN use from the audience’s point of view can be much more effective.
As RBM’s focus is a global initiative, there are many beneficiaries from various cultures and subpopulations. While some values tend to be universal, such as independence, freedom, control, respect, etc., values tend to vary across subgroups and they can vary across cultures. Marketers do not rely on intuition to know what the consumer wants and needs, but rather they perform formative research in order to understand the values, wants, and needs of the target audience (20). Essentially this requires, “getting inside the heads” of consumers (21). Formative research needs to be included in RBM’s marketing approach in order to have an empirical basis for their marketing efforts and marketing campaigns.
Overall, marketing of a health behavior is different from traditional public health paradigms such as HBM and TPB, which tries to “sell” a behavior based on an individual’s desire for health and their rational cognitive processes. While health is generally valued, it is also generally misunderstood by those who possess it, and largely taken for granted. By using marketing theory and formative research in the GMAP, RBM could focus their efforts on the actual wants and needs of their beneficiaries and effectively redefine and packages the behavior of ITN use in a more effective way.
Proposal 2 – Expand on Marketing Theory - Branding ITN Use
By using marketing theory as proposed, RBM would be selling the behavior of ITN use based on the core values discovered through formative research. However, RBM needs to extend this marketing approach one step further. After performing formative research, marketers repackage, reposition, and reframe their product in a way that shows the target audience that they will benefit from its consumption in a way that reinforces their core values (20). One of the primary modes of presenting a product in this manner is through branding. Branding is a concept used by marketers that associates a product or service being sold with something the brand represents (22). In public health, generally it is a branded message to partake in a health behavior, rather than a symbol of a product (23). A branded message is a “strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity, providing…a sense of value (24). The best brands represent the core values, wants, and needs discovered through formative research (20).
Public health has co-opting branding as a means of marketing healthy behavior. Unlike commercial branding, public health does not intend to brand products or services. Alternatively a behavior is branded which leads to a benefit from engaging in or refraining from a behavior and its consequences. Whereas the HBM and TPB associate the outcome of “health”, branding a public health behavior will associate the outcome with a core value (22). These branded behaviors can then be “sold” as embodying a “lifestyle” of the healthy behavior, which will become part of the identity of those who partake in the branded behavior, such as the use of ITNs (23). Branding of a health behavior is often more effective than educating about a health behavior. This is because the purpose of healthy behavior is often abstract, complex, and it is difficult to appropriately convey the benefits to the target audience (23). In addition, healthy behaviors often do not have quick or noticeable results, thus branding a behavior with a value can be much more effective (23). In the case of ITNs, it may be difficult for people to use ITNs on a hot night, when comfort is their immediate concern, rather than use them for the purpose of preventing a disease of which they have never experienced and which they may not contract. The benefit of a net-free bed may be seen as much better in the immediate moment then preventing an abstract event such as malaria. However, by branding ITN-use, the owner of a net may partake in the use of the net because they associate the use with an “identity” and core value. Branding, therefore, can create a value-based association with the behavior that is more likely to induce “compliance” than an abstract “health” concept.
There are three basic concepts surrounding a brand: a) building a relationship b) adding value and c) beneficial exchange (22). First, the public health brand, in this case ITN use, must build a relationship with its beneficiaries to encourage the adoption of the health behavior. This is often through the development of positive associations offering a “brand promise”. The brand promise is something of value that the consumer of the health behavior will acquire if they respond to the proposed “call to action” (22). Building a relationship is essentially making the brand “promise” understood to the beneficiaries. In the case of ITNs, the call to action would be for people in malaria endemic areas to use ITNs each night for themselves and their family members. Thus, RBM would need to link this “call to action” with a “promise” that their brand represents. The promise must be something appealing to consumers, such as the values of the target audience discovered through formative research.
There are three persuasive mechanisms for making the brand appealing to consumers of the health behavior based on these values which include: a) aspiration to an appealing ideal, b) modeling of a socially desirable good, or c) association with idealized imagery (22). These mechanisms are related to the second aspect of branding: adding value. This is making explicit the relationship between the brand and the value it is associated with, linking the brand with the values, needs, and wants of the consumers. An association with an aspiration of an appealing ideal is that the brand may represent beauty, status, sex appeal, or power (22). Some examples would be “ITN use gives you control” or “ITN use is a sign of status”, thus linking the behavior with other “social goods”, though this “value” may not be directly related to the actual utility of the ITNs.
The third aspect of branding is providing a beneficial exchange. This is what the individuals actually receive from the adoption of the behavior and is generally based on the added value and the brand promise. An important factor in this aspect is the development of trust that the individual will gain the promise of status, beauty, or power, by performing the desired behavior (22). While education campaigns might use scare tactics such as teaching individuals about the biology of malaria and how it can cause morbidity and mortality, building a trusting branding relationship for promoting the use of ITNs would work much better, thus creating a positive approach. An example that RBM partners promoting ITNs could use may be, “Wrapping your family’s beds with ITNs each night makes you an excellent mother,” or “It’s sexy to use an ITN,” or “ITNs – only for high-society.” Positive associations help build trust and will induce the brand to be associated with positive social norms. As Dan Ariely suggests, “There are social rewards that strongly motivate behavior – and one of the least used…is the encouragement of social rewards and reputation,” (10). By building associations between the public health “brand” of ITN use and social values and rewards, individuals are much more likely to want to participate in the behavior in order to gain these social rewards if they understand the association of the promise and trust that the behavior will result in this reward.
Proposal 3 – Use Psychological Reactance To Roll Back Malaria– Mitigating Reactance and the Brand-Value of Freedom
While the third critique of RBM’s GMAP showed how psychological reactance could induce non-compliance with ITN use, it is possible for RBM campaigns through branding to a) mitigate psychological reactance, and b) use psychological reactance in their favor to promote ITN use in branding.
Although there is a compelling amount of empirical evidence to support psychological reactance, attempts at social influence does not always reduce compliance (16). Some studies have evaluated factors that do not decrease compliance, despite attempts at social influence that would likely induce psychological reactance. One fact that has been empirically shown to reduce psychological reactance is introducing similarity in the source of the influence. Paul J. Silvia performed a study evaluating how similarity may overcome the resistance to persuasion (25). He showed that having the message of persuasion coming from someone who is similar to the recipient in certain characteristics, such as age or gender, can increase the positive force by increasing liking and decrease the negative force by decreasing perceptions of threat, both contributing to decreased psychological reactance (24). Based on this factor, branded messages from RBM about the use of ITNs to its beneficiaries can decrease the amount of psychological reactance by delivering them from someone similar to the beneficiaries. This means that any educational campaign or advertisements involved in the branding of ITN use should come from people who are similar to the target audience. For example, if RBM partners were targeting increased use of ITNs to mothers, they would associate the brand with values of the mothers of this community, and could decrease psychological reactance by having the message come from a mother in the community and culture.
Rather than reducing psychological reactance, RBM could actually use psychological reactance to their benefit and even combine it with their brand. Because psychological reactance often induces a boomerang effect, it is possible to induce psychological reactance as a means of promoting a desired behavior by challenging individual’s freedoms in the opposite manner. As described, psychological reactance is induced as a reaction to an influence that results in a perceived threat to freedom, causing the individual to perform the opposite behavior from what was asked. One way that RBM could use this to their advantage is by focusing on the value of freedom in their brand. This would first mean the overall association between the brand and the behavior of using an ITN would be the value of freedom. The ITN brand would thus need to “promise” that using the ITN would lead to freedom. However, first the target audience would need to believe there is a threat to their freedom, which would require support from the brand. One way in which RBM could do this is to present support in the advertisements of the ITN brand that the mosquito and malaria are a threat to their freedom, and that following the “cue to action” to use ITN nets would restore this freedom. Thus, RBM could use techniques of marketing theory, branding, and psychological reactance all to promote an increase in ITN use.
Roll Out Behavior Change
Overall, RBM has done an incredible job at getting nets to those who need them. However, as was shown, owning a net does not necessarily lead to use of the net – what is ultimately necessary to prevent malaria. By changing their tactics from focusing on demand, using assumptions of TPB and the HBM, and potentially inducing psychological reactance through education programs, RBM could change minimal behavior influence into wide scale use of ITNs. Marketing theory and branding are impressive tools that have been greatly refined by the commercial sector. By co-opting these methods into public health behavior change, and utilizing psychological reactance in their favor, RBM could reach a lot more people on a much more influential level – by eliciting the core values of individuals, a much greater motivator of behavior.








References

1. Roll Back Malaria. Key Facts, Figures, and Strategies: The Global Malaria Action Plan. Geneva, Switzerland: Roll Back Malaria Partnership, 2008.

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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.





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