Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008

Evaluating The Anti-Underage Drinking STOP Campaign-Vanessa Vazquez

Historically, in terms of alcohol control policies, the Minimum Legal Drinking Age Law (MLDA) has been credited with lowering the alcohol related morbidity and mortality rates in the United States (1). However, MLDA did not eliminate the ongoing problem of underage drinking itself. Underage Drinking continues to be a problem in all 50 states. Not only is underage drinking illegal, but it is also known to pose a threat to the individual and to society (2). Not surprisingly, alcohol is the most commonly used and abused drug amongst adolescents (3). A 2003 research study discovered that, on average, adolescents are 14 years old when they take their first drink (4). Age is of concern primarily because early initiation of drinking has been linked to alcohol consumption problems later in life (3).

In response to the escalating trend of underage drinking in the United States, Congress passed the Sober Truth On Preventing Underage Drinking Act or STOP ACT in 2006. The STOP Act has both federal and state provisions; the federal Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD) was established. The responsibility of (ICCPUD) is to ensure that the states are implementing laws and programs to counter underage drinking. As part of the STOP Act, the STOP media campaign was created to raise adults’ awareness of underage drinking through the use of information pamphlets, meetings, and other forms of advertisement.

The advertising campaign that accompanies the STOP Act shows promise with its focus on raising awareness in the community about teenage drinking. However, the campaign fails, because it relies on a rational model of behavior change, focuses only on increasing knowledge about risks, rather than dealing with the emotional and social reasons teenagers drink, and ultimately targets adults rather than teens.

1. Campaign Assumes Knowledge of Risk Factors Will Prompt Change
The STOP campaign tries to influence adolescent behavior by focusing on their intellect with facts, instead of focusing on their emotions, which can make more of an impression. The campaign uses a myth or fact pamphlet aimed at increasing the perceived risk of underage drinking intended to encourage adolescents to change their behavior. The campaign also assumes that people make rational decisions, not allowing the campaign to account for spontaneous teenage behavior and irrational decisions. Basically, the campaign is using the overused Health Belief model that focuses on behavioral change at the individual level and has been proven to be an ineffective model of behavior change (5). Some known determinants of behavioral change are perceived norms and self-efficacy, however the role of perceived risk is inconsistent to intention and behavior (6).

The STOP campaign further assumes that the causes of underage drinking are at the individual level instead of on a group level. By overlooking the impact of the social environment (peers, community, family) on behavior, the campaign is ignoring the role of others’ beliefs in shaping an adolescents’ own. The best method of sustaining prevention is not only to target the individuals but also their environment (7). Community involvement is also important in creating changes in institutional policies (schools, alcohol establishments, etc.) and public policies with regard to the underage access to alcohol (3).

The ineffectiveness of the traditional Public Health models should serve as a warning to the creators of the STOP campaign, who would be wise to use advertising models to reach their audience. In mass media campaigns, the group is more important than the individual. Considering a broad audience, messages are designed and audience segmentation, or targeting similar people, is ignored to achieve campaign objectives (8). Thus, the STOP campaign should not overlook the adolescents in delivering its campaign message of anti-underage drinking. Instead, the STOP campaign should try to incorporate framing theory, agenda setting theory, and social expectations theory to target teenagers.

According to agenda setting theory, “the media’s agenda sets the public’s agenda” and “the emphasis placed on issues in the mass media influences the priority [given to] these issues by the public” (9). The STOP campaign should use the media to influence what people think about, in this case, the problems facing America’s youth as a result of underage drinking. The STOP campaign can further use the media to put the issue of underage drinking on the public agenda. By doing so, the campaign will gain leverage by reaching out to the community, parents, and students themselves, helping to make everyone aware of the issue. Getting the underage drinking issue on the agenda and making society aware of the problem are the first steps to bringing about change in society.

Once the STOP campaign has made the underage drinking problem known to society, it is now time to target the teenagers themselves through the use of advertisements, such as commercials and print ads. Getting the message out to the public is important, but how the message is framed is what will determine whether or not adolescents will respond to it in terms of behavior (10).
Good framing will target the behavior that needs to be changed, in this case underage drinking, and frame the issue in a way that makes it look unfavorable for teenagers to do. Implementation of good framing will also require the STOP campaign to play on adolescents’ emotions with more images and fewer words or facts. In this arena, public health campaigns need to learn from the advertising industry in order to effectively reach teens.

Another strategy to consider is the use of social expectations theory, which says that people’s behaviors are affected by social norms, values, and roles. This theory defines how people are expected to interact with others in society and how to be integrated in the community (11). The STOP campaign should use this theory to advertise to teenagers that underage drinking is not the norm for people their age. For example, in a possible commercial, the STOP campaign can depict a fun party scene, but when one teenager brings alcohol in order to get the party started, everyone stops and looks at them in disbelief. Incorporating social expectations theory is vital because adolescents are primarily concerned with how others perceive them, which in turn is reflected in their behavior.

2. STOP Campaign Targets Adults Instead of Adolescents
Another flaw of the STOP Campaign is that the campaign is misdirected, targeting adults with the hopes that they will influence adolescent behavior, instead of targeting the adolescents themselves. Previous prevention programs have been successful by incorporating parents and the community, but ultimately targeting teens. One example of a successful prevention program is Project Northland, which is a multiyear youth intervention program. The program was first implemented in Minnesota in 20 school districts for three years from 6th to 8th grade, and was designed to address adolescent age appropriate concerns. In sixth grade, the program focused on adolescents’ skills to communicate with their parents about alcohol (12). Seventh grade education taught students to cope with peer issues and expectations about alcohol. Lastly, eighth grade taught students how to bring about community changes regarding alcohol programs and policies (12). A study later reported that at the end of the three years, when compared to the control communities, those in the intervention community reported a smaller percentage of students drinking or beginning to drink (3). The success of this anti-drinking program can be attributed to the fact that the program was designed specifically for teenagers’ needs during their adolescent years. Not only did the program try to change adolescents’ social environment, but also it allowed the students to be advocates of change by allowing them to write the newsletter “TEENSpeak.”

Another successful multiyear program is SADD, Students Against Drunk Driving or Students Against Destructive Decisions. SADD is an alcohol prevention program that primarily targets middle school and high school age adolescents. Chapters of SADD exist across the country and follow the philosophy “that young people, empowered to help each other, are the most effective force in prevention”(13). Therefore, it is the older SADD students who serve as mentors for younger adolescents in the group. Mentoring is vital to the programs’ success, because it is based on the idea that the most effective source for a message is the audience itself, in this case students educating other students about drinking. SADD also teaches students normative education, changing adolescents’ notions of peer alcohol use and provides peer discussion groups. The literature supports the use of such programs as SADD, stating, “the most effective programs utilize multiple years of behavioral health education, community-wide involvement and mass media complementing the school-based peer-led program” (14). Clearly, targeting teens is essential if the STOP campaign wants to promote behavioral change.

The STOP campaign’s insistence on targeting the parents of adolescents is ineffective because it ignores teenagers’ autonomy to make their own choices free of their parents’ beliefs. As stated before, the social environment does play a role in adolescents’ beliefs, but parental disapproval of drinking is not a key reason why teens abstain from alcohol (12). What the STOP campaign must consider is adolescents’ self-efficacy, or their confidence in being able to refuse the offer of alcohol and abstain from use. According to Bandura, it is perceived self-efficacy that influences behavior, from initiation of a new behavior to inhibition of another (5). One way to improve self efficacy is to change adolescents’ perceptions regarding their peers’ use of alcohol, making it known to them that it is not normal for kids their age to drink. By changing the adolescents’ norm perception, it will empower them to refuse alcohol, because they are not the only ones not drinking. The changing norm strategy relies on the value adolescents place on what others do and in turn how they are perceived.

Changing social norms, however, needs to involve parents of adolescents and, most importantly, how the parents perceive alcohol. Most adolescents report having been given alcohol by an adult or relative (15). Adults given adolescents alcohol might be explained by the fact that alcohol does not carry with it a social stigma like tobacco does, making it seem acceptable even for minors (1). Also, approval of underage drinking varies across households, primarily due to the difference in cultures and their acceptance of alcohol (15). Some cultures, such as the Hispanic culture, allow their children to drink wine at family functions or family dinners in order to share with the rest of the family. Cultural differences should not be shunned, but taken into consideration when planning alcohol prevention campaigns for youth in order to reach the broadest possible audience.

3. Interventions Will Be More Effective If Underage Drinking Is Viewed As a ‘Developmental Framework’
According to the Surgeon General, public health interventions will be more effective if they look at adolescents’ underage drinking through a “Developmental Framework” approach. The Surgeon General encourages campaigns to take a multifaceted approach to solve the underage drinking problem by focusing on adolescent development. Adolescence is a time when kids transition from childhood to a pseudo adulthood stage, in which time they are made to cope with ongoing biological changes, social changes, and behavioral changes. In the quest to find their identity and place in society, adolescents are known to increase their sense of risk taking in order to further state their independence. Research shows, that the puberty stage itself, or the shift to adolescence, has been associated with alcohol use (4). The brain, in particular, at this time begins remodeling itself and continues well into the twenties. The creation of new connections between nerve cells, and the pruning of some existing connections can in turn affect an adolescent’s impulse control, planning process and decision-making (16). Social changes will also occur, during which adolescents are placed in unfamiliar situations due to their peers, and since they lack experience, they often make unhealthy decisions. The STOP campaign should try to counter unhealthy decisions by educating teens about the changes they are undergoing and building their self-efficacy to resist making risky decisions.

Not only are teens likely to drink because of the changes they are undergoing, but also alcohol itself appears to have a different effect on adolescents than it does on adults. As a result of the brain’s remodeling, how adolescents respond to alcohol is altered as well. Studies have shown that adolescent memory is greatly affected and this cognitive impairment is lasting (16). Adolescents are also able to consume larger amounts of alcohol because they are able to stay awake longer and be mobile at higher blood alcohol levels as opposed to adults (4). The most common reason why alcohol has a different effect on teens than adults is because adolescents expect the positive effects of alcohol in social situations in order to have a good time and it is because of this ideal that they are inclined to drink more (4).

Identifying factors that predict alcohol use are not enough to change behavior. The STOP campaign should deal with the reasons why teens drink. The social environment, in particular, peer influence due to perceived norms of the American culture, might explain underage drinking. Adolescents want to be accepted by their peers and if they think that others are drinking, they want to do it too. However, adolescents’ perception of the quantity of drinking their peers do is skewed primarily because they overestimate the drinking habits of others (16). Overestimating is a problem because adolescents want to be like their peers and try to drink as much as they think their peers are drinking. The STOP campaign in this case should implement a social norming ideal to correct the misconceptions of adolescents regarding peer drinking. The Northland Project succeeded in this arena. By the end of the 8th grade, those in the intervention district had lower scores on the Peer Influence Scale (12).

Other reasons why teens might drink are because of their upbringing, its easy access, and the expectancies that teens have regarding alcohol. Beliefs regarding alcohol are established early in life. The positive expectancies that adolescents place on alcohol such as sociability and sexual attractiveness make drinking a pleasurable experience (16). Common sense indicates that those who associate alcohol with a pleasurable experience are more likely to drink. The most common reason teens gave with regards to drinking is because they enjoyed it and it got them in the “party mood” (14). Wanting to get in the “party mood” again plays on the notion that social acceptance influences teens’ behavior making them want to be perceived as cool by their peers. Easy access to alcohol makes adolescents not think twice about drinking, because no one is stopping them (1). Adolescents can get alcohol from adults or relatives in their families, older siblings, and older peers. These enablers do not think what they are doing is harmful to the adolescent, because they just see it as a way to help the teen out. In the college culture it is seen as, when I was underage an older peer bought me alcohol, thus, when I am of age I will do the same. Some bold teens even use fake IDs to purchase the alcohol themselves. The consequences of getting caught do not deter the use of the ID. On the contrary, students just try harder to avoid getting caught (1).

An adolescent’s upbringing is one factor that might affect their belief regarding alcohol. Family disruption, conflict, low parental supervision, and being a child of an alcoholic are factors that are well known to influence alcohol use among teens (17). These teens might see alcohol as a coping mechanism to deal with their less than picturesque life, of which they are victims.
If the STOP campaign seeks to address all the issues influencing a teen’s choice about alcohol use, a media campaign alone is not going to solve the problem. Instead, a multiyear prevention program will have to be considered to give adolescents the foundation to change their perceptions and encourage the community to realize that underage drinking is harmful to America’s youth.

By not addressing many of the previously mentioned factors, the STOP campaign will fail. Thus, future research needs to be done regarding other prevention methods for teen drinking. Incorporating Social Expectation theory to change existing norms in the community is one way to sustain behavioral change (18). Normative re-educative strategies should also be implemented to reinforce the fact that most teens do not use alcohol. Realizing that underage drinking is a group level problem, parents, the community, and the government need to act to change the escalating drinking trend among teens.

The community can try to incorporate the adolescents and make them feel useful by engaging them in positive activities such as volunteering, participating in local functions, and by creating more youth hang out venues (17). The government can set new underage drinking laws that will further enforce the STOP Act Law in local communities. If enough resources are devoted to the enforcement of the new policies, underage alcohol consumption will be reduced (1). State enforcement can be ensured if the government penalizes the state for not controlling underage drinking by threatening to withhold state funding.

Underage drinking is a national problem that has been escalating over the years, and an effective public health intervention is well over due. After considering all the reasons why teens drink, from the biological changes to the social factors, it only makes sense that the most powerful prevention programs will be those that implement a multiyear approach that can address adolescents’ changes first hand, much like Project Northland. Other public health campaigns should take this information and use it when creating alcohol prevention programs and anti-underage drinking media campaigns in order to target teens effectively. The STOP campaign cannot be expected to make an impact if it is just delivering a message to parents and then letting them fend for themselves. The STOP campaign must focus on their target audience, the teenagers, not their parents. Also, the STOP campaign will not change behavior simply by increasing knowledge of risk through a 3-minute media clip and a pamphlet. Behavioral change can only come about through a lengthy process of helping individuals change, by changing their belief system, and, ultimately, sustaining this change by altering social norms. Encompassing all these attributable factors is a whole system approach that looks at underage drinking as a “developmental framework.” The STOP campaign is failing, because it relies on a rational model of behavior change, focuses only on increasing knowledge about risks, rather than dealing with the emotional and social reasons teenagers drink, and, ultimately, targets adults rather than teens.

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