Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

Teens Getting Their Juice: National Campaigns Fail to Outmuscle Teen Steroid Use - Chris Blesso

Anabolic steroid use scandals in professional sports are currently at the forefront of every news channel. With the possibility of millions of dollars in rewards for athletic performance, many athletes are resorting to anabolic steroid use to enhance their abilities. Anabolic steroids are not allowed in any American professional sport, and are illegal without a prescription in the United States. They are also extremely physically dangerous if abused.

However, professional athletes may be damaging not only their bodies, but indirectly also their fans, as their influence as role models on youth in America is unassailable. It is widely known that youth tend to emulate their sports heroes, and recently, the sports world was shaken with steroid scandals. In December 2007, the Mitchell Report implicated more than 80 professional baseball players in the use of steroids (1). Olympic gold medal sprinter Marion Jones had her 5 gold medals stripped from her after admitting she lied about steroid use (1).

The Monitoring the Future survey, which is conducted annually on 8-12th graders by the National Institute on Drug Abuse (NIDA), showed that anabolic steroid use increased with age (2). The newest figures according to the NIDA represent increases since 1991 of approximately 75 percent among 8th - graders and over 50 percent among 10th - graders and 12th – graders (2). The Nutritional Supplementation and Anabolic Steroid Use in Adolescents study involved more than 3,200 students in 12 states and indicates that overall, 1.6 % of students reported using anabolic steroids (3). Now this number may be low, but it is a small survey and there may be bias in students that may sway them from reporting their steroid use. Higher levels of bias are observed among younger respondents and those with higher levels of drug use (4).
Methodological procedures, such as biological specimens, proxy reports (e.g., family member, peer), and repeated measures have been used to validate self-reported data, however these procedures are often impractical or too costly for community-based epidemiological studies (5, 6). Also, youth may be completely unaware that they are taking or have taken a steroid and this could attenuate self reported data on steroid use. There are several supplements on the market that include hidden designer steroids or pro-steroids in the ingredients, as they are not Food & Drug Administration (FDA) regulated (7). The University of California, Los Angeles (UCLA) Olympic Analytical Laboratory identified several designer steroids in supplements legally sold in bodybuilding stores and on the internet, which would potentially be available to teens (7).

Nevertheless, reported steroid use has increased to 6% in 12th grade males, which is a substantial increase (3). Not surprisingly, among students admitting steroid use, 57% said professional athletes influenced their decision to use the drugs and 63% said professional athletes influenced their friends to use them (1). Adding to the frightening statistics, 80% of users and 35% of non-users believed that steroids could help them achieve their athletic dreams (1).

With an increasing need to address teen steroid use, several public health initiatives will be examined, including The National Institute on Drug Abuse’s (NIDA) “Keep Your Body Healthy: Game Plan” and the Partnership for a Drug-Free America’s anti-steroid initiative. Let us first examine the NIDA’s public health campaign. While visiting the NIDA website, they provide several links to fact pages on various drugs that are abused by teens (including steroids). The link for anabolic steroids provides standard public health messages on steroids including: what they are, common street names, how to use them, prevalence, common side effects and details into more serious side effects including growth stunting, hormonal imbalances, mood swings, heart effects, and disfigurements (8). Besides a facts page, the NIDA website includes links for sections with information regarding true-life stories, question & answers, and parent/teacher educational information (8). The NIDA’s media campaign, entitled “Keep Your Body Healthy”, has a public service announcement for steroids called “Gameplan” (8). According to the NIDA, “Gameplan” is the “ latest installment in our "Keep Your Body Healthy" campaign (which) seeks to encourage young men and women to work with what nature has provided and not "cheat" by using steroids and thereby exposing themselves to the negative side-effects associated with these drugs” (8). Their media campaign involves a 60, 30, and 15-second PSA in both Spanish and English (8). It also includes a television special from their “In the Mix” series entitled “Steroids: The Hard Truth”, which debuted in 2002 on PBS and was hosted by celebrity Kevin Sorbo (8).

Now looking at the Partnership for a Drug-Free America’s anti-steroid initiative, we see similar to the NIDA, they have information on steroid education, although much less than the NIDA’s website (9). However, Major League Baseball (MLB) and the Partnership for a Drug-Free America joined together and developed an advertising campaign designed to educate America's youth and their parents about the dangers of steroids and performance-enhancing substances (9). They have several PSA’s which tell about the dangers of steroids on the body, and also show vivid images of destruction including a statue crumbling, and deflating sports balls (9). These PSA’s are aired on major networks including ESPN during the World Baseball Classic (10). No professional athletes or role models are present in these PSA’s; they feature sports related metaphors gradually destructing and are narrated mentioning the dangers of steroids (9)

A widely used psychological model called the Health Belief Model seems to be used in most public health campaigns, including the two described above. It attempts to predict behaviors by focusing on attitudes and beliefs (11). It involves an individual weighing the perceived benefits and costs of an action and then rationally deciding on an intention, which leads to a behavior (11). The perceived benefits are decided by weighing the perceived susceptibility and perceived severity. Perceived susceptibility refers to an individual’s perceptions regarding the possibility of a disease occurrence and perceived severity refers to the degree of seriousness of the given disease (11). These anti-steroid public health campaigns educate teens about their perceived susceptibility and severity of steroid use. However, The National Institute on Drug Abuse’s “Keep Your Body Healthy: Game Plan” and the Partnership for a Drug-Free America’s anti-steroid initiative have fallen short on preventing teen steroid use. By focusing on scare tactics and the dangers of steroids, with a judgmental tone, these campaigns have failed to make an impact on teen steroid use.

1. Failure to capitalize on branding
The anti-steroid campaigns are not effectively using the media to sufficiently communicate their message to teens. Campaigns need to target teens through multimedia that teens watch and create a brand for teens to recognize by employing youth marketing similar to the “truth” campaign (12). The “truth campaign is a large national youth-focused anti-tobacco education campaign which focuses on exposing tobacco companies as manipulators of teenagers (12). The “truth” campaign effectively reaches teens, because it is based on a brand name that youth identify and it is modeled after successful commercial youth brands (12). In a 2008 study that examined the three year impact of the American Legacy Foundation’s “truth” campaign and Philip Morris’s “Think. Don’t Smoke” campaign (13). Philip Morris’s campaign consists of a series of television advertisements entitled “Think. Don’t Smoke”, and has made them the focus of its anti-smoking campaign for teenagers telling children that they have a choice whether to smoke (14). The investigators found considerable evidence of influencing youth’s attitudes towards smoking and the tobacco industry (13). Study findings indicate that exposure to “truth” advertisements were associated with steady positive changes in teens attitudes, beliefs and intentions to smoke, whereas exposure to Philip Morris ads was associated with more favorable beliefs and attitudes toward the tobacco industry (13). This study shows that well-advertised anti-smoking campaigns can have an effect on youth’s attitudes on smoking, but tobacco companies are also crafting their advertisements in a similar style and being counterproductive towards anti-smoking efforts (13).

To be effective, anti-steroid campaigns must compete with the billion dollars a year supplement industry and illegal steroid dealers. The Partnership for a Drug-Free America has created PSA’s with a very cinematic and dramatic feel to them, but they fail to utilize the branding strategy that made the “truth” campaign so effective. The NIDA is somewhat branding their PSA’s with “Gameplan”, but media exposure is not widespread enough (outside of PBS), and therefore ineffective in changing youth attitudes.

2. Failure to take into account modeling theory
These initiatives assume that teens use steroids solely for sports performance and negate any aesthetic reasons. Campaigns need to incorporate Modeling Theory. Modeling theory argues that individuals learn to do specific actions by observation of others (models), and reproduce what they observe (14). Campaigns need role models like fit celebrities as well as professional athletes to speak out on use of steroids and publicly tarnish other individuals who use steroids. While the NIDA featured Kevin Sorbo, an actor who once portrayed Hercules, most teens do not know who that is (his most famous TV show ended in 1999) (15). The PSA’s for both campaigns did not include any professional athletes or celebrities. Reiterating, 57% of surveyed teens said professional athletes influenced their decision to use the drugs and 63% said professional athletes influenced their friends to use them (1).

3. Failure to account for teen attitudes
These campaigns assume that increasing knowledge of the risks of steroid use will lead to behavioral change (Health Belief Model). The temptation for teens to succeed in sports and make millions of dollars far outweighs the health risks, so a health risk based campaign is not relevant for teens. Campaigns need to utilize a normative-reeducation strategy and consider the Theory of Planned Behavior, which accounts for attitude and social norms of teens (16, 17). A study published in 2005 examined attitudes of teens towards the tobacco industry after being exposed to the counterindustry campaign of “truth” advertisements (18). Findings on teen attitudes were consistent with concepts from the Theory of Reasoned Action and Theory of Planned Behavior (18). The random-digit dial telephone survey found that in markets with higher levels of campaign exposure, teens had more negative beliefs about tobacco industry practices and more negative attitudes toward the tobacco industry (18). Findings also provided support for a social inoculation effect, a sort of “immunizing” of teens attitudes towards peer pressure and tobacco advertising (18). This social inoculation effect was shown by teens’ negative industry attitudes being associated with lower receptivity to pro-tobacco advertising (18).

4. Failure to utilize teen rebelliousness
The “Truth” campaign’s anti-manipulation strategy would be wise to employ by national anti-steroid campaigns. By explaining that steroids are dangerous, anti-steroid campaigns may be making steroids more appealing to youth (12). Campaigns need to target steroid dealers and also the supplement industry which are both preying on teenagers with dangerous untested chemicals and making outrageous performance claims. These supplement companies are putting teens and everyone else at risk with their hidden designer steroid ingredients (7). Teens then may think they are being manipulated; and a rebellion against steroid dealers could be an alternative to rebelling against authority.

5. Failure to market alternatives
Campaigns also need to market an alternative to using steroids, showing positive messages, results and success stories of someone achieving their athletic goals without steroids. The Health Belief Model campaigns are using invokes negative messages and teens will rebel against authority as they do not want to be indoctrinated.

In conclusion
Overall, these programs are effectively providing educational materials and PSA’s on the dangers and facts of steroid use. However, by not incorporating social & behavioral strategies that are fitting for teens specifically, teen steroid use may continue to rise and these programs may miss a key opportunity to make an impact during this recent onslaught of steroid scandals.

1. Jacqueline Stenson. Kids on steroids willing to risk it all for success. MSNBC.
2. NIDA InfoFacts: High School and Youth Trends. National Institute on Drug Abuse.
3. Hoffman JR et al. Nutritional Supplementation and Anabolic Steroid Use in Adolescents. Med Sci Sports Exerc. 2007; 40:15-24.
4. Fendrich M et al. Validity of drug use reporting in a high-risk community sample: a comparison of cocaine and heroin survey reports with hair tests. Am J Epidemiol. 1999; 149:955-62.
5. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res. 2002 May; 4(2):149-59.
6. Rosenstock IM. Historical Origins of the Health Belief Model. Health Educ Monogr.1974; 2: 84-91.
7. Shipley A et al. Designer Steroids: Hide and Seek. Washington Post.
8. Facts on Drugs: Anabolic Steroids. NIDA for Teens.
9. Interactive Feature: The Steroids Story. The Partnership for a Drug-Free America.
10. MLB and the Partnership Launch Second Phase of Anti-Steroid Initiative. The Partnership for a Drug-Free America.
11. Chin R, Benne KD. General Strategies for Effecting Changes in Human Systems (pp. 22- 45). In: Bennis et al., ed. The Planning of Change. USA: Holt, Rinehard, and Winston, 1976.
12. Hicks J: The strategy behind Florida’s “truth” campaign. Tob Control 2001; 10:3-5.
13. Farrelly MC et al. Sustaining 'truth': changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign. Health Educ Res. 2008 Jan 17.
14. Socialization and Theories of Indirect Influence (pp. 202-227). In: Defleur ML, Ball-Rokeach SJ, ed. Theories of Mass Communication. White Plains, NY: Longman, 1989.
15. Biography. Kevin Sorbo Official Site.
16. Icek Ajzen. Theory of Planned Behavior. Icek Ajzen: Homepage.
17. Novelli WD. “Don’t smoke,” buy Marlboro. BMJ. 1999 May 8; 318(7193): 1296.
18. Hershey JC et al. The theory of "truth": how counterindustry campaigns affect smoking behavior among teens. Health Psychol. 2005; 24:22-31.

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