Challenging Dogma - Spring 2008

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

Thursday, April 24, 2008

: The Partnership for A Drug Free America– Examining Prevention Efforts In Prescription Drug Abuse - Matthew Kluge

Founded in 1986, The Partnership for a Drug Free America (PDFA) is a non-profit organization which aims to reduce illicit drug use in America (1). Just as trends in specific drug abuse among America’s youth have changed throughout the organization’s 20 year history, so too have the PDFA’s approaches to dealing with these concerns. In 1986, they began what was originally a three-year program to “unsell” drugs in America. Fast forward to 2008: The PDFA now utilizes some of the largest media outlets in America, such as Super Bowl advertising, to unveil their new initiatives. These public service announcements (PSA’s), though well intended, often fall short of their goals due to an over-reliance on traditional health belief models. As the PDFA becomes open to a wider range of alternative models, they may improve the efficacy of their already commendable public health interventions.
In the mid 1980’s, the PDFA’s early strategy in their War on Drugs was to “demoralize” and “deglamorize” the use of narcotics, which had persisted since the 1960’s, while also increasing perceptions of risk (14). The most memorable ads of this era included the image of an egg frying to represent one’s brain on drugs, or likening the risk of a drug induced high to diving into an empty swimming pool (10). Such images of menace or melodrama were often accompanied by a message of strict chastisement through the slogan, “Just say No.”
The 1990’s saw PDFA’s ads narrow in specificity, tailoring each ad campaign to a particular type of drug abuse, even a specific demographic. Furthermore, by 1993, their mindset had changed noticeably, as PDFA campaign executives abandoned their old rhetoric of a War On Drugs, which suggested an obstacle that was short and winnable (10). In 1994, for example, a new campaign heeded research from inner city neighborhoods, which identified a sense of hopelessness, or a need to kill psychological pain, as reasons for drug abuse. Their campaign focused the message on individual empowerment, with images of hope, vision and strength (10). Other noteworthy PSA’s of the past include the Inhalant Campaign in 1997, the Heroin Campaign in 1998, the Check Yourself- Helping At risk teens campaign in 2004, and the Intervention & Treatment Campaign of 2005 (14).
Recent data from the University of Michigan suggests that overall teen drug use is in steady decline, yet more teens abuse prescription drugs than any other illicit drug except marijuana (1). In an effort to curb these alarming trends, the PDFA unveiled their most recent campaign in late January of 2008. The initiative involves a national public awareness campaign alerting parents to the dangers of prescription drug abuse. One parent-targeted ad portrays an indignant drug dealer, who attributes slow “business” to the ready availability of prescription drugs in the medicine cabinets of parents. He leaves parental viewers feeling guilty in the event that “something goes wrong with their kids;” holding them responsible for their son/daughter’s prescription drug abuse, even likening their role to that of a drug dealer. A second ad depicts a high school student cataloging his parent’s prescription medications, which presumably, he had taken from their medicine cabinet. The narrator closes by asking parents to, “Safeguard your kids against drugs” (1). One final noteworthy ad in this campaign attempts to heighten the perceived severity of prescription drug abuse by depicting a man in a morgue comparing the corpses of a teen who died from the use of illegal drugs and another who died from the use of prescription pain killers. He asks, ‘Which one is more dead?’ A narrator closes the PSA by warning parents to, “Talk to your kids about prescription drug use” (1).
To its credit, the PDFA has generally molded each of its ad campaign initiatives to the status of drug abuse in a particular region of the United States. Indeed, any quality advertising campaign should know and cater to its desired target “market.” However, since its inception in 1986, this program has often failed to utilize basic social science principles that could most effectively reach America’s youth. The PDFA’s Public Health initiative targeting prescription drug abuse among America’s youth ignores underlying social factors, overestimates the efficacy of their oversimplified message to parents, and targets a limited audience. In doing so, it has failed to realize its potential to reduce illicit drug use in America.

1. Media campaigns targeted towards parents fail to provide them with the proper tools; limiting specificity of instruction while at the same time enhancing perceptions of harm
In many PDFA ads employed between 1998 and 2003, the PDFA too broadly advised parents concerning intervention. Even in the most recent campaigns, parents are essentially informed to talk to their children about prescription drugs at, “teachable moments” but do little else to help parents with these “moments” depending on their teen’s specific choice of drug abuse and personal situation. According to the theory of reasoned action, an intervention will be most persuasive when the behavior is defined by its action, target, time, and context. Specific parenting should be addressed in the context of specific drug use (2). For example, a parent would most likely approach their studious son/daughter who has been abusing the common prescription medication Aderol for the purposes of a study aid differently than if they had been abusing a pain killer such as Oxycontin for recreational use on the weekends.
A study published in 2008 suggested a lack of communication entirely. They found that at least half of the respondents reported that their parents did not even provide them with information about drugs or drug abuse (5). Parents who feel ill equipped to talk to their children about drugs may avoid such conversations altogether.
Many of the PDFA advertisements utilize risk or fear as a tool to emphasize that a child’s drug use is serious or remind parents that their children are susceptible. The concept of Fear Appeal is defined by two important variables (in addition to the concept of Fear itself). First is the idea of perceived threat, which is defined by the familiar concepts of perceived severity and perceived susceptibility. Second is the idea of perceived efficacy, which has two components: Perceived self-efficacy and the concept of perceived response efficacy (one’s belief on the effectiveness of the recommended response) (16). Investigators involved in a 2000 meta analysis of public health campaigns which utilized fear appeal, showed that fear appeal can have persuasive effects, when accompanied by high-efficacy messages. If individuals believe they can effectively protect themselves from a given risk, than fear can be an effective impetus for behavioral change (16).
Early advertisements, which emphasized risk through drastic imagery, such as the memorable ad developed in 1986 which likened a fried egg to the condition of a drug user’s brain, tend to enhance perceptions of harm and risk. This technique is still implemented in current ads such as the PSA morgue ad mentioned earlier. Here, the fear appeal is pronounced, but how does this ad address the perceived efficacy – that “talking to one’s children about drugs” will ultimately keep them from prescription drug abuse? Unguided fear does little else than instill a culture of fear and paranoia. Thus, it is important to accompany risk messages with a message of efficacy to channel fear into an adaptive behavioral response (2). Underutilizing an efficacy message, though a common practice in Public Health, can severely deflate the overall utility of an ad campaign.
Finally, in the case of countless ads utilized since the PDFA’s inception, in which the use of drugs are framed as a stigmatized act of which parents and authorities do not approve, the overall effect may be to elicit rebellion amongst teens. Widely documented in the social science realm is the phenomenon of the “Boomerang Effect,” in which anti-drug messages may elicit the exact opposite response of the intended outcome. In his 2001 article, Julain De Meyrick warns against the dangers of a paternalistic approach, in which, “the experts speak and the citizens listen” (17). He reminds readers that adolescence is a time when children are struggling to achieve independence, and a paternalistic voice instructing them to avoid a particular behavior may have the opposite effect (17) In a 2002 study examining 30 PSA’s previously employed by the PDFA, the adolescents felt that they and their friends would actually be more likely to try drugs after viewing six of the 30 ads. (13). Indeed, the PDFA is commonly criticized for its reliance on the health belief. By establishing a mindset that, “Drugs Maim, Drugs Kill,” they are heightening the perceived severity of a social activity, thus, providing another outlet for a demographic of adolescents that are, by their very nature, seeking risky, rebellious behavior.

2. How does the most recent ad campaign address the larger confounding social factors that may influence a youth’s decision to use?
To merely address the question of how America’s youth is acquiring drugs, and not why, and under what circumstances, would do a great injustice to the potential potency of social science-based interventions. For example, in the current prescription drug campaign, an attempt to thwart individuals from illegally acquiring drugs that are legally distributed to hundreds of thousands of individuals on a daily basis seems like a fruitless endeavor. The distribution and abuse of prescription drugs is, and always will be, very difficult to police. My intent is not to devalue the PDFA’s efforts to reduce youth access to prescription in parent’s medicine cabinets, but rather to suggest that this is merely one minor source of a larger prescription drug abuse problem.
Rather than focusing on the physical mediums through which these medications are acquired, more influential interventions may be targeted towards the social environments of America’s youth. One advertisement from 1992 actually acknowledges the impact of societal problems, by criticizing the simplicity, the futility, even, of the, “Just Say No,” campaign in the face of larger social pressures. In this commercial, by Goodbye, Berlin & Silverstein in San Francisco, a boy takes a roundabout route to avoid drug dealers. He says: "My teacher tells us to just say no. Policeman said the same thing. They don't have to walk home through here" (10).
Changes need to be made much earlier in a youth’s life, before drugs are even available or socially apparent. According to the social networking theory, which states that one’s behavior is determined by the specific social network with which you associate, by prohibiting your son/daughter access to your medicine cabinet you will have little effect on the influence of their larger social network. Social networks are often formed based on similar interests, and interests are developed early on in one’s life. By creating a positive, activity filled environment in which a child can explore and identify positive interests at a young age, they may be more likely to engage in positive social networks in the future. Thus, the simple instructions, “talk to your kids about drugs,” may do very little to help parents develop anti-drug socialization.
Marketing research has also investigated how best to reach typical adolescents, who tend to display interdependent tendencies; those influenced by peer pressure. Researcher Jennifer Aaker holds that these individuals display an interdependent view of themselves, which is characterized by connectedness and social context (18). Thus, rather than utilizing scientific fact, the most effective campaigns portray “consensus” information that offers a type of social membership to drug free peer group. (18). Rather than stigmatizing the use of prescription drugs, perhaps these ads could be better served to tout the social benefits of a drug free community.
A conceptual framework of parent-child communication pertaining to anti-drug socialization to help inform parents and ultimately help socialize their children to make individually responsible decisions should be established early in a child’s life (5). Such socialization cannot be achieved quickly or simply. Social networks are very complex. A conventional, ‘social network’ often includes social or institutional influences in addition to individual learning.

3. The PDFA, in their latest campaign, underestimates or misunderstands their target audience resulting in campaigns that often miss their mark
The social marketing theory is based upon the notion that public health officials need a strong, research based understanding of their target audience –their needs, wants, etc, before they can adequately market to create change. The Parents, The Anti-Drug campaign ignores many important avenues for prescription drug acquisition. Furthermore, this ad campaign does little to target the individuals who are actually at risk - America’s youth.
Considering the wide range of viewers who tune in for the one of the biggest sporting events of the year, it seems misguided, and a foolish waste of money to market this Parents, The Anti-Drug campaign during the Super Bowl. If the PDFA wanted to specifically target parents, they should choose alternative timeslots, such as late night television shows or ten or eleven o’clock news broadcasts. To children, these ads function in few other ways than to reinforce the availability of prescription drugs in their household.
Not only should the age of the intended viewers be carefully considered, but the specific population finely focused and understood on multiple levels as well. In his article examining the effectiveness of anti-drug PSA’s, Dr. Martin Fishbein emphasizes the importance of recognizing that, “beliefs may be important determinants of attitudes, perceived norms, or self-efficacy in one population may be unimportant in another….for any behavioral change to be effective, it is first necessary to understand the factors underlying the behavior in the population in question” (13).
The PDFA has indeed fallen short in utilizing Social Marketing Theory to sell their ideas. Despite engaging in straightforward qualitative research to see if potential target audiences, “understand” or “like” a particular PSA, one study stated that of the 30 PDFA-developed PSA’s they reviewed, none were subjected to experimental evaluation before being broadcast (13). Not surprisingly, this study, which collected data from 3608 students, grades five through twelve showed, demonstrated great variability in the perceived effectiveness of 30 PSA’s developed by the PDFA. To prevent possible negative impacts of these PSAs, the authors stress the importance of critically evaluating effectiveness in addition to more traditional, empirical research (14).
Perspective can also be critical to identifying with a target audience. In a study published in 2006, investigators found that among current smokers who were subjected to anti-smoking campaigns, “denial, defensiveness, and rationalizations get in the way of sincere contemplation of a healthier lifestyle” (15). They highlight the weakness of a reliance on nonsmokers to develop their campaign, who may have difficulty creating resounding messages which truly understand the smokers’ perspective.
Finally, this ad campaign narrowly focuses on one means of acquiring prescription drugs, while largely ignoring other avenues, such as online sales, their own prescriptions, and the college network. The internet sale of prescription drugs, in particular, has risen sharply in recent years (12).

In Conclusion
The PDFA has a difficult task on their hands. They must stress to parents the importance of developing positive socialization in their child’s formative years which may lead to drug free social networks in adolescents. They must also effectively target their desired market, with specific instructions. Meanwhile, they must be careful to remain sensitive to the needs and wants of America’s youth as they mature in the complicated interdependent social networks which characterize the often fragile, and tumultuous adolescent years.
As the PDFA lessens their reliance on the health belief model, and looks toward alternative models, they may reach more individuals and help make positive change for America’s youth.

References

1) Parents. The Anti Drug. Rockville, MD. Natinoal Youth Anti-Drug Media Campaign. http://www.theantidrug.com/drug_info/prescription_tips.asp
2) Stephenson, Michael, Quick, Brian.Parent Ads in the National Youth Anti-Drug Media Campaign. Journal of Health Communication, 10:701-710, 2005
3) McCarthy, M. Prescription Drug Use Up Sharply in the USA. The Lancet. Volume 369 , Issue 9572 , Pages 1505 - 1506
4) Hornick, Robert. Yanovitzky, Itzhak. Using Theory to Design Evaluations of Communication Campaigns: The Case of the National Youth Anti-Drug Media Campaign. Communication Theory. Thirteen: Two May 2003 Pages 204-224.
5) Miller-Day, Michelle. Talking to Youth About Drugs: What Do Late Adolescents Say About Parental Strategies? Family Relations, 57 (January 2008), 1–12.
6) Hornick, Robert. Personal Influence and the Effects of the National Youth Anti-Drug Campaign. The ANNALS of the American Academy of Political and Social Science 2006; 608; 282.
7) Manchlkantl, Laxmalah. National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician 2007; 10:399-424
8) Forman, Robert F., Marlowe, Douglas B., Mclellan, Thomas A. The Internet as a source of drugs of abuse. Current Psychiatry Reports Volume 8, Number 5 / October, 2006. 377-382.
9) National Youth Anti-Drug Media Campaign Home Page. Office of National Health Control. http://www.mediacampaign.org/
10) George Bush President Library and Museum. College Station, TX. Texas A & M University. http://bushlibrary.tamu.edu/
11) Morgan, Et al. Associations Between Message Features and subjective evaluations of the Sensation Value of Antidrug Public Service Announcments. Journal of Communication, v53 n3 p512-26 Sep 2003
12) Robert F. Forman, Douglas B. Marlowe and A. Thomas McLellan. The internet as a source of drugs of abuse. Current Psychiatry Reports. Volume; 377-382.
13) Fishbein, M, et al. Avoiding the boomerang: Testing the relative effectiveness of antidrug public service announcements before a national campaign AMERICAN JOURNAL OF PUBLIC HEALTH Volume: 92 Issue: 2 Pages: 238-245
14) Partnership for a drug free America. Advertising Educational Foundation. http://www.aef.com/exhibits/social_responsibility/pdfa/2420
15) Wolburg, Joyce M. College student’s responses to antismoking message: Denial, Defiance, and other boomerang effects. ,” Journal of Consumer Affairs, 40 (2), 293-323. 2006
16) Witte, Kim; Allen, M A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns.. Health Educ Behav 2000; 27; 591.
17) de Meyrick, Julian. Forget the ``blood and gore'': an alternative message strategy to help adolescents avoid cigarette smoking. Health Education
Volume 101 . Number 3 . 2001 . pp. 99±107
18) Aaker, J.L. et al. (1997), ``The effect of cultural orientation
on persuasion'', Journal of Consumer Research, Vol. 24, pp. 315-28

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3 Comments:

  • At April 24, 2008 at 2:35 PM , Anonymous kdgetz said...

    I enjoyed reading your paper. I think you make an excellent point that the PSAs aimed at informing adults need to be aired at times parents are watching - not the kids. I saw the commercial regarding the prescription drug in the medicine cabinet the other night at dinner time and thought it was an odd time.

     
  • At April 25, 2008 at 2:56 PM , Blogger Elizabeth Victoria said...

    Good points. I'm wondering if we should "channel fear into an adaptive behavioral response" or just avoid it as a tactic altogether? It seems that scaring parents and kids into anti-drug "submission" doesn't do anything to address the social or cultural pressure they may be under. I liked your mention of the 80s "brain on drugs" ad. Because the message is so over-the-top, it almost makes drugs seem less harmful than they are.

     
  • At May 1, 2008 at 6:41 AM , Anonymous PAB said...

    I like Elizabeth's point. My high school science teacher had a "If what happened on your inside happened on your outside, would you still smoke?" poster in our classroom. It became a joke and was considered so "over-the-top" that it made smoking seem cool.

     

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